Public Health Goals for the Second Fifty Years

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Public Health Goals for the Second Fifty Years

• Steven M. Albert, PhD
• Department of Behavioral and Community Health,
  GSPH
• University of Pittsburgh

smalbert_at_pitt.edu
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Ten Great Public Health Achievements, 1900-1999

• Vaccination
• Motor vehicle safety
• Safer workplaces
• Control of infectious diseases
• Decline in mortality from heart disease and
  stroke

• Safer and healthier foods
• Healthier mothers and babies
• Family planning
• Fluoridation
• Recognition of tobacco as hazard

CDC 2000
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A Cultural Model of Aging (ours, too)
NRC, The Aging Mind, 1997
Aging viewed in light of ability and disability
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Part I Challenges of Success

• Reduction in mortality
• Older ages at death but greater prevalence of
  chronic disease and complex disability dynamics
• Reduction in fertility
• Greater investments in old-age (e.g., education)
  but fewer family caregivers

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Age Distribution of Deaths Swedish Females,
Selected Periods
Horiuchi 2003
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Part II Aging

• Whips and scorns of time or something more
  complex?

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• The aging process involves decline in many
  physiological parameters
• (Nathan Shock Model)

Few examples Reaction Time (longer) Cognitive
Status Nerve Conduction Velocity Muscle
Strength Visual Acuity Macro and Micronutrients
intake Insulin Sensitivity Testosterone Estrogens
IGF-1 Cytokines and APR (higher) ROS /
Antioxidants Complexity of CV reflexes
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100
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Physiologic reserve - Hypothetical Trajectory to
Illness, Functional Limitation, Disability
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hip fracture
pneumonia
congestive heart failure
Functional limitation
Physiologic reserve
2
Disability
3
Younger age
Older age
(Newman 2006)
Time
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Decline in Gait Speed with Age
Bohannon 1997
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Age and Grip Strength
Frederiksen 2006
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Mobility (and hence sarcopenia) is a better
predictor of mortality than chronologic age in C.
elegans
Herndon et al., Nature 2002
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Indicator 17 - Memory Impairment
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Indicator 20 - Respondent-Assessed Health Status
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Cumulative Risk of AD, by Race-Ethnicity, Limited
to APOE e3/3
From Table 1, Tang et al 1998
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Age and Cancer
NHIS 2004
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Age and Diabetes, Arthritis
NHIS 2004
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Age and Sensory Problems
NHIS 2004
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Age and Functional Limitation A Mixture of
Senescence, Disease, and Environment
NHIS 2004
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Draw a clock with hands showing the time 1120
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Unhealthy Physical or Mental Health Days, by Age
MMWR Oct 28, 2005 54(SS04) 1-35
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Aging Reduction in Behavioral Risk Factors
NHIS 2004
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Risk factors for total mortality in CHS

• Increasing age, male
• Low income
• Lack of moderate or vigorous exercise
• Smoking for more than 50 pack-years
• High ankle-brachial index (systolic blood
  pressure)
• Diuretic use by those without hypertension or
  congestive heart failure
• Elevated fasting glucose level (130 mg/dL)

• Low albumin level (
• Elevated creatinine level (or to 106
  micromoles/L 1.2 mg/dL)
• Low forced vital capacity (
• Aortic stenosis (moderate or severe) Abnormal
  left ventricular ejection fraction Congestive
  heart failure
• Difficulty in any IADL/ADL
• Worse Digit Symbol Substitution test score

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Part III Prospects for Optimal Aging

• Diversity in Aging
• Historical perspective
• Interventional gerontology

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What Has Changed Over Last Century?

• Less infectious disease ( less long-term
  effects, or scarring)
• Typhoid, diarrheal disease, cholera, measles,
  rheumatic fever, scarlet fever, diphtheria,
  whooping cough
• Less occupational stress
• Technologies reduce manual labor
• Greater affluence

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Plowing, 1868
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Plowing, 1910
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Plowing, 1940
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NYC, 1911, Dirty floor, vermin abounded, garbage
standing uncovered
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Prevalence of Symptoms and Conditions, 1900 and
1990 (Males, Age 60-74)
(Costa, 2002)
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Definitions of Optimal Aging
Physical, cognitive, and/or emotional
functioning
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Albert, J Cross-Cult Gerontol, 2006
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Preventable Diseases in Aging
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Preventable Diseases in Aging
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QOL Domains Supportive Service Populations
(Kane, 2000)

• Sense of security order
• Enjoyment
• Meaningful activity
• Social relationships (reciprocity)
• Dignity
• Privacy

• Individuality (identity with past)
• Autonomy (express choices)
• Spiritual well-being
• Functional competence
• Physical comfort

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Healthy People 2010 Goals

• Objective Target Current
• Reduce who are obese 15 22
• Reduce who have no
• leisure-time physical activity 20
  26
• Reduce who smoke 12
  23

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Healthy People 2010 Goals

• Objective Target Current
• Increase who have had
• cholesterol checked 80 73
• Increase who have had
• colorectal cancer screen 50 46
• Increase with annual
• influenza vaccine 90 66
• Increase who received
• mammography 70 76

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The 10 KeysTM to Healthy Aging

• Control blood pressure (SBP
• Regulate blood glucose (
• Lipids (LDL
• Stop smoking
• Be active

• Participate in cancer screenings
• Get regular immunizations
• Prevent bone loss and muscle weakness
• Combat depression
• Maintain social contact

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Heat Mortality Chicago, 1995
/100,000
Klinenberg 1995
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Place-Based Vulnerability
Mortality /100,000
Klinenberg, 15 communities with highest deaths,
10 lowest
Population lost 30 yr
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Neighborhood Effects on Relationship between
Individual Education and Cognitive Performance
75 of community HS education
Elder Cognitive Score

0
College
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12
Individual Educational Attainment
After Wight 2006
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Part IV Disability in Old Age

• The central challenge

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Function What Really Concerns Us
The women worked all the time washing laundry,
ironing shirts, mending socks, turning collars,
sewing on buttons, mothproofing woolens,
polishing furniture, sweeping and washing floors,
cleaning sinks, tubs, toilets, and stoves,
vacuuming rugs, nursing the sick, shopping for
food, cooking meals, feeding relatives, tidying
closets and drawers, overseeing paint jobs and
household repairs, arranging for religious
observances, paying bills and keeping the
familys books while simultaneously attending to
their children and health, clothing, cleanliness,
schooling, nutrition, conduct, birthdays,
discipline, and morale. Roth, The Plot Against
America, pg. 3
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Factors that Influence Function

• Function
• Disability (ADL) or broader engagement?
• Self-reported or observed performance?
• External or Internal Factors
• Built and community environment
• Home accessibility, safety assistive devices
• In-home services distance to key services
• Physical, cognitive, and psychological resources
• Strength, memory, mood
• Motivation to be independent, self-efficacy

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Basic Adult Competencies

• ADL
• Bathing
• Dressing
• Grooming
• Self-feeding
• Using toilet
• Transfer

• IADL
• Light shopping
• Light housework
• Preparing meals
• Managing medications
• Handling finances
• Using telephone
• Laundry

Advanced driving, working, programming
appliances, self-care, parenting, heavy cleaning,
complex shopping, home repairs
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Indicator 19 - Disability
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Trends in Old Age Disability
Spillman, 2004, NLTCS
Age standardized. Disability ADL help, IADL
difficulty, SNF, 3 mo helppersonal assistance
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Senescence, Chronic Disease, Environment, and
Disability
Physiologic changes of aging, not disease-based
(e.g., sarcopenia, hypometabolism)
A
Frailty
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Disability
Disease, comorbidity
B
C
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Albert, 2002
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A Model of Disablement
Self-Reported Disability
Functional Limitation
Pathology
Impairment
Loss of lower-extremity strength
Sarcopenia
Altered performance in daily tasks
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Disablement
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Preventing Disability

Primary-Secondary, 1-2
Functional Limitation
Self-Reported Disability
Pathology
Impairment
Loss of lower-extremity strength
Sarcopenia
Altered performance in daily tasks
Tertiary,3
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Partitioning Survival by Functional Status WHO
Model, 1
Survival

50
Age
75
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Partitioning Survival by Functional Status WHO
Model, 2
Disability
Survival

50

Age
70
75
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Partitioning Survival by Functional Status WHO
Model, 3
Disability
Survival

Pre-clinical disability
50
//
Age
70
60
75
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But Many Challenges

• To a certain extent, it is as if we have not
  fully engaged in applying public health practice
  to older populations . The aging network is
  looking to public health for science-based health
  promotion and disease prevention strategies that
  are tested and proven effective.
• --JS Marks, CDC, US Senate, 5/19/03

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Parallel Networks Aging Services and Public
Health
Department of Health and Human Services
AoA
CDC
CDD Chronic Disease Program Directors
NASUA Natl Assn of State Units on Aging
57 SUAs
58 SHDs
NACCHO National Asso of County City Health
Officials
N4A National Assn of Area Agencies on Aging
655 AAAs
3,000 LHDs
Community Orgs
Community Orgs
Benson, 2005