1 aging outside the box stanford continuing studies bio 59 james f. fries, md december 5, 2007...

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Aging Outside the Box

Stanford Continuing StudiesBio 59

James F. Fries, MDDecember 5, 2007

Slides Available at ARAMIS.Stanford.edu

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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

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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 94304• Be ready to say a few words about your arguments

at the last class meeting December 5

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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

Health Improvement Programs: Randomized Trials in Seniors

n time

health risk

score cost per person

savings per

person ROI

Bank of America 4,712

12 months -12% $29 $179 6.1

CALPers 57,268 12

months -10% $59 $300 5.1

Arthritis 809 6

months -7% $50 $260 5.2

Parkinson’s 290 6

months -10% $100 $570 5.7

Take Care of Yourself 2,833

12 months -17% $6 $20 3.5

Fries et al, Health Affairs, 1998

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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

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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

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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

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ConclusionsTheory, 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.

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QUESTIONS?

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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

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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

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SECONDARY PREVENTION

• Aspirin• Hypertensive control• Lipid control• Diabetes control• Beta blockers

• Bone strengthening• Fall Prevention• Self-management• Medical errors• Plus: Primary

prevention approaches

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FRAILTY, ORGAN RESERVE, AND RESILIENCE

The Frail Elder

The Resilient Senior

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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

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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

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BEING A WEEKEND WARRIOR IS NOT GOOD

• Insufficient Conditioning

• Prone to Injuries

• Sporadic and more Sporadic

• Too Easy a Habit to Break

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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

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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

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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

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WHERE YOU HURT:Listening to the Pain MessageThe Six-Week Re-Injury Rule

• Back - favor• Ribs - tape• Ankles - brace• Achilles Tendon - lift

• Knees - brace• Plantar Fascia - strap• Elbow - strap• Neck - collar

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Scenarios for Future Morbidity and Longevity

Morbidity Death

Present Morbidity

I. Life Extension

II. Shift to the Right

III. Compression of Morbidity

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7765

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8056

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