Summary

Americans are growing older. People over age 65 make up about 12 percent of the population now, and their proportion is predicted to reach 23 percent by the year 2040. The implications of an aging population for health care are being widely discussed but seldom with the understanding that health promotion and disability prevention are workable concepts for people in the ''second 50" years of life.

Toward that end, an assortment of diseases, causes of injury, and risk factors was selected for examination in this study. All play a significant role in disability in older people. They are misuse of medications, social isolation, physical inactivity, osteoporosis, falls, sensory loss, depression, oral health, screening for cancer, nutrition, smoking, high blood pressure, and infectious diseases. In the broadest sense they all are risk factors; each may function as the initial or early stage of a train of events leading to disability. High blood pressure (or hypertension) is a useful example of these relationships. It is a disease, but it is also a powerful causative factor for strokes and coronary artery disease, disorders that involve impairments of organ function; these may be followed in turn by losses of everyday personal functions and, ultimately, limitations in social roles. The World Health Organization has built a classification system around the transition from physical impairments on the organ level, to losses of personal function such as hygiene and feeding, to limitations in more social settings—conditions of impairment, disability, and



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The Second Fifty Years: Promoting Health and Preventing Disability Summary Americans are growing older. People over age 65 make up about 12 percent of the population now, and their proportion is predicted to reach 23 percent by the year 2040. The implications of an aging population for health care are being widely discussed but seldom with the understanding that health promotion and disability prevention are workable concepts for people in the ''second 50" years of life. Toward that end, an assortment of diseases, causes of injury, and risk factors was selected for examination in this study. All play a significant role in disability in older people. They are misuse of medications, social isolation, physical inactivity, osteoporosis, falls, sensory loss, depression, oral health, screening for cancer, nutrition, smoking, high blood pressure, and infectious diseases. In the broadest sense they all are risk factors; each may function as the initial or early stage of a train of events leading to disability. High blood pressure (or hypertension) is a useful example of these relationships. It is a disease, but it is also a powerful causative factor for strokes and coronary artery disease, disorders that involve impairments of organ function; these may be followed in turn by losses of everyday personal functions and, ultimately, limitations in social roles. The World Health Organization has built a classification system around the transition from physical impairments on the organ level, to losses of personal function such as hygiene and feeding, to limitations in more social settings—conditions of impairment, disability, and

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The Second Fifty Years: Promoting Health and Preventing Disability handicap, respectively. This system is discussed and recommended by the committee as a framework for the consequences of disease in Chapter 2. Besides a causal role in the process of disablement, each of the 13 issues selected met two other criteria. They had to affect appreciable numbers of older people, and interventions to modify them had to be available, although not necessarily fully developed. Although arthritis and Alzheimer's disease are not included in this report, their absence here should not be taken as a signal that they are undeserving of national attention. The report covers a wide range of health policies. Each chapter provides a definition of the health risks related to the central topic, a discussion of incidence and prevalence, costs and measures of cost, remediability, and a set of recommendations to the research, education, and service communities. These chapters address fields with varying degrees of maturity. Some issues such as high blood pressure, osteoporosis, and smoking are familiar to health care professionals, and so these chapters have been written to inform policymakers and the public about the latest findings and their relevance for health policy. Other issues such as physical inactivity, depression, nutrition, and sensory loss are familiar topics but still in the early stages of development in terms of research, service standards, and procedures to address the functional difficulties of older people. These chapters discuss the available evidence and suggest ways in which these fields should be broadened in light of the aging population. Of this latter group, perhaps social isolation is the youngest of all. This chapter therefore discusses strategies for laying theoretical groundwork. GENERAL ISSUES OF HEALTH PROMOTION AND DISABILITY PREVENTION Unfortunately, American culture clings to some very pessimistic assumptions about aging. Growing old is often associated with frailty, sickness, and a loss of vitality. We frequently assume that older individuals are a burden to the state, their families, or even to themselves. In fact, many older individuals lead satisfying lives and maintain their health well beyond society's expectations. "Quality of life": we are called upon as health professionals to improve it, yet it is an elusive goal. Certainly one reason is that no one individual or institution has proposed a definition that all can agree with. The committee will not attempt a definition in this report but would simply like to put forth the observation that health

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The Second Fifty Years: Promoting Health and Preventing Disability professionals who do not believe that there is a "quality life" for older people will not strive to assist older individuals to achieve it. The same could be said of society in general. Our misplaced pessimism gives rise to the particularly troubling consequence that many more individuals who could experience a fulfilling maturity are denied the chance by these stereotypes. This pessimistic attitude toward aging is carried over into our nation's health policies. Health research, education, and service policies are often written as though our older generations are beyond help. Although there is sufficient evidence of the benefits of health promotion and disability prevention among older individuals, many of them are not advised to stop smoking, to begin exercising, to be screened for various forms of cancer, or to be immunized against infectious diseases. Research with older people can be challenging methodologically and ethically, but the future centrality of health in old age means that these difficulties should be addressed now. Obviously, older people encounter more health problems than the general population, but there ought to be a distinction between pessimism and realism. Realistically, we can expect that an aging population will mean a significant increase in the number of individuals seeking care for chronic illnesses, disabilities, and acute conditions. Nevertheless, we should not let pessimism become an obstacle to the introduction of new research on interventions to restore and maintain function among physically or mentally impaired older people. There are ways to help individuals keep their physical limitations from becoming major limitations in society, and these ought to be pursued through a combination of research, health services policy, education, and legislation. The foremost reason for expanding health and social services to the elderly ought to be the benefits provided to individuals, but there are also societal benefits involved in health promotion and disability prevention. When older individuals are denied the opportunity to participate in constructive roles, it is not simply they who are cheated. The most obvious example occurs when we deny someone who is capable, but there is also the hidden discrimination of denying opportunities to regain these capabilities. An essential part of a new outlook on the health needs of the aging population is to recognize our responsibility to improve the quality of life for those who have already become ill or are disabled. Two goals have been at the core of health care: to cure disease and to prevent its occurrence. To accommodate the changing needs of an increasingly older society we must add several imperatives: we must promote health throughout life, and we must also prevent the ill

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The Second Fifty Years: Promoting Health and Preventing Disability from becoming disabled and help the disabled to prevent further disability. The central message of all the chapters of this report is intended for a broad audience, but it can be most clearly articulated when addressed directly to practicing health professionals, especially physicians. That message is: the responsibility neither begins nor ends with acute care. Individuals who come to physicians should be encouraged to adopt healthier lifestyles and avail themselves of preventive services. Patients with successfully treated acute conditions may need rehabilitation and assistance in learning to cope with long-term residual physical impairments. Moreover, a majority of older individuals are likely to have chronic conditions that greatly increase the chances for some kind of functional limitation. Older individuals do experience some diminution of function, but many of today's health professionals dismiss virtually all functional limitations as the natural consequences of aging. A major purpose of this report is to dissuade health professionals from the belief that growing old necessarily means growing frail. CONCLUSIONS AND RECOMMENDATIONS The committee recognizes that the risks associated with disease and disability in later life are linked to unhealthy behavior in earlier years. However, a full review of all health promotion activities is beyond the scope of this report. The full report, therefore, includes recommendations for new services, research, and professional and public education largely devoted to the later half of life. This section of the summary provides a brief description of the major points asserted in each of the chapters. The committee's major conclusion can be summarized as follows: The long-term consequences of disease are too important to ignore. The health professional's responsibility cannot begin or end with cure. High Blood Pressure Medicare and private insurance should reimburse for physician visits to evaluate blood pressure. Public education and public health strategies need to be developed to promote detection and treatment of high blood pressure, especially among black males, isolated older persons, and other people unlikely to have access to periodic health care. Research should be performed to determine the cost-effectiveness

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The Second Fifty Years: Promoting Health and Preventing Disability of treating mild diastolic high blood pressure in older people, with emphasis on quality-adjusted life years. The efficacy of nonpharmacologic intervention in treating diastolic or isolated systolic high blood pressure in older people should be tested further. More sophisticated measures of risk in mild hypertensives over age 50 are needed. Medications The proper medication can have a significant therapeutic effect; improper medication can be disabling and deadly. Age must be taken into account when testing drugs for efficacy, side effects, and dosage. Very few drugs now undergo testing in the elderly. Health professionals must learn more about the drugs their older patients are taking, both prescribed and unprescribed, and the multiple manifestations of the adverse reactions associated with their use. Older people must learn more about the medicines they take, the signals that prompt a consultation with their physician, and the enhanced danger of taking multiple medications. Infectious Diseases Pneumonia and influenza are among the leading causes of death and morbidity from infection among older people. Safe and effective vaccines to prevent pneumonia and influenza are available and should be universally used in persons over age 50. Nosocomial (institutionally acquired) infections have a major deleterious impact on persons over 50 and require good infection control practices in hospitals and nursing homes. Osteoporosis Osteoporosis progresses silently until fractures occur; therapy cannot then replace lost bone. Additional research is needed to design cost-effective screening programs so that those at high risk of osteoporosis can be identified and treated early. The number of osteoporotic fractures that will occur each year is large and will continue to increase in the foreseeable future.

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The Second Fifty Years: Promoting Health and Preventing Disability New efforts are needed to identify the determinants of poor outcomes following these fractures and to develop optimal patient management programs that reduce disability to the extent possible. Older persons would be wise to ensure adequate calcium and vitamin D intake, reduce tobacco and excessive alcohol use, and increase physical activity although data about the efficacy of these measures to prevent age-related fractures are limited. Postmenopausal women, especially those who experienced an early menopause, should discuss with their physicians the desirability of estrogen replacement therapy. Sensory Loss Standardized definitions of sensory loss in vision and hearing need to be established. The availability and accessibility of services or devices to prevent sensory losses from becoming personal and social disadvantages need to be improved. Public and private insurers should consider covering the cost of these items. Further research including longitudinal studies is needed to gain a greater understanding of single and multiple sensory losses. Oral Health Dental and oral disabilities are unnecessary and preventable in adults. Attaining oral health goals requires appropriate patterns of self care, access to appropriate professional services, and fluoridation of community water supplies. Greater efforts should be made to determine the incidence, prevalence, and natural history of dental and oral disabilities as well as the cost-effectiveness of interventions for their prevention and control. Cancer Screening Existing studies indicate that screening for cancer will be at least as effective in persons aged 50 to 80 as in younger persons. Cancers in older persons are at least as biologically aggressive as cancers in younger persons. Nonetheless, data indicate that several populations of women over age 50 have 12 to 17 percent less screening for cancers of the breast and cervix as compared with younger populations.

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The Second Fifty Years: Promoting Health and Preventing Disability Nutrition Diet and nutrition are as important in the promotion and maintenance of the health of older people as in younger people; they are critical in the causation and control of many health problems. Functionally related assessments and screening of nutritional status should be routine among older individuals, especially those in nursing homes. Because nutrition plays an important role in health before, during, and after illness, interventions should be comprehensive. In particular, consideration should be given to interventions that recognize the essential contribution of nutrition to the quality of life and independent function. We know very little about the minimal daily nutrient and energy requirements for older people; further research is needed. Smoking It is never too late to stop smoking. People of all ages should be advised against smoking. All advertising of tobacco products should be banned. Policymakers should continue to promote smoke-free environments. Depression Support for research on depression in the elderly, including estimates of its prevalence, should be increased. Physician training to detect and treat depression in older persons must be improved and expanded. Discriminatory limitations of reimbursement for psychiatric care by Medicare and other insurers must be removed. Physical Inactivity A sedentary lifestyle creates unnecessary health risks. Older individuals can avoid these risks, maintain self control, and gain a sense of empowerment by becoming physically active. Physical activity can be promoted through social support in the community and home, through improving perceptions of health and self, and by creating access to safe, convenient, and inexpensive places to exercise. Health care professionals should collaborate with exercise

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The Second Fifty Years: Promoting Health and Preventing Disability specialists in developing programs in exercise counseling, promotion, and instruction. Research should focus on behavioral change and should attempt to make exercise a routine practice for older adults. Social Isolation A lack of family and community supports plays an important role in the development and exacerbation of disease. An absence of social support reduces compliance with medical care regimes and weakens the body's defenses through psychological stress. Isolated individuals must be identified, and strategies for increasing social contact and diminishing feelings of loneliness must be developed. Clinicians, family, friends, and social institutions bear a responsibility for diminishing social isolation. Clinics and various types of community organizations may offer solutions to social isolation by increasing their contact with older people. Falls Falls among the elderly are a major cause of mortality, morbidity, and disability. Hip fracture is the most devastating consequence of falls, but other fractures, severe soft tissue injury, fear of falling, and loss of mobility and independence are frequent and often serious consequences. Effective prevention of falls could substantially reduce disability among the elderly. Most falls in the elderly are multifactorial, resulting from the convergence of health-related, pharmacologic, environmental, behavioral, and activity-related causes. The interaction of these risk factors for falling is poorly understood. Studies are needed to increase understanding of the causal role of these antecedents to falls. Prevention of falls must not unnecessarily compromise quality of life and independence of the elderly. Controlled trials are needed to determine which treatable risk factors are causal and to guide prevention efforts. In particular, randomized trials of exercise and strength training, conservative use of psychotropic medications, and targeted treatment of selected chronic and acute medical conditions are needed.

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The Second Fifty Years: Promoting Health and Preventing Disability Studies of the biomechanical and other determinants of fall injuries, particularly the understanding of impact responses and tolerances, should be emphasized as a potential means of preventing fall injuries through the environmental control of mechanical energy. This might lead to the design of energy-absorbing surfaces or unobtrusive protective clothing for high-risk older persons.

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