**January 11, 2003**

**An Overview of Programs and Initiatives\
Sponsored by DHHS to Promote Healthy Aging:\
A Background Paper for the Blueprint on Aging for the 21st Century
Technical Advisory Group (TAG) Meeting**

**Background Paper**

Prepared for

> **Andreas Frank**
>
> Department of Health and Human Services
>
> H. Humphrey Building
>
> 200 Independence Ave., SW
>
> Washington, DC 20201

Prepared by

> **Erik Crankshaw, M.P.H.**
>
> **Donna Rabiner, Ph.D.**
>
> **Janet O'Keeffe, Dr.P.H., R.N.**

RTI International

Health, Social, and Economics Research Division

Research Triangle Park, NC 27709

RTI Project Number 06871.021

RTI Project Number

06871.021

**An Overview of Programs and Initiatives\
Sponsored by DHHS to Promote Healthy Aging:\
A Background Paper for the Blueprint on Aging for the 21st Century
Technical Advisory Group (TAG) Meeting**

**Background Paper**

**January 11, 2003**

Prepared for

> **Andreas Frank**
>
> Department of Health and Human Services
>
> H. Humphrey Building
>
> 200 Independence Ave., SW
>
> Washington, DC 20201

Prepared by

> **Erik Crankshaw, M.P.H.**
>
> **Donna Rabiner, Ph.D.**
>
> **Janet O'Keeffe, Dr.P.H., R.N.**

RTI International\*

Health, Social, and Economics Research Division

Research Triangle Park, NC 27709

# Table of Contents {#table-of-contents .TOC-0}

Section Page

[Introduction 1](#introduction)

[Purpose and Focus of the Health Promotion and Aging Project
2](#purpose-and-focus-of-the-health-promotion-and-aging-project)

[Purpose and Overview of the Background Paper
4](#purpose-and-overview-of-the-background-paper)

[Topic Area I: Translating Health Promotion and Disease Prevention
Research into Practice
5](#topic-area-i-translating-health-promotion-and-disease-prevention-research-into-practice)

[Topic Area II: Health Promotion and Disease Prevention Strategies to
Maintain or Enhance Both Cognitive and Affective Mental Functioning
Among Older Persons
7](#topic-area-ii-health-promotion-and-disease-prevention-strategies-to-maintain-or-enhance-both-cognitive-and-affective-mental-functioning-among-older-persons)

[Topic Area III: Effective Health Promotion and Disease Prevention
Programs for Older Persons
10](#topic-area-iii-effective-health-promotion-and-disease-prevention-programs-for-older-persons)

[Topic Area IV: DHHS Data Collection Activities Related to the Health
Behaviors of Older Americans
12](#topic-area-iv-dhhs-data-collection-activities-related-to-the-health-behaviors-of-older-americans)

[Discussion 14](#discussion)

[Next Steps for the Health Promotion and Aging Project
15](#next-steps-for-the-health-promotion-and-aging-project)

[References for Background Paper 16](#references-for-background-paper)

[Appendix A 17](#appendix-a)

[Appendix B 28](#appendix-b)

[Appendix C 32](#appendix-c)

[Appendix D 36](#appendix-d)

[References for Appendices 44](#references-for-appendices)

# Introduction

As the population ages over the next three decades, the proportion of
Americans over age 65 will exceed 25 percent. This demographic change
will have a dramatic impact on income support and retirement programs,
health care utilization, family caregivers, and the demand for long-term
care (LTC) services, supportive housing, and transportation. The impact
will be particularly acute for the health, LTC, and social support
systems designed to serve older persons. Although many older individuals
will enjoy good health and lead active lives in the community, a
significant number of older Americans will have chronic illnesses and
disabilities that reduce their ability to live independently. Currently,
older Americans represent only 13 percent of the U.S. population, yet
they account for 36 percent of all hospital stays, 49 percent of all
days in the hospital, and 50 percent of all physician hours. It is
estimated that, as the population ages, older Americans will incur 50
percent of all medical care expenditures.

As myths of aging have been discredited and replaced with a new
understanding of the aging process, many middle-aged and older Americans
no longer believe that aging inevitably means being unhealthy and
impaired. There is a recognition that the adoption of positive, healthy
habits (e.g., regular exercise) and the cessation of negative habits
(e.g., smoking) can help to ensure a healthy and independent old age. An
"active aging" paradigm is being accepted and embraced by a larger
proportion of older Americans than ever before, and the baby boom cohort
is likely to take a much more active role in managing their health than
are current cohorts. This situation provides a fertile ground for public
health interventions to promote healthy aging.

Given the magnitude of growth in the number of older Americans projected
over the next three decades, it will become increasingly important for
the adult population to engage in health-promoting activities to both
reduce preventable illness and prevent premature impairment. Many
activities are being conducted that relate to health promotion and
disease prevention interventions for older persons, and private and
public organizations are learning much about the potential of public
health strategies to promote "healthy aging." Examining more closely the
research, evaluation activities, and targeted health promotion and
disease prevention programs will help identify areas that can be
strengthened as the government promotes models of healthy aging in the
future.

# Purpose and Focus of the Health Promotion and Aging Project

In the next 30 years, one of five people in this country will be over
the age of 65. Many older people are in good health and leading active
lives in the community. However, a significant number of older Americans
will have chronic illnesses and disabilities that limit their ability to
fully participate in everyday activities. While projects have sought to
examine the effectiveness of health promotion and disease prevention
interventions for older persons, there is an enormous unrealized
potential of larger public health strategies to promote healthy aging.

The last comprehensive attempt to synthesize the scientific knowledge
and expertise about health promotion activities in aging populations was
undertaken in 1984, when the Department of Health and Human Services
(DHHS) launched a major initiative to encourage the public and private
sector---at all levels---national, regional, state, and local---to work
together on promoting the health of older persons. This initiative
culminated with the Surgeon General's "Workshop on Health Promotion and
Aging" in the spring of 1988.

Since that time, new scientific breakthroughs in medical care, new
pharmaceuticals, the growing field of geriatric practitioners,
aging-related research studies, and the "active aging" paradigm have
caused us to reconsider how the public health community can best provide
research, support, and services that will allow older adults to live
well and remain as healthy as possible for as long as possible.

The Office of the Assistant Secretary for Planning and Evaluation (ASPE)
has launched the Health Promotion and Aging Project in order to provide
DHHS with a series of health promotion and aging messages; consolidate
work being conducted by the Research Coordination Council (an
interagency research council charged with preventing duplication in
research and encouraging coordination); and advance its knowledge of
health promotion and disease prevention programs initiated since the
publication of the 1988 Surgeon General's Report on Older Americans'
Call to Health.

The goals of the Health Promotion and Aging project are threefold:

\(1\) describe health promotion, disease prevention, and health
education activities aimed at older persons, highlighting the range of
these activities throughout DHHS;

\(2\) identify gaps in research, evaluation, and health
promotion/disease prevention activities that can be undertaken to
enhance health promotion and disease prevention programs for older
persons; and

\(3\) assemble a broad coalition of federal, state, and local public
health experts to advise and prioritize and recommend health promotion
activities for health promotion and disease prevention activities for
older Americans.

To achieve these goals, we will carry out the following activities:

\(a\) develop a background paper that identifies health promotion,
disease prevention, and health education activities for older persons
that have been undertaken by DHHS and a few of its public and private
partners (the focus of this document);

\(b\) convene a technical advisory group (TAG) to identify overarching
priorities for health promotion and disease prevention activities for
older persons in the future, and help identify and structure how best to
use a series of technical expert panels (TEPs) to arrive at a series of
recommendations and possible alternative suggestions;

\(c\) commission a series of papers on topics the TAG group recommends
and that will help focus the discussion at the TEP meetings;

\(d\) convene a series of expert meetings to debate, discuss, and begin
to prioritize key issues and suggestions for health promotion and
disease prevention among older persons in the future; and

\(e\) develop and publish a monograph that summarizes and prioritizes
the information obtained from the TAG and TEP meetings and that includes
suggestions for future health promotion and disease prevention
activities for older Americans. The monograph will consider both
short-term and long-term implementation timeframes, and distinctions
between public and private activities.

# Purpose and Overview of the Background Paper

This document was developed to provide background information and
stimulate debate and discussion at the Health Promotion and Aging
Technical Advisory Group meeting to be held in Washington, DC, on
January 29, 2003.

Its primary purpose is to highlight current federal health promotion and
disease prevention activities targeted for older persons. We organized
this material by grouping activities into four topics that a panel of
federal officials felt would help structure the discussions at the TAG
meeting. We realize that this grouping is somewhat artificial, but we
felt that by organizing federal activities into topic areas, it would be
easier to identify gaps, discuss challenges for the future, and identify
how best to use the expert panels to validate, inform, or further debate
priorities and recommendations for the future. This paper focuses on
activities that have been conducted by the federal government in the
following four topic areas:

I. Translating health promotion and disease prevention research into
practice

II\. Health promotion and disease prevention strategies to maintain or
enhance both cognitive and affective mental functioning among older
persons

III\. Effective health promotion and disease prevention programs for
older persons

IV\. DHHS data collection activities related to the health behaviors of
older Americans.

The health promotion and disease prevention activities described in this
paper are not a complete inventory of the programs and initiatives
funded by DHHS. We concentrated on those initiatives or programs that
were designed explicitly to promote health and minimize disease and
impairment among older persons. The descriptions of the projects are
based on information obtained from agency websites and input provided
from individuals affiliated with the following federal agencies:
Administration on Aging (AoA), Centers for Disease Control and
Prevention (CDC), Centers for Medicare & Medicaid Services (CMS), DHHS's
Office of Minority Health, DHHS's Office of Women's Health, DHHS's
Surgeon General's Office, Health Research and Services Administration
(HSRA), National Institute on Aging (NIA), Office of Public Health
Services (OPHS), and Substance Abuse and Mental Health Services
Administration (SAMHSA).

The paper concludes with recommendations for additional work in these
areas and a summary of the next steps to be undertaken by the project
team.

# Topic Area I: Translating Health Promotion and Disease Prevention Research into Practice

This issue focuses on the challenge of translating health promotion and
disease prevention research into practice across health professions,
health care settings, and community settings. The topic also addresses
the issue of how to deliver appropriate health promotion information to
disadvantaged subgroups, including minority populations and those with
low levels of health literacy. Finally, this topic includes an
investigation of activities designed to provide health promotion and
disease messages to individuals using a variety of home and community
services, including LTC services.

The remainder of this section briefly describes a range of federally
funded health promotion and disease prevention programs during the past
10 years, which have focused on translating health promotion research
for older adults into practice. Table A provides a list of these
programs and their principal sponsors. See Appendix A for specific
information on each program.

A review of these programs raises a number of questions for discussion
at the TAG meeting, including the following:

• How effective has DHHS been in translating health promotion/disease
prevention research into practice for older adults?

• Are there gaps in DHHS' approach to translating knowledge about
activities that promote healthy aging into practice for older Americans?

• What are the most promising "translation" approaches to health
promotion/disease prevention, and do they need to be modified to be more
effective for particular subpopulations among the elderly?

• What are the most significant barriers to the effective translation of
research into practice, both at the health care provider level and the
individual level?

• Are broad social marketing campaigns, similar to the U.S. Surgeon
General's campaign against smoking, needed to more fully translate
health promotion/disease prevention research into practice?

• Are there additional activities that DHHS should initiate in the
future to help ensure that research findings are translated into
practice? Why are these additional activities needed?

Table A. Programs Designed to Translate Health Promotion and Disease
Prevention Research into Practice and Their Sponsors

  -------------------------------- --------------------------------------
  Programs/Initiatives             Primary Sponsors

  Healthy Aging Project            CMS, Agency for Healthcare Research
                                   and Quality, in collaboration with
                                   NIA, AoA, CDC, and the National Heart,
                                   Lung, and Blood Institute

  The National Blueprint:          AARP, American College of Sports
  Increasing Physical Activity     Medicine, American Geriatrics Society,
  Among Adults Aged 50 and Older   CDC, NIA, and the Robert Wood Johnson
                                   Foundation with contributions from 43
                                   other organizations

  HealthierUS Initiative           White House initiative launched with
                                   the President's Executive Order
                                   13266---Activities to Promote Personal
                                   Fitness; A Personal Fitness
                                   Interagency Working Group, headed by
                                   DHHS, oversees this initiative

  Screen for Life: National        CDC and CMS with technical assistance
  Colorectal Cancer Action         provided by the National Cancer
  Campaign                         Institute

  Prevention Research Centers      CDC

  Healthy Aging Network (HAN)      CDC and seven of the funded Prevention
                                   Research Centers

  Growing Stronger: Strength       CDC, in collaboration with Tufts
  Training for Older Adults        University Center for Physical Fitness

  Training and Encouragement for   American Association for Active
  Senior Activity (TESA) Project   Lifestyles and Fitness and the
                                   National Senior Games Association

  The Older Adults Media Project   CDC, in partnership with the American
                                   Society on Aging, and the Journalists
                                   Exchange on Aging

  Spyglass on Aging: Tools for     CDC
  Journalists Covering Seniors     

  U.S.A. on the Move: Steps to     AoA and the National Policy and
  Healthy Aging                    Resource Center on Nutrition and Aging
                                   at Florida International University

  The Aging States Project         AoA, CDC, the Association of State and
                                   Territorial Chronic Disease Program
                                   Directors, and the National
                                   Association of State Units on Aging

  Behavioral Medicine and          NIA
  Interventions Program            

  Bilingual/Bicultural Service     DHHS Office of Minority Health
  Demonstration Grant Program      

  Community Programs to Improve    DHHS Office of Minority Health
  Minority Health Grants Program   

  Health Disparities in Minority   DHHS Office of Minority Health
  Health Grants Program            

  Older Americans Act, Title IV    AoA
  Demonstration Projects           

  Project REACH for the Elderly    AoA

  Surgeon General's Report on      DHHS Surgeon General's Office
  Osteoporosis and Bone Health     

  Women Living Long and Living     DHHS Office of Women's Health
  Well (WLLW) Project              
  -------------------------------- --------------------------------------

# Topic Area II: Health Promotion and Disease Prevention Strategies to Maintain or Enhance Both Cognitive and Affective Mental Functioning Among Older Persons

Older adults experience a number of stressful events that may trigger or
exacerbate mental disorders. Declining health, death of loved ones,
loneliness, and moves away from home are all stressors that may impact
mental health.^1^ It is estimated that as much as 20 percent of the
adult population over the age of 55 experiences some form of mental
illness.^2^ Along with early-onset disorders such as schizophrenia and
major affective disorders that continue to affect people as they age,
late-onset illnesses such as anxiety disorders, clinical depression, and
dementia are prevalent in the aging population.^2^ Additionally,
researchers are also now realizing the pervasiveness of substance
(alcohol and prescription drug) misuse and abuse among older adults.

All of these mental health conditions can have a major negative impact
on the functioning of older persons. Additionally, they can create
barriers to the adoption of behaviors aimed at promoting physical health
and can lead to additional health problems through their effect on self
care and compliance with medication regimes.

The Institute of Medicine (IOM) has developed a conceptual framework for
the prevention of, and early intervention for, mental disorders. This
framework categorizes preventive interventions as universal, selective,
and indicated.^3^

> "*Universal preventive interventions* are targeted to the general
> public or a whole population group that has not been identified on the
> basis of individual risk.... *Selective preventive interventions* for
> mental disorders are targeted to individuals or a subgroup of the
> population whose risk of developing mental disorders is significantly
> higher than average.... *Indicated preventive interventions* for
> mental disorders are targeted to high risk individuals who are
> identified as having minimal but detectable signs or symptoms
> foreshadowing mental disorder, or biological markers indicating
> predisposition for mental disorder, but who do not meet DSM diagnostic
> levels.... Indicated preventive interventions are often referred to as
> early intervention or an early form of treatment." ^3^ []{.mark}

This conceptual framework can be applied to activities that address all
types of mental disorders from depression to substance abuse. However,
more research is needed to increase our understanding of modifiable and
protective factors for the development of mental disorders in late life.
The IOM review of intervention research programs noted that most
prevention programs in the area of mental health are directed at
children and adolescents, and that there is a striking absence of
prevention research programs targeted to the mental health needs of
adults, including the elderly. ^4^ []{.mark}

According to the AoA, efforts to prevent mental disorders among older
adults have been inadequate, and there is currently no national agenda
to promote mental health and prevent mental disorders. Existing federal
activities to address mental disorders and substance abuse among older
persons are generally focused on the diagnosis and treatment of illness
rather than early identification of those at highest risk or the
implementation of preventive measures and mental health promotion
activities.^1^

There is research indicating successful activities that can be
undertaken to decrease depression, increase information processing,
enhance self-efficacy in the performance of mental tasks, and improve
memory. In particular, regular physical activity has been shown to have
a positive effect on mild depression.^5^ However, the IOM report noted
that the base of knowledge about prevention for some mental disorders is
considerably more advanced than for others, particularly for depression.
^3^ []{.mark}

Comprehensive mental health promoting programs ideally consider the
mental, physical, and spiritual well-being of the individual and provide
opportunities to increase self-efficacy in a supportive environment. The
goal of comprehensive mental health programs has been "to help older
adults find pleasure and meaning in their lives, use appropriate
supports, and retain or assume as much control over their lives as
possible."^6^ Such programs are more likely to generate interest and
participation among older persons. As one aging service provider noted,
"If we schedule a session on depression, no one will come. But if we
have a session on 'Making the Most of Your Life,' many will join---and
we can talk about depression as an obstacle to overcome." ^7^

The remainder of this section highlights recent federally sponsored
research and activities aimed at maintaining the mental functioning of
older persons or preventing its decline. The majority of the activities
listed below were designed for individuals who were already at least
somewhat impaired, rather than for healthy individuals interested in
maintaining and/or enhancing their mental functioning. Table B provides
a list of these programs and their principal sponsors. See Appendix B
for specific information on each program.

Table B. Programs and Activities Aimed at Maintaining the Mental
Functioning of Older Persons or Preventing Its Decline

  --------------------------------------------- -------------------------
  **Programs/Activities**                       **Primary Sponsors**

  Older Adults and Mental Health: Issues and    AoA
  Opportunities                                 

  NIA Behavioral and Social Research Program    NIA

  Alzheimer's Disease Anti-Inflammatory         NIA
  Prevention Trial (ADAPT)                      

  Moderate Exercise Program for Older Women     NIA
  Caregivers                                    

  SAMHSA Mental Health and Aging Activities     SAMHSA

  SAMHSA and National Council on Aging (NCOA)   SAMHSA and NCOA
  Joint Project                                 

  Substance Abuse Prevention and Treatment      SAMHSA
  Block Grant (SAPTBG) Program                  

  Treatment Improvement Protocol (TIP) on       SAMHSA
  Substance Abuse                               

  Community-Initiated Prevention Intervention   SAMHSA
  Program                                       
  --------------------------------------------- -------------------------

A review of these activities raises a number of questions for discussion
at the TAG meeting, some related to the prevention of mental disorders
and others to the special health promotion needs of persons with a range
of mental disorders:

• What are the major gaps in the literature on the prevention of mental
disorders among the elderly?

• What is the most effective role for caregivers, community programs,
and public health professionals in preventing mental disorders?

• What modifications are needed to ensure that existing health promotion
and disease prevention activities will be effective for people with
cognitive disabilities, substance abuse problems, or mental illness?

• What additional research, data collection, and evaluation activities
are needed in this area?

• Are health promotion and disease prevention programs for individuals
with cognitive disabilities, substance abuse problems, or mental illness
effectively targeted to subgroups of older Americans in the settings
where they reside?

• What gaps exist in research, data collection, and program evaluation
to assess mental functioning in old age in order to identify those at
risk for further decline and to identify those who might benefit from
treatment?

# Topic Area III: Effective Health Promotion and Disease Prevention Programs for Older Persons

A broad range of health promotion and disease prevention activities have
been shown to be effective in helping to maintain function and reduce
the risk of disease for older adults, whether or not they have chronic
health conditions. This topic area describes current health promotion
and disease prevention activities aimed at older adults. Federal health
promotion and disease prevention programs for older Americans have
largely focused on increased physical activity, improved nutrition,
early screening for chronic conditions, vaccination programs (primarily
for pneumonia and influenza), and injury prevention, specifically
dealing with injuries related to falls. Research and program evaluation
activities also have been initiated in areas including health risk
assessments and screenings, nutrition screening and educational
services, physical fitness, home injury control services, stress
management, and follow-up use of health services.

This section provides a description of a range of federally funded
health promotion and disease prevention activities aimed at older
persons during the past 10 years. Table C provides a listing of these
programs and their principal sponsors. See Appendix C for specific
information on each program.

Table C. Health Promotion and Disease Prevention Programs and Sponsors

  ----------------------------------- -----------------------------------
  Programs/Initiatives                Primary Sponsors

  Older Americans Act Nutrition       AoA
  Programs' Elderly Nutrition Program 

  Older Americans Act Disease         AoA
  Prevention and Health Promotion     
  Services Program                    

  Initiative to Eliminate Racial and  All of DHHS; however, AoA is the
  Ethnic Disparities in Health        lead agency focused specifically on
                                      older persons

  Health Care and Aging Studies       AoA in collaboration with the
  Branch Mini-Grants Program          Association of State and
                                      Territorial Chronic Disease Program
                                      Directors, the National Association
                                      of State Units on Aging, and the
                                      CDC's National Center for Chronic
                                      Disease Prevention and Health
                                      Promotion, Health Care and Aging
                                      Studies Branch

  WISEWOMAN: Well-Integrated          CDC, Division of Nutrition and
  Screening and Evaluation            Physical Activity
  Demonstration for Women Across the  
  Nation                              

  Creativity in Aging                 AoA, in partnership with a
                                      consortium developed to focus on
                                      Creativity in Aging, including the
                                      National Institute of Mental
                                      Health, SAMHSA, National Endowment
                                      for the Arts, AARP, and the Guttman
                                      Foundation
  ----------------------------------- -----------------------------------

A review of these programs raises a number of questions for discussion
at the TAG meeting, including the following:

• Are health promotion and disease prevention programs reaching all
settings where older Americans live?

• Does the coordination of health promotion and disease prevention
programs need to be enhanced? If so, through what mechanism (e.g.,
better interagency coordination, increased information sharing,
dissemination and/or public awareness, etc.)?

• How effectively do DHHS' health promotion and disease prevention
programs incorporate trends and new data (e.g., active aging paradigm,
declining rates of disability, increasing rates of obesity, new and
often conflicting data on diets, etc.)?

• How effective are federal activities in assisting, supporting, and
supplementing state and local public health activities, and where can
future efforts be best targeted to fill resource or information gaps?

• How can DHHS encourage health care and human service programs to
emphasize health promotion and disease prevention?

• Are additional research, data, and evaluation activities needed in
this area, and if so, why?

# Topic Area IV: DHHS Data Collection Activities Related to the Health Behaviors of Older Americans

Ideally, policy development, program planning, and program
implementation will be based on data, with each step of the
implementation process being "defined, structured, informed, evaluated,
and driven by high-quality, objective, and timely research." ^8^
Substantial resources, energy, and effort are devoted to research on
topics of direct relevance to aging and public health policy and program
development. The findings of this research hold the potential "to
enhance our understanding of health and disease in old age, enrich
programs for older persons, and improve the quality of life for the
elderly." ^8^

Data obtained from research may help health promotion and aging program
planners to avoid previously failed approaches, to adopt strategies that
have been proven successful, and to more effectively target programs to
identified needs. Similarly, as a program becomes well established, data
are often needed to document the program's outcomes and provide
additional information that may be shared with other communities and
programs. By disseminating information obtained through the evaluation
of a specific program or intervention, programs may be more efficiently
developed elsewhere, thus broadening the impact of the original project
or intervention. ^8^

This topic area focuses on a number of federally funded studies that can
be used to better understand the factors necessary for healthy aging,
including self care. We provide an overview of some publicly funded
large national data sets on older adults that have been collected over
the past 10 years. Several of these large data sets include questions on
the self-care practices of older persons, use of health and social
services, performance of health behaviors, and attitudes toward
different forms of care.

The remainder of this section describes the major studies and presents
their key findings. In addition, it examines gaps in existing knowledge,
as identified by the key investigators of these large-scale efforts, and
identifies opportunities to address these gaps in future research. The
information in this section is presented by the major agency or
institute that sponsors the data collection and research. Table D
provides a listing of these programs or activities and their principal
sponsors. See Appendix D for specific information on each program.

Table D. DHHS Funded Data Collection Activities Related to Health
Behaviors of Older Americans

  ----------------------------------- -----------------------------------
  **Program/Activity**                **Primary Sponsors**

  Evidence-Based Practice Centers     Agency for Healthcare Research and
                                      Quality (AHRQ)

  Broadening the Evidence Base for    AHRQ
  Evidence-Based Guidelines           

  Aging Trends                        CDC and NIA

  Trends in Health and Aging          CDC and NIA

  Longitudinal Studies of Aging       CDC and NIA
  (LSOA)                              

  Demography and Aging Centers        NIA

  National Long-Term Care Survey      NIA and ASPE

  The Health and Retirement Study     NIA

  Study of Assets and Health Dynamics NIA
  among the Oldest Old                

  The Wisconsin Longitudinal Study    NIA
  (WLS)                               

  Baltimore Longitudinal Study on     NIA
  Aging (BLSA)                        

  National Survey of Self Care and    NIA
  Aging (NSSCA)                       

  SAMHSA Data Collection Activities   SAMHSA
  ----------------------------------- -----------------------------------

A review of these studies raises a number of questions for discussion at
the TAG meeting, including the following:

-   How can existing data help us to determine whether older individuals
    who have been recently diagnosed with certain health conditions
    (such as diabetes, heart disease, and stroke) are more likely to
    engage in, and/or maintain, health-promoting behaviors, relative to
    those not diagnosed with specific chronic conditions?

-   What research is needed to determine whether older persons are more
    likely to engage in self-care and other health-enhancing activities
    if they have a regular source of care?

-   How can existing data be used to determine whether certain healthy
    behaviors (such as not smoking, regularly exercising, and obtaining
    routine medical exams) that have been routinely practiced by adults
    in their young and middle years are more likely to be retained in
    old age?

-   What are some of the most significant gaps in health
    promotion/disease prevention research and program evaluation, and
    what opportunities exist using DHHS' large national data sets?

-   How can DHHS best support health promotion/disease prevention
    research, and what areas are most in need of further study?

# Discussion

A tremendous amount of activity related to health promotion and disease
prevention for older persons is occurring within DHHS. While some
activities described above have been led by a sole federal agency, the
vast majority of health promotion and disease prevention activities
described in this document are collaborative, involving an impressive
number of federal partners. Some of these initiatives will not provide
information on the effectiveness or cost-effectiveness of a given health
promotion or disease prevention intervention for some years to come.
However, a large body of information is already available, and more will
be emerging in the coming years on methods for promoting health and
preventing disease both prior to, and throughout, the aging process.

Innovative models have begun to emerge, and specific efforts have been
made both to target hard-to-reach populations and to increase the
likelihood that established strategies will be adopted. Even so, more
work may be needed to ensure that a larger proportion of older Americans
incorporates regular exercise into their daily lives; receives annual
flu vaccinations; and obtains screenings for colorectal cancer, breast
cancer, and other serious conditions.

Additional efforts may be needed to explore how best to prevent the
onset of late-life mental disorders, to maintain and enhance cognitive
functioning as people age, and to prevent or delay the onset and
progression of cognitive impairment. For example, NIA is planning
additional research around neurodegenerative disorders as well as normal
cognitive brain functioning. Finally, there exist a number of surveys
that provide data and information on the health behaviors and health
status of older Americans, yet there has not been a comprehensive
analysis of the most effective uses of national surveys in evaluating
the efficacy of existing interventions or tracking trends in healthy
behaviors over time. In fact, many of the surveys described under Topic
Area IV have not focused explicitly on the health-promoting activities
and health behaviors of older respondents. It may be useful to explore
adding questions that focus explicitly on the use of health promotion
and disease prevention services by older Americans. (The Veteran's
Administration has conducted a large national health promotion/disease
prevention survey that may serve as a useful model in this regard.)

# Next Steps for the Health Promotion and Aging Project

Following this meeting, RTI will commission a series of expert papers,
as recommended by the TAG, to help shape the discussion and structure
the topics chosen by the TAG for several TEP meetings. Following the TEP
meetings, RTI will write a monograph that summarizes the information
obtained from this TAG meeting, as well as the TEP expert panels, and
lay out and prioritize a series of suggestions for possible future
activities related to health promotion and disease prevention for older
adults in the future.

The anticipated outcomes of this project are to

\(1\) describe health promotion, disease prevention, and health
education activities aimed at older persons, highlighting the range of
these activities throughout DHHS;

\(2\) identify gaps in research, evaluation, and health
promotion/disease prevention activities that need to be addressed to
enhance health promotion and disease prevention programs for older
persons; and

\(3\) develop suggested approaches DHHS can consider to deliver a
coordinated, effective, science-based active aging message.

# References for Background Paper

1\. Administration on Aging (AoA). (2001). *Older adults and mental
health: Issues and opportunities*. Retrieved from
<http://www.aoa.gov/mh/report2001/execsum.html>

2\. Department of Health and Human Services. (1999). *Mental health: A
report of the Surgeon General*. Rockville, MD: U.S. Department of Health
and Human Services, Substance Abuse and Mental Health Services
Administration, Center for Mental Health Services, National Institutes
of Health, National Institute of Mental Health.

3\. Mrazek, P.J., & Haggerty, R.J. (Eds.). (1994). *Reducing risks for
mental disorders: Frontiers for preventive intervention research.*
Washington, DC: National Academy Press.

4\. Smyer, M.A. (1995). Prevention and early intervention for mental
disorders of the elderly. In M. Gatz (Ed.), *Emerging issues in mental
health and aging*. Washington, DC: American Psychological Association.

5\. Rowe, J.W., & Kahn, R.L. (1998). *Successful aging*. New York:
Pantheon Books.

6\. Waters, E. (1995). Let's not wait till it's broke: Interventions to
maintain and enhance mental health in later life. In M. Gatz (Ed.),
*Emerging issues in mental health and aging* (pp. 183--209). Washington,
DC: American Psychological Association.

7\. Department of Health and Human Services, Substance Abuse and Mental
Health Services Administration. (2002). *Promoting older adult health:
Aging network partnerships to address medication, alcohol, and mental
health problems.* Publication Number (SMA) 02‑3628. Washington, DC:
DHHS.

8\. Wetle, T. (1997). Integrating research into program planning and
development. In T. Hickey, M.A. Speers, & T.R. Prohaska (Eds.), *Public
health and aging* (pp. 131--143). Baltimore, MD: Johns Hopkins
University Press.

# Appendix A

**Programs Designed to Translate Health Promotion and Disease Prevention
Research into Practice and their Sponsors**

## Healthy Aging Project

***Sponsors.*** The Centers for Medicare and Medicaid Services and
Agency for Healthcare Research and Quality (AHRQ) jointly developed the
Healthy Aging Project in collaboration with NIA, AoA, CDC, and the
National Heart, Lung, and Blood Institute.

***Background & Purpose.*** To identify, test, and disseminate
evidence-based approaches to promote health and prevention functional
decline in older adults.^1^ This project was designed to complement
other DHHS initiatives, such as Healthy People 2010, and the U.S.
Preventive Services Task Force. The Healthy Aging Project aims to review
the available research science to identify what approaches are most
effective for promoting health and preventing disease in older
populations.

According to CMS, many health promotion and disease prevention programs
have been shown to reduce risk factors and lower health care costs, but
until now, these programs have not been evaluated for effectiveness in
the Medicare population.^2^

***Description.*** This project was launched in 1998 and is planned as a
5-year, \$3.7-million project to identify and test interventions to
reduce behavioral risk factors in the managed care and fee-for-service
settings. Specifically, the Healthy Aging Project will examine whether
health promotion interventions have a measurable impact on behavior
change, health status, functional status, and quality of life, use of
services, consumer satisfaction, or cost of care. An additional
objective of the project is to identify ways to promote the use of
Medicare clinical preventive services, such as flu shots, colorectal
cancer screening, and mammograms.

CMS has contracted with RAND to produce reports that analyze the
evidence on how to improve the delivery of Medicare clinical preventive
and screening benefits and explore how behavioral risk factor reduction
interventions, such as smoking cessation, might be implemented by the
Medicare program. To date, three evidence reports have been completed.
These include *Interventions that Increase the Utilization of
Medicare-Funded Preventive Services for Persons Aged 65 and Older,
Interventions to Promote Smoking Cessation in the Medicare Population,*
and *Health Risk Appraisals and Medicare.* Reports that are currently
being produced focus on the areas of chronic disease self-management,
physical activity, and falls prevention.

The first evidence report, *Interventions that Increase the Utilization
of Medicare-Funded Preventive Services for Persons Aged 65 and Older*,
is a guide for providers and health care systems seeking to improve the
use of influenza immunizations, pneumococcal vaccinations, mammography,
Pap tests, and colon cancer screening. A major finding of this report is
that organizational changes in health care delivery systems are
effective in improving the delivery of preventive services. As a result
of this report, CMS and CDC are collaborating on an organizational
change project to increase influenza immunization rates. This project,
entitled the Standing Orders Project, is being implemented by Medicare's
quality improvement contractors, the Quality Improvement Organizations
(QIOs).

The overall goal of the Standing Orders Project is to reduce the burden
of vaccine-preventable diseases by improving influenza and pneumococcal
vaccination coverage levels in LTC facilities. Immunization standing
orders programs are policies and protocols that authorize nurses and
pharmacists to administer vaccinations according to an approved protocol
without the need for a physician's examination. Nine intervention states
and five control states are currently piloting this initiative, and
results are expected in late 2002.^3^

An evidence report on smoking cessation---*Interventions to Promote
Smoking Cessation in the Medicare Population*---resulted from a
systematic review of the scientific literature and identifies which
interventions are most effective for older smokers. One of the findings
was that multiple methods, including individual, group and telephone
counseling, were effective in promoting smoking cessation. An additional
finding was that patients whose physicians were trained in smoking
cessation had higher cessation rates than those who visited untrained
physicians. Another important result was that financial incentives,
specifically health insurance coverage for counseling and
pharmacotherapy, resulted in increased numbers of quitters.^4^

As a result of this evidence report, CMS, CDC, AoA, and the National
Cancer Institute (NCI) collaborated on a demonstration project to test
the effectiveness of Medicare smoking cessation benefits in seven
states. The Medicare Stop Smoking Program is designed to compare the
impact of offering three different types of benefits for smoking
cessation services on quit rates. The three benefits being tested are
reimbursement for provider counseling only, a quit smoking phone line
with pharmacotherapy coverage, and usual care. Recruitment of smokers
began in fall 2002, and the study is planned for completion in 2004. It
is anticipated that the results of this demonstration project will be
used to identify a potential new Medicare smoking cessation benefit.^4^

Similarly, in an effort to evaluate the potential effectiveness of
health risk appraisal (HRA) as a health promotion tool and to provide
evidence-based recommendations regarding the use of HRA in health
promotion programs for older adults, those involved with the Healthy
Aging Project recently commissioned a report---*Health Risk Appraisals
and Medicare*. For the purpose of this report, HRA was defined as "a
systematic approach to collecting information from individuals that
identifies risk factors, provides individualized feedback, and possibly
offers interventions to promote health, sustain function, and prevent
disease."^5^

One key finding from this report was that effective HRA programs
demonstrated beneficial effects on behavior, in particular on physical
activity. (One caveat was noted, however, namely that there were few
studies evaluating this approach, and they were of varying quality.)
Another key finding was that HRA programs could have positive effects on
physiological variables, such as blood pressure and weight, and on
general health status. However, in order to be effective over time, the
authors of this report found that HRA needed to be followed with
specific interventions.

The report suggested that interventions combining HRA feedback with
available health promotion programs would be most likely to be
successful. Finally, the authors recommended that CMS conduct a Medicare
demonstration to test the efficacy and cost-effectiveness of
administering the HRA questionnaire with tailored feedback and regular
follow-up in improving or maintaining the health of older persons.^5^

In response to the evidence report *Health Risk Appraisals and
Medicare,* the Senior Risk Reduction Program Demonstration Project was
enacted. CMS is taking the lead role in developing the Senior Risk
Reduction Program, with the aim of "testing comprehensive and systematic
approaches to identifying health risks and empowering Medicare
beneficiaries to improve their health."^6^ This demonstration is
designed to use an HRA to assess individual health risks such as
smoking, lack of physical activity, poor nutrition, and avoidance of
clinical preventive and screening services.

Results of the HRA will then be used to produce tailored information and
recommendations on an ongoing basis. An ancillary aim of this project is
to investigate the utility of novel, state-of-the-art message-tailoring
methods, such as tailored interventions delivered via the Internet. The
project also aims to act as a resource guide, connecting people to
available programs and services in their communities. The *Senior Risk
Reduction Program* is currently in the design stage, which is scheduled
to last from September 2002 to November 2003.

## The National Blueprint: Increasing Physical Activity Among Adults Aged 50 and Older

***Sponsors.*** AARP, the American College of Sports Medicine, the
American Geriatrics Society, CDC, NIA, and the Robert Wood Johnson
Foundation, with contributions from 43 other organizations.

***Background & Purpose.*** The aim of the National Blueprint is to use
the clear evidence regarding the effectiveness of interventions to
promote physical activity to support national action in this area. A
major goal of the National Blueprint is to identify the principal
barriers to physical activity among older adults and to outline
strategies for increasing physical activity levels throughout the entire
population. The National Blueprint report was developed as a guide for
organizations, associations, and agencies to plan strategies to help
people aged 50 and older increase their physical activity. The document
was designed to extend the work begun by a technical expert working
group that had previously met to discuss physical activity and mid-life
among older adults.

***Description.*** The National Blueprint report highlights several
recommendations for overcoming barriers to physical activity among older
adults, such as identifying the impact that activity-friendly
communities can have on the quality of life for older adults and
promoting such communities, designing health-impact assessments to help
communities measure how well they serve the needs of their aging
citizens, establishing tax incentives for employers who offer physical
activity opportunities to their employees, requiring more training for
health professionals on physical activity in older populations, and
providing incentives to states and communities that increase physical
activities among older adults.^7^

## HealthierUS Initiative 

***Sponsor.*** HealthierUS is a White House initiative launched with the
President's Executive Order 13266---Activities to Promote Personal
Fitness on June 20, 2002. The Executive Order establishes a Personal
Fitness Interagency Working Group, headed by DHHS, to provide a
government-wide perspective on the efforts of federal agencies to
improve the health and fitness of the American people and make
recommendations for strengthening these activities.

The departments and agencies represented by the Personal Fitness
Interagency Working Group include DHHS, the Department of Agriculture,
Department of Interior, Department of Education, the Environmental
Protection Agency, the office of National Drug Control Policy, the
Department of Defense, the Department of Labor, General Services
Administration, and Veteran's Affairs.^8^

***Background & Purpose.*** The goal of the HealthierUS initiative is to
empower all Americans with the knowledge, motivation, and skills they
need to make healthy choices and to improve government policies and
services to help provide the American people with an environment that
supports healthy choices. In addition, the initiative aims to increase
collaboration among the federal government, states, communities, and the
private sector to ensure that the American people receive health
promotion and disease prevention services that are effective and
efficient.^8^

***Description.*** The Personal Fitness Interagency Working Group has
prepared one White House report cataloging federal programs related to
physical activity, nutrition, preventive screenings, and health
promotion. Three subcommittees are currently at work on three
interagency memorandums of understanding dealing with (1) employee
health promotion, (2) public affairs, and (3) program coordination.
Additionally, a HealthierUS website has been launched to bring together
for the public the variety of government online resources related to
personal fitness and health.^9^

## Screen for Life: National Colorectal Cancer Action Campaign

***Sponsor.*** CDC and CMS, with technical assistance provided by NCI.

***Background & Purpose.*** Screen for Life: National Colorectal Cancer
Action Campaign is a national campaign utilizing a multimedia approach
to inform men and women aged 50 years and older about the importance of
having regular colorectal cancer tests.^10^ The initiative was developed
largely in response to the finding that colorectal screening rates were
not significantly increasing despite the dissemination of research
clearly showing their health benefits. This multiyear campaign was
enacted in 1999.

The Screen for Life campaign's objectives are to inform the public about
the benefits of colorectal cancer screening, motivate the target
audience to talk with their health care providers to establish a
colorectal cancer screening program, and promote Medicare's covered
colorectal cancer screening benefits. To accomplish these objectives,
the campaign developed multimedia materials to educate the public about
the importance of screening.

***Description.*** Campaign messages and materials were developed based
upon an extensive review of existing communication and behavioral
science literature and formative research, including information
gathered from over 100 focus groups of men and women aged 50 years and
older.

## Prevention Research Centers

***Sponsor.*** CDC.

***Background & Purpose.*** First authorized by Congress in 1984, the
CDC Prevention Research Centers are designed to involve community
members, academic researchers, and public health agencies in study
projects that attempt to find innovative ways of promoting health and
preventing disease. There are currently 26 Prevention Research Centers
associated with schools of public health, medicine, or osteopathy in the
United States.

Each of the centers conducts research on underserved populations as well
as special interest projects defined by the CDC and other agencies of
DHHS. According to CDC, the Prevention Research Centers "serve as a
national resource for developing effective prevention strategies and
applying those strategies at the community level."^11^

***Description.*** There are currently two Prevention Research Centers
focusing on healthy aging, one at the University of Washington and the
other at the University of Pittsburgh. Helping Seniors Stay Healthy and
Active, a research program being conducted by the University of
Washington in Seattle, involves the testing of strategies designed to
help seniors (at senior centers, in managed care programs, and in other
settings) to remain healthy and independent.

This project is designed to simultaneously produce scientific findings
and provide meaningful benefits to the participating seniors. For
instance, an ongoing intervention aimed at reducing minor depression is
improving participants' physical and mental health while elucidating the
most effective approaches, including counseling, social activities, and
group exercise programs.

Promoting Health and Preventing Disease Among Older Adults at the
University of Pittsburgh is a relatively new project, begun in 2001. The
primary research question that will be guiding this center's work is
"how can use of preventive care be increased among adults over 65 years
of age?"

## CDC Collaborations to Address Healthy Aging

In addition to funding research at the Prevention Research Centers, CDC
is collaborating with numerous agencies and private partners to address
healthy aging. For example, in collaboration with the School of Public
Health at the University of Illinois--Chicago, CDC is sponsoring an
Evidence-Based Review of Physical Activity Benefits for Older Adults
with the purpose of reviewing and updating the scientific evidence on
physical activity and older adults.^12^ Several other CDC-sponsored
Prevention Research Center activities are highlighted below.

### The Healthy Aging Network (HAN)

***Sponsors.*** The CDC Prevention Research Centers' Healthy Aging
Network (HAN) is a collaboration between CDC and seven of the funded
Prevention Research Centers: University of Washington (lead center),
University of North Carolina--Chapel Hill, University of South Carolina,
University of Pittsburgh, University of California--Berkeley, University
of Colorado, and the University of Illinois--Chicago.^12^

***Purpose.*** HAN is designed to promote healthy aging and
community-based prevention research focusing on older adult issues.

***Description.*** The HAN has launched two national demonstration
projects with a focus on physical activity. Members are currently
collaborating on an in-depth, evidence-based review and statement of the
role of public health in addressing physical activity for older adult
populations. The HAN is also in the process of designing and
implementing a HAN-wide survey of programmatic and environmental
community-based physical activity opportunities for older adults across
seven national sites, while collaborating with national organizations to
identify best practices for physical activity programming. Additionally,
HAN members are consulting with federal and state organizations working
to establish local-level infrastructure for healthy aging.

### Growing Stronger: Strength Training for Older Adults

***Sponsors.*** CDC is funding and collaborating with the Tufts
University Center for Physical Fitness.

***Purpose.*** To develop, use, and evaluate low-cost training materials
and programs that provide older adults with greater opportunities to
strength train.

***Description.*** Upon completion of the evaluation, the project will
disseminate the materials and programs to health and aging agencies to
promote resistance training in the home or in community settings.^12^

### Training and Encouragement for Senior Activity (TESA) Project

***Sponsors.*** The American Association for Active Lifestyles and
Fitness (AAALF) and the National Senior Games Association (NSGA), with
funding from CDC.

***Purpose.*** The TESA project focuses on promoting physical activity
for seniors. The project targets older adults who are contemplating
participating in a physical activity program, but do not already do so.

***Description.*** The project provides information on physical activity
guidelines and provides strategies and encouragement for potential
participants through a series of free, half-day workshops. The workshops
cover issues such as motivation and goal-setting; muscular, aerobic, and
flexibility training; nutrition; and safety. The Partners for Active
Lifestyles (PALs) program complements the TESA workshops by pairing up
currently active seniors with new workshop participants.^13^

### The Older Adults Media Project

***Sponsors.*** CDC has formed a partnership with the American Society
on Aging (ASA), in cooperation with the Journalists Exchange on Aging
(JEOA).

***Purpose.*** The project's goals are threefold: (1) to highlight
critical public health problems and to promote CDC's activities to
prevent or remedy them, (2) to foster greater public awareness of
national health issues that face the rapidly aging U.S. population, and
(3) to inform members of the news and information media about key public
health topics and issues.

***Description.*** Activities conducted during the initial year included
both a presentation about CDC's initiatives to protect the health of
older people and an online computer-reporting workshop demonstrating
CDC's surveillance systems at the Joint Conference of ASA and the
National Council on the Aging (NCOA) in April 2002. The project also
provided subsequent media outreach to journalists in the form of a media
kit with in-depth background papers on the special topics presented.
Topics covered last year included diabetes, falls prevention, and
disability. During the current year, the topics of interest have
included the West Nile virus, adult immunizations, diethylstilbestrol
(DES), and physical activity for older adults. The project will
culminate with a panel presentation at the 2003 ASA/NCOA joint
conference.^12^

## Spyglass on Aging: Tools for Journalists Covering Seniors

***Sponsor.*** CDC's National Center for Chronic Disease Prevention and
Health Promotion, Health Care and Aging Studies Branch.

***Background & Purpose.*** This activity was designed to inform members
of the news and information media about key issues and resources for
reporting on health issues facing a rapidly aging U.S. population.

***Description.*** Two workshops were provided for journalists at a
joint conference of ASA and NCOA in March 2002, which led to the
publication of several articles in local and national newspapers on
topics presented by the CDC.^14^

## U.S.A. on the Move: Steps to Healthy Aging

***Sponsors.*** AoA and the National Policy and Resource Center on
Nutrition and Aging at Florida International University.

***Background & Purpose.*** U.S.A. on the Move: Steps to Healthy Aging
is a two-part pilot project developed in response to the President's
HealthierUS Initiative. It is designed to improve nutrition and physical
activity among older adults.^15^

***Description.*** The Steps to Healthy aging project is divided into
two parts: *Eating Better* and *Moving More. Eating Better* is designed
to promote healthier eating among older adults. Operating at the state
level, this program collects healthy recipes and tips from participants
in the Older Americans Nutrition Program. AoA and The National Policy
and Resource Center will publish these recipes and tips in a *Guide to
Eating Better* for wide distribution.

*Moving More* is modeled after *Colorado on the Move,*^TM^ a statewide
lifestyle initiative designed to improve health through increased
physical activity. The *Moving More* project aims to increase walking
among older adults and uses step counters to inspire adults to walk
more. The National Policy and Resource Center will be collecting step
data and input from state nutritionists and administrators over an
8-week period and will use the data to customize program goals. There is
also a pilot step program operating at a senior center in Florida that
will be reviewed for effectiveness. These activities will also result in
a publication called a *Guide to Moving More*.

## The Aging States Project 

***Sponsors.*** This project is sponsored by the Association of State
and Territorial Chronic Disease Program Directors (ASTCDPD) and the
National Association of State Units on Aging (NASUA), with support from
the CDC and AoA.

***Background & Purpose.*** The Aging States Project, initiated in 2001,
is designed to identify ways in which public health and aging services
can collaborate to better meet the needs of older adults. The project
aims to systematically compile information on health-related needs,
activities, and partnerships related to older adults.

***Description.*** National health and aging organizations have joined
together with federal and state government partners to integrate the
expertise and capacity of both networks for the benefit of older
persons.^16^ This project will result in the identification of
opportunities for closer collaboration and the development of health
promotion strategies that will assist older people today and in the
future.^16^ The final product will be a compilation of health promotion
and disease prevention activities currently in the field and a listing
of recommendations for additional opportunities for collaboration
between public health and aging services agencies in the future.^17^

## NIA Behavioral Medicine and Interventions Program 

***Sponsor.*** NIA administers the Behavioral and Social Research
Program.

***Background & Purpose.*** The program "supports research, training,
and the development of research resources and methodologies to produce a
scientific knowledge base for maximizing active life and health
expectancy."^18^

**Description.** The studies conducted within NIA's Behavioral and
Social Research program examine the interrelationships among aging,
health, and behavior processes. Topics of interest include both the
individual processes of aging and behavior, and the role of the
sociocultural environment on the development and maintenance of numerous
health and illness behaviors. The Behavioral Medicine and Interventions
unit currently funds research on disease recognition, coping, and
management, including the physiological consequences of life stresses
and burdens; and social, behavioral, and environmental interventions for
health promotion, disease prevention, and disability postponement.^18^

## Bilingual/Bicultural Service Demonstration Grant Program 

***Sponsor.*** DHHS Office of Minority Health.

***Background & Purpose*.** To reduce barriers between providers and
clients with limited English proficiency and to improve access to
quality health care.

***Description.*** The grants provide support to improve and expand the
capacity and ability of health care providers and other health care
professionals to deliver culturally competent health services to
minority populations. Funded projects also serve to increase the
minority populations' knowledge and understanding of managed care and
its implications. Funded projects offer unique and appropriate
activities to meet the needs of the target community. In 2002--2003, 12
projects specifically focus on older adults.^19^

## Community Programs to Improve Minority Health Grants Program

***Sponsor.*** DHHS Office of Minority Health.

***Background & Purpose***. To address at least one of the following
primary health topics: cancer, cardiovascular disease, chemical
dependency, diabetes, homicide, suicide and unintentional injuries,
infant mortality, and HIV/AIDS. Individual projects are also asked to
address issues such as access to health care, health professions
personnel development, improved data collection analysis, and cultural
competency.

***Description.*** These DHHS-funded grants are administered by minority
community-based organizations with established coalitions. In 2002, 12
coalitions specifically focused on older adult populations.^19^

## Health Disparities in Minority Health Grants Program

***Sponsor.*** DHHS Office of Minority Health.

***Background & Purpose***. To address health disparities in minority
communities by funding activities by community-based, faith-based, and
tribal organizations to reduce health risk behaviors and to improve
access to health care.

***Description.*** Three of the funded projects currently address the
needs of older adults.^19^

## Older Americans Act, Title IV Demonstration Projects

***Sponsor.*** AoA.

***Background & Purpose.*** To sponsor health promotion and disease
prevention programs targeting older people of color.

***Description.*** Currently, AoA funds five projects with the National
Minority Aging Organizations that represent each of the four major
populations of color: African-Americans, Hispanic-Americans, Asian
Americans/Pacific Islanders, and Native Americans.^16^ The five grantees
are Asociacion Nacional Pro Personas Mayores (California); National
Caucus and Center for the Black Aged, Inc. (Ohio and Washington, DC);
National Hispanic Council on Aging (TX and Washington, DC); National
Asian Pacific Center on Aging (Seattle, WA); National Indian Council on
Aging (New Mexico).

Project activities are being conducted in both urban and rural areas to
provide health information at the community level on managing diabetes,
preventing stroke and cardiovascular disease, preventing cancer, and
promoting the use of immunizations.^16^ Of these five projects, the
Asociacion Nacional includes a unique component that focuses on life
cycle planning and health promotion.

## Project REACH for the Elderly

***Sponsor.*** AoA.

***Background & Purpose*.** AoA is currently partnering with CDC to
co-manage Project REACH for the Elderly (Racial and Ethnic Approaches to
Community Health). Project REACH is now in Phase II, the third year of a
5-year project period.^16^ During Phase I, four local community
coalitions were awarded planning grants to develop community action
plans. Now, during Phase II, these four grantees are in the beginning
stages of implementing unique health promotion and disease prevention
strategies to reach older individuals of color.

***Description.*** The four projects are Boston Public Health Commission
(African descent) (Massachusetts); Latino Education Project (Hispanic)
(Texas); Special Services for Groups, Inc. (Asian/Pacific Islanders)
(California); and National Indian Council on Aging (American Indians)
(New Mexico). Project REACH's health promotion strategies are focused on
managing diabetes, preventing stroke and cardiovascular disease,
preventing cancer, and promoting the use of immunizations.^16^

Project REACH is unique for its collaboration between two federal
agencies to assist local communities in narrowing the gap in health
disparities.^16^ This multiphase initiative is developing health
promotion information that can be tailored and used by various
populations. AoA and CDC believe that by cooperating on this initiative,
a structured mechanism will be in place for local communities to build
upon for future activities.

## Surgeon General's Report on Osteoporosis and Bone Health 

***Sponsor.*** DHHS Surgeon General's Office.

***Background & Purpose.*** To promote the development of strategies to
increase bone health and reduce the impact of skeletal diseases.
(Planned release: 2004)

***Description.*** The report will include information on the prevention
and control of diseases of the skeletal system and assess the current
level of scientific consensus on issues related to the prevention and
treatment of skeletal diseases. Ultimately, the document will serve as a
guide to the development of health promotion programs aimed at improving
bone health at the individual, community, county, state, and federal
levels.^19^

## Women Living Long and Living Well (WLLLW) Project

***Sponsor.*** DHHS Office of Women's Health.

***Background & Purpose.*** WLLLW aims (1) to promote women's health
research and education and (2) to provide guidance to health promotion
and health services providers about community needs and priorities and
the health promotion approaches most likely to succeed at the community
level. Although older women are not specifically being targeted for this
initiative, women in all stages of life have been encouraged to
participate.^19^

The project will report on women's health needs, identify gaps and
priorities, and develop a framework that focuses on the two primary
goals of the Healthy People 2010 national health agenda---improving the
quality and years of life and eliminating health disparities.

***Description.*** To develop the framework, the project synthesizes
information provided from a series of focus groups and listening
sessions conducted nationwide. To achieve the two primary goals, three
pathways have been proposed: (1) improving chances for independent
living through better access to, and coordination of, health care,
services, and messages; (2) building networks of providers and
communities to integrate prevention and treatment as well as mental and
physical health care; and (3) enhancing the knowledge base through
gender-based research and multidisciplinary collaboration. For each of
the three pathways, cultural relevance, evaluation, and rapid
implementation of the findings are key elements.

Participants in the listening sessions developed an understanding of the
need for a holistic approach to women's health. Early education and
self-esteem development were seen as key to the development and
maintenance of positive health practices.

# Appendix B

## Programs and Activities Designed to Maintain the Mental Functioning of Older Persons or Prevent its Decline 

## AoA

### Older Adults and Mental Health: Issues and Opportunities

The AOA report *Older Adults and Mental Health: Issues and
Opportunities*^20^ was written as a companion document to the Surgeon
General's report on Mental Health.^21^ The report highlights the major
issues in the field of mental health and aging and focuses on community
services available to older persons, particularly those funded through
the aging network by the Older Americans Act and/or by state, local, or
private sources or programs such as Title XX, Medicare, or Medicaid.

The report highlights several strategies for addressing the mental
health issues of older adults, while emphasizing the need for expanded
partnerships to ensure that appropriate and effective services are
widely available. Among the strategies advocated by the report are
increased emphasis on health promotion, disease prevention and early
intervention services, increasing collaboration among providers and with
consumer groups, increasing public awareness and education about mental
health issues, and addressing the needs of special populations.

## NIA Behavioral and Social Research Program 

This program supports research on changes in cognitive functioning over
the life course through its Individual Behavioral Process Branch. This
program encourages a number of studies that: (1) examine the influence
of contexts on the cognitive functioning of aging persons;
(2) investigate the effects of age-related changes in cognition on
activities of daily living, social relationships, and health status; and
(3) develop strategies for improving everyday functioning through
cognitive interventions. Topics such as problem solving and decision
making, social cognition, memory strategies, and reading and speech
comprehension are of primary interest.^18^ We summarize a few of the
studies in these areas below.

### Alzheimer's Disease Anti-Inflammatory Prevention Trial (ADAPT) 

ADAPT is a clinical trial, introduced in 2001, designed to test the use
of anti-inflammatory medications for the prevention of Alzheimer's
disease. Previous epidemiological studies have suggested an association
between the use of anti-inflammatory drugs and decreased risk for
Alzheimer's disease. In this study, two specific drugs \-- Naproxen and
Celecoxib \-- will be tested for their ability to prevent Alzheimer's
disease. Study participants are 70 years old or older and have a parent
or sibling who has or had serious age-related memory loss, dementia,
senility, or Alzheimer's disease.^22^

### Moderate Exercise Program for Older Women Caregivers

This study was designed to assess the physical and mental health effects
of exercising four times a week among 100 women aged 49 to 82. It was
the first investigation of the effectiveness of a physical activity
intervention tailored specifically to the mental and physical needs of
caregivers. In comparison to women receiving only nutrition counseling,
moderate exercisers slept better and lowered their blood pressure
reactivity to stress tests.

Given that many women eventually will provide care to an ill or disabled
relative, the findings of this study are very important. Dr. Sidney M.
Stahl, Chief of Behavioral Medicine within the NIA's Behavioral and
Social Research Program noted that "studies show that family caregiving
accompanied by emotional strain is an independent risk factor for
mortality among older adults. The study gives us some evidence that a
self-directed exercise program can reduce stress reactions and perhaps
improve the health of caregivers. This pilot intervention trial provides
encouraging results and hope for a low-cost, effective means to combat
caregiver stress."^23^

## SAMHSA Mental Health and Aging Activities 

Although SAMHSA's programs are often targeted to children and younger
adults, the agency has sponsored several activities focused on health
promotion and disease prevention for older adults. These activities are
highlighted below.

### SAMHSA and NCOA Joint Project

In FY 1999, SAMHSA and the NCOA began a project to identify ways to
engage the aging services network (e.g., senior centers, adult day care
programs, and nutrition programs) in addressing the mental health needs
of older adults. Through meetings with consumers and substance abuse,
mental health, and aging services providers, two key priorities were
identified: (1) increased awareness at all levels (including older
adults, aging services staff, substance abuse and mental health services
staff, federal/state/local public officials) of the substance abuse and
mental health issues facing older adults, and (2) greater knowledge
among services providers about how to address substance abuse and mental
health problems among their clients.

SAMHSA and NCOA have responded to these identified needs by implementing
two projects. The first is the development of a manual for
community-based programs on promising practices/successful strategies
for partnership between aging services organizations and substance abuse
and mental health providers to address the needs of older adults.

The second is the design of a tool kit to educate staff and clients at
aging services organizations about how to identify and address substance
abuse and mental health problems among older adults.

Both projects are being advised by a group of approximately 20
partners---national organizations that represent leading constituencies
in the substance abuse, mental health, and aging communities.

### Substance Abuse Prevention and Treatment Block Grant (SAPTBG) Program

The Substance Abuse Prevention and Treatment Block Grant (SAPTBG),
administered by the Center for Substance Abuse Treatment (CSAT) and
Center for Substance Abuse Prevention (CSAP), provided \$1.6 billion in
2001 to states and territories (including one tribal government) to
support substance abuse treatment and prevention services for persons at
risk of abusing alcohol and drugs. The SAPTBG supports state activities
to maintain viable treatment capabilities and to respond to the citizens
who are at greatest risk of or who are abusing alcohol and illegal
drugs.

The SAPTBG accounts for approximately 49 percent of all public funds
spent by the states for substance abuse prevention and treatment. Using
the SAPTBG application as a data source, CSAT collects data from the
states on treatment needs for alcohol and drug abuse by race/ethnicity,
sex, and age cohort (including persons 45 to 64 years of age and persons
65 years and older.) These data are analyzed annually by state and
sub-state planning areas.^24^

### Treatment Improvement Protocol (TIP) on Substance Abuse

SAMHSA's CSAT is developing a series of consumer and provider-oriented
materials related to the 1998 Treatment Improvement Protocol (TIP) on
Substance Abuse Among Older Adults. These materials will include
consumer brochures on substance abuse and the importance of good mental
health in preventing substance abuse among seniors, a poster, a provider
reference guide, and a pocket screener.^24^

### Community-Initiated Prevention Intervention Program

A grant award was made in FY 1999 to ASA under the CSAP
Community-Initiated Prevention Intervention Program. Through this grant,
ASA will refine, adapt, and test an alcohol abuse prevention
intervention in a community setting with at-risk older adults to
determine its effectiveness and potential use in other situations.

Over the past year, CSAP has worked with NCOA and others to disseminate
the Community-Initiated Prevention Intervention Program grant
announcement and pre-application workshop mailers to the aging services
constituency. It is hoped that additional grants targeting seniors will
be forthcoming.^24^

# Appendix C

## Health Promotion and Disease Prevention Programs and Sponsors

## Older Americans Act Nutrition Programs' Elderly Nutrition Program

***Sponsor.*** AoA, which administers the Elderly Nutrition Program,
funded under Titles III and VI of the Older Americans Act (OAA).^25^

***Background & Purpose.*** The Elderly Nutrition Program aims to help
older Americans build a foundation for health through improved diets,
increased physical activity, and improved lifestyle choices.

***Description.*** Through this program, AoA provides grants to 57 state
agencies on aging that make grants to 655 area agencies on aging which
contract with about 4,000 local nutrition service providers. In
addition, the AoA directly funds 233 Indian tribal organizations
representing American Indians and Alaska Natives and 2 grants to
organizations representing Native Hawaiians to promote the delivery of
nutrition services in their local communities.

The program seeks "to provide the opportunity for older Americans to
live their years in dignity."^25^ In order to achieve this goal, the
program is designed to provide healthy meals and reduce malnutrition
risk, promote health and prevent disease, and reduce social isolation,
while linking older adults with other community services. The program
also seeks to provide an opportunity for community involvement in
activities such as volunteering.

Services are targeted primarily for older adults with the greatest
social and/or economic need, with particular attention to low-income
minorities.^25^ According to AoA, a national evaluation issued in 1996
concluded that the program was successful in reaching vulnerable
populations and increasing nutrient intake and social interactions
(compared with non-participants), and participants reported satisfaction
with the program services.^25^

## Older Americans Act Disease Prevention and Health Promotion Services Program 

***Sponsor.*** AoA.

***Background & Purpose.*** AoA allocates funds to states to provide
disease prevention and health promotion services and information at
multipurpose senior centers, at congregate meal sites, through
home-delivered meal programs, or at other appropriate sites.^16^

***Description.*** The activities provided through this program include
health risk assessments and screenings, nutrition screening and
educational services, physical fitness, health promotion programs on
chronic disabling conditions, home injury control services, counseling
regarding social services, and follow-up health services. The states
give priority to areas of the state that are medically underserved, and
in which there are large numbers of older individuals who have the
greatest economic need for such services.^16^

## Initiative to Eliminate Racial and Ethnic Disparities in Health

***Sponsor.*** This initiative involves all of DHHS. However, when
focused specifically on the older population, the lead agency is AoA.

***Background & Purpose.*** AoA seeks to prevent or delay the onset of
diabetes, cardiovascular disease, influenza, and pneumococcal diseases
through the strategic use of nutrition programs, information outreach
programs, the adoption of culturally appropriate strategies, and methods
that ensure increased access to services for those in greatest economic
and social need, particularly low-income minorities.^26^

***Description.*** AoA activity related to this initiative has included
a commitment in three key areas: diabetes, cardiovascular disease, and
adult immunizations as they relate to minority elders.

## Health Care and Aging Studies Branch Mini-Grants Program 

***Sponsors.*** AoA in collaboration with the Association of State and
Territorial Chronic Disease Program Directors, the National Association
of State Units on Aging, and the CDC's National Center for Chronic
Disease Prevention and Health Promotion, Health Care and Aging Studies
Branch.

***Background & Purpose.*** The program is designed to coordinate
activities between public health and aging service agencies to provide
health promotion programs to older adults in the areas of physical
activity, proper nutrition, Medicare preventive services, arthritis, and
stress management.

***Description.*** The program has funded 10 mini-grants to the
following states: Arkansas, California, Iowa, Maine, Maryland,
Massachusetts, Michigan, North Carolina, Oklahoma, and Wyoming.^27^

## WISEWOMAN: Well-Integrated Screening and Evaluation Demonstration Program for Women Across the Nation 

***Sponsor.*** CDC, Division of Nutrition and Physical Activity.

***Background & Purpose***. The Wisewoman program will provide chronic
disease risk factor screening, lifestyle intervention, and referral
services in an effort to prevent cardiovascular disease. This program
targets low-income, underinsured and uninsured women aged 40--64
years.^28^

***Description.*** There are currently 12 WISEWOMAN demonstration
projects operating in 12 states, tribes, and territories. These projects
are completing the planning phase and are preparing to provide
preventive health services. To date, more than 10,000 women between the
ages of 40 and 64 years have been screened through the WISEWOMAN
projects. According to the CDC, WISEWOMAN will continue to extend risk
factor screening, interventions, and medical referrals to participants
in each of the 12 funded projects as long as funding is available.^28^

## Number range CHAPTERCreativity in Aging

***Sponsors.*** AoA in partnership with a consortium developed to
specifically focus on creativity in aging. A memorandum of understanding
was initiated between several federal and private‑sector partners to
provide joint support. Federal partners include the National Endowment
for the Arts (NEA) and two DHHS agencies, National Institute of Mental
Health (NIMH), and SAMHSA. NEA and NIMH are providing federal support
for the study, and AoA is actively involved on the study advisory board.
Two private-sector partners, AARP and the Guttman Foundation, are
providing support of \$600,000.

***Background & Purpose.*** This is the first study to evaluate the
impact of quality cultural programs on the overall physical health,
mental health, functioning, and sense of well-being of older adults.^16^

***Description.*** Dr. Gene Cohen, Director of George Washington
University's Center on Health, Aging and the Humanities, is conducting
the 3-year study at the sites of three cultural programs for older
persons. Sites included are Elders Share the Arts in Brooklyn, New York;
Artworks at the Goldman Institute in San Francisco; and the Levine
School of Music in Northern Virginia.^16^

# Appendix D

## DHHS Data Collection Activities Related to the Health Behaviors of Older Americans 

## AHRQ 

### Evidence-Based Practice Centers 

AHRQ awards 5-year contracts to institutions in the U.S. and Canada to
serve as Evidence-based Practice Centers (EPCs). Several of the topics
covered by these centers involve the health of older persons, with
particular focus on the Medicare population. Examples of evidence
reports produced by the centers that deal directly with the aging
population include *Osteoporosis in Postmenopausal Women* and
*Cost-Effectiveness Analysis of Colorectal Cancer Screening and
Surveillance Guidelines*.^29^ A report on screening for dementia is
forthcoming.

### Broadening the Evidence Base for Evidence-Based Guidelines

This AHRQ-supported report outlines some major areas in which research
is needed to define the appropriate use for specific screening tests,
counseling interventions, immunizations, and chemoprophylaxis. This
report focuses on identifying what the most reliable and effective ways
are to measure and improve the delivery and quality of preventive care
provided in the primary care setting.^30^

## CDC and NIA

CDC and NIA have collaborated on a number of reports that utilized
national data on the health and well-being of older Americans.

### Aging Trends

Aging Trends is a series of reports developed by the CDC's National
Center for Health Statistics, with support from NIA, that highlight some
of the most important health issues facing older Americans. These
reports use multiple sources of data to monitor the health and
well-being of the older populations. Each report identifies
opportunities for prevention and further research, describes those most
at risk, and identifies areas in which increased use of existing
services and aids would be beneficial. Four reports have been completed
to date, including *Trends in Causes of Death Among the Elderly, Trends
in Vision and Hearing Among Older Americans, The Oral Health of Older
Americans,* and *The Changing Profile of Nursing Home Residents:
1985--1997*.^31^

### Trends in Health and Aging

The CDC's National Center for Health Statistics, with support from NIA,
maintains a data warehouse and accompanying website (entitled *Trends in
Health and Aging)*. This website presents trends in health-related
behaviors, health status, health care utilization, and the cost of care
for the older U.S. population. Data are available for academic
researchers and public users to search and download. Users have free
access to a data dissemination tool to retrieve and display tabular
information. CDC plans a significant expansion of the resources and data
included in the warehouse on an ongoing basis.^32^

### Longitudinal Studies of Aging (LSOA)

The Longitudinal Studies of Aging (LSOA) is a collaborative project of
the CDC's National Center for Health Statistics and NIA. This study
analyzes multiple cohorts of persons 70 years of age and older and is
designed primarily to measure changes in health, functional status,
living arrangements, and the health services utilization of two cohorts
of Americans as they move into and through the oldest ages.

A Second Supplement on Aging followed the original LSOA in 1994. This
supplement replicated the first study, roughly 10 years later, with a
new cohort of persons 70 years of age and older. It was designed in part
to provide the data necessary for analyzing changes in health and
functioning among older Americans. The study used a nationally
representative sample of 9,447 civilian non-institutionalized persons,
and the data were collected through personal interviews in the
household.

All waves of the LSOA include questionnaire items dealing with self-care
practices and activities of daily living (ADL), with a focus on
identifying barriers and restraints to normal levels of activity.

The four identified aims of this Second Supplement on Aging are as
follows:

• provide a replication of the first Study on Aging in order to
determine whether there have been changes in the level of disability
among older persons between 1984 and the mid-1990s. Availability of
replicated health and functioning measures and their covariates
collected on two distinct cohorts will enable researchers to evaluate
whether the prevalence of disability or the factors associated with
disability are different for the current cohort of women and men aged 70
years and over as compared to those of the cohort who were aged 70 years
and over 10 years ago.

• provide information on the causes and correlates of changes in health
and functioning among older Americans, including background demographic
characteristics, health behaviors and attitudes, preexisting illness,
and social and environmental support.

• provide information on the sequence and consequences of health events,
including utilization of health care and services for assisted community
living; on the physiological consequences of disability such as changes
in social activities, living arrangements, social support, and use of
community services; and on the deployment of assisted living strategies
and the accessibility of technological and environmental adaptations.

• serve as the baseline for the first national second-generation
prospective study focusing on older Americans, the Second Longitudinal
Study of Aging.^33^

## NIA Demography of Aging Centers 

The NIA has established 11 centers on the demography of aging. These
centers have been charged with providing innovative and policy-relevant
research on health, social factors, economics, and other issues that
affect the U.S. older population. *Research Highlights in the Economics
and Demography of Aging* is a series of reports prepared for NIA as a
cooperative activity of the demography centers. Report titles include
*The Health and Retirement Study Part I---History and Overview; The
Declining Disability of Older Americans; Socioeconomic Status, Health,
and Longevity; Early Retirement in the United States; Social Security
and Retirement Around the World;* and *Health Insurance and Retirement*.
In addition to these reports, the centers have produced numerous
research reports and articles related to health and aging.^34^

We next briefly describe the major surveys conducted by the NIA's aging
centers.

### National Long Term Care (LTC) Survey

This longitudinal study, sponsored by NIA and ASPE focuses on the health
and well-being of older Americans. It was first conducted in 1982, again
in 1984, and has since been conducted every 5 years. The survey
population is drawn from Medicare beneficiary enrollment files and is
nationally representative of both community and institutional residents.

The survey's purpose is to provide nationally representative data on the
prevalence and patterns of functional limitations, both physical and
cognitive; longitudinal and cohort patterns of change in functional
limitation and mortality over a 12-year period; medical conditions and
recent medical problems; health care services used; the kind and amount
of formal and informal services received by impaired individuals and how
it is paid for; demographic and economic characteristics like age, race,
sex, marital status, education, and income and assets; out-of-pocket
expenditures for health care services and other sources of payment; and
housing and neighborhood characteristics.^35^

In 1994, several items assessing health promotion and self-care
activities were added to the LTC survey. The frequency and duration of
physical activity and the perceived effect of physical activity on heart
and breathing function were examined. Respondents also were asked about
their history of regular exercise and participation in sports, as well
as their perceived level of physical activity compared with that of
their peers. Barriers to physical activity also were assessed in the
1994 instrument. Finally, a section on current nutrition and social
activities, and five new items assessing current smoking and alcoholic
beverage consumption were added to the 1994 LTC survey.

### The Health and Retirement Study (HRS)

The Health and Retirement Study (HRS), conducted by the University of
Michigan, surveys more than 22,000 Americans over the age of 50 every 2
years. The study focuses on physical and mental health, insurance
coverage, financial status, family support systems, labor market status,
and retirement planning. Its purpose is to provide data for researchers,
policy analysts, and program planners who are making major policy
decisions that affect retirement, health insurance, saving, and economic
well-being.

The NIA first awarded the University of Michigan's Institute for Social
Research a 5-year cooperative agreement in 1990 to plan and undertake a
study that would contain a comprehensive source of data on retirement.
The study utilized a national panel design and included an initial
sample of 12,600 persons. The baseline survey was conducted in-home,
with follow-ups conducted by telephone every second year, with proxy
interviews after death. The stated objectives of HRS are to

• explain the antecedents and consequences of retirement;

• examine the relationship between health, income, and wealth over time;

• examine the life cycle patterns of wealth accumulation and
consumption;

• monitor work disability;

• provide a rich source of interdisciplinary data, including linkages
with administrative data; and

• examine how the mix and distribution of economic, family, and program
resources affect key outcomes, including retirement, dissaving, health
declines, and institutionalization.^36^

A section of the survey devoted to health status included items dealing
with activities of daily living (ADL), current levels of physical
activity, as well as current smoking and drinking practices. Questions
also were asked about the use of secondary prevention measures, such as
whether the respondent was following a special diet either to reduce
blood pressure or to prevent complications from diabetes.

The fourth wave of data collection was completed in 1999, and the study
is currently at the end of its second 5-year funding cycle. The
University of Michigan has recently submitted a proposal to NIA to renew
funding for three more waves of data collection.

### Study of Assets and Health Dynamics Among the Oldest Old (AHEAD)

The Study of Assets and Health Dynamics among the Oldest Old (AHEAD) was
designed to detail the joint dynamics among health (physical, cognitive,
and functional), economic and family resources, and care arrangements.
Wave I data collection for this national panel study was completed in
1994; Wave II was completed in 1996; and Wave III, which was fielded as
a joint data collection activity with HRS, ended in 1999. Among the
health promotion/disease prevention topics that were addressed by the
survey were barriers to physical activity, and current smoking and
drinking behaviors.

The overall objectives of this study are to:

• monitor transitions in physical, functional, and cognitive health in
advanced old age

• examine the relationship of late-life changes in physical and
cognitive health to patterns of dissaving and income flows

• relate changes in health to economic resources and intergenerational
transfers

• examine how the mix and distribution of economic, family, and program
resources affect key outcomes, including institutionalization,
dissaving, and health declines.^36^

### The Wisconsin Longitudinal Study (WLS)

The Wisconsin Longitudinal Study (WLS), supported in part by NIA, was
designed to study the life course, intergenerational transfers and
relationships, family functioning, physical and mental health and
well-being, and morbidity and mortality from late adolescence through
middle age. Items measured include social background, youthful
aspirations, schooling, military service, family formation, labor market
experiences, and social participation. Information about perceived
general health status, smoking and alcoholic beverage consumption, and
extent of self-care activities was also included.

This long-term study consists of a random sample of 10,317 men and women
who graduated from Wisconsin high schools in 1957. Survey data were
collected from the original respondents or their parents in 1957, 1964,
1975, and 1992, and from a selected sibling in 1977 and 1994. NIA is
supporting a new wave of interviews with graduates, siblings, spouses,
and widows during 2003--2004.

Because the WLS cohort was primarily born in 1939, it precedes the baby
boom generation by about a decade. Therefore, this study was designed to
provide an opportunity to assess early indications of trends and
problems that will become important as the baby boom generation reaches
old age. The study is unique in that it is the first large, longitudinal
study of American adolescents, and thus provides the first opportunity
to study the life course from late adolescence through the
mid-fifties.^37^

### Baltimore Longitudinal Study on Aging (BLSA)

The NIA's Baltimore Longitudinal Study on Aging (BLSA), begun in 1958,
is America's longest-running scientific study of human aging. The study
was designed to analyze what happens as people age and how to sort out
changes due to aging from those due to disease or other causes. More
than 1,200 men and women, ranging in age from the twenties to the
nineties, have been involved to date as study volunteers.

Included in the many (nearly 100) data types and associated studies
within the BLSA are several data files dealing with physical activity,
attitudes toward physical activity, nutrient intake, and smoking
history. For instance, at each visit, BLSA participants are asked to
complete a physical activity questionnaire. The questionnaire asks them
to estimate the amount of time they spend doing each of 100 activities.

The schedule and inventory entitled \"Your Activities and Attitudes\" is
given to each participant to be filled out without supervision at the
individuals' first visit and re-administered at every fourth visit. The
inventory is composed of three parts: background information, including
general information about the participant and his earlier life; an
activity inventory; and an attitude inventory.

The activity inventory component of the questionnaire provides eleven
sub-scores in such areas as leisure-time and religious activities,
intimate personal contacts, security, and health status. The attitude
inventory component deals with the personal aspects of adjustment. It
contains eight groups of statements concerning health, friends, work,
economic security, religion, and feelings of usefulness, happiness, and
family.

A Physical Functioning Inventory (PFI) is included in the overall
questionnaire to measure level of functioning with daily activities. It
consists of 22 items, with each item followed by several probes, as
appropriate. Each of 22 items describes a task commonly performed as
part of daily functioning, such as driving, preparing meals, climbing
stairs, bathing, and using the telephone. The probes establish the level
of difficulty (if any) experienced in performing the task, and
modifications made to enhance the performance of each task.

Since 1961, there has been an ongoing study of food habits of the men
participating in the longitudinal study. Daily average intakes have been
computed from a 7-day diet record, and additional calculations have been
performed to obtain the percentage of total calories from fats,
carbohydrates, and proteins; the polyunsaturated to saturated fatty acid
ratio; simple and complex carbohydrate intakes; and the percentage of
calories from saturated and unsaturated fatty acids.

Several important findings from this study have been reported in the
literature, including the following:

• Normal aging of the human heart and arteries is a risk factor for
cardiovascular disease at older age.

• Lifestyle and medications could help slow the decline in heart
function of older people.

• Cholesterol continues to be a risk factor for heart disease in elderly
men.

• Dementia and cognitive declines may be predicted as many as 20 years
before symptoms are observed.

• Short-term visual memory declines over time, but vocabulary increases
until people are in their eighties.

• Non-steroidal anti-inflammatory drugs such as ibuprofen may reduce the
risk for Alzheimer's disease.

• Older people cope more effectively with stress than young adults.

• Self-reported happiness is more predictable from a person's
disposition than from the special events he or she encounters.^38^

### National Survey of Self Care and Aging (NSSCA)

The National Survey of Self Care and Aging is a longitudinal data set of
community-based older adults. The sampling universe consists of all
Medicare beneficiaries in the contiguous United States who were 65 years
of age or older in 1989 and did not reside in nursing homes or
domiciliary care facilities at the time of selection. Baseline in-person
interviews were conducted during the fall and winter of 1990--1991 with
3,485 non-institutionalized adults aged 65 and older. Subjects were
selected from the Medicare beneficiary files according to a stratified
random sampling design. The unique aspects of this study include the
large number of subjects in the oldest-old (85 and older) category and
the large number of rural subjects. The initial in-person interviews
obtained extensive information on functional status and self-care coping
strategies related to functional status limitations. A telephone
follow-up survey of subjects was conducted in 1993--1994.

Among the functional status and self-care activities examined at both
time intervals was the presence and severity of difficulties in
performing basic activities of daily living (ADLs), mobility activities
of daily living (MADLs), and instrumental activities of daily living
(IADLs); and behavioral and environmental adaptations made by older
persons to mitigate actual or perceived functional difficulties
resulting from disability. Self-care coping strategies included
obtaining informal assistance from others; using equipment, clothing, or
devices (such as telephones with large numbers); modifying behavior
(such as avoiding stairs to prevent falls); and changing one's
environment (such as moving to a residence with more services) in order
to remain living in the community over time. ^39^

## SAMHSA Data Collection Activities

The SAMHSA Office of Applied Studies (OAS) collects and analyzes data on
older populations and projects the need for substance abuse treatment
among seniors through the year 2010. This project includes an in-depth
review of the literature and consultation with federal and non-federal
experts to better understand substance abuse among older persons,
including how substance abuse changes as people age and the incidence
and impact of comorbidities.

A significant focus of this project is to identify existing sources of
data and potential measures to enable projections of substance abuse
among older adults in the future. Of particular interest will be
projections of substance abuse among the baby boom cohort (born between
1946 and 1964), which evidenced the highest historic rate of substance
abuse. This cohort will begin turning 65 in 2011.

Currently, major sources of data (e.g., the National Household Survey of
Drug Abuse, the National Longitudinal Alcohol Epidemiological Study,
Veterans Administration patient data, and data from several surveys of
the National Center for Health Statistics) are being analyzed for
projections of future need. SAMHSA is considering expanding the National
Household Survey on Drug Abuse and developing a module that pertains to
older adults. Work on these activities is being shared with an
interagency workgroup composed of representatives of SAMHSA's three
Centers as well as NIA, CMS, NIMH, National Institute on Alcohol Abuse
and Alcoholism, National Institute on Drug Abuse, AoA, the Department of
Veterans Affairs, and other relevant agencies. A preliminary model is
under development that defines the measures necessary to project
substance abuse and misuse among older adults.^24^

# References for Appendices

 1. Centers for Medicare & Medicaid Services. (2002).\
Retrieved from <http://www.cms.hhs.gov/healthyaging/Background.asp>

2\. Department of Health and Human Services. (1998). *Healthy aging
project---fact sheet*. Retrieved from
<http://www.hhs.gov/news/press/1998pres/981014>

3\. Centers for Medicare & Medicaid Services. (2002).\
Retrieved from <http://www.cms.gov/healthyaging/1a.asp>

4\. Centers for Medicare & Medicaid Services. (2002).\
Retrieved from <http://www.cms.gov/healthyaging/2b.asp>

5\. Centers for Medicare & Medicaid Services. (2002).\
Retrieved from <http://www.cms.gov/healthyaging/2c.asp>

6\. Centers for Medicare & Medicaid Services. (2002).\
Retrieved from <http://www.cms.gov/healthyaging/srrp.asp>

7\. Centers for Disease Control and Prevention. (2001). *National
blueprint: Increasing physical activity among adults age 50 and
older---press release.\
*Retrieved from
<http://www.cdc.gov/nccdphp/dnpa/press/archive/blueprint.htm>

8\. Linda Isaac, Centers for Disease Control and Prevention (personal
communication, November 13, 2002).

9\. HealthierUS. (2002). Retrieved from
[http://www.healthierus.gov](http://www.healthierus.gov/)

10\. Centers for Disease Control and Prevention. (2002).\
Retrieved from <http://www.cdc.gov/cancer/ScreenForLife/background.htm>

11\. Centers for Disease Control and Prevention. (2002).\
Retrieved from <http://www.cdc.gov/nccdphp/aag/aag_prc.htm>

12 . David Brown, Centers for Disease Control and Prevention (personal
communication, November 13, 2002).

13\. American Association for Active Lifestyles and Fitness. (2002).
Retrieved from
<http://www.aahperd.org/AAALF/template.cfm?template=senioractivity.html>

14\. Jason Lang, Centers for Disease Control and Prevention (personal
communication, November 15, 2002).

15\. Administration on Aging. (2002). *U.S.A. on the move: Steps to
healthy aging*.\
Retrieved from http//www.aoa.gov/nasua-factsheet-rev211.pdf

16\. Lois Albarelli, Administration on Aging (personal communication,
November 20, 2002).

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