OPENING PLENARY SESSION Keynote Address Presented by C. Everett Koop, MD . Surzeon General, United States Public Health Service Sunday evening, March 20, 1988 a Thank you, Dr. Abdellah. I want to personally welcome you and thank you all for coming to this Surgeon General’s Workshop on Health Promotion and Aging. We have three days of serious deliberation, illuminating 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. If I had an extra hour or so, I would gladly name and thank each one of them personally. That’s not possible. 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 has been subtle but essential throughout the plan- ning process, 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— equipped 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: e Every state now has a lead agency of its own to spearhead the health promotion effort... © There are some 35 state interagency coalitions at work to promote the health ‘of older Americans... e A National Public Education Program, called the ‘Healthy Older Per- soris 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 Preven- 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.0.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. But 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 still 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 will 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 at 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 processes and disabling conditions that often interfere with the normal and healthful processes of aging. Rather, we believe that health professionals can put much greater empha- sis on health promotion without compromising in any way the more tradi- tional and still effective approaches to health care. We believe that this must be done ... we're here to say that it can be done ... and by noon on Wednesday, we will tell the health community how it might be done on behalf of the elderly and the very old. | 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 re-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 post 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 overall for our country’s older citizens. Older people—like people of all ages—do not live in a vacuum: ¢ They work in places that are pleasant—and in places that aren’t so pleasant... e Their human relationships may be loving and caring, or difficult and stressful ... « They may have financial independence, or they may be totally depen- dent on family or Government to provide all their basic needs ... e 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, another group will 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 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: * The yield of the research community has been prodigious, with much more yet to come. ¢ The nation is more health-conscious and more pro-health than at any time in 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’ll be back at this podium tomorrow to present my ““charge”’ to the working groups. ' Then, on Wednesday, Commissioner Carol Fraser Fisk, Dr. Williams, 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 will 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 AoA/PHS 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 Williams has helped us forge even stronger collaborative ven- tures. And, the vigilance of the Deputy Surgeon General, Dr. Faye Abdel- lah, 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 will be over 85 years old. The impact of those demographic changes in society today is significant, and that impact will continue to grow as the numbers of older Americans continues to increase. All segments and institutions of our society will need to change as our population ages. As I look into my crystal ball, I see vari- ous areas of our lives which will 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 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 will 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- Tent 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 particularly important in isolated rural areas. Our manpower needs will certainly change as we will need more per- sons in new types of careers. Technology will cause changes in the way 6 we deliver care and our needs for various types of care changes with age. But that new technology won't address all the issues of an aging America. Families and friends will continue to serve as caregivers, and they will need training as well as respite services. They may also need innovative wavs to cover the costs of health care expenses. Individuals will need to begin planning earlier and personally take more steps to assure a finan- cially secure old age. Perhaps we will even see more incentives for those who pursue healthy lifestyles. With 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 replaced 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 we live. The relationships between such factors as nutrition, exercise, preventive health and disease mean that we can take a more active part in our own health care. Each of us will need to be more pro-active in work- ing with health professionals, staying well, and when ill, taking part in our 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 well- 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, will produce significant and tangible benefits. I ask you, how can we reach more mature citizens with this important message? Third, we need to build partnerships to help educate people of all 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 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 to 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. _ [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. Address Presented by Assistant Surgeon General T. Franklin 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 1970s, 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 illnesses might be avoided. There 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 NIA. Investigators now had the direction from Congress to discover which aspects of aging processes might benefit from medical intervention. The goal was, and still is, to be able to understand normal aging processes and develop ways to improve the quality of life for all people as they grow 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, Baltes, 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 13,000 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 [Cornoni 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 or demented as they grow old, we can examine ways to maintain a per-