Williams et al The challenges of aging Social changes The social challenges of aging may be particularly stressful, as the size of social networks and the experience of social support can change drastically as an individual ages. At retirement, for example, many older individuals have left behind the workplace as a potential source of friendship and support from co-workers and associates. The loss of familiar roles may deprive older persons of the opportunity to feel competent in social relationships (Holahan and Holahan 1987). Changes in family structure, widowhood, the death of friends, and declines in mobility may further reduce opportunities for social involvement, making the older population more vulnerable to loneliness and the stress of social isolation (Gurung et al 2003). Such losses may lead to depression, which may further contribute to social disengagement (Gurung et al 2003). Older adults with greater emotional support from their network of social relationships tend have better cognitive functioning (Seeman et al 2001) and better health (DiMatteo and Martin 2002), although the correlational nature of such ﬁndings suggests that social support may be both a cause and a result of social connection. There is some prospective evidence to support the notion that individuals with better social relationships live longer (Berkman and Syme 1979). Evidence for the health beneﬁts of social support may be clearer. Social support has been associated, for example, with better blood pressure regulation in patients with hypertension (Uchino et al 1996) and with better immune functioning (Baron et al 1990). A pathway connecting social support to perceptions of stress through physiological functioning (eg, cardiovascular, immune) and ending in physical health outcomes has been suggested (Uchino et al 1999). In addition, cognitive factors and self-efﬁcacy can be both causes and effects of the physical and psychological challenges of aging, and can affect the maintenance of networks of social support (Holahan and Holahan 1987). Cognitive and psychological challenges The physical, economic, and social challenges of aging can increase the risk of depression and other psychological morbidity. The US National Institutes of Mental Health (NIMH), for example, estimates that 2 million of the 35 million Americans over the age of 65 have major depression and an additional 5 million have depressive symptoms. In the primary care setting, the prevalence of depressive symptoms in elders can be as high as 40% (Chen and Landefeld 2007). Major depression is a risk factor for 454 suicide, which is almost twice as likely in the elderly as in the general population (Alexopoulos 2005). Older patients being treated for depression have poorer outcomes than younger patients, with a higher chance for relapse during follow-up and shorter intervals until recurrence. Patients with no past psychiatric history also face late onset depression as a result of medical comorbidity, and they often face poor prognosis (Mitchell and Subramaniam 2005). Added challenges of low income and limited health care coverage can increase the threat of depression in older patients who have serious acute or chronic medical conditions. Age is highly associated with increased burden of disease, with 80% of adults over the age of 65 reporting at least one chronic condition, and 52% reporting two or more chronic conditions (Chen and Landefeld 2007). Research suggests that low socio-economic status, poor physical health, disability, social isolation, and relocation can combine to cause serious adjustment disorder with depressed mood, and can even lead to severe depressive episodes (Alexopoulos 2005). Older adults in the lowest income brackets are particularly vulnerable, with 60% higher rates of depression than those of higher income. Low income patients have twice the rate of functional limitations, and are less than half as likely to report good or very good health status compared with those of higher income (Chen and Landefeld 2007). As a group, the elderly are less educated than younger patients. In the 2000 US census, only 61% of adults over the age of 75 had at least a high school education and only 13% had higher than a bachelor’s degree. Although formal education does not guarantee adequate health literacy, education is an important element in the maintenance of cognitive functioning and in the understanding of and commitment to disease management (Baker et al 1996; Gazmararian et al 1999). In addition, technology has advanced rapidly within the last few decades and many physicians may perceive the elderly as not able or willing to make use of health information available to them via newer information technologies such as the World Wide Web (Halter 1999). Research shows, however, that older patients are no less likely than younger ones to use health information that is transmitted with newer technologies (ie, computers); some older patients are even more likely to use this form of technology to receive health information (Wagner and Wagner 2003). Income and health insurance Although some may approach retirement with good pensions and a comfortable “nest-egg,” many older individuals Clinical Interventions in Aging 2007:2(3)