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  1. "May you live a long, healthy life." Aging Sylvia Rozario Epidemiology of Chronic Diseases

  2. Overview Concept of aging Prevalence of aging Public health perspective Diseases involved with aging Prevention of diseases and disabilities Current translational researches Future areas of study Financial burden Conclusion

  3. Concept of Aging Aging starts at birth. Aging is often equated with chronological age. Dependency ratio: "the ratio of those in the population considered to be dependent (below 15 years and above 65 years), to those considered to be of working age (15-64 years)" (Connell and Pringle, 2004). Characterizing the aging population in terms of "dependency ratios" reflects negative image of ‘aging as dependency’ and hides the valuable contribution older people make to society (NCAOP 2005). We need to distinguish chronological age as a statistical fact from the process of aging as a complex phenomenon with physical, psychological, cultural and social aspects.

  4. Concept of Aging “Aging is a process, not an event" (Bigby; 2004). A life course approach: Analysis of the diversity of aging experiences by examining the different paths of transition from adulthood to old age for different social groups. Active Aging: Redefying aging in a positive way: "the process of optimizing opportunities for health, participation and security in order to embrace quality of life as people age" (WHO 2005). The key determinants of active aging are social, environmental, behavioral, economic, personal and health/social service related. Successful Aging: the ability to maintain three key behaviors or characteristics: low risk of disease and disability, high mental and physical function and active engagement with life (Rowe & Kahn; 1998).

  5. Global Health and Aging Percentage Change in the World’s Population by Age: 2010-2050 The New Trend in Aging: 2010-2050 Source: United Nations. World Population Prospects: The 2010.  Available at:

  6. Aging in USA In the US, the Healthy Aging Program of the Centers for Disease Control and Prevention defines aging people as individuals of 50 years and above (Economist Intelligence Unit, 2012). The geriatric population in the United States is defined as individuals ≥65 years of age. Between 1989 and 2010, geriatric population rose from 25 to 40 million (US Census Bureau, 2010). Currently, about one in eight individuals in this country (13 percent) is an older American (U.S. Census Bureau, 2011). The nation's 90-and-older population nearly tripled over the past three decades, reaching 1.9millionin 2010 (US Census Bureau, 2010). The U.S. population of older adults is predicted to grow rapidly as “baby boomers” (those born between 1946 and 1964) begin to reach 65 years of age. As a result, population of Americans 65 years of age and older will rise from approximately 40 million in 2010 to 55 million in 2020, a 36% increase (AoA, 2010).

  7. U.S. population, by age, selected years 1950–2080 Year Population (thousands) Percentage All ages Under 20 20–64 65 or older 65 or older Historical 1950 160,118 54,466 92,841 812,811 8 1970 214,765 80,684 113,158 20,923 10 1990 260,458 75,060 153,368 32,029 12 2005 302,323 83,963 181,457 36,902 12 Projected 2020 339,269 87,547 198,213 53,510 16 2040 376,856 92,268 207,416 77,172 20 2060 402,079 96,760 218,777 86,543 22 2080 428,214 101,159 230,137 96,918 23 SOURCE: Board of Trustees (2006, Table V.A2)

  8. U. S. Population by Age Based on the RAND Corporation 2003 study,

  9. Prevalence of Aging Population in USA Percentage of the U.S. population over age 65, selected years: source, U.S. Census Bureau, 2003

  10. Why Study Aging? Average lifespan has increased over the last centuries, as a consequenceofmedical and environmental factor. By 2015, one of every five Americans will be between the ages of 50 and 64 (CDC 2009). By 2030, approximately 20% of Americans will be over the age of 65, representing an overall 60% increase (U.S. Census Bureau, 2004). The pace of aging in the 21st century will be like that of no other period in human history, with unprecedented growth occurring in all states (overall 60% increase, U.S. Census Bureau, 2004). Understanding mechanisms of aging and determinants of life span will help to reduce age-related morbidity and facilitate healthy aging.

  11. Why Study Aging? Characteristics of the older population include: High levels of multiple chronic conditions. High level of hospital admissions and readmissions, and emergency room usage. Consumption of 10 or more prescription drugs on a daily basis. Limitations in terms of their activities of daily living. Low functional levels, requiring physical assistance. Prevention! Prevention!! Prevention!!! Clinical preventive services can help lower health risks and costs of treating chronic disease, as well as prevent or delay the onset of disease (National Prevention, Health Promotion, and Public Health Council , June 2011). Older adults who obtain clinical preventive services and practice healthy behaviors are more likely to remain healthy and functionally independent (Cranksaw 2002, CDC 2011b).

  12. The Increasing Burden of Chronic NoncommunicableDiseases: 2008 and 2030 Source: World Health Organization, Projections of Mortality and Burden of Disease, 2004-2030.

  13. Prevalence of Chronic Disease and Disability among Men and Women Aged 50-74 Years Source: American Journal of Public Health 2009; 99/3:540-548

  14. COMMON CHRONIC CHILDHOOD DISEASES Chronic lung disease, retinopathy of prematurity and developmental delays Caused by: Genetic (inherited) conditions Environmental factors and/or nutritional factors A combination of both Premature birth and low birth weight Asthma Cystic fibrosis Diabetes Obesity: diabetes, heart disease, high blood pressure, high cholesterol, stroke, some cancers, arthritis, and sleep-disordered breathing Malnutrition : Anemia Developmental disabilities: ADHD and ASD Cerebral palsy Mental illnesses

  15. Common Chronic Diseases in Young Adults (18 and over) Five fatal diseases: Asthma Ischemic heart disease Chronic obstructive  pulmonary disease Diabetes mellitus malignant neoplasms Three nonfatal diseases: Arthritis Visual impairment Hearing impairment

  16. Common Diseases in Older Adults • Cardiovascular Diseases • Coronary Heart Disease • Cerebrovascular Disease • Hypertension • Abdominal Aortic Aneurysm • Metabolic Disorders • Diabetes Mellitus • Hyperlipidemia • Hypothyroidism • Cancers • Colorectal Cancer • Prostate Cancer • Cervical Cancer • Breast Cancer

  17. Common Diseases/Conditions in Older Adults • Infectious Diseases • Influenza • PneumococcalPneumonia • Herpes Zoster (Shingles) • Hepatitis • Musculoskeletal Conditions • Osteoporosis • Arthritis • Frequent falls • Neurological Disorders • Dementia • Alzheimer’s disease • Mental Health • Depression

  18. Common Diseases/Conditions in Older Adults • Hearing Loss • Loss of visual acuity • Cataract • Glaucoma •   Macular degeneration  • Refractive errors • Prone to motor vehicle collisions • Visual, motor, cognitive and functional impairments • Incontinence • Lack of sleep (also difficulty sleeping and poor quality of sleep) • Abuse and Neglect • Physical violence, neglect, emotional abuse, and financial exploitation

  19. Mental Health and Aging Prevalence of frequent mental distress among adults aged ≥65 Prevalence of frequent mental distress, by age, among U.S. adults

  20. Leading Causes of Mortality Among Aging Population • Cardiovascular disease • Cancer • Diabetes • Vaccine-preventable diseases • Unintentional injury

  21. Cardiovascular Diseases in Aging Population 57% of the aging population identified cardiovascular disease as the most common health concern (Aging States Project,2005). Older adults have the highest rate of heart disease compared with any other age group (44% percent of all cases of heart disease and 61% of all cases of stroke; National Center for Health Statistics, 2001)  Of the five major risk factors for cardiovascular disease (hypertension, hypercholesterolemia, tobacco use, physical inactivity, and poor nutrition), 89% of adults aged 51–61 years had at least one, and almost 20% had three or more risk factors(CDC, 2001). After age 55, with each subsequent decade of life, an individual’s risk of stroke more than doubles (CDC, 2004). Coronary Heart Disease (CHD) is the leading cause of death among the elderly over the age of 65 years (CDC, 2010). HTN is a significant risk factor for morbidity and mortality in the elderly and often requires pharmacological treatment when present.

  22. Metabolic Disorders in Aging Population Diabetes Mellitus Among U.S. residents aged >65 yrs, 10.9 million (26.9%) had diabetes in 2010 (CDC,2011) 50%had prediabetes (based on fasting glucose or hemoglobin A1c level)(CDC, 2011). Diabetes-related morbidity and mortality are especially high among the elderly: 20%with macrovascular complications (eg, myocardial infarction) (Wallace J.I.: 1999) 9%with microvascular complications (eg, retinopathy, nephropathy) (Wallace J.I.: 1999) When treating elderly diabetics, the risk of hypoglycemic episodes is 2 fold compared to young patients. Hyperlipidemia The prevalence of high cholesterol (≥240 mg/dL) among older adults: 22% for men : 39% for women The relative risk of high cholesterol to cardiovascular disease is not as daunting in the elderly as in the general population.

  23. Cancers in Aging Population • Colorectal Cancer • The incidence of colorectal cancer increases with age (Patel BB et al.; 2009). • Prostate Cancer • Age is a significant risk factor for prostate cancer • Among 50-year-old men, the lifetime prevalence is 30% (Chodak G.; 2006) • Among 80-year-olds, the lifetime prevalence is >50% (Chodak G.; 2006) • Cervical Cancer • 10% of all cervical cancer cases occur in women greater than 75 years old (NCI, 2011) • The incidence in age >65yrs is 1.2 times greater than that for 45 to 64 years olds. • Breast Cancer • Ages of 55 to 64 years: 21% of cases and ages 65 to 74: 20% of cases (NCI, 2011) • Ages 75 to 84 years: 21% of cases and ages >85 years:15.1% of cases (NCI, 2011)

  24. The National Report Card on Healthy Aging Source: The State of Aging and Health in America 2013, CDC.

  25. Prevention strategies • Chronic diseases and its associated disabilities can be attenuated by: • Adoption of healthy behaviors: Regular physical activity Proper nutrition Tobacco Cessation Maintenance of healthy weight Proper sleep • Identification of health risks earlier • Treatment and management of any identifiable chronic conditions • Appropriate use of available preventive services

  26. Proper Nutrition and Aging SOURCE: Adapted from Ziliak and Gundersen, 2011.

  27. Staying Healthy at 50+ (NIA, 2010) DAILY STEPS TO GOOD HEALTH: Be tobacco free. Be physically active. Eat a healthy diet. If you drink alcohol, drink only in moderation. SCREENING TESTS AND PREVENTIVE MEDICINE: Heart and Vascular Diseases Aspirin to prevent heart attack: Men at risk* — Ages 50 to 80. Aspirin to prevent stroke: Women at risk* — Ages 55 to 80. Abdominal Aortic Aneurysm Screening Test: Once for men who have smoked—Ages 65 to 75. Cholesterol Screening Test: All men and women — Ages 50 and older. Diabetes Screening Test: Men and women — Ages 50 and older with high blood pressure.

  28. Staying Healthy at 50+ (NIA, 2010) Cancer Breast Cancer Screening (Mammogram): All women — Ages 50 and older, every 1 to 2 years. Breast Cancer Preventive Medicines: Women at risk*— Ages 50 to 80. Cervical Cancer Screening (Pap Test): All women — Ages 50 to 65, at least every 3 years. Colorectal Cancer Screening Test: All men and women — Ages 50 and older. Bone Disease Osteoporosis Screening (Bone Density Scan): Women at risk* — Ages 60 to 65, and all women — Ages 65 and older. Sexual Health HIV and Sexually Transmitted Infection Screening Tests: Men and women at risk* — Ages 50 and older. Mental Health Depression Screening: All men and women — Ages 50 and older. Immunizations Flu Vaccine: All men and women — Ages 50 and older, annually. Other Vaccines: You can prevent some serious diseases, such as pneumonia, whooping cough, tetanus, and shingles, by being vaccinated. Talk with your doctor or nurse about which vaccines you need and when to get them.

  29. Healthy Aging: Lessons from the Baltimore Longitudinal Study of Aging Get Moving: Consider Exercise and other Physical Activities Pay Attention to Weight and Shape Healthy Food for Thought: Think About what You Eat Participate in Activities You Enjoy Participate in your health care

  30. Disease specific Prevention(United States Preventive Services Task force) • Cardiovascular Diseases • Tobacco Cessation (Primary prevention) • Aspirin chemoprevention: For men, age 45 to 79 : For women, age 55 and 79 • Detection, Evaluation, and Treatment of High Blood Cholesterol. • Screening of all adults for high blood pressure. • Diabetes Mellitus • Screening for type 2 diabetes in asymptomatic adults with sustained hypertension (HTN; >135/80 mmHg): ( by USPSTF) • Screening for type 2 diabetes in all asymptomatic adults >45yrs. And repeating every 3 years (by American Diabetic Association).

  31. Disease specific Prevention • Cancers • Colorectal cancer: High consumption of fruits and vegetables (primary prevention) : Screening for colon cancer age 50 to 75 yrs (secondary prevention) : Fecal occult blood testing : Sigmoidoscopy and/or colonoscopy • Prostate Cancer: Prostate-specific antigen screening(USPSTF do not  recommend for or against it  in men <75 years but recommend against it in men <75.) • Cervical Cancer:  Pap smears (USPSTF currently recommends that women >65 years cease screening;  American Cancer Society recommends screening  stop at age 70). • Breast Cancer: Mammography (every 2 years for all women ages 50 to 74). : Annual clinical breast  examinations >40 yrs (American Cancer Soceity)

  32. The Public Health and Aging Service Network

  33. Prevention CDC ‘s mission is “to promote health and quality of life by preventing and controlling disease, injury, and disability,” Center for Disease Control and Prevention National Center for Chronic Disease Prevention and Health Promotion Healthy Aging Program (HAP) Injury Prevention Disability Prevention Adult Immunization Prevention and early detection of disease

  34. Healthy Aging Mini-Grant program Jointly funded by CDC and AoA Managed by CDD and NASUA (National Association of State Units on Aging) 24 states have conducted health promotion activities in various areas, such as: Physical activity : Proper nutrition : Medicare preventive services : Arthritis self-management : Immunization : Stress management.

  35. NationalPrevention plan • The National Prevention Strategy is a comprehensive plan to help increase the number of Americans who are healthy at every stage of life. • For aging populations: • Advance Care Planning: Ensuring their wishes are known and honored if they are unable to speak for themselves. • Caregiving: • Clinical Preventive Services: Preventing the onset or progression of disease or disability. 1) Immunization: Influenza and Pneumococcal vaccination. 2) Screening tests: Colorectal cancer screening, Breast cancer screening Lipid disorder screening, Diabetes screening and Osteoporosis screening. 3) Counseling: Smoking cessation.

  36. Low Rates of Use of Preventive Services • Rates of older adults (ages >65) not receiving clinical preventive services are (CDC 2011b): • Vaccinations:More than 31%reported not receiving an influenza vaccination in the past. • Breast Cancer Screening: Nearly 17% of women reported not receiving a mammogram within the past two years. • Colorectal Cancer Screening: More than 36% reported not receiving colorectal cancer screening. • Diabetes Screening: 31% without diagnosed diabetes reported not receiving a test for high blood sugar or diabetes within the past three years. • Osteoporosis Screening: 62%of black women and 54% of American Indian/Alaska Native women reported never receiving osteoporosis screening compared to 33% of white women. • Lipid Disorder Screening: 5% reported not receiving blood cholesterolscreening within past 5 years. • Smoking Cessation Counseling: 31% of older women reported not receiving advice to quit smoking during their annual checkup, compared to 24%of older men.

  37. Barriers To Receipt Of Preventive Services • A 2009 survey by AARP identified the following top barriers: • Cost of the screening • Insufficient funds to cover copayments or deductibles • Uncertainty over what health insurance would cover; lack of importance to them; or lack of health insurance • Unawareness of the services recommended for their age group • Physicians may not take the time to recommend or provide the routine services • May not know that the cost of most of the services is covered by Medicare • Do not have a primary care provider or a usual source of care • May be deterred from receiving services due to physical or social barriers (transportation, disability, culture or language challenges, or fear). • The biggest barrier to preventive care may be a lack of political will (Economist Intelligent Unit, 2012).

  38. Paradox in Prevention of common age-related Diseases Continually increasing resources are being expended to combat the age-related diseases. But the causes of these diseases still remain questionable. At the same time, the incidence and morbidity related to these diseases either remain constant or increase (Wallace, 2010a). Huge investments in biomedical research in the recent past have resulted in some important accomplishments, such as sequencing of the human genome, identification of thousands of human chromosomal single nucleotide polymorphisms (SNPs). However, these accomplishments have failed to reveal the genetic causes for the common age-related diseases (Wallace, 2008). To resolve the crisis, a new paradigm must be generated that comprise the potential of the previous founding whereby adding new elements that address the current problems being compared and possibly overcome (Kuhn, 1996).

  39. Prevention Research Centers Healthy Aging Research Network (PRC-HAN)  The only existing network of academic centers that focuses on community-based participatory research on older adult health. Established in 2001 Receives support from CDC. Works to better understand the determinants of healthy aging in older adult populations. Identifies interventions that promote healthy aging. Assists in the translation ofresearch that promote healthy aging into sustainable community-based programs throughout the nation. Assesses interventions that target health disparities among older adults. Examines a broad range of programmatic and environmental interventions for physical activity promotion.

  40. Research on Healthy Aging

  41. Research Highlights NIH researchers identify new gene mutation associated with ALS and dementia: April 7, 2014 NIH researchers find basal forebrain controls decision-making speed in rodents: March 26, 2014 Researchers find association between abnormal tau and damaged brain cell DNA: March 6, 2014 NIH-supported clinical trial finds antidepressant reduces Alzheimer’s agitation: February 25, 2014 Rare genetic variants may double risk for Alzheimer’s disease: January 30, 2014 New clinical trials to test Alzheimer’s drugs: December 23, 2013 Amylin deposits in the brain may link dementia and diabetes: July 30, 2013 Smoking in middle age is associated with increased rate of cognitive decline in men: March 22, 2012

  42. Living Long & Well in the 21st Century: Strategic Directions for Research on Aging (NIA, 2014) Improve our understanding of healthy aging and disease and disability among older adults. Continue to develop and disseminate information about interventions to reduce disease and disability and improve the health and quality of life of older adults. Improve our understanding of Alzheimer’s disease, other dementias of aging, and the aging brain. Develop drug and behavioral interventions for treating these diseases, preventing their onset and progression, and maintaining cognitive, emotional, sensory, and motor health. Improve our understanding of the consequences of an aging society and provide that information to inform intervention development and policy decisions. Improve our ability to reduce health disparities and eliminate health inequities among older adults. Support the infrastructure and resources needed to promote high-quality research and communicate its results.

  43. Anti-Aging: Can We Prevent Aging? • Antioxidants • Calorie Restriction, Intermittent Fasting, Resveratrol, and Rapamycin • Hormones: • Human Growth Hormone • Testosterone • Hormones in Women: Estrogen and progesterone • DHEA: Converts to testosterone and estrogen Source: National Institute on Aging, NIH; 2012

  44. A New Focus For Medical Research Medical Research on Delayed Aging • Delayed aging could increase life expectancy by an additional 2.2 years of good health. • The economic value of delayed aging is estimated to be $7.1 trillion over fifty years. • In contrast, addressing heart disease and cancer separately would yield diminishing improvements in health and longevity by 2060. • A highly efficient way to forestall disease, extend healthy life, and improve public health. Source: Goldman D. P. et al.; Health affair, 2013.

  45. Degeneration and Cell Death During Aging Cell stress responses. Expression of HS genes is induced in response to physiological and environmental stress conditions including longevity stimuli, such as fasting, caloric restriction or acetylcarnitine, and protein conformational diseases. HSF1 can also be directly stimulated by longevity stimuli such as the histone deacetylase SIRT1 that directly activates HSF1 by deacetylation, thus fostering longevity. During aging, a gradual decline in potency of the heat shock response occur and this may prevent repair of protein damage, leading to degeneration and cell death. Source: Molecular Aspects of Medicine, 2011.

  46. Proposed scheme for pathways contributing to cellular oxidative stress Nuclear Factor kappa beta(NF-κB) and Reactive Oxygen Species (ROS) such as hydrogen peroxide (H2O2) and superoxide contribute to the tissue injury and DNA damages in humans during old ages, resulting in muscle atrophy, aging of the immune system and inflammation. it is proposed that the signaling cascades mediated via Sirtuins and FoxO represent the lifespan extending, anti-aging type of regulation. Source: Molecular Aspects of Medicine, 2011.

  47. Financial burden By 2030, the number of U.S. adults age 65 or older will more than double to about 72 million (AoA 2011a). This rapid increase in the number of older adults will put pressure on public health and health care systems, and the aging services network, making the role of clinical preventive services even more important. The aging of the American population will bring increased health concerns about serious chronic illness, the ability to delay the onset of disabilities, and the associated costs of health care. Older adults in better health, compared to those in poorer health, have a longer life expectancy and lower cumulative health expenditures until death. a 70-year-old adult with no functional limitations can expect to live an additional 14.3 years with healthcare expenditures of $136,000; conversely, a person of similar age who has at least one activity of daily living limitation has a life expectancy of 11.6 years and cumulative healthcare expenditures of $145,000 (N Engl J Med, 2003).

  48. Financial Burden • Aging is the driver of the deficit issue in most developed economies. • National spending for "formal long-term care" in 2000: $137 billion  • Paid for by Medicaid: $62 billion or 45% • Paid for by Medicare: $20 billion or 14% • One-third of long-term care expenses are paid out-of-pocket by individuals and families. • The cost of long-term care will reach $207 billion in 2020 and $346 billion in 2040. • By 2030, spending for Social Security, Medicare and Medicaid will amount to almost 60% of the federal budget. • Source: Cost of care,; 2005.

  49. Aging Population and Polypharmacy • It is the use of more medications than is clinically necessary. • In USA, individuals >65 years of age account for 12% of the population, but consume 32% of prescriptions (US Census Bureau, 2010). • Polypharmacy leads to: • adverse drug events and decreased adherence to drug regimens • poor quality of life • unnecessary drug expenses • Use of >6 drugs may be an independent predictor of increased • mortality in the geriatric patient ( Incalzi R.A et al., 1992). • Primary prevention should include: • Assessing the total number and type and dose of medications • Reviewing for possible interactions • Minimizing nonessential medications • Gradual  optimization and reassessing.

  50. References • Hormesis, cellular stress response and vitagenes as critical determinants in aging and longevity • CDC Focuses on Need for Older Adults To Receive Clinical Preventive Services • Aging and Public Health: Partnerships That Can Affect Cardiovascular Health Programs • Exercise and the aging immune system • Aging and Disease Prevention • Predicting mortality and length of stay of geriatric patients in an acute care general hospital; • Age-related increase in colorectal cancer stem cells in macroscopically normal mucosa of patients with adenomas: a risk factor for colon cancer.  • • Chronic Diseases of Children, Torpy, J. M. MD el al.; JAMA, 2010