"L.egi&tjve and Administration Interests in Geriatric Health Promotion"

Presented by Roger Herdman, MD
Assistant Director for Health and Life- Sciences
Office of Technology Assessment, U.S. Congress
Monday morning, March 21, 1988

The title of my talk, as listed on the program, is Administration and Legis-
lative Interests in Geriatric Health Promotion. However, I believe it would
be a bit presumptuous of me to speak about the Administration's interests
or views, especially considering the individuals preceding me this mom-
ing. Also, I make no pretense of speaking for the Congress in any politi-
cal sense. That said, it is my goal to present some thoughts about health
promotion for elderly people and the forms of recent Congressional legis-
lation in this area.

In many ways, there should be difference between a legislative interest

`.  in geriatric health promotion and that of the executive branch. In general,
    it is clear to all parties that health promotion is a worthy goal. While all
    -  segments of society are struggling to meet rising health care costs, it is
    equally clear that we may not want or be able to pay for preventable ill-
        nesses.

Divergences in viewpoints and thus "interests" become important when
policy makers seek to turn the concept into reality. Actually, it would be
more accurate to say "seek to help" since we should not by any means
fall into the trap of thinking the federal government-whether legislative
or executive-is the only actor in the process.
From the federal perspective, making expanded health promotion a re-
allty involves a long (some would say cumbersome; others would describe
it as necessarily cautious) sequence of events. It includes exploration of
specific goals, information gathering about means of reaching those goals,
technical analyses about programs and methods that might accomplish
health promotion, decisions about how much and what types of health
promotion programs are to be supported or otherwise encouraged, com-
promises on who will pay for programs, enactment of any needed stat-
utes, actual implementation, and then evaluation of the success of the pro-
grams in bring about desired changes.
Congress has an interest in every one of those steps, but it has more
capability and more of a mandate in some than in others. Clearly, the Con-
gress has a large role in play in setting goals, since this is the first crucial
step in lawmaking and goals must flow in large part from the needs of
the elderly population. Identifying and reacting to this population-based

26


need is one of Congress' traditional roles. This must be supplemented by
"technical" information (for example, on disease and demographic pat-
terns and on behavioral characteristics) that in significant part can only
be derived by application of the expert&e and far larger resources of the
executive agencies.

Similarly, Congress often must rely on executive expertise and research
concerning the technical means to achieve the goals. This reliance is not
as heavy as it once was; Congress has improved it informational resources
over the years and now can turn to the General Accounting Office, the
Congressional Research Service, the Office of Technology Assessment, and
incertain cases, the Congressional Budget Office. But the fact remains that
the resokces of all the technical support offices of the Congress are
extremely smaIl compared to those of the executive branch.

Congress, of course, also has access to expertise in academia and the
private sector. Here again, Congress has enhanced it capacity recently with
respect to Medicare and Medicaid related issues by creating research and
policy advisory bodies such as the Prospective Payment Assessment and
Physician Payment Review Commissions. But still it is the executive branch
that generates or supports much work in those sectors. The specific, rele-
vant point here is .that in an emerging, increasingly visible and important
area such as geriatric health promotion, the ability of Congress to make
informed choices depends to some degree on the quality and form of the
information generated by the executive branch. The novelty is the con-
tinuing tendency of the Congress to increase its own research and exter-
nal advisory capacities.
In shaping the debate about how much and what types of health pro-
motion programs are to be supported or otherwise encourages, I believe
that Congress and the Administration both have large roles to play. Con-
gress plays its part through hearings, investigations by staff or by support
agencies, interaction with constituents, and commissions.
Congress, of course, then must make it own decisions concerning enact-
ment of authorizing statutes and of appropriations bills. This is one of the
primary roles that Congress plays in health promotion. It is certainly not
the only one-the oversight process can be significant- but it is one that
distinguishes a legislative interest.
In the remainder of my presentation, I would like to accomplish three
purposes. First, I would like to examine the context in which the Con-
gress considers geriatric health promotion. I would then like to describe
some of the efforts that have pursued by Congress to enact legislation in
this area. And I would like to conclude by discussing some of the issues
that the legislative branch must address in deciding which activities to sup
port and al what level.
The ways in which the Congress seeks to further health promotion are
in large part determined by broader concerns of the institution itself. At
least two such concerns affect health promotion for older Americans. The
first is the tendency to make incremental changes in existing programs
rather than to enact a comprehensive strategy to achieve a particular goal.

27


In part, this tendency may be borne out of. an appreciation for the corn--
plexities of implementing broad new programs as was done twenty years
ago. However, the overriding cause of Congress' reliance on incremental
strateiges may be fiscal reality. As I willexplore further in a moment, con-
cern over the federal budget during the past few years has made it more
difficult to garner the political support within Congress to establish large,
`new programs. Indeed, the bipartisan efforts of the legislative and execu-
tive branch to provide protection for the elderly against catastrophic health
expenses are one of the most successful attempts at "comprehensiveness"
considered by Congress in recent years. And they are really -an expansion
of ,optional coverage under the Medicare program.
As we shall see, most Congressional efforts for geriatric health promo-
tion in recent years have taken the form of incremental changes in four
existing federal programs: Medicare, Medicaid, social services under Title.
XX block grants (all of which are authorized under the Social Security Act),
and grants authorized by the Older Americans Act.
  Proposals for changes in Medicare and Medicaid almost all. seek to expand
reimbursable health services for beneficiaries. By focusing its attention on
insurance coverage, Congress emphasizes the importance of payment for
services in the promotion of geriatric health. However, changes in Medi-
care and Medicaid can have influences far beyond the marginal increases
in coverage for these programs' beneficiaries. As the largest single payer
of health services, the policies adopted by the federal government will
.-receive serious consideration by other insurers. This phenomonen has
occurred since Part A of Medicare adopted a prospective payment system
for hospital charges.
  In the area of health promotion, the influence of the federal government
as a major payer extends even farther. Proposals to expand Medicare and
Medicaid coverage represent an explicit recognition by the federal govem-
ment of the importance of health promotion and disease prevention. Cover-
age may educate the public about those activities that can improve or main-
tain health, and it may encourage behavior to bring it about. For example,
proposals to pay for disease screening or immunizations under Medicare
could thrust the federal government into a leadership role in encouraging
all consumers'to seek such care or health professionals to provide it.
  I have already alluded to the second characteristic of Congress that shapes
recent proposals for geriatric health promotion-the major role of the budget
process in determinin g the Congressional agenda. The necessity for fiscal
responsibility has set the terms of debate for recent proposals in geriatric
health promotion. Much legislative support for disease prevention and
health promotion lies in the hope that paying for prevention now will avoid
more expensive treatment `costs in the future. Hence, in carrying out its
legislative duties, the Congress has an obligation (much like that of the
executive branch) to consider both potential benefits and potential costs.
  A great many health promotion activities are "worthwhile," and a fair
number are "compelling" in their perceived value. Recent proposals to
provide Medicare coverage for routine mammography are one example


of this debate. As the Office of Technology Assessment recently found,
mammography coverage is unlikely to reduce Medicare costs in either the
short or long run.. However, it has tremendous potential in detecting early
cancers and prolonging life. Other work conducted by our office on the
regular use of outpatient pharmaceuticals suggests that Medicare cover-
age of "medically critical" drugs may reduce hospital costs and actually
-save money f&r Medicare. The Congress will ultimately weigh all this infor-
mation in deciding whether to support these activities and at what level.
Even if one argues that a proposal is "cost-saving," the meaning of this
statement can be ambiguous. The real question should be "cost saving
for whom?" The costs of health promotion can be borne by an individual
beneficiary, by a particular program by the federal government, or by soci-
ety as a whole. A given proposal may reduce the costs of one program
while increasing those in another. The net effect of the federal budget could
be either positive or negative. Given the distribution of jurisdictional
authority within the Congress, the ways in which these costs fall may have
much to do with the success of a given proposal.
The budget process itself has numerous complicated sfeps. In general,
the Congress passes an annual budget resolution in the spring or sum-
mer that sets broad spending limits. Appropriations bills provide funds
for specific, authorized programs. Reconciliation biJls allow changes in the
authorizing legislation of entitlement programs to bring their spending in
line with the budget resolution. As is probably well-known by this group
and the American public as a whole, in recent years the last two steps
of this process have been carried out well beyond the start of the fiscal year.
Attempts to contain or decrease the budget deficit have enhanced poten-
tial changes in entitlement programs like Medicare and Medicaid that have
the potential to realize large budget savings. One would not expect
appropriations or reconciliation bills to be vehicles for expanding eligibility
or benefits of these two programs since Congress requires all components
of this part&&~ legislation to be g ermane to its original purpose. However,
because the annual budget resolution passed early in the legislative year
provides in&n&ions for budget savings in entitlement programs like Medi-
care and Medicaid, any proposals to alter these programs become germane
to a reconciliation bill even if the changes do not bring about budget sav-
ings (Fuchs and Hoadley, 1987). Recent expansions of Medicare to cover
immunizations for pneumococcal pneumonia and Hepatitis B made use
of this process.
I would now. like to talk a bit more systematically about recent and cur-
rent legislative proposals for geriatric health promotion. I have alluded to
a number of changes in Part B of the Medicare program to pay for clinical
preventive services such as irnm~tions and disease screening. In addi-
tion to the coverage of'routine pneumococcal and Hepatitis vaccines, Con-
gress recently agreed to establish a demonstration project to provide
influenza immunications to Medicare beneficiaries.
In the 99th Congress, proposals were put forth to alter Medicare in other
ways as well. One bill (S. 358) would have raised the deductible to receive

29


Part B benefits,from $75 to $100, but would allow the cost of disease screen-
ing, immunizations and hypertension drugs to count towards that deduct-
ible. A companion bill (S. 357) would have lowered the Part B premium
by $1 per month for nonsmokers. The House considered a proposal (H.R.
1402) that would allow Medicare beneficiaries to purchase a supplemental
insurance option to cover the cost of an annual preventive health physi-
cian visit. A similar proposal discussed on the Hill recently would provide
a well-patient physician visit for new Medicare beneficiaries. In 1984 and
1986, Congress authorized a total of seven demonstration programs to pro
vide community-based disease screening and referral services. Two of these
projects have been funded and are currently in operation.
Medicare related proposals for health promotion in the current Congress
fall into two categories. The first is the further expansion of coverage under
Part B. There are currently five bills that would extend Medicare payment
to routine, annual mammography. Two of these bills would also autho-
rize Medicare to pay for annual Pap smears.
The second category consists of provisions in the catastrophic health
insurance bill currently under consideration. The Senate version of this
legislation (currently under discussion in conference committee) would
allow enrollees to count the cost of several preventive services toward the
annual deductible necessary to receive catastrophic benefits. These serv-
ices are screening for glaucoma, cholesterol, cervical cancer by Pap smear,
breast cancer by mammography, tuberculosis, colorectal cancer by occult

 blood in the stool, and immunizations against tetanus, influenza and bac-
terial pneumonias.
-  Both House and Senate versions of the catastrophic bill also provide for

prescription drug coverage. Although the two versions of the bill vary
somewhat, they nonetheless represent a legislative commitment to assist
the elderly and disabled in gaining access to needed prescription drugs.
In many cases, these drugs may dramatically improve the quality of an
older person's life. Many control chronic conditions such as hypertension
and prevent more serious manifestations of illness that might require
hospitalization. It is interesting and important that this legislative commit-
ment is made without clear-cut evidence that it will save money.
The prescription drug provisions of the catastrophic bills also express
concern that pharmaceuticals be used wisely and appropriately. As the
Office of Technology Assessment (OTA) recently pointed out, geriatric
polypharmacy is now commonplace, with over a third of community dwell-
ing and over half of institutionalized elderly using four or more drugs (U.S.
Congress, 1987~). One researcher has estimated that adverse drug reac-
tions play at least a contributory role in 12 to 17 percent of all hospitahza-
tions among the elderly (Lamy, 1984). One version of the bill would assign
the Secretary of Health and Human Services the responsibility for develop-
ing programs to ensure that drug therapy promotes rather than threatens
geriatric health.
Among those proposals for geriatric health promotion not aimed at
Medicare are changes in the Older Americans Act of 1965. In a set of

30


amendments to this act passed last fall (P.L. lOO-175), Congress autho-
rized the Administration on Aging to provide grants to states totaIling $5
million a year to establish periodic health services within community senior
centers. In addition to disease screening, the centers could offer exercise
programs, home injury control, nutritional counseling, mental health serv-
ices and education On Medicare benefits. The amendments also authorized
demonstration grants to institutions of higher education for the design of
prototype health education and promotion programs. States would be able
to draw upon these prototypes in implementing their own preventive serv-
ices. It is important toremember that each of these activities require that
Congress yet appropriate the funds necessary to implement them.
Congress has also recently expressed interest in Alzheimer's disease and
related dementias. It has provided funding for basic and health services
research and has utilized nationwide expertise to provide the Secretary
with particular external advice on this topic. Legislative interest and activity
in the growing area of geriatric mental health will likely grow over the
next several years.
Block grants to states are another way in which Congress has sought
to further health promotion. In 1981, Congress combined eight categorial
grant programs together in a Preventive Health Block Grant for public
health and health promotion activities. States were given broad discretion
in how they decided to spend these funds. This Preventive Health Block
Grant is currently awaiting reauthorization. Another block grant uses funds

authorized by Title XX of the Social Security Act to provide social serv-
ices. While some portion of all these grants probably support geriatic health
promotion activities, states vary greatly in how they spend their funds.
One analysis indicates that 34 states use Title XX funds for health educa-
tion (U.S. Congress, 1987b). On the other hand, despite its rather specific
title, the Preventive Health Block Grants allow states to invest in measures
as diverse as rodent control and fluoridation, emergency medical services
and home health care in addition to health education.

Legislative activities in geriatric health promotion extend to the Congres-
sional support agencies as well. At OTA, we have tried to help the Con-
gress sort out the merits of activities in this area. In past years, we have
examined the cost-effectiveness of pneumococcal and influenza vaccines.
We recently completed an e xamination of health promotion options in large
studies of Technology and Aging and Alzheimer's disease (U.S. Congress,
1985 and 1987b). Just this past fall, we analyzed the costs and effective-
ness of mammography under Medicare (U.S. Congress, 1987d). Over the
next year, at the request of the House Ways and Means Committee and
the Senate Labor and Human Resources Committee, we will study the
costs and effectiveness of up to five additional clinical preventive services
that might be considered in the future for coverage under Medicare.
Having talked a bit about the legislative environment in which proposaIs
for geriatric health promotion are considered and having outlined recent
Congressional activities, I would like to close by focusing on some of the
methodological issues that arise in evaluating various proposals. OTA is

31


grappling with each of these issues now as it analyzes potential costs and
effectiveness. The Congress deals with them as it considers particular pima
of legislation. And you wiIl face them in your deliberations over the next
two days.
One of the first problems encountered in evaluating geriatric health pro
motion is the uncertain efficacy of many proposals. The various authors
of the background papers prepared for your use have performed a valua-
ble function in uncovering and synthesizing a diverse academic and clim-
cal literature. In many cases, however, there is a pronounced lack of data
about how well specific services work for the elderly (St-&s, 1984).
This uncertainty has several sources. For some services, there have not
been well-designed, randomized clinical trials. Glaucoma is one example
where the efficacy of preventive treatment has not been well documented
and clinical trials are badly needed (Eddy, Sanders and Eddy, 1983). In
evaluating other services, researchers have excluded the elderly from those
clinical trials that do exist (StuIts, 1984). Traditionally, they have feared
that the multiple morbidities of many elderly would preclude efficient
statistical analysis of the activity under scrutiny. The Food and Drug
Administration is currently reevaluating its own guidelines in order to
expand elderly participation in its clinical trials. Finally, in some cases
researchers may have erroneously assumed that treatment does not result
in health benefits for individuals beyond a certain age. Smoking cessation
falls into this category.
Many times those data that do exist on the efficacy of health promotion
activities come from a single demonstration project. In trying to general-
ize from a particular project to an entire population, one must bear in mind
those characteristics of the demonstration that might have contributed to
the project's outcome. Such factors might not be reproducible in a pro-
gram aimed at an entire population.
Efficacy can also depend heavily on the outcome one decides to mea-
sure. Traditionally, one examines changes in mortality or morbidity. For
some services, hawever, this approach may not sufficiently measure the
impact of the intervention. For example, one would usually measure the
effect of screening for hypertension or cholesterol in terms of expected life-
years saved or expected reductions in disability. However, the contact with
a health professional afforded to the screening patient may have impor-
tant secondary health benefits. Such contact may educate a patient about
additional ways to maintain health or it may improve mental well-being
by relieving anxiety about the patients' health. Hence, traditional measures
of mortality and morbidity might undervalue the efficacy these health pro-
motion activities.
Measuring the costs of geriatric health promotion also presents some
complexities. Since I have already discussed these ideas in describing the
Congressional enviknment for health promotion activities, I will not dwell
on them here. I would, however, like to bear in mind that cost-effectiveness
is a relative term. One activity can only be cost-effective in relation to an
alternative. In a legislative environment that relies on incremental

32


changes in existing statutes, the cost-effectiveness of a health promotional
proposal will likely be its cost per unit of efficacy achieved compared to
not making an changes at all
As I also mentioned earlier, cost-savings depend on the perspective from
which one measures them. The Congress or one of its committees may
be interested in potential cost-savings for an individual program such as
Medicare or a select population such as the elderly or disabled. But such
savings to a given program or group may actually be borne by other parts
of the federal budget, other groups.of people, or society as a whole.
Finally, there are methodological problems inherent in implementing geri-
atric health promotion activities. The reliance on marginal changes in exist-
ing programs may reveal a tendency towards services that fit easily into
the established major payer structure, at least for federally implemented
programs. Hence, the easiest programs for Congress to consider are those
that expand reimbursable clinical services under Medicare or Medicaid.
Public education and some counseling services, on the other hand, have
little preexisting structure for implementation and are,. more difficult to
execute.

Other disease prevention activities may not be viable under Medicare
and Medicaid because of the nature of the disease itself. Osteoporosis
screening is one example. while no one would debate the fact that osteopo
rosis is an important problem among older Americans, particularly women,
or that the resulting fractures are seriously disabling, it is not clear that
Medicare interventions will effectively forestall or avoid these undesirable
outcomes. Rather, interventions need to begin at a younger age. For
women, most calcium depletion occurs after menopause but before they
become eligible for Medicare. Screening women at age 65 might alert them
to their elevated risk of fracture, but it would not result in a substantial
increase in bone density.
Another implementation issue important for geriatric health promotion
is the uncertain definition of some services and their potential for abuse.
This problem may be especially relevant to expansions of Medicare or
Medicaid coverage. Earlier I mentioned proposals that would allow Medi-
care beneficiaries to receive a well-patient physician visit on an annuaI basis
or when they enter the program. The legislation authorizing this coverage
does not indicate exactly what activities would be (or should be) performed
during such a visit. The cost of the proposal is dependent on its actual
content. In the absence of a better definition or some alternative control,
the services provided could use significantly fewer resources than are
reflected in the government's reimbursement. Indeed, physicians could
provide only a minimal or inadequate examination of their patients, or
patients could seek redundant care from providers. While there may be
potential health benefits and cost-savings of such visits , legislators will
want to design such services to minim& unintended outcomes.
I do not pretend to have described in this paper all of the complexities
in evaluating geriatric health promotion as public policy. Rather, I have
tried to outline some of the major issues and constraints Congress must

33


address in considering proposals in this area. My purpose has been some-
what selfish. As I suggested early on, the Congress' ability to promote
the health of elderly Americans depends in part on the expertise of the
executive branch. Your efforts here in the next few days will greatly aid
the legislative branch in its work. I wish you luck in your deliberations
and look forward to your conclusions.

References

Eddy, David M., Lauri E. Sanders, and Judy F. Eddy, "The Value of
Screening for Glaucoma With Tonometry." Survey of Ophthalmology,
28(3): 194-205, 1983.

Fuchs, Beth C. and John F. Hoadley, "Reflections from Inside the Belt-
way: How Congress and the President Grapple With Health Policy."
PS. 20(2): 2x2-220, 1987.
Lamy, Peter P., "Hazards of Drug Use in the Elderly." Postgraduate Medi-
cine. 76(l): 50-61, 1984.

Stults, Barry, "Preventive Care for the Elderly. Western Journal of Medi-
cine, 141(6): 832-845, 1984.

U.S. Congress, Office of Technology Assessment, Technology and Aging,
(Washington, DC: U.S. Government Printing Office, June 1985).
U.S. Congress, Office of Technology Assessment, Losing u Million Minds:
confronting kgedy 0fAkheirner's l3isn.w and Other Dmtias, (Washing-
ton, DC: U.S. Government Printing Office, April 1987a).
U.S. Congress, Senate Special Committee on Aging, Developments in
Aging, 1986 (Washington, DC: U.S. Government Printing Office, June
1987b).

U.S. Congress, Office of Technology Assessment, Prescription Drugs and
Elderly Americans: Ambulatory Use and Approaches to Coverage For Medi-
care. OTA Staff Paper (Washington, DC: October 1987~).
U.S. Congress, Office of Technology Assessment, Mamniogruphy: Costs,
Ej&Yimms and Use Under Medicare. OTA Staff Paper (Washington, DC:
November 1987d).

34


PLENARY SESSION-"Setting the Pace in
           Geriatric Health
              Promotion"

"Healthy Older People"

Presented by Susan Maloney
Office of Disease Prevention and Health Promotion
Monday morning, March 21, 1988

As this workshop progresses, I am sure we will be hearing in great detail
what is needed to spur the development of health promotion for older
people. We'll hear calls for training health and aging professionals to care
for today's elders-and to provide the opportunity of better health for
tomorrow's; calls for sustained and consistent leadership for building and
supporting the networks which provide services for older people; and calls
to educate older Americans about how to stay healthy.
In my time with you today, I would like to spend a few minutes look-
ing back to where we were in 1984 when the Federal initiatives in health
promotion and aging got underway and examine what impact we've had
to date. Specifically, I will be speaking from the perspective which has
been gained from the first national health promotion program aimed at
older Americans-Healthy Older People. In many ways, Healthy Older
People serves as a demonstration of the potential there is out there for
promoting the health and well-being of our older citizens-and there are
many lessons to be learned.
Let me say at .the outset, you would not believe the skeptical reactions
I received from colleagues when I began talking about planning a national
public education program for older people. Today, the skeptics are becom-
ing believers. Although we continue to debate how best to change behavior,
and to refine what we know regarding the potential impact of behavior
change in this age group, or any for that matter, health promotion for the
aging is moving into the mainstream.
In my view, that was certainly not the case a mere four years ago. In
1984, there was no consensus regarding what topics to address, no widely
held view on what to say, and perhaps most basic, no sense that older
people were indeed interested and willing to change behavior in order to
improve health. Even had all this been agreed upon, there was no sys-
tem, no network, no way to get the message out-much less provide the
opportunity for personal support and encouragement which we know is
necessary to change and sustain health habits. It goes without saying that
there was no clear or consistent leadership in this area and no system of
technical support to bring about such change.


!3o today, in assessing Healthy Older People, I ask what progress has
been made along these lines and what have we learned about what to
do next?

As I said before, the Healthy OlderPeople program is a national public
education program sponsored by the Office of Disease Prevention and
Health Promotion (ODPI-IP). These programs, of which the Public Health
Service has several, are often difficult to describe. While it is relatively easy
to describe the materials which are developed and the special activities
which are generated, it is difficult to convey how public education pro-
grams serve as a catalyst for action at the state and community-the level
of real impact.
The primary goal of our program was to inform and educate older Ameri-
cans about health practices which can reduce their risk of disabling illness
and increase their prospects for more productive and active lives. We tack-
led this challenge in several ways-by producing a wide variety of infor-
mative materials for older people; by working very hard to establish and
nurture a dissemination system to get the educational messages out; and
by fostering the development of local programs serving older people.
First let me tell you what we learned about the importance of clarifying
the health information we wanted to deliver and how that information
was received. Too often we point to the piles of materials in our offices
and to the press coverage of health-related topics, and conclude that there
is plenty of information available and people just won't pay attention. I
contend that it is not only important, but very difficult to develop under-
standable, accurate information that people actually can act on.
Before we developed the Healthy Older People materials, we conducted
careful reviews of the scientific literature to ascertain in which areas behavior
change can be most beneficial to health status in this age group. In fact,
many of the areas selected are featured at this workshop: eating right, exer-
cising, stopping smoking, preventing injuries, and using medicines and
preventive services wisely. Next, we conducted focus groups with older
people to determine how their beliefs and feelings coincided with the
science base. We were then able to use public relations and advertising
professionals to develop, test and refine the information.
The messages which were developed were clear, taught the skills needed
to act, and conveyed a positive upbeat tone to underscore the general theme
that health promotion is appropriate no matter what your age. The impor-
tance of this washighlighted in the evaluation conducted of the program.
The materials were consistently described as "the information people are
looking for" and as "taking complicated (nutrition) information and mak-
ing it easy to use."
The messages were translated into a variety of broadcast and print
materials including television and radio public service announcements,
posters, and brief consumer fact sheets. Press kits and TV and radio seg-
ments were produced for news and talk shows and a variety of support-
ing materials were prepared for state and local groups on how to use the
various media materials.

36


  A validation of the need for and interest in clear health messages is the
extent to which these materials were picked up. I must note that partici-
pation in the Healthy Older People program was completely voluntary-
-no State had to get involved. Even more telling is that no money was
available from'us to conduct programs or even to print materials. We were
only able to provide samples of print materials and groups had to find
  sponsors.
  Even with that, the results were excellent. Looking first at the TV public
service announcements for which the best data are available, every state
distributed the spots with 60% arranging personal deliveq to TV stations.
The service which tracks airplay of commercials reports that between Sep
tember 1985 and September 1987 the Healthy Older People spots were
aired 4713 times on local stations and all three networks. We saw it on
five different Cosby shows alone.
  The total advertising value of the spots, according to Broadcast Adver-
tisers Reports, Inc., was $3,221,693. That is what it would have cost us
to air these spots if we had to buy time from television stations. At this
time, ODPHP's total expenditure for the program has been about
$9oo,MlO-less than a fifth of comparable campaigns for high blood pres-
sure or cancer prevention.
  Though we do not have access to such precise numbers for other Healthy
Older People materials, we do have some success stories. The so-named
skill sheets proved to be a popular and versatile item. These two-pagers
`.  were available as camera-ready slicks and were used in nearly all the States.
Not only were they reproduced and handed out to older people at senior
centers, libraries, and drug stores, and in retirement seminars and hous-
ing units, but Blue Cross of New Hampshire sent them to each of their
customers over 65. Hospitals and social service agencies gave them to their
clients, and states and "house organs" used the information in their news-
letters. As much as we talk "high tech" for information, we are still very
reliant on the written word and we seek simple and concise direction for
  health maintenance.

One frequently reported use of the Healthy Older People materials which
I had not expected was how often these items were used for professional
training. We must keep in mind that, although we may have this infor-
mation down pat, most professionals whose primary responsibility is for
providing health or social services cannot keep current on the latest health
promotion findings even if they recognize the benefits to their older client.
The skill sheets were also described as having a cross-disciplinary focus.
We heard: "Both the health types and the aging types liked the sheets.
For the first time, they both got behind the same product."
Bringing together the health and aging fields under the common ban-
ner of health promotion for this segment of the population was perhaps
our greatest challenge and one of the most rewarding aspects of working
on Healthy Older People. The quality of the materials helped-but ahead
of that I'd place the opportunity to work jointly toward a common goal.
This is how a public education campaign is able to foster the support net-
work needed to provide programs and services.

37


  You have already heard about the Federal call for the establishment of
coalitions on health and aging. Speaking from the perspective of Healthy
Older People, we have learned a great deal about how the coalitions were
formed and what they are doing.
  Early in the program we contacted each Governor's designee and worked
our way through the bureaucracy to identify those who would be our own
program contacts. These people were most often staff of either the health
or aging department although sometimes the Governor asked both agen-
cies to be involved or sometimes one-agency decided to enlist the support
of the other. We encouraged collaboration at regional training workshops,
and via a toll free hotline, in a bi-monthly newsletter about the program,
and through technical notes for professionals on various program develop
ment topics.
  Eighty five percent of the states in which we conducted evaluation formed
coalitions-many adopting the name of the program. Today, for example,
we have Healthy Older Virginians and Michiganders and Iowans. The
makeup of the coalitions varies. In three states, membership is limited to
staff from state agencies. In just over half, the coalitions include state and
local agencies and service providers such as hospital associations, univer-
sity geriatric centers, the American Red Cross and AARJ?. Eleven states
formed even broader coalitions which include private sector representa-
tives. Among the six states which chose not to establish coalitions, two-
Connecticut and Rhode Island-said their small size already facilitated close
  coordination. Eight of the state coalitions went on to foster the develop-
ment of local coalitions.
  The coalitions identified health and aging resources within the state and,
most important, established viable, programmatic linkages which they
expect to continue even when Healthy Older People is no lonqer around.
Most coalition leaders reported that this was one of the first times there
was effective collaboration between the health and aging sectors in their
state. In some states this collaboration has led to an increasing interest in
health promotion among older adults. I am just beginning to get calls from
some of the state contacts asking for help in thinking through how to
approach upcoming meetings within their departments about integrating
health promotion more widely in existing programs. This represents a dis-
tinct shift from an initial focus on simply conducting an information
Program.
  In addition to what we were able to do to support the formation of co-
alitions, we also tried to encourage the development of programs-and
always to stress the need for local, accessible activities to encourage main-
tenance of healthy behaviors. Program development was enhanced by col-
laborative activities with national membership and voluntary organiza-
tions-organizations with ready access to our audience: older people. Two
activities stand out-a series of training conferences on community health
promotion programs sponsored by AARP and two teleconferences for
health and aging professionals done in conjunction with the American
Hospital Association.


It is in the area of program development that Healthy Older People
exceeded my expectations. In all the states evaluated-41 of !Xl-program
development of &me type occurred. It appears that tens of thousands of
older persons were reached in this way. Of the forty-one states queried,
15 reported doing needs assessments and compiling resource inventories;
38 desc&+ special events to educate consumers such as fairs, workshops,
or. "nutrition days"; several have developed their own video-taped pro-
grams which are shown on cable stations and in sites such as senior centers
and community colleges; 31 states conducted provider education principally
through statewide workshops and in an ongoing fashion through news-
letters; and 35 of the 41 reported providing some type of wellness services
to seniois.

  How the diffenmt Healthy Older People topics were integrated into com-
munity programs is also worth noting. The greatest amount of program
activity reported by our evaluation team must be categorized as wellness
or health promotion for older people. Thirty-seven of the 41 states reported
the adoption of this muhiple risk factor focus for programs. Contacts liked
the economy of scale in linking the topics, both in terms of limited staff
and resources, and in terms of limited opportunities to provide activities
for older persons. After wellness, the most frequently addressed single
topic was exe&se and fitness with walking events being the most popu-
lar. Special activities on the safe use of medicines and preventive health
services were reported by twelve states, and nutrition by ten.
  One factor which influenced selection of topics was familiarity with an
issue. For example, the public health agencies found it easy to use their
public health nurses to conduct risk assessments and health screening. The
aging agencies, on the other hand, said they were intimidated with the
medical topics, but felt they had a lot to offer in nutrition. The topics which
could be made fun-or social-held great appeal. They also stood a better
chance if they addressed a serious health risk or led to an easy intervention.
  Given that last caveat, it should be noted only one state, Rhode Island,
focused on smoking cessation. Since some of the definitive research on
the benefits of quitting at a late age have only recently been published,
I guess this is not surprising, but clearly more could. be done in this area.
  In assessing a national public education campaign in which participa-
tion is voluntary and schedules and activities are conducted as deemed
best by a very decentralized network, it is difficult to tease out the impact
of that program from concurrent events. For the 41 states evaluated, we
developed a rating scale to determine how Healthy Older People fit in with
other activities and priorities. Four categories were developed. In seven
states, there had been no preexisting activity in health promotion for the
aging1 Healthy Older People was cited as a direct impetus for program
development. In eight states there was preexisting activity, but Healthy
Older People caused a ree xamination and modification of strategies to
reflect the national program. In 16 states, the existing priorities were main-
tained and resources, materials, and ideas were incorporated from our pro-
gram. In ten states, Healthy Older People activities were conducted in

39


parallel, but not really related, to other health promotion activities. As of
last August, there was no. state in which Healthy Older People had no
apparent impact. Indeed this spring we see the launching of two more
major state initiatives-in Pennsylvania and Indiana.
The biggest lesson we've learned, I would say, is that Healthy Older
People demonstrates the ability of the Federal government to establish a
national agenda through a modest, but ambitious, program of this type.
I would add that the success of this program in doing just that is that we
had the right combination of the right people at the right time-not only
the audience we wanted to reach: our aging population-but the talent
and commitment of health and aging professionals who have recognized
the need for and value of health promotion for this special population.
As a result, we see a firm beginning of an interdisciplinary network of
health and aging agencies and organizations committed to this initiative.
And I think you will agree with me that we are further along in clarifying
what information older people need in order to change health behavior.
  Nevertheless some things are left undone-or I guess we would not be
here today. Among them are professional training, national"media atten-
tion, technical support for community programs, policy directions, and
research and demonstrations to assess the impact of activities on health
and functional status. The workgroups will help expand that list.
  So we have a good beginning. We have captured the attention of profes-
sionals and have whetted the interest of older people in health promo-
eon. But we know from experience that the substantial health benefits of
behavior change do not come quickly or easily. Healthy habits and actions
must be reinforced through repeated refrains from doctors, social workers
and the local TV anchor person. We need to encourage fitness and good
nutrition at the most personal level-in local parks and supermarkets,
restaurants and neighborhoods.
  I want to thank Surgeon General Koop for his leadership in convening
this meeting because it is through opportunities such as this that we can
help move health promotion for older adults up on the national agenda.
And with your work here today and tomorrow-and your work back
home-we eventually will see older people becoming healthier people.
  Information about the Healthy Older People program is available from
the ODPHP National Health Information Center, PO Box 1133, Washing-
ton, DC 20013, 80OEI36-4797, 301/5654176 in Maryland.


"Pkoject Age Well"

Presented by Anthony Vuturo, MD
School of Medicine, University of Arizona
Monday morning, March 21, 1988

Good morning, ladies and gentlemen. It is a pleasure to join you this
morning in Washington and participate in the Surgeon General's Work-
shop on Health Promotion,and Aging.
My task this morning is to give you an overview of Project Age Well.
Age Well is a comprehensive project of the College. of Medicine at the
University of Arizona. This program is a coordinated aperoach to preven-
tive geriatric care. It attempts to compress morbidity, reduce health care
costs, and enhance the quality of life in older Americans.
In 1981 the Department of Family and Community Medicine began to
develop primary health care efforts at apartment complexes devoted to the
elderly. Eventually clinics were established at four city sponsored apart-
ment complexes ranging in size from 75 to 450 apartments.
As with any good university enterprise, we initially focused on the three-
pronged thrust of academia-teaching, service and research. Medical stu-
dents and nursing students had the opportunity to enhance their educa-
tional experiences; service was provided both to the community and to
the senior population; and new research projects were initiated, particu-
larly in expanding our understanding of osteoporosis.
In the early 1980's the major driving mechanism for the service compo-
nent of the University was our desire to add geriatric health care services
to University Fan&Care, the health maintenance organization established
by the' Department of Family and Community Medicine.
We soon recognized that the traditional medical models were not capa-
ble of providing the scope of services required. We also believed that many
of the health problems we were seeing in our elderly were preventable
and could be anticipated. If targeted health issues could be promoted, we
believed our clientele could anticipate a higher state of wellness in the aging
process. This should reduce the potential financial risk to future HMO
involvement.
In 1983 we took our modest proposal to New York and presented our
ideas to the Brookdale Foundation. With the support and endorsement
of the foundation and its board, as well as a commitment from the City
of Tucson and the encouragement of the Area Council on Aging, we
proceeded to enhance our commitment to the approximately 1,ooO senior
d&ens with the initiation of a new activity called Age Well.

41


Our initial objectives were to provide and expand health maintenance
and to promote wellness. We wanted to support those individuals who
needed various types of rehabilitation. We recognized that we needed to
define new professional roles and still,be identified with the College of
Medicine. It was important for us to create settings not just for the educa-
tion of medical students and residents, but also for the training of nurses,
pharmacists, nutritionists and exercise physiologists. We made a commit-
ment from the outset to make our model widely available and to dis-
seminate our activities.
We focused i&ally on prevention. In 1984 we felt most comfortable with
a model that emphasized hypertension, cancer prevention, osteoporosis,
depression, and control of iatrogenic diseases, and we wanted to introduce
health promotion to counteract the belief that illness is inevitable.
By 1987 we had undergone significant changes in our focus areas. Rather
than hypertension, it beearne apparent to us that it was possible to focus
on the full spectrum of cardiovascular diseases. Our program of mental
wellness grew beyond a focus on depression and now deals with bereave-
ment, anxiety, loss, loneliness and stress. Clearly the leading iatrogenic
problem was related to medications. Visiting people for about 4 years in
their apartment complexes, seeing their furnishings, their kitchens, the way
they kept house, and assessing the types of morbidity that we were begin-
ning to see over time, we developed a vigorous campaign for safety pro-
motion and accident prevention.

_  The intervention strategies that we identified include enhanced nutri-
tion, education, a program in exercise, a strategy in community-based and
-peer-based health education, group and individual counseling methodol-
ogies focusing on medication and diet, health maintenance screening and
stress management.
From the birth of Age Well in 1982 to the present, we have seen on our
campus a major expansion of interest in the field of gerontology. We have
campus committees on gerontology and interdisciplinary groups function-
ing in numerous areas, one of which is a long-term care gerontology center.
The tradition departments within the College of Medicine have supported
the expansion of our concerns for the elderly by creating a Division of
Restorative Medicine which combines the disciplines of podiatry,medicine,
ophthalmology, orthopedics, rheumatology, and an active outreach pro-
gram which evolved out of Family Medicine.
Project Age Well is conducted at two types of sites. The first, as I have
mentioned, are apartment complexes which have anywhere from 75 to
400 apartment units. Apartments may have single people or married cou-
ples. (As a matter of fact, we have seen romances blossom and marriages
occur during our short involvement with Project Age Well). In addition
to the residential sites, we also conduct our formal activity in two commu-
nity centers, one located close to the central library and the second located
within a major school district in metropolitan Tucson.
Promoting health in the elderly cannot be done in a vacuum. Project
Age Well began a.detailed and time-consuming process of networking with

42


many groups and interested parties around our community. Our initial
objectives were to pass on some of the things that we were learning, as
well as pick up. new ideas and new thoughts in promoting a more fit
lifestyle in our older population. We linked with the Pima Council on
Aging, and with private local foundations dedicated to wellness. The Tuc-
son Parks and Recreation Department linked with us, particularly in the
area of physical fitness through walking, aerobics and stretching. We col-
laborated with the Wellness Council of Tucson, which had been estab-
lished to promote worksite wellness.. Numerous organizations, not all of
which had exclusively elderly constituencies, became advocates and
promoters of our activities.
Cable television adapted a new program called "The Prime of Life,"
which began to telecast many of our activities to the entire community.
The Interfaith Coalition on Aging became involved with Age Well. Pastoral
counseling students received instruction and the staff began to work with
ministers and rabbis within the interfaith Coalition. Before we knew it,
the process of health promotion was beginning to .expand beyond the
boundaries of the retirement commumties into the churches throughout
the community.
During the mid-1980's the notion of worksite wellness grew. Members
of the Age Well team served on the Board of Directors of the Wellness
Council of Tucson (WELCOT). At the moment, there are over 100 indus-
tries with 50,000 employees involved in health promotion, doing many
of the things that we are involved with in Project Age Well. What had
initially started off as a geriatric-focused health promotion and prevention
project began to move in multiple directions. The Arizona Association of
Community Health Centers, which is a statewide health promotion coali-
tion, sought our assistance. The Arizona Area Health Education Centers
began to provide the Age Well model with selected components through-
out the state under the AHEC umbrella. The Hispanic Council on Aging
in our city and state began to see unique applications crossing cultural
dimensions. Through the Brookdale Foundation our network spread as
far as New York City, where we shared information, videotapes, and
assessment instruments with the commissioner of the Department of Aging
in New York.

By word of mouth and through our presentations at various meetings,
the word spread and crossed national borders. Visitors from the Govern-
ment of Japan have come on at least two occasions to see the project first-
hand. Three months ago we were guests of the government of China in
Beijing, exchanging information and seeing which of their traditional health
practices could be incorporated into our community-based and residential-
based complexes to promote Age Well.
Now the Age Well and health promotion network is huge, reaching rural
and urban communities and using all methods of communication, includ-
ing television, newspapers, newsletters, fairs, walks, church and synagogue
participation, school districts, peer awareness and national and intema-
tional linkages.

43


  What has evolved has been a unique mixture of professionals providing
their various talents and skills in an interdisciplinary fashion to the needs
  of older people. At the present tune we have nutritionists, pharmacists,
  nurse practitioners,, exercise physiologists, pastoral counselors, social
  workers, anthropologists, and physicians involved in the team approach
  to Age Well.
  One striking effect of the program is the interdisciplinary educational
  opportunities that have been created. We find students collaborating not
only in health promotion and care, but also in research and scholarly
inquiry. Students involved with Age Well are from many disciplines,
  including anthropology, medicine, nursing, nutrition, pharmacy, rehabili-
  tation counseling and social work. The by-product of the educational
  experience is that we believe we are helping tram the next generation of
citizens to address the issues and questions of our aging population in
  thoughtful and informed ways.
  Within Project Age Well we focus on primary, secondary and tertiary
  prevention, along with health promotion and ftmctional assessments. You
  are quite familiar with primary prevention, including influenza, pneumo-
  coccal and tetanus vaccines, smoking cessation and diet modification. In
  secondary prevention, our emphasis is on early detection and treatment.
This includes hypertension; cancer of the breast, colon and cervix; sen-
  sory deficits, particularly in vision and hearing; mental health, focusing
on dementia, alcoholism and total mental wellness; social support; drug
  therapy; and numerous miscellaneous prevention activities directed at uri-
nary incontinence, hyperthyroidism, podiatric problems, and osteoporo-
-  sis. To date, our focus in the area of tertiary prevention has been in the
  areas of rehabilitation and physical medicine.
  Our attention in health promotion has been on accident prevention. We
have provided assistance and advice in the design of many of the apart-
ments, with particular concern to the floor coverings, lighting, and
bathroom engineering. In physical fitness and nutrition, our emphasis has
been on walking, stretching, and endurance. Our nutritional promotion
program includes some of our most popular activities. We have explored
the introduction and use of microwaves, the packaging of food products
for the elderly, and food wastage by older people.
  Functional assessments include psychological, cognitive, perceptual and
personality support. Within our assessment of the social support struc-
ture of our elderly clientele we have been able to enhance our understand-
ing of their places of interest, policies that impede and promote, and eco-
nomic situations affected by fixed incomes and discretionary spending.
  At the University one of our major responsibilities to society is the acqui-
sition of new knowledge through observation, evaluation, basic science
inquiry, applied and operational research. It is only through the process
of scholarly inquiry that we are able to continue to upgrade our educa-
tional methodology and add to those truths passed on to each new gener-
  ation of men and women.
  Our research projects at the moment include investigations into osteopo-
rosis screening, zinc supplementation and its effect on alcohol, exercise

                                44


and treatment of hypertension in the elderly, the effect of exercise on the
immune system; the role of sunscreen and its use on serum vitamin D
levels, protein-calorie malnutition in the elderly, the effects of endurance
training, fee-for-service models and health promotion models, and the
acoustic properties of emotional speech `in aging.
Also, we study attitudes toward life in the aging, beliefs in health use,
Post-hospital intervention strategies, reminiscence as a therapeutic tool,
peer counseling, spirituality and well-being in the aging, life care at home,
cancer prevention in the elderly through the development of quantitative
risk assessments, Telehealth and electronic communications, drug-food
interactions and case management of the frail elderly.
Despite the diversity of research projects, we believe we have just begun
to scratch the surface.
In many respects, health promotion cannot be separated from health
education. The roots of health promotion lie in effective and interdiscipli-
nary health education. The ability to communicate by whatever means
necessary those concepts, programs, and activities that promote better ways
of doing things, has been at the heart of our ongoing educational "classes."
Our classes occur in the morning, afternoon and evening, in social set-
tings; and at meal .times.
Permit me to sham with you some of the titles of the topics that we cover:
  Feelings-Let Them Go

Calcium and Osteoporosis
Making the Most of a Visit to Your Doctor
Immunizations and the Elderly
Cough and Cold
Vitamins

Coping With Depression
Nutrition and the Elderly
Medical Self-Care-How To Be Your Own Doctor-Sometimes
Are You Healthy?
What Will Your Medical Exam Tell You?
Stress and Your Well-Being
An Old Dog Can Learn New Tricks
Community Resources: Do You Know What Is Available To Protect
and Promote Your Health?
Medications: How They Help and How They Harm
Accident Prevention: In Your Home and in Your Environment
Nutrition: You Are What You Eat
Thoughts and Feelings About Cancer
Stress and Cancer
Eating To Avoid Cancer,
Additional topics include Coping With Death and Loss
Do You Play the Blues?
Learning To Manage Your Stress
If I'm Depressed
Who Can Help? Community Resources for Depression

45


Antidepressant Medicines and Their Effects
Hypertension (medications, nutrition, stress, exercise)
Osteoporosis (medications, nutrition, exercise)
Bone Scane Information
Leisure Resources
Medicare

Positive Sleep Habits (techniques, medications)
Personal Safety (safety outside the home, first aid)
Arthritis (exercise, nutrition, medications)
Gastrointestinal Problems (nutrition, medications)
Constipation and Diarrhea (diet, medications)
Medications and Aging

Using the Health Care System
Health Care Maintenance
Problem Solving.
Finally, we offer:
Diabetes (medications, nutrition, exercise)
Food Safety
The Grieving Process
  chronic Pam
Medications for Pain
Biophysical Feedback

Stress Reduction Techniques Which Also Can Relieve Pain
Physical Therapy
An Overview of CPR
Normal Sexual Function and Aging
Medications That Affect Sexual Activity
AIDS
Meeting Your Sexual Needs
Marital Therapy
Depression and Anger.

One of the fascinating observations that we have made is that health
education is not a one-way street. We have been singuiarly impressed by
how peers become involved in explaining, clarifying, and restating in differ-
ent words the themes of the topics. We believe that health promotion
through peer education, example, and guidance is a tool that should not
be overlooked nor underestimated. It doesn't take a doctorate to be an
effective communicator and instructor.
We have been with the group long enough to develop close friendships
with the people we serve, but it is still possible to step back and from a
more academic perspective try to put in perspective what we have learned.
There is no question that it is better to prevent and promote wellness than
to commit energy and resources to 20-30 years of ongoing care. It appears
to us that the physician model of illness intervention through diagnosis
and treatment is inadequate for the broadly defined health needs of our
older people. We have learned and have been taught that very many older
people are not necessarily disease-oriented. Many of their problems and

46


concerns are preventable. Older people are concerned with coping and
with loneliness.

We have found that many people are on too many medications. Given
our understanding of the importance of diet, it could be said that their
diet is inadequate. Inadequacy is emphasized not only in terms of insuffi-
cient calories, vitamins, minerals, etc., but due to the beliefs, customs and
the energy related to preparing meals, shopping for food, spoilage of food.
  We have learned that the existing sources of public transportation are
often inadequate. They don't meet the needs of many older people and
can't accommodate chronic conditions that they have, the speed at which
they move and the ability and time required for them to enter and exit
the vehicles.
We have been surprised to find out that in our population there is more
interest in cancer prevention than in the prevention of heart disease. Pri-
ority is given to dealing with existing infirmities, taking priority over screen-
ing for potential problems. We have found that people can develop a com-
mitment to exercise, and many of our clients have been in programs for
more .than 3 years. We have observed that those people'who bring to the
community marginally social capabilities find a way of life in health pro-
motion. We have noticed significant changes in the attitude of professionals,
in the way they perceive the aging process, and also in our young people,
as we incorporate young schoolchildren into some of our programs.
In summary, while we may have been a bit ambitious in our goals, and
while we certainly have been expansive in our approach, it is not because
the need has not been there. We have learned over time that the needs

of our senior citizens are complex. We are as concerned with the demo-
graphic changes and trends that we see as you are. We believe that our
understanding of the boundaries of health promotion and prevention are
limited only by our imagination and by the time and energy we are able
to wish to devote to the needs of this special population group.
We have learned that it is impossible to plan programs unless one has
lived, worked and experienced the issues first-hand over a period of time.
We have experienced the fact that there is no f0rma.I constituency for health
promotion. The informal constituency is not limited to the aged but cuts
acmss age boundaries and working class. We have learned that while there
is no quick fix to the problems of health care for the aged, there are numer-
ous strategies that improve the quality of their lives.

I would Iike to thank my senior colleague, Dr. Evan KIigman, who has
orchestrated, implemented, negotiated and developed much of what I have
told you, to the Brookdale Foundation for their generous support, not only
financialIy but through their insistence that we share our information as
widely &s possible, even though the last word is not in on many of the
strategies and directions we have taken, and finally to the Pima Council
on Aging under the direction of Mrs. Marian Lupu, who has played such
an instrumental role on networking the activities and actions of Project
Age Well.
Finally, I would like to thank the Surgeon General, Dr. C. Everett Koop,
for his keynote address and his kind invitation, particularly to a group based

47


so far from Washington, to discuss the key directions and dimensions of
Project Age Well with you.

48


"International Geriatric Health Promotion Study/Activities"

Presented by David Macfayden, MD
former Manager, WHO Global Programme for Health for the Elderly
Monday morning, March 21, 1988

I have been asked to speak on the theme "International Activities in Geri-
atric Health Promotion." Geriatrics is a word coined 80 years ago by the
New York physician, lgnatz Leo Nascher. Dr. Nascher used the term to
cover the same field in old age that is covered by the term pediatrics in
childhood. This idea crystallized from his international perspective. On
a European trip he observed low mortality in Viennese elderly people
whose physicians dealt with them as individuals with needs particularly
to their age group, just as pediatricians dealt with children. Thus, a new
word, a new discipline and a new philosophy of aging emerged when
a first generation American compared health approaches in New York and
Vienna. Eighty years on, international comparisons on aging offer the same
opportunity for generating creative ideas. As an international physician,
I passionately believe that searching for cross-national experiences of
healthy aging will benefit all. Indeed cross-national research is indispens-
able if we are to understand how to remain healthy as we age.
Let me first give you the context in which activities in health promotion
have gained prominence in the World Health Organization. In doing so,
I should like to emphasize that the recent international movement towards
health promotion paralleled moves at the national level, not least of which
was that imparted by the 1979 Surgeon General's Report "Healthy Peo-
ple" and the national goals and objectives emanating from that publication.
When the World Health Organization's constitution was ratified few real-
ized that is definition of health would be seized upon by the world's elder
citizens. It is now the aspiration of many in this room to transit through
their 6Os, 70s and even 80s "not merely in the absence of disease, but in
a state of complete physical, mental and social well-being." And, on the
Organization's 40th anniversary, on April 7,1988, this aspiration is clearly
articulated in the World Health Day theme "Health for all: all for health."
A more recent international anniversary is commemorated in the ten year
old UniceflWHO Declaration of Alma-Ata, which established the
philosophy of primary health care. The keystone of this philosophy is that
prevention and promotion should be the central focus on health care.
Just as the 1979 United States report was translated into some 223 health
objectives, so the WHO policy statements of Alma-Ata were collectively
refined by the countries of Europe into 30 time-specific targets. Broadly,
the European goals were:

49


o to add years, by preventing premature death;
o to add health to life, by mininGng disability and preventable d&-
  ease; and
o to add life to years, to attain the highest attainable level of health for
  elderly people.
The involvement of European governments in settling collective health
targets gave a high political profile to health promotion, witnessed by the
Ottawa Charter on Health Promotion -and the Second International Con-
ference in Health Promotion taking place next month in Adelaide, Australia.
As stated earlier, what happened internationally was a reflection of what
was happening within nations. Advocates for health promotion in older
persons spoke with two tongues within nations. There was the voice of
rhetoric and the voice of reason. Thus, when the World Health Organiza-
tion's expert committee on health of the elderly came to consider preven-
tive actions, they were cautious about the rhetoric but nevertheless accorded
prevention high priority, based on rational examination of available evi-
dence. ,Here are some of the conclusions:
There have been great enthusiasm of late for the concept of promoting
wellness among the elderly. Recommendations for diet and exercise claim
great benefits in terms of improved function and enhanced well-being.
Unfortunately, there is very little evidence to support this enthusiasm.
One potential problem lies in confusing risk factors with modes of mter-
vention: they are not synonymous. In some cases, the risk factor may be
associated with permanent changes in the organ at risk. For example,
diastolic hypertension is a well known risk factor for heart disease and
stroke, but its effects may be due to changes in the vessel wall already
in place. Lowering the blood pressure may thus have less effect than mea-
sures which lower the risk of thrombosis.
Recent data from Sweden descrii impressive improvements in the phys-
iological performance of 70 year olds separated by only five years. Although
these reports suggest that such improvements are the result of alterable
conditions on lifestyle, we have not yet demonstrated which ones produce
the desired ends nor how susceptiile to direct influence they are.
A number of areas of potential preventive action for the elderly have
been identified. Some involve primary preventive strategies, others screen-
ing. The former include immunization for influenza and pneumococcal
pneumonia, and smoking cessation. Elderly cigarette smokers can markedly
reduce their risks of lung cancer and heart disease by stopping smoking
even into their 70s.
Screening tests are appropriate if they have a reasonable chance of
uncovering medically and economically treatable conditions. Thus vision
screening for cataracts can be very helpful. So too can audiometry uncover
remediable conditions. Certain laboratory tests such as thyroid screening
can uncover treatable pathology. Other candidates for secondary preven-
tive efforts are screening for breasts, cervix and colorectal cancer, oral exami-
nation, detection of alcohol abuse, attention to nutritional status, evalua-
tion of blood cholesterol levels, and accident prevention. These areas