1

Aging Outside the Box

Stanford Continuing StudiesBio 59

James F. Fries, MDDecember 5, 2007

Slides Available at ARAMIS.Stanford.edu

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

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

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

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

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

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

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

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.

10

11

QUESTIONS?

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

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

SECONDARY PREVENTION

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

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

prevention approaches

15

16

FRAILTY, ORGAN RESERVE, AND RESILIENCE

The Frail Elder

The Resilient Senior

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

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

BEING A WEEKEND WARRIOR IS NOT GOOD

• Insufficient Conditioning

• Prone to Injuries

• Sporadic and more Sporadic

• Too Easy a Habit to Break

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

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

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

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

24

25

26

27

28

29

30

31

32

33

34

35

36

37

Scenarios for Future Morbidity and Longevity

Morbidity Death

Present Morbidity

I. Life Extension

II. Shift to the Right

III. Compression of Morbidity

56

7765

8060

8056

76

38