1. 1 Aging Outside the Box Stanford Continuing Studies Bio 59 James F. Fries, MD December 5, 2007 Slides Available at ARAMIS.Stanford.edu

2. 2 Class Schedule General Themes October 17 – Longevity October 24 – Compression of Morbidity October 31 – Declining Disability November 7 – Aging and Health Policy December 5 – Questions and Application _ Evaluations

3. 3 For a Letter Grade Pick an article, any article, from the course reader. Write a page, double-spaced, bullets allowed, on ”Why you should believe this paper” Write a second page on “Why you should not believe this paper.” Email to jff@stanford.edu or mail to J. F. Fries, 1000 Welch Road, Suite 203, Stanford, CA 94304jff@stanford.edu Be ready to say a few words about your arguments at the last class meeting December 5

4. 4 A General Theory of Morbidity and Mortality Perturbations to the individual health may be classified quantitatively as increasing or decreasing morbidity and as increasing or decreasing mortality The individual is subject to many perturbations and it is usual for some to have positive and some negative effects on morbidity and/or mortality Consider, for example, the perturbations of ‘suicide’ and ‘osteoarthritis’, which have opposite effects on mortality and morbidity Population morbidity and population mortality are the integrated sums of the positive or negative effects of different perturbations on individuals in the population

5. Health Improvement Programs: Randomized Trials in Seniors Fries et al, Health Affairs, 1998

6. 6 Health Improvement and Cost Reduction Programs in Senior Populations: Goals Improved Self-Efficacy Reduction in Health Risks Increased Self-Management Targeting High-Risk Persons Targeting Chronic Disease Advance Directives: Humanizing the Last Year

7. 7 Parameters of Programs that Improve Health and Save Money Program cost $100/year or less (medical costs per senior per year = $6,000). Design ROI 5:1 Multiple interventions in one Multiple contacts through the year Tailored interventions - to each his or her own health improvement program Not doctor/hospital/one-on-one based: too expensive Computer-driven, mail (and increasingly Web) delivered Focus on big, modifiable health and cost issues

8. 8 Senior Risk Reduction Program Medicare Demonstration Program 2007-2010 Tailored health improvement and cost reduction programs (‘HRA based’) Potential established by RAND; randomized trial design by MedSTAT Five interventions ‘best in class’, two control groups, three years, 85,000 subjects, independent assessment of results Goals:health up, risks down, costs neutral or down = a new Medicare benefit

9. 9 Conclusions Theory, Longitudinal Studies, Population Surveys, and Randomized Trials document that: Disability has been decreasing by 2% or more per year in the U.S.for at least 10 years. Mortality rates are decreasing at only 1% a year, documenting Compression of Morbidity Health enhancement programs can improve health and reduce costs in mature adult populations The Senior Risk Reduction Demonstration is a randomized controlled trial which could lead to better senior health and lower medical costs Further Compression of Morbidity is feasible but not inevitable.

10. 10

11. 11 QUESTIONS?

12. 12 HOW CAN BETTER SENIOR HEALTH BE ACHIEVED? Self-Efficacy Health Policies Targeted Postponement of Morbidity Behavioral Health Risk Reduction Medical Primary Prevention Medical Secondary Prevention Social and Environmental Policies

13. 13 PRIMARY PREVENTION Smoking Passive Smoking Inactivity Obesity Lipids Inflammation Salt Fiber Screenings:mam, col, pap, bp, eye, bmd Alcohol Caffeine Sun Seat Belts Vehicles Highways Aspirin Pollution Vaccines

14. 14 SECONDARY PREVENTION Aspirin Hypertensive control Lipid control Diabetes control Beta blockers Bone strengthening Fall Prevention Self-management Medical errors Plus: Primary prevention approaches

15. 15

16. 16 FRAILTY, ORGAN RESERVE, AND RESILIENCE The Frail Elder The Resilient Senior

17. 17 Abundant Benefits of Exercise Increased Longevity Postponed Disability Heart Disease Down Brain Function Up Lung Disease Down Muscle Strength Up Endurance Up Osteoporosis Down Blood Clots Down Better Appearance Better Sleep Less Stress Better Self-Efficacy Better Sex Increased Reserves Endorphans The Overweight Dividend: Fit but Fat

18. 18 CREDENTIALS OF AN AGING EXERCISE GURU Boston Marathon age 40 (3:09) Grand Teton ages 40,50,60 Nevada Pisco age 46 Everest, almost, age 54 Six Summits, age 50 + Twenty 14ers, age 60 + Pike’s Peak Marathon age 65

19. 19 BEING A WEEKEND WARRIOR IS NOT GOOD Insufficient Conditioning Prone to Injuries Sporadic and more Sporadic Too Easy a Habit to Break

20. 20 THE PROBLEM OF TIME A Matter of Habit Put the Time In first, Intensity Later 2-3 Endurance Hours a Week for 90 % Effect Breaking a Sweat on a cool day Plateau occurs at 8 hours/week

21. 21 THE PROBLEM OF BOREDOM There is an Activity for Everyone It Must Be A Happy Habit Scenery or Television or Meditation Cross-Training Dogs and Aerobic Gardening No Excuses Please Exercise is its Own Reward Feeling Good All Day Long

22. 22 WHEN YOU HURT Reduce or discontinue activity Increase alternative activity – most frequently bicycling (moving or stationary), swimming, brisk walking, cross-country ski machine Usually smooth and gradable is best When resuming an activity, take as long to get back to baseline as you took away from the activity

23. 23 WHERE YOU HURT: Listening to the Pain Message The Six-Week Re-Injury Rule Back - favor Ribs - tape Ankles - brace Achilles Tendon - lift Knees - brace Plantar Fascia - strap Elbow - strap Neck - collar

24. 24

25. 25

26. 26

27. 27

28. 28

29. 29

30. 30

31. 31

32. 32

33. 33

34. 34

35. 35

36. 36

37. 37 Scenarios for Future Morbidity and Longevity Morbidity Death Present Morbidity I. Life Extension II. Shift to the Right III. Compression of Morbidity 56 77 65 80 60 8056 76

38. 38