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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 [email protected] 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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