1. 1 Aging Outside the Box Stanford Continuing Studies James F. Fries, MD October 24, 2007 Slides Available at ARAMIS.Stanford.edu

2. 2 A Personal Background Information Science, Chronic Disease Databank Model, ARAMIS (Arthritis, Rheumatism, and Aging Medical Information System) Outcomes of Chronic Illness (HAQ) Compression of Morbidity Medical Self-Care Disease Criteria, NSAID Gastropathy, Inverting the Pyramid, Improving Outcomes in Arthritis

3. 3 ON REDUCTIONIST SCIENCE Science as Observation, Science as Experiment Truth as Correspondence (James), Truth as Cohesion (Dewey)

4. 4 Class Schedule General Themes October 17 – Longevity October 24 – Compression of Morbidity October 31 – Declining Disability November 7 – Aging and Health Policy December 5 – Synthesis and Application

5. 5 THE COMPRESSION OF MORBIDITY A Classic 1980 Article for Discussion: Concept, Logic, Data, Errors Citations and Google Readings: Fries 1980, Vita 1998, Wang 2002

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7. 7 The Compression of Morbidity: Central Thesis The age at first appearance of aging and chronic disease symptoms can increase more rapidly than life expectancy

8. 8 Errors in the Classic Article

9. 9 “Number of very old will not increase” – It will, but driven by birth cohorts and early life survival Lifespan = 85 years – more like 90 + but close Standard Deviation of Age at Death = 4 years; it’s always been 8 years (Figure 5) Centenarians 1:10,000; No, more than 1:100

10. 10 ORIGINS OF THE COMPRESSION OF MORBIDITY HYPOTHESIS Center for Advanced Study in the Behavioral Sciences The Plasticity of Aging: Baltes, Riley, Loftus, Seligman, Valliant, Fries An Interdisciplinary Light Bulb Clicks On The Realities of Life Span: Crapo

11. 11 Elements of the Paradigm Shift Natural and Premature death Postponement Replaces Prevention The Epidemiologic Transitions: Acute (infection) to Chronic (heart) to Aging (frailty) Or: Early Death, Little Morbidity to Expansion of Morbidity to Compression of Morbidity

12. 12 Critics of the Compression of Morbidity Hypothesis Demographers vested in contrary predictions Basic Scientists fearing lost grant funds Humanists positing ‘blaming the victim’ Gerontologists wanting time to prepare Pessimists believing it will never happen

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18. 18 Evidence for Compression of Morbidity Longitudinal studies document morbidity compression by social class, exercise, education level, combined risk factors National surveys of disability since 1982 show current disability decreases of over 2% a year Randomized studies in seniors show disability and cost reductions with health risk improvements

19. 19 University of Pennsylvania Study 1986-2007 Three Lifestyle Risk Factors at Age 68 –Overweight or obese –Cigarette smoking –No regular vigorous activity Three Risk Groups: -LOW=zero risk factors -MODERATE=1 risk factor -HIGH=2 or 3 risk factors

20. 20 University of Pennsylvania Study, 2007 Death Rates (per 10,000 Person-Years) Low RiskModerate RiskHigh Risk NDead by 2003 RateNDead by 2003 RateNDead by 2003 Rate 6052002191073420269649308342

21. 21 Hubert et al, A&R, 2006 University of Pennsylvania Study, 2007

22. 22 University of Pennsylvania Study, 2007

23. 23 University of Pennsylvania Attendees 1939-40 Disability Index by Age and Risk Factor Category Age Disability Index Vita et al, NEJM, 1998

24. 24 University of Pennsylvania Study, 2007 Conclusions: –Mortality reduction from low risk to high risk groups is about 4 years –Disability postponement from high to low risk groups is about 8 years –Healthy lifestyle-related risk factors in seniors, including normal weight, regular physical activity and smoking abstinence offer protection against disability despite the associated survival advantages over time

25. 25 Exercise and Disability: A 21-Year Study Wang et al, Archives Internal Medicine, 2002: Chakravarty et al, Archives Internal Medicine, 2008 (in press) 538 Runners Club Members 423 Community Controls Average Age 58 in 1984 Average Age 79 in 2005

26. Disability by Age in Runners and Controls Age Category Community Control (n=249) Runners Club (n=369) Mean Disability Score Wang et al, Arch Int Med, 2002

27. 27 Exercise and Disability

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29. 29 Exercise and Disability Conclusions Regular vigorous physical activity, including running and jogging, may postpone disability by 12 to 16 years, far more than more casual exercise. Bone mineral density is increased by exercise; osteoporosis is decreased. X-rays of knees are better in exercising subjects, even regular long-distance runners, than controls.

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