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Testimony Special Committee on Aging U.S. Senate by Robert N. Butler, M.D. Brookdale Professor and Chairman Department of Geriatrics and Adult Development Mount Sinai School of Medicine My purpose today is to emphasize practical actions that can be undertaken to improve both the quality of life of older persons and control costs through effective means of health promotion and disease prevention. I. General Principles * To accomplish these objectives there is a shared responsibility of both the individual and public health in the broadest sense. Each and everyone of us must accept reeponsibility for our own lifestyle. At the same time, all of us have a right to expect that the government at all levels and the business sector will insure public education and sanitation to insure the safety of our water, food supply and public space. * It is never too late to introduce health promotion and disease prevention. Table 1 details various lines of defense, from efforts to prevent the original occurrence of dysfunction to efforts to compensate for compromised function. Revised 5/4/93 -1-

* Everyone benefits from effective health promotion and disease prevention, including the individual and his or her family, the community including the non-profit sector, and industry including labor unions. The family is released of its burden, community resources are protected and money is saved by industry. For example, business would gain measurably from reduced claims upon retiree health benefits. * Health promotion and disease prevention should not be punitive and stressful. Disciplined behavior is only one part of the process. A healthy lifestyle also promotes recreation and brings pleasure to people's lives. It promotes a sense of well-being as well as self-esteem. Such positive reinforcement helps maintain health and salutary habits. A sedentary lifestyle on the other hand curtails vitality and brings pain and various discomforts, ultimately the "doddering" associated with persons who grow older in a deconditioned state. * Human behavior can change. Indeed, cigarette consumption has fallen 2% to 3% per year in the United States over the past decade and has fallen markedly since the Surgeon General's report in 1963. Thus, pessimism over the human capacity to both change and to maintain change is not warranted. * One key element to changing behavior is the opportunity to~ (M make informed choices. People wish to have some mastery7j. W Revised 5/4/93 -2-

and control over their own lives. With education, they become aware of the dangers of certain behaviors and the advantages of others. That is why public education and effective health communication by the media is so important. This also requires physician education since not all physicians understand the importance of lifestyle to health and disease. our academic medical institutions have been so preoccupied by acute care and high-technology medicine that they have neglected primary care and prevention. For example, physicians are often surprisingly inattentive to the importance of nutrition despite the obvious fact that it constitutes fuel for the body. Physicians have frequently been equally oblivious to exercise which is necessary to maintain good conditioning. * Nonetheless, it is now possible to write specific and detailed lifestyle prescriptions. If we could put exercise into a pill we would have the first major anti-aging medication. The fact that we still have much to learn is no longer an excuse for physicians to fail to counsel and educate their patients about healthy lifestyles. * The great self-help movement in the United States, the most successful of which has been Alcoholics Anonymous, can expand beyond their primary concern with already existing disease and foster health promotion and disease prevention activities as well. Moreover, this wonderful example of Revised 5/4/93 -3-

Americana can be encouraged to show more interest in older persons. * The oldest Baby Boomer is now 47. Just 18 years from now, he/she will turn 65, the conventional marker of the beginnings of old age. The Baby Boomers make up one-third of our present population and constitute the largest generation in U.S. history. This important transitional group to the 21st Century is a generation at risk of a disastrous old age. We must build relevant social policies and a biomedical research agenda to assist the present and the future generations of older persons. • The Baby Boomers of today, soon to be the older Americans of tomorrow, will doubtless have a very different type of late life than older people today. This shows the elasticity of age. Age is not fixed and immutable. It changes from era to era, generation to generation. In the last century, for example, a person seemed to be older earlier. * Will all the efforts at health promotion and disease prevention save money? We know from data analyzed at the Health Care Financing Administration that were it possible to defer physical dependency by only one month the country would save over $5 billion a month or $60 billion a year. HCFA recently completed its cost effectiveness study of flu vaccine with a generally favorable conclusion. Both the National Institute on Aging and the Alliance for Aging Revised 5/4/93 -4 -

Research seek to build the basis for an independent old age. * Some have feared that we might experience a mass production of disabled older persons. In fact, active life expectancy, health span or quality time is expanding (see Table 2). Indeed, manifest disability rates are falling, following the use of modern rehabilitative techniques, geriatric medicine, new assistive devices and specific alterations in living arrangements. * This points to the importance of function whose maintenance is the essential goal of geriatrics. Improvements of function are seen daily in patients who receive geriatric and rehabilitative care. But this could be generalized. Reduction of the number of ventilator-dependent patients would represent a major contribution to curbing our health costs. * * * * * We must support major efforts in research and development. II. Research Topics and Strategies The first question is, what accounts for the disparity in life expectancy between men and women that favors women? Perhaps we should be asking the question that is the reverse of the song Henry Higgins sang in My Fair Lady "Why can't a woman be more like a man?" We know that two-thirds of the difference in life expectancy is due to the greater utilization of tobacco and alcohol among men - along with greater exposure to toxins and disabling accidents in Revised 5/4/93 -5-

the foundry, factory and mine and also to risk-taking behavior. Nonetheless, tobacco is beginning to have its adverse effect upon women since cancer of the lung has now surpassed cancer of the breast as the leading cause of cancer death among women. But we need to learn more about gender differences in the genetic, endocrine, and immune systems. There would be great social consequences to the extension of men's life expectancy since women are often reduced to poverty through widowhood. Second, research must be devoted to behavioral and social research. What are the incentives and disincentives involved in changing lifestyle and health behavior? How does one maximize discipline in the pursuit of conditioning? Third, special study should be focused upon the relatively recently recognized condition sarcopenia, or muscle loss, undoubtedly related to deconditioning. We already know that it is possible to both revitalize muscle function and regain muscle mass through both strengthening exercises and aerobic exercises. Fourth, in general we need a data base of a variety of longitudinal studies including specific attention to the menopause in women after which women become more vulnerable to heart disease and osteoporosis. Fifth, special attention must be directed to addictive behavior, not only to illegal drugs but to alcohol, nicotine and even certain food stuffs. We need to better distinguish between genetically-determined addiction and problematic socialization. Either may account for the difficulty some have in stopping Revised 5/4/93 -6-

smoking, for example, and treatment would be different for each. Happily, the National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism are now located on the intramural campus of the National Institutes of Health, which will facilitate pursuit of such studies. Sixth, short of cure, it is essential to undertake studies of strategies to delay dysfunction in later life at the basic science level. For example, suppose it were possible to postpone Alzheimer's disease by five years? What is the threshold of cell loss necessary before visual impairment or parkinsonism occurs? Here genetics, molecular biology, immunology and other disciplines can contribute. Seventh, HCFA should have funds to continue studies of the cost-effectiveness of various preventive measures. • • * * +r But in addition to these few examples of the research strategy necessary to advance our understanding of prevention, we must undertake specific action programs that makes clear that there is much we can do now without waiting for further knowledge. III. Action Programs 1) We should supplement the important initiative of President Clinton to immunize all children and add universal immunization for older persons. Every older person should receive the vaccines against pneumonia, flu and tetanus. At present, less than 50% are immunized against the flu and yet the flu afflicts more than 5 million people 65 and older each Revised 5/4/93 -7-

year. The flu and its complications can cause 10,000 deaths in a mild year and up to 70,000 deaths in an epidemic. Following completion of a pilot study under Medicare to determine the cost-effectiveness of flu shots, Secretary Donna Shalala made flu vaccinations a Medicare benefit beginning this April. Since perhaps 8% of persons are allergic to the egg in the flu vaccine there should be special research designed to deal with this problem. Women are less apt to have tetanus shots because those in the older age group were not usually in military services. However, many women enjoy working in the garden which puts them at risk for tetanus. 2) Prevention of infectious disease is essential. While we do not employ a vaccine for tuberculosis in the U.S. the PPD test should be given to older persons in hospitals before admission to a nursing home where the prospect of contagion is so much greater. There has also been a shocking increase in multi- antibiotic resistant tuberculosis. Active preventive and treatment programs are essential for the welfare of people of all ages. It is also necessary to protect against nosocomial infections, infections which develop in hospitals and nursing homes, which account for $5 to $10 billion a year in health costs. Revised 5/4/93 -8 -

3) Intensify National Campaigns. The National Institute of Heart, Lung and Blood Diseases' hypertension campaign should be reinforced to help further lower the incidence of stroke and stroke-dementia. The Institute's cholesterol education campaign should be expanded to become a comprehensive national dietary and nutrition campaign. It was shocking to read the recent report of the Nutrition Screening Initiative, which supplements previous studies demonstrating the surprising extent of malnutrition among older persons. People need more education concerning the role of calcium in preventing osteoporosis. People need to reduce their fat intake because of cancer and atherosclerosis as well as to curb obesity which worsens the pain of arthritis and other conditions. It is necessary to acquaint people more thoroughly with the new food pyramid which recommends at least five servings of vegetables or fruits per day; only 9% of Americans comply. Fortunately, there has been a step forward in food labeling but not yet in restaurant menu labeling. 4) The media should be mobilized to develop, in coordination with government and the private sector, more effective health communications and advertisements and even anti- advertisements, to help promote healthy lifestyles. Special attention must be devoted to efforts to moderate alcohol use and promote tobacco cessation. Together these constitute the major causes of preventable diseases and death in the U.S. Revised 5/4/93 -9 -

Alcoholism is an extraordinarily dangerous problem. More lives are lost through alcoholism than those claimed by cocaine, heroin and other illegal drugs combined. There are 18 million problem drinkers in the United States and 10 million suffering from alcoholism. There are some survivors of life-long alcoholism and others who become alcoholic for the first time in late life. They may be seeking solace or pain control. The negative impact on cognitive function is considerable. Alcohol adds to the risk of cancer, and untoward interactions of medications. It furthers bone loss. Like smoking, alcohol shortens life. Smoking has a dose and duration effect. In studies in the 1950s and 60s we found that following cessation of tobacco intake, pulmonary function tests significantly improved. Smoking also has adverse effects on cancer, osteoporosis, 5 ) heart disease and chronic obstructive lung disease. Smoking affects the skin, causing wrinkles; we should also appeal to vanity. Further, smoking has been associated with cataract formation. Government (the U.S. Public Health Service and particularly the Centers for Disease Control and Prevention) should strengthen relationships with self-help groups and build new ones as necessary. This should include the establishment of national walking clubs to advance physical fitness, to encourage special sports for older persons (for example, "senior olympics") and to overcome sarcopenia. Only 29% of Revised 5/4/93 -10-