Successful Aging Opportunities for Clinicians Gail M Sullivan

Successful Aging: Opportunities for Clinicians Gail M. Sullivan, MD, MPH UConn Center of Aging

Successful Aging • Prolong health span, extend middle age • Many changes attributed to aging modifiable: diseases, environment, diet, habits, lifestyle • Successful aging: appear biologically “younger” than chronological age + Study to understand determinants & write “prescriptions” for successful aging + Increase ‘vitality span’ to catch up with 21 st century life span gains

Longitudinal study - Healthy Survival • ~6, 000 Japanese-American men, av. age 54, 40 -year follow-up • Mid-life factors assoc. w/ survival to 85 yrs+ with no morbidity or dysfunction – – – – High grip strength Avoid overweight Avoid hyperglycemia Avoid HTN Avoid smoking Avoid excessive alcohol High education Married JAMA 2006; 296: 2343 ( > 39 kg) (BMI > 25) (Glu > 200) (>140/90 or on treatment) ever ( > 3 drinks/d) ( > 12 yrs)

More Longitudinal Studies • Physician Health Study – men only – Modifiable RF assoc. w/ survival to age 90 w/ good function • Risk Factors – – – Smoking DM Obesity HTN Sedentary lifestyle • No RF – • All 5 RF – 60% survival w/ good function 4% survival • Longit. UK study, ♀ & ♂: smoking, poor diet, low exercise – all RF So what? Functional decline is partly avoidable Stop thinking about finding diseases; think about preserving health Arch Intern Med 2008; 168: 284 & J Am Geriatr Soc 2008; 56: 1098

Longevity Gap: USA Last Amongst Industrialized Nations Commonwealth Fund, 2008 • US av. life expectancy at birth: 78 yr – UK 80, Canada 81, Japan 83 – 101, 000 US lives/yr saved if US like France, Japan, Australia, etc. • US health care system blamed! • Dr. Preston et al, U Penn disagrees – Detailed analysis finds OBESITY & high rate of HEAVY SMOKING explains difference in life expectancy – US per capita smoking rate highest in world til 1980’s, (esp. ♀) • If you reach 80 in US, your av. life expectancy is longer than in most developed countries

Centenarians Age > 100 • • • About 40, 000 in USA; ~85% are women See delay in functional decline 90% independent to age 92; 75% to age 95 Less morbidity (MI, cancer, CVA) Most have 1 st degree relative living to old age • Survival based on genetics (est. 20 -30% from twin studies) • But environment & personal choices account for 70%+ • Potential definition of successful aging? – Compression of morbidity to very end of life

“Super” Centenarians Age > 110 yrs • Estimated to be 60 -70 in USA, 250 -300 worldwide • Oldest (proven) human was Mme Jeanne Calment, died age 122 • International Database on Longevity (www. supercentenarians. org) • • Case series: ages 110 -119 yrs, N=32, 84% female 41% independent or minimal assistance Little morbidity from usual diseases (ca, CVA, DM, MI) Osteoporosis (44%) & cataract (88%) still common

Health Promotion for Elders – Strong Evidence for Effectiveness Improved outcomes: mortality, hospitalization, accidents, heath care costs • • Blood pressure screening - systolic & diastolic Immunization - flu, pneumovax Exercise counseling Smoking cessation counseling Osteoporosis prevention & treatment Falls risk reduction: target risk factors Aspirin – only those w/ vascular disease risk Seatbelt use

Some Evidence Supporting Improved QOL or Morbidity = Quality of Life • • • Vision screening (prevent blindness, ↓ falls) Hearing screening Diet: Calcium, Vit. D, fiber, fluid, fruit Sun protection Driving safety, esp. testing vision, cognition Oral health Depression detection Home safety Medications – more appropriate use Alcohol screening

Screening for Selected Elders – Little evidence – mostly ‘consensus’ recommendations • • • Mammography for ≥ 70 yrs FOBT, flexible sigmoidoscopy, or colonoscopy for ≥ 70 PAPs – can stop at age 65 if 3 normal Lipids – yes, if have cardiac disease Mental status examination, start at age 75 Thyroid function tests, particularly women

No Evidence to Support (For prevention in elders) • • • Low fat diets Vitamin E, estrogen (for dementia prevention) Breast self-exams Continued PAP smears after 3 normal PSA screening in men CXR, CT, spiral CT (lung cancer)

Strong Evidence

Immunizations • Pneumococcal vaccine - once is enough • Influenza vaccine - annually • Tetanus - good idea, but <200 cases annually – most important: those never immunized Physician actions: Give pneumovax & tetanus at 65 Flu annually

Exercise for Elders • Physiologic aging & disuse syndromes are indistinguishable • Culture & lifestyle are principle determinates of late life fitness • Use it or lose it

Aging: Usual Changes Maximum heart rate Maximum O 2 consumption Chest wall & lung compliance Muscle mass, strength, reaction time Elasticity of joints & ligaments Cardiac output Fat free mass All but max HR reverse w/exercise

Exercise Myths • Decreased activity is inevitable with aging • Exercise is dangerous in the elderly • Frailty is never reversible • Exercise is of little benefit in the elderly because it is “too late”

Many Benefits of Exercise • Decreased incidence, mortality & hospitalization from cardiovascular disease • Amelioration of Diabetes mellitus, HTN • Improved profile of blood lipids (HDL) • Increased bone mineral density, decreased fractures • Decreased falls • Reduced incidence of depression • Improved physical functional status, & sleep • Decreased pain & disability due to osteoarthritis

OLD SURFERS! Surfing for Life

Exercise • • • Activity good but exercise better All functional groups benefit - even frail NH elders 30 min. /day, 5 x/week moderate OR 60 min. 3 x/wk vigorous Elders more compliant & have less complications Exercise = strength, aerobic (endurance), flexibility, balance MD actions: Prescribe exercise for ALL Elders need Hx/PE; other tests only if indicated by Hx/PE

Best Walking Partners: Man v. Dog NY Times 12/14/2009 • Research Center for Human-Animal interaction (Missouri) • 12 wk study of walking programs (5 d/week) • 54 older adults from assisted living • 2 groups – Paired with a partner (spouse or close friend) vs. – Dog from local shelter

Results • Dog-walking group twice as likely to complete the program • Walking speed increased among dog walkers by 28% compared to just 4%

Smoking Cessation Myths • It’s too late, after 50 years of damage • It’s her only pleasure • Elders can’t change a life-long habit • Treatments aren’t safe for elders All untrue!

Smoking • • Benefits accrue after quitting at any age Old have lowest relapse rate, most likely to succeed Meds & patches effective & safe for older smokers Quitting at even advanced ages lowers all risks MD actions: Debunk myths Give specific reasons to quit Assess readiness to quit Negotiate quit date Prescribe for withdrawal, etc.

Osteoporosis in Women - USA % pop. National Health & Nutrition Survey III. 1997

Osteoporosis 60%+ of current women ≥ 65 have osteoporosis or severe osteopenia Men get osteoporosis about 10 yrs after women • • 1500 mg calcium + 800 U vitamin D /day works even in nursing home elders Exercise for bone density & strength/ balance Life-long adequate Ca++ lowers risk of this condition Smoking, alcohol, corticosteroids add risk MD actions: Follow height Assess risk Consider BMD (bone mineral density) Treat

Falls About 25% of persons > 65 fall each year Risk of falling doubles for the next yr if: – Patient has fallen at least once in previous yr OR – Patient has poor mobility on office exam MD actions: Ask about falls in the past year Assess mobility in office, yearly

Mobility – Falls Prevention • Mobility assessments – Timed up and go (TUG), or Get up and go • > 15 seconds - ↑ falls, functional decline, deaths • < 10 seconds – best outcomes – 3 -chair rises (also can be timed) – Timed walking: normal ~ 1 meter per second or faster – Semi-tandem stance; one-leg balance + Exercise: Lower extremity strengthening & balance exercises work MD actions: Add mobility to physical exam EXERCISE prescription

Some Evidence to Support

Vision • Distance visual acuity needed for safe walking & driving • ↓ near vision starts 40 -50’s – affects reading • Diseases + Cataract is still #1 cause of blindness in elders • Not rare: vision improved w/ new glasses • At least ¼ elders have treatable visual loss MD actions: Take hx about vision or last optometry visit, annually

Hearing • Hearing loss very common, esp. men • Often mistaken for confusion • Aural rehabilitation not as effective as visual rehab, but can help communication MD actions: Ask about hearing Screen or refer for testing

Screening for Selected Elders For elders > 70 yrs with 10+ years life expectancy: • Mammography • CRC: FOBT yearly, flex. sigmoidoscopy q 3 -5, or colonoscopy q 10 yrs CDC recommends stop by age 85, consider stopping age 75 Others • PAPs • Lipids • Mental status examination • Thyroid • PSA stop at age 65 if normal x 3 check only if have cardiac disease or DM if ≥ 75 or ↑ vasc. risk periodically ( especially women) Evidence does not support screening unless >20 yrs life expectancy MD actions: Individualized approach Consider competing mortality risks Consider patient values

Why Not Screen Everyone? Guidelines originally based on research excluding – Elders – Persons with co-morbidity or poor function Tests lead to interventions & complications, can ↓ QOL & fn Takes time, $ away from treating current problems (e. g. , falls osteoporosis, decreased function) Examples – Elderly women w/ 100% 10 -yr mortality risk, screened with PAPs, even those with hysterectomies Annals 2004: 140: 681 – Men > 85 w/ 100% 10 -yr mortality risk, 40% screened w/PSA JAMA 2006; 2336 – Elders w/advanced ca: 10% got mammo’s & 15% PSA tests JAMA 2010; 1584

Which Is More Fatal in Elders? Longitudinal cohort study of 9, 704 women > 65 Invasive Breast Ca 457 incident cases – Total mortality: 25% Hip Fracture 803 incident cases – Total mortality: 48% Survival ↓↓ after hip fx, controlling for – Body mass index, age, educ. , mental status, weight change since youth, function, self-rated health, & time spent upright – LR+ 226 (p<0. 0001) Older women at much greater risk of death following hip fx vs. breast ca

Average Life Expectancy • 65 years woman? • 65 years man? • 75 years? • 80 years? • 90 years? • 100 years?

Average Life Expectancy • Age 65 female • Age 65 male 19 yr 16 • Age 75 • Age 80 11 8. 5 • Age 90 • Age 100 4 2. 5 • Recent MI – Male – Female • CHF – Male – Female 1 yr mortality 25% 38% Av. life exp. from onset 1. 7 yr 3. 2 yr

Preserving Health of Individuals – vs. Populations • Known good for you – – Social integration Positive efficacy, ‘can do, ’ optimism Exercise Education & cognitive stimulation • Solution: Experience Corps -19 cities; Baltimore RCT - 1, 000+ in study – Age 60+, large group/school, volunteer >15 hr/wk over full yr, grades K-3, monthly travel stipend – Work with kids (reading, math, computers) & open/maintain school libraries • RCT: impact on elders (physical activity, cognition, social activity, other RF) & on kids – – – Hope to affect downstream functional & cognitive decline Data so far: walking ↑ 31% vs. ↓ 9% controls (on wait list) Significantly increased phys. activity & kcal expended; e. g. , ↓TV watching ↑Strength, ↓falls Dramatic ↑cognitive tests The worse the elder at start, the more improvement seen

Conclusions • Improved medical care & life style changes may increase number of elders aging ‘successfully’ • Goal: compression of morbidity & dysfunction into last few months of life • Strong evidence showing improvement in key outcomes (BP screening, immunizations, smoking, exercise, osteoporosis, falls reduction, seat belts) • Some evidence showing improvement in QOL or morbidity (vision & hearing screening, diet, sun protection, driving safety, oral health, depression detection, home safety, better meds use, alcohol screening) • Other screening lacks data (mammo, FOBT & other CRC screening, cholesterol) – use individualized approach, consider competing mortality risks • FUNCTION is paramount: MEASURE!

“ As I like to point out, a dog is the only exercise machine you cannot decide to skip when you don’t feel like it. The houses of my friends are cluttered with exercise machines and often sit ignored…. but late every morning, however I am feeling, Bianca and I have our walk. ” Heilbrun, The Last Gift of Time; Life Beyond Sixty