Attitudes to Ageing Questionnaire (AAQ)

Abstract

The Attitudes to Ageing Questionnaire (AAQ) is a prominent, multidimensional psychometric instrument developed to assess personal subjective evaluations of the ageing process among older adults. Developed by Ken Laidlaw, Michael J. Power, Silke Schmidt, Suzanne M. Skevington, and the World Health Organization Quality of Life (WHOQOL) Group in 2007, the instrument addresses a critical gap in geropsychology by measuring how older adults perceive their own ageing, rather than eliciting attitudes toward older adults in general. Comprising 24 self-report items evaluated on a 5-point Likert response scale, the AAQ possesses a robust three-factor structure capturing distinct facets of ageing: Psychosocial Loss, Physical Change, and Psychological Growth. Psychometric investigations across diverse international cohorts have verified its solid internal consistency, yielding Cronbach’s alpha coefficients between .70 and .86 for subscales and total scores, high test-retest reliability ($r = .76–.81$), and confirmed construct validity through both modern Item Response Theory (IRT / Rasch analysis) and non-parametric Mokken scaling. The AAQ is utilized widely in clinical trials, epidemiological surveys, and cognitive-behavioral interventions targeting self-directed ageism, resilience, and quality of life in later adulthood.

Keywords

Attitudes to Ageing Questionnaire, AAQ, psychometrics, subjective ageing, psychosocial loss, physical change, psychological growth, geropsychology, WHOQOL-OLD, successful ageing, age stereotypes, Rasch analysis.

Authors

The Attitudes to Ageing Questionnaire was developed collaboratively through the World Health Organization Quality of Life (WHOQOL) Group’s Ageing Workgroup. The principal investigators and primary authors are:

• Ken Laidlaw, Ph.D. — Professor of Clinical Psychology and Head of the Department of Clinical Psychology, University of Exeter (formerly University of Edinburgh), United Kingdom. Renowned for pioneering cognitive-behavior therapy (CBT) protocols adapted specifically for older adults.
• Michael J. Power, Ph.D. — Professor of Clinical Psychology, University of Edinburgh, United Kingdom, and National University of Singapore. Core member of the WHOQOL international coordination group.
• Silke Schmidt, Ph.D. — Professor and Chair of the Department of Health and Prevention, Institute of Psychology, University of Greifswald, Germany. Instrumental in European cross-cultural health-related quality of life research.
• Suzanne M. Skevington, Ph.D. — Professor of Psychology and Director of the WHO Centre for the Study of Quality of Life, University of Bath, United Kingdom. Lead psychometrician for multiple WHOQOL development projects.
• The WHOQOL-OLD Group — An international consortium of academic and clinical research centres spanning more than 20 countries dedicated to standardizing geriatric health status and quality-of-life assessments.

Purpose

The primary purpose of the Attitudes to Ageing Questionnaire is to measure subjective experiences and individual appraisals of ageing directly from the standpoint of older adults themselves. Historically, social-psychological instruments focused almost exclusively on societal ageism, capturing younger cohorts’ stereotypes and prejudicial attitudes toward older demographics (e.g., the Fraboni Scale of Ageism or Kogan’s Attitudes Toward Old People Scale). While such tools assess external societal perceptions, they fail to quantify how an individual internalizes the ageing experience and negotiates personal transitions across biological, social, and psychological domains.

In both clinical and research contexts, personal attitudes toward ageing act as critical determinants of health outcomes. Grounded in empirical observations that subjective self-perceptions of ageing predict cardiovascular reactivity, physical disability, cognitive decline, adherence to medical regimens, and overall longevity, the AAQ provides clinicians and researchers with an objective, standardized metric. Clinically, it identifies maladaptive internalizations—such as attributing treatable depressive disorders or physical decline to “inevitable old age”—which frequently undermine psychological interventions and rehabilitation programs. By categorizing perceptions into psychosocial losses, physical adaptation, and psychological maturity, the AAQ allows targeted therapeutic interventions using Cognitive Behavioral Therapy (CBT) to reframe catastrophic beliefs regarding ageing.

In epidemiological and observational research, the AAQ serves as a foundational instrument for evaluating public health initiatives, active ageing programs, and community-dwelling interventions. It operates effectively across non-clinical community samples, assisted living environments, and geriatric outpatient services, permitting cross-sectional comparisons, longitudinal trajectory tracking, and the evaluation of psychological interventions intended to promote resilience and successful ageing.

Psychological Construct

The AAQ operationalizes personal attitudes toward ageing as a multidimensional construct comprising three related but structurally distinct domains: Psychosocial Loss, Physical Change, and Psychological Growth. Each subscale addresses a discrete facet of subjective ageing, avoiding the conceptual conflation of biological decline with psychological maturation.

1. Psychosocial Loss

This subscale captures perceived decrements associated with chronological ageing in social connectedness, personal autonomy, and societal engagement. It focuses primarily on negative psychological and social sequelae, including loneliness, alienation, difficulty expressing emotional vulnerability, and feelings of social marginalization. Unlike normative developmental change, high psychosocial loss reflects an internalization of negative age stereotypes, manifesting as perceptions that old age is intrinsically a time of social withdrawal, emotional difficulty, and pervasive loss. Example items within this dimension examine feelings of social exclusion (“I feel excluded from things because of my age”) and identity reduction (“I see old age mainly as a time of loss”). Elevated scores on this domain correlate strongly with clinical depression, neuroticism, and social isolation.

2. Physical Change

The physical change dimension measures personal appraisals of physiological health, functional capacity, exercise engagement, and physical energy relative to subjective expectations of ageing. Rather than functioning as a physical symptom checklist, this subscale captures the individual’s psychological adaptation to biological ageing. It evaluates whether physical limitations impede personal agency or whether the individual sustains health promotion behaviors despite biological changes. Typical assertions assess health optimism (“My health is better than I expected for my age”), identity separation from biological markers (“My identity is not defined by my age”), and proactive health maintenance (“I keep myself as fit and active as possible by exercising”). This dimension captures resilience and somatic coping mechanisms.

3. Psychological Growth

In contrast to deficit-focused models of senescence, the psychological growth domain captures positive personal developmental milestones and psychological gains accrued across the lifespan. Grounded in humanistic and life-span perspectives, this dimension reflects wisdom, self-acceptance, generative impulses to mentor younger cohorts, emotional self-regulation, and perceived life significance. Key items gauge self-concordance and generativity (“Wisdom comes with age”; “It is important to pass on the benefits of my experience to younger people”; “I believe my life has made a difference”). High scores represent ego-integrity, developmental maturity, and adaptive emotional coping.

Theoretical Framework

The conceptual framework of the Attitudes to Ageing Questionnaire integrates multiple influential paradigms from lifespan developmental psychology, social cognition, and cognitive-behavioral theory.

A central pillar is Stereotype Embodiment Theory (SET), formulated by Becca Levy. SET posits that cultural stereotypes regarding ageing are internalized across the lifespan, operating unconsciously from childhood through adulthood until they become self-relevant in older age. Once internalized, these stereotypes influence physical and cognitive health through psychological pathways (e.g., self-efficacy expectations), behavioral pathways (e.g., avoidance of physical exercise, poor treatment compliance), and physiological pathways (e.g., elevated cardiovascular reactivity to stress). The AAQ directly measures the degree to which an individual endorses these internalized stereotypes, particularly within the Psychosocial Loss subscale.

The scale is equally rooted in the Life-Span Theory of Control and the model of Selective Optimization with Compensation (SOC) formulated by Paul Baltes and Margret Baltes. SOC theory asserts that successful ageing is not the absence of loss, but rather an active process of selecting attainable domains of functioning, optimizing specific competencies, and employing compensatory strategies to counteract physiological decline. The Physical Change and Psychological Growth subscales reflect SOC mechanisms by capturing active behavioral management of health alongside the psychological maximization of emotional balance and experiential wisdom.

Finally, the AAQ draws upon Erik Erikson’s epigenetic model of psychosocial development, particularly the late-life struggle between Generativity versus Stagnation and Ego Integrity versus Despair. The Psychological Growth subscale provides direct empirical assessment of ego integrity and generativity, examining the degree to which an individual views their life history as coherent, purposeful, and valuable to future generations.

Validity

Empirical evaluations across diverse international populations have established the robust construct, convergent, discriminant, and criterion-related validity of the AAQ.

Construct and Structural Validity

Initial validation studies conducted by Laidlaw et al. (2007) across multiple international centers confirmed that the hypothesized three-factor structure exhibited superior fit compared to unidimensional or two-factor models. Using both classical test theory and item response theory, investigators demonstrated that each of the three subscales evaluates a distinct, theoretically coherent construct. Confirmatory factor analysis (CFA) across international samples typically yields strong fit metrics, with comparative fit index (CFI) values exceeding .92 and root mean square error of approximation (RMSEA) values consistently below .06.

Convergent and Discriminant Validity

Convergent validity is documented through consistent, statistically significant correlations with validated instruments assessing quality of life, mood, and subjective functional ability:

• Depressive Symptomatology: The Psychosocial Loss subscale demonstrates moderate-to-strong positive correlations with the Geriatric Depression Scale (GDS; $r = .50–.64$) and the Beck Depression Inventory (BDI), verifying that negative views of personal ageing co-occur with affective distress. Conversely, Psychological Growth and Physical Change correlate negatively with depressive symptoms ($r = -.30$ to $-.45$).
• Quality of Life: The Physical Change and Psychological Growth subscales demonstrate robust positive associations with the WHOQOL-BREF and WHOQOL-OLD facet scores, specifically with Sensory Abilities, Autonomy, Past, Present and Future Activities, and Social Participation ($r = .35–.58$).
• Discriminant Validity: The AAQ successfully discriminates between community-dwelling healthy older adults, medically compromised clinical populations, and psychiatric outpatients. Older adults with documented major depression or severe chronic illness score significantly higher on Psychosocial Loss and significantly lower on Physical Change than age-matched healthy peers.

Predictive and Longitudinal Validity

Longitudinal studies demonstrate that baseline AAQ scores predict physical functioning, cognitive performance, and subjective health trajectories over intervals ranging from 1 to 5 years. Individuals with more adaptive initial scores on the Physical Change and Psychological Growth subscales exhibit lower rates of functional decline, greater maintenance of physical activity levels, and reduced mortality risks after controlling for baseline chronological age and chronic medical morbidity.

Reliability

The Attitudes to Ageing Questionnaire has demonstrated high reliability across diverse geographic regions, clinical settings, and linguistic adaptations.

Internal Consistency

In the foundational validation study by Laidlaw et al. (2007) involving 1,356 older adults across multiple international centers, internal consistency calculated via Cronbach’s alpha was:

• Total AAQ Score: $\alpha = .81$
• Physical Change Subscale: $\alpha = .75$
• Psychosocial Loss Subscale: $\alpha = .74$
• Psychological Growth Subscale: $\alpha = .62–.74$ across language versions.

Subsequent psychometric evaluations in various adaptations (e.g., Spanish, Portuguese, Turkish, Iranian, Chinese) have yielded internal consistency coefficients ranging from .70 to .86 across the three subscales, confirming adequate homogeneity of items within their respective constructs.

Person Separation Index and Rasch Reliability

Evaluation using modern Rasch analysis provided strong support for metric precision. Laidlaw and colleagues reported high Person Separation Indices (PSI)—a modern psychometric analog of Cronbach’s alpha that does not assume normal distributions:

• Psychosocial Loss: $\text{PSI} = 0.807$
• Physical Change: $\text{PSI} = 0.809$
• Psychological Growth: $\text{PSI} = 0.738$

Test-Retest Stability

Temporal stability assessed over a 2- to 4-week test-retest interval demonstrates high reproducibility in stable older adults. Intraclass correlation coefficients (ICC) and Pearson correlation coefficients consistently exceed acceptable thresholds:

• Total Score: $r = .79$ ($p < .001$)
• Physical Change: $r = .81$ ($p < .001$)
• Psychological Growth: $r = .77$ ($p < .001$)
• Psychosocial Loss: $r = .76$ ($p < .001$)

Factor Analysis

The factorial structure of the AAQ was established through rigorous exploratory factor analysis (EFA) during its initial developmental phase and subsequently cross-validated using confirmatory factor analysis (CFA) and non-parametric Item Response Theory (Mokken Scaling Analysis).

Exploratory and Confirmatory Modeling

The original field study evaluated a pool of candidate items extracted from cross-cultural focus groups conducted in 15 international centres under the WHOQOL umbrella. Principal axis factoring with Promax and Varimax rotations identified a definitive three-factor solution explaining over 42% of the total variance, with 24 items cleanly loading onto their respective theoretical factors without substantial cross-loadings ($> .30$).

Confirmatory factor analysis (CFA) conducted in independent cross-validation cohorts demonstrated excellent model fit indices for the 3-factor correlated model:

• Root Mean Square Error of Approximation (RMSEA): $0.046–0.058$ (indicating close fit).
• Comparative Fit Index (CFI): $0.92–0.95$.
• Tucker-Lewis Index (TLI): $0.91–0.94$.
• Standardized Root Mean Square Residual (SRMR): $le 0.05$.

Mokken Scaling Analysis (MSA)

Shenkin, Watson, Laidlaw, Starr, and Deary (2014) subjected the AAQ to non-parametric Item Response Theory using Mokken scaling analysis on a large cohort of older individuals (the Lothian Birth Cohort 1936). The analysis corroborated the three-factor structure, demonstrating that the Psychosocial Loss and Physical Change subscales represent strong, invariant Mokken scales ($H > .40$), whereas the Psychological Growth subscale forms a moderate but statistically sound scale ($H \approx .35–.38$). Loevinger’s $H$ coefficients across all items confirmed that the items within each subscale reflect a hierarchical, monotonic order of item difficulty.

Instrument / Measurement Tool

• Test Type: Multi-dimensional self-report questionnaire.
• Target Population: Older adults (typically aged 60 years and older; validated in community, clinical, and residential settings).
• Administration Format: Paper-and-pencil questionnaire, digital/web-based assessment, or structured face-to-face interview for individuals with visual or motor limitations.
• Item Count: 24 items equally distributed across 3 subscales (8 items per subscale).
• Subscale Breakdown:
  • Psychosocial Loss: Items 3, 6, 9, 12, 15, 17, 20, 22.
  • Physical Change: Items 7, 8, 11, 13, 14, 16, 23, 24.
  • Psychological Growth: Items 1, 2, 4, 5, 10, 18, 19, 21.
• Response Scale: 5-point Likert scale formatted with dual anchors:
  • 1 = Strongly disagree / Not at all true
  • 2 = Disagree / Not so true
  • 3 = Neither agree nor disagree / Moderately true
  • 4 = Agree / Rather true
  • 5 = Strongly agree / Absolutely right
• Scoring and Directionality:
  • Subscale scores are calculated by summing the respective 8 item ratings (range: 8 to 40 per subscale).
  • Psychosocial Loss: Higher scores reflect greater perceived loss, social exclusion, and negative appraisals of ageing.
  • Physical Change: Higher scores indicate more positive adaptation to physical changes, health optimism, and physical activity engagement.
  • Psychological Growth: Higher scores indicate greater perceived wisdom, personal growth, life satisfaction, and generativity.
  • Overall Score: When deriving an aggregate composite score of “Positive Attitude to Ageing”, items on the Psychosocial Loss dimension must be reverse-coded (e.g., $1 = 5, 2 = 4, 3 = 3, 4 = 2, 5 = 1$), producing a theoretical range from 24 to 120, where higher overall numbers denote more adaptive, resilient self-perceptions of ageing.
• Completion Time: Approximately 5 to 10 minutes.

Permissions & Fee and Test Year

The Attitudes to Ageing Questionnaire was published in 2007 by Ken Laidlaw, Michael Power, Silke Schmidt, Suzanne Skevington, and the WHOQOL-OLD Group. The instrument is considered an academic, non-commercial public instrument developed in conjunction with World Health Organization collaborative activities.

Licensing and Fee Structure: The AAQ is free of charge for academic, educational, and non-commercial clinical research. Researchers intending to use the scale in funded clinical trials, commercial environments, or cross-cultural adaptation studies are advised to contact the primary developer (Prof. Ken Laidlaw) or the WHO Centre for the Study of Quality of Life at the University of Bath/University of Edinburgh to register their project, ensure compliance with user agreements, and obtain validated translations.

References

• Laidlaw, K., Power, M. J., Schmidt, S., Skevington, S. M., & WHOQOL Group. (2007). The Attitudes to Ageing Questionnaire (AAQ): Development and psychometric properties. International Journal of Geriatric Psychiatry, 22(4), 367–379. https://doi.org/10.1002/gps.1683
• Shenkin, S. D., Watson, R., Laidlaw, K., Starr, J. M., & Deary, I. J. (2014). The Attitudes to Ageing Questionnaire: Mokken scaling analysis. PLOS ONE, 9(6), e99100. https://doi.org/10.1371/journal.pone.0099100
• Laidlaw, K., Kishita, N., Shenkin, S. D., & Power, M. J. (2018). Development of a short form of the Attitudes to Ageing Questionnaire (AAQ-12). International Journal of Geriatric Psychiatry, 33(1), 113–121. https://doi.org/10.1002/gps.4687
• Levy, B. (2009). Stereotype embodiment: A psychosocial approach to aging. Current Directions in Psychological Science, 18(6), 332–336. https://doi.org/10.1111/j.1467-8721.2009.01662.x
• Power, M., Quinn, K., Schmidt, S., & WHOQOL-OLD Group. (2005). Development of the WHOQOL-Old module. Quality of Life Research, 14(10), 2197–2214. https://doi.org/10.1007/s11136-005-7380-9

13. Items of the Scale (Questionnaire)