SURGEON GENERAL'S WORKSHOP Health Promotion and Aging Proceedings Edited by: DEP SG Faye G. Abdelk& SR PHARM Steven R. M- Note: AU opinions contained in these contents represent the vkwpoint solely of tbe authors and participants and do not necessarily represent the viewpoint of tbe Office of the Surgeon General, tbe Public Health Service and its constituent Agencies, or the Editors. 7 for this Workshop are Administration on Aging. Health Resources and Services dmtnismw Food and Drq Admioistntion, National h~~timte on &iog. the Off3ce of Minority Health, Ollkx of Diseae Ptwentioo and Health Promotion, Cents for Di Control. National bt.stitutc of Mental Health, National Institute on Alcohol Abuse and Alcoholism, the Brookdale Foundation, and the Henty J. K&et Family Foundation. Support for the printing of this publication is provided by the Henry J. Kaisr Family Foundation of Menlo F'xk. California, PREFACE As with any effort that seeks to take a somewhat disparate body of knowledge and attempt to create uniformity and concensus, the final .product may not be exactly what was expected. In this instance of trying to assimilate all of the scientific knowledge and experience about health promotion activities in aging populations into a coherent body or recom- mendations and policy options, the product is more than expected! In addi- tion to the insight that the 180 invited guests for this Surgeon General's Workshop on Health Promotion and Aging were able to provide individu- ally, the cohesive and often synergistic results of their deliberations have given the Public Health Service and the much larger aging audience a view of what is possible. Instead of individual agendas, the larger picture has been shaped before us and the vision is clear. That vision is the ability to provide research, support and services that will allow the years in later life to remain as full and fruitful as those in the earlier years. Although the prospect of death is certainly inevitable to all of us, that period prior to death may well afford some of the truly golden years of life. In addition to these years being golden for the individuals, the ability to use their wealth of personal knowledge and experience to enrich society and the extented family units and communities is immense. The seed of ideas and potential areas of activity are presented in this final report with its recommendations. The participants at the Workshop present to the much larger audience of interested parties our blueprint for the nation in health promotion and aging. I join with you in seeking now to implement these ideas and options so that our aging society is provided with the maximum impact of our corporate knowledge for the benefit of the health of all senior members. C. Everett Koop, M.D., Sc.D. Surgeon General CONTENTS opting Plenary Session Keynote Address Surgeon General C. Everett Koop . . . . . . . . . . . . . . . . . . . . . . . . . . . United States Public Health Service 1 Address Carol Fraser Fisk, Commissioner . .`. . . . . . . . . . . . . . . . . . . . . . . . . . Administration on Aging 5 Address Assistant Surgeon General T. Franklin Williams . . . . . . . . . . . . . . Director, National Institute on Aging 9 Plenary Session "Health Promotion and Surgeon General's Workshop" . . . , . . . Assistant Surgeon General David Sundwall, Administrator Health Resources and Services Administration 14 "Year 2ooO Health Objectives for the Nation" . . . . . . . . . . . . . . , . 2o Assistant Surgeon General J. Michael McGinnis, Director Office of Disease Prevention and Health Promotion "Legislative and Administration Interests in Geriatric Health Promotion". . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Roger Herdman, M.D., Assistant Director for Health and Life sciences, Office of Technology Assessment U.S. Congress "Setting the Pace in Geriatric Health Promotion" . "Healthy Older People" . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Susan Maloney Office of Disease Prevention and Health Promotion "Project Age Well" . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anthony Vuturo, M.D. School of Medicine, University of Arizona . "International Geriatric Health Promotion Study/Activities" David Macfayden, M.D., former Manager WHO Global Progra.mme for Health for the Elderly . . . . 35 . . . . 41 . . . . 49 Charge to Participants Surgeon General C. Everett Koop , . . . . . . . . . . . . . . , . . . . . . . United States Public Health Service 54 Plenary Session Recommendations of Working Groups: Alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dental (Oral) Health ; . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Physical Fitness and Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Injury Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Medications .:......................................... Fi MentalHealth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 Preventive Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Smoking Cessation 88 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Response to Recommendations . . . . . . . . . . . . . . . . , . . . . . . . . . . . . Surgeon General C. Everett Koop United States Public Health Service 94 List of Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . * 103 OPENING PLENARY SESSION Keynote Address presented by C. Everett Koop, MD S-eon General, United States Public Health Service s,&ay evening, March 20, 1988 Thank you, Dr. Abdellah. I \,-mnt to personally welcome you and thank you all for coming to this SurgeIn General's Workshop on Health Promotion and Aging. We have three days of serious deliberation, illbating discussion, and-I sincerely hope-innovative thinking ahead of us. The outcome should help point us-and society-in worthwhile directions for the future. Many people have worked long and hard to make this workshop hap- pen. lf I had an extra hour or so, I would gladly name and thank each one oi them personally. That's not possl%le. However, with your understanding and permission, let me-at the very least-extend a word of special thanks to Dr. Faye Abdellah, Deputy Surgeon General of the U. S. Public Health Service, whose guiding hand hti been subtle but essential throughout the plan- ning FrOCeSS, and to Senior Pharmacist Steven Moore, lent to us from the Food and Drug Administration, who accomplished all the thousands of planning and administrative details that enabled us to get here today- &pipped and on time. To both of you . . . thank you very, very much. I do not want to monopolize the podium and steal time away from my good friends and colleagues, Commissioner on Aging Carol Fraser Fisk, and Dr. Frank Williams, Director of the National Institute on Aging. So I will limit my remarks to a brief review of how we got here . . . and why . . . and for what purpose. Early in 1984 the Department of Health and Human Services launched a major initiative to encourage the public and private sectors-at all levels, national, regional, state, and local-to work together on promoting the health of America's older citizens. The U.S. Public Health Service and the Administration on Aging shortly thereafter signed an agreement in which we pledged to do a number of things together in order to invest this health promotion initiative with increased momentum and importance. And there has been a great deal of momentum generated throughout the country on behalf of older Americans: o Every state now has a lead agency of its own to spearhead the health promotion effort.. . o There are some 35 state interagency coalitions at work to promote the health .of older Americans.. . o A National Public Education Program, called the "Healthy Older Per- sons Campaign," has raised the consciousness of tens of thousands of older men and women concerning the benefits of promoting their own health, instead of just passively waiting and hoping for the best... . At the Federal level, the agencies and offices of the U. S. Public Health Service itself have been actively engaged in this cooperative effort, but chief among them has been the work of the Office of Disease keven- tion and Health Promotion, directed by Dr. Michael McGinnis. You'll hear more about that tomorrow morning. A key element of this P.H.S.-A.O.A. cooperative venture is our mutual pledge to do what we can to help prepare all health professionals- physicians, nurses, dentists, nutritionists, social workers, pharmacists, and so on-for the eventual "graying of America." I don't have to repeat the demographic projections. I'm sure you're quite familiar with the numbers. Rut those projections are much more than mere numbers. Those are projections about the lives of real people-flesh-and-blood men and women who will be old and who will need a certain level and type of health care that, I'm afraid, is stiIl not very well understood, much less practiced, in our society today. And that's why seven components of the Public Health Service and the Administration on Aging agreed to jointly plan and conduct a "Surgeon General's Workshop on Health Promotion and Aging." I'm delighted to add that the Henry J. Kaiser Family Foundation and the Brookdale Foundation are supporting the workshop. Also, we have included six graduate and professional students who wiIl be pursuing careers in geriatrics and will serve as working group members. We wanted it to be a workshop in which the spectrum of health care disciplines would be well represented and all of them would be challenged to think creatively and pro-actively about ways to promote good physical and mental health among people age 65 and older. That's the kind of workshop we wanted-and, I'm pleased to say, that's the kind we got. The emphasis here is emphatically upon the promotion of good health. But let's be clear on at least one point. We don't believe health promotion needs to take place af the expense of good curative medical care. And it ought not to occur at the expense of good rehabilitative medicine. And certainly not at the expense of good research into the disease pmcesies and disabling conditions that often interfere with the normal and healthful processes of aging. Bather, we believe that health professionals can put much greater empha- sis on health promotion without compromising in any way the more tradi- tional and stiIl effective approaches to health care. 2 we b&eve that this must be done . . . we`re here to say that it am be done . . . and by noon on Wednesday, we will tell the health community jlm ib mig& `be done on behalf of the elderly and the very old. I don't expect us to be prescriptive in this workshop. But I do hope that the recommendations generated by the work sessions tomorrow and Tues- day are clear enough and direct enough that health professionals every- where can immediately see the relevance of the health promotion concept to their own particular disciplines or practice. What then should we'keep in. mind?. First, we ought to focus on ways to sensitize the health professions to the specific risk factors of older people-and then how to reduce or even eliminate those risk factors from the lives of one's patients. Second, we need to m-examine the' way we organize and deliver our medical, dental, nursing, and other health-related services to see if we can change-once and for all-their built-in pst facto bias. Health care ought to be just as effective-or even more effective--before illness strikes. And third, we need to do these things with some sense of what we hope to accomplish ovwall for our country's older citizens. Older people-like people of all ages-do not live in a vacuum: o They work in places that are pleasant-and in places that aren't so pleasant... o Their human relationships may be loving and caring, or difficult and stressful . . . o They may have financial independence, or they may be totally depen- dent on family or Government to provide a.lI their basic needs . . . o And finally, the phrase "the graying of American" can be misleading. More of us will have gray or white hair-(or no hair at all). But most Americans-about 80 percent of the population-will be young or middle-aged. Hence, older people will still be living in a society in which all age groups compete for attention . . . and for resources. I was reminded of this just the other day, when I read that the rock star Bruce Springsteen is going on a nationwide tour that will earn him millions and millions of dollars. And while he's singing to enthusiastic audiences of young people, anotheb group wiIl also be on a national concert tour of their own. In fact, I saw them on TV last night in New Orleans. They're the so-called "Rat Pack"-Frank Sinatra, Dean Martin, and Sammy Davis, Jr.. We are told that these gentlemen also expect to earn millions of dollars from the enthusiastic sextugenarians who will show up at their concerts. It was an interesting juxtaposition of news items. And whether or not you'll attend either or neither of those concerts, you still have to be impressed by the inter-generational vitality that is already emerging in our society . . . a vitality that is, in itself, a reflection of generally good physical and mental health among the American people, In other words, we have every reasons to be optimistic and adventurous in our thinking at this workshop, because we're not here to reverse the direction of America's health status, but rather to be built on-and 3 accelerate-the progress in health that Americans have achieved over the past decade or two. This is an exciting period in the history of health care in America: o The yield of the research community has been prodigious, with much more yet to come. o The nation is more health-conscious and more pro-health than at any time i&our history. * And it's a period in which all Americans are more sensitive and more responsive to the health needs of their fellow citizens . . . regardless of race, sex, ethnic origin, or age. We have, therefore, an extraordinary opportunity to help our citizens not only to live a few years longer, but also to make those extra years- and indeed all the years of their lives-good and healthful years. Now it's time to hear from my two distinguished colleagues, Commis- sioner Carol Fraser Fisk and Dr. Frank Williams. But rest assured, I'm not ducking out. In fact, I'lI be back at this podium tomorrow to present my "charge" to the working groups. Then, on Wednesday, Commissioner Carol Fraser Fisk, Dr. WiIliams, and I will return to hear your recommendations and speak to the next phase of this initiative. But we will not be inactive meanwhile. You will also note from your agenda that things don't end there either. Following the close of the workshop on Wednesday morning, there will be an afternoon public hearing, one of a series of such hearings that have been held throughout the country. At this Washington, DC hearing, our workshop recommendations will . become part of the development of our National Public Health "Objec- tives for the Nation for the Year 2000." Thus, we will make sure that aging concerns are given the prominence they deserve in the evolution of those national objectives. You're all invited to that open hearing and I hope many of you wilI attend. Between now and then, we've got a lot of work to do. So let's do it. Let's do it together. And let's start now. Dr. Abdellah, the microphone is yours. Thank you. Address presented by Carol Fraser Fisk Commissioner of Aging, Administration on Aging Sunday evening, March 20, 1988 Good afternoon. It's a pleasure to join in welcoming you to this impor- tant meeting. This conference is a very significant event, for through it I hope we will help more older Americans have a healthy old age. Over the past several years, we have made significant progress in mak- ing health and social service providers more aware of the concepts of health promotion. Through this joint AoAlPHS initiative, countless numbers of older persons have participated in health promotion activities. Now it is time for us to take a look at what we have learned from these and other activities and to chart a course for future action. It is a special pleasure to join Surgeon General Koop and Dr. Williams in this venture. The vision of the Surgeon General has helped mobilize the Public Health Service and all of us to undertake health promotion activi- ties, including those which led to our having this conference. The creativity of Dr. Frank Wii has helped us forge even stronger collaborative ven- tures. And, the vigilance of the Deputy Surgeon General, Dr. Faye Abdel- lab, has helped us produce practical results time and time again. It is indeed an honor for me to join these distinguished national leaders here today. As Dr. Koop has already said, we know a good deal about the older population. Let me highlight just a few statistics that may startle you. Today, one in nine Americans is over sixty years old. By the year 2030, one in four persons, or twenty-five percent of our population will be over sixty. In fact, in the next twenty-five years, the population over sixty will more than double. Among the elderly, the fastest growing segment will continue to be that over eighty-five years. Today, one in fifteen is over 85. By the year 2030, one in ten wilI be over 85 years old. The impact of those demographic changes in society today is significant, and that impact wi.lI continue to grow as the numbers of older Americans continues to increase. Ail segments and institutions of our society wiIl need to change as our population ages. As I look into my crystal ball, I see vari- ous areas of our lives which wilI need to change as more and more of us live longer lives. ' The lengthening of the lifespan will cause a continual increase in the size of the general population. The average age and the median age of the population will continue to move upward. Of necessity, there will be more focus on the needs and the talents of our mature citizens. Older 5 people, even a growing and a vocal force, will keep reminding us of the challenge and opportunities they offer. The increase in longevity already has and will continue to have an impact on American families. There wiIl be more generations, and new roles for them in the family. In some families, more grandparents will become caregivers for their grandchildren while the middle aged generation is work- ing. In many other families, adult children will continue to serve as caregivers for their parents and even their grandparents. The graying of America has many implications for the production and allocation of resources, too. Both the work force and the marketplace will be affected. People will have longer working lives, although they may have several different careers, different working hours, shared jobs and different work- ing places in their later years. Changes that allow elders to stay in the work force will be essential. With fewer well trained younger workers as well as with more older people who want or need to be employed in later life, the work environment will need to change. By the year 2000, we will have an equal number of persons entering and leaving the work force. We will not be able to waste the talents of our older citizens. Work force benefits will have to change accordingly. Employers will have to structure benefit packages differently because of different assumptions about retirement, health care, and caregiving responsibilities, to name just a few considerations. Corporations will have to expand their efforts to help keep current workers, young, middle aged, and old, productive and healthy. They will also increasingly look for ways to reduce health care expenses incurred by retirees. An aging society will also mean that different types of products will be demanded and consumed. For example, one change could be in the pack- aging of food products. Instead of microscopic labeling, manufacturers should soon realize that older persons will be more likely to buy their products if they could read the package contents. Large print will be more common, as will better lighting. Other changes might include affordable long-term care insurance, cars with mirrors to compensate for the loss of visual acuity, personal con- venience and comfort items, home shopping services, grocery delivery serv- ices, and better timed street crossing lights. Health care and social service delivery systems must change too. Cur- rent institutions and organizations may not be appropriate or adequate for the needs of an aging society. We are already seeing changes in the use of acute hospital beds and increasing needs for long-term care services and facilities. Community caregiving organizations will be severly strained by the increasing patient load, especially if they must care for AIDS victims simultaneously. To com- bat this pressure, we must find ways to reach people more effectively in their homes. Such progress would be particuIarly important in isolated rural areas. Our manpower needs wilI certainly change as we will need more per- sons in new types of careers. Technology will cause changes in the way 6 ,,.e deliver care and our needs for V~OUS types of care changes with age. Put that new technology won't address all the issues of an aging America. Fades and friends will continue to serve as caregivers, and they will nrrd haining as well as respite services. They may also need innovative ,,.avs to cover the costs of health care `expenses. Individuals wilI need to ty& planning earlier and personally take more steps to assure a finan- cidv secure old age. Perhaps we will even see more incentives for those ,,& pursue healthy lifeStYleS. \Vith an increased older population, society's attitude toward longevity and the quality of life in later years will continue changing. The assump- tion that being old means being sick and frail is disappearing. It is being *placed by the notion that most older persons are healthy, vital, and want to stay well and functioning as long as possible. More and more of us will realize that we have the ability to chose how kve live. The relationships between such factors as nutrition, exercise, preventive health and disease mean that we can take a more active part h our own health CUR Each of us wilI need to be more pro-active in work- ing with health professionals, staying well, and when ill, taking part in OUT recovery and rehabilitation. This brief glimpse into the future reinforces my strong conviction that it is our job to take the message of the value of health promotion and we& ness for older persons to the leaders and citizens of our communities. Our society must stay healthy. Our elders must stay healthy. Dr. Koop has challenged us in three areas: First, we need to assist doctors, nurses, and other health profes- sionals to incorporate health promotion into their regular plans of patient care. Older persons are particularly sensitive to messages from their doctors. Why not begin here? What recommendations can we develop that makes that a reality? Second, we need to educate older persons to the value of health promotion and wellness at any age. We must get the message out that changing habits, even in later life, wilI produce significant and tangible benefits. I ask you, how can we reach more mature c&ens with this important message? Third, we need to build partnerships to help educate people of alI ages to get ready for later life. Public, private, and voluntary groups must combine their strenghts in each community across the nation. What better place is there to start than taking care of one's health. The legacy of this conference must be manifested in several areas: new directions in program areas; sharing of information about methods of prevention and treatment; the development of a health promotion and well- ness agenda for older persons for the coming decade; and a commitment to implement these recommendations. We have a lot of work to do over the next three days. You have a unique opportunity to bring your knowledge and expertise to the forefront of this effort. Over the next few days, I ask you to develop 7 recommendations which you will take back of your communities, your organizations and your colleagues. I urge you to develop ways to assist your designed State coalitions on health in achieving their agendas. I encourage you to organize local coalitions which sponsor health promo- tion and wellness activities for older persons. Finally, I challenge each of you tp personally set a good example of health promotion practices. You are here because you are leaders in your field and I congratulate you on all that you have done thus far. But I urge you to do more. The needs of our older population today are significant. The talents of older people today are exciting. In the future, both those needs and that talent pool will grow. What makes a difference to each of us as we age is what happens in the community and neighborhood where we live and work. I urge you to seize the opportunities that are before you to help make those communities better places for all of us to live and to mature today and in the future. Working together-we can do it! Thank you. 8 Address Resented by Assistant Surgeon General T. Franklii Williams Director, National Institute on Aging Sunday evening, March 20, 1988 Dr. Abdellah, Dr. Koop, Commissioner Fisk, and colleagues: It is indeed an honor to be part of this important Surgeon General's Workshop in Health Promotion and Aging. I am particularly glad that Dr. Koop has focused attention on these very significant public health issues. In the 197Os, the orientation toward age and aging of many persons in fields of medical research and health policy began to assume new direc- tions. This change in focus was primarily due to three growing realiza- tions. The first, and perhaps most apparent, was the tremendous growth in the number of people who were living-and living well-past their 65th birthdays. As a result of this phenomenon new questions arose. Would this trend continue? What would be the far-reaching implications of such a demographic change in the United States, and perhaps around the world? The second realization was that, regardless of how many people were achieving healthy old age, aging was still looked upon with dread. If you were turning 50 or 60 you expected physical and mental declines. Just as unfortunate, so did your physician. Myths about aging prevailed. Many in our youth-oriented society even viewed 30 as being past prime. The question: What could reasonably be expected from people as they age? The third realization was that many older people did, in fact, suffer phys- ical and mental `declines. But, considering the large number of healthy older people, it became apparent that some iIlnesses might be avoided. Theie were many gaps in our scientific knowledge of the aging process. On May 31, 1974, to respond to growing concerns in this area, Congress enacted the Research on Aging Act creating the National Institute on Aging (NIA) with a mandate "to conduct and support biomedical, social, and behavioral research and training related to the aging process and diseases and other special problems and needs" of older persons. In July 1975, the Adult Development and Aging Branch and the Gerontology Research Center were separated from the National Institute of Child Health and Human Development and were made the core components of the new NM. Investigators now had the direction from Congress to discover which aspects of aging processes might benefit from medical intervention. The goal was, and stiIl is, to be able to understand normal aging processes and develop ways to improve the quality of life for all people as they grow 9 old. Irrational myths and fears needed to be replaced by reliable data on physiological, psychological, and social changes which often take place dur- ing one's lifetime. NIA research is conducted by scientists at the Gerontology Research Center in Baltimore and in the National Institutes of Health (NIH) Clinical Center in Bethesda, and through multidisciplinary grant programs which give support to research institutions throughout the United States and, to a limited degree, in other countries. Additionally, several interagency agreements, for example with National Center for Health Statistics and the Bureau of the Census, have expanded our ability to develop more pre- cise information about the older population. Since. its inception, NIA has developed priorities based upon the con- cerns which led to the Institute's formation. Research on aging is poten- tially unlimited in scope, so judgments must favor areas which show scien- tific promise or which society deems to be important public issues. Priorities, of course, evolve over time but a continuing major emphasis at NIA is to understand aging processes and how ,aging is distinct from disease. The passage of time imposes change on everyone but it is vital to understand which changes are inevitable and which are open to modifi- cation. The Baltimore Longitudinal Study of Aging, conducted at the NIA Gerontology Research Center, was initiated in 1958 to permit repeated observations of the same subjects over time. Results of numerous studies there have shown that if one can identify and separate out people with disease conditions and focus study on healthy aging, changes with age are far fewer than previously thought. Increasingly, studies demonstrate _ that older people do not necessarily suffer heart and kidney problems, nor do their personalities change with the passing of time [Rodeheffer, Linde- man, Costa]. In fact, these studies show that very few, if any, changes occur uniformly to all people as they age. Aging is highly individual. It is for this reason that I object to and do not use the term "the elderly" as it implies, erroneously, that older people are all alike-a stereotyping term. Other research results from around the country support this perspec- tive. For example, Dr. K. Warner Schaie at Pennsylvania State University and others, in evaluating intellectual and cognitive changes over time, have found that many people do not suffer loss of intellectual function, and those who do can often benefit from cognitive training programs that reverse or decrease their intellectual decline [Schaie, Bakes, Rodin]. Epidemiologic studies have contributed greatly to our understanding of the aging population. Data from the Established Populations for Epidemi- ological Studies of the Elderly (EPESE), supported by NIA, includes infor- mation on over 13,OCHl participants in four communities: New Haven, Con- necticut; East Boston; Massachusetts; two rural counties (Iowa and Washington) in Iowa; and an enrolled predominantly black population in the vicinity of Durham, North Carolina [Comoni Huntley]. These studies are presenting detailed, longitudinal information on healthy older people living in the community. 10 once we accept the notion that people do not inevitably become frail c,r demented as they grow old, we can examine ways to maintain a per- zc,n's health, independence, and function into later years. This, then, is ,nother priority at NIA. Can positive changes in a person's attitude and lifest)lle affect health and vitality later in life? In many areas we are just now' beginning to collect data. In the area of nutrition, for example, we Generally support the Dietary Guidelines of the National Research Coun- t., hut these guidelines are based on studies of persons under the age <,t 51, and we simply do not know whether or how nutrient requirements differ for older people. NIA is participating in a seven-institute collabora- ti\re follow-up of the National Health and Nutrition Examination Survey (NHANES). This survey should provide key information-and the largest archive of data to date-on patterns of health and disease related to nutri- tional habits. Careful research studies have given us some answers to questions about health promotion and disease prevention. John Holloszy of Washington University in St. Louis and his colleagues have shown that when previ- ously sedentary older people enter a fitness program, approved by their physicians, their aerobic capacity improves as much as that for younger people. There also are accompanying improvements in blood lipids and glucose tolerance. Studies by Gail Dalsky, also at Washington University, show that in women between the ages of 55 and 70, the typical decline in bone mineral content of the spine can be minimized or eliminated by following a sensible exercise regimen [Holloszy, Seals, Dalsky]. This find- ing has important implications for prevention of fractures in older people. We also know that smoking cessation, good medical and dental care, moderate, if any, alcohol use, a good mental outlook, and a knowledge of drugs and their possible adverse effects can benefit a person's health. At the same time, much further research and program development at NIA and other agencies, such as the Office of Disease Prevention and Health Promotion, Office of Technology Assessment, the Food and Drug Administration, the National Institute of Mental Health, and other Insti- tutes of NIH, are critical to our full understanding of what is possible in health promotion for older people. The NIA also focuses its research, training, and information dissemina- tion efforts on the common disabling conditions of older people-those which threaten loss of function and loss of independence. Rehabilitative efforts, i.e. restoration or improvement in function in these situations to the maximum extent possible, are also a part of health promotion. Probably the greatest threat to personal independence in older people is dementia. Between 5 and 10 percent of alI people over 65 suffer from Alzheimer's disease, with the numbers increasing substantially among the oldest age groups. Research on the etiology and pathogenesis of demen- tia is crucial to eliminating this terrible affliction. Through sophisticated techniques researchers are beginning to gain a better understanding of the changes that take place in Alzheimer's disease. Diagnostic capabilities have been increased. In response to Congressional legisiation, the NIA now 11 supports ten AIzheimer's Disease Research Centers which bring together some of the best basic and clinical research in the field. Congress also has directed NIA to establish an Alzheimer's Disease Education Center and Clearinghouse to assist families, health care professionals and the general public in obtaining the most up-to-date research results. We also are work- ing with the World Health Organization (WHO) which has made this area a top priority. Other problems which often threaten loss of function as people age include incontinence, falls and hip fractures, osteoarthritis and osteoporo- sis, and losses of hearing and vision. We have made some progress. For example, studies by Drs. Bernard Engel, Kathleen McCormick and their colleagues in the Gerontology Research Center have shown that urinary incontinence can be controlled through pelvic floor exercises and related strategies in about 80 percent of affected women living within the com- munity [Burgio]. In the area of falls and fractures, we now have better understanding of the multiple risk factors that can lead to repeated falls in older people [Radebaugh, Tinetti]. More attention is being given to research on deafness, blindness, osteoarthritis and osteoporosis in older people. In relation to all these efforts we need to expand the training of person- nel in geriatrics and gerontology. The recently completed study on per- sonnel for health needs of older people through the year 2020, conducted at the request of Congress by NIA, the Bureau of Health Professions, and other federal agencies, documents these needs and in particular the urgent need for more academic leaders and teachers in these fields [Personnel]. The Institute of Medicine of the National Academy of Sciences has recom- mended that NIA support development of "Centers of Excellence" for research and training in geriatrics, to help meet this need. The Institute on Medicine has also recently proposed a study of "Health Promotion and Disability Prevention for the Second Fifty" [Report]. The purpose of the study would be to establish a solid body of knowledge on selected health risk factors for older people and measure the efficacy of health promotion and disease/disability prevention interventions begin- ning in the middle years and extending on through the last half of life-a purpose quite congruent with that of this workshop. These workshop ses- sions should provide current information on health promotion in older pea ple in relation to medications, alcohol, dental health, preventive health serv- ices, mental health, nutrition, physical fitness and exercise, smoking cessation, and injury prevention. Further research on these topics is of immense importance if we are to gain a full understanding of what it means to grow old healthfully and vigorously. Old myths about aging are being replaced by fact. Sessions such as this should help us all to develop a realis- tic picture of what growing old is all about. References Baltes PB, Kliegl, R: Neurology: On the dynamics between growth and decline in the aging of intelligence and memory. Springer Press, Ber- lin: p l-17, 1986. 12 Bu@o, KL, Engel BT, etc. al: Urinary incontinence in the elderly: bladder- sphincterbiofeedback and toileting skills training. Annals Int. Med 103: 507-15, 1985: Cornoni-Huntley J, Brock DB, etc. al (Ed): Established Populations for Epidemiologic Studies of the Elderly. National Institute on Aging, U.S. Department of Health and Human Services, 1986. Dalsky, GP, article in press, AM& Int. Med, June, 1988. Holloszy JO, Seals DR, Dalsky GP, etc. al: Glucose tolerance in young and older athletes and sedentary men.. J Appl Physio 56: 1521-1525, 1984. fIolloszy JO, Seals R, etc. al: Effects of endurance training on glucose toler- ance and plasma lipid levels in older men and women. JAMA 252: 645649, Aug. 3, 1984. Lindeman RD, Tobin J, Shock N: Longitudinal studies on rate of decline in renal function with. age. J Am Geriatric Sot 33278-285, 1985. McCrae RR, Costa PT: Emerging Lives, Enduring Dispositions. Boston, Little, Brown, 1984. Personnel for Health Needs of the Elderly Through the Year 2020, Na- tional Institute on Aging, National Institutes of Health, 1987. Radebaugh, TS,.Hadley E, Suzman, R (Ed): Falls in the elderly: biologic and behavioral aspects. Clinic in Ger Med 1: 497-697, 1085. Report of the Institute of Medicine: Academic Geriatrics for the year 2000, J Am Geriatric Sot 35: 773-791, 1987. Rodeheffer RJ, Gerstenblith G, etc. al: Exercise cardiac output is maintained with advancing age in healthy human subjects: Cardiac dilatation and increased stroke volume compensate for a diminished heart rate. Cir- culation 69:203-213, 1984. Rodin, J: Aging and health effects of the sense of control. Sci Mag 233: X271-1276, Sept. 19, 1986. Schaie KW (Ed): Seattle Longitudinal Study: A 21-year exploration of psychometric intelligence in adulthood. Longitudinal Studies of Adult Psychological Development, pp 64-135, 1983. Seals DR, Hagberg JM, etc. al: Endurance training in older men and women. J Appl Physio 57: 10241029, 1984. Tinetti M, Williams TF, etc. al: Fall risk index for elderly patients based on the number of chronic disabilities. Am J of Med 80: 429-434, 1986. 13 PLENARY SESSION "Health F'romoti& and Surgeon General's Workshop" Presented by Assistant Surgeon General David Sundwall Administrator, Health Resources and Services Administration Monday morning, March 21, .1988 Thank you, Dr. Abdellah. And thank you, Dr. Koop, for calling together this group of distinguished professionals. It's a pleasure, as well as an honor, to be a participant in these work- shops on health promotion and aging. I want you to know I respect the work you're doing here and elsewhere around the country. And I admire your concern for older Americans and your dedication to their welfare and health. This forum provides a unique opportunity to focus on health promo- tion and disease prevention in aging individuals. You've heard Carol Fraser Fisk describe what the Administration on Aging is doing in this area and Dr. Frank WilIiams describe the activities of the National Institute on Aging. I've been asked to review some of what we're doing for older Ameri- cans in the Health Resources and Services Administration, particularly as it relates to health promotion and disease prevention. That I-IRSA should be involved in health promotion activities is appropn- ate in light of our designated mission. So that you'll better understand how we fit into the public Health Service and, particularly, into health pro- motion activities, let me briefly outline what that mission is. It comes in two parts. Simply put, the first half has to do with resource building and the second with service delivery. We're charged with helping to assure that this nation has the necessary resources, both facilities and health professionals, to meet the nation's cur- rent. and future needs. In this capacity, we support the education of health professionals through guaranteed student loans, scholarships for minorities and the disadvan- taged, and a variety of grants to institutions for developing and support- ing health education and training programs. We also administer the Hill/Burton indigent care program. Much of the hospital construction that took place between the end of the Second World War and 1973 was financed with Hill/Burton funds. Even though Con- gress~discontinued funding for the construction portion of the program, many HiIllBurton facilities retain their obligation to provide free care to qualifying low income individuals. Our new Office of Rural Health Policy is another good example of what we're doing to help build the nation's health care resources. Congress 14 ,ppropriated $1.2 milEon for M'88 for grants to develop Rural Health policy/Research Centers. These Centers will collect, develop and dis- ,-eminate current information on rural health and conduct policy research and analysis of rural health issues of national significance. We also support organ transplantation activities and 7 regional educa- tional centers for training health professionals in the prevention and care and treatment of patients with AIDS. Taken together, these programs are instrumental in developing essential health resources across the nation. NOW, the second half of HRSA's mission is to support the delivery of health services to special populations and those who, because of lack of resources or geographic location, are unable to obtain appropriate serv- ices for themselves. America's homeless population is a prime example. HRSA recently awarded $46 million to 109 communities that demonstrated the ability to provide comprehensive .health services to homeless individuals. Another population of Americans having diificulty obtaining appropri- ate services is that infected with the AIDS virus., HRSA's AIDS related activities bridge the two segments of our mission. Whereas, our 4, soon to be 7, area education centers fall under the resource building portion, the 11 AIDS Services Demonstration Projects that are designed to build on existing resources to provide comprehensive services for AIDS patients fall under the health services portion. The homeless initiative and the AIDS Service Demonstration Projects are relatively new compared to our participation in maternal and child health programs. We've had a long history of involvement in this area. I-IRSA administers the MCI-I Block Grant as well as numerous other initia- tives, some of them designed to reduce the incidence of infant mortality. Many of the services provided by HRSA's nearly 600 Community and Migrant Health Centers are for mothers and their children. And although they provide traditional curative medical care, increasing emphasis is being placed on preventive health services as a means of improving the health status of their clientele. There's a lot of truth in the old saying-an ounce of prevention is worth a pound of cure. Frankly, I believe it's worth more than a pound, both from the standpoint of cost as well as from pain and suffering. Now, if preventive medicine is important to the general population, it's of even greater significance to senior citizens because of its potential for improving the quality of life during the senior years while conserving scarce health resources. Right now those 65 or older are `I.2 percent of the population but account for more than 30 percent of the total cost of health care. This percentage is projected to increase as the number of older Americans, and particu- larly those 85 years of age and older, increases through the end of this century. Therefore, the topic of these workshops is of utmost importance, not just for senior citizens, but for the health and well-being of the U.S. treasury that will spend about $145 billion on health care this year. About $1.5 billion of that will go for HRSA programs-many of them having geriatric components. 15 At HRSA, we recently established a Committee on Aging-Related Issues. Because many of the bureaus and divisions administer programs with geri- atric components, the Committee's goal is to coordinate these internal initia- tives in addition to coordinating with other governmental agencies that administer ,programs for senior citizens. It will also develop a plan to increase relevance and accessibility of HRSA programs to the aging popu- lation. It will keep abreast of aging-related activities within the private sec- tor. And it will develop and maintain an inventory of HRSA aging-related activities. Many of these aging activities are found in Community and Migrant Health Centers. Nearly ten percent of their clientele is over 65. And, `although the percentage is remainin g relatively constant, there is an increase in the number of elderly obtaining services at CHC's that parallels the expansion of the older population. Traditionally, Community Health Centers have emphasized primary and preventive care, but recently they've been more aggressive in efforts to actively incorporate prevention activities into their service regimes for senior citizens. In 1984, we awarded $1.7 million in supplemental funds to 57 Commu- nity Health Centers to assist these Centers in developing and implement- ing preventive health programs to serve as models for other Centers. To build on this, I-IRSA and the Administration on Aging are jointly sponsoring a networking initiative between State Primary Care Associa- tions and State Agencies on Aging. For those who are unfamiliar with State Primary Care Associations, they're made up of Community Health Centers _ and other nonprofit organizations, including some state health depart- ments, that provide primary care services. State Units on Aging working with State Primary Care Associations will develop an action plan that correlates with local circumstances and health care needs. To help participants formulate these plans, we sponsored a series of 10 planning seminars that were completed in December of last year. Now that the first stage of the program is completed with the working plans-hopefully-"signed, sealed and delivered" we're in the process of contracting for a study to evaluate their implementation and effectiveness. We hope to improve collaboration and cooperation among the various administrative and management levels of the aging and primary care net- work, whether they're local, state or federal, so that we'll be better pre- pared to meet the health care needs of the expanding older population. By linking Community Health Centers to the aging network and mak- ing the Centers more sensitive to the unique health care needs of older individuals, we'll enhance our ability to provide appropriate, comprehen- sive Geriatric care. We're so confident that this networking relationship between HRSA and the Administration on Aging wiIl prove to be effective-that it will improve accessibility and quality of care for aging citizens-that we're in the process 16 of drafting a Memorandum of Understanding that will cement our official ties and build and expand upon our earlier collaborative efforts. The Memorandum has 5 stated objectives. They are: o To support states and communities in the development of improved health care systems serving older persons; o To promote expanded education and training opportunities for health personnel serving the elderly; o To collaborate with the private sector to improve health care for the elderly; and o To promote the maintenance and expansion of health services for older persons living in rural areas. o To support model programs for older I-RSA and AoA employees and employees providing care to older family members. Although it's still in the negotiation stages, we hope to soon finalize the formal agreement even as we continue our joint objective to improve quality and accessibility of health care services for older Americans. One of the real stumbling blocks to doing this is the documented short- age of health professionals with geriatric training. At the request of Con- gress, we recently conducted a study entitled "Personnel for Health Needs of the Elderly Through Year 2020." The study was jointly sponsored by the Bureau of Health Professions and the National Institute on Aging. Congress specificalIy requested that the report contain recommendations on-first, the number and training needs of primary care physicians and other health and human services personnel required to provide adequate care-and second, the necessary changes in Medicare and other third-party reimbursement programs to support such training. The published report to Congress contains 16 findings and 5 compre- hensive recommendations. Even though they're vitally important to the aged and their health care, I don't intend to review them individually because they alI don't relate directly to health promotion. However, one of the more sobering is that the demand for services for older Americans will double by the year 2020 if current utilization rates are maintained. Approximately 2 out of every 3 patients will be over 65. Geriatric person- nel requirements will greatly exceed the current supply. That's the bad news, ladies and gentlemen. The good news is that the increasing demand for geriatric services will coincide with an anticipated growth in the supply of health care practitioners. Our challenge is to make sure that they tiill he prepared and well-trained in geriatric medicine. That's not going to be easy because one of the reasons we don't have a cadre of health professionals trained in geriatrics is that we don't have the faculty to train them. In fact, the report estimates that we only have from 5 to 10 percent of the faculty we'll need to train the number of health professionals that our projections estimate wiII be needed to meet the health care needs of the expanding aging population. At HRSA, we have several initiatives specifically designed to address both shortages. 17 Over the years, our Bureau of Health Professions has supported the edu- cation of health professionals in a variety of ways, including scholar~~p~, student loans and grants to educational institutions. Now that we have a surplus of physicians in most medical specialties, we no longer indiscrimin ately supljort medical education. We now target our limited resources toward shortage areas-those where the greatest needs occur. Our sole remaining scholarship program is for minorities and `the disadvantaged. And most of our grants support programs in family medicine, primary care and geriatrics with requirements that recipients implement aspects of disease prevention and health promotion into their curricula. We fund grants to schools of medicine and osteopathy; teaching hospi- tals; and graduate medical education programs to train physicians and den- tists who plan to teach geriatric medicine or geriatric dentistry. The insti- tutions themselves then award fellowships in geriatric retraining programs for physicians who are faculty members in departments of internal medi- cine and family medicine. In addition, we're funding several programs to develop curriculum models in geriatrics, all of which contain elements of health promotion. One of our grants funded a program where over a six-month period, 22 family medicine physicians participated in a 4 week mini-fellowship pro- gram in geriatric medicine. The participants were then required to evalu- ate the program. Using the feedback from the mini-fellowships, a curricu- lum resource package is being prepared and will be made available nationally to assist family medicine faculty or faculty in other specialties involved in teaching residents. We also support geriatric training in dentistry, family medicine, general internal medicine and preventive medicine. A number of programs sup- port the development of geriatric nurse practitioners and physician assis- tants. In addition to these grants, HRSA funds 31 Geriatric Education Centers that are strategically located around the country. The Centers are gener- ally a consortia of several academic institutions, a broad range of health professions schools and a variety of clinical facilities. They will be funded at about $9 million for FYTB. The Centers stress the muhidisciplinary approach with an emphasis on health promotion. Their main objective is to train and prepare faculty to teach geriatrics to various health care providers. However, they do partic- ipate in continuing education for practicing health professionals. Now that I've given you a sketch of what HRSA's doing in geriatrics and health promotion, I want to assure you we are practicing what we preach. HRSA's Division of Federal Occupational and Beneficiary Health Services is the federal focus for health promotion programs for federal employees right through the time of retirement. The Division functions primarily as a consultant for the various federal agencies. It conducts studies, advises management on health promotion activities, and sets up programs for employees. 18 For example, right in HRSA we sponsor a annual health fair for all employees. Among other things, we have nutrition analysis and counsel- ing, weight reduction counseling, and high blood pressure, cardiovascu- lar and cholesterol screening. We also operate health units and employee counseling units in many federal agencies. These units offer a wide range of counseling services and routine physicals and health screening programs for federal employees so that we can incorporate the principles of health promotion into the lives of federal employees. I want to reemphasize that health promotion is a vital element in each of HRSA's geriatric programs. With increasing longevity and rising health care costs, welIness is becoming more and more important to our finan- cial as well as our physical health. We believe that by combining health promotion activities with miraculous new technology and curative powers, we can help assure that the last years of life are spent in better health than ever before. We have the tools to help change what once were "the declining years" into "the golden years." HRSA is dedicated to this objective. And our geriatric programs are tar- geted toward this end. We want to work with related government agen- cies and those of you in the private sector to promote the health and well- being of America's senior citizens. I look forward to this joint endeavor and to reviewing the conclusions of this workshop. Thank you again for inviting me to participate. 19 "Year 2000 Health Objectives for the Nation" Presented by Assistant Surgeon General J. Michael McGinnis Director, Office of Disease Prevention and Health Promotion Monday morning, March 21, 1988 I would like at the outset to pay special tribute to the Surgeon General for his insight and timing in convening this workshop. As you-the experts in health promotion and aging-know, one of the gravest challenges this Nation faces is how to ensure the vigor of its expanding aging popula- tion. I am here today to tell you that much of our success. in meeting that challenge will depend on what we do now-and in the intervening years before the baby boom retires-to prevent disease and promote health. My job this morning is to discuss with you a framework within which we can collectively channel our thoughts on how we would take on those challenges-within the context of the Year 2000 Health for the Nation objec- tives setting initiative. The application of the tenets of health promotion/disease prevention to older adults is a relatively new notion. This workshop, however, is one - of the signals of the growing recognition that there are benefits to be gained through the adoption of healthy practices and behaviors at most any age. Part of this recognition comes from learning how to see aging for what it is-and isn't. Many of the so-called signs of old age are actually the se- quelae of disease. And the most prevalent diseases, furthermore, are those which derive from lifestyle and environmental factors, factors within our control. The interplay of these factors as we age accounts in large part for the wide variation between chronological and physiological age we see in the older. population. In addition to separating aging from disease, the scientific evidence is building a strong case that preventive practices and healthy behaviors can have a substantial impact on the quality of later life, through less prema- ture disability, shortened periods of acute illness, and less need for long term care. While research in prevention is just starting to address older people, a substantial body of knowledge has been developed over the past 20 years linking personal behavior to health status. I would like to review briefly, if I may, some of the milestones bringing us to this point today-with the humble acknowledgment that some of the foremost experts and scientists who have contributed to these efforts are amongst us. A pioneering study to demonstrate the correlation between cardiovas- cular disease and the risk factors of smoking, obesity, and hypertension was the Framingham study, begun back in 1948. This study continues to provide valuable scientific support for health promotion and disease prevention programs. For example, researchers found that the rate of coro- nary disease for men with sedentary lifestyles is about three times higher than that for active men. In the mid-1960s Lester Brewlow and his colleagues looked into the per- sonal habits of 7,000 people living in Alameda County, California, and found seven health habits to be related to physical health status and mor- tality. The longest living turned out to.be those who followed most or all of seven common sense practices: they did not smoke; maintained a reasonable.weight; ate breakfast; rarely snacked between meals; drank alco- hol in moderation, if at all; slept seven to eight hours a night; and took part in some sort of regular physical activity. Between 196!5 and 1974, the death rate for men observing ail seven good health practices was only 28 percent that of men who followed three or fewer. For women, the com- parable statistic was 43 percent. What's more, the survival rates were sub stantially the same for those age 65 and above, as well as for those in youn- ger age groups. In the 7Os, new ground was broken by the Stanford Three Community Study-setting thebenchmark for the public education campaigns we see today. They took on a problem which has often confounded the public health community-that of how to bridge the gap between getting people to know what is a health risk and getting them to actually reduce their risk through behavior change. The Stanford field study in three California towns found that cardiovascular risk scores were reduced through a com- bination of mass media appeals and were further reduced in those people who received both mass media and personal communications. Prompted by the new insights into the links between risk factors and disease, Federal policy-makers both here and in Canada began paying parallel attention to the relative importance of lifestyle factors to health sta- tus. The Canadians came first, issuing a report in 1974 which held up the modest gains in health status attributable to medical care against the poten- tial gains from changes in environmental or lifestyle factors. The next year, the Fogarty International Center of the National Insti- tutes of Health and the American College of Preventive Medicine co- sponsored a National Conference on Prevention here in the U.S. A grow- ing consensus was developing around the need for a national focus on disease prevention and health promotion. The next year, the Office of Dis- ease Prevention and Health Promotion was created to coordinate Federal health promotion programs. As other research initiatives were launched, including the Hypertension Detection and Follow-up Program, the Multiple Risk Factor Intervention Trial (MRFIT), the Lipid Research Clinics Coronary Primary Prevention Trial and many others, prevention climbed up the national agenda. The evidence linking lifestyle factors and health led to the conclusion prominently emphasized in the 1979 Surgeon General's report Healthy Peo- ple that further improvements in the health of the American people 21 would not be achieved from increased medical care and greater health expenditures alone-but through a renewed national commitment to efforts designed to prevent disease and promote health. Broad goals were set to reduce death and disability rates by 1990 in the different age groupings. For older people, however, the explicit goal was to improve the health and quality of life and reduce the average annual number of days of re- stricted activity by 20 percent, to fewer than 30 days per year. Implicit was the goal of allowing each individual to seek an independent and reward- ing life in old age, unlimited by many health problems within his or her capacity to control. The approach chosen to achieve these national goals outlined in the Sur- geon General's report was to draft a comprehensive national prevention strategy based on 226 measurable objectives in 15 separate priority areas. Specific targets were set to be achieved by 1990 for improving health sta- tus and reducing risk for disease, disability, or death in areas encompass- ing preventive interventions, health-related behaviors, and changes in the physical environment. Over the past eight years, the so-called 1990 health objectives have been used to spotlight problems, set priorities, and allocate resources at the local, State, and national levels. And we have shown some progress. Midway, in 1985, we were pleased to report that despite problems in pregnancy and infant health, family planning, and violent behavior, about half of the objectives had either been achieved or were on the path to suc- cess. The greatest progress was made in areas such as high blood pres- sure control, prevention of injuries, smoking reduction, immunization, and control of infectious diseases. In the past 15 years, we've seen a 25 per- cent reduction in tobacco use, a 15-2~ percent decline in the consumption .of saturated fat and cholesterol, a 40 percent drop in salt consumption, and a two- to three-fold improvement in blood pressure control. But, perhaps the more dramatic conclusion which can be drawn from the mid-course review is that people are not dying as they did before. There has been a 55 percent decline in stroke deaths and a 40 percent drop in heart attack deaths. With five years left to 1990 at midway, we were already 70 percent on the way to our goal of reducing infant deaths, 90 percent on the way for child mortality, 90 percent for adolescent mortality, and 70 percent for adult mortality. This is good news, to be sure. But what does all this mean for older Americans? Indeed, some claim that the factors which have led to reductions in mortality will not yield overall improvements in health status. Prolonged longevity by itself, goes the argument, could simply mean that more people will spend longer proportions of their lives afflicted with chronic and degenerative diseases. I join those who posit another view. It is exactly the elders of the Year 2000 who will be the beneficiaries of healthier lifestyles and behaviors in their early and middle years and of advances from research in treatment and rehabilitation. So it is quite reasonable to expect that the benefits of a lifetime of healthy practices, carried into the later years, will lead to fewer chronic diseases and ameliorate those which do occur. Certainly that con- stitutes a worthy goal. 22 So where do we go from here? As I mentioned at the outset, we are now beginning to'set new health objectives for the Year 2000 and a spe- cial concern is setting targets for older Americans. 7'he 1990 objectives did not adequately address this population because of the attention given to premature. mortality and morbidity. But the Year 2000 gives us the opportunity to make such adjustments. This time we know more about the aging process, we know more about the aging population, and we know more about the value and effectiveness of a variety of health pro- motion strategies in general, and for this age group specifically. Furthermore, we are compelled to take special notice. Between 1985 and the Year 2020, the population 65 and older is likely to increase by almost two percent a year, an average of about 750,000 additional older persons per annum. The oldest-old-the %-plus generation-are projected to increase at an even faster rate, at about three percent a year. In con- trast, the total United States population is anticipated to grow each year by less than one percent. While the rate of growth of the 65-plus population is expected to be somewhat greater after the Year 2000, between 1985 and Year 2000, the oldest-old will grow faster, at an average rate of about four percent a year. Then, as the baby boomers ease into the elderly category, we can expect a nearly three percent growth rate in the young-old, the 65 to 74 age range. Although the majority of older adults in the future are expected to be relatively healthy, most wilI develop one or more chronic health problems. Many of these conditions should cause few difficulties but others could result in severe disabilities. A widely used measure of disability among older persons is the number of persons with activity of daily living limi- tations (ADL). Data from the 1984 Health Interview Survey aging sup- plement show that over 22 percent of older persons living in the com- munity have some degree of disability. We also know that the impact of chronic health problems increases with age. More than 60 percent of those age 85 and over reported some degree of limitation. Since we will have more people living longer in the Year 2000, NCHS projects a 30 to 50 percent increase in the numbers of older persons with some limitations in activities of daily living, if current pat- terns of disease continue. The sum of these trends, then, is that we have a growing high risk group whose only option to health care currently is expensive, and not always appropriate, acute care medical treatment. So clearly, one national strategy must be to balance the prevailing focus on curative medicine with attention to preventing disease and promoting and maintaining health. The leading chronic conditions afflicting older people-arthritis, hyper- tension, hearing and visual loss, and heart problems-are conditions we know have the potential in many cases to respond to health promotion interventions such as exercise, healthy diet, and early care. And at least two of the three most debilitating conditions which lead to a need for long term care-stroke and hip fracture-could be prevented. 23 For those people already ilI, our goal should be to maximize function and prevent further deterioration. Changes in diet, exercise, and other health behaviors-may have an impact on function and ability to cope with the demands of daily life, even beyond their gains in health status. So when planning for the Year 2000, we must broaden the perspective which has been applied to the younger ages of preventing morbidity and premature mortality. The challenge is not how to prolong life, but how to extend active life expectancy. What can be done to delay the onset of disease? How can we maintain function and independence in those older adults with chronic and degenerative diseases? How can we measure func- tional independence ? How do we set priorities amongst preventable problems? What do we know about the effectiveness and e,fj?uzcy of such strategies in the 65plus group? Over the next few days you are going to be giving a close look to the range of behaviors and practices identified to be of the most benefit to the health of older people. It is my hope that we will be able to take the work you will be doing here and use it as the groundwork for designing Year 2000 objectives which address the specific preventable problems of older Americans. Let me just touch briefly on how that will actually happen. First, you should know that the Public Health Service is collaborating in the Year 2000 effort with the Institute of Medicine, under the guidance of a steer- ing committee representing all the PHS agencies who will have the ulti- mate responsibility for carrying out the objectives. The first step of this process has been one of gathering information. Regional hearings are being - held around the country to solicit grassroots testimony about preventive health priorities in the coming decade. Special hearings are also being spon- sored by interested organizations at their annual meetings. In addition, we are convening a special hearing to focus on the needs of older people following this workshop on Wednesday afternoon. If you are not already plannin g to attend, I invite you to do so. We are expecting to hear first from Dr. Koop-who will be sharing the recommendations from this work- shop with us and entering them into the record. We'll also hear from the American Association of Retired Persons, the National Council on the Aging, the . . . and many other interested groups. There should be time following the scheduled testimony to hear from you and I encourage you to come forward. Once all the hearings have been held, the task of drafting the actual objec- tives will be assigned to those agencies within the Public Health Service who will have the lead responsibility for a given area. We anticipate that a draft of the objectives will go out for review and comment by the end of this year and that the final Year 2000 objectives will be issued at the end of 1989. In closing now, I'd like to thank you for the opportunity to share with you what we are doing and I certainly am looking forward to hearing your recommendations two days hence. 24 As we rise to the challenges of our demographic destiny, we must acknowledge that neither knowledge nor change come easy. But with the collective spirit, wisdom, and commitment of people like you, I believe we will be successful. If L may, I'd like to close with a quote from the last line of Healthy People, the Surgeon General's report on health promotion and disease prevention which got us started, with one alteration: "If the commitment is made at every level, we ought to achieve out goals, and older Americans, who might otherwise have suffered disease and disability, will instead be healthy people." Thank you. "L.egi&tjve and Administration Interests in Geriatric Health Promotion" Presented by Roger Herdman, MD Assistant Director for Health and Life- Sciences Office of Technology Assessment, U.S. Congress Monday morning, March 21, 1988 The title of my talk, as listed on the program, is Administration and Legis- lative Interests in Geriatric Health Promotion. However, I believe it would be a bit presumptuous of me to speak about the Administration's interests or views, especially considering the individuals preceding me this mom- ing. Also, I make no pretense of speaking for the Congress in any politi- cal sense. That said, it is my goal to present some thoughts about health promotion for elderly people and the forms of recent Congressional legis- lation in this area. In many ways, there should be difference between a legislative interest `. in geriatric health promotion and that of the executive branch. In general, it is clear to all parties that health promotion is a worthy goal. While all - segments of society are struggling to meet rising health care costs, it is equally clear that we may not want or be able to pay for preventable ill- nesses. Divergences in viewpoints and thus "interests" become important when policy makers seek to turn the concept into reality. Actually, it would be more accurate to say "seek to help" since we should not by any means fall into the trap of thinking the federal government-whether legislative or executive-is the only actor in the process. From the federal perspective, making expanded health promotion a re- allty involves a long (some would say cumbersome; others would describe it as necessarily cautious) sequence of events. It includes exploration of specific goals, information gathering about means of reaching those goals, technical analyses about programs and methods that might accomplish health promotion, decisions about how much and what types of health promotion programs are to be supported or otherwise encouraged, com- promises on who will pay for programs, enactment of any needed stat- utes, actual implementation, and then evaluation of the success of the pro- grams in bring about desired changes. Congress has an interest in every one of those steps, but it has more capability and more of a mandate in some than in others. Clearly, the Con- gress has a large role in play in setting goals, since this is the first crucial step in lawmaking and goals must flow in large part from the needs of the elderly population. Identifying and reacting to this population-based 26 need is one of Congress' traditional roles. This must be supplemented by "technical" information (for example, on disease and demographic pat- terns and on behavioral characteristics) that in significant part can only be derived by application of the expert&e and far larger resources of the executive agencies. Similarly, Congress often must rely on executive expertise and research concerning the technical means to achieve the goals. This reliance is not as heavy as it once was; Congress has improved it informational resources over the years and now can turn to the General Accounting Office, the Congressional Research Service, the Office of Technology Assessment, and incertain cases, the Congressional Budget Office. But the fact remains that the resokces of all the technical support offices of the Congress are extremely smaIl compared to those of the executive branch. Congress, of course, also has access to expertise in academia and the private sector. Here again, Congress has enhanced it capacity recently with respect to Medicare and Medicaid related issues by creating research and policy advisory bodies such as the Prospective Payment Assessment and Physician Payment Review Commissions. But still it is the executive branch that generates or supports much work in those sectors. The specific, rele- vant point here is .that in an emerging, increasingly visible and important area such as geriatric health promotion, the ability of Congress to make informed choices depends to some degree on the quality and form of the information generated by the executive branch. The novelty is the con- tinuing tendency of the Congress to increase its own research and exter- nal advisory capacities. In shaping the debate about how much and what types of health pro- motion programs are to be supported or otherwise encourages, I believe that Congress and the Administration both have large roles to play. Con- gress plays its part through hearings, investigations by staff or by support agencies, interaction with constituents, and commissions. Congress, of course, then must make it own decisions concerning enact- ment of authorizing statutes and of appropriations bills. This is one of the primary roles that Congress plays in health promotion. It is certainly not the only one-the oversight process can be significant- but it is one that distinguishes a legislative interest. In the remainder of my presentation, I would like to accomplish three purposes. First, I would like to examine the context in which the Con- gress considers geriatric health promotion. I would then like to describe some of the efforts that have pursued by Congress to enact legislation in this area. And I would like to conclude by discussing some of the issues that the legislative branch must address in deciding which activities to sup port and al what level. The ways in which the Congress seeks to further health promotion are in large part determined by broader concerns of the institution itself. At least two such concerns affect health promotion for older Americans. The first is the tendency to make incremental changes in existing programs rather than to enact a comprehensive strategy to achieve a particular goal. 27 In part, this tendency may be borne out of. an appreciation for the corn-- plexities of implementing broad new programs as was done twenty years ago. However, the overriding cause of Congress' reliance on incremental strateiges may be fiscal reality. As I willexplore further in a moment, con- cern over the federal budget during the past few years has made it more difficult to garner the political support within Congress to establish large, `new programs. Indeed, the bipartisan efforts of the legislative and execu- tive branch to provide protection for the elderly against catastrophic health expenses are one of the most successful attempts at "comprehensiveness" considered by Congress in recent years. And they are really -an expansion of ,optional coverage under the Medicare program. As we shall see, most Congressional efforts for geriatric health promo- tion in recent years have taken the form of incremental changes in four existing federal programs: Medicare, Medicaid, social services under Title. XX block grants (all of which are authorized under the Social Security Act), and grants authorized by the Older Americans Act. Proposals for changes in Medicare and Medicaid almost all. seek to expand reimbursable health services for beneficiaries. By focusing its attention on insurance coverage, Congress emphasizes the importance of payment for services in the promotion of geriatric health. However, changes in Medi- care and Medicaid can have influences far beyond the marginal increases in coverage for these programs' beneficiaries. As the largest single payer of health services, the policies adopted by the federal government will .-receive serious consideration by other insurers. This phenomonen has occurred since Part A of Medicare adopted a prospective payment system for hospital charges. In the area of health promotion, the influence of the federal government as a major payer extends even farther. Proposals to expand Medicare and Medicaid coverage represent an explicit recognition by the federal govem- ment of the importance of health promotion and disease prevention. Cover- age may educate the public about those activities that can improve or main- tain health, and it may encourage behavior to bring it about. For example, proposals to pay for disease screening or immunizations under Medicare could thrust the federal government into a leadership role in encouraging all consumers'to seek such care or health professionals to provide it. I have already alluded to the second characteristic of Congress that shapes recent proposals for geriatric health promotion-the major role of the budget process in determinin g the Congressional agenda. The necessity for fiscal responsibility has set the terms of debate for recent proposals in geriatric health promotion. Much legislative support for disease prevention and health promotion lies in the hope that paying for prevention now will avoid more expensive treatment `costs in the future. Hence, in carrying out its legislative duties, the Congress has an obligation (much like that of the executive branch) to consider both potential benefits and potential costs. A great many health promotion activities are "worthwhile," and a fair number are "compelling" in their perceived value. Recent proposals to provide Medicare coverage for routine mammography are one example of this debate. As the Office of Technology Assessment recently found, mammography coverage is unlikely to reduce Medicare costs in either the short or long run.. However, it has tremendous potential in detecting early cancers and prolonging life. Other work conducted by our office on the regular use of outpatient pharmaceuticals suggests that Medicare cover- age of "medically critical" drugs may reduce hospital costs and actually -save money f&r Medicare. The Congress will ultimately weigh all this infor- mation in deciding whether to support these activities and at what level. Even if one argues that a proposal is "cost-saving," the meaning of this statement can be ambiguous. The real question should be "cost saving for whom?" The costs of health promotion can be borne by an individual beneficiary, by a particular program by the federal government, or by soci- ety as a whole. A given proposal may reduce the costs of one program while increasing those in another. The net effect of the federal budget could be either positive or negative. Given the distribution of jurisdictional authority within the Congress, the ways in which these costs fall may have much to do with the success of a given proposal. The budget process itself has numerous complicated sfeps. In general, the Congress passes an annual budget resolution in the spring or sum- mer that sets broad spending limits. Appropriations bills provide funds for specific, authorized programs. Reconciliation biJls allow changes in the authorizing legislation of entitlement programs to bring their spending in line with the budget resolution. As is probably well-known by this group and the American public as a whole, in recent years the last two steps of this process have been carried out well beyond the start of the fiscal year. Attempts to contain or decrease the budget deficit have enhanced poten- tial changes in entitlement programs like Medicare and Medicaid that have the potential to realize large budget savings. One would not expect appropriations or reconciliation bills to be vehicles for expanding eligibility or benefits of these two programs since Congress requires all components of this part&&~ legislation to be g ermane to its original purpose. However, because the annual budget resolution passed early in the legislative year provides in&n&ions for budget savings in entitlement programs like Medi- care and Medicaid, any proposals to alter these programs become germane to a reconciliation bill even if the changes do not bring about budget sav- ings (Fuchs and Hoadley, 1987). Recent expansions of Medicare to cover immunizations for pneumococcal pneumonia and Hepatitis B made use of this process. I would now. like to talk a bit more systematically about recent and cur- rent legislative proposals for geriatric health promotion. I have alluded to a number of changes in Part B of the Medicare program to pay for clinical preventive services such as irnm~tions and disease screening. In addi- tion to the coverage of'routine pneumococcal and Hepatitis vaccines, Con- gress recently agreed to establish a demonstration project to provide influenza immunications to Medicare beneficiaries. In the 99th Congress, proposals were put forth to alter Medicare in other ways as well. One bill (S. 358) would have raised the deductible to receive 29 Part B benefits,from $75 to $100, but would allow the cost of disease screen- ing, immunizations and hypertension drugs to count towards that deduct- ible. A companion bill (S. 357) would have lowered the Part B premium by $1 per month for nonsmokers. The House considered a proposal (H.R. 1402) that would allow Medicare beneficiaries to purchase a supplemental insurance option to cover the cost of an annual preventive health physi- cian visit. A similar proposal discussed on the Hill recently would provide a well-patient physician visit for new Medicare beneficiaries. In 1984 and 1986, Congress authorized a total of seven demonstration programs to pro vide community-based disease screening and referral services. Two of these projects have been funded and are currently in operation. Medicare related proposals for health promotion in the current Congress fall into two categories. The first is the further expansion of coverage under Part B. There are currently five bills that would extend Medicare payment to routine, annual mammography. Two of these bills would also autho- rize Medicare to pay for annual Pap smears. The second category consists of provisions in the catastrophic health insurance bill currently under consideration. The Senate version of this legislation (currently under discussion in conference committee) would allow enrollees to count the cost of several preventive services toward the annual deductible necessary to receive catastrophic benefits. These serv- ices are screening for glaucoma, cholesterol, cervical cancer by Pap smear, breast cancer by mammography, tuberculosis, colorectal cancer by occult blood in the stool, and immunizations against tetanus, influenza and bac- terial pneumonias. - Both House and Senate versions of the catastrophic bill also provide for prescription drug coverage. Although the two versions of the bill vary somewhat, they nonetheless represent a legislative commitment to assist the elderly and disabled in gaining access to needed prescription drugs. In many cases, these drugs may dramatically improve the quality of an older person's life. Many control chronic conditions such as hypertension and prevent more serious manifestations of illness that might require hospitalization. It is interesting and important that this legislative commit- ment is made without clear-cut evidence that it will save money. The prescription drug provisions of the catastrophic bills also express concern that pharmaceuticals be used wisely and appropriately. As the Office of Technology Assessment (OTA) recently pointed out, geriatric polypharmacy is now commonplace, with over a third of community dwell- ing and over half of institutionalized elderly using four or more drugs (U.S. Congress, 1987~). One researcher has estimated that adverse drug reac- tions play at least a contributory role in 12 to 17 percent of all hospitahza- tions among the elderly (Lamy, 1984). One version of the bill would assign the Secretary of Health and Human Services the responsibility for develop- ing programs to ensure that drug therapy promotes rather than threatens geriatric health. Among those proposals for geriatric health promotion not aimed at Medicare are changes in the Older Americans Act of 1965. In a set of 30 amendments to this act passed last fall (P.L. lOO-175), Congress autho- rized the Administration on Aging to provide grants to states totaIling $5 million a year to establish periodic health services within community senior centers. In addition to disease screening, the centers could offer exercise programs, home injury control, nutritional counseling, mental health serv- ices and education On Medicare benefits. The amendments also authorized demonstration grants to institutions of higher education for the design of prototype health education and promotion programs. States would be able to draw upon these prototypes in implementing their own preventive serv- ices. It is important toremember that each of these activities require that Congress yet appropriate the funds necessary to implement them. Congress has also recently expressed interest in Alzheimer's disease and related dementias. It has provided funding for basic and health services research and has utilized nationwide expertise to provide the Secretary with particular external advice on this topic. Legislative interest and activity in the growing area of geriatric mental health will likely grow over the next several years. Block grants to states are another way in which Congress has sought to further health promotion. In 1981, Congress combined eight categorial grant programs together in a Preventive Health Block Grant for public health and health promotion activities. States were given broad discretion in how they decided to spend these funds. This Preventive Health Block Grant is currently awaiting reauthorization. Another block grant uses funds authorized by Title XX of the Social Security Act to provide social serv- ices. While some portion of all these grants probably support geriatic health promotion activities, states vary greatly in how they spend their funds. One analysis indicates that 34 states use Title XX funds for health educa- tion (U.S. Congress, 1987b). On the other hand, despite its rather specific title, the Preventive Health Block Grants allow states to invest in measures as diverse as rodent control and fluoridation, emergency medical services and home health care in addition to health education. Legislative activities in geriatric health promotion extend to the Congres- sional support agencies as well. At OTA, we have tried to help the Con- gress sort out the merits of activities in this area. In past years, we have examined the cost-effectiveness of pneumococcal and influenza vaccines. We recently completed an e xamination of health promotion options in large studies of Technology and Aging and Alzheimer's disease (U.S. Congress, 1985 and 1987b). Just this past fall, we analyzed the costs and effective- ness of mammography under Medicare (U.S. Congress, 1987d). Over the next year, at the request of the House Ways and Means Committee and the Senate Labor and Human Resources Committee, we will study the costs and effectiveness of up to five additional clinical preventive services that might be considered in the future for coverage under Medicare. Having talked a bit about the legislative environment in which proposaIs for geriatric health promotion are considered and having outlined recent Congressional activities, I would like to close by focusing on some of the methodological issues that arise in evaluating various proposals. OTA is 31 grappling with each of these issues now as it analyzes potential costs and effectiveness. The Congress deals with them as it considers particular pima of legislation. And you wiIl face them in your deliberations over the next two days. One of the first problems encountered in evaluating geriatric health pro motion is the uncertain efficacy of many proposals. The various authors of the background papers prepared for your use have performed a valua- ble function in uncovering and synthesizing a diverse academic and clim- cal literature. In many cases, however, there is a pronounced lack of data about how well specific services work for the elderly (St-&s, 1984). This uncertainty has several sources. For some services, there have not been well-designed, randomized clinical trials. Glaucoma is one example where the efficacy of preventive treatment has not been well documented and clinical trials are badly needed (Eddy, Sanders and Eddy, 1983). In evaluating other services, researchers have excluded the elderly from those clinical trials that do exist (StuIts, 1984). Traditionally, they have feared that the multiple morbidities of many elderly would preclude efficient statistical analysis of the activity under scrutiny. The Food and Drug Administration is currently reevaluating its own guidelines in order to expand elderly participation in its clinical trials. Finally, in some cases researchers may have erroneously assumed that treatment does not result in health benefits for individuals beyond a certain age. Smoking cessation falls into this category. Many times those data that do exist on the efficacy of health promotion activities come from a single demonstration project. In trying to general- ize from a particular project to an entire population, one must bear in mind those characteristics of the demonstration that might have contributed to the project's outcome. Such factors might not be reproducible in a pro- gram aimed at an entire population. Efficacy can also depend heavily on the outcome one decides to mea- sure. Traditionally, one examines changes in mortality or morbidity. For some services, hawever, this approach may not sufficiently measure the impact of the intervention. For example, one would usually measure the effect of screening for hypertension or cholesterol in terms of expected life- years saved or expected reductions in disability. However, the contact with a health professional afforded to the screening patient may have impor- tant secondary health benefits. Such contact may educate a patient about additional ways to maintain health or it may improve mental well-being by relieving anxiety about the patients' health. Hence, traditional measures of mortality and morbidity might undervalue the efficacy these health pro- motion activities. Measuring the costs of geriatric health promotion also presents some complexities. Since I have already discussed these ideas in describing the Congressional enviknment for health promotion activities, I will not dwell on them here. I would, however, like to bear in mind that cost-effectiveness is a relative term. One activity can only be cost-effective in relation to an alternative. In a legislative environment that relies on incremental 32 changes in existing statutes, the cost-effectiveness of a health promotional proposal will likely be its cost per unit of efficacy achieved compared to not making an changes at all As I also mentioned earlier, cost-savings depend on the perspective from which one measures them. The Congress or one of its committees may be interested in potential cost-savings for an individual program such as Medicare or a select population such as the elderly or disabled. But such savings to a given program or group may actually be borne by other parts of the federal budget, other groups.of people, or society as a whole. Finally, there are methodological problems inherent in implementing geri- atric health promotion activities. The reliance on marginal changes in exist- ing programs may reveal a tendency towards services that fit easily into the established major payer structure, at least for federally implemented programs. Hence, the easiest programs for Congress to consider are those that expand reimbursable clinical services under Medicare or Medicaid. Public education and some counseling services, on the other hand, have little preexisting structure for implementation and are,. more difficult to execute. Other disease prevention activities may not be viable under Medicare and Medicaid because of the nature of the disease itself. Osteoporosis screening is one example. while no one would debate the fact that osteopo rosis is an important problem among older Americans, particularly women, or that the resulting fractures are seriously disabling, it is not clear that Medicare interventions will effectively forestall or avoid these undesirable outcomes. Rather, interventions need to begin at a younger age. For women, most calcium depletion occurs after menopause but before they become eligible for Medicare. Screening women at age 65 might alert them to their elevated risk of fracture, but it would not result in a substantial increase in bone density. Another implementation issue important for geriatric health promotion is the uncertain definition of some services and their potential for abuse. This problem may be especially relevant to expansions of Medicare or Medicaid coverage. Earlier I mentioned proposals that would allow Medi- care beneficiaries to receive a well-patient physician visit on an annuaI basis or when they enter the program. The legislation authorizing this coverage does not indicate exactly what activities would be (or should be) performed during such a visit. The cost of the proposal is dependent on its actual content. In the absence of a better definition or some alternative control, the services provided could use significantly fewer resources than are reflected in the government's reimbursement. Indeed, physicians could provide only a minimal or inadequate examination of their patients, or patients could seek redundant care from providers. While there may be potential health benefits and cost-savings of such visits , legislators will want to design such services to minim& unintended outcomes. I do not pretend to have described in this paper all of the complexities in evaluating geriatric health promotion as public policy. Rather, I have tried to outline some of the major issues and constraints Congress must 33 address in considering proposals in this area. My purpose has been some- what selfish. As I suggested early on, the Congress' ability to promote the health of elderly Americans depends in part on the expertise of the executive branch. Your efforts here in the next few days will greatly aid the legislative branch in its work. I wish you luck in your deliberations and look forward to your conclusions. References Eddy, David M., Lauri E. Sanders, and Judy F. Eddy, "The Value of Screening for Glaucoma With Tonometry." Survey of Ophthalmology, 28(3): 194-205, 1983. Fuchs, Beth C. and John F. Hoadley, "Reflections from Inside the Belt- way: How Congress and the President Grapple With Health Policy." PS. 20(2): 2x2-220, 1987. Lamy, Peter P., "Hazards of Drug Use in the Elderly." Postgraduate Medi- cine. 76(l): 50-61, 1984. Stults, Barry, "Preventive Care for the Elderly. Western Journal of Medi- cine, 141(6): 832-845, 1984. U.S. Congress, Office of Technology Assessment, Technology and Aging, (Washington, DC: U.S. Government Printing Office, June 1985). U.S. Congress, Office of Technology Assessment, Losing u Million Minds: confronting kgedy 0fAkheirner's l3isn.w and Other Dmtias, (Washing- ton, DC: U.S. Government Printing Office, April 1987a). U.S. Congress, Senate Special Committee on Aging, Developments in Aging, 1986 (Washington, DC: U.S. Government Printing Office, June 1987b). U.S. Congress, Office of Technology Assessment, Prescription Drugs and Elderly Americans: Ambulatory Use and Approaches to Coverage For Medi- care. OTA Staff Paper (Washington, DC: October 1987~). U.S. Congress, Office of Technology Assessment, Mamniogruphy: Costs, Ej&Yimms and Use Under Medicare. OTA Staff Paper (Washington, DC: November 1987d). 34 PLENARY SESSION-"Setting the Pace in Geriatric Health Promotion" "Healthy Older People" Presented by Susan Maloney Office of Disease Prevention and Health Promotion Monday morning, March 21, 1988 As this workshop progresses, I am sure we will be hearing in great detail what is needed to spur the development of health promotion for older people. We'll hear calls for training health and aging professionals to care for today's elders-and to provide the opportunity of better health for tomorrow's; calls for sustained and consistent leadership for building and supporting the networks which provide services for older people; and calls to educate older Americans about how to stay healthy. In my time with you today, I would like to spend a few minutes look- ing back to where we were in 1984 when the Federal initiatives in health promotion and aging got underway and examine what impact we've had to date. Specifically, I will be speaking from the perspective which has been gained from the first national health promotion program aimed at older Americans-Healthy Older People. In many ways, Healthy Older People serves as a demonstration of the potential there is out there for promoting the health and well-being of our older citizens-and there are many lessons to be learned. Let me say at .the outset, you would not believe the skeptical reactions I received from colleagues when I began talking about planning a national public education program for older people. Today, the skeptics are becom- ing believers. Although we continue to debate how best to change behavior, and to refine what we know regarding the potential impact of behavior change in this age group, or any for that matter, health promotion for the aging is moving into the mainstream. In my view, that was certainly not the case a mere four years ago. In 1984, there was no consensus regarding what topics to address, no widely held view on what to say, and perhaps most basic, no sense that older people were indeed interested and willing to change behavior in order to improve health. Even had all this been agreed upon, there was no sys- tem, no network, no way to get the message out-much less provide the opportunity for personal support and encouragement which we know is necessary to change and sustain health habits. It goes without saying that there was no clear or consistent leadership in this area and no system of technical support to bring about such change. !3o today, in assessing Healthy Older People, I ask what progress has been made along these lines and what have we learned about what to do next? As I said before, the Healthy OlderPeople program is a national public education program sponsored by the Office of Disease Prevention and Health Promotion (ODPI-IP). These programs, of which the Public Health Service has several, are often difficult to describe. While it is relatively easy to describe the materials which are developed and the special activities which are generated, it is difficult to convey how public education pro- grams serve as a catalyst for action at the state and community-the level of real impact. The primary goal of our program was to inform and educate older Ameri- cans about health practices which can reduce their risk of disabling illness and increase their prospects for more productive and active lives. We tack- led this challenge in several ways-by producing a wide variety of infor- mative materials for older people; by working very hard to establish and nurture a dissemination system to get the educational messages out; and by fostering the development of local programs serving older people. First let me tell you what we learned about the importance of clarifying the health information we wanted to deliver and how that information was received. Too often we point to the piles of materials in our offices and to the press coverage of health-related topics, and conclude that there is plenty of information available and people just won't pay attention. I contend that it is not only important, but very difficult to develop under- standable, accurate information that people actually can act on. Before we developed the Healthy Older People materials, we conducted careful reviews of the scientific literature to ascertain in which areas behavior change can be most beneficial to health status in this age group. In fact, many of the areas selected are featured at this workshop: eating right, exer- cising, stopping smoking, preventing injuries, and using medicines and preventive services wisely. Next, we conducted focus groups with older people to determine how their beliefs and feelings coincided with the science base. We were then able to use public relations and advertising professionals to develop, test and refine the information. The messages which were developed were clear, taught the skills needed to act, and conveyed a positive upbeat tone to underscore the general theme that health promotion is appropriate no matter what your age. The impor- tance of this washighlighted in the evaluation conducted of the program. The materials were consistently described as "the information people are looking for" and as "taking complicated (nutrition) information and mak- ing it easy to use." The messages were translated into a variety of broadcast and print materials including television and radio public service announcements, posters, and brief consumer fact sheets. Press kits and TV and radio seg- ments were produced for news and talk shows and a variety of support- ing materials were prepared for state and local groups on how to use the various media materials. 36 A validation of the need for and interest in clear health messages is the extent to which these materials were picked up. I must note that partici- pation in the Healthy Older People program was completely voluntary- -no State had to get involved. Even more telling is that no money was available from'us to conduct programs or even to print materials. We were only able to provide samples of print materials and groups had to find sponsors. Even with that, the results were excellent. Looking first at the TV public service announcements for which the best data are available, every state distributed the spots with 60% arranging personal deliveq to TV stations. The service which tracks airplay of commercials reports that between Sep tember 1985 and September 1987 the Healthy Older People spots were aired 4713 times on local stations and all three networks. We saw it on five different Cosby shows alone. The total advertising value of the spots, according to Broadcast Adver- tisers Reports, Inc., was $3,221,693. That is what it would have cost us to air these spots if we had to buy time from television stations. At this time, ODPHP's total expenditure for the program has been about $9oo,MlO-less than a fifth of comparable campaigns for high blood pres- sure or cancer prevention. Though we do not have access to such precise numbers for other Healthy Older People materials, we do have some success stories. The so-named skill sheets proved to be a popular and versatile item. These two-pagers `. were available as camera-ready slicks and were used in nearly all the States. Not only were they reproduced and handed out to older people at senior centers, libraries, and drug stores, and in retirement seminars and hous- ing units, but Blue Cross of New Hampshire sent them to each of their customers over 65. Hospitals and social service agencies gave them to their clients, and states and "house organs" used the information in their news- letters. As much as we talk "high tech" for information, we are still very reliant on the written word and we seek simple and concise direction for health maintenance. One frequently reported use of the Healthy Older People materials which I had not expected was how often these items were used for professional training. We must keep in mind that, although we may have this infor- mation down pat, most professionals whose primary responsibility is for providing health or social services cannot keep current on the latest health promotion findings even if they recognize the benefits to their older client. The skill sheets were also described as having a cross-disciplinary focus. We heard: "Both the health types and the aging types liked the sheets. For the first time, they both got behind the same product." Bringing together the health and aging fields under the common ban- ner of health promotion for this segment of the population was perhaps our greatest challenge and one of the most rewarding aspects of working on Healthy Older People. The quality of the materials helped-but ahead of that I'd place the opportunity to work jointly toward a common goal. This is how a public education campaign is able to foster the support net- work needed to provide programs and services. 37 You have already heard about the Federal call for the establishment of coalitions on health and aging. Speaking from the perspective of Healthy Older People, we have learned a great deal about how the coalitions were formed and what they are doing. Early in the program we contacted each Governor's designee and worked our way through the bureaucracy to identify those who would be our own program contacts. These people were most often staff of either the health or aging department although sometimes the Governor asked both agen- cies to be involved or sometimes one-agency decided to enlist the support of the other. We encouraged collaboration at regional training workshops, and via a toll free hotline, in a bi-monthly newsletter about the program, and through technical notes for professionals on various program develop ment topics. Eighty five percent of the states in which we conducted evaluation formed coalitions-many adopting the name of the program. Today, for example, we have Healthy Older Virginians and Michiganders and Iowans. The makeup of the coalitions varies. In three states, membership is limited to staff from state agencies. In just over half, the coalitions include state and local agencies and service providers such as hospital associations, univer- sity geriatric centers, the American Red Cross and AARJ?. Eleven states formed even broader coalitions which include private sector representa- tives. Among the six states which chose not to establish coalitions, two- Connecticut and Rhode Island-said their small size already facilitated close coordination. Eight of the state coalitions went on to foster the develop- ment of local coalitions. The coalitions identified health and aging resources within the state and, most important, established viable, programmatic linkages which they expect to continue even when Healthy Older People is no lonqer around. Most coalition leaders reported that this was one of the first times there was effective collaboration between the health and aging sectors in their state. In some states this collaboration has led to an increasing interest in health promotion among older adults. I am just beginning to get calls from some of the state contacts asking for help in thinking through how to approach upcoming meetings within their departments about integrating health promotion more widely in existing programs. This represents a dis- tinct shift from an initial focus on simply conducting an information Program. In addition to what we were able to do to support the formation of co- alitions, we also tried to encourage the development of programs-and always to stress the need for local, accessible activities to encourage main- tenance of healthy behaviors. Program development was enhanced by col- laborative activities with national membership and voluntary organiza- tions-organizations with ready access to our audience: older people. Two activities stand out-a series of training conferences on community health promotion programs sponsored by AARP and two teleconferences for health and aging professionals done in conjunction with the American Hospital Association. It is in the area of program development that Healthy Older People exceeded my expectations. In all the states evaluated-41 of !Xl-program development of &me type occurred. It appears that tens of thousands of older persons were reached in this way. Of the forty-one states queried, 15 reported doing needs assessments and compiling resource inventories; 38 desc&+ special events to educate consumers such as fairs, workshops, or. "nutrition days"; several have developed their own video-taped pro- grams which are shown on cable stations and in sites such as senior centers and community colleges; 31 states conducted provider education principally through statewide workshops and in an ongoing fashion through news- letters; and 35 of the 41 reported providing some type of wellness services to seniois. How the diffenmt Healthy Older People topics were integrated into com- munity programs is also worth noting. The greatest amount of program activity reported by our evaluation team must be categorized as wellness or health promotion for older people. Thirty-seven of the 41 states reported the adoption of this muhiple risk factor focus for programs. Contacts liked the economy of scale in linking the topics, both in terms of limited staff and resources, and in terms of limited opportunities to provide activities for older persons. After wellness, the most frequently addressed single topic was exe&se and fitness with walking events being the most popu- lar. Special activities on the safe use of medicines and preventive health services were reported by twelve states, and nutrition by ten. One factor which influenced selection of topics was familiarity with an issue. For example, the public health agencies found it easy to use their public health nurses to conduct risk assessments and health screening. The aging agencies, on the other hand, said they were intimidated with the medical topics, but felt they had a lot to offer in nutrition. The topics which could be made fun-or social-held great appeal. They also stood a better chance if they addressed a serious health risk or led to an easy intervention. Given that last caveat, it should be noted only one state, Rhode Island, focused on smoking cessation. Since some of the definitive research on the benefits of quitting at a late age have only recently been published, I guess this is not surprising, but clearly more could. be done in this area. In assessing a national public education campaign in which participa- tion is voluntary and schedules and activities are conducted as deemed best by a very decentralized network, it is difficult to tease out the impact of that program from concurrent events. For the 41 states evaluated, we developed a rating scale to determine how Healthy Older People fit in with other activities and priorities. Four categories were developed. In seven states, there had been no preexisting activity in health promotion for the aging1 Healthy Older People was cited as a direct impetus for program development. In eight states there was preexisting activity, but Healthy Older People caused a ree xamination and modification of strategies to reflect the national program. In 16 states, the existing priorities were main- tained and resources, materials, and ideas were incorporated from our pro- gram. In ten states, Healthy Older People activities were conducted in 39 parallel, but not really related, to other health promotion activities. As of last August, there was no. state in which Healthy Older People had no apparent impact. Indeed this spring we see the launching of two more major state initiatives-in Pennsylvania and Indiana. The biggest lesson we've learned, I would say, is that Healthy Older People demonstrates the ability of the Federal government to establish a national agenda through a modest, but ambitious, program of this type. I would add that the success of this program in doing just that is that we had the right combination of the right people at the right time-not only the audience we wanted to reach: our aging population-but the talent and commitment of health and aging professionals who have recognized the need for and value of health promotion for this special population. As a result, we see a firm beginning of an interdisciplinary network of health and aging agencies and organizations committed to this initiative. And I think you will agree with me that we are further along in clarifying what information older people need in order to change health behavior. Nevertheless some things are left undone-or I guess we would not be here today. Among them are professional training, national"media atten- tion, technical support for community programs, policy directions, and research and demonstrations to assess the impact of activities on health and functional status. The workgroups will help expand that list. So we have a good beginning. We have captured the attention of profes- sionals and have whetted the interest of older people in health promo- eon. But we know from experience that the substantial health benefits of behavior change do not come quickly or easily. Healthy habits and actions must be reinforced through repeated refrains from doctors, social workers and the local TV anchor person. We need to encourage fitness and good nutrition at the most personal level-in local parks and supermarkets, restaurants and neighborhoods. I want to thank Surgeon General Koop for his leadership in convening this meeting because it is through opportunities such as this that we can help move health promotion for older adults up on the national agenda. And with your work here today and tomorrow-and your work back home-we eventually will see older people becoming healthier people. Information about the Healthy Older People program is available from the ODPHP National Health Information Center, PO Box 1133, Washing- ton, DC 20013, 80OEI36-4797, 301/5654176 in Maryland. "Pkoject Age Well" Presented by Anthony Vuturo, MD School of Medicine, University of Arizona Monday morning, March 21, 1988 Good morning, ladies and gentlemen. It is a pleasure to join you this morning in Washington and participate in the Surgeon General's Work- shop on Health Promotion,and Aging. My task this morning is to give you an overview of Project Age Well. Age Well is a comprehensive project of the College. of Medicine at the University of Arizona. This program is a coordinated aperoach to preven- tive geriatric care. It attempts to compress morbidity, reduce health care costs, and enhance the quality of life in older Americans. In 1981 the Department of Family and Community Medicine began to develop primary health care efforts at apartment complexes devoted to the elderly. Eventually clinics were established at four city sponsored apart- ment complexes ranging in size from 75 to 450 apartments. As with any good university enterprise, we initially focused on the three- pronged thrust of academia-teaching, service and research. Medical stu- dents and nursing students had the opportunity to enhance their educa- tional experiences; service was provided both to the community and to the senior population; and new research projects were initiated, particu- larly in expanding our understanding of osteoporosis. In the early 1980's the major driving mechanism for the service compo- nent of the University was our desire to add geriatric health care services to University Fan&Care, the health maintenance organization established by the' Department of Family and Community Medicine. We soon recognized that the traditional medical models were not capa- ble of providing the scope of services required. We also believed that many of the health problems we were seeing in our elderly were preventable and could be anticipated. If targeted health issues could be promoted, we believed our clientele could anticipate a higher state of wellness in the aging process. This should reduce the potential financial risk to future HMO involvement. In 1983 we took our modest proposal to New York and presented our ideas to the Brookdale Foundation. With the support and endorsement of the foundation and its board, as well as a commitment from the City of Tucson and the encouragement of the Area Council on Aging, we proceeded to enhance our commitment to the approximately 1,ooO senior d&ens with the initiation of a new activity called Age Well. 41 Our initial objectives were to provide and expand health maintenance and to promote wellness. We wanted to support those individuals who needed various types of rehabilitation. We recognized that we needed to define new professional roles and still,be identified with the College of Medicine. It was important for us to create settings not just for the educa- tion of medical students and residents, but also for the training of nurses, pharmacists, nutritionists and exercise physiologists. We made a commit- ment from the outset to make our model widely available and to dis- seminate our activities. We focused i&ally on prevention. In 1984 we felt most comfortable with a model that emphasized hypertension, cancer prevention, osteoporosis, depression, and control of iatrogenic diseases, and we wanted to introduce health promotion to counteract the belief that illness is inevitable. By 1987 we had undergone significant changes in our focus areas. Rather than hypertension, it beearne apparent to us that it was possible to focus on the full spectrum of cardiovascular diseases. Our program of mental wellness grew beyond a focus on depression and now deals with bereave- ment, anxiety, loss, loneliness and stress. Clearly the leading iatrogenic problem was related to medications. Visiting people for about 4 years in their apartment complexes, seeing their furnishings, their kitchens, the way they kept house, and assessing the types of morbidity that we were begin- ning to see over time, we developed a vigorous campaign for safety pro- motion and accident prevention. _ The intervention strategies that we identified include enhanced nutri- tion, education, a program in exercise, a strategy in community-based and -peer-based health education, group and individual counseling methodol- ogies focusing on medication and diet, health maintenance screening and stress management. From the birth of Age Well in 1982 to the present, we have seen on our campus a major expansion of interest in the field of gerontology. We have campus committees on gerontology and interdisciplinary groups function- ing in numerous areas, one of which is a long-term care gerontology center. The tradition departments within the College of Medicine have supported the expansion of our concerns for the elderly by creating a Division of Restorative Medicine which combines the disciplines of podiatry,medicine, ophthalmology, orthopedics, rheumatology, and an active outreach pro- gram which evolved out of Family Medicine. Project Age Well is conducted at two types of sites. The first, as I have mentioned, are apartment complexes which have anywhere from 75 to 400 apartment units. Apartments may have single people or married cou- ples. (As a matter of fact, we have seen romances blossom and marriages occur during our short involvement with Project Age Well). In addition to the residential sites, we also conduct our formal activity in two commu- nity centers, one located close to the central library and the second located within a major school district in metropolitan Tucson. Promoting health in the elderly cannot be done in a vacuum. Project Age Well began a.detailed and time-consuming process of networking with 42 many groups and interested parties around our community. Our initial objectives were to pass on some of the things that we were learning, as well as pick up. new ideas and new thoughts in promoting a more fit lifestyle in our older population. We linked with the Pima Council on Aging, and with private local foundations dedicated to wellness. The Tuc- son Parks and Recreation Department linked with us, particularly in the area of physical fitness through walking, aerobics and stretching. We col- laborated with the Wellness Council of Tucson, which had been estab- lished to promote worksite wellness.. Numerous organizations, not all of which had exclusively elderly constituencies, became advocates and promoters of our activities. Cable television adapted a new program called "The Prime of Life," which began to telecast many of our activities to the entire community. The Interfaith Coalition on Aging became involved with Age Well. Pastoral counseling students received instruction and the staff began to work with ministers and rabbis within the interfaith Coalition. Before we knew it, the process of health promotion was beginning to .expand beyond the boundaries of the retirement commumties into the churches throughout the community. During the mid-1980's the notion of worksite wellness grew. Members of the Age Well team served on the Board of Directors of the Wellness Council of Tucson (WELCOT). At the moment, there are over 100 indus- tries with 50,000 employees involved in health promotion, doing many of the things that we are involved with in Project Age Well. What had initially started off as a geriatric-focused health promotion and prevention project began to move in multiple directions. The Arizona Association of Community Health Centers, which is a statewide health promotion coali- tion, sought our assistance. The Arizona Area Health Education Centers began to provide the Age Well model with selected components through- out the state under the AHEC umbrella. The Hispanic Council on Aging in our city and state began to see unique applications crossing cultural dimensions. Through the Brookdale Foundation our network spread as far as New York City, where we shared information, videotapes, and assessment instruments with the commissioner of the Department of Aging in New York. By word of mouth and through our presentations at various meetings, the word spread and crossed national borders. Visitors from the Govern- ment of Japan have come on at least two occasions to see the project first- hand. Three months ago we were guests of the government of China in Beijing, exchanging information and seeing which of their traditional health practices could be incorporated into our community-based and residential- based complexes to promote Age Well. Now the Age Well and health promotion network is huge, reaching rural and urban communities and using all methods of communication, includ- ing television, newspapers, newsletters, fairs, walks, church and synagogue participation, school districts, peer awareness and national and intema- tional linkages. 43 What has evolved has been a unique mixture of professionals providing their various talents and skills in an interdisciplinary fashion to the needs of older people. At the present tune we have nutritionists, pharmacists, nurse practitioners,, exercise physiologists, pastoral counselors, social workers, anthropologists, and physicians involved in the team approach to Age Well. One striking effect of the program is the interdisciplinary educational opportunities that have been created. We find students collaborating not only in health promotion and care, but also in research and scholarly inquiry. Students involved with Age Well are from many disciplines, including anthropology, medicine, nursing, nutrition, pharmacy, rehabili- tation counseling and social work. The by-product of the educational experience is that we believe we are helping tram the next generation of citizens to address the issues and questions of our aging population in thoughtful and informed ways. Within Project Age Well we focus on primary, secondary and tertiary prevention, along with health promotion and ftmctional assessments. You are quite familiar with primary prevention, including influenza, pneumo- coccal and tetanus vaccines, smoking cessation and diet modification. In secondary prevention, our emphasis is on early detection and treatment. This includes hypertension; cancer of the breast, colon and cervix; sen- sory deficits, particularly in vision and hearing; mental health, focusing on dementia, alcoholism and total mental wellness; social support; drug the