Copyright 1991 by The Cerontological Society of America The Cerontologist Vol. 31, No. 6,822-829
The changing nature of disease risks and functional health status with aging suggests the need to focus health promotion efforts in the older population where they will be most effective in reducing morbidity, mortality, and disability. However, there is little consensus in the literature regarding the efficacy of various health promotion practices and the appropriate target groups within a diverse older population. Careful research on and thoughtful application of findings to this older population are needed to ensure the effective use of limited health promotion resources. Key Words: Health maintenance, Disability reduction, Functional health
Health Promotion for Older People: All Is Not Well Tom Hickey, DrPH,1 and Diana L. Stilwell, MPH1
tion in the elderly, as well as to call attention to what may be feasible given the gaps and deficiencies in our knowledge base and the limitations of available resources for preventive medicine. Necessarily limited investments in health promotion must be directed where positive outcomes can be expected, especially in a social climate where the high costs of caring for a growing older population have provoked concern and criticism. Although the growing interest in geriatric health promotion is welcome, a cautious approach informed by empirical data and tempered by political realities will be required to produce needed change. The Goal of Health Promotion in the Older Population
An important initial consideration is to identify the changing characteristics of health promotion and disease prevention for individuals and cohorts as they grow older. The focus of health promotion in younger persons is clearly preventive in nature. Convincing younger individuals of the importance of maintaining a good diet, exercising regularly, and not smoking is hoped to minimize risk factors for conditions such as cancer and coronary artery disease, thereby reducing the incidence of these lifeshortening diseases later in life. The changing nature of illness risks and health maintenance needs over the life course suggest a broader health promotion focus for older adults. Some diseases, such as influenza and pneumonia, require aggressive prevention strategies in old age to reduce the increasing risks of morbidity and mortality. Many chronic conditions, however, are frequently the end result of lifelong exposures to risks, the effects of which become less remediable with age. Where disease prevention is not possible, behavioral and life-style changes and early treatment may slow the progression of existing chronic diseases and the rate of disability associated with them. Thus, many diseases can be prevented in the tradi-
^epartment of Health Behavior and Health Education, School of Public Health, and Institute of Gerontology, University of Michigan, 1420 Washington Heights, Ann Arbor, Ml 48109-2029.
822
The Gerontologist
Downloaded from http://gerontologist.oxfordjournals.org/ by guest on August 11, 2015
Disease prevention and the promotion of health have received a great deal of attention lately, as evidenced by increasing social constraints on cigarette smoking, changing patterns in the use of alcohol, the proliferation of diet and exercise plans, and the aggressive marketing of various health foods and vitamin supplements. As a vulnerable high-risk group and the most rapidly increasing segment of the population, older people have become an important target group for health promotion activities. Old age is accompanied by increasing risks of morbidity and mortality and a greater need for health care services. Thus, avoiding illness, pain, and disability are high priorities in the quality of life for many older people who are the primary consumers of medications and health care services. The health status of older people is also important to society generally, since the provision of geriatric care accounts for a large portion of the national health budget. Although health promotion in the older population has broad appeal, the present momentum risks overlooking important considerations of the potential efficacy of various health initiatives and the identification of appropriate target groups. There is a great deal that we do not know about applying preventive medicine to older people. There is also a danger that health promotion will be defined only in terms of the health outcomes of individual behaviors, ignoring important epidemiologic, environmental, and societal etiologies. A comprehensive review of current research and conceptual thinking on health promotion in the elderly risks being a reiteration of what has already been stated well (e.g., Berg & Cassells, 1990; Kane, Evans, & Macfadyen, 1990). However, in the context of growing interest, it is important to clarify the objectives of health promotion and disease preven-
Deficiencies in the Knowledge Base
The effectiveness of efforts to change health behaviors and modify risk factors in the older population will be determined, in large part, by selecting those behaviors and risks most amenable to change and the most effective means of changing them. This represents a considerable challenge, since the evidence in many high-risk areas is sparse and often contradictory. Difficulties also arise in attempting to assess the relative contributions of health promotion efforts, biogenetic vulnerability, and lifelong health habits to the risks of disease in older adults. Some preventive measures are more likely to lead to successful outcomes — for example, the right type of influenza vaccine appropriately administered to a high-risk elderly population can be fairly effective in reducing hospital admissions, overall morbidity, and mortality (Stults, 1984). However, as will be shown in subsequent examples, the merits of many other preventive actions, which are often widely promoted by either the professional or popular media, have not been clearly demonstrated in the older population. There are several reasons for uncertainty about the effectiveness of disease prevention and health promotion in the older population. A major problem has been the lack of important epidemiologic data on older populations and the absence of well-designed, randomized, clinical trials of health promotion interventions. Although longitudinal investigations such as the Framingham and Alameda County studies, as well as several national health interview surveys, have been useful in providing information about risk factors, these studies have necessarily been limited Vol. 3 1 , No. 6,1991
in scope. Also, most clinical trials in recent years have yielded only inconclusive evidence regarding the efficacy of various health promotion initiatives (Abdellah & Moore, 1988). Similarly, health promotion research has been limited by difficulties in replicating descriptive studies or demonstration projects and generalizing from their results, as well as with the choices of intervention strategies and outcome measures (Herdman, 1985). The exclusion of elderly individuals from existing trials often is based on the belief that treatment or prevention produces either similar or very few health benefits beyond a certain age. But assumptions about the ineffectiveness of interventions or behavior changes among older and/or disabled individuals are often unfounded. For example, positive health effects have been observed following a relatively brief exercise intervention with a frail older population — individuals who would have been excluded from similar studies based on their poor health status (Hickey, Wolf, & Robins, 1990). Ironically, practitioners often advocate specific health promotion programs for the elderly, despite the fact that older people have been almost ignored in empirical investigations of the effectiveness of those very interventions. Thus, current acceptance of what is considered good preventive or rehabilitative practice for older adults is based on either limited data or studies of middle-aged persons — frequently self-selected samples of persons without diagnosable chronic disease, or other atypical populations. This is especially true in clinical trials of various drugs and medications used by chronically impaired older people on an ongoing basis for such conditions as arthritis and hypertension. Also, in the absence of carefully designed studies, little is known about the effects of health promotion efforts in important subgroups of older adults, especially those who are being treated for multiple chronic conditions. Health promotion in the older population is hindered further by limited knowledge of the course of disease in the later years, the changing importance of various risk factors, and the benefits and adverse outcomes of intervention (Berg & Cassells, 1990; Davies, 1990). In light of these deficiencies, some of the underlying assumptions about the efficacy and necessity of specific health promotion interventions may be erroneous and actually hinder efforts to implement useful programs in older populations. Rather than simply adopting an intervention used successfully with other age groups as a basis for health promotion in the older population, setting priorities for health promotion interventions in the older population will require a careful examination of likely outcomes, including their costs and longer term effects on health status, behavior, and quality of life.
823
Current Priorities and Future Directions
Full consideration of these and related concerns about the knowledge base is beyond the scope of a single paper. However, some of their implications
Downloaded from http://gerontologist.oxfordjournals.org/ by guest on August 11, 2015
tional sense in older persons, although prevention also takes on a broader perspective related to health maintenance in this population. Consequently, health promotion priorities for older adults include timely detection and treatment of major illness conditions, such as cancer and heart disease, and interventions designed to reduce the potential impact of such conditions on overall functional health. Health promotion must also be adapted to the changing nature of health status in late life, as well as to the variability that is present in the older population as a result of biological and personal differences in health risks. This variability suggests the importance of health promotion for modifying behavioral factors as a means of reducing disability and slowing the progression of disease, and for targeting those individuals who are at higher risk due to life-style. Therefore, in a context of diminishing opportunities to prevent the major diseases of old age (e.g., other than high-risk, acute problems such as influenza and respiratory illnesses), the overall goal of health promotion in the elderly population should be to prevent the progression of disease and the risks of disability and death. As with geriatric medical care, health promotion should be designed to help older persons maintain their functional independence and autonomy for as long as possible (Davies, 1990).
In addition, regular Pap smears have not been a part of routine health care for the present cohort of older women. Fifteen percent of women over age 65 and 38% of those over age 75 have never had this test, which is the most commonly used screen for cervical cancer (Leventhal, 1986). Abnormal tests are two to three times more likely in women 65 years and older than in those under age 65, and most occur in women who have not been screened previously. At least one recent study has found that regular screenings would lead to greater reductions in mortality among women over age 65 when compared with other age groups (Fletcher, 1990). Thus, in women over 65 who have never had regular Pap smears, it may be helpful to screen regularly for several years, while those who have had normal Pap smears for several years consecutively may not need to continue them past that age (Robie, 1989), although the complete discontinuation of screening after age 65 is currently under debate (Berg & Cassells, 1990). Colorectal and prostate cancers are also of increasing concern with aging. However, the efficacy of screening and detection programs is less clear. Given that the peak incidence of colorectal cancer is around age 80, with 60% of new cases occurring after age 60, it appears that older persons are at particular risk for this form of cancer (National Cancer Institute, 1988). By age 70, colorectal cancer is one of the major causes of mortality for both men and women (List, 1987), yet over 60% of older whites and 70% of older Blacks report never having received the fecal occult blood test, a preliminary screen for cancer at this site (National Cancer Institute, 1988). The data for prostate cancer indicate a similar relationship with age: most incidence and virtually all mortality occur after the age of 60 (Silverberg, Boring, & Squires, 1990). Available information about the benefits of regular colorectal and prostate exams is insufficient to suggest general recommendations for the older population (Robie, 1989). It is generally agreed that screening for prostate cancer by means of rectal examinations is not effective at any age. Screening for colorectal cancer is more effective in detecting disease, but uncertainties about the natural history of this disease suggest that increased detection may be identifying only less aggressive forms of illness. It is not yet clear whether this increased rate of detection is related to a decrease in cancer mortality (U.S. Congress, Office of Technology Assessment, 1990). More information is needed about the most appropriate target groups for colorectal cancer screening in the oldest population, as well as the likely impact of increased screening efforts on ageadjusted mortality rates and overall quality of life. Given the invasiveness frequently associated with screening methods and the potential impairments, discomfort, and disability that may result from the treatment of cancer, additional attention should also be given to qualitative outcomes when identifying appropriate target groups for cancer screening (Berg & Cassells, 1990). Quality of life considerations are even more important when one considers that, with
Effectiveness of Cancer Detection and Screening Cancer detection and screening programs have been a much higher priority in health promotion for the general population than for older people, with the result that little is known about the benefits, risks, and feasibility of cancer screening and intervention in the older population (Davies, 1990). Yet 50% of new cases of cancer and 60% of cancer deaths occur in persons over age 65 (National Cancer Institute, 1988). These rates vary widely by type of cancer, with age-related incidence and mortality even higher for certain types of cancer. As evidenced by the examples that follow, the early detection and treatment of many forms of cancer in the older population could have considerable impact on overall cancer morbidity and mortality rates. However, widespread screening programs may be too costly or invasive to justify their implementation beyond high-risk groups. Also, fear of a diagnosis of cancer or of the pain and disability associated with treatment may inhibit reporting of important symptoms. Thus, aggressive detection efforts will be of little value if few cases are actually identified and treated, and if high-risk target groups are unlikely to acknowledge or deal with symptoms or to see cancer as amenable to prevention and health maintenance strategies. For instance, breast cancer is a leading cause of cancer death in women after age 35, and women over the age of 60 account for over half of all incidence (Silverberg, Boring, & Squires, 1990). Having regular mammograms reduces breast cancer mortality (Tabar et al., 1985), yet only 16% of mammograms are performed on women over the age of 60 (Leventhal, 1986). At least one study has observed that physicians are often less likely to recommend mammograms for older women (Coll et al., 1989). Breast cancer is often detected at more advanced stages in older women than in younger women, suggesting that the disease is progressing further in older women, who are being overlooked in screening programs (Holmes & Hearne, 1981). 824
The Gerontologist
Downloaded from http://gerontologist.oxfordjournals.org/ by guest on August 11, 2015
for establishing future objectives need to be considered in the context of major priorities for disease prevention and health promotion related to behavior risk factors. Health screening, illness detection programs, and other initiatives related to smoking, diet, exercise, and personal life-style, which have received considerable scientific attention as well as broad public visibility, provide useful examples of the difficulties of establishing clear directions for disease prevention and health promotion in the older population. For the most part, these efforts have been related to cardiovascular disease and cancer, given their predominant association with morbidity and mortality in the older population. Yet, although cancer and heart disease represent major priorities for health promotion research and intervention, the track record of various strategies for early detection and overall risk reduction and for management of these problems in older adults has not been outstanding.
many older adults, life expectancy may not differ significantly with or without treatment for cancer in the presence of competing causes of death; however, the quality of their remaining lifetimes may be affected markedly. The objective should be the detection of treatable cases at fairly early stages, rather than widespread cancer screening.
cause of death and disability in older adults, suggesting the need for continued health promotion efforts. Although the positive benefits of various health promotion activities related to cardiovascular risks are not disputed, the degree and intensity with which specific behaviors should be promoted in older adults is often unclear. For example, overweight individuals with age-related elevated blood pressure, but with no personal or family history of heart disease or related illness events, may well be at low risk and not a high-priority group for intervention. The safest conclusion is that the risk factors that predict cardiovascular morbidity and mortality in middle age continue to be important in old age, although their association is thought to be reduced — especially after age 80 (Davies, 1990).
Vol. 31, No. 6,1991
Smoking Cessation Due to its association with lung cancer and heart disease, smoking cessation has been a major health promotion initiative in the general adult population. Although this is an important area for intervention, very little research has been done on smoking cessation among older people. However, it seems clear that smoking cessation remains beneficial for persons over 65, decreasing the risk of death from coronary heart disease among those who quit (Jajich, Ostfeld, & Freeman, 1984). A recently completed prospective study of three community populations found that the benefits of smoking cessation are especially marked for reduction in coronary heart disease mortality for older men and women (LaCroix et al., 1991). Overall, the data on smoking cessation indicate that life expectancy at all ages increases, and that the increase for older adults is proportional to that for younger persons. Risk of mortality from lung cancer is also reduced by up to 30-50% after 10 years of nonsmoking, and reductions in morbidity and disability from other cardiopulmonary and respiratory conditions are also significant following smoking cessation. Perhaps the most important aspect of smoking cessation is that it is utterly free of the side effects sometimes associated with pharmacological means of reducing disease risk, and is said to offer a greater benefit than any other therapy for avoiding cardiovascular morbidity and mortality — even in older populations (Kannel & Higgins, 1990). Current smoking rates among older adults aged 50 to 74 are still relatively high, despite the fact that significant numbers have quit smoking. Current smokers aged 50 to 74 are believed to be at especially high risk since they have smoked longer and are heavier smokers (Shopland & Brown, 1987). For the most part, this age group has been ignored in health promotion efforts due to the belief that the effort entailed in changing a well-entrenched habit of many years was greater than the modest health outcomes that could be anticipated from smoking cessation. In light of more optimistic findings, there is a need for smoking cessation programs targeted specifically at older age groups on the basis of their greater vulnerability to morbidity and disability. At present, little is 825
Downloaded from http://gerontologist.oxfordjournals.org/ by guest on August 11, 2015
Cardiovascular Disease and Hypertension Risk Reduction Despite considerable progress in risk reduction over the past 20 years, heart disease and stroke continue as the major causes of death in the older population, with high blood pressure as a primary risk factor. Although some estimates suggest that over half of all persons over age 65 have chronic high blood pressure, recent estimates using averaged measures over a period of time report that the true prevalence of hypertension in the elderly is somewhat lower (Applegate, 1989). Despite the prevalence of cardiovascular disease with aging, the considerable variability in individual risk of heart disease in old age suggests the merits and potential costeffectiveness of initiatives that are focused more on the highest risk groups. For those at risk, hypertension tends to rise with age, and isolated systolic hypertension affects about 20% of persons over age 80 (SHEP Cooperative Research Group, 1991). Results from the Framingham study indicate that elevated systolic hypertension is the single greatest risk factor for cardiovascular disease in persons over age 50 (Kannel,1986). Although the pathophysiology of hypertension reflects presumably irreversible age effects, treating hypertension in the older population has shown great potential. For example, a recently completed major study of systolic hypertension in the elderly found that the use of diuretic drugs reduced the incidence of stroke by 36% even among those over age 80 (SHEP Cooperative Research Croup, 1991). Interventions to reduce diastolic hypertension in persons over 60 have also demonstrated reductions in total mortality (Hypertension Detection Follow-up Group, 1979); total cardiac events (MacMahon et al., 1984); and cardiovascular and cerebrovascular mortality and overall cardiac mortality (Amery et al., 1985; Coope & Warrender, 1986). However, the majority of research on the effects of lowering blood pressure on morbidity and mortality has focused on pharmacologic interventions to reduce diastolic blood pressure (Kannel, 1986). Given the problems of multiple drug use among the very old, the merits of other types of intervention (e.g., diet, exercise) for maintaining blood pressure control need more careful study. The remarkable downward trend in mortality from coronary heart disease can be attributed, at least in part, to successful health promotion efforts in the areas of hypertension management, smoking behavior, and dietary and related life-style changes, which are discussed further in the following sections. However, cardiovascular problems remain the major
known about the types of programs that are likely to be effective with older adults. Further research is needed into the types of motivators elderly people respond to, the ways in which they decide to quit, and their perceptions of the benefits of smoking cessation.
Dietary Factors Extensive evidence indicates the benefits of good nutrition for older adults. Reducing the intake of sodium, sugars, fats, and cholesterol has been found to lower the risk of developing various diseases in middle-aged and older persons (Costell, 1985), as well as to slow the progression of existing chronic conditions such as osteoporosis, hypertension, and diabetes (Posner et al., 1987). For example, diets that are high in fat and low in fiber have been linked to some forms of cancer, especially those of the digestive tract, that affect the elderly. Diets high in calcium are also thought to provide some protection against osteoporosis. At the same time, there is a good deal of confusion about the health implications of various food products, as evidenced by a recent Newsweek cover story (Shapiro et al., 1991). It would seem that dietary recommendations represent an area where there is so much information that it is contradictory and confusing. Since the best course of action is not always clear, there is a generalized expectation that what is considered healthful today may change tomorrow with new evidence. For example, restricting the intake of sodium, long implicated in heart disease, now appears to be important only for a subset of the population. Also, for most people, the moderate use of sugar is probably less harmful in the long run than the use of artificial sweeteners. On the other hand, the increased consumption of oat products, considered by many as a passing fad, appears to have a beneficial impact on the reduction of LDL cholesterol (Humble, 1991). Uncertainties in scientific beliefs about how healthful various foods are makes it easy for many people to justify making no changes in dietary patterns. Also, older persons often feel even more complacent about their eating habits on the basis of their longevity. The role of health promotion in regard to diet lies in the interpretation and application of research findings to older adults with specific health risks in terms that help them to integrate scientific findings with general recommendations about diet and healthful eating behaviors. Regardless of uncertainties about specific foods, there is considerable room for im-
826
The Gerontologist
Downloaded from http://gerontologist.oxfordjournals.org/ by guest on August 11, 2015
Physical Fitness The relationship between physical fitness and allcause mortality — especially in relation to coronary heart disease — suggests that some form of exercise is probably beneficial for most individuals (Paffenbarger et al., 1986), although it is far from clear to most older persons what type and intensity of exercise might be best for them. Longitudinal studies of middle-aged persons have shown that regular exercise is associated with reduced risks of arteriosclerosis and coronary heart disease; some studies also report similar findings with samples of older adults (Pollock et al., 1987; Seals et al., 1984). Many studies have examined the effects of vigorous exercise, such as running or biking, on cardiovascular function measured by maximum oxygen uptake, physical work capacity, and resting heart rate (e.g., Cunningham et al., 1987; deVries, 1970; Morey et al., 1989). However, the association between these parameters and either cardiovascular disease or overall functional health has not been clearly established, and the majority of studies of the effect of exercise on chronic conditions such as coronary artery disease, diabetes, and hypertension have reported either negative or only marginal improvements (Holloszy, 1983). These mixed results suggest that the current outcome variables that measure cardiovascular and related physiology may not reflect important functional changes and ADL benefits in the older population. Relatively few studies measure the effects of less intensive forms of exercise on the maintenance of function and delay of disability associated with heart disease, arthritis, and other chronic conditions. In a recent series of pilot studies that examined the effects of low-intensity exercise on chronically impaired older adults, consistent reductions in blood pressure were observed over time among individuals with multiple chronic conditions. The sustained effects of a physical activity intervention — especially on individuals with isolated or borderline systolic hypertension — were also significant (Wolf et al., 1990). Improvements were noted in mobility, flexibility, and self-reported pain as well, suggesting the potential contribution of low-intensity exercise to the reduction of dysfunctions associated with arthritis (Hickey, Wolf, & Robins, 1990). Despite the attention given to exercise as a means of reducing disease risk, its specific contributions to overall health maintenance in general and cardiovascular disease prevention in particular remain unclear. The available evidence does not appear conclusive enough to justify the recommendation of vigorous exercise, and available data on the effects of
less intensive physical activity are insufficient to specify the high-risk target groups most likely to benefit. Different outcome variables are needed to determine the effectiveness of exercise performed at various intensities on reducing morbidity and disability. For example, it is possible that maximal aerobic capacity or resting heart rate are not the most important measures of risk reduction in older people. For chronically impaired individuals, changes in ADL capacity might be a more meaningful measure of the effectiveness of a physical activity program. Longitudinal studies of both well and chronically impaired older persons are needed to determine the benefits and risks of exercise in both groups and to provide more specific guidance regarding the efficacy of physical activity.
Vol. 31, No. 6,1991
ease events and mortality. It has been suggested that the most cost-effective means of lowering serum cholesterol would be dietary changes (U.S. Congress Office of Technology Assessment, 1989); this may be especially relevant for individuals whose cholesterol falls into the borderline high range. Research is needed to determine who among the older population will benefit the most from screening and intervention, and to examine the behavioral components of the life-style changes needed to maintain compliance with dietary regimens. Specific modifications in diet may be the least costly both to the older person and the health care system, suggesting their inherent appeal for health promotion and health maintenance in older people. Continued attention should be given to the effectiveness of diet, both alone and in conjunction with physical activity and smoking cessation, in decreasing the incidence of cardiac events in older adults (Kannel, 1986). Conclusion The prevalence of cardiovascular disease in the older population, as well as its potential for causing serious disability, makes it an obvious priority for health promotion efforts. Weight reduction, dietary changes, hypertension management, and at least moderate exercise on a regular basis are likely to have beneficial effects on the reduction of cardiovascular risk factors in late life. At the same time, because of the wide range of variability among older people in terms of individual risk of cardiovascular morbidity and mortality, disease prevention efforts and health promotion interventions need to be carefully targeted to those who are likely to derive the greatest benefits. In addition to targeting high risk groups, there are at least three other important objectives for disease prevention and health promotion in the older population. Diseases like influenza and pneumonia, with high morbidity and mortality rates, require aggressive prevention strategies. For other conditions, as evidenced from the review of cancer detection, many questions remain about the benefits of screening and intervention. Available clinical research data indicate a number of potential adverse effects in treating cancer, especially in frail older persons with other comorbid conditions. At the same time, the positive findings of the recently completed SHEP study regarding the treatment of systolic hypertension in the very elderly suggests that issues of efficacy need to be given high priority in further research. Finally, health promotion in the older population must also address the declining mobility and functional status that often results from specific conditions, such as osteoarthritis, or from multiple chronic problems. The combined effects of such chronic conditions are often more predictive of health status than any one of them individually. As a consequence, priority should be given to health promotion efforts that address older persons' basic functional needs regardless of their pathologic origins. 827
Downloaded from http://gerontologist.oxfordjournals.org/ by guest on August 11, 2015
provement in dietary patterns in the older population — e.g., obesity, very common among older people, is a major risk factor for a number of agerelated chronic conditions. Many individuals who could benefit from changing their dietary habits may well avoid this task in the absence of a clear idea of the relationship of their food intake and their health status. Older persons might have greater receptivity to a more focused approach that would identify specific priorities related to major health risks than to the more typical promotion of the general benefits of overall dietary improvements. Perhaps the most promising areas for intervention and research into the benefits of good nutrition are its effects on hypertension and plasma lipid levels, two of the most important risk factors for cardiovascular disease. Dietary interventions, including weight loss and monitoring of sodium, cholesterol, and fat intakes, have been found effective in reducing hypertension and improving plasma lipid levels in high-risk individuals (Stamler, 1988). Interventions to reduce hypertension through dietary changes have several advantages over pharmacological therapies: lower cost, decreased likelihood of medication side effects, and avoidance of drug interactions (Berg & Cassells, 1990). However, some combination of diet and medication is often necessary for optimal blood pressure control. Hypercholesterolemia is a significant risk factor for coronary heart disease at all ages, but the association between elevated plasma lipid levels and cardiac events is attenuated after age 65. Elevated LDL cholesterol fractions remain a risk factor in elderly persons, and higher HDL cholesterol levels continue to be protective, although this relationship is also less strong than at younger ages (Kannel, 1986). Because of this observed lessening of risk with age, some researchers have argued that screening for elevated plasma lipid levels after age 70 has questionable predictive value (Garber, Sox, & Littenberg, 1989). However, others maintain that because the incidence of coronary events increases with age, screening and intervention past age 65 will continue to save a significant number of lives (Multiple Risk Factor Intervention Trial, 1990). The general recommendation is to screen asymptomatic individuals and those without other risk factors for heart disease at least every 5 years; however, some regard even this as optional for women and older persons (Garber, Sox, & Littenberg, 1989). At least two major studies have found that high dietary intake of fats is associated with the development of coronary heart disease (Shekelleetal., 1981; Kushi et al., 1985). However, the impact of dietary interventions to reduce cholesterol levels is not clear, especially in older populations. Most clinical trials of the efficacy of cholesterol-lowering interventions on subsequent coronary events have used pharmacologic methods to lower cholesterol levels that were initially extremely high; the Lipid Research Clinics Coronary Primary Prevention Trial demonstrated the positive impact of lowering cholesterol by diet and drug interventions on coronary heart dis-
in personal health maintenance may be fairly high. In fact, a number of cross-sectional and longitudinal studies (e.g., Belloc & Breslow, 1972; Prohaska et al., 1985) have found higher rates of preventive health practices in older people when compared with younger groups. As suggested by Borgatta et al. (1990), there may be transition points at which positive behavioral change has a greater likelihood of success. Such a transition point may well occur at that stage in life when personal health appears to be most threatened. Although it is not likely that all people want good health at all times, older people may at least not want poor health more than at any other time in their lives. References Abdellah, F. C , & Moore, S. R. (1988). Surgeon general's workshop — health promotion and aging background papers. Washington, DC: U.S. Public Health Service. Amery, A., Birkenhager, W., Brixko, P., Bulpitt, C , Clement, D., Deruyttere, M., DeSchaepdryver, A., Dollery, C , Fagard, R., Forette, F., Hamdy, R., Henry, J. F., Joossens, J. V., Leonetti, C , Lund-Johansen, P., O'Malley, K., Petrie, ) . , Strasser, T., Tuomilehto, J., & Williams, B. (1985). Mortality and morbidity results from the European Working Party on high blood pressure in the elderly trial. Lancet, 2, 1349-1354. Applegate, W. B. (1989). Hypertension in elderly patients. Annals of Internal Medicine, 110, 901-915. Belloc, N. B., & Breslow, L. (1972). Relationship of physical health status and health practices. Preventive Medicine, 1, 409-421. Berg, R. L , & Cassells, J. S. (Eds). (1990). The second fifty years: Promoting health and preventing disability. Institute of Medicine. Washington, DC: National Academy Press. Borgatta, E. F., Bulcroft, K., Montgomery, R. ). V., & Bulcroft, R. (1990). Health promotion over the life course: Strategies for effective action. Research on Aging, 12, 373-388. Coll, P. P., O'Connor, P. ] . , Crabtree, B. F., & Besdine, R. W. (1989). Effects of age, education, and physician advice on utilization of screening mammography. journal of the American Geriatrics Society, 37, 957-962. Coope, J., & Warrender, T. S. (1986). Randomized trial of treatment of hypertension in elderly patients in primary care. British Medical Journal, 293, 1145-1151. Costell, D. O. (1985). Diagnosis of non-cardiac chest pain in older patients. Geriatrics, 40(10), 61-86. Cunningham, D. A., Rechnitzer, P. A., Howard, J. H., & Donner, A. P. (1987). Exercise training of men at retirement: A clinical trial. Journal of Gerontology, 42, 17-23. Davies, A. M. (1990). Prevention in the aging. In R. L. Kane, J. G. Evans, & D. Macfadyen (Eds.), Improving the health of older people (pp. 317-337). New York: Oxford University Press. deVries, H. A. (1970). Physiological effects of an exercise training regimen on men aged 52 to 88. Journal of Gerontology, 25, 325-336. Fletcher, A. (1990). Screening for cancer of the cervix in elderly women. Lancet, 335, 97-99. Garber, A. M., Sox, H. C , & Littenberg, B. (1989). Screening asymptomatic adults for cardiac risk factors: The serum cholesterol test. Annals of Internal Medicine, 110, 622-639. Herdman, R. (1985). Health promotion and disease prevention proceedings. U.S. Congress, Office of Technology Assessment. Washington, DC: U.S. Government Printing Office. Hickey, T., Wolf, F. M., & Robins, L. S. (1990). Exercise and mobility in the older population. Paper presented at the 118th annual meeting of the American Public Health Association, New York. Holloszy, J.O. (1983). Exercise, health, and aging: A need for more information. Medicine and Science in Sports and Exercise, 15, 1-5. Holmes, F. F., & Hearne, E. (1981). Cancer stage-to-age relationship: Implications for cancer screening in the elderly. Journal of the American Geriatrics Society, 29, 55-57. Humble, C. G. (1991). Oats and cholesterol: The prospects for prevention of heart disease. American Journal of Public Health, 87(2), 159-160. Hypertension Detection Follow-up Group. (1979). Five-year findings of the Hypertension Detection Follow-up Program. Journal of the American MedicaJ Association, 242, 2562-2577. Jajich, C. L , Ostfeld, A. M., & Freeman, D. H., Jr. (1984). Smoking and coronary heart disease mortality in the elderly. Journal of the American Medical Association, 252, 2831-2834. Kane, R. L, Evans, J. G., & Macfadyen, D. (Eds.) (1990). Improving the health of older people. New York: Oxford University Press. Kannel, W. B. (1986). Nutritional contributors to cardiovascular disease in the elderly. Journal of the American Geriatrics Society, 34, 27-36.
828
The Gerontologist
Downloaded from http://gerontologist.oxfordjournals.org/ by guest on August 11, 2015
It is easy to be somewhat pessimistic about the likely outcomes of the current enthusiasm for health promotion in the older population. The health care system remains oriented to the medical treatment of disease, with a strong focus on primary prevention. Resources for prevention and promotion will be limited, given the competing demands for our health care dollars and the lack of priority for health maintenance services within most reimbursement mechanisms. Thus, it becomes easier to tell people what to do rather than enabling them to do it. The Surgeon General's national health objectives, for example, provide far more emphasis on personal initiative than on changing the health care system. Healthy People 2000 also fails to address the underlying socioeconomic concerns that continue to lead to wide differences in disease risk and health status across the population (U.S. Public Health Service, 1990). Although it is important to stress the need for commitment to a healthy aging society on the part of older people themselves, this does not justify further abrogation of governmental responsibility for public health, which has been evident in recent years. At the same time, it is important to be realistic about expectations. The costs of disease prevention are often greater than our society has been willing to invest. For example, while universal colorectal cancer screening after age 65 would add 45,000 additional years to older people's lives, the costs of screening far exceed savings from the reduction in treatment costs (U.S. Congress, Office of Technology Assessment, 1990). There are obviously a number of trade-offs here. It is neither possible for society to do everything nor is it reasonable to assume that all individuals will adopt healthy behaviors. However, a national health promotion agenda for older people is more likely to be effective if it focuses on those outcomes with the greatest potential for success. Moreover, to gain wider acceptance within prevailing value systems, such efforts must also be part of a commitment to promoting a healthy aging society, which necessarily includes both individual and governmental responsibility. Accommodating to an aging society will reguire new policy priorities as well as an overall commitment to health maintenance on the part of a growing population of older people. In an era of growing resentment of the affluence of (some members of) the older population, it does not seem unreasonable to expect older people to assume greater responsibility for maintaining personal health as part of a national commitment to health promotion. There is evidence for cautious enthusiasm, too. Older people are likely to be more sensitive than any other age group to the fragile nature of their health. The illness and disability experiences of their age peers, combined with personal exposure to chronic illness, represent a critical reminder of the risks they face in maintaining the independent and autonomous life-styles that strongly characterize the current cohort of older people. Thus, conceivably, the motivation of many older people for taking the initiative
Vol. 31, No. 6,1991
829
Downloaded from http://gerontologist.oxfordjournals.org/ by guest on August 11, 2015
Seals, D. R., Allen, W. K., Hurley, B. F., Dalsky, G. P., Ehsani, A. A., & Hageberg, ]. M. (1984). Elevated high-density lipoprotein cholesterol levels in older endurance athletes. American Journal of Cardiology, 54, 390-393. Shapiro, L., Koehl, C , Springen, K., Manley, H., Pyrillis, R., Hager, M., & Starr, M. (1991, May 27). Feeding frenzy. Newsweek, pp. 46-53. Shekelle, R. B., MacMillan-Shryock, A., Paul, O., Lepper, M., Stamler, )., Liu, S., & Raynor, W . ) . (1981). Diet, serum cholesterol and death from coronary heart disease. The Western Electric Study. New England Journal of Medicine, 304, 65-70. SHEP Cooperative Research Group. (1991). Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Journal of the American Medical Association, 265(24), 32553264. Shopland, D. R., & Brown, C. (1987). Toward the 1990 objectives for smoking: Measuring the progress with the 1985 NHIS data. Public Health Reports, 702(1), 68-73. Silverberg, E., Boring, C. C , & Squires, T. S. (1990). Cancer Statistics 1990. Cancer, 40(1), 9-26. Stamler, J. (1988). Risk factor modification trials: Implications for the elderly. European Heart Journal, 9(Suppl. D), 9-53. Stults, B. M. (1984). Preventive health care for the elderly. Western Journal of Medicine, 141, 832-845. Tabar, L., Faberberg, C. J. G., Gad, A., Baldetorp, L., Holmberg, L. H., Ljunquist, U., Lundstrom, B., Manson, J. C , Eklund, G., & Day, N. E. (1985). Reduction in mortality from breast cancer after mass screening with mammography. Lancet, 1, 829-832. U.S. Congress, Office of Technology Assessment. (1989). Cosfs and effectiveness of cholesterol screening in the elderly. Washington, DC: U.S. Government Printing Office. U.S. Congress, Office of Technology Assessment. (1990). Costs and effectiveness of colorectal cancer screening in the elderly — Background paper. Washington, DC: U.S. Government Printing Office. U.S. Public Health Service. (1990). Healthy people 2000: National health promotion and disease prevention objectives. Washington, DC: U.S. Department of Health and Human Services. Wolf, F. M., Hickey, T., Robins, L. S., Wagner, M. B., & Harik, W. (1990). Effects of low-intensity exercise for older women with systolic hypertension. Paper presented at the 43rd scientific meeting of the Gerontological Society of America, Boston, MA.
Kannel, W. B., & Higgins, M. (1990). Smoking and hypertension as predictors of cardiovascular risk in population studies. Journal of Hypertension, 8 (Suppl. 5), S3-S8. Kushi, L. H., Lew, R. A., Stare, F. )., Ellison, C. R., el Lozy, M., Bourke, C , Daly, L, Graham, I., Hickey, N., Mulcahy, R., & Kevaney, J. (1985). Diet and 20-year mortality from coronary heart disease. The Ireland-Boston Heart Study. New England Journal of Medicine, 312, 811-818. LaCroix, A. Z., Lang, )., Scherr, P., Wallace, R. B., Comoni-Huntley, )., Berkman, L., Curb, |. D., Evans, D., & Hennekens, C. H. (1991). Smoking and mortality among older men and women in three communities. New England Journal of Medicine, 324(23), 1619-1625. Leventhal, E. A. (1986). The dilemma of cancer in the elderly. Frontiers of Radiation Therapy and Oncology, 20, 1-6. List, N. D. (1987). Perspectives in cancer screening in the elderly. Clinics in Geriatric Medicine, 3, 433-445. MacMahon, S. W., Blacket, R. B., MacDonald, G. ] . , & Hall, W. (1984). Obesity, alcohol consumption, and blood pressure in Australian men and women. The National Heart Foundation of Australia Risk Factor Prevalence Study. Journal of Hypertension, 2, 85-91. Morey, M. C.,Cowper, P. A., Feussner, J. R., DiPasquale, R. C., Crowley, G. M., Kitzman, D. W., & Sullivan, R. J. (1989). Evaluation of a supervised exercise program in a geriatric population. Journal of the American Geriatrics Society, 37, 348-354. Multiple Risk Factor Intervention Trial. (1990). Mortality after 101/2 years for hypertensive participants. Circulation, 82(5), 1616-1628. National Cancer Institute. (1988). 1987 Annual Cancer Statistics Review. NIH Publ. No. 88-2789. Bethesda, MD: National Institutes of Health. Paffenbarger, R. S., Hyde, R. T., Wing, A. L., & Hsieh, C. C. (1986). Physical activity, all-cause mortality, and longevity of college alumni. New England Journal of Medicine, 314, 605-613. Pollock, M. L., Foster, C , Knapp, D., Rod, J. L., & Schmidt, D. H. (1987). Effect of age and training on aerobic capacity and body composition of master athletes. Journal of Applied Physiology, 62, 725-731. Posner, B. M., Fanelli, M. T., Krackenfels, M. M., & Saffel-Shrier, S. (1987). Position of the American Dietetic Association: Nutrition, Aging, and the Continuum of Health Care. Journal of the American Dietetic Association, 87(3), 344-347. Prohaska,T. R., Leventhal, E. A., Leventhal, H., & Keller, M. L. (1985). Health practices and illness cognition in young, middle-aged, and elderly adults. Journal of Gerontology, 40, 569-578. Robie, P. W. (1989). Cancer screening in the elderly. Journal of the American Geriatrics Society, 37, 888-893.
The changing nature of disease risks and functional health status with aging suggests the need to focus health promotion efforts in the older population where they will be most effective in reducing morbidity, mortality, and disability. However, there is little consensus in the literature regarding the efficacy of various health promotion practices and the appropriate target groups within a diverse older population. Careful research on and thoughtful application of findings to this older population are needed to ensure the effective use of limited health promotion resources. Key Words: Health maintenance, Disability reduction, Functional health
Health Promotion for Older People: All Is Not Well Tom Hickey, DrPH,1 and Diana L. Stilwell, MPH1
tion in the elderly, as well as to call attention to what may be feasible given the gaps and deficiencies in our knowledge base and the limitations of available resources for preventive medicine. Necessarily limited investments in health promotion must be directed where positive outcomes can be expected, especially in a social climate where the high costs of caring for a growing older population have provoked concern and criticism. Although the growing interest in geriatric health promotion is welcome, a cautious approach informed by empirical data and tempered by political realities will be required to produce needed change. The Goal of Health Promotion in the Older Population
An important initial consideration is to identify the changing characteristics of health promotion and disease prevention for individuals and cohorts as they grow older. The focus of health promotion in younger persons is clearly preventive in nature. Convincing younger individuals of the importance of maintaining a good diet, exercising regularly, and not smoking is hoped to minimize risk factors for conditions such as cancer and coronary artery disease, thereby reducing the incidence of these lifeshortening diseases later in life. The changing nature of illness risks and health maintenance needs over the life course suggest a broader health promotion focus for older adults. Some diseases, such as influenza and pneumonia, require aggressive prevention strategies in old age to reduce the increasing risks of morbidity and mortality. Many chronic conditions, however, are frequently the end result of lifelong exposures to risks, the effects of which become less remediable with age. Where disease prevention is not possible, behavioral and life-style changes and early treatment may slow the progression of existing chronic diseases and the rate of disability associated with them. Thus, many diseases can be prevented in the tradi-
^epartment of Health Behavior and Health Education, School of Public Health, and Institute of Gerontology, University of Michigan, 1420 Washington Heights, Ann Arbor, Ml 48109-2029.
822
The Gerontologist
Downloaded from http://gerontologist.oxfordjournals.org/ by guest on August 11, 2015
Disease prevention and the promotion of health have received a great deal of attention lately, as evidenced by increasing social constraints on cigarette smoking, changing patterns in the use of alcohol, the proliferation of diet and exercise plans, and the aggressive marketing of various health foods and vitamin supplements. As a vulnerable high-risk group and the most rapidly increasing segment of the population, older people have become an important target group for health promotion activities. Old age is accompanied by increasing risks of morbidity and mortality and a greater need for health care services. Thus, avoiding illness, pain, and disability are high priorities in the quality of life for many older people who are the primary consumers of medications and health care services. The health status of older people is also important to society generally, since the provision of geriatric care accounts for a large portion of the national health budget. Although health promotion in the older population has broad appeal, the present momentum risks overlooking important considerations of the potential efficacy of various health initiatives and the identification of appropriate target groups. There is a great deal that we do not know about applying preventive medicine to older people. There is also a danger that health promotion will be defined only in terms of the health outcomes of individual behaviors, ignoring important epidemiologic, environmental, and societal etiologies. A comprehensive review of current research and conceptual thinking on health promotion in the elderly risks being a reiteration of what has already been stated well (e.g., Berg & Cassells, 1990; Kane, Evans, & Macfadyen, 1990). However, in the context of growing interest, it is important to clarify the objectives of health promotion and disease preven-
Deficiencies in the Knowledge Base
The effectiveness of efforts to change health behaviors and modify risk factors in the older population will be determined, in large part, by selecting those behaviors and risks most amenable to change and the most effective means of changing them. This represents a considerable challenge, since the evidence in many high-risk areas is sparse and often contradictory. Difficulties also arise in attempting to assess the relative contributions of health promotion efforts, biogenetic vulnerability, and lifelong health habits to the risks of disease in older adults. Some preventive measures are more likely to lead to successful outcomes — for example, the right type of influenza vaccine appropriately administered to a high-risk elderly population can be fairly effective in reducing hospital admissions, overall morbidity, and mortality (Stults, 1984). However, as will be shown in subsequent examples, the merits of many other preventive actions, which are often widely promoted by either the professional or popular media, have not been clearly demonstrated in the older population. There are several reasons for uncertainty about the effectiveness of disease prevention and health promotion in the older population. A major problem has been the lack of important epidemiologic data on older populations and the absence of well-designed, randomized, clinical trials of health promotion interventions. Although longitudinal investigations such as the Framingham and Alameda County studies, as well as several national health interview surveys, have been useful in providing information about risk factors, these studies have necessarily been limited Vol. 3 1 , No. 6,1991
in scope. Also, most clinical trials in recent years have yielded only inconclusive evidence regarding the efficacy of various health promotion initiatives (Abdellah & Moore, 1988). Similarly, health promotion research has been limited by difficulties in replicating descriptive studies or demonstration projects and generalizing from their results, as well as with the choices of intervention strategies and outcome measures (Herdman, 1985). The exclusion of elderly individuals from existing trials often is based on the belief that treatment or prevention produces either similar or very few health benefits beyond a certain age. But assumptions about the ineffectiveness of interventions or behavior changes among older and/or disabled individuals are often unfounded. For example, positive health effects have been observed following a relatively brief exercise intervention with a frail older population — individuals who would have been excluded from similar studies based on their poor health status (Hickey, Wolf, & Robins, 1990). Ironically, practitioners often advocate specific health promotion programs for the elderly, despite the fact that older people have been almost ignored in empirical investigations of the effectiveness of those very interventions. Thus, current acceptance of what is considered good preventive or rehabilitative practice for older adults is based on either limited data or studies of middle-aged persons — frequently self-selected samples of persons without diagnosable chronic disease, or other atypical populations. This is especially true in clinical trials of various drugs and medications used by chronically impaired older people on an ongoing basis for such conditions as arthritis and hypertension. Also, in the absence of carefully designed studies, little is known about the effects of health promotion efforts in important subgroups of older adults, especially those who are being treated for multiple chronic conditions. Health promotion in the older population is hindered further by limited knowledge of the course of disease in the later years, the changing importance of various risk factors, and the benefits and adverse outcomes of intervention (Berg & Cassells, 1990; Davies, 1990). In light of these deficiencies, some of the underlying assumptions about the efficacy and necessity of specific health promotion interventions may be erroneous and actually hinder efforts to implement useful programs in older populations. Rather than simply adopting an intervention used successfully with other age groups as a basis for health promotion in the older population, setting priorities for health promotion interventions in the older population will require a careful examination of likely outcomes, including their costs and longer term effects on health status, behavior, and quality of life.
823
Current Priorities and Future Directions
Full consideration of these and related concerns about the knowledge base is beyond the scope of a single paper. However, some of their implications
Downloaded from http://gerontologist.oxfordjournals.org/ by guest on August 11, 2015
tional sense in older persons, although prevention also takes on a broader perspective related to health maintenance in this population. Consequently, health promotion priorities for older adults include timely detection and treatment of major illness conditions, such as cancer and heart disease, and interventions designed to reduce the potential impact of such conditions on overall functional health. Health promotion must also be adapted to the changing nature of health status in late life, as well as to the variability that is present in the older population as a result of biological and personal differences in health risks. This variability suggests the importance of health promotion for modifying behavioral factors as a means of reducing disability and slowing the progression of disease, and for targeting those individuals who are at higher risk due to life-style. Therefore, in a context of diminishing opportunities to prevent the major diseases of old age (e.g., other than high-risk, acute problems such as influenza and respiratory illnesses), the overall goal of health promotion in the elderly population should be to prevent the progression of disease and the risks of disability and death. As with geriatric medical care, health promotion should be designed to help older persons maintain their functional independence and autonomy for as long as possible (Davies, 1990).
In addition, regular Pap smears have not been a part of routine health care for the present cohort of older women. Fifteen percent of women over age 65 and 38% of those over age 75 have never had this test, which is the most commonly used screen for cervical cancer (Leventhal, 1986). Abnormal tests are two to three times more likely in women 65 years and older than in those under age 65, and most occur in women who have not been screened previously. At least one recent study has found that regular screenings would lead to greater reductions in mortality among women over age 65 when compared with other age groups (Fletcher, 1990). Thus, in women over 65 who have never had regular Pap smears, it may be helpful to screen regularly for several years, while those who have had normal Pap smears for several years consecutively may not need to continue them past that age (Robie, 1989), although the complete discontinuation of screening after age 65 is currently under debate (Berg & Cassells, 1990). Colorectal and prostate cancers are also of increasing concern with aging. However, the efficacy of screening and detection programs is less clear. Given that the peak incidence of colorectal cancer is around age 80, with 60% of new cases occurring after age 60, it appears that older persons are at particular risk for this form of cancer (National Cancer Institute, 1988). By age 70, colorectal cancer is one of the major causes of mortality for both men and women (List, 1987), yet over 60% of older whites and 70% of older Blacks report never having received the fecal occult blood test, a preliminary screen for cancer at this site (National Cancer Institute, 1988). The data for prostate cancer indicate a similar relationship with age: most incidence and virtually all mortality occur after the age of 60 (Silverberg, Boring, & Squires, 1990). Available information about the benefits of regular colorectal and prostate exams is insufficient to suggest general recommendations for the older population (Robie, 1989). It is generally agreed that screening for prostate cancer by means of rectal examinations is not effective at any age. Screening for colorectal cancer is more effective in detecting disease, but uncertainties about the natural history of this disease suggest that increased detection may be identifying only less aggressive forms of illness. It is not yet clear whether this increased rate of detection is related to a decrease in cancer mortality (U.S. Congress, Office of Technology Assessment, 1990). More information is needed about the most appropriate target groups for colorectal cancer screening in the oldest population, as well as the likely impact of increased screening efforts on ageadjusted mortality rates and overall quality of life. Given the invasiveness frequently associated with screening methods and the potential impairments, discomfort, and disability that may result from the treatment of cancer, additional attention should also be given to qualitative outcomes when identifying appropriate target groups for cancer screening (Berg & Cassells, 1990). Quality of life considerations are even more important when one considers that, with
Effectiveness of Cancer Detection and Screening Cancer detection and screening programs have been a much higher priority in health promotion for the general population than for older people, with the result that little is known about the benefits, risks, and feasibility of cancer screening and intervention in the older population (Davies, 1990). Yet 50% of new cases of cancer and 60% of cancer deaths occur in persons over age 65 (National Cancer Institute, 1988). These rates vary widely by type of cancer, with age-related incidence and mortality even higher for certain types of cancer. As evidenced by the examples that follow, the early detection and treatment of many forms of cancer in the older population could have considerable impact on overall cancer morbidity and mortality rates. However, widespread screening programs may be too costly or invasive to justify their implementation beyond high-risk groups. Also, fear of a diagnosis of cancer or of the pain and disability associated with treatment may inhibit reporting of important symptoms. Thus, aggressive detection efforts will be of little value if few cases are actually identified and treated, and if high-risk target groups are unlikely to acknowledge or deal with symptoms or to see cancer as amenable to prevention and health maintenance strategies. For instance, breast cancer is a leading cause of cancer death in women after age 35, and women over the age of 60 account for over half of all incidence (Silverberg, Boring, & Squires, 1990). Having regular mammograms reduces breast cancer mortality (Tabar et al., 1985), yet only 16% of mammograms are performed on women over the age of 60 (Leventhal, 1986). At least one study has observed that physicians are often less likely to recommend mammograms for older women (Coll et al., 1989). Breast cancer is often detected at more advanced stages in older women than in younger women, suggesting that the disease is progressing further in older women, who are being overlooked in screening programs (Holmes & Hearne, 1981). 824
The Gerontologist
Downloaded from http://gerontologist.oxfordjournals.org/ by guest on August 11, 2015
for establishing future objectives need to be considered in the context of major priorities for disease prevention and health promotion related to behavior risk factors. Health screening, illness detection programs, and other initiatives related to smoking, diet, exercise, and personal life-style, which have received considerable scientific attention as well as broad public visibility, provide useful examples of the difficulties of establishing clear directions for disease prevention and health promotion in the older population. For the most part, these efforts have been related to cardiovascular disease and cancer, given their predominant association with morbidity and mortality in the older population. Yet, although cancer and heart disease represent major priorities for health promotion research and intervention, the track record of various strategies for early detection and overall risk reduction and for management of these problems in older adults has not been outstanding.
many older adults, life expectancy may not differ significantly with or without treatment for cancer in the presence of competing causes of death; however, the quality of their remaining lifetimes may be affected markedly. The objective should be the detection of treatable cases at fairly early stages, rather than widespread cancer screening.
cause of death and disability in older adults, suggesting the need for continued health promotion efforts. Although the positive benefits of various health promotion activities related to cardiovascular risks are not disputed, the degree and intensity with which specific behaviors should be promoted in older adults is often unclear. For example, overweight individuals with age-related elevated blood pressure, but with no personal or family history of heart disease or related illness events, may well be at low risk and not a high-priority group for intervention. The safest conclusion is that the risk factors that predict cardiovascular morbidity and mortality in middle age continue to be important in old age, although their association is thought to be reduced — especially after age 80 (Davies, 1990).
Vol. 31, No. 6,1991
Smoking Cessation Due to its association with lung cancer and heart disease, smoking cessation has been a major health promotion initiative in the general adult population. Although this is an important area for intervention, very little research has been done on smoking cessation among older people. However, it seems clear that smoking cessation remains beneficial for persons over 65, decreasing the risk of death from coronary heart disease among those who quit (Jajich, Ostfeld, & Freeman, 1984). A recently completed prospective study of three community populations found that the benefits of smoking cessation are especially marked for reduction in coronary heart disease mortality for older men and women (LaCroix et al., 1991). Overall, the data on smoking cessation indicate that life expectancy at all ages increases, and that the increase for older adults is proportional to that for younger persons. Risk of mortality from lung cancer is also reduced by up to 30-50% after 10 years of nonsmoking, and reductions in morbidity and disability from other cardiopulmonary and respiratory conditions are also significant following smoking cessation. Perhaps the most important aspect of smoking cessation is that it is utterly free of the side effects sometimes associated with pharmacological means of reducing disease risk, and is said to offer a greater benefit than any other therapy for avoiding cardiovascular morbidity and mortality — even in older populations (Kannel & Higgins, 1990). Current smoking rates among older adults aged 50 to 74 are still relatively high, despite the fact that significant numbers have quit smoking. Current smokers aged 50 to 74 are believed to be at especially high risk since they have smoked longer and are heavier smokers (Shopland & Brown, 1987). For the most part, this age group has been ignored in health promotion efforts due to the belief that the effort entailed in changing a well-entrenched habit of many years was greater than the modest health outcomes that could be anticipated from smoking cessation. In light of more optimistic findings, there is a need for smoking cessation programs targeted specifically at older age groups on the basis of their greater vulnerability to morbidity and disability. At present, little is 825
Downloaded from http://gerontologist.oxfordjournals.org/ by guest on August 11, 2015
Cardiovascular Disease and Hypertension Risk Reduction Despite considerable progress in risk reduction over the past 20 years, heart disease and stroke continue as the major causes of death in the older population, with high blood pressure as a primary risk factor. Although some estimates suggest that over half of all persons over age 65 have chronic high blood pressure, recent estimates using averaged measures over a period of time report that the true prevalence of hypertension in the elderly is somewhat lower (Applegate, 1989). Despite the prevalence of cardiovascular disease with aging, the considerable variability in individual risk of heart disease in old age suggests the merits and potential costeffectiveness of initiatives that are focused more on the highest risk groups. For those at risk, hypertension tends to rise with age, and isolated systolic hypertension affects about 20% of persons over age 80 (SHEP Cooperative Research Group, 1991). Results from the Framingham study indicate that elevated systolic hypertension is the single greatest risk factor for cardiovascular disease in persons over age 50 (Kannel,1986). Although the pathophysiology of hypertension reflects presumably irreversible age effects, treating hypertension in the older population has shown great potential. For example, a recently completed major study of systolic hypertension in the elderly found that the use of diuretic drugs reduced the incidence of stroke by 36% even among those over age 80 (SHEP Cooperative Research Croup, 1991). Interventions to reduce diastolic hypertension in persons over 60 have also demonstrated reductions in total mortality (Hypertension Detection Follow-up Group, 1979); total cardiac events (MacMahon et al., 1984); and cardiovascular and cerebrovascular mortality and overall cardiac mortality (Amery et al., 1985; Coope & Warrender, 1986). However, the majority of research on the effects of lowering blood pressure on morbidity and mortality has focused on pharmacologic interventions to reduce diastolic blood pressure (Kannel, 1986). Given the problems of multiple drug use among the very old, the merits of other types of intervention (e.g., diet, exercise) for maintaining blood pressure control need more careful study. The remarkable downward trend in mortality from coronary heart disease can be attributed, at least in part, to successful health promotion efforts in the areas of hypertension management, smoking behavior, and dietary and related life-style changes, which are discussed further in the following sections. However, cardiovascular problems remain the major
known about the types of programs that are likely to be effective with older adults. Further research is needed into the types of motivators elderly people respond to, the ways in which they decide to quit, and their perceptions of the benefits of smoking cessation.
Dietary Factors Extensive evidence indicates the benefits of good nutrition for older adults. Reducing the intake of sodium, sugars, fats, and cholesterol has been found to lower the risk of developing various diseases in middle-aged and older persons (Costell, 1985), as well as to slow the progression of existing chronic conditions such as osteoporosis, hypertension, and diabetes (Posner et al., 1987). For example, diets that are high in fat and low in fiber have been linked to some forms of cancer, especially those of the digestive tract, that affect the elderly. Diets high in calcium are also thought to provide some protection against osteoporosis. At the same time, there is a good deal of confusion about the health implications of various food products, as evidenced by a recent Newsweek cover story (Shapiro et al., 1991). It would seem that dietary recommendations represent an area where there is so much information that it is contradictory and confusing. Since the best course of action is not always clear, there is a generalized expectation that what is considered healthful today may change tomorrow with new evidence. For example, restricting the intake of sodium, long implicated in heart disease, now appears to be important only for a subset of the population. Also, for most people, the moderate use of sugar is probably less harmful in the long run than the use of artificial sweeteners. On the other hand, the increased consumption of oat products, considered by many as a passing fad, appears to have a beneficial impact on the reduction of LDL cholesterol (Humble, 1991). Uncertainties in scientific beliefs about how healthful various foods are makes it easy for many people to justify making no changes in dietary patterns. Also, older persons often feel even more complacent about their eating habits on the basis of their longevity. The role of health promotion in regard to diet lies in the interpretation and application of research findings to older adults with specific health risks in terms that help them to integrate scientific findings with general recommendations about diet and healthful eating behaviors. Regardless of uncertainties about specific foods, there is considerable room for im-
826
The Gerontologist
Downloaded from http://gerontologist.oxfordjournals.org/ by guest on August 11, 2015
Physical Fitness The relationship between physical fitness and allcause mortality — especially in relation to coronary heart disease — suggests that some form of exercise is probably beneficial for most individuals (Paffenbarger et al., 1986), although it is far from clear to most older persons what type and intensity of exercise might be best for them. Longitudinal studies of middle-aged persons have shown that regular exercise is associated with reduced risks of arteriosclerosis and coronary heart disease; some studies also report similar findings with samples of older adults (Pollock et al., 1987; Seals et al., 1984). Many studies have examined the effects of vigorous exercise, such as running or biking, on cardiovascular function measured by maximum oxygen uptake, physical work capacity, and resting heart rate (e.g., Cunningham et al., 1987; deVries, 1970; Morey et al., 1989). However, the association between these parameters and either cardiovascular disease or overall functional health has not been clearly established, and the majority of studies of the effect of exercise on chronic conditions such as coronary artery disease, diabetes, and hypertension have reported either negative or only marginal improvements (Holloszy, 1983). These mixed results suggest that the current outcome variables that measure cardiovascular and related physiology may not reflect important functional changes and ADL benefits in the older population. Relatively few studies measure the effects of less intensive forms of exercise on the maintenance of function and delay of disability associated with heart disease, arthritis, and other chronic conditions. In a recent series of pilot studies that examined the effects of low-intensity exercise on chronically impaired older adults, consistent reductions in blood pressure were observed over time among individuals with multiple chronic conditions. The sustained effects of a physical activity intervention — especially on individuals with isolated or borderline systolic hypertension — were also significant (Wolf et al., 1990). Improvements were noted in mobility, flexibility, and self-reported pain as well, suggesting the potential contribution of low-intensity exercise to the reduction of dysfunctions associated with arthritis (Hickey, Wolf, & Robins, 1990). Despite the attention given to exercise as a means of reducing disease risk, its specific contributions to overall health maintenance in general and cardiovascular disease prevention in particular remain unclear. The available evidence does not appear conclusive enough to justify the recommendation of vigorous exercise, and available data on the effects of
less intensive physical activity are insufficient to specify the high-risk target groups most likely to benefit. Different outcome variables are needed to determine the effectiveness of exercise performed at various intensities on reducing morbidity and disability. For example, it is possible that maximal aerobic capacity or resting heart rate are not the most important measures of risk reduction in older people. For chronically impaired individuals, changes in ADL capacity might be a more meaningful measure of the effectiveness of a physical activity program. Longitudinal studies of both well and chronically impaired older persons are needed to determine the benefits and risks of exercise in both groups and to provide more specific guidance regarding the efficacy of physical activity.
Vol. 31, No. 6,1991
ease events and mortality. It has been suggested that the most cost-effective means of lowering serum cholesterol would be dietary changes (U.S. Congress Office of Technology Assessment, 1989); this may be especially relevant for individuals whose cholesterol falls into the borderline high range. Research is needed to determine who among the older population will benefit the most from screening and intervention, and to examine the behavioral components of the life-style changes needed to maintain compliance with dietary regimens. Specific modifications in diet may be the least costly both to the older person and the health care system, suggesting their inherent appeal for health promotion and health maintenance in older people. Continued attention should be given to the effectiveness of diet, both alone and in conjunction with physical activity and smoking cessation, in decreasing the incidence of cardiac events in older adults (Kannel, 1986). Conclusion The prevalence of cardiovascular disease in the older population, as well as its potential for causing serious disability, makes it an obvious priority for health promotion efforts. Weight reduction, dietary changes, hypertension management, and at least moderate exercise on a regular basis are likely to have beneficial effects on the reduction of cardiovascular risk factors in late life. At the same time, because of the wide range of variability among older people in terms of individual risk of cardiovascular morbidity and mortality, disease prevention efforts and health promotion interventions need to be carefully targeted to those who are likely to derive the greatest benefits. In addition to targeting high risk groups, there are at least three other important objectives for disease prevention and health promotion in the older population. Diseases like influenza and pneumonia, with high morbidity and mortality rates, require aggressive prevention strategies. For other conditions, as evidenced from the review of cancer detection, many questions remain about the benefits of screening and intervention. Available clinical research data indicate a number of potential adverse effects in treating cancer, especially in frail older persons with other comorbid conditions. At the same time, the positive findings of the recently completed SHEP study regarding the treatment of systolic hypertension in the very elderly suggests that issues of efficacy need to be given high priority in further research. Finally, health promotion in the older population must also address the declining mobility and functional status that often results from specific conditions, such as osteoarthritis, or from multiple chronic problems. The combined effects of such chronic conditions are often more predictive of health status than any one of them individually. As a consequence, priority should be given to health promotion efforts that address older persons' basic functional needs regardless of their pathologic origins. 827
Downloaded from http://gerontologist.oxfordjournals.org/ by guest on August 11, 2015
provement in dietary patterns in the older population — e.g., obesity, very common among older people, is a major risk factor for a number of agerelated chronic conditions. Many individuals who could benefit from changing their dietary habits may well avoid this task in the absence of a clear idea of the relationship of their food intake and their health status. Older persons might have greater receptivity to a more focused approach that would identify specific priorities related to major health risks than to the more typical promotion of the general benefits of overall dietary improvements. Perhaps the most promising areas for intervention and research into the benefits of good nutrition are its effects on hypertension and plasma lipid levels, two of the most important risk factors for cardiovascular disease. Dietary interventions, including weight loss and monitoring of sodium, cholesterol, and fat intakes, have been found effective in reducing hypertension and improving plasma lipid levels in high-risk individuals (Stamler, 1988). Interventions to reduce hypertension through dietary changes have several advantages over pharmacological therapies: lower cost, decreased likelihood of medication side effects, and avoidance of drug interactions (Berg & Cassells, 1990). However, some combination of diet and medication is often necessary for optimal blood pressure control. Hypercholesterolemia is a significant risk factor for coronary heart disease at all ages, but the association between elevated plasma lipid levels and cardiac events is attenuated after age 65. Elevated LDL cholesterol fractions remain a risk factor in elderly persons, and higher HDL cholesterol levels continue to be protective, although this relationship is also less strong than at younger ages (Kannel, 1986). Because of this observed lessening of risk with age, some researchers have argued that screening for elevated plasma lipid levels after age 70 has questionable predictive value (Garber, Sox, & Littenberg, 1989). However, others maintain that because the incidence of coronary events increases with age, screening and intervention past age 65 will continue to save a significant number of lives (Multiple Risk Factor Intervention Trial, 1990). The general recommendation is to screen asymptomatic individuals and those without other risk factors for heart disease at least every 5 years; however, some regard even this as optional for women and older persons (Garber, Sox, & Littenberg, 1989). At least two major studies have found that high dietary intake of fats is associated with the development of coronary heart disease (Shekelleetal., 1981; Kushi et al., 1985). However, the impact of dietary interventions to reduce cholesterol levels is not clear, especially in older populations. Most clinical trials of the efficacy of cholesterol-lowering interventions on subsequent coronary events have used pharmacologic methods to lower cholesterol levels that were initially extremely high; the Lipid Research Clinics Coronary Primary Prevention Trial demonstrated the positive impact of lowering cholesterol by diet and drug interventions on coronary heart dis-
in personal health maintenance may be fairly high. In fact, a number of cross-sectional and longitudinal studies (e.g., Belloc & Breslow, 1972; Prohaska et al., 1985) have found higher rates of preventive health practices in older people when compared with younger groups. As suggested by Borgatta et al. (1990), there may be transition points at which positive behavioral change has a greater likelihood of success. Such a transition point may well occur at that stage in life when personal health appears to be most threatened. Although it is not likely that all people want good health at all times, older people may at least not want poor health more than at any other time in their lives. References Abdellah, F. C , & Moore, S. R. (1988). Surgeon general's workshop — health promotion and aging background papers. Washington, DC: U.S. Public Health Service. Amery, A., Birkenhager, W., Brixko, P., Bulpitt, C , Clement, D., Deruyttere, M., DeSchaepdryver, A., Dollery, C , Fagard, R., Forette, F., Hamdy, R., Henry, J. F., Joossens, J. V., Leonetti, C , Lund-Johansen, P., O'Malley, K., Petrie, ) . , Strasser, T., Tuomilehto, J., & Williams, B. (1985). Mortality and morbidity results from the European Working Party on high blood pressure in the elderly trial. Lancet, 2, 1349-1354. Applegate, W. B. (1989). Hypertension in elderly patients. Annals of Internal Medicine, 110, 901-915. Belloc, N. B., & Breslow, L. (1972). Relationship of physical health status and health practices. Preventive Medicine, 1, 409-421. Berg, R. L , & Cassells, J. S. (Eds). (1990). The second fifty years: Promoting health and preventing disability. Institute of Medicine. Washington, DC: National Academy Press. Borgatta, E. F., Bulcroft, K., Montgomery, R. ). V., & Bulcroft, R. (1990). Health promotion over the life course: Strategies for effective action. Research on Aging, 12, 373-388. Coll, P. P., O'Connor, P. ] . , Crabtree, B. F., & Besdine, R. W. (1989). Effects of age, education, and physician advice on utilization of screening mammography. journal of the American Geriatrics Society, 37, 957-962. Coope, J., & Warrender, T. S. (1986). Randomized trial of treatment of hypertension in elderly patients in primary care. British Medical Journal, 293, 1145-1151. Costell, D. O. (1985). Diagnosis of non-cardiac chest pain in older patients. Geriatrics, 40(10), 61-86. Cunningham, D. A., Rechnitzer, P. A., Howard, J. H., & Donner, A. P. (1987). Exercise training of men at retirement: A clinical trial. Journal of Gerontology, 42, 17-23. Davies, A. M. (1990). Prevention in the aging. In R. L. Kane, J. G. Evans, & D. Macfadyen (Eds.), Improving the health of older people (pp. 317-337). New York: Oxford University Press. deVries, H. A. (1970). Physiological effects of an exercise training regimen on men aged 52 to 88. Journal of Gerontology, 25, 325-336. Fletcher, A. (1990). Screening for cancer of the cervix in elderly women. Lancet, 335, 97-99. Garber, A. M., Sox, H. C , & Littenberg, B. (1989). Screening asymptomatic adults for cardiac risk factors: The serum cholesterol test. Annals of Internal Medicine, 110, 622-639. Herdman, R. (1985). Health promotion and disease prevention proceedings. U.S. Congress, Office of Technology Assessment. Washington, DC: U.S. Government Printing Office. Hickey, T., Wolf, F. M., & Robins, L. S. (1990). Exercise and mobility in the older population. Paper presented at the 118th annual meeting of the American Public Health Association, New York. Holloszy, J.O. (1983). Exercise, health, and aging: A need for more information. Medicine and Science in Sports and Exercise, 15, 1-5. Holmes, F. F., & Hearne, E. (1981). Cancer stage-to-age relationship: Implications for cancer screening in the elderly. Journal of the American Geriatrics Society, 29, 55-57. Humble, C. G. (1991). Oats and cholesterol: The prospects for prevention of heart disease. American Journal of Public Health, 87(2), 159-160. Hypertension Detection Follow-up Group. (1979). Five-year findings of the Hypertension Detection Follow-up Program. Journal of the American MedicaJ Association, 242, 2562-2577. Jajich, C. L , Ostfeld, A. M., & Freeman, D. H., Jr. (1984). Smoking and coronary heart disease mortality in the elderly. Journal of the American Medical Association, 252, 2831-2834. Kane, R. L, Evans, J. G., & Macfadyen, D. (Eds.) (1990). Improving the health of older people. New York: Oxford University Press. Kannel, W. B. (1986). Nutritional contributors to cardiovascular disease in the elderly. Journal of the American Geriatrics Society, 34, 27-36.
828
The Gerontologist
Downloaded from http://gerontologist.oxfordjournals.org/ by guest on August 11, 2015
It is easy to be somewhat pessimistic about the likely outcomes of the current enthusiasm for health promotion in the older population. The health care system remains oriented to the medical treatment of disease, with a strong focus on primary prevention. Resources for prevention and promotion will be limited, given the competing demands for our health care dollars and the lack of priority for health maintenance services within most reimbursement mechanisms. Thus, it becomes easier to tell people what to do rather than enabling them to do it. The Surgeon General's national health objectives, for example, provide far more emphasis on personal initiative than on changing the health care system. Healthy People 2000 also fails to address the underlying socioeconomic concerns that continue to lead to wide differences in disease risk and health status across the population (U.S. Public Health Service, 1990). Although it is important to stress the need for commitment to a healthy aging society on the part of older people themselves, this does not justify further abrogation of governmental responsibility for public health, which has been evident in recent years. At the same time, it is important to be realistic about expectations. The costs of disease prevention are often greater than our society has been willing to invest. For example, while universal colorectal cancer screening after age 65 would add 45,000 additional years to older people's lives, the costs of screening far exceed savings from the reduction in treatment costs (U.S. Congress, Office of Technology Assessment, 1990). There are obviously a number of trade-offs here. It is neither possible for society to do everything nor is it reasonable to assume that all individuals will adopt healthy behaviors. However, a national health promotion agenda for older people is more likely to be effective if it focuses on those outcomes with the greatest potential for success. Moreover, to gain wider acceptance within prevailing value systems, such efforts must also be part of a commitment to promoting a healthy aging society, which necessarily includes both individual and governmental responsibility. Accommodating to an aging society will reguire new policy priorities as well as an overall commitment to health maintenance on the part of a growing population of older people. In an era of growing resentment of the affluence of (some members of) the older population, it does not seem unreasonable to expect older people to assume greater responsibility for maintaining personal health as part of a national commitment to health promotion. There is evidence for cautious enthusiasm, too. Older people are likely to be more sensitive than any other age group to the fragile nature of their health. The illness and disability experiences of their age peers, combined with personal exposure to chronic illness, represent a critical reminder of the risks they face in maintaining the independent and autonomous life-styles that strongly characterize the current cohort of older people. Thus, conceivably, the motivation of many older people for taking the initiative
Vol. 31, No. 6,1991
829
Downloaded from http://gerontologist.oxfordjournals.org/ by guest on August 11, 2015
Seals, D. R., Allen, W. K., Hurley, B. F., Dalsky, G. P., Ehsani, A. A., & Hageberg, ]. M. (1984). Elevated high-density lipoprotein cholesterol levels in older endurance athletes. American Journal of Cardiology, 54, 390-393. Shapiro, L., Koehl, C , Springen, K., Manley, H., Pyrillis, R., Hager, M., & Starr, M. (1991, May 27). Feeding frenzy. Newsweek, pp. 46-53. Shekelle, R. B., MacMillan-Shryock, A., Paul, O., Lepper, M., Stamler, )., Liu, S., & Raynor, W . ) . (1981). Diet, serum cholesterol and death from coronary heart disease. The Western Electric Study. New England Journal of Medicine, 304, 65-70. SHEP Cooperative Research Group. (1991). Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Journal of the American Medical Association, 265(24), 32553264. Shopland, D. R., & Brown, C. (1987). Toward the 1990 objectives for smoking: Measuring the progress with the 1985 NHIS data. Public Health Reports, 702(1), 68-73. Silverberg, E., Boring, C. C , & Squires, T. S. (1990). Cancer Statistics 1990. Cancer, 40(1), 9-26. Stamler, J. (1988). Risk factor modification trials: Implications for the elderly. European Heart Journal, 9(Suppl. D), 9-53. Stults, B. M. (1984). Preventive health care for the elderly. Western Journal of Medicine, 141, 832-845. Tabar, L., Faberberg, C. J. G., Gad, A., Baldetorp, L., Holmberg, L. H., Ljunquist, U., Lundstrom, B., Manson, J. C , Eklund, G., & Day, N. E. (1985). Reduction in mortality from breast cancer after mass screening with mammography. Lancet, 1, 829-832. U.S. Congress, Office of Technology Assessment. (1989). Cosfs and effectiveness of cholesterol screening in the elderly. Washington, DC: U.S. Government Printing Office. U.S. Congress, Office of Technology Assessment. (1990). Costs and effectiveness of colorectal cancer screening in the elderly — Background paper. Washington, DC: U.S. Government Printing Office. U.S. Public Health Service. (1990). Healthy people 2000: National health promotion and disease prevention objectives. Washington, DC: U.S. Department of Health and Human Services. Wolf, F. M., Hickey, T., Robins, L. S., Wagner, M. B., & Harik, W. (1990). Effects of low-intensity exercise for older women with systolic hypertension. Paper presented at the 43rd scientific meeting of the Gerontological Society of America, Boston, MA.
Kannel, W. B., & Higgins, M. (1990). Smoking and hypertension as predictors of cardiovascular risk in population studies. Journal of Hypertension, 8 (Suppl. 5), S3-S8. Kushi, L. H., Lew, R. A., Stare, F. )., Ellison, C. R., el Lozy, M., Bourke, C , Daly, L, Graham, I., Hickey, N., Mulcahy, R., & Kevaney, J. (1985). Diet and 20-year mortality from coronary heart disease. The Ireland-Boston Heart Study. New England Journal of Medicine, 312, 811-818. LaCroix, A. Z., Lang, )., Scherr, P., Wallace, R. B., Comoni-Huntley, )., Berkman, L., Curb, |. D., Evans, D., & Hennekens, C. H. (1991). Smoking and mortality among older men and women in three communities. New England Journal of Medicine, 324(23), 1619-1625. Leventhal, E. A. (1986). The dilemma of cancer in the elderly. Frontiers of Radiation Therapy and Oncology, 20, 1-6. List, N. D. (1987). Perspectives in cancer screening in the elderly. Clinics in Geriatric Medicine, 3, 433-445. MacMahon, S. W., Blacket, R. B., MacDonald, G. ] . , & Hall, W. (1984). Obesity, alcohol consumption, and blood pressure in Australian men and women. The National Heart Foundation of Australia Risk Factor Prevalence Study. Journal of Hypertension, 2, 85-91. Morey, M. C.,Cowper, P. A., Feussner, J. R., DiPasquale, R. C., Crowley, G. M., Kitzman, D. W., & Sullivan, R. J. (1989). Evaluation of a supervised exercise program in a geriatric population. Journal of the American Geriatrics Society, 37, 348-354. Multiple Risk Factor Intervention Trial. (1990). Mortality after 101/2 years for hypertensive participants. Circulation, 82(5), 1616-1628. National Cancer Institute. (1988). 1987 Annual Cancer Statistics Review. NIH Publ. No. 88-2789. Bethesda, MD: National Institutes of Health. Paffenbarger, R. S., Hyde, R. T., Wing, A. L., & Hsieh, C. C. (1986). Physical activity, all-cause mortality, and longevity of college alumni. New England Journal of Medicine, 314, 605-613. Pollock, M. L., Foster, C , Knapp, D., Rod, J. L., & Schmidt, D. H. (1987). Effect of age and training on aerobic capacity and body composition of master athletes. Journal of Applied Physiology, 62, 725-731. Posner, B. M., Fanelli, M. T., Krackenfels, M. M., & Saffel-Shrier, S. (1987). Position of the American Dietetic Association: Nutrition, Aging, and the Continuum of Health Care. Journal of the American Dietetic Association, 87(3), 344-347. Prohaska,T. R., Leventhal, E. A., Leventhal, H., & Keller, M. L. (1985). Health practices and illness cognition in young, middle-aged, and elderly adults. Journal of Gerontology, 40, 569-578. Robie, P. W. (1989). Cancer screening in the elderly. Journal of the American Geriatrics Society, 37, 888-893.
