Chapter 28

Public Health and the Aging

Population

How old would you be if you didnt

know how old you are?
-- Satchel Paige

HOW DO WE AGE ?
The physiological age is not the same as
chronological age
people-lifestyle-genetics
To die young as late in life as possible
--Ashley Montagne

HOW DO WE AGE ?
Rethinking NORMAL aging versus
TYPICAL aging
Diseases: heart disease, cancer,
osteoporosis, diabetes, obesity,
hypertension .

STATISTICS ON AGING
Some statistics on longevity mislead us.
Include: death at birth, early childhood, early life
by accidents, violence
Ancient Greeks and Romans: Greeks born before
100 B.C. lived about 72 years
Romans after 100 B.C. lived about 66 years:
Romanss richer diet, more sedentary lifestyle,
peace, prosperity

THEORIES ABOUT AGING

What is the limit of the human span?

Gerontologist L. Hayflick: separated human

cells in laboratory environment: 120 years
No: high fat diet, overeating, rush-hours,
drinking, prime news, income taxes,
aggravation ..
Influence on speed at which cells wear out

THEORIES ABOUT AGING

Variety of interacting processes:
genetic - less vulnerable to environmental
factors such as dietary fat, stress,
sedentary,lifestyle carcinogens.
Two major theories of aging:
Damage Theories and Program Theories

THEORIES ABOUT AGING

Free radicals
Atom with at least one unpaired electron, highly reactive,
usually seeks other electron to become paired,
If antioxidants unavailable: free radicals suddenly
multiply, the cells functioning disrupted, cell components
damaged, cell necrosis
Free radical stress: lipid peroxidation, atherogenic activity,
carcinogenic activity, ..
Pro-oxidant effect: cigarette smoke, imbalanced diet,
exhaustive exercise, environmental pollutants,
psychological, emotional stress,

THEORIES ABOUT AGING

Inflammation - a major source of oxidants
inflammation activates the arachidonic acid
cascades,
PGG2
Free radicals are present at higher levels in colon
patients with ulcerative collitis
Oxidative stress: inadequate dietary intake of
antioxidant nutrients, or also chronic conditions as
malabsorption syndrome

THEORIES ABOUT AGING

Metabolic dysregulation

Cumulative exposure to high levels of

glucocorticoids
exposure to higher omega-6 fatty acids with
decline in beta-6 desaturation,

THEORIES ABOUT AGING

What to do?
Reduce energy of free radicals
Stop the free radicals from forming
Interrupt chain reaction to minimize the
damage of free radicals
Reactivate, support and balance immune
system

Issues for the Aging Population

Average age of Americans is increasing

Baby boomers are approaching retirement
Older people are in poorer health
Older people use more medical care
Growth in cost of Medicare is unsustainable
Quality of life in later years depends on
lifestyle in youth and middle age

Trends in Aging of the

Population
Median age of Americans increased from 20 in 1860 to
35.3 in 2000; will peak at 39.1 in 2035
Life expectancy at birth increased from 47.3 in 1900 to
76.9 in 2000
Population 85 and older is fastest growing age group
Females outnumber males in older age groups
After age 75, most women are widowed and live alone,
most men are married and living with wives
Percentage of people over 65 living in poverty has
declined from 35% in 1959 to 10% in 2002
Poverty rates higher for older women than men
Poverty rates higher for older blacks and Hispanics

Health Status of the Elderly

Young old 65 to 74 80% are in good, very
good, or excellent health
Aged 75 to 84 71% are in good, very good,
or excellent health
Oldest old 85 and older 18% live in nursing
homes; 15% require assistance
Men more likely to die at a younger age; women
more likely to have chronic, disabling conditions
Causes of death in elderly are similar to causes of
death in overall population

DISEASES OF AGING
Interestingly, many changes that accompany aging
are the same types as changes that can be expected
with inactivity and weightlessness.
The identifying characteristics of both aging and
the disuse syndrome are : decrease in cardiorespiratory function, obesity, musculoskeletal
fragility, premature aging

DISEASES OF AGING

Arthritis - 48%
Obesity - 38%
Hypertension - 65%
Heart disease - 32%
Hypercholesterolemia - 30%
Orthopedic impairment - 32%
Cataracts - 17%

DISEASES OF AGING
Diabetes - 18% of elderly population
Visual impairments - 9%
Osteoporosis - 22 million Americans, 1.5 million
fractures/year if > 45 years of age
Cancer - lifetime risk 48% for men, 38% for women, 1.4
million diagnosed/year
Mental impairment: senile dementia, Alzheimers type >
half of all dementia ,
Stroke
.. 88% of elderly suffer at least one chronic disease

EXERCISE
Sedentary + overweight = lose about 1/2
aerobic power between 35-70
Who remain lean and active have only very
slight decline

power decline strongly if sedentary (30 body fat%)

power decline less if moderate active (20 body fat%)
power decline very slowly if active (15% body fat)
Medicine & Science in Sports and Exercise, 1995

THE FOUNTAIN OF YOUTHBIOLOGY AND HUMAN AGING

There will come a time when our

descendants will be amazed that we did
not know things that are so plain to them.
--Seneca (first century)

Compression of Mortality
Biological life span has not changed
More people live to end of biological span
Compression of morbidity?
Does longer life mean more years of healthy
life or more years of chronic disease?
Some evidence that older people are healthier
now than in the past

Factors that Affect Health in Old

Age
Smoking
Causes cardiovascular disease, cancer, lung disease,
osteoporosis, disorders of the mouth
Prevalence of smoking declines in older people

Diet and physical activity

Obesity causes cardiovascular disease, cancer, diabetes,
arthritis
Prevalence of obesity declines in older people

Hormone replacement therapy?

Was believed to have anti-aging effects

Medical care secondary prevention

Preventing Disease and Disability

Immunization against pneumonia and influenza
Medications
Older people often take drugs for many conditions
Older people metabolize drugs less actively
Risk of drug interactions

Osteoporosis
Risk of broken bones leading to disability

Falls
Many risk factors in older people
When person has osteoporosis, risk of broken bones

Preventing Disease and

Disability, ctd.
Impairment of vision and hearing
Sensory loss leads to social isolation
Cataracts from exposure to sunlight; glaucoma, diabetic
retinopathy, macular degeneration
Hearing loss from exposure to noise

Oral health
Tooth loss, periodontal disease, etc.
May lead to social isolation

Medicare does not cover dental care, eyeglasses,

or hearing aids

Alzheimers and Other

Dementias

Risk increases with increasing age

Tremendous burden on caregivers
Costs up to $100 billion per year in long-term care
Biomedical research and epidemiologic studies are
beginning to give clues on risk factors
No effective treatment known, but some studies
are giving hope
Even delaying onset by a few years could
substantially reduce the financial and personal
burden

Medical Costs of the Elderly

Medicare enrollment has doubled since 1967 and
will continue to grow
Cost per enrollee is rising, even faster than health
care costs in general
More of costs being shifted to the individual
Medicare does not pay for long-term care
Medicaid pays for long-term care strain on state
budgets
Changes in family structure mean families are less able
to care for elderly relatives

Only hope is for baby boomers to be healthier and

more independent than past generations

Proposals for Rationing

Richard Lamm old people have a duty to die and
get out of the way
Elderly consume disproportionate amount of resources

Proposals to deny expensive technology to people

over a set age
However, most of cost is for long-term care

Preferable to get control of medical costs overall

Need integration of public health and medical
services to reduce demand for medical care

Discussion Question 1
Where do you fit in the age distribution of
the population? How do you expect to pay
for your medical care when you reach
retirement age?

Discussion Question 2
In what ways can public health save
medical care costs for elderly patients of the
future?

Discussion Question 3
If present trends continue, Medicare will be
bankrupt in the near future. How do you
think the nation should deal with this
problem?

Discussion Question 4
Visit the Web site of the U.S. Census and find the
publication, The 65 Years and Older Population:
2000.
(www.census.gov/prod/2006pubs/p23-209.pdf)
In Table 3 there is information for each state and
region on the percentage of the population 65 and
over. What is the percentage for your state? How
did it change between 1990 and 2000? Do you
have any ideas why this change occurred?

Discussion Question 5
Visit the Web site of the National Institute
of Aging (www.nia.nih.gov)
Review news releases for the past several
months. What research findings has the NIA
publicized? What are the implications for
public health? What are the implications for
medical care costs?

 Please see links:

In the road map for week 5

Chapter 29
Emergency Preparedness, Post9/11

Types of Disasters
Natural disasters many are predictable
Prior evacuation when possible

Technological disasters less predictable

Include terrorism

Response is similar for both types

Search and rescue

Treatment and evacuation of injured
Food, water, shelter for survivors
Minimize environmental hazards

All types of disasters need planning for

World Trade Center Response

13,000 to 15,000 people evacuated from towers

2,801 people died
Many failures of communication and coordination
Failure to protect rescue and cleanup workers
from environmental hazards
Victim location services; shelters for displaced
residents
Monitoring for biological agents

World Trade Center Response:

Routine Public Health Functions
Issued death certificates and burial permits
Monitored safety of food and drinking
water served to emergency workers
Cleaned up food in abandoned restaurants
Sampled dust and debris to assess risk
Surveillance of cleanup workers and area
residents for symptoms
Arranged for mental health counseling

Response to Hurricane Katrina

Lack of planning for populations with special
needs (hospital patients, poor people without cars)
Poor communication - lack of clear directions on
evacuation until too late
Too little help from outside New Orleans
Racist incidents
Damaged housing, contaminated air in FEMA
trailers; large displaced population

Principles of Emergency
Preparedness
Importance of advance planning involving all
agencies; practice at least once
Importance of good communication
Incident Command System puts a single person
in charge at the scene
Local authorities take the lead

Federal government has provided funding to states

and metropolitan areas for planning
Strategic National Stockpile of medical supplies,
antibiotics, vaccines, antidotes for chemical agents

Bioterrorism Preparedness
Same as preparedness for natural epidemics
Challenge to recognize an attack is occurring
Public health surveillance is important

Need for laboratory capability

Need for public health laws enabling authorities to
take action
Problem of whether uninsured will seek care
Need for coordination between public health and
law enforcement

Possible Bioterrorism Agents

Smallpox
Anthrax
Plague
Botulinum toxin
Tularaemia bacteria
Hemorrhagic fever viruses

Surveillance Activities

Emergency room visits

Calls to 911 and poison control centers
Pharmacy records
Veterinary diseases

Smallpox Preparedness
Highly contagious, no immunity in population
Dark Winter exercise
Public health is a major national security issue
An attack could cause massive civilian casualties,
breakdown in essential institutions, civil disorder, etc.

Vaccination campaign military and health

workers
Resistance by civilians because of side effects and
uncertainty of risk

Discussion Question 1
Discuss the mistakes that were made during
the World Trade Center emergency
response on 9/11. What should have been
done differently, and how many lives do
you think might have been saved if your
suggestions had been used?

Discussion Question 2
Discuss the mistakes that were made during
and after Hurricane Katrina. What should
have been done differently, and how many
lives do you think might have been saved if
your suggestions had been used.

Discussion Question 3
Think of a disaster that might be predicted
to occur in your area. Considering the
guidelines suggested in the Public Health
Management of Disasters, who should be
included in a planning meeting? What
special plans should be made so that your
area will be prepared?

Discussion Question 4
Visit the Web site of the World Trade
Center Health Registry
(http://nyc.gov/html/doh/wtc/html/registry/registry
.shtml) Read the latest findings.

What kind of follow-up studies are being

done on residents, emergency responders,
and cleanup workers?

Discussion Question 5
Browse the Web sites of the CDC, EPA,
FDA, HHS, NIH, USDA, AHRQ, and your
state health department. Do these agencies
have information about planning for
emergencies and disasters? What special
emergencies do they have plans for? For
each agency, find one issue that it focuses
on that is unique to its mission.

 Please see links:

In the road map for week 5 and in the
lecture

Chapter 30
Public Health in the 21st Century:
Achievements and Challenges

Top 10 Public Health

Achievements of the 20th Century

Routine use of vaccination

Improvements in motor vehicle safety
Safer workplaces
Control of infectious diseases
Decline in deaths from heart disease, stroke
Safer and healthier foods
Healthier mothers and babies
Access to family planning and contraceptive
services
Fluoridation of drinking water
Recognition of tobacco use as a health hazard

Challenges for the

st
21

Century

Renewed threats from infectious diseases

Climate change
Rising costs of medical care for aging
population
Understanding and altering human behavior
Need to strengthen public health system
Persistent disparities in health

Strategic Planning for Public

Health
Decentralized system requires management
by objective
Healthy People: The Surgeon Generals
Report on Health Promotion and Disease
Prevention (1979)
Healthy People 2000 (1990)
Healthy People 2010 (2000)
Healthy People 2020 (2010)

Strategic Planning for Public

Health, ctd.
National goals set by broad range of participants
in and outside of government
State and local communities encouraged to use
national objectives as a basis for developing
objectives of their own
Need to collect data to measure progress in
meeting goals
Periodic evaluation of degree of success in
meeting goals
The nation has made progress on most goals

Hope for the Integration of Public

Health and Medical Practice
Managed care moves incentives of medicine
closer to public health
Managed care permits setting goals and
evaluation of progress
Managed care backlash frustrated the hope
for turning medical care into a system more
in tune with public health

Information Technology
Improves communication and data sharing among
public health agencies at various levels and
between public health agencies and clinical
settings
Enables tracking of emerging infectious diseases,
investigation of outbreaks and possible
bioterrorism attacks, monitoring of disease trends
Databases useful in assessment and evaluation
activities
Makes health information available to individuals

Challenges of Information
Technology
How to keep private what ought to be private and
how to make public what ought to be public
HIPPAA privacy rules may discourage
outcomes studies and prevent release of useful
information
Concern about accuracy and reliability of
information on some Web sites
Possibility of circumventing FDA controls on sale
of prescription drugs, laws restricting sale of
tobacco, etc.

Challenge of Biotechnology
Unprecedented possibilities of genetic
engineering, cloning, individualized
medicines, etc.
Ethical and legal issues
Can we afford it?

Ultimate Challenge to Public

Health in the 21st Century
To educate the public and policy makers
about the role of non-medical factors in
determining peoples health
And to foster a national debate on priorities
that will bring spending on medical care
more in line with its value in assuring health

Discussion Question 1
Visit the Healthy People 2010 Web site
(www.health.gov/healthypeople)
Choose one of the 28 focus areas and look
at the objectives that have been set for the
year 2010. For each of the objectives,
comment on whether you think the nation
has a realistic chance of meeting it.

Discussion Question 3
What kind of medical information in a large
managed care organization database should
be kept confidential? Why? What kind of
information in a governmental database
should be make public? Why?

Discussion Question 2
What would be an example of a public
health function that might be carried out by
a managed care medical plan? What would
be an example of a public health function
that a managed care organization would not
perform?

Discussion Question 4
What would be the impact on society of a
biotechnological technique that could slow
the aging process and extend an individuals
life by 10 years? Do you think Medicare
should pay for such a technique? Explain
your answer.

Discussion Question 5
Visit the Healthy People 2020 Web site
(www.healthypeople.gov)
Choose one of the 38 topic areas and look at
the objectives that have been set for the year
2020. For each of the objectives, comment
on whether you think the nation has a
realistic chance of meeting it.

Discussion Question 6
One of the challenges for the 21st century is the vast amount
of health information available on the Internet, some of it
accurate and useful, some of it inaccurate and biased. The
federal government has created a site with links to other
Web sites that can provide reliable information on many
health topics.
Visit the site (www.healthfinder.gov), choose a category of
information you are interested in, and explore the
information available. What could you find here that you
might not find otherwise?

 Please see links:

In the road map for week 5 and in the
lecture