SURGEON GENERAL'S
WORKSHOP
Health Promotion and Aging

Proceedings

Edited by: DEP SG Faye G. Abdelk&
       SR PHARM Steven R. M-

Note:

AU opinions contained in these contents represent the
vkwpoint solely of tbe authors and participants and do not
necessarily represent the viewpoint of tbe Office of the
Surgeon General, tbe Public Health Service and its
constituent Agencies, or the Editors.

7 for this Workshop are Administration on Aging. Health Resources and Services
dmtnismw Food and Drq Admioistntion, National h~~timte on &iog. the Off3ce of Minority
Health, Ollkx of Diseae Ptwentioo and Health Promotion, Cents for Di Control. National
bt.stitutc of Mental Health, National Institute on Alcohol Abuse and Alcoholism, the Brookdale
Foundation, and the Henty J. K&et Family Foundation.
Support for the printing of this publication is provided by the Henry J. Kaisr Family Foundation
of Menlo F'xk. California,


PREFACE

As with any effort that seeks to take a somewhat disparate body of
knowledge and attempt to create uniformity and concensus, the final
.product may not be exactly what was expected. In this instance of trying
to assimilate all of the scientific knowledge and experience about health
promotion activities in aging populations into a coherent body or recom-
mendations and policy options, the product is more than expected! In addi-
tion to the insight that the 180 invited guests for this Surgeon General's
Workshop on Health Promotion and Aging were able to provide individu-
ally, the cohesive and often synergistic results of their deliberations have
given the Public Health Service and the much larger aging audience a view
of what is possible.
Instead of individual agendas, the larger picture has been shaped before
us and the vision is clear. That vision is the ability to provide research,
support and services that will allow the years in later life to remain as full
and fruitful as those in the earlier years. Although the prospect of death
is certainly inevitable to all of us, that period prior to death may well afford
some of the truly golden years of life. In addition to these years being
golden for the individuals, the ability to use their wealth of personal
knowledge and experience to enrich society and the extented family units
and communities is immense.
The seed of ideas and potential areas of activity are presented in this
final report with its recommendations. The participants at the Workshop
present to the much larger audience of interested parties our blueprint for
the nation in health promotion and aging. I join with you in seeking now
to implement these ideas and options so that our aging society is provided
with the maximum impact of our corporate knowledge for the benefit of
the health of all senior members.

C. Everett Koop, M.D., Sc.D.
Surgeon General


CONTENTS

opting Plenary Session

Keynote Address

Surgeon General C. Everett Koop . . . . . . . . . . . . . . . . . . . . . . . . . . .
United States Public Health Service

1

Address

Carol Fraser Fisk, Commissioner . .`. . . . . . . . . . . . . . . . . . . . . . . . . .
Administration on Aging

5

Address

Assistant Surgeon General T. Franklin Williams . . . . . . . . . . . . . .
Director, National Institute on Aging

9

Plenary Session

"Health Promotion and Surgeon General's Workshop" . . . , . . .
Assistant Surgeon General David Sundwall, Administrator
Health Resources and Services Administration

14

"Year 2ooO Health Objectives for the Nation" . . . . . . . . . . . . . . , .   2o
Assistant Surgeon General J. Michael McGinnis, Director
Office of Disease Prevention and Health Promotion

"Legislative and Administration Interests in
Geriatric Health Promotion". . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   26

Roger Herdman, M.D.,

Assistant Director for Health and Life sciences,
Office of Technology Assessment
U.S. Congress

"Setting the Pace in Geriatric Health Promotion"

.

"Healthy Older People"  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Susan Maloney
Office of Disease Prevention and Health Promotion

"Project Age Well"   . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Anthony Vuturo, M.D.
School of Medicine, University of Arizona

.

"International Geriatric Health Promotion Study/Activities"
David Macfayden, M.D., former Manager
WHO Global Progra.mme for Health for the Elderly

. . . .   35







. . . .   41






. . . .   49


Charge to Participants

Surgeon General C. Everett Koop  , . . . . . . . . . . . . . . , . . . . . . .
United States Public Health Service

54

Plenary Session

Recommendations of Working Groups:
Alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental (Oral) Health           ;
                      . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Physical Fitness and Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . .   63
Injury Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
  Medications .:.........................................  Fi
  MentalHealth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   74
  Nutrition  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   80
  Preventive Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   84
Smoking Cessation                             88
                     . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Response to Recommendations  . . . . . . . . . . . . . . . . , . . . . . . . . . . . .
Surgeon General C. Everett Koop
  United States Public Health Service

94

List of Participants  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . *  103



OPENING PLENARY SESSION

Keynote Address

presented by C. Everett Koop, MD
S-eon General, United States Public Health Service
s,&ay evening, March 20, 1988

Thank you, Dr. Abdellah.

I \,-mnt to personally welcome you and thank you all for coming to this
SurgeIn General's Workshop on Health Promotion and Aging.
We have three days of serious deliberation, illbating discussion,
and-I sincerely hope-innovative thinking ahead of us. The outcome
should help point us-and society-in worthwhile directions for the future.
Many people have worked long and hard to make this workshop hap-
pen. lf I had an extra hour or so, I would gladly name and thank each
one oi them personally.
That's not possl%le. However, with your understanding and permission,
let me-at the very least-extend a word of special thanks to Dr. Faye
Abdellah, Deputy Surgeon General of the U. S. Public Health Service,
whose guiding hand hti been subtle but essential throughout the plan-
ning FrOCeSS, and to Senior Pharmacist Steven Moore, lent to us from the
Food and Drug Administration, who accomplished all the thousands of
planning and administrative details that enabled us to get here today-
&pipped and on time.
To both of you . . . thank you very, very much.
I do not want to monopolize the podium and steal time away from my
good friends and colleagues, Commissioner on Aging Carol Fraser Fisk,
and Dr. Frank Williams, Director of the National Institute on Aging. So
I will limit my remarks to a brief review of how we got here . . . and why

. . . and for what purpose.
Early in 1984 the Department of Health and Human Services launched
a major initiative to encourage the public and private sectors-at all levels,
national, regional, state, and local-to work together on promoting the
health of America's older citizens.
The U.S. Public Health Service and the Administration on Aging shortly
thereafter signed an agreement in which we pledged to do a number of
things together in order to invest this health promotion initiative with
increased momentum and importance.
And there has been a great deal of momentum generated throughout
the country on behalf of older Americans:
o Every state now has a lead agency of its own to spearhead the health
promotion effort.. .


o There are some 35 state interagency coalitions at work to promote the
  health .of older Americans.. .
o A National Public Education Program, called the "Healthy Older Per-
sons Campaign," has raised the consciousness of tens of thousands
of older men and women concerning the benefits of promoting their
own health, instead of just passively waiting and hoping for the best...
. At the Federal level, the agencies and offices of the U. S. Public Health
Service itself have been actively engaged in this cooperative effort, but
chief among them has been the work of the Office of Disease keven-
tion and Health Promotion, directed by Dr. Michael McGinnis. You'll
hear more about that tomorrow morning.
A key element of this P.H.S.-A.O.A. cooperative venture is our mutual
pledge to do what we can to help prepare all health professionals-
physicians, nurses, dentists, nutritionists, social workers, pharmacists, and
so on-for the eventual "graying of America."
I don't have to repeat the demographic projections. I'm sure you're quite
familiar with the numbers.
Rut those projections are much more than mere numbers. Those are
projections about the lives of real people-flesh-and-blood men and women
who will be old and who will need a certain level and type of health care
that, I'm afraid, is stiIl not very well understood, much less practiced, in
our society today.
And that's why seven components of the Public Health Service and the
Administration on Aging agreed to jointly plan and conduct a "Surgeon
General's Workshop on Health Promotion and Aging."
I'm delighted to add that the Henry J. Kaiser Family Foundation and
the Brookdale Foundation are supporting the workshop.
Also, we have included six graduate and professional students who wiIl
be pursuing careers in geriatrics and will serve as working group members.
We wanted it to be a workshop in which the spectrum of health care
disciplines would be well represented and all of them would be challenged
to think creatively and pro-actively about ways to promote good physical
and mental health among people age 65 and older.
That's the kind of workshop we wanted-and, I'm pleased to say, that's
the kind we got.
The emphasis here is emphatically upon the promotion of good health.
But let's be clear on at least one point.
We don't believe health promotion needs to take place af the expense of
good curative medical care.
And it ought not to occur at the expense of good rehabilitative medicine.
And certainly not at the expense of good research into the disease
pmcesies and disabling conditions that often interfere with the normal and
healthful processes of aging.
Bather, we believe that health professionals can put much greater empha-
sis on health promotion without compromising in any way the more tradi-
tional and stiIl effective approaches to health care.

2


we b&eve that this must be done . . . we`re here to say that it am be
done . . . and by noon on Wednesday, we will tell the health community
jlm ib mig& `be done on behalf of the elderly and the very old.
I don't expect us to be prescriptive in this workshop. But I do hope that
the recommendations generated by the work sessions tomorrow and Tues-
day are clear enough and direct enough that health professionals every-
where can immediately see the relevance of the health promotion concept
to their own particular disciplines or practice.
What then should we'keep in. mind?.
First, we ought to focus on ways to sensitize the health professions to
the specific risk factors of older people-and then how to reduce or even
eliminate those risk factors from the lives of one's patients.
Second, we need to m-examine the' way we organize and deliver our
medical, dental, nursing, and other health-related services to see if we can
change-once and for all-their built-in pst facto bias. Health care ought
to be just as effective-or even more effective--before illness strikes.
And third, we need to do these things with some sense of what we hope
to accomplish ovwall for our country's older citizens.
Older people-like people of all ages-do not live in a vacuum:
o They work in places that are pleasant-and in places that aren't
so pleasant...
o Their human relationships may be loving and caring, or difficult and
stressful . . .

o They may have financial independence, or they may be totally depen-
dent on family or Government to provide a.lI their basic needs . . .
o And finally, the phrase "the graying of American" can be misleading.
More of us will have gray or white hair-(or no hair at all). But most
Americans-about 80 percent of the population-will be young or
middle-aged. Hence, older people will still be living in a society in which
all age groups compete for attention . . . and for resources.
I was reminded of this just the other day, when I read that the rock
star Bruce Springsteen is going on a nationwide tour that will earn him
millions and millions of dollars.

And while he's singing to enthusiastic audiences of young people,
anotheb group wiIl also be on a national concert tour of their own. In fact,
I saw them on TV last night in New Orleans. They're the so-called "Rat
Pack"-Frank Sinatra, Dean Martin, and Sammy Davis, Jr.. We are told
that these gentlemen also expect to earn millions of dollars from the
enthusiastic sextugenarians who will show up at their concerts.
It was an interesting juxtaposition of news items. And whether or not
you'll attend either or neither of those concerts, you still have to be
impressed by the inter-generational vitality that is already emerging in our
society . . . a vitality that is, in itself, a reflection of generally good physical
and mental health among the American people,
In other words, we have every reasons to be optimistic and adventurous
in our thinking at this workshop, because we're not here to reverse the
direction of America's health status, but rather to be built on-and

3


accelerate-the progress in health that Americans have achieved over the
past decade or two.
This is an exciting period in the history of health care in America:
o The yield of the research community has been prodigious, with much
   more yet to come.
o The nation is more health-conscious and more pro-health than at any
  time i&our history.
* And it's a period in which all Americans are more sensitive and more
  responsive to the health needs of their fellow citizens . . . regardless
  of race, sex, ethnic origin, or age.
We have, therefore, an extraordinary opportunity to help our citizens
not only to live a few years longer, but also to make those extra years-
and indeed all the years of their lives-good and healthful years.
Now it's time to hear from my two distinguished colleagues, Commis-
sioner Carol Fraser Fisk and Dr. Frank Williams. But rest assured, I'm not
ducking out. In fact, I'lI be back at this podium tomorrow to present my
"charge" to the working groups.
Then, on Wednesday, Commissioner Carol Fraser Fisk, Dr. WiIliams,
and I will return to hear your recommendations and speak to the next phase
of this initiative. But we will not be inactive meanwhile.
You will also note from your agenda that things don't end there either.
Following the close of the workshop on Wednesday morning, there will
be an afternoon public hearing, one of a series of such hearings that have
been held throughout the country.
At this Washington, DC hearing, our workshop recommendations will
. become part of the development of our National Public Health "Objec-
tives for the Nation for the Year 2000."
Thus, we will make sure that aging concerns are given the prominence
they deserve in the evolution of those national objectives.
You're all invited to that open hearing and I hope many of you wilI
attend.
Between now and then, we've got a lot of work to do.
So let's do it. Let's do it together. And let's start now.
Dr. Abdellah, the microphone is yours.
Thank you.


Address

presented by Carol Fraser Fisk
Commissioner of Aging, Administration on Aging
Sunday evening, March 20, 1988

Good afternoon. It's a pleasure to join in welcoming you to this impor-
tant meeting. This conference is a very significant event, for through it
I hope we will help more older Americans have a healthy old age.
Over the past several years, we have made significant progress in mak-
ing health and social service providers more aware of the concepts of health
promotion. Through this joint AoAlPHS initiative, countless numbers of
older persons have participated in health promotion activities. Now it is
time for us to take a look at what we have learned from these and other
activities and to chart a course for future action.

It is a special pleasure to join Surgeon General Koop and Dr. Williams
in this venture. The vision of the Surgeon General has helped mobilize
the Public Health Service and all of us to undertake health promotion activi-
ties, including those which led to our having this conference. The creativity
of Dr. Frank Wii has helped us forge even stronger collaborative ven-
tures. And, the vigilance of the Deputy Surgeon General, Dr. Faye Abdel-
lab, has helped us produce practical results time and time again. It is indeed
an honor for me to join these distinguished national leaders here today.
As Dr. Koop has already said, we know a good deal about the older
population. Let me highlight just a few statistics that may startle you.
Today, one in nine Americans is over sixty years old. By the year 2030,
one in four persons, or twenty-five percent of our population will be over
sixty. In fact, in the next twenty-five years, the population over sixty will
more than double. Among the elderly, the fastest growing segment will
continue to be that over eighty-five years. Today, one in fifteen is over
85. By the year 2030, one in ten wilI be over 85 years old.
The impact of those demographic changes in society today is significant,
and that impact wi.lI continue to grow as the numbers of older Americans
continues to increase. Ail segments and institutions of our society wiIl need
to change as our population ages. As I look into my crystal ball, I see vari-
ous areas of our lives which wilI need to change as more and more of us
live longer lives.    '
The lengthening of the lifespan will cause a continual increase in the
size of the general population. The average age and the median age of
the population will continue to move upward. Of necessity, there will be
more focus on the needs and the talents of our mature citizens. Older

5


people, even a growing and a vocal force, will keep reminding us of the
challenge and opportunities they offer.
The increase in longevity already has and will continue to have an impact
on American families. There wiIl be more generations, and new roles for
them in the family. In some families, more grandparents will become
caregivers for their grandchildren while the middle aged generation is work-
ing. In many other families, adult children will continue to serve as
caregivers for their parents and even their grandparents.
The graying of America has many implications for the production and
allocation of resources, too. Both the work force and the marketplace will
be affected.

People will have longer working lives, although they may have several
different careers, different working hours, shared jobs and different work-
ing places in their later years. Changes that allow elders to stay in the work
force will be essential. With fewer well trained younger workers as well
as with more older people who want or need to be employed in later life,
the work environment will need to change. By the year 2000, we will have
an equal number of persons entering and leaving the work force. We will
not be able to waste the talents of our older citizens.

Work force benefits will have to change accordingly. Employers will have
to structure benefit packages differently because of different assumptions
about retirement, health care, and caregiving responsibilities, to name just
a few considerations. Corporations will have to expand their efforts to help
keep current workers, young, middle aged, and old, productive and
healthy. They will also increasingly look for ways to reduce health care
expenses incurred by retirees.
An aging society will also mean that different types of products will be
demanded and consumed. For example, one change could be in the pack-
aging of food products. Instead of microscopic labeling, manufacturers
should soon realize that older persons will be more likely to buy their
products if they could read the package contents. Large print will be more
common, as will better lighting.
Other changes might include affordable long-term care insurance, cars
with mirrors to compensate for the loss of visual acuity, personal con-
venience and comfort items, home shopping services, grocery delivery serv-
ices, and better timed street crossing lights.
Health care and social service delivery systems must change too. Cur-
rent institutions and organizations may not be appropriate or adequate
for the needs of an aging society.
We are already seeing changes in the use of acute hospital beds and
increasing needs for long-term care services and facilities. Community
caregiving organizations will be severly strained by the increasing patient
load, especially if they must care for AIDS victims simultaneously. To com-
bat this pressure, we must find ways to reach people more effectively in
their homes. Such progress would be particuIarly important in isolated
rural areas.
Our manpower needs wilI certainly change as we will need more per-
sons in new types of careers. Technology will cause changes in the way

6


,,.e deliver care and our needs for V~OUS types of care changes with age.
Put that new technology won't address all the issues of an aging America.
Fades and friends will continue to serve as caregivers, and they will
nrrd haining as well as respite services. They may also need innovative
,,.avs to cover the costs of health care `expenses. Individuals wilI need to
ty& planning earlier and personally take more steps to assure a finan-
cidv secure old age. Perhaps we will even see more incentives for those
,,& pursue healthy lifeStYleS.

\Vith an increased older population, society's attitude toward longevity
and the quality of life in later years will continue changing. The assump-
tion that being old means being sick and frail is disappearing. It is being
*placed by the notion that most older persons are healthy, vital, and want
to stay well and functioning as long as possible.
More and more of us will realize that we have the ability to chose how
kve live. The relationships between such factors as nutrition, exercise,
preventive health and disease mean that we can take a more active part
h our own health CUR Each of us wilI need to be more pro-active in work-
ing with health professionals, staying well, and when ill, taking part in
OUT recovery and rehabilitation.
This brief glimpse into the future reinforces my strong conviction that
it is our job to take the message of the value of health promotion and we&
ness for older persons to the leaders and citizens of our communities. Our
society must stay healthy. Our elders must stay healthy.
Dr. Koop has challenged us in three areas:
  First, we need to assist doctors, nurses, and other health profes-
  sionals to incorporate health promotion into their regular plans of
patient care. Older persons are particularly sensitive to messages from
  their doctors. Why not begin here? What recommendations can we
  develop that makes that a reality?
  Second, we need to educate older persons to the value of health
  promotion and wellness at any age. We must get the message out
that changing habits, even in later life, wilI produce significant and
tangible benefits. I ask you, how can we reach more mature c&ens
  with this important message?
  Third, we need to build partnerships to help educate people of alI
ages to get ready for later life. Public, private, and voluntary groups
must combine their strenghts in each community across the nation.
What better place is there to start than taking care of one's health.

The legacy of this conference must be manifested in several areas: new
directions in program areas; sharing of information about methods of
prevention and treatment; the development of a health promotion and well-
ness agenda for older persons for the coming decade; and a commitment
to implement these recommendations. We have a lot of work to do over
the next three days.
You have a unique opportunity to bring your knowledge and expertise
to the forefront of this effort. Over the next few days, I ask you to develop

7


recommendations which you will take back of your communities, your
organizations and your colleagues. I urge you to develop ways to assist
your designed State coalitions on health in achieving their agendas. I
encourage you to organize local coalitions which sponsor health promo-
tion and wellness activities for older persons. Finally, I challenge each of
you tp personally set a good example of health promotion practices.
You are here because you are leaders in your field and I congratulate
you on all that you have done thus far. But I urge you to do more. The
needs of our older population today are significant. The talents of older
people today are exciting. In the future, both those needs and that talent
pool will grow. What makes a difference to each of us as we age is what
happens in the community and neighborhood where we live and work.
I urge you to seize the opportunities that are before you to help make those
communities better places for all of us to live and to mature today and
in the future.

Working together-we can do it! Thank you.

8


Address

Resented by Assistant Surgeon General T. Franklii Williams
Director, National Institute on Aging
Sunday evening, March 20, 1988

Dr. Abdellah, Dr. Koop, Commissioner Fisk, and colleagues:
It is indeed an honor to be part of this important Surgeon General's
Workshop in Health Promotion and Aging. I am particularly glad that Dr.
Koop has focused attention on these very significant public health issues.
In the 197Os, the orientation toward age and aging of many persons in
fields of medical research and health policy began to assume new direc-
tions. This change in focus was primarily due to three growing realiza-
tions. The first, and perhaps most apparent, was the tremendous growth
in the number of people who were living-and living well-past their 65th
birthdays. As a result of this phenomenon new questions arose. Would
this trend continue? What would be the far-reaching implications of such
a demographic change in the United States, and perhaps around the world?
The second realization was that, regardless of how many people were
achieving healthy old age, aging was still looked upon with dread. If you
were turning 50 or 60 you expected physical and mental declines. Just as
unfortunate, so did your physician. Myths about aging prevailed. Many
in our youth-oriented society even viewed 30 as being past prime. The
question: What could reasonably be expected from people as they age?
The third realization was that many older people did, in fact, suffer phys-
ical and mental `declines. But, considering the large number of healthy older
people, it became apparent that some iIlnesses might be avoided.
Theie were many gaps in our scientific knowledge of the aging process.
On May 31, 1974, to respond to growing concerns in this area, Congress
enacted the Research on Aging Act creating the National Institute on Aging
(NIA) with a mandate "to conduct and support biomedical, social, and
behavioral research and training related to the aging process and diseases
and other special problems and needs" of older persons. In July 1975, the
Adult Development and Aging Branch and the Gerontology Research
Center were separated from the National Institute of Child Health and
Human Development and were made the core components of the new
NM.
Investigators now had the direction from Congress to discover which
aspects of aging processes might benefit from medical intervention. The
goal was, and stiIl is, to be able to understand normal aging processes and
develop ways to improve the quality of life for all people as they grow

9


old. Irrational myths and fears needed to be replaced by reliable data on
physiological, psychological, and social changes which often take place dur-
ing one's lifetime.
NIA research is conducted by scientists at the Gerontology Research
Center in Baltimore and in the National Institutes of Health (NIH) Clinical
Center in Bethesda, and through multidisciplinary grant programs which

give support to research institutions throughout the United States and,
to a limited degree, in other countries. Additionally, several interagency
agreements, for example with National Center for Health Statistics and
the Bureau of the Census, have expanded our ability to develop more pre-
cise information about the older population.
Since. its inception, NIA has developed priorities based upon the con-
cerns which led to the Institute's formation. Research on aging is poten-
tially unlimited in scope, so judgments must favor areas which show scien-
tific promise or which society deems to be important public issues.
  Priorities, of course, evolve over time but a continuing major emphasis
at NIA is to understand aging processes and how ,aging is distinct from
disease. The passage of time imposes change on everyone but it is vital
to understand which changes are inevitable and which are open to modifi-
cation. The Baltimore Longitudinal Study of Aging, conducted at the NIA
Gerontology Research Center, was initiated in 1958 to permit repeated
observations of the same subjects over time. Results of numerous studies
there have shown that if one can identify and separate out people with
disease conditions and focus study on healthy aging, changes with age

are far fewer than previously thought. Increasingly, studies demonstrate
_  that older people do not necessarily suffer heart and kidney problems, nor
do their personalities change with the passing of time [Rodeheffer, Linde-
man, Costa]. In fact, these studies show that very few, if any, changes
occur uniformly to all people as they age. Aging is highly individual. It
is for this reason that I object to and do not use the term "the elderly"
as it implies, erroneously, that older people are all alike-a stereotyping
  term.
  Other research results from around the country support this perspec-
tive. For example, Dr. K. Warner Schaie at Pennsylvania State University
and others, in evaluating intellectual and cognitive changes over time, have
found that many people do not suffer loss of intellectual function, and
those who do can often benefit from cognitive training programs that
reverse or decrease their intellectual decline [Schaie, Bakes, Rodin].
  Epidemiologic studies have contributed greatly to our understanding of
the aging population. Data from the Established Populations for Epidemi-
ological Studies of the Elderly (EPESE), supported by NIA, includes infor-
mation on over 13,OCHl participants in four communities: New Haven, Con-
necticut; East Boston; Massachusetts; two rural counties (Iowa and
Washington) in Iowa; and an enrolled predominantly black population in
the vicinity of Durham, North Carolina [Comoni Huntley]. These studies
are presenting detailed, longitudinal information on healthy older people
living in the community.

10


once we accept the notion that people do not inevitably become frail
c,r demented as they grow old, we can examine ways to maintain a per-
zc,n's health, independence, and function into later years. This, then, is
,nother priority at NIA. Can positive changes in a person's attitude and
lifest)lle affect health and vitality later in life? In many areas we are just
now' beginning to collect data. In the area of nutrition, for example, we
Generally support the Dietary Guidelines of the National Research Coun-
t., hut these guidelines are based on studies of persons under the age
<,t 51, and we simply do not know whether or how nutrient requirements
differ for older people. NIA is participating in a seven-institute collabora-
ti\re follow-up of the National Health and Nutrition Examination Survey
(NHANES). This survey should provide key information-and the largest
archive of data to date-on patterns of health and disease related to nutri-
tional habits.
Careful research studies have given us some answers to questions about
health promotion and disease prevention. John Holloszy of Washington
University in St. Louis and his colleagues have shown that when previ-
ously sedentary older people enter a fitness program, approved by their
physicians, their aerobic capacity improves as much as that for younger
people. There also are accompanying improvements in blood lipids and
glucose tolerance. Studies by Gail Dalsky, also at Washington University,
show that in women between the ages of 55 and 70, the typical decline
in bone mineral content of the spine can be minimized or eliminated by
following a sensible exercise regimen [Holloszy, Seals, Dalsky]. This find-
ing has important implications for prevention of fractures in older people.
We also know that smoking cessation, good medical and dental care,
moderate, if any, alcohol use, a good mental outlook, and a knowledge
of drugs and their possible adverse effects can benefit a person's health.
At the same time, much further research and program development at
NIA and other agencies, such as the Office of Disease Prevention and
Health Promotion, Office of Technology Assessment, the Food and Drug
Administration, the National Institute of Mental Health, and other Insti-
tutes of NIH, are critical to our full understanding of what is possible in
health promotion for older people.
The NIA also focuses its research, training, and information dissemina-
tion efforts on the common disabling conditions of older people-those
which threaten loss of function and loss of independence. Rehabilitative
efforts, i.e. restoration or improvement in function in these situations to
the maximum extent possible, are also a part of health promotion.
Probably the greatest threat to personal independence in older people
is dementia. Between 5 and 10 percent of alI people over 65 suffer from
Alzheimer's disease, with the numbers increasing substantially among the
oldest age groups. Research on the etiology and pathogenesis of demen-
tia is crucial to eliminating this terrible affliction. Through sophisticated
techniques researchers are beginning to gain a better understanding of the
changes that take place in Alzheimer's disease. Diagnostic capabilities have
been increased. In response to Congressional legisiation, the NIA now

11


supports ten AIzheimer's Disease Research Centers which bring together
some of the best basic and clinical research in the field. Congress also has
directed NIA to establish an Alzheimer's Disease Education Center and
Clearinghouse to assist families, health care professionals and the general
public in obtaining the most up-to-date research results. We also are work-
ing with the World Health Organization (WHO) which has made this area
a top priority.

Other problems which often threaten loss of function as people age
include incontinence, falls and hip fractures, osteoarthritis and osteoporo-
sis, and losses of hearing and vision. We have made some progress. For
example, studies by Drs. Bernard Engel, Kathleen McCormick and their
colleagues in the Gerontology Research Center have shown that urinary
incontinence can be controlled through pelvic floor exercises and related
strategies in about 80 percent of affected women living within the com-
munity [Burgio]. In the area of falls and fractures, we now have better
understanding of the multiple risk factors that can lead to repeated falls
in older people [Radebaugh, Tinetti]. More attention is being given to
research on deafness, blindness, osteoarthritis and osteoporosis in older
people.
In relation to all these efforts we need to expand the training of person-
nel in geriatrics and gerontology. The recently completed study on per-
sonnel for health needs of older people through the year 2020, conducted
at the request of Congress by NIA, the Bureau of Health Professions, and
other federal agencies, documents these needs and in particular the urgent
need for more academic leaders and teachers in these fields [Personnel].
The Institute of Medicine of the National Academy of Sciences has recom-
mended that NIA support development of "Centers of Excellence" for
research and training in geriatrics, to help meet this need.
The Institute on Medicine has also recently proposed a study of "Health
Promotion and Disability Prevention for the Second Fifty" [Report]. The
purpose of the study would be to establish a solid body of knowledge on
selected health risk factors for older people and measure the efficacy of
health promotion and disease/disability prevention interventions begin-
ning in the middle years and extending on through the last half of life-a
purpose quite congruent with that of this workshop. These workshop ses-
sions should provide current information on health promotion in older pea
ple in relation to medications, alcohol, dental health, preventive health serv-
ices, mental health, nutrition, physical fitness and exercise, smoking
cessation, and injury prevention. Further research on these topics is of
immense importance if we are to gain a full understanding of what it means
to grow old healthfully and vigorously. Old myths about aging are being
replaced by fact. Sessions such as this should help us all to develop a realis-
tic picture of what growing old is all about.

References

Baltes PB, Kliegl, R: Neurology: On the dynamics between growth and
decline in the aging of intelligence and memory. Springer Press, Ber-
lin: p l-17, 1986.

12


Bu@o, KL, Engel BT, etc. al: Urinary incontinence in the elderly: bladder-
sphincterbiofeedback and toileting skills training. Annals Int. Med 103:
507-15, 1985:

Cornoni-Huntley J, Brock DB, etc. al (Ed): Established Populations for
Epidemiologic Studies of the Elderly. National Institute on Aging, U.S.
Department of Health and Human Services, 1986.
Dalsky, GP, article in press, AM& Int. Med, June, 1988.
Holloszy JO, Seals DR, Dalsky GP, etc. al: Glucose tolerance in young
and older athletes and sedentary men.. J Appl Physio 56: 1521-1525,
  1984.

fIolloszy JO, Seals R, etc. al: Effects of endurance training on glucose toler-
ance and plasma lipid levels in older men and women. JAMA 252:
645649, Aug. 3, 1984.

Lindeman RD, Tobin J, Shock N: Longitudinal studies on rate of decline
in renal function with. age. J Am Geriatric Sot 33278-285, 1985.
McCrae RR, Costa PT: Emerging Lives, Enduring Dispositions. Boston,
Little, Brown, 1984.

Personnel for Health Needs of the Elderly Through the Year 2020, Na-
tional Institute on Aging, National Institutes of Health, 1987.
Radebaugh, TS,.Hadley E, Suzman, R (Ed): Falls in the elderly: biologic
and behavioral aspects. Clinic in Ger Med 1: 497-697, 1085.
Report of the Institute of Medicine: Academic Geriatrics for the year 2000,
J Am Geriatric Sot 35: 773-791, 1987.
Rodeheffer RJ, Gerstenblith G, etc. al: Exercise cardiac output is maintained
with advancing age in healthy human subjects: Cardiac dilatation and
increased stroke volume compensate for a diminished heart rate. Cir-
culation 69:203-213, 1984.

Rodin, J: Aging and health effects of the sense of control. Sci Mag 233:
X271-1276, Sept. 19, 1986.

Schaie KW (Ed): Seattle Longitudinal Study: A 21-year exploration of
psychometric intelligence in adulthood. Longitudinal Studies of Adult
Psychological Development, pp 64-135, 1983.
Seals DR, Hagberg JM, etc. al: Endurance training in older men and
women. J Appl Physio 57: 10241029, 1984.
Tinetti M, Williams TF, etc. al: Fall risk index for elderly patients based on
the number of chronic disabilities. Am J of Med 80: 429-434, 1986.

13


PLENARY SESSION

"Health F'romoti& and Surgeon General's Workshop"

Presented by Assistant Surgeon General David Sundwall
Administrator, Health Resources and Services Administration
Monday morning, March 21, .1988

Thank you, Dr. Abdellah. And thank you, Dr. Koop, for calling together
this group of distinguished professionals.

It's a pleasure, as well as an honor, to be a participant in these work-
shops on health promotion and aging. I want you to know I respect the
work you're doing here and elsewhere around the country. And I admire
your concern for older Americans and your dedication to their welfare and
health.

This forum provides a unique opportunity to focus on health promo-
tion and disease prevention in aging individuals. You've heard Carol Fraser
Fisk describe what the Administration on Aging is doing in this area and
Dr. Frank WilIiams describe the activities of the National Institute on Aging.
I've been asked to review some of what we're doing for older Ameri-
cans in the Health Resources and Services Administration, particularly as
it relates to health promotion and disease prevention.
That I-IRSA should be involved in health promotion activities is appropn-
ate in light of our designated mission. So that you'll better understand
how we fit into the public Health Service and, particularly, into health pro-
motion activities, let me briefly outline what that mission is. It comes in
two parts. Simply put, the first half has to do with resource building and
the second with service delivery.
We're charged with helping to assure that this nation has the necessary
resources, both facilities and health professionals, to meet the nation's cur-
rent. and future needs.
In this capacity, we support the education of health professionals through
guaranteed student loans, scholarships for minorities and the disadvan-
taged, and a variety of grants to institutions for developing and support-
ing health education and training programs.
We also administer the Hill/Burton indigent care program. Much of the
hospital construction that took place between the end of the Second World
War and 1973 was financed with Hill/Burton funds. Even though Con-
gress~discontinued funding for the construction portion of the program,
many HiIllBurton facilities retain their obligation to provide free care to
qualifying low income individuals.
Our new Office of Rural Health Policy is another good example of what
we're doing to help build the nation's health care resources. Congress

14


,ppropriated $1.2 milEon for M'88 for grants to develop Rural Health
policy/Research Centers. These Centers will collect, develop and dis-
,-eminate current information on rural health and conduct policy research
and analysis of rural health issues of national significance.
We also support organ transplantation activities and 7 regional educa-
tional centers for training health professionals in the prevention and care
and treatment of patients with AIDS. Taken together, these programs are
instrumental in developing essential health resources across the nation.
NOW, the second half of HRSA's mission is to support the delivery of
health services to special populations and those who, because of lack of
resources or geographic location, are unable to obtain appropriate serv-
ices for themselves.
America's homeless population is a prime example. HRSA recently
awarded $46 million to 109 communities that demonstrated the ability to
provide comprehensive .health services to homeless individuals.
Another population of Americans having diificulty obtaining appropri-
ate services is that infected with the AIDS virus., HRSA's AIDS related
activities bridge the two segments of our mission. Whereas, our 4, soon
to be 7, area education centers fall under the resource building portion,
the 11 AIDS Services Demonstration Projects that are designed to build
on existing resources to provide comprehensive services for AIDS patients
fall under the health services portion.
The homeless initiative and the AIDS Service Demonstration Projects
are relatively new compared to our participation in maternal and child
health programs. We've had a long history of involvement in this area.
I-IRSA administers the MCI-I Block Grant as well as numerous other initia-
tives, some of them designed to reduce the incidence of infant mortality.
Many of the services provided by HRSA's nearly 600 Community and
Migrant Health Centers are for mothers and their children. And although
they provide traditional curative medical care, increasing emphasis is being
placed on preventive health services as a means of improving the health
status of their clientele.
There's a lot of truth in the old saying-an ounce of prevention is worth
a pound of cure. Frankly, I believe it's worth more than a pound, both
from the standpoint of cost as well as from pain and suffering.
Now, if preventive medicine is important to the general population, it's
of even greater significance to senior citizens because of its potential for
improving the quality of life during the senior years while conserving scarce
health resources.

Right now those 65 or older are `I.2 percent of the population but account
for more than 30 percent of the total cost of health care. This percentage
is projected to increase as the number of older Americans, and particu-
larly those 85 years of age and older, increases through the end of this
century. Therefore, the topic of these workshops is of utmost importance,
not just for senior citizens, but for the health and well-being of the U.S.
treasury that will spend about $145 billion on health care this year.
About $1.5 billion of that will go for HRSA programs-many of them
having geriatric components.

15


At HRSA, we recently established a Committee on Aging-Related Issues.
Because many of the bureaus and divisions administer programs with geri-
atric components, the Committee's goal is to coordinate these internal initia-
tives in addition to coordinating with other governmental agencies that
administer ,programs for senior citizens. It will also develop a plan to
increase relevance and accessibility of HRSA programs to the aging popu-
lation. It will keep abreast of aging-related activities within the private sec-
tor. And it will develop and maintain an inventory of HRSA aging-related
activities.
Many of these aging activities are found in Community and Migrant
Health Centers. Nearly ten percent of their clientele is over 65. And,
`although the percentage is remainin g relatively constant, there is an increase
in the number of elderly obtaining services at CHC's that parallels the
expansion of the older population.
Traditionally, Community Health Centers have emphasized primary and
preventive care, but recently they've been more aggressive in efforts to
actively incorporate prevention activities into their service regimes for senior
citizens.

  In 1984, we awarded $1.7 million in supplemental funds to 57 Commu-
nity Health Centers to assist these Centers in developing and implement-
ing preventive health programs to serve as models for other Centers.
  To build on this, I-IRSA and the Administration on Aging are jointly
sponsoring a networking initiative between State Primary Care Associa-
tions and State Agencies on Aging. For those who are unfamiliar with State


Primary Care Associations, they're made up of Community Health Centers
_ and other nonprofit organizations, including some state health depart-
ments, that provide primary care services.

State Units on Aging working with State Primary Care Associations will
develop an action plan that correlates with local circumstances and health
care needs. To help participants formulate these plans, we sponsored a
series of 10 planning seminars that were completed in December of last
year.

Now that the first stage of the program is completed with the working
plans-hopefully-"signed, sealed and delivered" we're in the process of
contracting for a study to evaluate their implementation and effectiveness.
We hope to improve collaboration and cooperation among the various
administrative and management levels of the aging and primary care net-
work, whether they're local, state or federal, so that we'll be better pre-
pared to meet the health care needs of the expanding older population.
By linking Community Health Centers to the aging network and mak-
ing the Centers more sensitive to the unique health care needs of older
individuals, we'll enhance our ability to provide appropriate, comprehen-
sive Geriatric care.
We're so confident that this networking relationship between HRSA and
the Administration on Aging wiIl prove to be effective-that it will improve
accessibility and quality of care for aging citizens-that we're in the process

16


of drafting a Memorandum of Understanding that will cement our official
ties and build and expand upon our earlier collaborative efforts.
The Memorandum has 5 stated objectives. They are:
o To support states and communities in the development of improved
health care systems serving older persons;
o To promote expanded education and training opportunities for health
personnel serving the elderly;
o To collaborate with the private sector to improve health care for the
elderly; and

o To promote the maintenance and expansion of health services for older
persons living in rural areas.

o To support model programs for older I-RSA and AoA employees and
employees providing care to older family members.
Although it's still in the negotiation stages, we hope to soon finalize the
formal agreement even as we continue our joint objective to improve quality
and accessibility of health care services for older Americans.
One of the real stumbling blocks to doing this is the documented short-
age of health professionals with geriatric training. At the request of Con-
gress, we recently conducted a study entitled "Personnel for Health Needs
of the Elderly Through Year 2020." The study was jointly sponsored by
the Bureau of Health Professions and the National Institute on Aging.
Congress specificalIy requested that the report contain recommendations
on-first, the number and training needs of primary care physicians and
other health and human services personnel required to provide adequate
care-and second, the necessary changes in Medicare and other third-party
reimbursement programs to support such training.
The published report to Congress contains 16 findings and 5 compre-
hensive recommendations. Even though they're vitally important to the
aged and their health care, I don't intend to review them individually
because they alI don't relate directly to health promotion. However, one
of the more sobering is that the demand for services for older Americans
will double by the year 2020 if current utilization rates are maintained.
Approximately 2 out of every 3 patients will be over 65. Geriatric person-
nel requirements will greatly exceed the current supply.
That's the bad news, ladies and gentlemen. The good news is that the
increasing demand for geriatric services will coincide with an anticipated
growth in the supply of health care practitioners. Our challenge is to make
sure that they tiill he prepared and well-trained in geriatric medicine.
That's not going to be easy because one of the reasons we don't have
a cadre of health professionals trained in geriatrics is that we don't have
the faculty to train them. In fact, the report estimates that we only have
from 5 to 10 percent of the faculty we'll need to train the number of health
professionals that our projections estimate wiII be needed to meet the health
care needs of the expanding aging population.
At HRSA, we have several initiatives specifically designed to address
both shortages.

17


Over the years, our Bureau of Health Professions has supported the edu-
cation of health professionals in a variety of ways, including scholar~~p~,
student loans and grants to educational institutions.
Now that we have a surplus of physicians in most medical specialties,
we no longer indiscrimin ately supljort medical education. We now target
our limited resources toward shortage areas-those where the greatest
needs occur. Our sole remaining scholarship program is for minorities and
`the disadvantaged. And most of our grants support programs in family
medicine, primary care and geriatrics with requirements that recipients
implement aspects of disease prevention and health promotion into their
curricula.
We fund grants to schools of medicine and osteopathy; teaching hospi-
tals; and graduate medical education programs to train physicians and den-
tists who plan to teach geriatric medicine or geriatric dentistry. The insti-
tutions themselves then award fellowships in geriatric retraining programs
for physicians who are faculty members in departments of internal medi-
cine and family medicine.
In addition, we're funding several programs to develop curriculum
models in geriatrics, all of which contain elements of health promotion.
One of our grants funded a program where over a six-month period,
22 family medicine physicians participated in a 4 week mini-fellowship pro-
gram in geriatric medicine. The participants were then required to evalu-
ate the program. Using the feedback from the mini-fellowships, a curricu-
lum resource package is being prepared and will be made available
nationally to assist family medicine faculty or faculty in other specialties
involved in teaching residents.
We also support geriatric training in dentistry, family medicine, general
internal medicine and preventive medicine. A number of programs sup-
port the development of geriatric nurse practitioners and physician assis-
tants.

In addition to these grants, HRSA funds 31 Geriatric Education Centers
that are strategically located around the country. The Centers are gener-
ally a consortia of several academic institutions, a broad range of health
professions schools and a variety of clinical facilities. They will be funded
at about $9 million for FYTB.
The Centers stress the muhidisciplinary approach with an emphasis on
health promotion. Their main objective is to train and prepare faculty to
teach geriatrics to various health care providers. However, they do partic-
ipate in continuing education for practicing health professionals.
Now that I've given you a sketch of what HRSA's doing in geriatrics
and health promotion, I want to assure you we are practicing what we
preach. HRSA's Division of Federal Occupational and Beneficiary Health
Services is the federal focus for health promotion programs for federal
employees right through the time of retirement.
The Division functions primarily as a consultant for the various federal
agencies. It conducts studies, advises management on health promotion
activities, and sets up programs for employees.

18


For example, right in HRSA we sponsor a annual health fair for all
employees. Among other things, we have nutrition analysis and counsel-
ing, weight reduction counseling, and high blood pressure, cardiovascu-
lar and cholesterol screening.
We also operate health units and employee counseling units in many
federal agencies. These units offer a wide range of counseling services and
routine physicals and health screening programs for federal employees so
that we can incorporate the principles of health promotion into the lives
of federal employees.
I want to reemphasize that health promotion is a vital element in each
of HRSA's geriatric programs. With increasing longevity and rising health
care costs, welIness is becoming more and more important to our finan-
cial as well as our physical health.

We believe that by combining health promotion activities with miraculous
new technology and curative powers, we can help assure that the last years
of life are spent in better health than ever before. We have the tools to
help change what once were "the declining years" into "the golden years."
HRSA is dedicated to this objective. And our geriatric programs are tar-
geted toward this end. We want to work with related government agen-
cies and those of you in the private sector to promote the health and well-
being of America's senior citizens.

I look forward to this joint endeavor and to reviewing the conclusions
of this workshop. Thank you again for inviting me to participate.

19


"Year 2000 Health Objectives for the Nation"

Presented by Assistant Surgeon General J. Michael McGinnis
Director, Office of Disease Prevention and Health Promotion
Monday morning, March 21, 1988

I would like at the outset to pay special tribute to the Surgeon General
for his insight and timing in convening this workshop. As you-the experts
in health promotion and aging-know, one of the gravest challenges this
Nation faces is how to ensure the vigor of its expanding aging popula-
tion. I am here today to tell you that much of our success. in meeting that
challenge will depend on what we do now-and in the intervening years
before the baby boom retires-to prevent disease and promote health.
My job this morning is to discuss with you a framework within which
we can collectively channel our thoughts on how we would take on those
challenges-within the context of the Year 2000 Health for the Nation objec-
tives setting initiative.
The application of the tenets of health promotion/disease prevention to
older adults is a relatively new notion. This workshop, however, is one
- of the signals of the growing recognition that there are benefits to be gained
through the adoption of healthy practices and behaviors at most any age.
Part of this recognition comes from learning how to see aging for what
it is-and isn't. Many of the so-called signs of old age are actually the se-
quelae of disease. And the most prevalent diseases, furthermore, are those
which derive from lifestyle and environmental factors, factors within our
control. The interplay of these factors as we age accounts in large part for
the wide variation between chronological and physiological age we see in
the older. population.
In addition to separating aging from disease, the scientific evidence is
building a strong case that preventive practices and healthy behaviors can
have a substantial impact on the quality of later life, through less prema-
ture disability, shortened periods of acute illness, and less need for long
term care. While research in prevention is just starting to address older
people, a substantial body of knowledge has been developed over the past
20 years linking personal behavior to health status.

I would like to review briefly, if I may, some of the milestones bringing
us to this point today-with the humble acknowledgment that some of
the foremost experts and scientists who have contributed to these efforts
are amongst us.
A pioneering study to demonstrate the correlation between cardiovas-
cular disease and the risk factors of smoking, obesity, and hypertension


was the Framingham study, begun back in 1948. This study continues to
provide valuable scientific support for health promotion and disease
prevention programs. For example, researchers found that the rate of coro-
nary disease for men with sedentary lifestyles is about three times higher
than that for active men.

In the mid-1960s Lester Brewlow and his colleagues looked into the per-
sonal habits of 7,000 people living in Alameda County, California, and
found seven health habits to be related to physical health status and mor-
tality. The longest living turned out to.be those who followed most or all
of seven common sense practices: they did not smoke; maintained a
reasonable.weight; ate breakfast; rarely snacked between meals; drank alco-
hol in moderation, if at all; slept seven to eight hours a night; and took
part in some sort of regular physical activity. Between 196!5 and 1974, the
death rate for men observing ail seven good health practices was only 28
percent that of men who followed three or fewer. For women, the com-
parable statistic was 43 percent. What's more, the survival rates were sub
stantially the same for those age 65 and above, as well as for those in youn-
ger age groups.
In the 7Os, new ground was broken by the Stanford Three Community
Study-setting thebenchmark for the public education campaigns we see
today. They took on a problem which has often confounded the public
health community-that of how to bridge the gap between getting people
to know what is a health risk and getting them to actually reduce their
risk through behavior change. The Stanford field study in three California
towns found that cardiovascular risk scores were reduced through a com-
bination of mass media appeals and were further reduced in those people
who received both mass media and personal communications.
Prompted by the new insights into the links between risk factors and
disease, Federal policy-makers both here and in Canada began paying
parallel attention to the relative importance of lifestyle factors to health sta-
tus. The Canadians came first, issuing a report in 1974 which held up the
modest gains in health status attributable to medical care against the poten-
tial gains from changes in environmental or lifestyle factors.
The next year, the Fogarty International Center of the National Insti-
tutes of Health and the American College of Preventive Medicine co-
sponsored a National Conference on Prevention here in the U.S. A grow-
ing consensus was developing around the need for a national focus on
disease prevention and health promotion. The next year, the Office of Dis-
ease Prevention and Health Promotion was created to coordinate Federal
health promotion programs.

As other research initiatives were launched, including the Hypertension
Detection and Follow-up Program, the Multiple Risk Factor Intervention
Trial (MRFIT), the Lipid Research Clinics Coronary Primary Prevention Trial
and many others, prevention climbed up the national agenda.
The evidence linking lifestyle factors and health led to the conclusion
prominently emphasized in the 1979 Surgeon General's report Healthy Peo-
ple that further improvements in the health of the American people

21


would not be achieved from increased medical care and greater health
expenditures alone-but through a renewed national commitment to efforts
designed to prevent disease and promote health. Broad goals were set to
reduce death and disability rates by 1990 in the different age groupings.
For older people, however, the explicit goal was to improve the health
and quality of life and reduce the average annual number of days of re-
stricted activity by 20 percent, to fewer than 30 days per year. Implicit was
the goal of allowing each individual to seek an independent and reward-
ing life in old age, unlimited by many health problems within his or her
capacity to control.
The approach chosen to achieve these national goals outlined in the Sur-
geon General's report was to draft a comprehensive national prevention
strategy based on 226 measurable objectives in 15 separate priority areas.
Specific targets were set to be achieved by 1990 for improving health sta-
tus and reducing risk for disease, disability, or death in areas encompass-
ing preventive interventions, health-related behaviors, and changes in the
physical environment.
Over the past eight years, the so-called 1990 health objectives have been
used to spotlight problems, set priorities, and allocate resources at the local,
State, and national levels. And we have shown some progress.
Midway, in 1985, we were pleased to report that despite problems in
pregnancy and infant health, family planning, and violent behavior, about
half of the objectives had either been achieved or were on the path to suc-
cess. The greatest progress was made in areas such as high blood pres-
sure control, prevention of injuries, smoking reduction, immunization, and
control of infectious diseases. In the past 15 years, we've seen a 25 per-
cent reduction in tobacco use, a 15-2~ percent decline in the consumption
.of saturated fat and cholesterol, a 40 percent drop in salt consumption,
and a two- to three-fold improvement in blood pressure control.
But, perhaps the more dramatic conclusion which can be drawn from
the mid-course review is that people are not dying as they did before. There
has been a 55 percent decline in stroke deaths and a 40 percent drop in
heart attack deaths. With five years left to 1990 at midway, we were already
70 percent on the way to our goal of reducing infant deaths, 90 percent
on the way for child mortality, 90 percent for adolescent mortality, and
70 percent for adult mortality. This is good news, to be sure.
But what does all this mean for older Americans? Indeed, some claim
that the factors which have led to reductions in mortality will not yield
overall improvements in health status. Prolonged longevity by itself, goes
the argument, could simply mean that more people will spend longer
proportions of their lives afflicted with chronic and degenerative diseases.
I join those who posit another view. It is exactly the elders of the Year
2000 who will be the beneficiaries of healthier lifestyles and behaviors in
their early and middle years and of advances from research in treatment
and rehabilitation. So it is quite reasonable to expect that the benefits of
a lifetime of healthy practices, carried into the later years, will lead to fewer
chronic diseases and ameliorate those which do occur. Certainly that con-
stitutes a worthy goal.


                             22


So where do we go from here? As I mentioned at the outset, we are
now beginning to'set new health objectives for the Year 2000 and a spe-
cial concern is setting targets for older Americans. 7'he 1990 objectives
did not adequately address this population because of the attention given
to premature. mortality and morbidity. But the Year 2000 gives us the
opportunity to make such adjustments. This time we know more about
the aging process, we know more about the aging population, and we
know more about the value and effectiveness of a variety of health pro-
motion strategies in general, and for this age group specifically.

Furthermore, we are compelled to take special notice. Between 1985
and the Year 2020, the population 65 and older is likely to increase by
almost two percent a year, an average of about 750,000 additional older
persons per annum. The oldest-old-the %-plus generation-are projected
to increase at an even faster rate, at about three percent a year. In con-
trast, the total United States population is anticipated to grow each year
by less than one percent.

While the rate of growth of the 65-plus population is expected to be
somewhat greater after the Year 2000, between 1985 and Year 2000, the
oldest-old will grow faster, at an average rate of about four percent a year.
Then, as the baby boomers ease into the elderly category, we can expect
a nearly three percent growth rate in the young-old, the 65 to 74 age range.
Although the majority of older adults in the future are expected to be
relatively healthy, most wilI develop one or more chronic health problems.
Many of these conditions should cause few difficulties but others could
result in severe disabilities. A widely used measure of disability among
older persons is the number of persons with activity of daily living limi-
tations (ADL). Data from the 1984 Health Interview Survey aging sup-
plement show that over 22 percent of older persons living in the com-
munity have some degree of disability.

We also know that the impact of chronic health problems increases with
age. More than 60 percent of those age 85 and over reported some degree
of limitation. Since we will have more people living longer in the Year
2000, NCHS projects a 30 to 50 percent increase in the numbers of older
persons with some limitations in activities of daily living, if current pat-
terns of disease continue.

The sum of these trends, then, is that we have a growing high risk
group whose only option to health care currently is expensive, and not
always appropriate, acute care medical treatment. So clearly, one national
strategy must be to balance the prevailing focus on curative medicine with
attention to preventing disease and promoting and maintaining health.
The leading chronic conditions afflicting older people-arthritis, hyper-
tension, hearing and visual loss, and heart problems-are conditions we
know have the potential in many cases to respond to health promotion
interventions such as exercise, healthy diet, and early care. And at least
two of the three most debilitating conditions which lead to a need for
long term care-stroke and hip fracture-could be prevented.

23


For those people already ilI, our goal should be to maximize function
and prevent further deterioration. Changes in diet, exercise, and other
health behaviors-may have an impact on function and ability to cope with
the demands of daily life, even beyond their gains in health status.
So when planning for the Year 2000, we must broaden the perspective
which has been applied to the younger ages of preventing morbidity and
premature mortality. The challenge is not how to prolong life, but how
to extend active life expectancy. What can be done to delay the onset of
disease? How can we maintain function and independence in those older
adults with chronic and degenerative diseases? How can we measure func-
tional independence ? How do we set priorities amongst preventable
problems? What do we know about the effectiveness and e,fj?uzcy of such
strategies in the 65plus group?
Over the next few days you are going to be giving a close look to the
range of behaviors and practices identified to be of the most benefit to the
health of older people. It is my hope that we will be able to take the work
you will be doing here and use it as the groundwork for designing Year
2000 objectives which address the specific preventable problems of older
Americans.

Let me just touch briefly on how that will actually happen. First, you
should know that the Public Health Service is collaborating in the Year
2000 effort with the Institute of Medicine, under the guidance of a steer-
ing committee representing all the PHS agencies who will have the ulti-

mate responsibility for carrying out the objectives. The first step of this
process has been one of gathering information. Regional hearings are being
- held around the country to solicit grassroots testimony about preventive
health priorities in the coming decade. Special hearings are also being spon-
sored by interested organizations at their annual meetings. In addition,
we are convening a special hearing to focus on the needs of older people
following this workshop on Wednesday afternoon. If you are not already
plannin g to attend, I invite you to do so. We are expecting to hear first
from Dr. Koop-who will be sharing the recommendations from this work-
shop with us and entering them into the record. We'll also hear from the
American Association of Retired Persons, the National Council on the
Aging, the . . . and many other interested groups. There should be time
following the scheduled testimony to hear from you and I encourage you
to come forward.
Once all the hearings have been held, the task of drafting the actual objec-
tives will be assigned to those agencies within the Public Health Service
who will have the lead responsibility for a given area. We anticipate that
a draft of the objectives will go out for review and comment by the end
of this year and that the final Year 2000 objectives will be issued at the
end of 1989.
In closing now, I'd like to thank you for the opportunity to share with
you what we are doing and I certainly am looking forward to hearing your
recommendations two days hence.

24


As we rise to the challenges of our demographic destiny, we must
acknowledge that neither knowledge nor change come easy. But with the
collective spirit, wisdom, and commitment of people like you, I believe
we will be successful. If L may, I'd like to close with a quote from the last
line of Healthy People, the Surgeon General's report on health promotion
and disease prevention which got us started, with one alteration:
   "If the commitment is made at every level, we ought to achieve
out goals, and older Americans, who might otherwise have suffered
  disease and disability, will instead be healthy people."
Thank you.



"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



deserve further investigation to ascertain their potential benefit for the
elderly, but specific trials are required before they can be broadly advocated.
The problem of fractures is an excellent example of the complex nature
of preventive activities.in the elderly.. The growing body of information
about osteoporosis suggests that the judicious use of estrogens can retard
the onset of.the condition with acceptable risks, given appropriate super-
vision. Fxenise may have a useful, if modest, contribution to delaying bone
loss. It also seems to improve the sense of well-being and for this reason
alone it should be encouraged.
Retarding osteoporosis can reduce the risk of fractures, but other fac-
tors contribute to this problem. For example, hip fractures are often the
result of falls. Such fractures occur more often in the presence of
osteoporotic bone. Preventive strategies can be usefully directed toward
reducing the propensity to fall by altering the environment to remove haz-
ard%, identifying and treating correctable causes of falling or by teaching
older people how to fall more safely.
A major role for prevention in the elderly is the avoidance of iatrogenic
disease by interrupting transition from a disease process to a disability.
Such prevention is more easily attained when care is provided from a con-
tinuous source. The caregiver can then observe subtle signs of change
against what is often a busy background of symptoms associated with mul-
tiple chronic diseases. With such attention, the caregiver will often notice
early signs of degeneration that would otherwise be dismissed as unim-
portant. Preventive work designed to reduce disability must include atten-
tion to the patient's wide range of needs. Sensitivity to such problems as
depression, changes in speech and hearing, cognitive impairment and
incontinence can lead to timely prevention.
Disability can be reduced even after a chronic problem has developed
by careful attention to structuring the patient's physical and social environ-
ment so as to promote autonomy. Physical modifications of various types
can make things more accessible and manageable, but more subtle effort
is required to. establish a rehabilitative climate where patients are
encouraged to attempt as much as possible on their own. There are strong
pressures from regulatory agencies and those concerned with the patient's
safety to encourage care givers to do things for patients instead of encourag-
ing autonomy.
Many preventive strategies that benefit the elderly involve efforts best
directed at younger groups, who wilI then be in better health at the time
they enter old age. This observation means that resources that benefit the
elderly in time may be redirected toward other age groups. It is also use-
ful to appreciate that investments in preventive actions are often difficult
to selI to governments more concerned with short term events than with
those that may. not yield results for some years to come.
There is some danger in withholding preventive services from the elderly
on the grounds of lack of demonstrated benefit. In a sense, elderly people
are the victims of age discrimination. They have been systematically
excluded from most trials of prevention. Thus the absence of evidence may
be due to the fact that it has not been sought.

51


Preparatory to its Expert Committee meeting, the World Health Organi-
zation held a meeting in Hamilton, Canada to review the effectiveness of
health promotion in the elderly. Frankly, it did not achieve this objective
since the participants were tom between applying the strictest rules of scien-
tific evidence.-and accepting health promotion practices which merely
proclaim benefits in terms of improved function and enhanced well-being.
In the end, the participants tried to achieve a unity of science with com-
mon sense by describing actual health promotion activities in different coun-
tries. In South Australia, for example, rational criteria are used to select
geriatric health promotion activities for a state-wide program. Priority is
given:

o to the most prevalent contributors to disability or death
o the most prominent societal concerns
o interventions likely to yield significant outcomes from resources
o invested conditions which are amendable to intervention in that
o large scale studies demonstrate that sustainable results can be
achieved, or

o studies suggest the problem is amendable to intervention but local
testing is necessary.

Evidence for the interventions were supported for:
o treatment of moderate to severe hypertension at least up to the age
of 70
o influenza vaccination

o targeting breast cancer self examination in older women
o ameliorating social isolation

o relieving the care burden of family members
o correcting unfavorable societal attitudes
o pre-retirement education.

Close liaison was reported in Hamilton between the work of the Cana-
dian and United States task forces on periodic health examination and on
preventive health services. Both were exigent in using quality of evidence
assessment criteria. On analyzing the evidence, the Canadian task force's
principle recommendation was that routine annual checkup be abandoned
in favor of a selective approach, based on a patient's age and sex. Accord-
ingly, age- and sex-specific "health promotion packages" were developed
and it was recommended that these be incorporated, opportunistically, into
visits to a health facility. The package for 65-74 year old men and women
includes:

o immunization against influenza, tetanus and diphtheria
o correction of hearing impairment
o measurement of blood pressure
o oral examination

o testing for occult blood in the stools
o two-yearly assessment of nutritional status and
o a condition called "progressive incapacity"

52


When screening practices from the United Kingdom and Israel ;vere
added to United States and Canadian experience there was little to add
to the content of the health promotion encounter in the primary health
setting beyond social and psychological function and measuring height and
weight.

  At the same time that the WHO experts were urging caution on the
rhetoric of health promotion, the research community was encouraging
WHO to develop world wide collaborative studies on aging. This is now
formally established as the WHO Special Program for Research on Aging,
and is based here at the National Institute of Aging. The central research
question in the Program is to identify the determinants of healthy aging.
Transitions in health status over time will be related to a battery of identi-
cal baseline measurements. Subject to the availability of funds, these
prospective studies wilI be conducted simultaneously in some 8 countries.
  Healthy aging, successful aging- effective aging all slip easily into our
language. I am not suggesting that we do not use these terms. Indeed
it is honest public health practice to do so if we wish to raise the health
expectations of people and promote healthy public policy. Few have come
to terms with the demographic reality that the third age emerged only some
3 decades ago in the United States and, now, half the women born will
transit the age of 81. But aging people, their care providers and policy
makers need facts more than exhortation. The collaborative endeavors
which the international research community is tackling in harness with
`-  the World Health Organization and the National Institute of Aging are
designed to generate these facts.

References

Abelin, T., Brezinski, Z.J. and Carstairs, V.D.L. Measurement in health
pnmdon and protection. World Health Organization, Copenhagen Euro-
pean Series, No. 22, 1987.

World Health Organization. Health qf Ela'erly People, Report of an Expert
Committee. Technical Report Series Geneva, 1988 (in preparation).
World Health Organization. The eJ$dwms of health pmmtion in the Elderly.
Report 4 an Advisory Group. Unedited Report Copenhagen, 1987.
Kane, R.L., Evans, J. Grimley, Macfadyen, David M. (edit) Impmving the
Health of Older Pe@k A World View. Oxford University Press (in prepa-
ration).

53


charge to Palticipants

Resented by C. Everett Koop, MD

Surgeon General, United States Public Health Service
Monday morning, March 21, 1988

   We`ve heard much good information last night and this morning and
  now we ought to get to work . . . in our work groups.
   I've had the pleasure of convening seven workshops during my 61/2 years
  as your Surgeon General. Some have been very large with a hundred or
  two hundred people . . . some have had fewer than 50 people attending.
   But the size has no relationship to the ultimate effectiveness of these
  workshops-and many of them have been extremely effective.
     What's the secret?
   Nothing very esoteric, believe me. The first requirement is that each per-
  son attending a Surgeon General's Workshop understands that his or her
  active participation is essential at every step of the workshop process.
. .  If we didn't think you were important to the outcome of this workshop
  _ on health promotion and aging . . . you wouldn't be here.
    So . . . please . . . jump in and help pull together the kind of outcome of
   whichwecanallbeproud... an outcome that will help make a real differ-
   ence in the lives of older Americans today and in the years to come.
   The first requirement for success, then, is your participation.
   The second requimment is to stay within the general framework of my
  "charge" to the workshop. And that's what I intend to deliver right now.
   The "charge" is meant to keep everyone generally on track in some
  reasonably organized way so that-within the tight time frame we have
  before us+e can p~~Iuce a set of sound and solid recommendations that
   can focus and energize the work in health promotion and aging.
   This, then, is my "charge" to this workshop.
   First, please keep in mind that our work is directed to the attention of
  the health care community, we want them to begin doing some new and
   different things-or to start doing some old things better.
   Second, we need to reach the health care community through different
   avenues. I would think, for example, that some attention ought to be given
  to the role of professional and educational associations and institutions in
  this work. What do we want them to do? What kinds of pm-service and
   in-service educational program would we want them to carry out?
   Maybe there are other ways to telI the story of health promotion and
   aging to health professionals now in the at work health system. Let's get
   those ideas out .on the table and let's talk about them.

54


Third-and it's related to one I just mentioned-we need to think not
only about the health professionals already at work but also about the
young men and women who should ,be entering this field . . . those bright
and dedicated young people who would be most' receptive to a recruit-
ment message that talks about a real challenge . . . about opportunities for
growth . . . and about the tangible and intangible rewards of personal and
community service.
Again, I'm delighted we have six graduate students with us. They've
already chosen a career in geriatrics. I hope they'll help us convince other
bright young people to do the same thing.
Fourth, I'm very, very impressed by the background papers prepared
for this workshop. And I want to extend to every author of every paper
my own personal thanks for taking the assignment very seriously and help
ing us get off to a strong, running start.
But there's some "background" we still don't have about health pro-
motion . . . about aging . . . and about both of them together.
At this workshop, we should zero in on the kinds of research that ought
to be on our agenda for the future. This has been touched on already by
several of the speakers already, but let's do more than just "touch on"
this issue.

Let's talk about the areas where new knowledge is vitally needed-in
the nature of the aging process, the health care needs of the elderly, or
whatever. But let's get them down on paper also.
Fifth and finally, we need to speak candidly about the strengths and
weaknesses of our nation's system for delivering health services, with refer-
ence to the elderly-and especially with reference to the promotion of the
health of the elderly.
If this task were being effectively accomplished today, there would be
no need for a "Surgeon General's Workshop on Health Promotion and
Aging." But it is not-and we are here.

Let's look, then, at the kinds of services we now have . . . the kinds of
serviqes we ought to have . . . and the way these services do-and should-
relate to each other in this matter of health promotion for older Americans.
At 9 a.m. on Wednesday morning, we will begin to hear the recom-
mendations of the many work groups. These will be the culmination of
our work here this week.

What should these recommendations look like or sound like?
Again, going back to the first "charge" I mentioned a few moments ago,
the recommendations ought to be directed to the health care community
and ought to be related somehow to the role of that community in promot-
ing the health of older Americans.
Past workshops have been able to handle sometimes dozens of recom-
mendations by arranging them under one or another of three headings:
mearch, education, and se&~. I would encourage you to do this, also,
because I gather, from talking with many of you, that we're going to have
both quality and quantity in the recommendations of this workshop.

55


Try to keep your recommendations tied as closely as possible to specific,
do able actions by particular institutions, professions, levels of Govem-
ment, or other responsible elements in our society.
Finally, while Commissioner Fraser Fisk, Director Williams, and I will
be formally receiving your recommendations tomorrow, do not limit your
recommendations just to the work of our own respective agencies or even
our Department.
Keep them on as broadly applicable a plain as you can. Remember, while
you may have been convened by the Surgeon General for a "Surgeon
General's Workshop;" the actual scope of authority of the Surgeon
General-as with any other public official-is carefully circumsaiid by
law, regulation and tradition.
Maybe some of these ought to be changed. Then say so, but please do
not become mired in the details of life in the bureaucracy.
Speaking for my own little "newcastle," I have quite enough coal of
my own, thank you,
Now, let me close by indicating what we plan to do with your recom-
mendations.

As with previous workshops, we intend to publish them all-the good,
the bad, and the indifferent-without any further editing for content or
substance.

Our staff will clean up the grammar and syntax, where such might be
necessary: This is the Government and we do have some standards. But
we will not "clean up" the thinking that's expressed by that grammar, in
deference to any political or other interest.
-  So, please do your very best. And we will respect that effort.
Thefinalprintedd ocument will be distributed to those very associations,
institutions, and agencies-public and private-who constitute the "health
care community" in American life.
Many of you may be called upon for advice, as we put together our dis-
tribution plan. We want to make sure that the people who should act upon
the message of this workshop actually get that message in the first place.
I'm pleased to say that we print and reprint thousands of copies of reports
from these workshops. They tend to be benchmark documents and of great
value for poIicy-makers, decision-makers, teachers, students, and involved
persons from among the general public.
I am sure the document you produce here this week will have the same
active longevity, appearing in every office and meeting room around the
country, where people are serious about providing better health services
for our older citizens.

That, ladies and gentlemen, is my "charge" to you. I've made it sound
simple and straightforward . . . because we need that more than we need
jargon, rigmarole, and hot air.
I know you agree. And I know you will be terrific. Thank you.

56


PLENARY SESSION

RECOMMENDATIONS OF THE WORK GROUPS

Wednesday, March 23, 1988

ALCOHOL WORKING GROUP

      Chair Enoch Gordis, MD
Technical Manager: Susan Maloney
   Reporter: Angela Mickalide, PhD
Group Members: Thomas Beresford, MD
           Gerald Bloedow
        Jacob Brody, MD
         Teri Dowling
           Barbara Giloth
        Edith Lisansky Gomberg, PhD
           Marie Gooderham
           Millicent Gorham
          John Horn, PhD
          Robin Room, PhD
         Anthony Vuturo, MD
        Nancy Wartow
        Erma Polly Williams

In the area of education (health care providers), we recommend that:
1. health'care pmviders be educated through CME courses, professional
astitions, and other networks as to the patterns of alcohol use
. among older persons, risks and potential benefits of such use, effec-
t&e detection and intervention techniques, and communicating effec-
tively with their patients about alcohol issues.
2. Federal agencies provide incentives to medical schools and other
health professions academic institutions to carry out a plan for edu-
cation on alcohol abuse within the context of geriatric health care.
3. the content and effectiveness of educational materials on alcohol use
among older persons be evaluated by HRSNNIA/NIAAA to iden-
tify gaps and highlight opportunities for material development.
4. Federal agencies responsible for training health care providers and
identifying personnel needs stemming from the aging of the popu-
  lation be attentive to alcohol issues.

57


   In the area of education (alcoholism service providers), we recommend
   that:
   1. alcoholism service providers be educated to the potential benefits
    of treatment at a late age.
   2. organizations of service providers, State alcohol authorities and
    voluntary groups such as the National Council on Alcoholism be
    asked to include this information in ongoing education and training
      activities.
  In the area of education (social service providers), we recommend that:
     1. social service providers, including home health aides, be made aware
    of the potentiai for alcohol problems among older clients and of
    methods of identification and referral:
  2. training for caregivers and advice for family members affected by
    alcohol abuse in older relatives be made readily available.
   In the area of education (public), we recommend that:
     1. Federal agencies, national membership and voluntary,~organizations,
    and associations, e.g., the American Association of Retired Persons,
    the National Cormcil on Alcoholism, the American Society on Aging,
    and the National Council on the Aged, be encouraged to develop
    and disseminate information about alcohol problems among older
      adults.
   2. public and private sector employers providing pre-retirement edu-
      cation include information about alcohol use.
`.
   In the area of service, we recommend that:
   1. third-party payment for detoxification and rehabilitation be modi-
    fied to reflect adequate length of time for recovery from alcohol abuse
    among older people.
    2. the relative benefits of treating older alcohol abusers in community
    vs. hospital-based alcoholism treatment programs and in elder-
    specific vs. mixed-age alcoholism treatment programs be explored.
    3. AoA fund demonstrations to develop broad-based community level
    programs to address alcohol problems among older people.
   4. community-based programs, e.g., area agencies, county and city
    health departments, and voluntary agencies, develop linkages with
    the alcohol services network to identify, refer, and treat the older
      alcoholic.
    5. existing State coalitions on health and aging expand their member-
    ship to include alcohol-related networks.
   6. the Veterans Administration include an alcohol use component in
    their delivery of preventive services, inchuiing alcoholism cormsel-
    ing when appropriate.
   In the area of research (epidemiology), we recommend that:
   1. cross-sectional and longitudinal studies, including those using
    indirect measures and qualitative methods, be expanded on patterns
    of drinking among older adults to determine quantity, frequency,
      and duration of alcohol intake.


2

3.


4.


5.

6.

I

available data sets such as the National Health Interview Survey,
the NIMH Epidemiologic Catchment Area Study, and the National
Health and Nutrition Survey(s) be mined more camfully to answer
questions about alcohol use patterns among older adults.
anal@s of drinking patterns with special attention to socioeconomic
groups, minority groups, and women be conducted.
in all epidemiol@c studies, special attention be paid to attrition rates
due to alcohol-related deaths.
research be conducted to determine the extent of lifetime versus late
onset problem drinking among the aging and to resolve the dis-
crepancy between early and late onset problem drinkers in the
general population as compared to clinical, e.g., hospital and out-
patient, populations.
research be conducted to e xamine the role of retirement, bereave-
ment, and changes in discretionary income on alcohol consump-
tion patterns. This includes examination of the reasons for the
observed reductions in alcohol consumption with age.
                                      L

In the area of research (physiology), we recommend that:

1.

2.
3.

4.


5.

6.

i

8.

present studies be expanded on the impact of alcohol consumption'
on cardiovascular disease, particularly hypertension and stroke in
the older population.
studies of alcohol metabolism in older people be replicated.
the interplay of the aging process and alcohol abuse on cognitive
functioning in older adults be examined, and further exploration of
the "premature aging hypothesis" be conducted,
the causal and intervening, role of alcohol use in injuries common
to older adults such as burns and fractures due to falls be examined.
both animal model and human studies be conducted to determine
patterns of sensitivity and the acquisition and loss of tolerance to
alcohol in older persons.
clinkal investigatory study the alcohol withdrawal syndrome in older
persons to discover whether it is more lengthy, severe, and requires
different treatment strategies specific to older adults.
the relationship between alcohol and nutrition in older populations
be explored in terms of appetite suppression/stimulation and inter-
ference with nutrient metabolism.
current researbh on osteoporosis be expanded to include the role
of alcohol.

In the area of research (other), we recommend that:
L tax policy research include an exploration of the effects of such
change on the alcohol consumption patterns of older people.
2. the role of alcohol in family violence and the behavior of violent
  older offenders be examined.

3. possible beneficial effects of small amounts of alcohol on eating
behavior, mood, and sleeping patterns, and social functioning
among older adults be further examined.

59


4. research be done to determine the role of alcohol in the risk of sui-
cide and victimization among older people.
5. research be conducted on the effect of alcohol on errors in presaip-
tion and over-the-counter medication use and medication/alcohol
interactions.

6. more reliable and valid meening instruments be developed to detect
alcohol problems in older populations.
7. NTA and NIAAA pay special attention to alcohol use among older
adults in their prevention research p&folios.
8. this research agenda be widely disseminated to potential funding
sources including Federal agencies and foundations and to the
research community.

DENTAL (ORAL) HEALTH WORKING.GROUP

      Chair: James D. Beck, PhD
Technical Manager: DENT DIR Frank Martin
    Reporter: SR DENT Scott Presson
Group Members: Ronald Ettinger, DDS
          P. Jean Frazier, PhD
         Mary Alice Gaston
          Helen C. Gift, PhD
          Neville Derek Gihnore, DMD, DrPH
          Marc W. Heft, DMD, PhD
        H. Asuman Kiyak, PhD
         James Y. Marshall
        Roseann Mulligan, DDS
          Linda C. Niessen, DMD
        Vincent C. Rogers, DDS
         Michele J. Saunders, DMD
        Ruth Siegler

Hongying Wang, DDS

The recommendations of the working group on oral (dental) health are
based on the following premises:
* oral health implies an oral status that is stable, relatively disease--free,
comfortable, and permits adequate function that includes mastication,
speech, and swallowing.
o older persons should have access to appropriate oral health education,
primary prevention, and oral health services.
o many oral diseases that afflict older adults are diseases of all ages and
many preventive regimens, especially community water fluoridation
are appropriate for older adults.


o while few conditions pose mortality risks, they may lead to pain phys-
ical dysfunction, and psychological anguish.
o many of the systemic diseases and the medications used in their
management have direct or indirect impact on oral health and func-
tioning. Because there is an age-related increase in systemic disease
and medication usage, older individuals may be at greater risk for
orofacial problems.
o in the provision of oral health services, it is recognized that compe-
tent older persons have the right to self-determination.
o where appropriate, specific guidelines will be developed to implement
the following recommendations.

In the area of education, we recommend that:
1. all health care providers should be educated in the relationship
between oral and general health including the contributions of each
health care provider in maintaining oral health and function.
2. educational programs for current and future oral health care
providers should improve their knowledge, attitudes, and behaviors
regarding primary preventive, treatment, and educational needs of
older adults that include culturally and ethnically sensitive aspects
of meeting these needs.
3. educational pmgrams should be available to develop competent edu-
cators and researchers in all areas pertinent to the achievement and
  maintenance of oral health in the older adult.
4. appropriate curriculum guidelines and accreditation standards
specific to meeting the oral health needs of older adults should be
developed and reflected in licensure, certification, and national board
examinations for all health disciplines.
5. older adults and their caregivers should be educated to enhance their
knowledge, attitudes, and behaviors regarding:
o the value of primary preventive methods to maintain oral health
  including commtity water fluoridation and other fluoride uses;
o the importance of regular professional oral health services;
o the uses of scientifically valid personal oral hygiene practices;
   and
  o ??oo????? associated with the uses of tobacco alcohol, and medi-
   ?????o??
6. accurate and appropriately designed educational materials and other
resources specific to the oral health needs of older adults should
be developed or adapted and disseminated through all relevant
agencies, services, and organizations.
In .the area of service, we recommend that:
1. indivi&ml oral health care providers, organized dentistry, Federal,
State, and local agencies, and other organizations should continue
appropriate preventive, restorative, and rehabilitative services with
emphasis on oral health promotion and primary prevention pro-
grams for older adults.

61


2. alternative methods for the delivery of primary preventive and restor-
ative oral health services should be developed to meet the oral needs
of older adults, especially the homebound, the institutionalized, and
the functionally dependent.

3. long-term care facilities should have an established oral health care
program that includes timely and appropriate diagnostic, primary
  preventive, and restorative services.
In the area of research, we recommend that:
1. more basic and applied research be conducted to clarify relationships
  between systemic conditions, medications, and orofacial conditions
  in older adults.
2. studies be done to elucidate and characterize oral changes associated
  with "normal aging" and assess their impact on oral function.
3. more health services research be conducted to develop, evaluate, and
  demonstrate methods of health care delivery to .improve the oral
  health of older adults.

4. studies be conducted on the prevalence, incidence, cohort differences
  and risk factors of canes (coronal, root, recurrent), periodontal dis-
  eases, soft tisstie lesions, chronic orofacial pain trauma, and salivary
  gland dysfunction including development of appropriate indicators.
5. studies be conducted to identify adults who are at high risk for orofa-
   cial diseases and methods to meet their needs.

6. studies be conducted to determine the relative efficacy and benefits
of primary preventive procedures for older adults.
7. studies be conducted on the knowledge, attitudes, and behaviors
  of older adults in relation to oral health status.
8. studies be conducted to determine the interaction among oral health
status, psychosocial function, nutrition, and general health.
In the area of policy, we recommend that:
1. all community water systems be fluoridated.
2. oral health services for older adults be an integral part of public and
private health benefits programs, including but not &ted to: Medi-
care Part B, Medicaid, employee retirement benefits, and other health
insurance programs.

3. special efforts in oral health promotion and service delivery be
directed to older adults who are currently underserved, such as
Native Americans, the homebound, Hispanics, and Blacks.
4. Federal guidelines for long-term care facilities should include:
o a dental examination within 30 days after admission and annu-
  ally thereafter;
o a program in oral primary prevention and health education for
  residents and staff;
o access to dental treatment when needed; and
  o oral health status information in residents' medical charts.
Reimbursement mechanisms should be developed to support these
activities.

62


5. access barriers to prevention and basic oral health services for older
adults, such as financing, transportation, and physical barriers be
removed.

6. appropriate Federal, State, and other agencies such as NCHS,
HCFA, NIA, and NIDR be encouraged to include an appropriate
oral health component, e.g., clinical and psychosocial variables, in
their existing data collection efforts, and make provision for appropri-
ate data analysis.
7. the VA be encouraged to establish one or more GRECC's focusing
on health promotion and disease prevention that include an oral
health component.
8.  in order to reduce the risks of oral lesions, National efforts continue
to discourage use of tobacco and alcohol.

PHYSICAL FlTNESS AND EXERCISE WORKING GROUP

     Chair: John Holloszy, MD
Technical Manager: Shirley Bagley
    Reporter: PHARM DIR Gayle Dolecek
Group Members: Neal Belles
            Richard Burnett
        Carl J. Caspersen, PhD
        Jean Coyle
         Janice Eldred
         SR SURG Jerome Fleg
        Andrew Goldberg .MD
        Stephen Gordon, PhD
         Raymond Harris, MD
           SCIENT DIR William Kachadorian
          David Lamb, PhD
           York Onnen
          Barbara Quaintance
         Kathleen Shay
          Richard Weindruch, PhD

The working group on physical fitness and exercise encourages the U.S.
Public Health Service to place a major emphasis on physical activity and
serve as a catalyst to encourage cooperation between institutions that can
implement the results of exercise research.
In the area of education, we recommend that:
1. educational components be developed that relate to the health
  benefits of physical activity that can be included as part of existing
  medical school curricula. Such components should include physio-
  logic effects and health benefits of physical activity.


   the development of components within residency and internship pro
   grams that relate to the health benefits of physical activity be
   encouraged. Special areas would include cardiology, pulmonary
   medicine, physical medicine, orthopedics, geriatrics, etc.
   3. continuing medical education programs on health benefits of physi-
   cal activity be promoted by such means as symposia at national and
   international professional meetings,. courses, etc.
  4. the development and use of physical activity assessment, presaip-
   tion, and follow-up protocols that offer guidelines to the health care
   provider for increasing physical activity patterns in a wide range of
   persons be encouraged.
  5. opportunities be developed for pre- and postdoctoral programs, and
   the available pool of expertise in the promotion of physical activity
   for the older adult be expanded.
   6. the development of courses dealing with health benefits of physical
   activity as it relates to aging for programs of exercise physiology,
   epidemiology, nursing, physical therapy, health education, physi-
    cal education, etc., be fostered.

7. physical activity in-service training programs be developed for nurs-
  ing home care' providers to offer safe physical activity to patients.
8. training be supported that fosters interdisciplinary collaboration in
  the promotion of physical activity in the older adult. Collaborators
  include psychologists, physical educators, cardiologists, physiologists,
  health educators, nutritionists, gerontologists, etc.
- In the area of service, we recommend that:

1. Federal, State, and local governments provide leadership and sup-
port to programs that will promote physical activity for older citizens.
2. leadership be provided in the promotion of physical activity as an
important component of a healthy life-style and that all agencies of
the Federal Government provide physical fitness programs for their
employees. I
3. the Federal Gov emment encourage local communities to identify and
develop focal points, such as senior centers or other concerned com-
munity resources, to coordinate physical activity services to older
citizens.

4. health care institutions, such as hospitals and nursing homes, pro-
vide encouragement, equipment, and facilities to enhance the phys-
ical activity of their staff and clients.
5. health care insurers, including Medicare, provide incentives to
appropriate clienti to increase their levels of physical activity.
6. designs for all multifamily housing incorporate facilities such as exer-
cise rooms or open spaces and gardens into their housing designs
to provide physical activity options. This should be a requirement
for Federally funded housing.
7. professional associations develop position statements regarding
appropriate physical activity for older persons and educational pro-
grams to reinforce those statements.

64


8. a.physical activity assessment be incorporated into regular physical
  examinations and routine medical visits.
9. local communities be encouraged to assess health-related compo
nents of physical fitness of older citizens to raise awareness of the
jrnportance of physical activity.

In the area of research, we recommend:
1. research to determine the effects of exercise, independent of other
lifestyle and behavioral factors, on degenerative processes including:
  o cardiovascular disease such as atherosclerosis;
  o endocrine metabolic diseases such as adult-onset diabetes and
   dyslipoproteinemia;

o musculoskeletal diseases such as osteoporosis and osteoarthritis;
o neurobehavioral diseases such as depression; and
o immune. dysfunction such as susceptibility to infection.
2. research at molecular, cellular, organ, and whole body levels to
investigate the mechanisms by which exercise exerts its biological
  effects.
3. multidisciplinary research focusing on the effects of exercise on ftmc-
tional capacity and disease in diverse populations.
4. research to determine the role of physical exercise in the maintenance
of functional capacity including muscular strength and endurance,
cardiorespiratory function, agility, coordination, and flexibility.
5. reseaxrh to determine the role of regular physical activity in the main-
tenance of mental health, well-being, and psychosocial functioning.
6. research to develop guidelines for screening and baseline medical
evaluations of healthy people, as well as people who are disabled
or have specific medical problems, in order to formulate an individu-
alized exercise program.
7. research to determine the appropriate types and levels of physical
activity in terms of intensity, frequency, and duration necessary to
safely' achieve the potential benefits in health and functional capac-
ity across a wide age span and range of abilities.
8. research to determine the interaction between physical activity and
  other health-related behavior.
9.  research to assess the modifiable behavioral and environmental fac-
tors that encourage individuals to adopt and maintain physical
activity patterns.
10. research to examin e whether there are gender, ethnic, and/or
socioeconomic differences in participation and responses to physi-
calactivity.
11. research focusing on the effects of exercise on functional capacity
and degenerative disease prevention in women, especially in the
peri- and postmenopausal period.

32. research to establish reliable and valid measures of physical activity
for epidemiologic, behavioral, and evaluation research.

65


In the area of policy, we recommend that:

  1.





2 *



  3.



  4.


  5:





  6.



  7.






  8.



  9.

apppriat~ physical activity be encouraged for individuals of all ages
to maintain functional capacity and protect against the development
of conditions such as obesity and disease processes such as coro-
nary heart disease and adult-onset diabetes.
regular physical activity, a beneficial behavior, begin at childhood
and continue throughout life. However, such activity may be benefi-
cial to individuals beginning at any age.
physical activity presaiption be recommended in the management
and treatment of selected chronic diseases, many of which are com-
mon in older adults.
specific physical activity recommendations be individualized accord-
ing to age, health status, and current level of physical conditioning.
the development of physical facilities and behavioral programs that
lead to increased participation at low levels of physical activity and
progression toward more rigorous exercise and activity be en-
couraged.
institutional environments, e.g., schools, medical settings, and work-
places, encourage exercise and physical activity by providing time,
facilities, and supervised programs.
the Federal Government and private insurers provide financial and
other incentives for State and local governments, health care
providers, corporations, and other private organizations to make
available health screening, physical facilities (including fitness trails
and bike paths), and programs to promote physical activity.
the Federal Government promote the expansion and development
of the parks and recreation systems to provide places for physical
activity participation.

the Federal Government promote more communications media
attention, particularly broadcast media attention, to the promotion
of regular, physical activity in the aging population.
     _-                  _ . .     . . a      .

10. the Federal Government promote the dissemination ot gerontolog-
ical research and training information on the beneficial effects of
physical activity and exercise to health professionals.

66


INJURY PREVENTION WORKING GROUP

     Chair: Wilson C. Hayes, PhD
Technical Manager: SR SURG Richard Sattin
    Reporter: SR PHARM Wayne Turner
Group Members: Ingrid Azvedo
        George Everyingham
        Carol Hague, PhD
           Steve Luchter

L. Joseph Melton III, MD
Henry Montes
`Jana Mossey, PhD
Michael Nevitt, PhD
Marcia Ory, PhD
Wayne A. Ray, PhD
Linda Sal&man, PhD
Richard H. Seiden, PhD
Suzanne K. Steinmetz, PhD
Patricia F. Waller, PhD

Members of the Injury Prevention Working Group understand that:

intentional and unintentional injuries have serio-us consequences for
older persons, their families, and the health care system at large
efforts in injury control must include attention to epidemiology,
prevention, biomechanics, acute care, and rehabilitation.
while there are many commonalities, there are important differences
in the extent, causes, and consequences of different injuries occur-
ring in aging persons. Major injury categories important to older per-
sons include falls and fractures; motor vehicular and pedestrian inju-
ries; fires, homicides, assaults, abuse, and suicides.
while input from many agencies is essential, the Centers for Disease
Control, the National Institute on Aging andthe Administration on
Aging will coordinate efforts in injury prevention and control for older
perso*.

Our recommendations in injury prevention and control are based on the
following assU?npfions:
o injury risk must be minimized without compromising quality of life.
o There is great demographic, cultural, and functional variability among
  older persons.
  o Health care professionals should include older persons and their fami-
  lies in decision-making about injury prevention.
o Older persons with functional limitations benefit from more support-
  ive environments than are found in a world designed for younger
  adults.

o Improvements in safety for older persons will improve the safety for
all.

67


o Research, education, service, and policy in injury prevention require
multidisciplinary efforts with participation from experts in geron-
tology, geriatrics, and specific injuries.
In the area of education, we recommend that:
1. content in injury prevention for the older person be a required com-
ponent of the academic core curricuhrm of initial and continuing
education of health care professionals and other service providers.
Curriculum areas should include, at the least, the significance of
injury as a public health problem, risk factors for injury, and
presumptive and demonstrated injury control strategies.
2. professionals providing primary care be trained in the clinical assess-
ment of risk for injury as well as the development and implemen-
  tation of appropriate interventions.
3. professional disciplines, such as architects, engineers, and city plan-
ners, receive, as part of their required training, information on the
capabilities and limitations of older persons so that these factors are
incorporated into designs and standards.   ..
4. the general population, especially children and youth, be educa-
tion to understand the capabilities and limitations of older persons
and their place as valued members of the community. For exam-
ple, driver education classes and handbooks should provide infor-
mation on the decreased sensorirnotor capabilities of older drivers
and the consequent need to share the road in an understanding
manner. Moreover, in our youth-oriented culture, we need to rein-
stall the traditional values of respect for the older citizen, not only
as a worthwhile end in itself, but as a means of both reducing the
risk of suicide, homicide, and, assault among the elderly and ena-
bling younger people to better accept their own aging.
5. older persons be provided with information concerning risk factors
for injury, ways to modify them, and sources of assistance in risk
  reduction.
6. educational activities be aggressive and comprehensive and utilize
.  existing programs for older individuals, television, radio, and other
  media, as well as the health care delivery system.
In the area of service, we recommend that:
1. organizations providing services to older persons involve and
ensure, through an identified advocate, the input of older persons
  into decisions which affect them.
2. coordination at the Federal, State, and local level in order to ensure
efficient and effective development and delivery of services to the
  elderly.
In the area of research, we recommend that:
1. new and existing data systems collect information in a standardized
way to assess the prevalence, incidence, course, and costs of both
  intentional and unintended injuries.
2. data linkages be established between medical records and other
information related to injury prevention in order to facilitate the


identification of risk factors and the development of intervention
strategies.
3. further analytic studies incorporating standardized measurements
and definitions be conducted to determine the factors that alter the
r@k of both intentional and unintentional injury.
4. the rigorous evaluation of risk assessment and prevention strategies
to support their dissemination and reimbursement. There are many
promising ideas, technologies, and services of unknown efficacy and
cost effectiveness, including risk assessment. and screen devices.
5. development of specific strategies to reduce injuries in the elderly,
such as occupant restraint systems for the frail and automatic water
temperature controls on showers and faucets.
6. increased research to identify the etiology of fall injuries including
the determinants of age-related reductions in bone strength (osteopo-
rosis), the pathophysiology of falls, and, more importantly, the
biomechanical factors that determine injury given that a fall has
  occurred.
7. studies should be initiated to assess the effect of current strategies
for the diagnosis and treatment of injured older people.
8. evaluation of the effect of injury on the psychological functioning
and quality of life of older persons (including injury victims, sur-
vivors, and significant others).
In the area of policy, we recommend that:
1. agencies that set and enforce safety standards affecting the environ-
ments of older persons must take into account the capabilities of older
  person-s-
2. new drugs be evahxued for efficacy in the elderly and that monitor-
ing be done for specific adverse effects such as falls.
3. all hospital dixharge and emergency room records require E-coding
and that trauma registries be redesigned to be population-based and
include a representation of all injury types.
4. the health care system be responsive to the needs of older persons
. through the following:
6 modifying reimbursement to support preventive clinical services.
o develop protocols for assessments, evaluations, and interventions.
o include rehabilitation professionals in primary health care teams.


MEDICATION WORKING GROUP

     Chair: Hugh H. Tilson, MD, DrPH
Technical Manager: SR PHARM Steven R. Moore
   Reporter: PHARM DIR Frederick J. Abramek
Group Members: WilIiam B. Abrams, MD
         Donald R. Bennett, MD, PhD
        Barry &sack, MD
       Mary Ann Danello,. PhD
         Pearl S. German, PhD
        PHARM DIR Stephen C. Croft
         Daniel A. Hussar, PhD
         Judith K. Jones, MD, PhD
         Barbara E. Naegele
         Nancy Ohs

Frank P. Ollivierre
David G. SchuIke ,,
Dorothy L. Smith, PharmD
Thomas E. Stevens
William N. Tindall, PhD

The panel recognizes that drug therapy is an essential component of
preventive, as well as curative, strategies. It is the least expensive and most
cost effective component of health care costs.
Optimal use of medication in the elderly requires certain reconceptual-
izations: the value of incremental improvement in functional status as an
outcome measure and the therapeutic objective of maintaining the highest
level of functioning at any given level of illness.
A new paradigm is needed which recognizes the patient as a partner
with the caregiver in the use of medications.
In the area of education, we recommend that:
1. health professional schools create an awareness of resources avail-
`able for the presaiber, e.g., current geriatric text books in concert
  with PDR, USPDI, AMA-DE, and AI-IFS, to improve prescribing.
2. identifiable sites for prescribing information be available in all prac-
  tice settings.

3. a different role for the pharmacist in geriatric medication-an
expanded partnership with physicians as essential members of the
care-giving team.

4. patients be educated to keep their own medication profile including
over-the-couner drugs.
5. programs are needed for the training of family, community, and other
home care providers in medication management.
6. prescribers, dkpenms, and monitors of medication must understand
age-related physiologic metabolic changes. Most important is decline
in renal (kidney) function-the most frequently observed age-related

70


change which can influence the use and safety of drugs that are
excreted in the urine.

7. the gerontological community should be encouraged to become
actively involved in the drug development process.
8. as a way of improving drug use in the elderly, all professional schools
should include in the curriculum for all students' courses in the fol-
lowing areas:
o nonjudgmental patient counseling skills which recognize
  individual and cultural differerices, and which recognize inher-
  ent ethnic differences, particularly in the use of nontraditional ther-
  apies;
o interdisciplinary communication skills; and
o basic concepts of epidemiology, pharmacology, and therapeutics,
  especially as relates to efficacy and risk of medications in the
  elderly.

9. a cadre of health professionals skilled in geriatric epidemiology and
basic and clinical pharmacology must be trained.
In the area of service, we recommended that:
1. there be sustained, enhanced, and focused efforts to insure that older
Americans have the information and tools they need (and have the
right to expect) to be responsible partners in the medication enter-
prise:
  o the most effective tool for this is direct effective verbal commun.i-
  cation, consultation and education regarding benefits, risks, and
  management of medication.
o written information must be understood as a complement and not
  a substitute for dialogue.

2. third-party payors be encouraged to reimburse pharmacy services
independent of the act of dispensing or the cost of the product. This
includes such services as patient or provider consultation and with-
holding a prescription pending consultation with physicians.
3. alternative mechanisms of access to medicines for the geographically
isolated and mobility impaired elderly. Study is needed of the poten-
. tial limitations of such systems and the need for supported services,
e.g., home health aids to encourage proper medication use and
monitoring for side effects.

4. access to medicines and pharmaceutical services must be included
as a basic part of broad health care programs for the elderly.
5. third-party reimbursement mechanisms must encourage (pay for)
access to medical care appropriate for unique situations of complex
medication regimens and isolated patients.
In the area of research, we recommend:
1. research regarding the most cost-effective means of educating the
consumer or the home caregiver regarding proper use of and
monitoring for side effects.

2. researdl regarding standardization of the medication profile and drug
interaction information in the computer software that supports medi-
cation profiling.

7-l


3. research in the cost-effectiveness of medication profiling in the elderly.
4. research and evaluation regarding current and promising tools to
improve the older Americans understanding and effective use of
medications (compliance), e.g., .medication diaries, colorcoding spe
cial packaging, large print and braille, pictographs, coordinated and
consolidated dose forms, innovative delivery systems, easy-to-open
packages, and messages adopted to social and cultural differences.
5. in the area of pharmacoepidemiological (postmarketing) research, we
recommend:

o post approval epidemiologicaJ research on elderly populations
focusing on large automated linked data bases to study efficacy,
  risk, compliance, cost and new users rather than inefficient meth-
  ods of ad hoc postmarketing Grrveillance, which require signifi-
  cant professional time;
o current potential data sets be explored, particularly those relating
  to the elderly; e;g., Medicare, AARP, VA, and TRIMIS; the VAMP
  (England) automated medical practice model be examined as a pos-
   sible model for use in the U.S.
o development of better drug utilization denominators to understand
  risks from adverse reaction signalling systems; FDA should pub
  lish their data for general use;
o targeted studies on nonlethal side effects to enhance patient accept-
  ance and compliance and prevent secondary effects, e.g., dizi-
  I&S, sexual dysfunction, nausea, incontinence, etc.; and
o in epidemiological research, greater clarity in definitions and meas-
  urement of outcomes and exposure.
In the area of policy, we recommend that:
1. the standard of practice for pharmacists which includes use of up-
to-date patient profiles and their application at the time of dispens-
ing be endorsed.

2. consideration of medication provisions is vital in the Catastrophic
Health Coverage Act (Medicare) (H.R. 2470) as follows:
o Medicare should cover pharmaceutical benefits (prescribed items)
  . including prescription and over-the-counter medication, biologi-
  cals, devices and appliances on an outpatient basis.
o State windfalls from Medicare assumption of coverage should be
  required to be redirected to the health benefits, including drug
  benefits, of the non-Medicaid poor and near poor elderly.
o States should be permitted Federal matching funds for Medicaid
  pmgrams pxtwidjng medication services to elderly persons at 200%
  of poverty.
o so-called cost saving mechanisms in Medicare and Medicaid which
  control numbers or types of prescriptions or require co-payment
  for the poor and near poor for medicines are potentially hazardous
  and ineffective and should be abandoned.
o correction of problems detected by drug utilization programs
should emphasize education of professionals and not sanctions.
  Such efforts should be based upon current a-edible scientific

72


indicators of medical practice and should focus upon direct
  professional and collegial contact.
o a new national mechanism is needed constituted by represen-
  tatives of the gerontologic medication community for oversee-
ing and evaluating this effort.    ~
3. pharmacological tools currently available need broader application
to attack the major causes of illness, disability, and preventable death
in the older American. The Federal Government should vigorously
pursue and support research for the use of medications in National
preventioi~ strategies based upon the considerable success in hyper-
tension. Fruitful current areas include: arteriosclerotic cardiovascu-
lar disease, congestive heart failure, diabetic complications, and
osteoporosis.
o there is also promise in the longer term:
  -protection `of renal function;
   -brain function and dementias;
  -protection of connective tissues;      ,C
  -preservation of immune function; and
  -benign prostate hypertrophy.
o priority areas for treatment should also be directed to:
  -chronic obstructive pulmonary disease (COPD);
  -circulatory disturbances; and
  -cognition restoration.
4. official governmental health agencies explore and expose fraud and
quackery.

5. vitamins, certain food stuffs, and nutritional supplements which
arebeingusedasdnrgsbereviewedbyappropriateregulatoryagen-
ties; regulatory changes be made.
6. new drug labeling include, where appropriate, directions for use
in the elderly or other subgroups at risk. If no data are available,
the labeling should state that data are not available.
7. for existing products, label statements regarding use in the elderly
be added incrementally as the label is revised. A schedule for such
* reviews needs to be developed.
8. the use of official drug labeling as a patient teaching tool should
be enhanced.

9. the FDA proceed with the final development and implementation
of proposed guidelines for development of drugs for use in the
elderly, especially elderly subgroups at risk; in particular, persons
should not be excluded from clinical trials on the basis of age alone
(ASCFP Workshop, December, 1986).

10. the Federal Government be a more active partner in the drug
development process, both in establishing the basic science form-
dation and in other stages of evaluating drugs of importance for
the elderly.

11. the Federal Government should restore the extramural programs
of core support for population pharmacoepidemiologic resources.

73


I.2 emphasis should be placed on the development of cost effective
strategies for incremental improvement of health status and main-
tenance of highest possible function through the use of medications
for symptomatic. relief of pain, sleeplessness, anxiety, depression,
and problems of the preterminal state.
13. public exploration is needed of current policy, e.g., the orphan drug
act, to stimulate the development of drugs, especially those without
adequate profit incentive or with excessive liability concerns, e.g.,
non-patentable compounds, drugs off .patent, vaccines, and orphan
indication which could address unresolved problems in the elderly.
14. Post approval studies focusing on the aging population at risk.

MENTAL HEALTH WORKING GROLJP

       Chair: MED DIR Gene D. Cohen
Technical Manager: Mary Harper, PhD
    Reporter: HSO Vivian Chen
Group Members: Michael Bernstein
        Nathan Billig, MD
           Steven W. Brummel
        J. Timothy Fagan
          Jean Cutler Fox, PhD
         Mary C. Howell, MD, PhD
          Lorraine l&etch. PhD
        Gretchen Lagodna, PhD
           Adelaide Luber
          Peter Rabins, MD
          Paul S. Rhodes, MD
         Marymae Seward
          Gwen Solon, MD

Misperceptions and a lack of information about mental health problems
in later life are common among the public and health care practitioners
alike. Many clinically significant changes are dismissed as representing
inevitable mental or behavioral manifestations of normal aging. The early
recognition of these problems, however, can often prevent excess patient
disability, promote a higher level of health and social functioning, and
reduce family stress among close caregiving relatives.

There is gmwing recognition of risk factors that have the potential of
influencing the onset, clinical course, and response to treatment of mental
health problems in elderly individuals. Such risk factors include: major
losses, especially of a sudden or unexpected nature, as with loss of physi-
cal health, loss of a loved one, or loss of self-esteem; medication side

74


effects; social isolation; relocation trauma; and forced transitions, e.g.,
involuntary retirement.
The adverse influence of mental health problems on the course of physi-
cal illness in older adults is significantly underappreciated; similarly, the
potential contribution of mental health interventions toward promoting
more rapid recovery from major medical problems and surgical procedures
in later life is greatly overlooked.
The capacity of an individual with mental or behavioral problems to
respond to mental health interventions knows no end point in the life cycle.
Even chronic mental disorders in later life can respond to clinical inter-
ventions and rehabilitation strategies aimed at preventing excess disabil-
ity in affected individuals.
Older persons with mental health, alcohol, and other drug problems typi-
cally have physical health problems as well, bringing them into contact
with multiple services and a range of health care providers. As a result,
strategies to promote mental health and to prevent the exacerbation of men-
tal disorder in an older. person must take into consideration multidiscipli-
nary and service coordination issues.
The consideration of mentally retarded older adults'should be included
in deliberations on research, training, service, and policy recommenda-
tions pertaining to mental health promotion and the prevention of mental
illness in later life.
The promotion of mental health among older adults occurs in an environ-
ment which includes, and is influenced by, family members, friends, and
various natural support groups.
In the area of education, we recommend that:
  1. in order to assure the existence of a cadre of mental health teachers
  to effectively transmit state-of-the-art knowledge in clinical and
   research training and education for the range of health cam providers
   who can contribute to promoting mental health and preventing men-
   tal illness in elderly persons, a national program, multidisciplinary
   in focus, should be assured and adequately funded.
   The diversity of health care providers who encounter older adults
   with (or at risk for) mental health problems, together with the diver-
  . sity of service settings utilized by these elderly individuals, requires
   a multifocal training program. Given this:
  2. mental health training models should be researched and developed,
    focused on:
   o mental health professionals in general training;
   o continuing education for mental health professionals who have
    completed their formal training
   o primary health care providers;
   o paraprofessionals;
   o in-service training areas, e.g., senior citizen centers, older adult
    nutrition sites, senior housing projects, nursing homes, and board
     and care homes;
   o service systems serving the elderly, e.g., community health and
    mental health centers, area agencies on aging, home health care
    agencies, etc.;
                             75



o informal support system care providers, including older adults
  themselves and families;
o volunteers; and
o special training areas, such as for minorities (Asian Americans,
  blacks, Hisljanics, and Native Americans), elderly individuals, and
  other special older population groups (mentally retarded, develop
  mentally and physically disabled), team approaches to the provi-
  sion of care, etc.
3. educational materials and dissemination of information efforts should
be further developed to (a) address stigma issues relating to mental
health care of older adults and (b) provide information aiding in the
-recognition of mental health problems and the awareness of mental
health interventions relevant to. older patients. Such educational
materials should focus on a diversity of target groups including:
o older persons and their families;
o the range of. health care providers;
o other service providers who come into contact with, and assume
  direct responsibility for, mentally ill older adults, including those
  serving as gatekeepers and those involved in the disposition of
  care, e.g., clergy, guardians;
o the diversity of individuals and service settings utilized by older
   adults;
   o State and local level health, mental health, and aging departments
  and other specialized assistance programs, e.g., State pharmaceu-
  tical assistance programs;

o foundations, corporations, and other grant makers.
4. a directory should be developed, compiling a list of higher educa-
tion programs with an emphasis on training and research opportu-
nities in mental health and aging. Such a directory should be devel-
oped by a multidisciplinary group such as the Association for
Gerontology in Higher Education.

In the area of service, we recommend that:
1. there be continued development of service systems for treatmentlre-
habilitation programs for mentally ill older adults, aimed at prevent-
ing unnecessary institutionalization of the elderly.
2. there be an expansion of service systems providing interventions to
address the overlooked opportunities to promote mental health and
prevent excess disability among nursing home residents and other
older adults living in various institutional settings.
3. there should be continued development of service systems focused
on self-help and the use of older persons as mental health service
providers, e.g,, through the use of an older volunteer program receiv-
ing funding and technical assistance through the collaboration of
NIMH; ACTION, and HRSA.
4. given the access problems experienced by the frail elderly with mental
health problems, mobile mental health outreach efforts, including
assessment and treatment, and other mental health outreach serv-
ices should be fostered at the local level.

76


5. since increased risk of mental health symptoms is associated with
various problems, disorders, and treatments in the elderly, and
prevenuon/intervention strategies can reduce the frequency of
adverse mental health consequences (analogous to the impact of treat-
ing hypertension to prevent stroke), practitioners should pay partic-
ular attention to those high-risk situations which include:
  o untreated depression associated with increased risk of suicide
  (greatest frequency in the elderly);
o medication misuse and unintended side effects (drug use and
  polypharmacy are greatest in the elderly) causing mental health
  symptoms (high frequency of depression, dementia, and
   delirium);
0 Alzheimer's disease leading to high frequency (25+ percent) of
  depression in close caregiving family members;
o compounding mental health problems, e.g., delirium, depression,
  or delusion, causmg excess disability in dementia;
   o hearing loss in later life (approximately 30 percent of older adults)
  associated with increased onset of delusional'ideation (sensory
  deprivation phenomenon) and depression consequent to commu-
   nication difficulties;
6. in light of the frequent use by the elderly of multiple drugs pmsa&ed
by multiple health cam providers, services must be developed to pro-
tect against potential mental health morbidity, e.g., drug-induced
dementia and altered mental status due to unanticipated drug inter-
actions/adverse reactions (active coordination among the prescribers
and pharmacists is needed in administering patient drug regimens);
7. communities need to assure the coordination of formal linkages
among medical, social service, and family service agencies with men-
tal health practitioners and the mental health service system.
In the area of research, we recommend that:
2. at the national level, research support should be strengthened for
studies aimed at identifying risk factors which can influence the (a)
onset, (b) clinical course, and (c) response to treatment of mental dis-
orders (especially delirium, depression, dementia, paraphrenia and
anxiety) in older adults.

2. further studies should be carried out on how mental problems
influence the onset, clinical course, and response to treatment for
general health and medical disorders.
3. further studies should be conducted on the potential for, and fre-
quency of, mental health symptomatology resulting from side effects
of medications (over-the-counter and prescription) used for the tmat-
ment of general health and medical disorders; similar studies should
be conducted on psychotropic medications relevant to the onset of
somatic syniptornatology.

4. further studies on suicide (most fnquent in the elderly) should be
conducted with the goal of advancing our understanding of risk fac-
tors and the development of strategies for its prevention.

77


5. further studies should be conducted to identify strategies that foster
psitke adaptation to kiter life stre.?des; coping strategies that mdd
be developed in earlier adulthood in anticipation of such possible
  stresses should also be further researched.
6. further studies should be conducted to determine mental heakh pro
motion strategies and risk factors influencing the onset of mena
illness in mentally retarded older adults.
7. further studies should be undertaken to improve our ability to
achieve early and accurate diagnosis of mental health problems, with
attention to the development of necessary diagnostic tools, to fast@
early intervention and more rapid return to higher levels of func-
tioning.
8. further studies should attempt to establish the optimal use of
behavioral, psychosocial, and somatic interventions in prevention
and mental health promotion approaches.
9. further studies should be conducted which focus on the range of
existing services (home-based, community-based, and institution-
based) utilized by older adults, to establish efficacious and costeffec-
tive model approaches for addressing the mental health needs of
elderly individuals and their families in those service settings that
they more frequently utilize. Such studies should include attention
to preventing unnecessary institutionalization.
10. studies should be expanded on mental health promotion efforts for
special aging subgroups, such as minority and rural elderly, older
  widows, those over 35, etc. Research should focus on intergenera-
tional approaches to mental health enhancement in later life.
11. further studies should be conducted to determine when and for
which groups of older adults mental health services should be age
homogeneous or age heterogeneous in design; similarly, studies
should be conducted to improve our understanding of the impact
on the mental health of older adults living in, or being treated in,
age-homogeneous and age-heterogeneous settings.
12. fmthhr studies should explore effecbve models of using older volun-
teers in mental health promotion efforts focused on elderly in-
  dividuals.
13. further studies should focus on alternative residential settings (other
than home and nursing home), with attention to promoting men-
tal health and preventing excess mental disability in the elderly.
In the area of policy, we recommend that:
I. treatment, diagnosis, and care of mental disorders should be reim-
bursed by all insurance providers at comparable levels to general
medical disorders in order to assure adequate access to mentat health
sewices by ol& patients and their families, in order to prevent men-
  tal clisabsty.
2. to promote mental health and encourage maximum independence,
the provision and reimbursement of mental health services in
specific community setthgs, e.g., housing pmgrams, health centers,
nutrition settings, and outreach to in-home family providers, should
  be mandated.             70


3. since homebound persons at risk for mental health problems have
limited access to mental health diagnostic and treatment services
by mental health professionals and primary care physicians, third-
party payers (public and private sector) should be encouraged to
remove the financial disincentives to mental health home visits to
the. elderly aimed at preventing excess disability.
4. nursing homes should be mandated at legislative and regulatory
levels as sites of mental health services and should be evaluated
for the quality of their services designed to promote mental health
and prevent excess disability.

5. State licensing agencies should develop policies that promote the
role of the nursing home medical director in preventing excess men-
tal disability in nursing home residents.
6. all Federal, State, and local public agencies that serve older persons
should develop policies relevant to the promotion and coordina-
tion of mental health-such should be reflected in the development
of national, State, and local plans.

7. State mental health agencies should be mandated to specifically tar-
get mental health services for the elderly.
8. there should be a legislative commitment to protect the mental
health of the spouses, family, and other lay caregivers of the elderly.
Specific funding for mental health care for caregivers could be incor-
porated into the upcoming rural health bill, long-term care bills,
and/or catastrophic health benefits and/or existing Medicaid pro-
9. xiarty coverage (Medicare and private insurance) should be
available for hearing aids and other assistive devices to prevent men-
tal health morbidity.

10. reimbursement under the PEYRUG should have an allowance for
psychosoci%l care in institutional and community settings.
11. drug utilization review to prevent psychotropic drug misuse among
the elderly should be required in all Federal or State programs that
provide access to pharmaceuticals for the elderly.
12. the, Food and Drug Administration should require inclusion of
elderly subjects during new psychotropic drug trials to assure that
risk potential will be understood in medication management of older
patients. l%stmarketing surveillance of such drugs should similarly
include a focus on older patients.

79


NUTRITION WORKING GROUP

     Chair: Johanna Dwyer, ScD
Technical Manager: Ann Sorenson, PhD
    Reporter: PHARM DIR Frank J. Nice
Group Members: Jeffrey B. Blur&erg, PhD
        Nancy Chapman
          Ronni Chemoff, PhD
         Wilda Ferguson
         Patricia Goode, MD
          Judith Ha&i-i&, PhD
          Clinton Hess

Norge W. Jerome, PhD
Shiriki Kumanyika, PhD
Marylen Mann
Walter Mertz, MD
Jo AM Pegues

Members of the working group on nutrition stated that the overriding
goals basic to their recommendations are:
1. improved quality of life for older Americans and the promotion of
  continued autonomy; not cost containment.
2. good nutritional status is essential for a high quality of life, and food
  contributes to the quality of life through psychological and social,
  as well as physical, mechanisms.

In addition, the following assumptions are basic to their recommenda-
tions:

1. older people vary greatly in their social, economic, and life-style sit-
uations; functional capacity; and physical conditions.
2. nutrition policy should be crafted from a multi&plinary framework.
3. a critical shortage of knowledgeable personnel in the areas of nutri-
tion education, research, and service now- exists (see "Health Per-
*  sonnel for the 1990's").

4. the research base for nutrition of older Americans is evolving there-
fore, specific recommendations must be periodically updated.
In the area of education, we recommend that:
1. in all aspects of training for dieticians and other health care profes-
sionals (e.g., physicians, nurses, and pharmacists) and para-pro-
fessionals (e.g., nursing assistants), basics of geriatric nutrition should
be require+ in core curriculum, in-service training, and continuing
  education.

2. Federal agencies (e.g., NIA, USDA, and FDA), professional societies
(e.g., ADA, SNR, AIN, and ASCN), and private health organiza-
tions (e.g., the American Heart Association and the American Dia-
betes Association) should develop new or adapt existing health pro
motion nutrition messages to the special concerns of the elderly,


e.g., multiple use of drugs, low energy intakes, and existing chronic
  diseases. These groups should coordinate efforts to assure wide dis-
semination of nutrition education materials and messages to older
  persOIlS.
3. Federal agencies supporting nutrition research should provide health
  care professionals with criteria for the evaluation of diets of older
adults and information on efficacy and safety of commonly used
nutrient supplements for use in counseling on their proper use as
a supplement to, but not as a replacement for, adequate diet.
4. all DHHS agencies that have responsibilities for provision of serv-
ices for older persons must provide ongoing formal geriatric nutri-
tion training for staff with nutrition responsibilities in their service
  networks.
5. Health promotion messages from the public and private sectors
should utilize advanced communication techniques:
  o recognizing different life-styles;
  o adapting to different sensory capacities;   c
  * adjusting to different cultural experiences; aud
  o recognizing different learning styles.
6. Data bases should be developed by the Public Health Service for
use by pharmacists and dietitians in counseling older persons on
  drug-nutrient interactions.
7. Primary and secondary school districts can have a positive influence
on health status of parents and grandparents of students by provid-
ing nutritional information to students, promoting a better under-
standing of the relationship of good nutrition to health status in old
  age-
In the area of service, we recommend that:
1. assessment be done at admission or enrollment in all institutional
or community-based health services for older adults, e.g., acute and
long-term care inpatient services, hospital-based outpatient services,
alcohol and drug treatment programs, community health services,
and home delivered meals programs.
2. nutrition counseling by a credentialed nutrition professionallregis-
tered dietician be a part of all institutional or community-based pro-
grams providing health services to older adults.
3. hospital discharge planners assess the need for in-home nutrition
servkes for patients and refer patients to the appropriate area agen-
cies on aging to link older persons with services in the community.
4. in providing outpatient nutrition services to older adults, program
  models should minimke the burden placed on patients, e.g.,
encourage health professionals to coordinate services and function
  as patient advocates.
5. any evaluation of institutional or community-based nutrition serv-
ices providing meals or nutritional supplements for older adults
  should include an assessment of the various nutrition-related charac-
teristics against criteria such as the RDA, dietary guidelines, ther-
apeutic considerations, and cost and food preferences.


6. nutritional data bases that include dietary or nutrition data on older
adults, e.g., NHANES, NHIS, and the Nationwide Food Consump
tion Survey, should be linked with data bases that have outcome
variables, e.g., the National Death Index and the National Hospital
Discharge Survey.
7. nation4 nutrition data collection for older adults, i.e., NHANES,
USDA, and the Nationwide Food Consumption Survey, should be
based on samples sufficiently large and representative to support
analysis within age-sex-income-race/ethnic categories.
In the area of research, we recommend that:
1. funding agencies, e.g., NIH and USDA, establish permanent study
sections composed of experts in aging and nutrition.
2. Federal agencies provide adequate, additional funds to support the
research efforts described below:
o definition of nutrient and energy requirements of older adults,
  now extrapolated from younger age groups, and establishment
  of recommended dietary allowances;
  o studies on the interactions between nutritional status and activi-
  ties of daily living and other aspects of life-style and behavior;
o research on the effects of nutrition on age-related impairment of
  organ system functions, e.g., cardiovascular, gastrointestinal/oral
  cavity, immune, musculoskeletal, nervous, and other systems;
o studies on the efficacy and cost-effectiveness of dietary assess-
  ments and interventions for reducing the risk of age-associated
  diseases among populations over 65 years of age;
  o research on interactions among nutrients and between nutrients
  and drugs in older adults;
o development of age-specific methods to assess the nutrient, nutri-
  tional status, and body composition of older adults;
o studies dire&d toward comprehensive dietary recommendations
  relevant to common morbidity patterns among older adults.
In the area of @icy, we recommend that:
1. aedentialed nutritionists/registered dietitians be employed as staff
at all levels of the Federal and State Government in all agencies
involved in policy, planning, administration, and evaluation of aging
programs. Examples of agencies at the Federal level within DHHS
include NE-I's Nursing Institute, other NIH Institutes, HRSA, AOA,
HCFA, CDC, NCHS, and FDA. Other relevant agencies include both
the Federal and State offices of the VA, and AID, USDA, and DOD.
2. State and local agencies on aging use the expertise of credentialed
nutritionists/registered dietitians and encourage other appropriate
agencies to use such expertise.
3. Federal, State, and local legislators and agency administrators give
high priority to nutrition services, education, and research on the
aging when they allocate FTE's and target both existing funds and
  future increases.


4. HCFA require that staffing in long-term care and skilled nursing
facilities include credentialed nutritionists/registered dietitians.
5. third-party payers (Federal and private insurance entities) pay for
nutrition counseling services provided by credentialed nutritionists/
registered dietitians for older persons at nutritional risk.
6. State and Federal agencies encourage development and implemen-
tation of innovative public-private sector models for health promo-
tion and education including nutrition for older adults.
7. successful public-private sector models for nutrition, health promo-
tion, and education for older adults, e.g., Healthy Older People, Age
well, and OASIS (Older Adult Service and Information System),
be widely disseminated by Federal and State agencies.
8. by 1990, an NIH Consensus Conference be held and information
disseminated on dietary recommendations for older adults, both well
and ill.

9. funding be provided from third parties and other sources, e.g., Medi-
care, Medicaid, OAA,. and private insurance, for outpatient and in-
home nutrition and other services that permit older Americans who
are iIl to remain in their own homes with an optimal quality of life
and function.

10. existing guidelines for categorical funding of nutrition services for
older adults should be evaluated to determine if they permit suffi-
cient feasibility for overcoming speci6c situational barriers and accom-
modating preferences of individuals and cultural subgroups.
11. the Interagency Committee on Human Nutrition Research:
o assign responsibiIities for interagency coordination in aging to a
  nutrition researcher at the Secretary's office in each department
   and agency;
o continue to give aging research priority; and
  o continue to coordinate aging research efforts at NIH, CDC, and
   elsewhere in DHHS, USDA, DOD, AID, etc.
12. all research, service, and education programs should be periodically
reviewed to keep pace with a constantly changing knowledge base.
13. nutrition education and service programs should be designed to meet
the diverse needs and living situations of older adults.

83


PREVENTIVE HEALTH SERVICES WORKING GROUP

Chair: F. Marc IaForce, MD

Technical Manager: Robert Fried, MD



   Reporter: HSO Susan Lockhart
Group Members: Joseph C. Barbaccia, MD
        Enriqueta Bond, PhD
       John,Diaz
      Anne Fainsinger
       Estelle Greenberg, PhD
        Dennis W. Jahnigen, MD
         Robert L. Kane, MD
       Katherine Keaveney
       Richard W. Lindsay, MD
        MED DIR Paul Nutting
          Fred Tavill
       Judith Wagner, PhD
         Susan Noble Walker, EdD
        Gregg Warshaw, MD

Working group members agreed that effective preventive care of the
elderly requires an appreciation of problems outside the more traditional
focus of primary and secondary prevention. Health in the elderly is often
best measured in terms of functional status as well as the absence of disease.
Effective prevention strategies must recognize that informal caregivers
are appropriate recipients of information about preventive services needed
by the elderly. Preventive services should not be arbitrarily started at a
specific age. Ideally, health promotion for the elderly would not begin in
old age, but would be part of an ongoing program begun in childhood.
Individuals of all ages need to be encouraged to take increased responsi-
bility for their `own wellness and health promotion.
The World Health Organization's model which underscores the transi-
tion from disease to impairment to disability and to handicap is a useful
framework since interventions may be made at one or more of these stages.
Preventive services for the elderly should foster the development of effec-
tive environmental and social support systems.
The recommendations that follow address these two goals:
o To prevent physical, psychological, and iatrogenic disorders.
o To prolong the period of independent living with particular atten-
  tion to quality of life.

A significant inhibitory factor in the provision of preventive health serv-
ices is lack of reimbursement. Preventive services should be reimbursed.
While reimbursement will surely increase utilization, the working group
agreed that only those preventive services that have been scientifically
shown to have merit should be reimbursed. Several expert groups like the
U.S. Preventive Services Task Force have systematically reviewed preven-
tive services on the basis of rules of evidence and it seems reasonable to

s4


reimburse those services for which there exists good evidence in favor of
efficacy. For example, medicare coverage should be expanded to include
yearly influenza immunization for the elderly. The working group felt
strongly that curative or diagnostic services should also be reviewed with
the same level of scrutiny.
It is importamto emphasize that preventive services need to be individu-
alized according to the following characteristics:
  o active life expectancy;
  o physical activity;
o cognitive capacity; and
o presence, nature and stage of disease(s) processes.
This individualization of preventive services should respect these prin-
ciples:
  o ?
       ? ? ?  unnecessary disruption of life-style.
o Preserve the patient's autonomy.
  o ??*????? ???????O*?? ?*??o???
o Recognize that avoidance of death may not be the ultimate goal
  of preventive services.
In the area of education, we recommend that:
1. certifyhg organizations for health professional and allied health
  training mams should require inclusion of didactic and clinical
  training on health promotion and disease prevention in the elderly.
   Some areas which should be addressed include:
    o Awareness of the det erminants of successful aging and develop
   ment of positive attitudes about normal aging and the preserva-
   tion of independent function.
  o Appreciation of the heterogeneity of elderly persons with respect
   to functional status, individual values and goals.
   o Knowledge of basic principles of preventive medicine, methods
   of assessing values of screening and intervention programs.
   o Development of professional learning practices which allow for
   incorporation of emerging information regarding the utility of
   specific preventive practices.
  . o Training in identification of individuals "at risk" for decline in
   health status which may be preventable based on the model of
   progression from wellness to disease to disability.
   o Training in functional assessment methodologies.
   o Expedence in multidisciplinary approaches to wellness and health
   promotion.
2. all primary care training programs emphasize geriatric wellness and
  disease prevention.
3. continuing education programs for practitioners focus on preven-
  tive medicine practices for the elderly.
4. all certification and licensure examinations include testing for
  knowledge of preventive medicine strategies in the elderly.
5. service agencies educate and train their staff to recognize elderly
  who are at high risk for preventable conditions.


6. service agencies develop educational programs for their staff in dis
  ease prevention and health promotion in the elderly.
  7. service agencies develop training programs for informal caregivers
  about preventive strategies in the care of the elderly inchxiing
knowledge of commrmity resources.
  8. service organizations develop well being and stress reduction pro
  grams directed at caregivers themselves.
9. private and government employers provide information to their
  older employees regarding normal aging, wellness and disease
   prevention.
10. programs be developed by the aging network and professional
  organizations that educate the elderly consumer to actively seek
  out preventive services as a part of their regular health care.
11. public and private funding sources provide faculty development
  programs designed to enhance knowledge and skills in the teach-
  ing of health promotion and disease prevention in the elderly.
In the area of service, we recommend that: '
  1. mass screening programs should be viewed with skepticism unless
  they adhere to standardized criteria (WHO), are targeted to a
  focused population, and are linked to the primary care system for
  follow-up. Fmestanding screening programs are to be avoided, since
  they are often ineffective and potentially ex-ploitive.
2. the provision of preventive services should take into account the
  heterogeneity of the elderly population.
  3. preventive services for the elderly should address factors that pre-
  vent disease from producing disability and that prevent disability
  from becoming handicaps.
  4. hospital/nursing home admissions and discharges should be viewed
  as opporhmities to assess preventive services or special risk fac-
  tors (iatrogenic disease, dependency).
  5. preventive services should be targeted for the elderly living in nurs-
   ing homes.
*  .6. health promotion programs should emphasize self-responsibility for
  health and lifestyle modification.
  7. nxommendations for behaviorat change, especially for the very old,
  should be balanced against life-style disruption.
8. prevention strategies should include families and informal care-
   givers.
  9. secondary prevention (screening) services in the elderly should be
  addressed in primary care settings since the effective provision of
  these ser&es depends on detection, response and follow-up of sub
   tle changes in hctional status.
10. primary health care providers should be encouraged and assisted
  to look for easily detected and treatable conditions, e.g., depres-
  sion, incontinence and vision, hearing, foot and oral health
   problems.


11. primary ,health care providers should carefully evaluate physical,
mental,- ftmctional status, and existing social support systems for
each of their elderly patients.,

12. primary health care providers should use &&lists and other specific
tools that facilitate and guide specific preventive services for the
elderly.

In the area of research, we recommend that:
1. with regard to those preventive services for which effectiveness in
the elderly has not been established, a vigorous, well funded, and
well coordinated research program should be undertaken to inves-
tigate their applicability to the elderly.
2. specific research efforts should be devoted to strategies aimed at
behavioral changes in the elderly. Such research should encompass
a variety of life-style changes among elderly in different functional
  categories.

3. studies to measure and control adverse events seecondary to medi-
cal intervention should be encouraged and funded.
4. studies of the determinan ts of behavioral change in the elderly and
utilization of preventive services should be funded.
5. agencies funding health care training programs should develop
incentives aimed at increasing researchers in health promotion and
disease prevention.

In the area of policy, we recommend that:
1. medicine and other third-party payers should reimburse for those
preventive services that have been found to be efficacious and effec-
tive for the elderly by independent panels such as the U.S. Preven-
  tive Services Task Force.

2. quality assurance standards promulgated by health care organiza-
tions should include standards for the provision of preventive serv-
ices to the elderly.

3. both Federal and nonfederal research organizations should develop
mechanisms for the prompt translation of prevention related
research findings into guidance for health care providers, payers
and the public.

4. a preventive geriatrics grant program analogous to the Preventive
Cardiology Career Development Award should be established to
provide ,the academic leadership essential to the further advance-
ment of the field, and such a program should accept applications
from researchers in a number of health care disciplines.
5. AoA, NTA, and other relevant PHS agencies, and the VA should
develop a joint strategy for ongoing consumer education on preven-
tive services.

W


SMOKING CESSATION WORKING GROUP

     Chair: Dorothy Rice, ScD
Technical ManAger: Sara White
    Reporter: PHARM Michael Dreis
Group Members: Dianne Bracco
           Diana Fabacher
        Saadia Greenberg, PhD
         Jessie Gruman, PhD
         Sharon Jaycox
           Edna Kane-Williams
       Gregory J. Morosco, PhD
         SR SURG Thomas Novotny
        Terry Pechacek, PhD
          Daniel Quirk
          William Rakowski, PhD
          Barbara Rim&,, DrPH
          Michael Stoto, PhD
           Rebekah Street

The smoking cessation working group bases its recommendations on
the following tenets:

1.
2.

3.


4.

5.


6.

7.

8.

Cigarette smoking produces serious disease in smokers.
Environmental tobacco smoke can cause disease, including lung
cancer, in healthy nonsmokers. Furthermore, the simple separation
of smokers and nonsmokers provides inadequate protection of the
nonsmoker.

Older Americans have the right to protect their health from the toxic
chemicals of tobacco smoke through a smoke free environment.
Older Americans should quit smoking. By doing so, they can real-
ize immediate gains in their quality of life through substantial
improvements in physiological, psychological, and functional status.
The addictive nature of nicotine creates a dependency on cigarettes
which threatens the health of older smokers.
The dearth of smoking cessation initiatives for older Americans, in
spite of the graving scientific evidence showing both short- and long-
term health benefits, constitutes a serious public health need.
Smoking cessation initiatives aimed at older Americans should give
special attention to the concerns and needs of minority and low
income older people and should include in their planning the
representation or involvement of these subgroups.
The decision to stop smoking-and the behavior that follows-is not
the result of one or two exposures to smoking-related information
but is a cumulative effect.

In the area of education and training, we recommend that the Surgeon
General undertake the following:

88


1. emphasize, in his contact with opinion leaders and the media, the
short- and long-term health benefits of smoking cessation for older
smokers, and the effects of passive smoking on older people, partic-
ularly those with disease.
2. encourage health care educators to incorporate the importance of
smoking cessation for older adults and effective interventions in cur-
ricula for health care professional students, including preventive
medicine, nursing, social work, dentistry, gerontology, public health,
and other allied health disciplines.
3. stimulate the training of professionals to incorporate a strong smok-
ing cessation message into their encounters with older adults in emer-
gency room and community and rural health center settings, in order

to reach lower income older adults who lack access to the health care
system.
4. encourage State. and' local professional societies and other organiza-
tions to include information on the importance of smoking cessa-
tion for older adults in continuing medical education programs for
health professionals.
5. urge the development and adoption of smoking cessation messages
and interventions as standards for primary health care delivered to
older persons to include:
o identification of the individual's risk factor (smoking);
o identification of potential medical and pharmacologic complica-
  tions of smoking
o delivery of strong cessation and educational messages to all
   smokers;
o referral to or direct behavioral cessation therapy; consideration of
  pharmacologic therapies; and
o monitoring of progress toward cessation and maintenance at each
  encounter between the patient and the health care provider.
6. work with the Administration on Aging to promote the establish-
ment of "No Smoking" policies in all settings in which services are
provided to older persons. The work site and service delivery areas
of the aging network, as authorized under the Older American Act,
should be models for older persons in the provision of smoke free
environments to encourage .smoking cessation for older persons.
7. convene the Interagency Committee on Smoking and Health to
address the issues of smoking and older adults.
8. provide information to State and local governments on the health
effects of smoking in public places, restaurants, workplaces, public
transportation vehicles, and on airplanes. These deterrents would
protect nonsmokers from the adverse health effects of passive smok-
ing and eliminate the possibility of fires caused by smoking.
9. encourage long-term care providers to facilitate smoking cessation
for older persons in long-term care facilities through:
o pmviding access to cessation materials for residents and their
  families;

89


o educating staff to the benefits of cessation for themselves and
older adults; and
o designating nonsmoking resident rooms and no smoking in all
common areas.

10. recommend that pre-retirement programs currently conducted by
public and private employers, private insurers, and labor unions con-
tam a health promotion focus, including an emphasis on the posi-
tive health benefits of smoking cessation for older adults.
11. designate responsibility to a PHS working group to meet with rele-
vant public and private sector agencies and organizations to coor-
dinate the development of a public. education initiative. The group
would explore the feasibility of sharing resources and networks to
stimulate community program development.
12. encourage public and private sector agencies/organizations actively
engaged in anti-smoking education activities to examine existing
educational materials and public service announcements on preven-
tion, cessation, and maintenance for cultural, ethnic, racial, and
gender relevance to the older audience.
13. insure that the Office on Smoking and Health include an overview
of smoking and older adults in the 25th Anniversary Surgeon
General's Report on Smoking and Health and biannual reports to
Congress.

In the area of education and training, we recommend that:
1. State and local health departments, voluntary health agencies,
advocacy groups, and coalitions be strongly urged to work with pub
lit and private organizations serving the social service needs of older
Americans to support them in:
o the development, implementation, and enforcement of restric-
  tive smoking policies directed toward clients and staff;
o the education of staff in such agencies to serve as credible and
   effective sources of smoking cessation support;
o the provision of cessation materials (pamphlets, posters) to sup-
  port clients and staff in their attempts to stop smoking.
Such oqpizations would include:
  o ?????????
  o senior centers;
  o veterans' groups;
  o fraternal organizations;
  o congregate meal sites;

o minority and ethnic clubs and centers;
o self-help groups; and
o area agencies on aging.

2. the organizations and agencies that serve older adults and the pi-
vate, public, and voluntary agencies that focus on smoking control
issues create a coalition to organize their resources in order to create

90


  a smoke free environment that repeats and reinforces, through many
  and varied channels, smoking cessation messages specifically targeted
  to older adults, and that encourages participation in such national
  smoking cessation activities as the Great American Smokeout.
3. agencies,' organizations, and medical facilities `distriiuting informa-
  tion to `older persons about smoking cessation methods refer,
  whenever possible, older persons to local self-help/mutual aid groups
  formed to encourage ex-smokers to stay nicotine free.
4. providers of direct services to the older population, including social
  workers, educational special&, nutritionists, and other support per-
  sonnel be targeted with smoking cessation messages which identify
  the benefits of quitting for older adults.
5. professional and accrediting organizations be encouraged to offer
  seminars and workshops on smoking cessation and that supplemen-
  tal materials (e.g., posters, brochures) be made available.
An underlying assumption is that research on smoking cessation with
older adults must address the difficulties inherent in reaching a popula-
tion for whom smoking is likely to have been a lifelong habit. Associated
with this lengthy duration is a history of nicotine addiction, unsuccessful
quit attempts, and &ychological and situational dependencies on smok-
ing. By the very nature of the duration and cumulative exposure to smok-
ing, older smokers may present the most significant challenges to smok-
ing cessation efforts. Furthermore, because of decades of self-selection, the
population of older people who still smoke are heavier smokers and are
-more likely to have low incomes and be members of minority groups.
Research on smoking and smoking cessation among older adults can
benefit from advances in research design and methodology that occur with
yomger target groups. Moreover, as with other populations research on
smoking and aging should investigate smoking as it broadly affects the
fives of older persons, not only its morbid and mortal outcomes.
In the area of research, we recommend that:
1. knowledge of smoking and older adults be improved and refined
  by studies that include but are not limited to:
      o the interaction of smoking status and smoking history with other
    risk factors of mortality, morbidity, and loss of functional health
    in older adults;
   o the association of smoking with older adults' status on other
    health-related practices;
   o the benefits of smoking cessation in improving the quality of life
    which extend beyond the biological, behavioral, and health aspects
    of smoking

o evaluation of age-related or intergenerational differences in the
smoking cessation process, strategies used in quitting, and fac-
tors influencing relapse;

o development of a research agenda that examines the value of self-
help groups as a mechanism to help older people stop smoking
and stay nicotine free; and

91


o investigation of the effects and consequences of nicotine with-
drawal which are affected by aging, coexisting illness, and the
duration and intensity of smoking.

2. the Centers for Disease Control (CDC) be encouraged to expand
the National Health Intervrew Survey to include the ?????*? sup
plement annually, and that its sample be sufficient to report statisti-
cally significant results for subgroups of the older population (e+,
the young-old, blacks, Hispanics, and Native Americans).
3. the National Ambulatory Care Survey of Physicians in Private Prac-
tice, conducted by the National Center for Health Statistics, include
questions on advice and assistance physicians provide to their
patients, especially older patients, regarding the benefits of smok-
ing cessation. Although U.S. physicians view smoking as a serious
health risk, less than one-fourth offer any kind of structured
assistance in helping patients quit, and physicians are less likely to
give a strong cessation message to older adults.
4. CDC should encourage states to include smoking data on older
adults in The Behavioral Risk Factor Surveillance System ????????
5. research focus on epidemiologic analyses to improve chronic dis-
ease risk estimates for continued smoking into the seventh and
eighth'decades of fife, particularly for female smokers.
6. researchers incorporate questions about smoking status and smok-
ing history into longitudinal epidemiologic studies of older popula-
tiOllS.

7. major trials and other studies of smoking cessation be encouraged
to include older persons in numbers sufficient to make separate ana-
lyses meaningful and useful.

8. academic researchers evaluate the application of smoking cessation
techniques and materials for older adults.
9. academic researchers evaluate the delivery of smoking cessation mes-
sages by physicians, dentists, and other health care professionals
to older adults.

10. the Surgeon General encourage the Food and Drug Administration
to formally ask drug companies (holders) of already approved New
Drug Applications @DA's) to initiate pharmacokinetic studies on
the interaction of nicotine on serum and tissue levels of the compa-
nies' drugs and to include such information in the physicians pack-
age insert.

II. foundations with health promotion and/or aging agendas be
encouraged to fund demonstration and other research projects that
focus on smoking cessation and to incorporate information on smok-
ing cessation into new and existing health promotion programs.
In the area. of policy, we recommend that:
I. the Social Security Administration be encouraged to include health
promotion messages, including smoking cessation information, in
beneficiary mailings.

92


2. private insurers be encouraged to charge differential rates to smokers
in their Medicare supplemental and long-term care policies.
3. the SurgeOn General encourage the United States Pharmacopeia, the
American Society of Hospital Pharmacy, the American Pharmaceu-
tical Association, and other organizations that disseminate patient
package inserts to develop a section on "Effects of Smoking on Drug
Serum and Tissue Levels" focused especially on the potential for such
interactions in older persons.

4. the Surgeon General encourage the Food and Drug Administration
to require drug companies to undertake pharmacokinetic studies on
the interaction of nicotine on serum and tissue levels of the spon-
sor`s drug, especially in older persons, as a condition for comple-
tion and approval of all forthcoming NDA's, and that such informa-
tion be included in the physician's package insert.
5. the sale of + tobacco products be eliminated from all government
health facilities.

6. the Surgeon General encourage the Administration on Aging to
establish a priority in its discretionary grants funding for model State
level smoking cessation campaigns for older persons and for dissemi-
nation of smoking cessation materials targeted for older persons.
7. the year 2000 health objectives should be set which measure:
o reductions in smoking prevalence by sex and race for older adults;
o increases in public awareness of cessation benefits at older ages;
   and
o increases in the frequency of smoking cessation advice being given
  in primary care settings.
8. the Surgeon General urge the tobacco industry to manufacture only
*safe products, in order to reduce the risk of morbidity and mor-
tality in older persons from residential fires.

93


Response to Workshop Recommendations

Presented by C. Everett Koop, MD
Surgeon General, United States Public Health Service
Wednesday morning, March 23, 1988

This is the moment that I always look forward to at the close of a Sur-
geon General's workshop, but it also is a moment that I dread. You've
all made my task today much simpler than is usually the case and for that
I am grateful.
I would like to extend my congratulations to the chairpersons of the var-
ious working groups and my thanks to all of the participants. You have
done an outstanding job.
As I told you in my charge, what you have presented to us as recom-
mendations will not be edited as to substance. Grammatical and syntax
changes will be kept to a minimum.

It is almost impossible to have a workshop such as this without having

`.  several participants who come with private agendas which supersede the
   work at hand, but to my knowledge that has not happened on this occa-
    - sion and I am not only pleased but very grateful. You have indeed shown
   what a cooperative effort can be.

This has been the best organized Surgeon General's Workshop, and I
ought to know. My thanks again to DSG Faye G. Abdellah, SR PHARM
Steve Moore, and countless others for a job exceedingly well done. My
thanks to Social and Scientific Systems, Inc. of Bethesda, Maryland. This
was our contractor and people worked all night to type the recommenda-
tions you will receive at the end of this conference.
I didnIt work all night, but almost. As I make my response, I will stum-
ble, stutter; appear to loose my place but be assured none of these are
the result of the short night, my age, or my eyesight. Rather, it is my pen-
manship which is at fault which is vintage physician. It is unreadable, even
by the author.
When President Reagan nominated me to be his Surgeon General, back
in 1981, I was just a youngster of 65. But, unfortunately that was the age
at which-traditionally-Surgeons General were supposed to Zeez2 the Pub
lit Health Service-not enter it for the first time.
So a great hue and cry went up, alleging that I was too old for the job.
You can imagine that this did not sit very well with the man who nomi-
nated me. President Reagan had just celebrated his 70th birthday, when
he sent my nomination to the United States Senate.
I don't recall that he took very kindly to the idea that someone who was
5 years punger than he would be considered too old to serve his country.

94


Senator Hatch spend many hours of many months convincing his senate
colleagues to accept the idea that chronological age ought not to be the sole
and final criterion of an individual's personal or professional worth.
Senator -Hatch prevailed . . . and I became your Surgeon General. I am
indebted to him for the courage and fore@@ he demonstrated at that time..
.I also happen to think he was right.
And just as a footnote to all this history, I am pleased to say that, when
the Resident renominated me for a second term, the whole process took
less than 5 minutes and there were no "MY" votes.
Now, my personal story had a happy ending. I got the job. But that's
not always the case for everyone, as I'm sure you alI agreed at your work
groups-
As so many of us know from personal experience, age prejudice is still
far too common in America. Yet, that makes no sense at all, because the
new scientific information coming to light ought to be pointing society in
exactly the opposite direction.
We're now coming to understand that-medically speaking-there is such
a thini as a disease fke aging pmess. A process during which all systems
in a person's body continue to function normally.
So let's get a few things straight:
o Gray or white hair is not a sign of disease. Never has been. Never
.g;& is a natural phenomenon of aging. We don't know why
  it happens-but it's not the result of disease.
o Taking things a little easier is not a disease condition, either. It's more
  like a sign of maturity.
o And getting a stronger prescription for your eyeglasses or being fit-
  ted for a hearing aid is not evidence that you have one foot in the
  grave and another on a banana peel. It just isn't so.
From this common-sensical, scientifically accurate perspective, you soon
realize that a great muny older Americans today enjoy a disease free old age,
mentally and physicalIy healthy.
And we'd better get used to the idea that that's the way it's going to
be perhaps for most older people in the future, because fomorrozu's elderly
are today's bikers, joggers, and swimmers.
They're people who snack on salad and yogurt.
They're today's young and the middle-aged Americans who've given
up cigarettes and hard liquor . . . who wear seat belts and sensible shoes

. . . and who do more about managing stress than just to pop another
Valium.
We need to remember that the aging process is not just a biophysioZogica2
process. As the work groups have amply demonstrated, the aging process
is also a social . . . and political . . . and an f3mwrnic process as well.
Good health in one's senior years may be a result of good diet, regular
exercise, and an overall healthy life-style.


But it is also the result of decent housing . . . and public order . . . and
environmental safety.
It can be the result of a life spent in steady and safe employment, clos-
ing with one's senior .years protected by financial security.
It is also the sum-total of a lifelong sense of personal and family well-

being . . . and of one's ability to continue to live an independent, private
life . . . a life that is not a burden to one's self, to one's loved ones, or to
society at large.
In hearing these remarks, I'm sure some of you recognize how your
recommendations triggered these thoughts as I was preparing them in the
not so wee hours of the morning.
And now to the specific recommendations of the working groups:
  There are a number of recommendations that are common to several
work groups. For example, not exhaustively:
  1. Adequate dissemination of the material to specific special interest
    groups.

This will be done. More on that subject later.      . .

2. Public-Private Partnerships and Coalitions.
We intend to implement these relationships by education, by precept, and
by armngement.

3. Inclusion in core curricula of health and professional schools of the
basic precepts pecubar to the unique needs of older people.
Your mwmmendations will be circulated to those who can make a differ-
ence, to the best of our ability to do so.
4. The assistance of the Surgeon General when and where advanta-
geous.
I pledge to do this within time constraints, but you tend to win on this one
bacause of my compulsive personality.
5. Access to care.

This penmid pden~ is not easily addressed. We will try where we can.

Alcohol

I feel g little foolish addressing these issues in the presence of Dr. Gordis
who understands so well those concerns expressed in the research agenda,
such as the need to understand the differences between lifetime and late
onset alcohol abuse.

I will transmit to the National Heart, Lung, and Blood Institute your con-
cerns in nhrence to cardiovascukx disease and premature aging and their
relationship to alcohol.
Secretary Bowen has recently launched a very comprehensive initiative
on alcohol abuse and alcoholism. He will be pleased with your educational
annments and a special letter of transmittal will be sent by me to the group
responsible for this initiative.
To HCFA and the private insurance carriers I will pass on your concerns
about third party payment for detoxification and rehabilitation.
Finally, the Veterans Administration will be apprised of the specific con-
cerns and recommendations made regarding veterans.


Oral Health

I was pleased that these recommendations recognized that the mouth
contained more than teeth because that concept conforms to my life-long
professional belief that the mouth was part of the body and that dentists

belonged in the mainstream of caregivers.
The suggestions for a research agenda will be transmitted personally to
Dr. Harold Loe, Director of the National Institute of Dental Research.
Through the Chief Dental Officer, every Rrivate sector organization will
also be notified about service recommendations.

The particular concerns about oral health in long-term facilities and the
need for financing will be delivered to appropriate umbrella organizations
involved with long-term care, with HCFA, and private insurance carriers.

Physical Fitness and Rxercise

I am impressed by and endorse your concerns dir&ed toward types
and levels of physical activity in terms of intensity, frequency, and dura-
tion to achieve, safely, the potential benefits in health and functional capac-
ity across a wide age span and range of abilities.
[Dr. Williams was asked to comment on this research agenda and spoke
at this time.]

Dr. Williams:

I agree fully with the major emphases in the recommendations on phys-
ical fitness and exercise. In particular, the recommendations in the area
of research are clearly german e to the mission of the National Institute on
Aging (NIA); we are already involved in research related to a number of
the recommendations and expect to increase our activities in the field.
Chmall, I urge emphasis on incorpomting fitness into dairy living. We should
encourage, and.pactice ourself, walking briskly up and down stairs and
between sites in our work place, at home, in retirement activity, and should
encourage fitness programs as a part of all employment and living settings.
We should emphasize maintenance of function. It is also important that
we learn more about how to tailor fitness programs and daily exercise activi-
ties to the needs and capabilities of persons who have varying types of
chronic disabilities or disorders, just as we tailor fitness programs to the
needs and capabilities of generally healthy older people.

The educational component is universal and complete. We will seek
appropriate community endeavors to take on this responsibility.
My penuItimate Surgeon General's Workshop was on Self-Help and
Public Health. I will attempt a cross fertilization of appropriate groups to
see that some of these excellent educational suggestions see practical appli-
cation.
And now a personal note. There are, as you know, Presidential Awards
for young people who pass rigorous fitness examinations. Some of us

97


believe others who do not get superlative ratings on these exams deserve
some .&cognition. Therefore, we are working on a Surgeon General's
Award for physical fitness for youngsters.
I don't know .quite how, yet, but I will seek ways to provide senior
c&ens with a Surgeon General's Recognition for physical performance
appropriate to age. Perhaps the best place to start is with Commissioner
Carol Fraser Fisk, and I will do just that.
I will lend my own powers of moral suasion to this effort.

Injury Prevention

me preamble of this excellent summary calls for coordinated effort among
the Centers for Disease Control, the National Institute on Aging, and the
Administration on Aging. This already exists as CDC and NIA are com-
ponents of the Public Health Service, and we already have a coalition with
AoA. That's why you' are here! But, we will seek to strengthen and refine it.
The suggestions about injury prevention are quite valid. I will seek to
provide all participants with some pilot program information on this
,subject.

Many of the research recommendations are in line with surveillance and
epidemiology studies now underway at CDC. I will be certain that the
specific recommendations made here are transmitted to the CDC.
Some of the policy recommendations overlap with education but
whatever the recommendations are, they will be passed on to the various
agencies that establish and enforce safety standards.

The detailed exposition of 33 recommendations is noted. The PHS is com-
posed of 11 disciplines. One large group are the pharmacists. Our phar-
macists function, in many instances, at an interactive level with patients
somewhat higher than is the usual expectation. Experience with pharma-
cists in the ~@.ian Health Service has proven the worth of this interactive
relationship.

It is my intent to turn the recommendations and proposals over to the
Chief Pharmacist of the Public Health Service and ask him and his Rofes-
sional Advisory Committee to implement the service, policy, and educa-
tion components in cooperation with the Administration on Aging with
whom we have already an initiative on medications for the elderly.
The research proposals will be turned over to the NIA and FDA. Finan-
cial implications will be directed to HCFA and the private sector.

Mental Health

Many of the recommendations of this Workgroup grew out of a recog-
nition of risk factors that have the potential of influencing the onset, clini-
cal course, and response to treatment of mental health problems in elderly
individuals.

98


Many also recognized that older persons with mental health problems,
alcoholism, or other drug problems have had physical health problems
which bring them into multidisciplinary and service coordination settings.
The reco~endatiom of this group'cross cut many of those for other work
groups as you might imagine. Some will in a sense be covered as we seek
to implement the recommendations of other groups.

Many of the suggested outcomes are being addressed by the AoA and
I'd like Commissioner Fisk to speak to some of them after which I've asked
Dr. Williams to address some of the research agenda items.

Commissioner Fisk:

Thank you Dr. Koop. I was impressed with the Workshop recommen-
dations in this area, so many of which emphasized co&&oration between
the aging and mental health networks. The Administration on Aging has
conducted a number of demonstration projects at the State level that have
been targeted at coordination. Clearly, we need to do more in this area.
Also, this seems to be a good area for State Coalitions on Health Promo-
tion to get involved in.
My agency is currently funding six projects in the area of mental health
promotion. Through these projects, we hope to address some of the con-
cerns of the participants such as drugs and depression, access, problem
recognition and identification.
I see mental health issues, and especially depression among the elderly,
as a serious concern. You have my assurance that AoA will continue to
address these issues and will involve other agencies in our efforts.

Dr. WiIIiams

In considering the recommendations and needs related to mental health
it is important to note, as is done in these recommendations, the close
interaction of mental health with physical and social health issues.
Among the recommendations for research, I would emphasize in par-
ticular the importance in identifying risk factors, attention to coping strate-
gies, and again the need for further studies on the interactions of mental
problems with other characteristics including medication.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The specific policy issues that touch on reimbursement will be called to
the attention of HCFA and the private sector. Others, where appropriate
will fuid their way to the proper agency such as FDA.
Hearing problems were also addressed by this group. Some of you may
have noted the announcement in MMWR that the National Institute of
Occupational Safety and Health will be starting a prevention of hearing
loss initiative for the present work force that will be the next generation
of the elderly. I am starting an information program on what can be done
for those already suffering from hearing loss.

99


Fhdy, copies of the final report of this WAshop fi go to the mem-
&q of the `State and Territorial Health Officers Association carrying the
sting ~mrnendation t0 the state concerning their responsibility in men-
tal health to the elderly.

Nutrition

As with the mental health recommendations, the nutrition recommen-
dations overlap and intertwine with many others. I note with pleasure that
one of the overriding goals is "improved quality of life for older Ameri-
cans and the promotion of continued autonomy, not cost containment."
Many of the policy recommendations were specific in reference to Fed-
eral and state responsibility, as well as agency cooperation. We will
endeavor to bring the. concerns to those who can make a difference.
There is almost -no agency in or out of government-at all levels-that
is not involved in nutrition. We will attempt to build bridges and transmit
specific recommendations not only to the individual groups mentioned,
but also to others who will have an increasing role to play such as the
JCAHO committee on accreditation of hospitals, interagency committees,
etc.
The specific recommendations of computer data bases for use by phar-
macists and dietitians on medication-nutrient interaction will be given seri-
ous consideration and I will seek a niche for it in the Public Health Service.
These promises of catalytic action apply to service, education, and
research.
There is in preparation by the- Office of Health Promotion and Disease
Rrevention a new-first time "Surgeon General's Report on Nutrition."
I see the launching of this report-much of which deals with the specific
concerns of the nutrition work group-as a mechanism of bringing atten-
tion to your recommendations above and beyond the reach of this
Workshop. .

Incidentally, the attention paid to the elderly in the Surgeon General's
Report on Nutrition is considerable, including medication-nutrition incom-
patabilities.

Preventive Health Services

Preventive health services are inexpensive, not glamorous, very effec-
tive, and seldom reimbursed. Those are my words,-not those of the work-
ing group, but many of the recommendations recognize these four truths.
Many of the concerns of this group were addressed in my generic
remarks early on this morning especially in education as it affects the core
curricula of health schools.
I was impressed with the working group's understanding of the
relevance of their goals to primary care. Accordingly, I will take special
care to direct this working group's concerns to those organizations which
draw together and serve family practitioners as well as those umbrella
organizations specifically concerned with preventive medicine.



Once again access and reimbursement are key issues and I will address
them in appropriate circles with special attention to reimbursement for
immunization against influenza, appropriate screening services, and atten-
tion to readiIy diagnosed and easily treatable conditions.
Policy matters will be delineated and referred to appropriate authorities
where responsive action seems most likely.

Smoking

I will continue my personal efforts to convince elderly Americans of the
benefits of kicking the habit as well as my constant pressure on physi-
cians to acknowledge that it is never too late to quit, that preventive medi-
cine does have an important role in the health care of elderly people, and
that no means to quitting is as effective as a physicians personal advice
to .his patient to stop smoking.
These recommendations will be turned over to the revitalized Office of
Smoking and Health and I will see that each recommendation gets the
attention it deserves.

The Federal government buildings have a restricted smoking policy. All
Health and Human Services buildings have had a total ban on smoking
for the past month. We will get smoking off airlines, out of public build-
ings, including restaurants, and before the year 2000 smokers will ask for
permission to smoke in the presence of nonsmokers-and that will fit my
definition of a smoke-free society by the year 2000.
It is in the area of smoking and health that I probably have my greatest
clout, and I promise my personal attention to each recommendation made.
I hope to be around long enough to convene the Interagency Commit-
tee on Smoking and Health to address smoking and the elderly.
And finally, I have already begun to work with the churches which have
awakened to realize that smoking is the number one cause of disease, dis-
ability, and death.

There is one other area that I will address, if possible and when feasi-
ble, that can only enhance the outcome of many of the recommendations
made here.

That area is cross generational relationships. Not only are the relation-
ships of the elderly with children socially and emotionally beneficial to the
elderly, but they can be a source of education, indeed, wisdom, and com-
panionship, but they can also prepare the youngster for much that is to
come in life.

Kids don't know enough about old people and about people of all ages
with handicaps. This is one place and one way to began.
Only 9 percent of children in the United States live within walking dis-
tance of a grandparent. How tragic that seems as I recall my childhood!
I reaped great benefits as a child from a relationship with my grandpar-
ents. But I truly believe my interest in and concern for the elderly is not
because I am old, but because of the bond that existed with my grandpar-
ents. Every child lives within walking distance of an elderly person who
might weIl serve i&co grand parentis if there is such a word.


What a great project for our next first lady-whoever she might be. We'll
see!

When I addressed you on Monday, I told you that the recommenda-
tions would be given the widest possible circulation. Because the docu-
ment I have before me is in such good form, I think it may be possible
to have a printed copy off the press within 6 weeks. You will recall that
I said we may be asking some of you for help in reference to distribution
suggestions. But let me say now that if there are any of you here who
just know that there are several obscure individuals or groups that you
just knav we will not think of, we would be happy to have your sugges-
tions even before we ask for them. Just use your judgment.
One of the greatest satisfactions .for me that comes from a Surgeon
General's Workshop is to look back a year hence and see how much has
been accomplished. With that in mind I would suggest that, as the year
goes by, when you are able to do something that implements suggestions
made at this workshop that you notify us. It is our intent to collate these
and to report to you at 6 months and again at a year.
Walt Whitman was also a Brooklyn boy, like myself, and maybe that's
why I like him. It was Walt Whitman who wrote these lines:
Youth, `large, lusty, luuing-youth full of grace, force, fascination,
Do you kmw that old age my come after you with equal force, grace,
jZS&UltiO?l?
Our answer to Walt Whitman ought to be . . . Yes, we know. And we
should really mean it.
I hope to see some you at the hearing for the Objectives of the Nation
this afternoon.

Have a safe trip home.
Thank you.

102


LIST OF PARTICIPANTS

Faye G. Abdellah, EdD, ScD. Deputy Surgeon General, United States Pub
  lit Health Service, Washington, DC..
Frederick J.Abramek. Food and Drug Administration, Rockville, MD.
William B. Abrams, MD. Executive Director, Scientific Development, Merck
Sharp & Dohme Research Laboratories, West Point, PA.
Ingrid Azvedo. Chairperson, Federal Council on Aging, Elk Grove, CA.
Shirley Bagley. National Institute on Aging, National Institutes of Health,
  Bethesda, MD.                             \
Joseph C. Barbaccia, MD. President, Association of Teachers of Preventive
  Medicine, Professor and Vice Chairman, Division of Family and Com-
munity Medicine, University of California, San Francisco, CA.
James D. Beck, PhD. Professor and Chairman, Department of Dental
Ecology, University of North Carolina School of Dentistry, Chapel Hill,
  NC.

Neal Bellos. President, Association for Gerontology in Higher Education,
The Geronotology Center, Syracuse University, Syracuse, NY.
Donald R. Bennett, MD, PhD. Director, Division of Drugs and Toxicology,
American Medical Association, Chicago, IL.
Thomas Beresford, MD. Department of Psychiatry, University of Michigan,
School of Medicine, Ann Arbor, MI.
Michael Bernstein. Executive Director, Gulf Coast Jewish Family Services,
Largo, FL:

Nathan Bill&, MD. Associate Professor, Department of Psychiatry,
Georgetown University, School of Medicine, Washington, DC.
Gerald Bloedow. Executive Director, Minnesota Board of Aging, St. Paul,
  MN.

Jeffrey B. Blumberg, PhD. Associate Director, USDA Human Nutrition,
Tufts University, Boston, MA.
Enriqueta Bond, PhD. Institute of Medicine, Washington, DC.
Dianne Bracco. Acting Executive Director, New York City Self-Help
Qearinghouse, Brooklyn, NY.
Jacob L. Brody, MD.. Dean, School of Public Health, University of Illinois
at Chicago, Chicago, IL.

Steven W. Brummel. President, Elvirita Lewis Foundation, Palm Springs,
  CA.

Richard Burnett. Regional Program Director, Administration on Aging
Region VII, m City, KS.

103


Carl J. Caspersen, PhD. Behavioral Epidemiology and Evaluation Bran&,
Division ,uf Health Education, Centers for Disease Contml, Atlanta, GA.
Nancy Chapman. President, Chapman Associates, Washington, DC.
Vii Chen, Healm Resoumes and Servkes Adm@stration, RockviUe, MD.
Ronni Chemoff, PhD. Associate Director, Geriatric Research Education and
Evaluation, John L. McClellan Memorial Hospital, Little Rock, AR.
Jan&t Clinton, MD. Director, Bureau of Health Professions, Health Resources
and Services Administration, Rockville, MD.
Gene D. Cohen, MD, PhD. Associate Director on Aging, National Insti-
tute of Mental Health, Rockville,. MD.
Jean Coyle. National Center for Health Promotion and Aging, National
Council on the Aging, Washington, DC.
Barry J. Cusack, MD. Chief of Geriatrics, Veterans Administration Medical
  center, Boise, ID.

Mary Ann Danello, PhD. Special Assistant to the Commissioner for
Science, Food and Drug Administration, Rockville, MD.
John Diaz. Regional Pmgram Dire&r- Region IV, Administration on
Aging, Dallas, TX.

Gayle Dolecek. Health Resources and Services Administration, RockviIle,
  MD.

Teri Dowling. .Director, Office of Senior Information, Referral, and Health
Pmmotion, San Francisco Department of Health, San Francisco, CA.
Michael Dreis. Food and Drug Administration, Rockville, MD.
Johanna Dwyer, ScD. Director, Frances Stem Nutrition Center, New
England Medical Center Hospital, Boston, MA.
Janice Eldred. Henry J. Raiser Family Foundation, Menlo Park, CA.
Bernard Engel, PhD. Gerontology Research Center, National Institute on
Aging Baltimore, MD.

Ronald Ettinger, DDS. Professor of Dentistry, University of Iowa, Iowa
city, IA.

George Everyingham. Director, Egyptian Area Agency on Aging, Carter-
  die, IL.

Diana Fabacher. University of Mississippi Medical Center, Jackson, MS.
Anne Fainsinger. Alliance for Aging Research, Washington, DC.
Timothy Fagan. Director, Baltimore County Department of Aging, Towson,
  MD.

Carol Fraser Fisk. Commissioner, Administration on Aging, Washington,
  DC.

Wilda Ferguson. Commissioner, Department for the Aging Richmond, VA.
Jerome Fleg MD. Gemntology Research Center, National Institute on Aging,
  Baltimore, MD.

Jean Cutler Fox, PhD. Director, Graduate Mental Health/Psychiatric Nurs-
ing, School of Nursing, University of Vii, Charlottesville, VA.
J P. Jean Frazier, PhD. Professor, Department of Health Ecology, University
of Minnesota School of Dentistry, Minneapolis, MN.
Robert Fried, MD. Office of Disease Prevention and Health Promotion,
Washington, DC.

104


Mary Alice Gaston. Department of Dental Hygiene, University of Tennessee,
Memphis,, TN.
Pearl S. German, ScD. Professor, Division of Health Policy and Manage-
ment, School of Hygiene and Public Health, Johns Hopkins Univer-
sity, Baltimore, MD.
Helen C. Gift, PhD. Epidemiology and Oral Disease Prevention Program,
National Institute of Dental Research, National Institutes of Health,
  Bethesda, MD.
Neville Derek Gilmore, DMD, DrPH. Professor and Chair, Department of
Community Dentistry and Human Behavior, Southern Illinois Univer-
sity, Alton, IL.
Barbara G&h. Manager, Patient Education, Division of Ambulatory Care,
Health Promotion, and Women and QQren's Health, American Hospi-
tal Association, Chicago, IL.
Andrew Goldberg MD. Division of Geriatric Medicine, Francis Scott Key
Medical Center, Baltimore, MD.
Edith s. LisansQ Gomberg PhD. Professor, university,of Michigan, School
~ofSocialWork,Ann&bor,MI.
Patricia Goode, MD. University of Alabama School of Medicine, Birming-
  ham, AL.
Marie Gooderham. Member, Board of Directors, American Association of
Retired Persons, Washington, DC.
Enoch Gordis, MD. Director, National Institute on Alcohol Abuse and
Almholism, RockdIe, MD.
Stephen Gordon, PhD. National Institute of Arthritis, Musculoskeletal and
Skin Disorders, National Institutes of Health, Bethesda, MD.
Milkent Gorham. Associate Director for Federal Relations, American Opto-
metric Association, Alexandria, VA.
Estelle Greenberg, PhD. Brookdale Foundation, New York, NY.
Saadia Gmenberg PhD. Division of Program Development, Administra-
tion on Aging Washington, DC.
Stephen C. Graft, PharmD. Executive Director, Commission on Orphan
Diseases, Office of the Assistant Seaetaq for Health, Rockville, MD.
Jessie Gnunan, PhD. Manager, Public Education, American Cancer Society,
  N& York, NY.
Judith Hall&s&, PhD. Gerontology Research Center, National Institute of
Aging, Baltimore, MD.
Mary Harper, PhD. National Institute on Mental Health, Rockville, MD.
Raymond Harris, MD. Center for the Study of Aging Albany, NY.
Wilson C. Hayes, PhD. Professor and Director, Orthopedic Biomdanics
Laboratory, Beth Ismel Hospital, Harvard Medical School, Boston, MA.
Marc W. Heft, DMD, PhD. Associate Professor, Oral and Maxillofacial
Surgery, University of Florida, College of Dentistry, Gainesville, FL.
RogerHerdman,~.AssistantDirectarfarHealthandLifesciences,qffice
of Technokrgy Assessment, United States Congress, Washington, DC.
CIinton Hess. Regional Program Dimctor, Administration on Aging-Region
VIII office, Denver, co.


Carol Hogue, PhD. Associate Professor, !3chool of Nursing, University of
North Camlina, Chapel Hill, NC.
John Holloszy, MD. Professor of Medicine, Washington University, St.
  Louis, MO.

John HOm, PhD. Adult Development and Aging Division, Department of
  P$hology, University of Southern California, Los Angeles, CA.

Mary C. Howell, MD, PhD. Assistant Clinical Pmfessor, Director, Kennedy
Aging Project, Harvard Medical S&001, Watertown, MA.
Daniel A. Hussar, PhD. Rerninjjon Pmfessor of Pharmacy, Philadelphia
College of Pharmacy & Science, Philadelphia, PA.
Dennis W. Jahnigen, MD. Head, section of Geriatric Medicine, Department
of Intemal Medicine, The Cleveland Clinic Foundation, Cleveland, OH.
Sharon Jaycox. Program Associate, Smoking or Health, American Lung
Association, New York, NY.

Norge W. Jerome, PliD. Professor, Department of Preventive Medicine,
school of Medicine, University of Kansas M+ical Center, Kansas City,
  KS.

Judith K. Jones, MD, PhD. Associate Clinical Director for Researh George
town University Center on Aging, Great Falls, VA.
William Kachadorian, PhD. Gerontology Research Center, National Insti-
tute on Aging, Baltimore, MD.
Edna Kane-Williams. Health Advocacy Services, American Association of
Retired Persons, Washington, DC.
Robert L. Kane, MD. Dean, !?chool of Public Health, University of Mhne-
sota, Minneapolis, MN.

Katherine Keaveney. University of Alabama school of Optometry, Birming-
  ham, AL.

H. Asuman Kiyak, PhD. Associate Professor, Depa$rnent of Oral and
Maxillofacial Surgery, University of Washington, !3chool of Dentistry,
  Seattle, WA.

C. Eve&t Koop, MD. Surgeon General, United States Public Health Sewice,
Washhigton, DC.

Lorraine Kmetch, PhD. Chief, Services to Older Adults, Department of
' Mental Health, Sacramento, CA.
Shhiki Kumanyika, PhD. Department of Epidemiology, Johns Hopkins
university, Baltimore, MD.

F. Marc LaFa, MD. Professor of Medicine, Univehty of Rochester School
of Medicine and Dent&y, Rochester, NY Gretchen Lagodna, PhD.
Associate Professor, College of Nursing, University of Kentucky, Lex-
ington, KY.

David Lamb, PhD. Department of Exercise Physiology, Ohio State Uni-
versity, Coluhbus, OH.

Richard Lindsay, MD. Professor of Medicine, University of Virginia !.%hool
of Medicine, Charlottesville, MD.
Susan Lo&hart. Office of the Surgeon General, Rockville, MD.
Adelaide Luber. Dhztor, Rhode Island Department of Elderly Affairs, Pmvi-
dence, RI.

106


Steve Luchter. Chief, Planning and Policy Development Division, National
Highway `I'raffic Safety Administration, Washington, DC.
David Macfayden, MD. Former Manager, WHO Global Programme for
Health of the Elderly, Jefferson `Medical School, Philadelphia, PA.
Susan Maloney. office of Disease Prevention and Health Promotion, Wash-
ington, DC.

Marylen Mann. Executive Director, OASIS, St. Louis, MO.
James Y. Marshall. American Dental Association, Chicago, IL.
Frank Martin, DDS. Bureau of Health Professions/Health Resources and
  Services Administration, Rockville, MD.
Kathleen MKormick, PhD. Geriatric Research Center, National Institute on
Aging, Baltimore, MD.

J. Michael McGinnis, MD. Director, Office of Disease Prevention and Health
Promotion, Washington, DC.

L. Joseph Melton, III, MD. Head, Section of Clinical Epidemiology, Mayo
Clinic, Rochester; MN.

Walter Merk, MD. Director, Human Nutrition Research Center, USDA,
  BeltsvilIe, MD.

Angela Mickalide, PhD. Office of Disease Prevention and Health Promotion,
Washington, DC.

Steven R. Moore. Food and Drug Administration, Rokville, MD.
Jana Mossey, PhD. Associate Professor, Community and Preventive
Medicine and Psychiatry, Medical College of Pennsylvania, Philadel-
phia,' PA.

Henry Monks. Of&e of Minority Health, Department of Health and Human
!3ervices, Washington, DC.

Gregory Morosco, PhD. Chief, Health Education Branch, National Heart,
Lung, and Blood Institute, National Institutes of Health, Bethesda, MD.
Roseann MuIligan, DDS. Chaknan Section of Geriatric and SpeciaI Patient
Dent&y, University of Southern California, School of Dentistry, Los
Angeles, CA.

Badma E. Naegele. Chief, Health Promotion Directorate, Minis&y of Health,
Ottawa, Ontario, Canada.

Michael Nevitt, PhD. Assistant Professor, Department of Medicine and
Epidemiology, University of California, San Francisco General Hospi-
tal, San Francisco, CA.

Frank Nice. National Institute of Neurological and Communkative Disorders
and Stroke, National Institutes of Health, Bethesda, MD.
Herbert Nickens, MD. Dim&r, Office of Minority Health, US Public Health
Semice, Washington, DC.

Linda C. Niessen, DMD. Director, Geriatric Dental Program, VA Medical
center, Perry Point, MD.

Thomas Novotny, MD. Office of Smoking and Health, Centers for Disease
Contml, Rockvine, MD.

Paul Nutting, MD. Mercy Medical Center, Denver, CO.
Nancy J. Olins, MA. Director of Program Development, American Associa-
tion of Retired Persons Pharmacy Service, Alexandria, VA.

107


   Franklin P. Ollivierre. Region I%- Director-Region I, Administration
     on Agiiq, Boston, MA.
   York Qnnen. iXector of Prog~~- Development, President's Council on
    Physical Fitness and Sports, i$:ashington, DC.
   Marria Ory, PhD. Chief, Social !?cexe Research ofi Aging, Behavioral and
     SociaLResearch Progmn, Ntiti Institute on Aging, National Ins&
      tutes of Health, Bethesda, M3.
   Terry Pechacek, PhD. Division of Cancer Prevention and Control, National
      Cancer Institute, National In&lutes of Health, Bethesda, MD.
   Jo ANI Peps. Nutrition Coon&mm, Health and Human Services-Region
      VIII Office, Denver, CO.
   Scott pressOn, DDS. Indian Heath Ser$ce, Rockville, MD.
   Barbara Quaintawe. Health Advocacy %-vices, American Association of
     Retired Persons, Washington, DC.
   Daniel Quirk. Executive Director! *National Association of State Units on
     Aging Washington, DC.
   Peter Rabins, MD. Chief, Department of Psychogexiatrics, Johns Hopkins
      .School of Medicine, Baltimore, MD.           . .
   William Rakowski, PhD. Center for kntology and Health Care Reseaxh,
     Brown University Pmgram in Medicine, Providence, RI.
   Wayne A. Ray; PhD. Director, Division of Pharmacoepiderniology, Van-
     derbilt University School of Medicine, Nashville, TN.
   Paul S. Rhodes, MD. Director, Geriatric Care of Greater Washington,
     Washington, DC.
   Barbara Rimer, DrPH. Director, Health Communications Research, Fox
     Chase Cancer Center, Philadelphia, PA.
   Dorothy Rice, ScD. Professor, Department of Social and Behavioral Sciences,
     School of Nursing, University of California, San Francisco, CA.
   Vicent C. Rogers, DDS. Chairman, Department of Community Dentistry,
     Georgetown University School of Dentistry, Washington, DC.
   Robin Room, PhD. Director, Alcohol Research Group, Medical Research
     Institute of San Fran&co at Pacific Presbyterian Medical Center, Ber-
     keley, CA.
   I.,inda.Saltzman, PI-0 Division of Injury Epidemiology and Control, Centers
      for Disease Control, Atlanta, GA.
   Richard Sattin, MD. Division of Injury Epidemiology and Control, Centers
      for Disease Control, Atlanta, GA.
   Michelle J. Saupders, DMD. Director, South Texas Geriatric Education Center
     University of Texas, San ArItOdo, TX.
   David G. Schulke. Special Commit@ on Aging, United States Senate,
     Washington, DC.
   Ruth %igler. Executive Director, South Carolina Commission on Aging,
      Columbia, SC.
   Richard H. Seiden, PhD. Suicid&gist Consultant, Oakland, CA.
   Marymae Seward. Department d Psychology, University of Southern
     CaIifornia, Los Angeles, CA.
   Kathleen Shay. Department of F+hOlOgy, University of Alabama at
     Birmingham, Birmingham, .M-


Domthy L. Smith, PharmD. President, Consumer Health Information Cor-
poration, McLean, VA.

Gwen Solon, MD. Office of Technology Assessment, Congress of the United
States, Washington, DC.

Ann Sorenson, PhD. National Institute on Aging, National Institutes of
Health, Bethesda, MD.

Suzanne K. Steinmetz, PhD. Professor, Individual and Family Studies,
University of Delaware. Newark, DE.
Thomas E. Stevens. University of Mississippi School of Medicine, Jackson,
MS.

Michael Stoto, PhD. Institute of Medicine, Washington, DC.
Rebekah Street. University of Southern California School of Nursing,
Paramount, CA.

David Sundwall, MD. Administrator, Health Resources and Services Ad-
ministration, RockvIle, MD.

Fred Tavill. Dire&or, Milwaukee International Health Training Center,
Milwaukee, WI.

Hugh H. Tilson, MD, DrPH. Head, Product Surveillance and Epidemiology,
Burroughs Wellcome Company, Research Triangle Park, NC.
William N. Tindall, PhD. Director of Professional Affairs, National As=
ciation of .Retail Druggists, Alexandria, VA.
Wayne Turner, PharmD. Food and Drug Administration, Rockville, MD.
Anthony Vutum, MD. Professor and Head, Department of Family and Com-
munity Medicine, University of Arizona Medical School, Tucson,
AZ.

Judith Wagner, PhD. Office of Technology Assessment, United States
Congress, Washington, DC.

Susan Nobel Walker, PhD. Health Promotion Research Program, !3ocial
Science Research Institute, Northern Illinois University, Dekalb, IL.
Patricia F. Waller, PhD. Director, Injury Prevention Research Center, Uni-
versity of North Carolina, Chapel Hill, NC.
Hongying Wang DDS. School of Stomatologyj Beijing Medical University,
Minneapolis, MN.

Gregg War&w, MD. Department of Family Medicine, University of Cin-
tinnati Cdege of Medicine, Cincmnati, OH.
Nancy Wartow, Pmgram Analyst, Office of Program Development, Admin-
istration on Aging, Washington, DC.
Richard Weindruch, PhD. Biomedical Research and Clinical Medicine,
National Institute on Aging, National Institutes of Health, Bethesda,
MD.

Charles Wells, Deputy Commissioner, Administration on Aging, Wash-
ington, DC.

Sara White. Office of Disease Prevention and Health Promotion, Washing-
ton, DC.

Emla Polly Williams. Cherry Hill, NJ.
T. Franklin Williams, MD. Director, National Institute on Aging, National
Institutes of Health, Bethesda, MD.

109