Studying Our Aging Population to Improve Healthcare

Studying our aging population may be a new opportunity to improve healthcare for all of us.

You are listening to ReachMD, The Channel for Medical Professionals. I am your host, Dr. Maurice Pickard, and joining me today is Dr. William Hall. Dr. Hall is the fine Professor of Medicine, the Director of the Center for Healthy Aging, both at the University of Rochester School of Medicine.

DR. MAURICE PICKARD:

Thank you very much for joining us today.

DR. WILLIAM HALL:

Well, thank you very much. It's my pleasure and a privilege to be part of the show.

DR. MAURICE PICKARD:

Dr. Hall, to begin with, we have over 55,000 centenarians and 85-year-olds are the most rapidly growing cohort in our entire population. Is it time that we begin to look at them as a possible source of improving healthcare for all of us.

DR. WILLIAM HALL:

Well, I think that the centenarians are usually defined as people, who live to be at least 100 years. A kind of a metaphor for one of the really big challenges not only for the medical profession, but for society in general is that over the next 50 years, there were never had been so many older people as a proportion of the population so what we learn from centenarians hopefully will allow us to modify our entire medical approach to the aging process, so they are very very important to us.

DR. MAURICE PICKARD:

What should we look at, I mean in the past many research projects have excluded the elderly. What can we learn if we begin to include them or actually even study (01:30) them as a, shall we say, unique part of our population?

DR. WILLIAM HALL:

Well, you know, for many years by law, the NIH excluded people over age 70 from clinical trials so the huge body of information we have about caring for adults is really based on a population that by and large isn't really suffering the advanced stages of chronic disease. Fortunately, that's changed so what we can learn by including these individuals in research is a great deal about the pathogenesis and the natural history and response to therapy of chronic disease, which is really what medical care increasingly is all about.

DR. MAURICE PICKARD:

Can a person with a chronic disease actually live to be a 100?

DR. WILLIAM HALL:

Well, you know, they can, and the interesting thing, there has been some recent literature on this that it is possible to start to kind of disentangle the role of disability and morbidity associated with disease to survival and old age and while some of this has to do with probably genetic factors and good luck, increasingly it looks like the kind of medical care we receive is very, very important.

DR. MAURICE PICKARD:

I used to think in my practice that if you gave a patient a chronic nonfatal disease, he might have better health because of it, are we seeing that actually?

DR. WILLIAM HALL:

Surely, one could cynically argue that the more times you see your physician, the more chance there is for error to occur as you get older because of the very thin margin between effective therapeutic and adverse reactions particularly to pharmaceuticals. I (03:00) think that the increase in life expectancy and particularly the increase in functional life expectancy has a great deal to do with really solid good medical care.

DR. MAURICE PICKARD:

Do you think that some of these people who reached this age may actually even have some type of functional reserve that we can't measure. I used to have patients, two people would fracture their hip on the same day, I knew which one would recover more rapidly based on their personality or some factor that I couldn’t actually quantitate, but I knew existed.

DR. WILLIAM HALL:

Well, that's kind of the Holy Grail; undiscovered functional capacity is as good a way to say it as there is. For example, there has been some interesting studies among close communities of people, particularly Roman Catholic nuns who have been followed from the time they are out of eighth grade until they die and some of them are centenarians and it's been just fascinating. What's been discovered there that the correlation between functionality, let's say brain function, and one of our benchmarks, pathology of the brain, the correlation is not very good and that some of these women, who died with the plaques and tangles of Alzheimer's, in point of fact, had exceptional function. While others who didn’t have those kinds of pathological changes, seemed to become demented and lose a lot of their functional capability. So there is some element there as yet undefined biologically and clinically that makes a difference and your haunch I think is right on target in terms of that you could often (04:30) times pick out these people.

DR. MAURICE PICKARD:

What interests most of us is not so much the years that we live, but the quality that we live and you look at these people 85 and above and measure the amount of disability they have and is there some way that you can avoid being disabled despite living to an advanced age?

DR. WILLIAM HALL:

The answer is yes and no, I mean clearly it would be pollyanish to say that we can all escape the deterioration associated with aging. On the other hand, there seems to be so many examples of people, who in some cases by lifestyle choices have really learned to cope with chronic illness and also to maintain functionality, both physical function and mental function, and my hope is that, as we understand these factors more thoroughly that this will become part and parcel of primary care and that physicians will actually be financially compensated for paying attention to these sorts of things as opposed to only being paid for procedures and for specific therapies.

DR. MAURICE PICKARD:

If you are just joining us, you are listening to The Clinician's Roundtable on ReachMD XM160, The Channel for Medical Professionals. I am your host Dr. Maurice Pickard and joining me today is Dr. William Hall. Dr. Hall is the fine Professor of Medicine and also the Director of the Center for Healthy Aging at the University of Rochester School of Medicine, and we are discussing today the possibility of looking at people, who have reached 85 and above as a source of knowledge to help all of us live a healthier life. (06:00)

You bring up a very interesting point and that's looking at certain aspects of our older population in a way that isn't often given much credence especially by medicare or any kind of compensation systems and I am really talking about ACOVE, which is the acute care of the vulnerable elderly. Could you tell us a little bit about this?

DR. WILLIAM HALL:

Well, ACOVE is one of the least well discovered jewels of medical research right now. These studies to come out of the RAND Corporation, have been asking a simple yet very profound question that says if you ask a group of medical experts, what is reasonable care for people who are on the verge of frailty say adults over age 75 living in the community, how good is their care, particularly in terms of issues that are very important to older people such as the proper care of diabetes, congestive heart failure, and all other things that we could name, but they also threw in how are we looking at the so called geriatric syndromes beginning of cognitive disorders, urinary incontinence, the fear of falling, these kinds of things, and what they find very briefly is that it's about 50-50 as most of these studies have when they look at medical practices, is about 50% of the time, physicians score very well on addressing the pressing issues of chronic illness. ACE inhibitor, for example, the treatment of CHF and adequate control of the diabetes measured by glycosylated hemoglobin, but when we look at things that seemed to be more associated with functionality in older people (07:30), physical strength, stability so that they don’t fall, urinary incontinence, dementia, depression, the completion rate falls down to about 30%. So what the ACOVE study is trying to show is can we do these assessments in an office practice in a way the distance is totally unrealistic that no one is ever going to do them and the answer is it seems to be yes, we can do better.

DR. MAURICE PICKARD:

I have often felt that falling changed the life of my patients much more than a myocardial infarction, the quality of their life deteriorated after a fall much more than say a major heart attack. They were able to return to a pretty normal lifestyle often after a heart attack, but not a fall and so little time is given in an office practice to how to keep people involved in their neuromuscular function and also that probably goes along with incontinence and depression as you mentioned. Is there any work really being done in studying the genomes of the elderly and their children?

DR. WILLIAM HALL:

Well, you know the cardinal rule of living a long life is to pick your parents carefully and most of us haven’t quite had that choice. So there has been a lot of work done, I am thinking particularly of the studies such as the Centenarian Study that comes out of Boston University where they in fact have now used the modern tools of genomic analysis to sort of say what can we pick out of these various changes in gene expression that might give us some clues and (09:00) while there does seem to be very good correlation with let's say early dementia there is much unfortunately somewhat disappointing evidence to date on the impact of genes on functionality. In all probability we just haven’t been smart enough yet, so that looking at genes for instance that might promote muscular regeneration or healthy blood vessels, it's probably only a matter of time until we understand it. Now the better thing, of course, as you apply is let's study the children of those individuals and then get some idea of when if there is genetic up regulation or down regulation, when does it occur and what can we do to promote the right sort of fit between genes and a long life? It's going to be very important, but probably we are going to learn as much from the children than we are from the centenarian parents.

DR. MAURICE PICKARD:

I have read at some place that by the year 2050 we will have over 800,000 centenarians in our country and all I can think about is our president writing letters the way he does now, supposedly from the White House to everybody who reaches 100. If he is really going to do that and get writer's cramp from all of that, shouldn’t the rest of the community benefit from this cohort that is going to be so variable for us to look at?

DR. WILLIAM HALL:

Well, probably someone should be writing a letter to the children of the centenarians and urge them to take a certain amount of self-responsibility to show how they can build on this sort of genetic lottery that they seem to have won and preserve their function by lifestyle choices such as exercise, exercising the mind as well as the body (10:30), maintaining adequate body weight and other things that we know are highly predictive of long life. Yes, I think that the writer's cramp will be there, but more importantly, let's look at those children.

DR. MAURICE PICKARD:

So much is said about preventive health now, it appears that the leadership in the medical community as well as congress is beginning to look at preventive health as a way to save money by keeping people healthier and I think this group of people seemed to have less operations, less hospitalizations, and be on less drugs, but what are we supposed to do in screening this particular group of population, is there too much or too little that we should be doing?

DR. WILLIAM HALL:

You know, in general the rule is from a population standpoint that no preventive measure we take will likely alter very much in terms of disease prevalence or cost of disease unless there is at least a 5-year life expectancy. The interesting thing is that people in their 80s in reasonably good health already have a life expectancy of 5-8, may be 10 years, so that first of all the argument is, is it worthwhile urging prevention on people that old and the answer is in a qualified way it really is very useful and when we figure out the math on this whether it saves money or not everything you said about reduced need for particularly invasive medical procedures is true, the other thing that probably has to be factored in though is that this older population has great value to society in terms of their wisdom and things that they can do often to an advanced age such as community volunteerism (12:00) so that there is a payback that's out there. It isn't just people with their feet up and sitting in an armchair is really allowing people to be at sort of their peak of their wisdom much more involved in their communities.

DR. MAURICE PICKARD:

What we were talking about today is something that's here to stay, our older population, there is going to be more and more of them and they want the best in medical care and I think looking at this age group will give us a lot of information about preventive care.

I want to thank Dr. Hall who has been our guest today and we've been discussing a very important issue. I am Dr. Maurice Pickard, your host, and you've been listening to the Clinician's Roundtable on ReachMD XM160, The Channel for Medical Professionals.

To listen to our on-demand library, visit us at www.reachmd.com. Thank you for listening.

You are listening to ReachMD XM160, The Channel for Medical Professionals. Welcome to the CDC Flu View Update provided by the Centers for Disease Control and Prevention.

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Flu activity is increasing across the country, but does it show that flu vaccination rates drop off significantly after the Thanksgiving Holiday. Hey! may be it's the turkey, but flu season actually peaks in February or later most years, so it's not too late to vaccinate. To encourage people to get vaccinated and remind them that flu season isn't just the fall, National Influenza Vaccination Week is December 8-14 this year. On Tuesday (13:30), the 9th, Children's Vaccination Day is recognized, then on the 11th it's Senior's Vaccination Day. So hopefully providers and partners can help boost vaccination rates for these high risk groups, important to both you as a healthcare provider as well as your community, Friday, December 12, has been designated Healthcare Worker Vaccination Day. Across the country, healthcare worker vaccination rates hover at around 43%. Surely, your practice can do better than that. Don't forget for a deft receptionist, who knows that they might be greeting patients with a sneeze. Of course, you know that vaccinating can stop the spread of flu to your patients, but it goes far beyond that. You can help reduce Adventism in your practice and keep from bringing the flu home to your own families. Encourage your patients and your staff to get their flu vaccine, and of course, don’t forget to get your own flu vaccine if you haven’t gotten one already. Look for free materials including posters encouraging vaccination for your staff and patients at www.cdc.gov/flu.

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