Health Promotion for Older Adults: What Is the Potential? 11th Annual Herbert Lourie Memorial Lecture on Health Policy

As a greater number of people reach old age, medicine is challenged to develop new approaches to this population. Health promotion, not just treatment of disease but improving the quality of life for older persons, must play a role. What happens to individuals in terms of health status as they get older, and what are the implications for health care needs? Where should we focus to get the biggest benefits in terms of health promotion? Overall, we have learned a tremendous amount over the last 25 years about the components of health as people get older, and what modifies their health. We know, for example, that the health status of older adults is a composite of the chronic diseases that they may have, of how many chronic diseases are present, and of underlying physiological changes of aging, such as a decline in muscle strength, that appear to be an intrinsic part of the aging process. Disability can result from chronic disease. In addition, people are more susceptible to acute illnesses and injuries as they get older.

Health Promotion for Older Adults: What Is the Potential?

As a greater number of people reach old age, medicine is challenged to develop new approaches to this population. Health promotion, not just treatment of disease but improving the quality of life for older persons, must play a role. What happens to individuals in terms of health status as they get older, and what are the implications for health care needs? Where should we focus to get the biggest benefits in terms of health promotion? Overall, we have learned a tremendous amount over the last 25 years about the components of health as people get older, and what modifies their health. We know, for example, that the health status of older adults is a composite of the chronic diseases that they may have, of how many chronic diseases are present, and of underlying physiological changes of aging, such as a decline in muscle strength, that appear to be an intrinsic part of the aging process. Disability can result from chronic disease. In addition, people are more susceptible to acute illnesses and injuries as they get older

Formulating a Curriculum on Aging and Health for University Undergraduates

There is a need in our society to raise the national consciousness about aging, health, and the prospects for longevity, so that many more persons take responsibility for their personal health and understand what we will need in an era of health-care reform to promote health across the life course. We address this imperative by offering a relevant curriculum through a public-health lens, designed especially for university undergraduate students. Unlike the traditional educational focus on graduate students who are already committed to a career in the health professions, the students in our sights have little prior exposure to the course content and are still largely uncertain of their career plans. We believe this proposed course will help students understand aging processes as these evolve over time, understand the opportunities that arise from greater life expectancy, encourage them to promote their own health, and make a social contract to do so for society

MODIFICATION BY FRAILTY STATUS OF AMBIENT AIR POLLUTION EFFECTS ON LUNG FUNCTION IN OLDER ADULTS IN THE CARDIOVASCULAR HEALTH STUDY

Older adult susceptibility to air pollution health effects is well-recognized. Advanced age may act as a partial surrogate for conditions associated with aging. The authors investigated whether gerontologic frailty (a clinical health status metric) modified the effects of ambient ozone or particulate matter (PM10) air pollution on lung function in 3382 older adults using 7 years of followup data from the Cardiovascular Health Study (CHS) and the CHS Environmental Factors Ancillary Study. Monthly average pollution and annual frailty assessments were related to up to 3 repeated measurements of lung function using novel cumulative summaries of pollution and frailty histories that account for duration as well as concentration. Frailty history was found to modify long-term pollution effects on Forced Vital Capacity (FVC). For example, the decrease in FVC associated with a 70 ppb-month increase in the cumulative sum of monthly average O3 exposure was 8.8 mL (95% confidence interval (CI): 7.4, 10.1) for a woman who had spent the prior 7 years prefrail or frail compared to 3.3 mL (95% CI: 2.7, 4.0) for a similar not frail woman (interaction P\u3c0.001)

SURROGATE SCREENING MODELS FOR THE LOW PHYSICAL ACTIVITY CRITERION OF FRAILTY

Background and Aims. Low physical activity, one of five criteria in a validated clinical phenotype of frailty, is assessed by a standardized questionnaire on up to 20 leisure time activities. Because of the time demanded to collect the interview data, it has been challenging to translate to studies other than the Cardiovascular Health Study (CHS), for which it was developed. Considering subsets of activities, we identified and evaluated streamlined surrogate assessment methods and compared them to one implemented in the Women’s Health and Aging Study (WHAS). Methods. Using data on men and women ages 65 and older from the CHS, we applied logistic regression models to rank activities by “relative influence” in predicting low physical activity. We considered subsets of the most influential activities as inputs to potential surrogate models (logistic regressions). We evaluated predictive accuracy and predictive validity using the area under receiver operating characteristic curves and assessed criterion validity using proportional hazards models relating frailty status (defined using the surrogate) to mortality. Results. Walking for exercise and moderately strenuous household chores were highly influential for both genders. Women required fewer activities than men for accurate classification. The WHAS model (8 CHS activities) was an effective surrogate, but a surrogate using 6 activities (walking, chores, gardening, general exercise, mowing and golfing) was also highly predictive. Conclusions. We recommend a 6 activity questionnaire to assess physical activity for men and women. If efficiency is essential and the study involves only women, fewer activities can be included

Elevated Serum Carboxymethyl-Lysine, an Advanced Glycation End Product, Predicts Severe Walking Disability in Older Women: The Women's Health and Aging Study I

Advanced glycation end products (AGEs) have been implicated in the pathogenesis of sarcopenia. Our aim was to characterize the relationship between serum carboxymethyl-lysine (CML), a major circulating AGE, and incident severe walking disability (inability to walk or walking speed $<0.4$ m/sec) over 30 months of followup in 394 moderately to severely disabled women, $\ge 65$ years, living in the community in Baltimore, Maryland (the Women's Health and Aging Study I). During followup, 154 (26.4%) women developed severe walking disability, and 23 women died. Women in the highest quartile of serum CML had increased risk of developing of severe walking disability in a multivariate Cox proportional hazards model, adjusting for age and other potential confounders. Women with elevated serum CML are at an increased risk of developing severe walking disability. AGEs are a potentially modifiable risk factor. Further work is needed to establish a causal relationship between AGEs and walking disability

Productivity and Engagement in an Aging America: The Role of Volunteerism

Volunteering in late life is associated with health benefits such as reduced risk of hypertension, improved self-related health and well-being, delayed physical disability, enhanced cognition, and lower mortality. Although the mechanisms of these correlations are not clear, increases in physical activity, cognitive engagement, and social interactions likely play contributing roles. Volunteers are typically thought to represent a select group, often possessing higher levels of education and income, good health, and strong social networks. However, group evidence indicates that there are many members of groups of lower socioeconomic status (SES), including elderly adults, who serve their communities on a regular basis and in high-priority programs. We propose that the impact of volunteering in an aging population be recognized and invested into, and that effective programs harness social capital of older adults to address critical societal needs and also improve the well-being of older adults. While members of low-SES groups are less likely to volunteer, they exhibit disproportionately great benefits. The Experience Corps represents a model of an effective volunteerism program, in which elders work with young schoolchildren. Existing federal initiatives, in cluding the Foster Grandparent Program and Senior Companion Program – which target low-income elders – have had low participation with long waiting lists. Given the proven benefits and relatively low proportion of older persons who volunteer, enhancement of elder volunteerism presents a significant opportunity for health promotion and deserves consideration as a national public health priority

Association of IGF-I Levels with Muscle Strength and Mobility in Older Women

The functional consequences of the age-associated decline in IGF-I are unknown. We hypothesized that low IGF-I levels in older women would be associated with poor muscle strength and mobility. We assessed this question in a population representative of the full spectrum of health in the community, obtaining serum IGF-I levels from women aged 70–79 yr, enrolled in the Women’s Health and Aging Study I or II. Cross-sectional analyses were performed using 617 women with IGF-I levels drawn within 90 d of measurement of outcomes. After adjustment for age, there was an association between IGF-I and knee extensor strength (P = 0.004), but not anthropometry or other strength measures. We found a positive relationship between IGF-I levels and walking speed for IGF-I levels below 50 μg/liter (P < 0.001), but no relationship above this threshold. A decline in IGF-I level was associated with self-reported difficulty in mobility tasks. All findings were attenuated after multivariate adjustment. In summary, in a study population including frail and healthy older women, low IGF-I levels were associated with poor knee extensor muscle strength, slow walking speed, and self-reported difficulty with mobility tasks. These findings suggest a role for IGF-I in disability as well as a potential target population for interventions to raise IGF-I levels

An objective metric of individual health and aging for population surveys

Background We have previously developed and validated a biomarker-based metric of overall health status using Mahalanobis distance (DM) to measure how far from the norm of a reference population (RP) an individual’s biomarker profile is. DM is not particularly sensitive to the choice of biomarkers; however, this makes comparison across studies difficult. Here we aimed to identify and validate a standard, optimized version of DM that would be highly stable across populations, while using fewer and more commonly measured biomarkers. Methods Using three datasets (the Baltimore Longitudinal Study of Aging, Invecchiare in Chianti and the National Health and Nutrition Examination Survey), we selected the most stable sets of biomarkers in all three populations, notably when interchanging RPs across populations. We performed regression models, using a fourth dataset (the Women’s Health and Aging Study), to compare the new DM sets to other well-known metrics [allostatic load (AL) and self-assessed health (SAH)] in their association with diverse health outcomes: mortality, frailty, cardiovascular disease (CVD), diabetes, and comorbidity number. Results A nine- (DM9) and a seventeen-biomarker set (DM17) were identified as highly stable regardless of the chosen RP (e.g.: mean correlation among versions generated by interchanging RPs across dataset of r = 0.94 for both DM9 and DM17). In general, DM17 and DM9 were both competitive compared with AL and SAH in predicting aging correlates, with some exceptions for DM9. For example, DM9, DM17, AL, and SAH all predicted mortality to a similar extent (ranges of hazard ratios of 1.15–1.30, 1.21–1.36, 1.17–1.38, and 1.17–1.49, respectively). On the other hand, DM9 predicted CVD less well than DM17 (ranges of odds ratios of 0.97–1.08, 1.07–1.85, respectively). Conclusions The metrics we propose here are easy to measure with data that are already available in a wide array of panel, cohort, and clinical studies. The standardized versions here lose a small amount of predictive power compared to more complete versions, but are nonetheless competitive with existing metrics of overall health. DM17 performs slightly better than DM9 and should be preferred in most cases, but DM9 may still be used when a more limited number of biomarkers is available