>> Good afternoon, good evening, or good morning,
depending on from when and where you are joining us.
I'm Dr. Phoebe Thorpe.
And it's my pleasure to welcome you
to the CDC Public Health Grand Rounds for September 2017.
We have an exciting session, so let's get started.
But first, a few housekeeping slides.
Public Health Grand Rounds has continuing education available
for physicians, nurses, pharmacists, veterinarians,
health educators, and others.
Please see the Public Health Grand Rounds website
for more details.
We are available on all your favorite social media sites.
Please send your questions for today's sessions and/or comments
to the Grand Rounds email box at grandrounds@cdc.gov.
Want to know more about healthy aging?
We have a featured video segment on YouTube and posted
to our website called Beyond the Data.
It is posted shortly after the session.
This month's session features my interview with Dr. Baumgart.
We have also partnered with the CDC Public Health Library
to feature scientific articles about healthy aging.
The full listing is available at CDC.gov/scienceclips.
Also on your way out, the Public Health Library has put together
a display about healthy aging.
Check it out.
Here a preview of the upcoming Grand Rounds session.
Please join us live or on the web at your convenience.
And in addition to our outstanding speakers,
I'd also like to acknowledge the important contributions
of the individuals listed here.
Thank you.
I'd also like to take a moment to thank CDC for the opportunity
to give this presentation, as my father-in-law passed away
from Alzheimer's early this year, and it is a great honor
for me to be part of this session.
And now for a few words
from CDC's deputy director, Dr. Schuchat.
[ Applause ]
>> Thanks so much, Phoebe.
And thank you all for joining us today.
You may have heard that orange is the new black,
but some of us are saying that 80 is the new 60.
[ Laughter ]
And a staggering number of people can expect
to reach their 100th birthday.
Meanwhile, many of us have brains on our minds --
not just the developing brains of babies
but the potential deterioration of brains as we age.
Too many of us are managing the consequences
of cognitive loss in loved ones.
And enormous numbers of us are serving as caregivers
for relatives in a territory we had never planned for.
Not enough of us are confident
about the latest scientific findings on aging
and the implications for public health.
To fill this gap, today's Grand Rounds brings experts
and problem solvers together to enlighten us
about the topic of healthy aging.
Now, I've decided to subvert the usual introduction
to Public Health Grand Rounds where we try
to hit the key points that you're going to hear.
You heard about the podcast and all the other ways
that you can keep up with the key points.
And instead, what I wanted
to do today was something a little different
for the Public Health Grand Rounds
and introduce a moment of poetry.
So here is an excerpt from the UK's --
apparently the UK's most popular poem
about aging -- by Jenny Joseph.
It's called "Warning."
And for those of you used to seeing me
in my Commission Corps uniform,
this may seem particularly apropos.
When I am an old woman, I shall wear purple with a red hat,
which doesn't go, and doesn't suit me.
And I shall spend my pension on brandy, and summer gloves,
and satin sandals, and say we've no money for butter.
I shall sit down on the pavement when I'm tired,
and gobble up samples in shops, and press alarm bells,
and run my stick along the public railings,
and make up for the sobriety of my youth.
I shall go out in my slippers in the rain, and pick flowers
in other people's gardens, and learn to spit.
[ Laughter ]
So with that, let us proceed
with today's Public Health Grand Rounds.
[ Applause ]
>> Thank you.
And now for our first speaker, Sarah Lock.
>> Thank you.
I'll do my best not to spit -- I'll save that for afterwards.
So thank you.
My goal today is to introduce the concept of healthy aging,
along with reviewing some of the benefits we gain,
as well as the challenges we face as our population ages.
Then I discuss some strategies to promote healthy aging.
So, of course, healthy aging occurs across all age groups,
and it is not merely the absence of disease or disability.
As shown in this model, healthy aging requires a comprehensive
vision of physical, cognitive, and mental health,
along with ongoing social engagement.
Aging is society's greatest achievement.
We have added more years to life expectancy since 1900
than in all previous human history.
Advances in public health
and healthcare have reduced death rates of children
and young adults and improved the lives of millions.
The result of all this progress is that a child born
in 2011 can expect to live 79 years --
32 years longer than a child born in 1900 at the turn
of the century when life expectancy was only 47.
And as its trends show, many will live well
into their 90's and beyond.
At the same time that people are living longer, birth rates,
which peaked during the Baby Boom --
of which I'm proudly part --
from 1946 to 1964 are also declining.
Another way to look at these trends is
to track the proportion
of our population age 65 and over by state.
Darker colors indicate a higher percent of older population.
Following the last census in 2010, only a handful
of states had more than 15%
of their population age 65 and older.
But by the next census, not four states but more
than 40 states will have exceeded that 15% threshold;
and two states will have crossed the 20% mark.
But if you look at 2030, you can see
that the youngest Boomers will have turned 65, and every state
but one will have more than 15% of its population over the age
of 65, and nearly half of all states exceed the 20% threshold.
Aging leads to new abilities and knowledge
that older people can share with their communities.
We want to make the most of that by not only increasing lifespan
but health span as well,
increasing the years Americans live
without disabling conditions.
People over 50 in the United States generate $7.6 trillion
annually in economic activity.
And to give you a sense of proportion, when you add
up all the economic activity they drive, older Americans make
up the third-largest economy in the world,
only behind the United States in its entirety and China.
Recruiting and retaining 50-plus workers is smart
because of the value they bring to the workforce.
Seasoned workers get high marks for loyalty, reliability,
and have a deep network of contacts
from a lifetime of work.
Older workers score high in leadership,
detail-oriented tasks, organization, listening
and writing skills, even in cutting-edge fields
like computer science.
But perhaps the greatest asset older workers bring is their
workplace wisdom.
By the time you reach my age and older, we've learned how
to get along with people, solve problems without drama,
and call for help when necessary.
Older workers bring great value and productivity
to a diverse work environment, including people of all ages.
And what's true in America is the older population is becoming
much more racially and ethnically diverse.
Between 2014 and 2060, the share of the older population
that is non-Hispanic white is projected to drop
by 24 percentage points, from 78% to 54% or almost 55%.
As diversity increases, our approaches
to promote healthy aging needs to be adaptive to be relevant
to all people in all cultures.
Among our older population,
the fastest-growing age group is those age 85 and older.
And the second-fastest is the those 100 and over.
And a majority of those people are women.
Consider that by 2050, 65-plus population
in the US will double, while
at the same time the 85-plus will triple.
And the number of centenarians, those over 100 or older,
will exceed 400,000 people by 2050.
So we've talked about the 80-plus population increasing,
and it will be by 44% between 2030 and 2040.
Yet the number of caregivers aged 45 to 64 is projected
to increase only by 10%.
The caregivers' support ratio is the number
of potential caregivers who are mostly adult children age 45
to 64 to each person 80 and over.
So in 2010, the ratio was and is about seven caregivers
for every 80-year-old.
But fast forward a couple of decades to 2030,
the ratio will only be four-to-one, and it continues
to decrease going forward.
In 2040, the ratio is expected to begin to bottom
out as the population aged 80-plus is projected
to increase 17% and the 45 to 64 population increases by 8%.
So along with some of the benefits that I've talked about,
aging has to -- we have to acknowledge that aging carries
with it an increase in the prevalence of chronic diseases,
such as hypertension, diabetes, and arthritis.
And you will hear from our next speaker
about important public health considerations related
to another group of chronic conditions --
Alzheimer's disease and dementias.
Other challenges are the racial and ethnic disparities
which pervade many had been health measures are also seen
with regard to lifespan and health span issues as well.
Lower socioeconomic status has an adverse impact
on healthy aging unfortunately.
And with the majority of Americans living paycheck
to paycheck and three-quarters of Americans between the ages
of 55 and 64 having less than $30,000 stacked away,
many people do not have the resources to retire
and are having to work longer.
So we need to make sure they're healthy and can do so.
Older adults also face more challenges
with everyday activities, which can be compounded
by their living situation or lack of social supports.
One-third of people over the age of 65 face restrictions
in their ability to perform activities of daily living
or what we call ADL's -- things like carrying for themselves;
or IADL's -- things like managing money, preparing meals,
or taking medications appropriately.
So one of the things to deal
with the issues I've outlined is the Healthy Aging
in Action Plan.
Released in November of 2016, it is intended to be part
of the national prevention strategy.
The strategy's cornerstones include eliminating health
disparities, encouraging safe and healthy communities,
promoting clinical and community preventative services,
and empowering people to make healthy decisions.
All of these ideas are relevant to make healthy aging a reality.
The goals of federal action steps are
to support prevention efforts to enable adults to remain active,
independent, and involved in their community.
It highlights innovative and evidence-based programs
like from the National Prevention Council departments
and agencies that address the physical, mental,
and emotional social well-being of adults.
And the last goal is to inform future efforts to promote
and facilitate healthy aging in communities.
I'd like to review several programs highlighted
in the report that provide great examples
of the diverse groups working
to keep older adults healthier and more active.
So while the health industry offers preventative services,
patients can face challenges that they can't get
to those services if they no longer drive or have limited
or no access to transportation.
So in response, the Department
of Transportation's Federal Transit Administration launched
the Ride to Wellness Initiative.
It aims to increase access to care, improve health outcomes,
and reduce healthcare costs.
The Department of Transportation finances innovative projects
to help the disadvantaged get non-emergency
medical transportation.
DOT is also cosponsoring a national survey of health
and community centers to document the magnitude
of missed medical appointments due to transportation issues.
Results of this research will inform not only the work of Ride
to Wellness but also other local efforts
to increase healthcare access to those
who have limited transportation options.
The benefits of physical activities to your brain
and body's health as you age have been well documented.
For example, those who are physically fit have half the
risk of chronic health conditions such as hypertension,
coronary heart disease, type 2 diabetes,
and some cancers compared to those who are less active.
However, only about one-third
of older Americans meet the recommendations
for physical activity.
So launched in 2011, the Go for Life Campaign,
which is an initiative of the National Institute on Aging
at the National Institutes of Health, it's a campaign
to raise awareness about the benefits of exercise
and physical activity and enlist individuals
to become more active.
As of January 2016, Go for Life had more than 340 partners,
primarily agencies, organizations, and companies
that serve older adults or have physical activity as part
of their core mission.
And one of my favorites is Vote and Vax,
a Robert Wood Johnson initiative aiming to increase the number
of Americans who get flu shots
by offering them near polling places.
Less than half of adults aged 50 to 64 were vaccinated
against the influenza flu during 2010 to 2011 winter.
And unfortunately,
flu vaccination rates are even lower amongst African-American
and Latino adults.
In 2012, Vote and Vax served 651 polling locations
and was active in all state.
The program, also supported by AARP and the CDC,
coordinates the activities of local public health departments,
visiting nurses services, and pharmacies.
In 2012, 45% of those receiving flu shots at Vote
and Vax clinics identified as African-American or Latino,
indicating that Vote and Vax may represent a very helpful
strategy to reduce racial and ethnic vaccination disparities.
So as you all are probably aware,
Medicare is the primary payer for healthcare for older adults.
In order to improve the quality of care provided
and reduce costs in the program, Congress made changes
to Medicare to promote increased use of preventative care.
During the welcome to Medicare visit, a beneficiary's medical
and social history, risk for depression and mood disorders,
and functional ability are reviewed.
Their history of tobacco use, diet,
and physical activities are also reviewed.
The creation of a written plan for the patient is a tool used
to promote ongoing use of clinical preventative services.
Annual wellness visits include personalized prevention plan
services and include a comprehensive health
risk assessment.
Importantly, it includes screenings
to detect cognitive impairment
and implements a screening schedule for things
like diabetes and high blood pressure,
and helps to keep vaccinations current.
The goal is better health outcomes
through an increased focus on prevention, allowing seniors
and doctors to work together
to catch conditions before they become serious and more costly.
The goals are to increase the uptake of preventative services
and reduce overall costs,
but only 7% of older adults are receiving their recommended
preventative services and only 16%
of Medicare recipients had an annual wellness visit in 2014.
Evidence on the improved health outcomes related
to welcome wellness visits is limited
because research is at the early stage.
Most current research has been focused on whether
or not people are getting the recommended
preventative services.
Medicare supports not only clinical prevention
but also community-based prevention.
An evaluation of community-based prevention
and wellness programs conducted
by CMS identified seven nationally disseminated programs
with sufficient data to evaluate costs
in health services utilized.
For Medicare beneficiaries who participated in a wellness
and prevention program between two and three years ago,
changes in health outcomes and levels of healthcare utilization
and cost were compared to those of a control group.
The main outcomes evaluated were total medical costs,
costs by healthcare settings, and health services utilized.
Medication adherence, physical and occupational therapy use,
the incidence of falls
and fall-related fractures were also evaluated as appropriate.
While key results included decreased costs
for beneficiaries and Medicare for selected outcomes for those
who participated in the wellness programs, CMS concluded
that more research development
and implementation is needed before broader scale
implementation is warranted.
So how can we promote healthy aging in our communities?
It's important to facilitate across all sectors,
as I've described early in the presentation, across disciplines
and professions to create incentives to work together.
We need to expand the evidence base for strategies by designing
and implementing methodologically
rigorous evaluations.
We need to widely disseminate best practices and guides
that address adopting healthy behaviors over lifespan.
Promoting the relevance of prevention
across the life course and recognize the aging
of the population is creating both unique opportunities,
as well as challenges.
And finally, enhancing a multidimensional view
of healthy aging.
One example of how AARP is embracing all five
of these principles to promote healthy aging is our efforts
to create and collaborate
with the Global Council on Brain Health.
The GCBH is a cross-sector collaboration helping
to disseminate the evidence base on brain health
where we empower people to reduce their risk
for cognitive decline across their lifespan
by encouraging healthy lifestyles.
It's now my pleasure to introduce Matthew Baumgart.
[ Applause ]
>> Thank you very much, Sarah.
Sarah, in her conversation mentioned
that with an aging society comes an increase
in chronic conditions, and I'm going to talk to you today
about one of those chronic conditions, Alzheimer's.
But I want to back up and start with the concept of dementia.
Dementia is not in and of itself a disease; rather,
it's an umbrella term for a set of symptoms
that are characterized by the loss of cognitive function
that is severe enough to interfere with daily life.
Now, there's several diseases and conditions
that cause dementia, the most common
of which is Alzheimer's disease.
Scientists actually believe that many, if not a majority,
of the cases of dementia are mixed, that is,
a person with dementia has more than one cause of that dementia.
Now, traditionally, Alzheimer's disease has been virtually
synonymous with dementia, that is,
if you did not have dementia,
if you did not have certain symptoms,
then you did not have Alzheimer's disease.
But since 2011 when the National Institute on Aging
and the Alzheimer's Association published proposed revised
diagnostic criteria, Alzheimer's is being recognized as a disease
with a long continuum where dementia is only one stage.
So it starts with physical changes in the brain,
even before symptoms --
it's known as the pre-clinical stage --
followed by mild cognitive impairment caused
by Alzheimer's disease, and then finally the dementia stage
of the disease.
But while the continuum is now seen as Alzheimer's disease --
which has particular significance, I believe,
for public health, as I will discuss shortly --
the data have not caught up.
So when you hear statistics about Alzheimer's,
such as the prevalence of Alzheimer's,
understand that these are statistics about people
in the dementia stage of Alzheimer's disease and not
about all people with the disease.
Another traditional conception about Alzheimer's is the idea
that Alzheimer's is an aging issue,
not a public health issue.
But that view is changing.
More and more people are heeding Dr. David Satcher's call to see
and address Alzheimer's as a public health crisis.
Now, an issue is defined in public health terms
when the burden is large, the impact is major,
and there are ways to intervene.
And Alzheimer's meets all three of those criteria.
Today more than 5 million Americans are living
with Alzheimer's.
And caring for them this year will cost the health
and long-term care systems more than a quarter
of a trillion dollars.
In 2013, a study found
that dementia was the most expensive disease in America.
In addition, it is the fifth-leading cause of death
in the United States for older Americans.
Since 1999 the Alzheimer's death rate has increased 55%
and the number of deaths from Alzheimer's has increased 110%.
The impact is major.
In fact, it has a disproportionate impact
on African-Americans and Hispanics,
who develop the disease at greater rates.
One-quarter of all hospitalizations among people
with dementia are preventable, placing a big burden
on our hospital system.
It has an impact on families;
more than 15 million caregivers provide the economic equivalent
of $230 billion in unpaid care each year.
And two-thirds of the direct costs of caring for people
with Alzheimer's are borne by government budgets, that is,
Medicare and Medicaid.
But there are ways for public health to intervene
through surveillance, risk reduction, early detection
and diagnosis, and management of co-morbidities.
And the rest of my presentation is going to focus on these ways
that public health can intervene,
beginning with primary prevention.
Now, there's a growing consensus
that individuals can reduce their risk of cognitive decline
by addressing certain risk factors.
In 2015, in separate published reviews of the evidence,
The Institute of Medicine
and the Alzheimer's Association independently concluded
that individuals could reduce their risk of cognitive decline
with regular physical exercise and the management
of certain cardiovascular risk factors, specifically smoking,
diabetes, and midlife hypertension.
The association also concluded
that midlife obesity was a risk factor.
Basically the saying is what's good
for your heart is good for your brain.
Now, earlier this year the National Academies released a
second report, this one examining what the science says
about preventing dementia, not just cognitive decline.
And it found the strongest prospects for risk reduce
in the areas of physical activity,
managing blood pressure for those with hypertension,
and cognitive training.
Now, the report called on the NIH and the CDC to make clear
to the public that positive effects of interventions
in these areas are supported by encouraging,
although limited evidence.
In 2013 the CDC and Alzheimer's Association released the Healthy
Brain Initiative, a public health roadmap
for addressing cognitive decline, Alzheimer's disease,
and the needs of caregivers.
One of the action items included in the roadmap is
for public health officials to disseminate messages
about risk reduction
for preserving a person's cognitive health.
So secondary prevention, as you know,
involves promoting early detection and diagnosis
and disclosure of that diagnosis.
Data from the 2015 Behavioral Risk Factor Surveillance System
found that more than half of those
who say they are having memory problems
that are getting worse --
this is known as subjective cognitive decline --
more than half of these people have not talked
to a healthcare provider about their memory problems.
And this hesitancy is one reason why as many as half
of people living
with Alzheimer's today have not been diagnosed.
Now, to make matters even worse,
Healthy People 2020 baseline data show that even among those
who have been diagnosed with dementia, nearly two-thirds
of them or their caregivers are unaware
of the diagnosis -- unaware.
In other words, people are not talking
to healthcare professionals about their memory problems,
people are not being diagnosed,
and those who are diagnosed are not being told.
And this is happening even though there are demonstrable
benefits to an early and disclosed diagnosis.
For example, it allows individuals
to access available treatments, build a care team,
and improve medication management.
On the social side, individuals
who have been diagnosed early can access support services,
create advanced care directives while they're still able
to do so, and address driving and safety issues.
So there's a big gap for public health to fill here.
And the roadmap calls for public health to educate providers
about recognizing early signs
and using validated assessment tools.
It also calls on public health to promote early diagnosis
through culturally appropriate public awareness campaigns.
And significantly, one of the objectives
of Healthy People 2020 is to increase the proportion
of people who have been diagnosed with Alzheimer's
and other dementias or their caregivers
who are aware of the diagnosis.
So finally, looking at tertiary prevention, that is,
managing co-occurring chronic conditions among people
with Alzheimer's, there may not be a lot
that can be done medically to treat Alzheimer's.
But those with the disease are nonetheless extremely expensive
to the healthcare system because the disease complicates the
management of other chronic conditions.
And this makes costs go up for a couple of reasons.
For example, 25% of hospitalizations,
as I mentioned, are preventable among people with dementia.
People with dementia have unnecessary emergency
department visits.
And illustrating this better
than probably anything else is diabetes.
There's been a great movement towards self-management
of diabetes.
But think about this: How does a person
with a cognitive impairment self-manage?
Well, it requires a different approach,
a more intense approach; but unfortunately,
that usually does not happen.
And as a consequence the diabetes is mismanaged,
and a senior with Alzheimer's and diabetes ends up costing
on average 81% more than a person
with diabetes but not Alzheimer's.
And as you can see from the slide,
these increased costs can be seen
across a variety of conditions.
Now, one key way to better manage co-occurring chronic
conditions among people with Alzheimer's is
through care planning.
Care planning can improve the quality of care and quality
of life for people with Alzheimer's
because it helps a diagnosed individual get
on the right path of care.
Studies have found care planning results in better disease
and medication management,
and individuals receiving care planning specifically geared
toward those with dementia have fewer hospitalizations
and fewer emergency room visits.
The good news is that as of the beginning
of this year Medicare now covers care planning
for cognitively-impaired individuals.
In addition to a formal care plan,
this new Medicare benefit includes an evaluation
of neuropsychiatric symptoms and safety issues,
helping develop advanced care directives,
referral to support services, and innovatively identifying
and assessing the capabilities
of an individual's primary caregiver --
that's part of this process.
An analysis by the non-partisan healthcare consulting firm
Healthsperien concluded that reimbursing providers
for care planning services would actually save the federal
government through Medicare
and Medicaid nearly $700 million over ten years.
So as I mentioned at the beginning of my presentation,
the new understanding of Alzheimer's disease
as a continuum from the first appearance of physical changes
or biomarkers to the onset of symptoms, to the development
of dementia -- this continuum creates significant
opportunities, I believe, for public health.
Looking at Alzheimer's disease this way makes it clear --
in fact, make it imperative --
that we stop thinking of Alzheimer's as a matter
of custodial care for someone once they have developed
dementia and start seeing it in public health terms.
And it's imperative that we employ the traditional tools
of public health across this continuum,
including risk reduction, early detection and diagnosis,
and the management of co-morbidities,
employing those tools of public health
to address the growing Alzheimer's crisis.
Thank you for listening.
And I am now pleased to introduce Grace Whiting
of the National Alliance for Caregiving.
[ Applause ]
>> Thank you so much, Matthew.
And thank you to the CDC
for hosting this amazing conversation today
on healthy aging.
I'm really excited to talk to you
about the caregiving aspect of this.
Now, if you're not familiar with us, the National Alliance
for Caregiving is a nonprofit organization with more
than 50 national members, including not-for-profit,
government agencies, and corporations.
And together we work
on caregiving issues across the lifespan.
Today I'm going to talk in particular about some
of the data that we found in our Caregiving in the US 2015 Report
that was conducted with AARP.
And I would just note that when I say family caregiver,
I'm talking about families of choice and relatives,
including friends, family, and neighbors
who are providing unpaid care to someone who needs assistance
with activities of daily living.
And this would be different
than someone who's a formal caregiver who's providing paid
care, such as a home care worker,
direct care aide often working through a defined healthcare
or long-term care system.
So what is it that -- when we say family caregiving is a
public heal issue, what is we really mean?
I think the first thing here is that we estimate
that there's 44 million family caregivers in the US --
this is roughly the same size as the population of Argentina.
So it's a huge number of people who are providing care unpaid
to a friend, family, or a neighbor.
And if you were to replace each one of those family caregivers
with a direct care worker,
it would cost the US economy $470 billion a year.
Now, we think about caregivers as typically being a woman who's
in her late 40's/early 50's caring for an older relative,
but what we know from the data is that as time has gone on,
caregiving, much like other older adults,
is a group of folks that's become increasingly diverse,
and it affects people from all backgrounds and walks of life.
And on the right-hand side here you can see a snapshot
of caregivers.
One thing I would note is
that men are increasingly becoming caregivers
as America ages.
And in younger cohorts, for example, Millennials,
men and women are equally as likely to be caring for someone.
Now, what are they doing?
We know that they're spending
about 24 hours a week providing activities of daily living,
which is high-touch tasks, such as helping someone bathe,
get dressed, and eat; instrumental activities
of daily living, which would be coordinating-type skills,
such as managing finances, or running errands, or cooking;
and medical or nursing tasks, which would be things
like changing wounds, using a catheter, giving injections.
And at the same time that people are giving 24 hours a week
caring for someone, most people are also working.
So 34% have a full-time job, a quarter are working part time,
and then 28% are in what we would call the
sandwich generation.
So they are not only caring for an older adult,
but they're also raising children in their household.
So you start to get a sense of how difficult it is
to balance both caring for someone, your own employment
and financial needs, and your own personal needs.
This slide is from the Caregiving in the US data.
And what it illustrates is that caregivers are truly members
of the healthcare team.
So there's three activities here, and we have a comparison
on the right-hand side between your sort
of typical caregiver -- people who are caring for someone
where the primary reason is cancer and dementia caregiving.
And each of these cases you can see
that caregivers are communicating
with healthcare professionals about the care plan,
they're monitoring the severity of a condition,
and they're advocating for someone not just
within the healthcare system but with long-term care
and service providers and government agencies.
And as the intensity or the complexity
of the care situation increases, caregivers are even more likely
to be engaged in these activities.
Additionally, I mentioned
that caregivers are doing medical nursing tasks,
and likewise there, the more hours that you're caring
or the more complex the care situation,
the more likely you're doing medical tasks in many cases
without any prior preparation -- meaning no one's shown you
or walked you through how to do these activities.
So how is it that caregivers support the healthy aging
of populations?
We know that caregivers help individuals age better
by being their advocates
and helping them manage what they need to do
on a daily basis, but we also have seen new research
that shows that caregivers can reduce avoidable hospital
readmissions by as much as a quarter at the 90-day mark
and by 24% at 180 days.
We also know that for conditions
where someone might have a disability
or an older person is having difficulty living independently
in a community, a caregiver can help them continue to live
on their own in their homes and communities
and to avoid costly institutionalization,
such as a nursing home.
Now, in order to do this, to be a true partner in care,
caregivers need care, too.
And we know that if we neglect the health, the psychological
and financial wellness of the caregiver,
it not only makes it more difficult for someone to care,
but it puts the care recipient at risk.
There is tons of research that shows that as someone is caring
for a person whose condition is declining,
the caregiver's own health will decline.
Many caregivers experience psychological stress,
such as depression and anxiety.
And we know that caregivers spend a significant amount
of income out-of-pocket to pay for the costs of care.
And this last number here from AARP estimates
that it's nearly $7,000 a year.
And for minority populations,
many of whom have lower income thresholds,
they spend as much as $9,000 a year.
So what can we do about it?
Well, the first thing is health systems can help support family
caregivers by looking at evidence-based interventions
that promote health and well-being.
And this is an example of some of the programs that we know
that science has said works.
This first program, the REACH program was administered
through the Department of Veteran Affairs,
but it's been expanded to include not only caregiving
for dementia, but also other conditions like ALS and TBI.
Powerful tools for caregivers is a self-care course,
enabling caregivers to better understand how to take care
of themselves so that they can care for others.
And next step in care addresses care transitions,
which would enable a caregiver to help someone move
through different settings of care, for example,
from a hospital to the home.
Finally, the chronic disease self-management program is
useful not only to a caregiver who's helping someone who's
managing multiple chronic conditions in their loved ones,
such as hypertension and diabetes,
but also for many caregivers.
We know the average caregivers are middle-aged,
they themselves are aging, and so it's important for them
to manage those chronic diseases as they grow older.
From a system-level standpoint,
providers can also include family caregivers
and the healthcare team.
And one of the major recommendations would be
to use caregiver assessments that identify the willingness,
readiness, and ability
of an individual caregiver to provide care.
So as Matthew mentioned, some of this is being done
through new Medicare billing codes.
And traditionally, this has also been done --
this idea of assessing a caregiver --
through the Medicaid program home
and community-based services waivers.
We also see when we look internationally
that there is work to assess caregivers,
but it's not fully prevalent in our system of healthcare today.
The other aspect of this is just simply including caregivers
as members of the healthcare team,
noting them in the medical records
and electronic healthcare records, and treating them
as a member of the healthcare team.
And there is state legislation in more than 40 states led
by AARP called the CARE Act.
And the CARE Act actually does require hospitals
to note family caregivers and to provide training
to them upon discharge.
The great news is there are already several wonderful
programs from the federal government
that support family caregivers,
the biggest of which is the National Family Caregiver
Support Program led through the Administration
on Community Living.
It supports 700,000 family caregivers across the US
and is usually disseminated through the Aging Network.
And it provides information and referral services,
as well as access to respite care.
Likewise, the Lifespan Respite Care Program helps strengthen
state networks to provide respite,
and the VA Caregiver Support Program provides education,
information, and a referral hotline
for those caring for veterans.
And especially those who might be older caring for veterans
of a post-9/11 conflict -- Iraq or Afghanistan --
the VA program even provides financial stipends based
on the level of need.
In some places state and federal tax credits may be available
to help caregivers offset the costs of care.
And many working caregivers are eligible for the Family
and Medical Leave Act, which in some states has been expanded
to include new kinds of caregiving relationships,
such as caring for a grandparent or an in-law.
And there are even a handful of states
where you can now get paid family and medical leave,
which can help caregivers manage that work/life balance.
Finally, if people are looking for resources about caring
for an older adult, whether it's nutrition, transportation,
or the family caregiver program,
the Eldercare locator Provides a registry of what types
of resources are available across the United States.
I think all of us have a stake in supporting family caregivers.
If we're not one now, we either will be or we'll need one.
And with that, I'd like to turn things over to
Dr. Lisa MacGuire.
[ Applause ]
>> Thank you, Grace.
From our previous speakers we heard
about national efforts related
to keeping older Americans healthy
and remaining independent as long as possible.
That is the primary focus of CDC's Alzheimer's Disease
and Healthy Aging Program.
CDC's activities touch on each of these target audiences:
Older adults; healthcare professionals; and caregivers
of older adults, especially those who are caring
for a person who has a cognitive impairment.
The types of activities that CDC's engaged in are data
for action, partnership, raising awareness,
training and education.
And I'm going to highlight our efforts in each of these areas.
The goal at CDC's Healthy Brain Initiative is
to promote cognitive aging, both brain health and awareness
of cognitive decline as part of public health practice.
The roadmap shown on the left side of this slide is a second
in the roadmap series.
It outlines 35 action items for state, local,
and public health officials.
The national plan to address Alzheimer's disease
that is updated annually establishes five ambitious goals
to both prevent future cases of Alzheimer's disease,
to better meet the needs of millions of American families
who are currently facing this disease.
The national plan serves
as an additional driver for CDC's work.
CDC has both the subjective cognitive decline
and caregiving optional modules included
on the Behavioral Risk Factor Surveillance System.
Subjective cognitive decline is a common precursor to dementia.
It is a self-evaluation of one's memory functioning.
For public health, this is an indicator
of potential future burden and the needs
in a healthcare system, long-term services and support,
and also in communities.
This module assesses in adults 45 years and older,
worsening memory problems, potential difficulties
in daily living associated with those memory problems,
and if memory problems have been discussed
with a healthcare provider.
This slides shows the states
that have administered the subjective cognitive decline
module in 2015, 2016, and 2017.
Those states are the combination of colors of the orange
and the purple administer the module, for example,
in both 2015 and in 2016.
Based on the 2015 BRFSS data,
subjective cognitive decline appears
to be decreasing slightly.
Those with SCD tend to report lower educational levels
and are more likely to live alone.
These surveillance results can be used to target interventions
to vulnerable populations, especially those concerned
about cognitive decline, those who live alone,
and those who might lack caregivers.
For the caregiving module, participants were 18 years old
and older who indicated if they were a caregiver.
They also reported on the intensity and duration
of the caregiving situation, problems that they encounter
as a caregiver, and what their greatest care needs are.
Additionally, if they were not a caregiver, they also indicated
if they expect to become a caregiver in the next two years.
This slide once again shows the states
that administered the module in 2015, 2016, and 2017.
So, for example, states that had the orange
and purple together administered the module
in both 2015 and 2016.
The results from the 2015 BRFSS module indicate that 22%
of respondents 18 years old and older provide regular care
or assistance to a friend or family member;
9% of caregivers indicate that dementia is the main reason
that they are providing for the care,
so the main reason the person is needing their
caregiving assistance.
So what do we know about the physical
and mental health of caregivers?
Caregivers are more likely to report fair
to poor physical health, depression, also more likely
to report frequent mental
and physical distress, as well as obesity.
However, we do find that there are no differences
between caregivers and non-caregivers
on coronary heart disease, stroke, CVD in diabetes,
and also on receiving a routine checkup
within the past two years.
To increase accessibility
of BRFSS subjective cognitive decline and caregiving data
in partnership with the Alzheimer's Association,
a series of state-specific infographics were developed
and released.
Additionally, CDC launched a public data portal on the health
of older adults, which provides access to key indicators
of the health and well-being of older Americans.
These indicators provide a snapshot
of currently available surveillance information
and can be useful for prioritizing or evaluation
of public health interventions.
Partnerships are the cornerstone of the Healthy Brain Initiative
and the accomplishment of the roadmap activities.
Some of our key partners are shown here, and I'm going
to highlight some of the activities
through the remainder of the presentation.
The Balm in Gilead, CDC's newest partner,
established the National Brain Health Center
for African-Americans.
The goal of the center is to raise awareness
of the issues affecting brain health
through capacity development within church congregations
as an integral partner in the prevention,
disease management, and caregiving.
As a way to raise awareness of brain health and caregiving
in the church congregations,
The Balm in Gilead initiated Memory Sunday in June of 2017.
Highlights of Memory Sunday included 130 churches
participated, reaching approximately 80,000
congregational members.
There were 13 related events in locations shown on the map
with nearly 4,000 participants in them as well.
To further raise awareness of brain health issues,
the Healthy Brain Research Center at the University
of Pennsylvania, a Healthy Brain Research Network site,
developed a series of research-based
and tested messages targeted to adult children, encouraging them
to accompany their parent
to a doctor appointment regarding memory concerns.
Recruiting and training a workforce that is skilled
to work with older adults is important,
given the demographic trends that we've heard about today
in changes within this population.
The public health curriculum is designed
to educate public health students
about the growing issues related to Alzheimer's disease
and dementia, and it is tied to the core competencies
for public health professionals.
Healthcare providers are another important focus
of education efforts related to brain health and dementia.
There is a need to increase the awareness, knowledge,
and abilities of healthcare providers who interact with
and support people of cognitive impairment
and also their caregivers.
The Balm in Gilead developed a curriculum and educated
over 300 nursing professionals in 14 chapters
of the National Black Nurses Association in 2016.
In 2017 they developed additional curriculum
to educate African-American physicians about brain health
in partnership with the National Medical Association.
In another initiative for healthcare providers,
the KAER toolkit developed by the Gerontological Society
of America helps to get cognitive screening
and assessment resources into the hands
of primary care physicians.
The materials in this toolkit are designed
to improve detection of cognitive impairment,
earlier diagnostic evaluation, and referrals for education
and supportive community services for persons
with dementia and also their family caregivers.
The resulting toolkit provides options
to the primary care physicians.
Health plans and healthcare systems can select the
approaches and tools that best fit
with their existing primary care structure.
The Alzheimer's Association awarded small grants
to public health agencies in seven states.
I want to highlight two of these states
that focused their efforts
on training healthcare professionals.
Colorado trained first responders
to effectively interact with people with dementia
who are residing in communities.
Utah developed dementia-related competency
for primary care providers, including both medical
and nursing students, as well as other non-health workforces
that work with older adults
across the continuum of their care.
CDC moving forward with our partners will continue
to support the collection of data
for both the cognitive decline and caregiving modules
on the BRFSS and other surveillance systems.
This data can be used for action,
and innovative tools facilitating access will
be developed.
We are currently in the process
of analyzing the recently released 2016 BRFSS data.
CDC will continue to increase awareness about dementia
and risk reduction strategies while reducing conflicting
messages for both patients and healthcare providers,
in addition to increasing supports for caregivers.
The key is to improve the awareness
but just improve awareness that will actually result in action.
CDC will also continue to promote cognitive screening
and assessment, and the early diagnosis and disclosure
of Alzheimer's disease and related dementias.
We will continue to do this through the training
and education of healthcare providers
and public health professionals and the development
and promotion of tools to facilitate assessment,
diagnosis, and disclosure.
The ultimate goal is to promote the health and well-being
of persons with a cognitive impairment and their caregivers.
CDC's Alzheimer's Disease
and Healthy Aging Program will keep moving the field forward
together with our partners to keep older Americans healthy
and remaining as independent as long as possible.
This slide highlights some
of the program's current collaborations; however,
there is a lot that needs to be done in this field
that we can only accomplish together through collaborations
across multiple sectors.
Thank you very much.
And now I want to open the session up for questions.
If you are participating remotely,
please make sure you submit your questions electronically.
If you're on site, please raise your hand
or move to a microphone.
And I'm going to first ask Susan
if we have any questions remotely.
[ Applause ]
>> We have several questions online.
In the absence of a sense of purpose, what can we do
to help older adults who have mobility and sight issues and,
thus, cannot volunteer teaching children how
to read and play ball?
I'm struggling to think outside the box,
but I'm having difficulty.
So what can we help the aging population do
to stay interactive?
>> Sarah, do you want to take that?
>> Sure. Thanks for that question.
There are so many opportunities for people to volunteer
and find purpose in their community.
I can recommend AARP's Connect2Affect.
It's an initiative to link older adults
with volunteer opportunities
in their communities throughout the country.
There are lots of opportunities, both in-person and remotely
to find ways to engage with your community.
And even if you have certain physical limitations,
there are ways around it.
>> Thank you very much.
Susan, did you want to comment?
>> One more.
I want to summarize we have multiple questions
on accommodations in housing.
What can families plan to do to adapt their households
and how can they find more information on that?
>> That -- I'd like to follow up with you about that.
Because there are enormous opportunities for that.
Other aging organizations and the creation
of livable communities is a big initiative of AARP's,
and that's to enable people
to live independently in their communities.
I'll be happy to provide a list of resources and opportunities
for you to address that specific question.
>> And we can post that on our Grand Rounds website.
>> Great.
>> I would just add to that very briefly, the Americans
with Disabilities Acts does also protect people who are caring
for somebody with limitations.
So people who are caring for families,
that should be one thing that they should think about,
is whether they might be able
to get accommodations through the ADA.
So, for example, if you're heard of hearing,
you can actually get a free caption telephone
through the ADA.
And a lot of people aren't aware of that.
And the other would be to go to the elder care locator
because it does provide a lot of resources for families
and for individuals who may be dealing
with functional limitations.
>> And then we had a question in the room.
>> Thank you very much for your commitment to healthy aging
and sharing that with us.
It seems if we're going to get from treatment to prevention,
we need really good early diagnosis so we can separate
out it's not just the general population in trying
to see what seems to be better, but we have early detection
of people who would otherwise develop
and we can tell what's working to prevent.
What's the on the horizon for highly reliable,
can be reliably given,
and highly specific ways to diagnose early?
>> So one of the things
that I think is the most exciting is something called the
IDEAS Study.
That's currently $100 million study that's been funded
by the Centers for Medicare and Medicaid Service, CMS.
And it's the American College of Radiology
and the Alzheimer's Association are doing it.
And what it's doing is testing --
about 20,000 people are in this study --
testing amyloid PET scans.
So there's an agent that's used in a PET scan
that can detect amyloid on the brain.
And what the study is looking at is what is the impact of that
on healthcare, and on the treatment
of healthcare, and on the diagnosis?
One of the -- the agent has been approved by the FDA,
but CMS said we need more information on its usefulness,
its utility in order to approve its coverage under Medicare.
And the Alzheimer's Association believes that this tool,
for example, this amyloid PET scan is particularly relevant
in the diagnostic sense when you're dealing
with differential diagnosis.
So you know there's something wrong with an individual,
and you need to pinpoint more accurately or you need
to pinpoint exactly what that diagnosis is,
and this would be a great tool to use to enhance that diagnosis
and to be able to better make that diagnosis and potentially
at an earlier point in the process.
And so this is a very exciting study.
There were some preliminary results
that were released last summer that were very, very promising.
And so that's one potential.
Another is the ongoing research for biomarkers.
So we know, for example, on amyloid on the brain --
so that's the plaque that develops on your brain --
if you don't have the plaque on the brain,
you don't have Alzheimer's.
But the question remains, if you do have plaque on the brain,
does that mean you have Alzheimer's?
So does it work both ways?
And so can you use amyloid, which you can now see
on this PET scan, can you use that as a biomarker?
And so that's additional research that needs to go on.
And I'll mention one more,
and that is a study called the DIAN trial.
And this the Dominantly Inherited Alzheimer's Network,
D-I-A-N, DIAN.
This is a group of people who have a genetic anomaly
that guarantees that they will get Alzheimer's.
This is very rare.
So this is less than 1%
of all Alzheimer's cases have this genetic anomaly
and they will get it at a very young age.
But because they are guaranteed to get it,
we know that they will get it so we can study various means
of prevention and whether certain things can delay the
onset of the disease in people
that we know are going to get it.
The problem is doing a research study on preventive measures
for this disease is problematic because it takes a long time
for to you get to the point of being 85 years old and,
you know, following people for 30
or 40 years is extremely difficult in a study.
And so what's exciting about the DIAN trial is
because you know these people are going to get it,
whereas me, we don't know that.
So those are just a couple of things that I think are exciting
on the horizon about diagnosis and prevention.
>> We've had so many questions, I'm going to go
to Susan one more time.
>> Yes. And I'll, again, summarize from Katie
in our Facebook Live stream, what efforts are being done
at the local level to reach and impact the health
of the young old or early prevention for the young old?
>> So I will, again, mention livable communities.
There is an enormous effort underway in association
with local communities all over the United States,
an effort coming out of the World Health Organization
to create livable communities.
And that's to make sure that streets
and housing are accessible,
that there are transportation options,
places for healthy eating, a whole variety of ways
of thinking about how to build communities
for people of all ages.
You know, the kinds of innovations that are great
for mothers and strollers who are able to take advantage
of curb cuts are the same kinds of advantages that disabled
and older people find really helpful.
So finding local communities
who are constructing the opportunities and the means
to transform their communities into places
that promote exercise and healthy food options are,
I think, part of the best way.
There's lots of workplace and wellness initiatives
for the middle-aged folk.
And some of the initiatives that Grace was mentioning
around caregiving, kind of linking the importance
of maintaining your health over age as you age.
>> All right.
Fascinating session, a lot of good stuff.
Please join me in thanking the speakers.
[ Applause ]
And, again, if you have a moment,
please pop down to the library and see their display.
And thank you very much for joining us.
We'll see you next month for Public Health Grand Rounds.
We'll see you next month for
Public Health Grand Rounds.
