Andrew Reed
Consider the following scenario: The government offers you the opportunity to enroll in a heavily subsidized prescription drug coverage plan, through which you can purchase a wide range of medications at drastically reduced prices, all from the comfort of your home computer. But there’s a catch: there are over 50 plans to choose from, each of which can be assessed along a dozen attributes, from monthly premiums and deductibles to customer service ratings and pharmacy coverage. And, as if this decision weren’t daunting enough, now imagine that you are a senior citizen with little to no computer experience.
If this scenario seems troubling to you, you are not alone. In fact, over 40 million Americans aged 65 and older are offered this very decision on a yearly basis, and, of those, several million (over 4 million in 2008) fail to make any choice whatsoever (The Henry J. Kaiser Family Foundation, 2008). Research evidence suggests that older adults, who are the fastest growing cohort in the US, may differ substantially from younger adults in how they make decisions. For example, although older adults may experience declines in basic-level cognitive abilities, which is why research is so essential, older adults’ decision making may be best conceptualized as a combination of particular vulnerabilities and, in some cases, particular strengths (see below and Strough, Mehta, McFall, & Schuller, 2008). Despite these research findings, seniors are being offered increasingly more decisions and choices. What can be done to help older adults make these complex decisions? Interdisciplinary research conducted by psychologist Dr. Joseph Mikels, in collaboration with economist Dr. Kosali Simon, offers several prescriptions for improving older adults’ decision-making.
Aging of the Mind and Heart
What is the first thing that comes to mind when you think about older adults? If you answered something along the lines of “cognitive decline,” you may not be too far from the truth. There is extensive research evidence of age-related deficits in a variety of mental processes, from working memory and information processing to reasoning and numerical abilities—all of which have been implicated as crucial to effective decision making (for a review, see Peters et al., 2007). Based on such findings, one would expect older adults to be inferior to their younger counterparts in decision making skills, and there is some evidence to support this notion.
However, in contrast to the bleak portrait of cognitive decline, most research depicts age-related changes in emotion in a more positive light. Older adults, relative to younger adults, demonstrate preserved, if not improved emotional functioning and regulation, and also report more frequent positive emotions and fewer negative emotions (for a review see Carstensen, Mikels, & Mather, 2006). In addition, while younger adults tend to focus more on negative information in the environment, older adults are more likely to focus on, and remember, positive information (Carstensen & Mikels, 2005). As such, while older adults’ cognitive abilities appear to deteriorate over time, their emotional skills are largely spared from age-related declines (e.g. Mikels et al., 2005).
Going with Your Gut
Do the best decisions come from the mind, or from the gut? It has been assumed by many western philosophers that the surest path to a sound decision is to gather and evaluate all available information about one’s options through careful, rational thinking. But recently, psychologists have suggested that conscious thinking about options may actually impair accuracy and satisfaction for certain decisions relative to “snap judgments” or decisions based on “unconscious” deliberation (Dijksterhuis et al., 2006). In addition, other “decision scientists” have called attention to the utility of emotion in the decision-making process (e.g. Slovic et al., 2002).
Research by Dr. Mikels addressed the age old debate between the supremacy of “rational” deliberation versus emotional intuitions from a life-span perspective. In light of the aforementioned diverging trajectories in the aging mind and heart, Dr. Mikels questioned whether older adults’ decision making might benefit from a reliance on the skills which are spared from age-related declines—namely emotional processing. In a series of laboratory-based studies, Dr. Mikels’ research team presented hypothetical healthcare-related decisions (choosing a physician, for example) to older and younger adults in which one of the alternatives was objectively superior to the others. When older adults used memory-based, detail-focused strategies to decide, their accuracy was, as expected, worse than that of younger adults. However, when older adults eschewed this “rational” approach to choosing in favor of one based on emotional reactions to the information, they were just as accurate as younger adults.
Thus, by focusing older adults’ attention to their “gut feelings,” Dr. Mikels was able to significantly enhance the quality of their decisions. In a separate study, older adults reported that their capacity to engage in effortful deliberation when making decisions, and their interest in doing so, were reduced relative to younger adults. The combined results of these studies suggest that older adults may not only prefer to “go with their gut,” but that their decisions may benefit immensely from doing so.
Follow-up studies of younger adults demonstrated that they may also benefit from relying on intuitive, emotion-based decision strategies for complex decisions. In particular, college students were more likely to choose the “best” option for complex decisions among vacations or apartments when focusing on their feelings, relative to students who relied on their memory for details about the alternatives. However, emotion-based decision strategies were no more accurate for domains in which students are relatively inexperienced, such as selecting hospitals or doctors. Thus, the benefits of emotion-based decisions may extend to adults of all ages, depending on the choice domain.
How Much Choice is Enough?
When it comes to choice in decision making, the contemporary mentality seems typified by a more-is-better mantra. But is this the case for all individuals? Research by Dr. Mikels and Dr. Simon suggests that while such a mentality may be part of the exuberance of youth, older adults neither desire, nor value, choice to the same extent that younger adults do (Reed, Mikels, & Simon, 2008). In a series of large-scale surveys conducted in Ithaca and New York City, hundreds of older adults (over 65) and undergraduate students reported how many options they wished to choose from in a variety of domains, from prescription drug plans to ice cream flavors. As expected, older adults desired on average less than half as many options as younger adults did, and this preference for choice continued to decline even among the oldest participants. That is, not only did the average 70 year old desire fewer options than a 20-year old, but 80-year olds desired even fewer options than 70-year olds. Additionally, older adults preferred only one-tenth as many options for Medicare Part D prescription drug plans as they are currently offered, on average, across the country (i.e. 5 versus 50).
Clearly then, older adults do not desire as much choice as they are offered, nor as much choice as younger adults do when making decisions. But how would they react to the possibility of having greater choice? In a separate study, Dr. Mikels’ research team measured self-reports of how much money older versus younger adults would be willing to pay for varying degrees of choice among prescription drug plans (i.e. 55, 25, 10, 5, or no options). Whereas younger adults were willing to pay increasingly more for additional options (roughly 50 dollars for every doubling of the choice set), older adults were largely unwilling to pay extra for more choice (Mikels, Reed, & Simon, under review).
But what is so bad about giving older adults too many options? In direct contrast to the more-is-better mentality, research suggests that excessive choice may be especially detrimental to decision making, as it not only undermines the quality of decisions, but also people’s motivation to choose anything at all (for a review see Botti & Iyengar, 2006). Individuals who are faced with dozens of options are less satisfied with their decisions than people who choose from relatively few options, even when the decisions appear as simple as selecting a variety of jam. And, given age-related declines in decision-making competence, this “choice overload” effect may be especially pronounced for older adults. As such, it would seem especially prudent to buffer older adults from these ill effects by tailoring decision environments more closely to their abilities and preferences.
What is the Best Way to Convey Information?
Having too much choice is only one of many factors contributing to the excessively complex decisions facing older adults. Another culprit in the onslaught of complex decisions may be the way in which these choices are presented. For example, when seniors select a Medicare Part D plan, they are not only choosing among dozens of options, but the plans are, by default, displayed on the website in only one manner—by cost to the average consumer. As a result of this one-size-fits-all approach, seniors may not be able to find the plan that best suits their particular health profiles. But how might we improve the system for presenting information about such crucial decisions? To combat the difficulties associated with choosing a Medicare Part D insurance plan, Dr. Simon developed innovative and consumer-friendly methods of presenting older adults with prescription drug plan information. Through the Cornell University Resource Education for Medicare Part D (CURxED) program, her team disseminated easy-to-read comparative information on each drug coverage plan to county extension offices, offices of aging, public libraries and the like. So as to facilitate the communication of plan differences to seniors, information sheets were compiled into three separate binders organized by insurance plan, illness (or combination of illnesses), and prescription drugs, respectively. By presenting various paper-based alternatives to the problematic electronic plan-based presentation of the Medicare Part D website, Dr. Simon’s team was able to convey to older adults the most cost-effective plans based on their individual backgrounds, and to encourage seniors to consider whether they should sign up for the benefit.
Implications
How can you apply these research findings to your daily life? If you are helping an older adult make a decision, you may want to consider the following suggestions:
Encourage going-with-your-gut when appropriate. For example, when helping older adults make complex decisions, it may be best to encourage them to focus on their feelings as opposed to the specific details. They may not only make better decisions, but also feel more satisfied with their choices. Similarly, when younger adults are making complex decisions for familiar domains, it may not hurt for them to “go with their gut” either.
Present age- and person-appropriate numbers of options. Older adults neither desire too many options, nor do they fare well when faced with complex decisions, so make sure that the choices you offer them are both reasonable and desired. For example, instead of listing all of the available home health care agencies in the area, first present the 5 or so most popular ones. If the person you are assisting isn’t satisfied with any of them, present an additional few options. By restricting the flow of information in this manner, you will increase the odds of making a high-quality, satisfying decision.
Give them the amount of information they want, not how much you think they want. Older adults’ decision-making strategies and preferences are significantly different from those of younger cohorts. As such, it is crucial to keep in mind that what seems reasonable and desirable to you may be overwhelming to older adults. The safest way of ensuring a good fit between the decisions presented to older adults and their individual characteristics is to simply ask them what they feel they can handle and/or prefer in terms of decision complexity.
Help seniors find the right information. There is a wealth of knowledge out there for seniors about critical healthcare decisions, including the Medicare Part D prescription drug benefit. Unfortunately, most of it is on the Internet, which is an unfamiliar medium for the average older adult. Helping seniors effectively surf the web, especially on senior-specific sites such as the AARP website, may substantially increase their ability to make more informed and accurate healthcare decisions.
Don’t underestimate older adults’ abilities. Although there are certain types of decisions for which older adults do not perform as well as younger adults, most studies find little to no difference in the quality of decisions made by adults across age groups. It is now believed that older adults are able to effectively compensate for their diminished memory and processing resources through the use of accumulated knowledge and emotional skills. As such, discounting seniors’ abilities to make effective decisions for themselves based on common stereotypes of aging is not recommended.
Just because seniors prefer simple decisions doesn’t mean they cannot process complex ones. Research has shown that older adults are more selective than younger adults in their use of mental processing and deliberation. That is, they do not engage in effortful deliberation over judgments and decisions indiscriminately, but rather conserve them for major social and emotional decisions. The next time you notice an older person appear to skim over a decision instead of diving into the details, keep in mind that he or she may be doing so voluntarily, and not because of any mental impairment.
Further Resources
Emotion & Cognition Laboratory
Cornell University Resource Education for Medicare Part D
AARP (formerly American Association for Retired Persons)
References
Botti, S. & Iyengar, S.S. (2006). The Dark Side of Choice: When Choice Impairs Social Welfare. Journal of Public Policy and Marketing, 25(1), 24-38.
Carstensen, L. L. & Mikels, J. A. (2005). At the intersection of emotion and cognition: Aging and the positivity effect. Current Directions in Psychological Science, 14(3), 117-121.
Carstensen, L. L., Mikels, J. A., & Mather, M. (2006). Aging and the intersection of cognition, motivation and emotion. In J. Birren & K. W. Schaie (Eds.), Handbook of the Psychology of Aging (Sixth ed., pp. 343-362). San Diego: Academic Press.
Dijksterhuis, A., Bos, M.W., Nordgren, L.F., & van Baaren, R.B. (2006). On making the right choice: The deliberation-without-attention effect. Science, 311, 1005-1007.
Mikels, J. A., Larkin, G. R., Reuter-Lorenz, P. A., & Carstensen, L. L. (2005). Divergent trajectories in the aging mind: Changes in working memory for affective versus visual information with age. Psychology and Aging, 20(4), 542-553.
Mikels, J.A., Reed, A.E., & Simon, K.I. (2008). Older Adults Place Lower Value on Choice Relative to Young Adults. Manuscript under review.
Peters, E., Hess, T.M., Västfjäll, D., & Auman, C. (2007). Adult age differences in dual information processes: Implications for the role of affective and deliberative processes in older adults’ decision making. Perspectives on Psychological Science, 2(1), 1-23.
Reed, A.E., Mikels, J.A., & Simon, K.I. (2008). Older adults prefer less choice than young adults. Psychology and Aging, 23(3), 671-675.
Slovic, P., Finucane, M., Peters, E., & MacGregor, D. G. (2002). The affect heuristic. In T. Gilovich, D. Griffin, & D. Kahneman (Eds.), Heuristics and biases: The psychology of intuitive judgment (pp. 397-420). New York: Cambridge University Press.
Strough, J., Metha, C.M., McFall, J.P., & Schuller, K.L. (2008). Are older adults less subject to the sunk-cost fallacy than younger adults? Psychological Science, 19(7), 650-652.
The Henry J. Kaiser Family Foundation. (2008). The Medicare Prescription Drug Benefit - An Updated Fact Sheet (KFF Publication No. 7044-08). Retrieved September 4, 2008, from http://www.kff.org/medicare/upload/7044-08.pdf.