Healthy Aging: Promoting Well-being in Older Adults


>>Good afternoon, good
evening, or good morning, depending on from when and
where you are joining us. I’m Dr. Phoebe Thorpe. And it’s my pleasure
to welcome you to the CDC Public Health Grand
Rounds for September 2017. We have an exciting session,
so let’s get started. But first, a few
housekeeping slides. Public Health Grand Rounds has
continuing education available for physicians, nurses,
pharmacists, veterinarians, health educators, and others. Please see the Public
Health Grand Rounds website for more details. We are available on all your
favorite social media sites. Please send your questions for
today’s sessions and/or comments to the Grand Rounds email
box at [email protected] Want to know more
about healthy aging? We have a featured video
segment on YouTube and posted to our website called
Beyond the Data. It is posted shortly
after the session. This month’s session features
my interview with Dr. Baumgart. We have also partnered with
the CDC Public Health Library to feature scientific
articles about healthy aging. The full listing is available
at CDC.gov/scienceclips. Also on your way out, the Public
Health Library has put together a display about healthy aging. Check it out. Here a preview of the
upcoming Grand Rounds session. Please join us live or on
the web at your convenience. And in addition to our
outstanding speakers, I’d also like to acknowledge
the important contributions of the individuals listed here. Thank you. I’d also like to take a moment
to thank CDC for the opportunity to give this presentation, as
my father-in-law passed away from Alzheimer’s early this
year, and it is a great honor for me to be part
of this session. And now for a few words from CDC’s deputy
director, Dr. Schuchat. [ Applause ]>>Thanks so much, Phoebe. And thank you all
for joining us today. You may have heard that
orange is the new black, but some of us are saying
that 80 is the new 60. [ Laughter ] And a staggering number
of people can expect to reach their 100th birthday. Meanwhile, many of us have
brains on our minds — not just the developing
brains of babies but the potential deterioration
of brains as we age. Too many of us are
managing the consequences of cognitive loss in loved ones. And enormous numbers of us
are serving as caregivers for relatives in a territory
we had never planned for. Not enough of us are confident about the latest
scientific findings on aging and the implications
for public health. To fill this gap, today’s
Grand Rounds brings experts and problem solvers
together to enlighten us about the topic of
healthy aging. Now, I’ve decided to subvert
the usual introduction to Public Health Grand
Rounds where we try to hit the key points
that you’re going to hear. You heard about the podcast
and all the other ways that you can keep up
with the key points. And instead, what I wanted to do today was something
a little different for the Public Health
Grand Rounds and introduce a moment
of poetry. So here is an excerpt
from the UK’s — apparently the UK’s
most popular poem about aging — by Jenny Joseph. It’s called “Warning.” And for those of you
used to seeing me in my Commission Corps uniform, this may seem particularly
apropos. When I am an old woman, I shall
wear purple with a red hat, which doesn’t go,
and doesn’t suit me. And I shall spend my pension
on brandy, and summer gloves, and satin sandals, and say
we’ve no money for butter. I shall sit down on the
pavement when I’m tired, and gobble up samples in
shops, and press alarm bells, and run my stick along
the public railings, and make up for the
sobriety of my youth. I shall go out in my slippers
in the rain, and pick flowers in other people’s
gardens, and learn to spit. [ Laughter ] So with that, let us proceed with today’s Public
Health Grand Rounds. [ Applause ]>>Thank you. And now for our first
speaker, Sarah Lock.>>Thank you. I’ll do my best not to spit —
I’ll save that for afterwards. So thank you. My goal today is to introduce
the concept of healthy aging, along with reviewing some
of the benefits we gain, as well as the challenges we
face as our population ages. Then I discuss some strategies
to promote healthy aging. So, of course, healthy aging
occurs across all age groups, and it is not merely the absence
of disease or disability. As shown in this model, healthy
aging requires a comprehensive vision of physical,
cognitive, and mental health, along with ongoing
social engagement. Aging is society’s
greatest achievement. We have added more years to
life expectancy since 1900 than in all previous
human history. Advances in public health and healthcare have reduced
death rates of children and young adults and improved
the lives of millions. The result of all this
progress is that a child born in 2011 can expect
to live 79 years — 32 years longer than a child
born in 1900 at the turn of the century when life
expectancy was only 47. And as its trends show,
many will live well into their 90’s and beyond. At the same time that people
are living longer, birth rates, which peaked during
the Baby Boom — of which I’m proudly part — from 1946 to 1964
are also declining. Another way to look
at these trends is to track the proportion of our population age
65 and over by state. Darker colors indicate a higher
percent of older population. Following the last census
in 2010, only a handful of states had more than 15% of their population
age 65 and older. But by the next census,
not four states but more than 40 states will have
exceeded that 15% threshold; and two states will have
crossed the 20% mark. But if you look at
2030, you can see that the youngest Boomers will
have turned 65, and every state but one will have more than 15%
of its population over the age of 65, and nearly half of all
states exceed the 20% threshold. Aging leads to new
abilities and knowledge that older people can share
with their communities. We want to make the most of that
by not only increasing lifespan but health span as well, increasing the years
Americans live without disabling conditions. People over 50 in the United
States generate $7.6 trillion annually in economic activity. And to give you a sense of
proportion, when you add up all the economic activity
they drive, older Americans make up the third-largest
economy in the world, only behind the United States
in its entirety and China. Recruiting and retaining
50-plus workers is smart because of the value they
bring to the workforce. Seasoned workers get high
marks for loyalty, reliability, and have a deep network
of contacts from a lifetime of work. Older workers score
high in leadership, detail-oriented tasks,
organization, listening and writing skills, even
in cutting-edge fields like computer science. But perhaps the greatest asset
older workers bring is their workplace wisdom. By the time you reach my age
and older, we’ve learned how to get along with people,
solve problems without drama, and call for help
when necessary. Older workers bring great
value and productivity to a diverse work environment,
including people of all ages. And what’s true in America is
the older population is becoming much more racially and
ethnically diverse. Between 2014 and 2060, the
share of the older population that is non-Hispanic
white is projected to drop by 24 percentage points, from
78% to 54% or almost 55%. As diversity increases,
our approaches to promote healthy aging needs
to be adaptive to be relevant to all people in all cultures. Among our older population, the fastest-growing age group
is those age 85 and older. And the second-fastest is
the those 100 and over. And a majority of
those people are women. Consider that by 2050,
65-plus population in the US will double, while at the same time the
85-plus will triple. And the number of centenarians,
those over 100 or older, will exceed 400,000
people by 2050. So we’ve talked about the
80-plus population increasing, and it will be by 44%
between 2030 and 2040. Yet the number of caregivers
aged 45 to 64 is projected to increase only by 10%. The caregivers’ support
ratio is the number of potential caregivers who are
mostly adult children age 45 to 64 to each person
80 and over. So in 2010, the ratio was
and is about seven caregivers for every 80-year-old. But fast forward a
couple of decades to 2030, the ratio will only be
four-to-one, and it continues to decrease going forward. In 2040, the ratio is
expected to begin to bottom out as the population
aged 80-plus is projected to increase 17% and the 45 to
64 population increases by 8%. So along with some of the
benefits that I’ve talked about, aging has to — we have to
acknowledge that aging carries with it an increase in the
prevalence of chronic diseases, such as hypertension,
diabetes, and arthritis. And you will hear
from our next speaker about important public
health considerations related to another group of
chronic conditions — Alzheimer’s disease
and dementias. Other challenges are the
racial and ethnic disparities which pervade many had been
health measures are also seen with regard to lifespan and
health span issues as well. Lower socioeconomic status
has an adverse impact on healthy aging unfortunately. And with the majority of
Americans living paycheck to paycheck and three-quarters
of Americans between the ages of 55 and 64 having less
than $30,000 stacked away, many people do not have
the resources to retire and are having to work longer. So we need to make sure
they’re healthy and can do so. Older adults also
face more challenges with everyday activities,
which can be compounded by their living situation
or lack of social supports. One-third of people over the
age of 65 face restrictions in their ability to perform
activities of daily living or what we call ADL’s — things
like carrying for themselves; or IADL’s — things like
managing money, preparing meals, or taking medications
appropriately. So one of the things to deal with the issues I’ve
outlined is the Healthy Aging in Action Plan. Released in November of 2016,
it is intended to be part of the national prevention
strategy. The strategy’s cornerstones
include eliminating health disparities, encouraging
safe and healthy communities, promoting clinical and
community preventative services, and empowering people to
make healthy decisions. All of these ideas are relevant
to make healthy aging a reality. The goals of federal
action steps are to support prevention efforts to
enable adults to remain active, independent, and involved
in their community. It highlights innovative
and evidence-based programs like from the National
Prevention Council departments and agencies that address
the physical, mental, and emotional social
well-being of adults. And the last goal is to inform
future efforts to promote and facilitate healthy
aging in communities. I’d like to review several
programs highlighted in the report that
provide great examples of the diverse groups working to keep older adults
healthier and more active. So while the health industry
offers preventative services, patients can face
challenges that they can’t get to those services if they no
longer drive or have limited or no access to transportation. So in response, the Department of Transportation’s Federal
Transit Administration launched the Ride to Wellness Initiative. It aims to increase access to
care, improve health outcomes, and reduce healthcare costs. The Department of Transportation
finances innovative projects to help the disadvantaged
get non-emergency medical transportation. DOT is also cosponsoring a
national survey of health and community centers to
document the magnitude of missed medical appointments
due to transportation issues. Results of this research will
inform not only the work of Ride to Wellness but also
other local efforts to increase healthcare
access to those who have limited
transportation options. The benefits of physical
activities to your brain and body’s health as you age
have been well documented. For example, those who are
physically fit have half the risk of chronic health
conditions such as hypertension, coronary heart disease,
type 2 diabetes, and some cancers compared to
those who are less active. However, only about one-third of older Americans meet
the recommendations for physical activity. So launched in 2011, the
Go for Life Campaign, which is an initiative of the
National Institute on Aging at the National Institutes
of Health, it’s a campaign to raise awareness about
the benefits of exercise and physical activity
and enlist individuals to become more active. As of January 2016, Go for Life
had more than 340 partners, primarily agencies,
organizations, and companies that serve older adults or
have physical activity as part of their core mission. And one of my favorites
is Vote and Vax, a Robert Wood Johnson initiative
aiming to increase the number of Americans who get flu shots by offering them
near polling places. Less than half of adults
aged 50 to 64 were vaccinated against the influenza flu
during 2010 to 2011 winter. And unfortunately, flu vaccination rates are even
lower amongst African-American and Latino adults. In 2012, Vote and Vax
served 651 polling locations and was active in all state. The program, also supported
by AARP and the CDC, coordinates the activities of
local public health departments, visiting nurses services,
and pharmacies. In 2012, 45% of those
receiving flu shots at Vote and Vax clinics identified as
African-American or Latino, indicating that Vote and Vax
may represent a very helpful strategy to reduce racial and
ethnic vaccination disparities. So as you all are
probably aware, Medicare is the primary payer
for healthcare for older adults. In order to improve the
quality of care provided and reduce costs in the
program, Congress made changes to Medicare to promote increased
use of preventative care. During the welcome to Medicare
visit, a beneficiary’s medical and social history, risk for
depression and mood disorders, and functional ability
are reviewed. Their history of
tobacco use, diet, and physical activities
are also reviewed. The creation of a written plan
for the patient is a tool used to promote ongoing use of
clinical preventative services. Annual wellness visits include
personalized prevention plan services and include
a comprehensive health risk assessment. Importantly, it includes
screenings to detect cognitive impairment and implements a screening
schedule for things like diabetes and
high blood pressure, and helps to keep
vaccinations current. The goal is better
health outcomes through an increased focus on
prevention, allowing seniors and doctors to work together to catch conditions before they
become serious and more costly. The goals are to increase the
uptake of preventative services and reduce overall costs, but only 7% of older adults
are receiving their recommended preventative services
and only 16% of Medicare recipients had an
annual wellness visit in 2014. Evidence on the improved
health outcomes related to welcome wellness
visits is limited because research is
at the early stage. Most current research has
been focused on whether or not people are
getting the recommended preventative services. Medicare supports not
only clinical prevention but also community-based
prevention. An evaluation of
community-based prevention and wellness programs conducted by CMS identified seven
nationally disseminated programs with sufficient data
to evaluate costs in health services utilized. For Medicare beneficiaries
who participated in a wellness and prevention program between
two and three years ago, changes in health outcomes and
levels of healthcare utilization and cost were compared to
those of a control group. The main outcomes evaluated
were total medical costs, costs by healthcare settings,
and health services utilized. Medication adherence, physical
and occupational therapy use, the incidence of falls and fall-related fractures were
also evaluated as appropriate. While key results
included decreased costs for beneficiaries and Medicare
for selected outcomes for those who participated in the
wellness programs, CMS concluded that more research development and implementation is
needed before broader scale implementation is warranted. So how can we promote healthy
aging in our communities? It’s important to
facilitate across all sectors, as I’ve described early in the
presentation, across disciplines and professions to create
incentives to work together. We need to expand the evidence
base for strategies by designing and implementing
methodologically rigorous evaluations. We need to widely disseminate
best practices and guides that address adopting healthy
behaviors over lifespan. Promoting the relevance
of prevention across the life course
and recognize the aging of the population is creating
both unique opportunities, as well as challenges. And finally, enhancing
a multidimensional view of healthy aging. One example of how AARP
is embracing all five of these principles to promote
healthy aging is our efforts to create and collaborate with the Global Council
on Brain Health. The GCBH is a cross-sector
collaboration helping to disseminate the evidence
base on brain health where we empower people
to reduce their risk for cognitive decline
across their lifespan by encouraging healthy
lifestyles. It’s now my pleasure to
introduce Matthew Baumgart. [ Applause ]>>Thank you very much, Sarah. Sarah, in her conversation
mentioned that with an aging
society comes an increase in chronic conditions, and
I’m going to talk to you today about one of those chronic
conditions, Alzheimer’s. But I want to back up and start
with the concept of dementia. Dementia is not in and of
itself a disease; rather, it’s an umbrella term
for a set of symptoms that are characterized by the
loss of cognitive function that is severe enough to
interfere with daily life. Now, there’s several
diseases and conditions that cause dementia,
the most common of which is Alzheimer’s disease. Scientists actually believe
that many, if not a majority, of the cases of dementia
are mixed, that is, a person with dementia has more
than one cause of that dementia. Now, traditionally, Alzheimer’s
disease has been virtually synonymous with dementia,
that is, if you did not have dementia, if you did not have
certain symptoms, then you did not have
Alzheimer’s disease. But since 2011 when the
National Institute on Aging and the Alzheimer’s Association
published proposed revised diagnostic criteria, Alzheimer’s
is being recognized as a disease with a long continuum where
dementia is only one stage. So it starts with physical
changes in the brain, even before symptoms — it’s known as the
pre-clinical stage — followed by mild
cognitive impairment caused by Alzheimer’s disease, and
then finally the dementia stage of the disease. But while the continuum is now
seen as Alzheimer’s disease — which has particular
significance, I believe, for public health, as I
will discuss shortly — the data have not caught up. So when you hear
statistics about Alzheimer’s, such as the prevalence
of Alzheimer’s, understand that these are
statistics about people in the dementia stage of
Alzheimer’s disease and not about all people
with the disease. Another traditional conception
about Alzheimer’s is the idea that Alzheimer’s
is an aging issue, not a public health issue. But that view is changing. More and more people are heeding
Dr. David Satcher’s call to see and address Alzheimer’s
as a public health crisis. Now, an issue is defined
in public health terms when the burden is large,
the impact is major, and there are ways to intervene. And Alzheimer’s meets all
three of those criteria. Today more than 5 million
Americans are living with Alzheimer’s. And caring for them this
year will cost the health and long-term care
systems more than a quarter of a trillion dollars. In 2013, a study found that dementia was the most
expensive disease in America. In addition, it is the
fifth-leading cause of death in the United States
for older Americans. Since 1999 the Alzheimer’s
death rate has increased 55% and the number of deaths from
Alzheimer’s has increased 110%. The impact is major. In fact, it has a
disproportionate impact on African-Americans
and Hispanics, who develop the disease
at greater rates. One-quarter of all
hospitalizations among people with dementia are preventable,
placing a big burden on our hospital system. It has an impact on families; more than 15 million caregivers
provide the economic equivalent of $230 billion in
unpaid care each year. And two-thirds of the direct
costs of caring for people with Alzheimer’s are borne by
government budgets, that is, Medicare and Medicaid. But there are ways for
public health to intervene through surveillance, risk
reduction, early detection and diagnosis, and
management of co-morbidities. And the rest of my presentation
is going to focus on these ways that public health
can intervene, beginning with primary
prevention. Now, there’s a growing consensus that individuals can reduce
their risk of cognitive decline by addressing certain
risk factors. In 2015, in separate published
reviews of the evidence, The Institute of Medicine and the Alzheimer’s Association
independently concluded that individuals could reduce
their risk of cognitive decline with regular physical
exercise and the management of certain cardiovascular risk
factors, specifically smoking, diabetes, and midlife
hypertension. The association also concluded that midlife obesity
was a risk factor. Basically the saying
is what’s good for your heart is
good for your brain. Now, earlier this year the
National Academies released a second report, this one
examining what the science says about preventing dementia,
not just cognitive decline. And it found the strongest
prospects for risk reduce in the areas of physical
activity, managing blood pressure for
those with hypertension, and cognitive training. Now, the report called on the
NIH and the CDC to make clear to the public that positive
effects of interventions in these areas are
supported by encouraging, although limited evidence. In 2013 the CDC and Alzheimer’s
Association released the Healthy Brain Initiative, a
public health roadmap for addressing cognitive
decline, Alzheimer’s disease, and the needs of caregivers. One of the action items
included in the roadmap is for public health officials
to disseminate messages about risk reduction for preserving a
person’s cognitive health. So secondary prevention,
as you know, involves promoting early
detection and diagnosis and disclosure of
that diagnosis. Data from the 2015 Behavioral
Risk Factor Surveillance System found that more than
half of those who say they are
having memory problems that are getting worse — this is known as subjective
cognitive decline — more than half of these
people have not talked to a healthcare provider
about their memory problems. And this hesitancy is one
reason why as many as half of people living with Alzheimer’s today
have not been diagnosed. Now, to make matters even worse, Healthy People 2020 baseline
data show that even among those who have been diagnosed with
dementia, nearly two-thirds of them or their
caregivers are unaware of the diagnosis — unaware. In other words, people
are not talking to healthcare professionals
about their memory problems, people are not being diagnosed, and those who are
diagnosed are not being told. And this is happening even
though there are demonstrable benefits to an early
and disclosed diagnosis. For example, it allows
individuals to access available
treatments, build a care team, and improve medication
management. On the social side, individuals who have been diagnosed early
can access support services, create advanced care directives
while they’re still able to do so, and address
driving and safety issues. So there’s a big gap for
public health to fill here. And the roadmap calls for public
health to educate providers about recognizing early signs and using validated
assessment tools. It also calls on public health
to promote early diagnosis through culturally appropriate
public awareness campaigns. And significantly,
one of the objectives of Healthy People 2020 is
to increase the proportion of people who have been
diagnosed with Alzheimer’s and other dementias
or their caregivers who are aware of the diagnosis. So finally, looking at
tertiary prevention, that is, managing co-occurring chronic
conditions among people with Alzheimer’s,
there may not be a lot that can be done medically
to treat Alzheimer’s. But those with the disease are
nonetheless extremely expensive to the healthcare system because
the disease complicates the management of other
chronic conditions. And this makes costs go up
for a couple of reasons. For example, 25% of
hospitalizations, as I mentioned, are preventable
among people with dementia. People with dementia have
unnecessary emergency department visits. And illustrating this better than probably anything
else is diabetes. There’s been a great movement
towards self-management of diabetes. But think about this:
How does a person with a cognitive
impairment self-manage? Well, it requires a
different approach, a more intense approach;
but unfortunately, that usually does not happen. And as a consequence the
diabetes is mismanaged, and a senior with Alzheimer’s
and diabetes ends up costing on average 81% more
than a person with diabetes but
not Alzheimer’s. And as you can see
from the slide, these increased costs
can be seen across a variety of conditions. Now, one key way to better
manage co-occurring chronic conditions among people
with Alzheimer’s is through care planning. Care planning can improve the
quality of care and quality of life for people
with Alzheimer’s because it helps a
diagnosed individual get on the right path of care. Studies have found care planning
results in better disease and medication management, and individuals receiving care
planning specifically geared toward those with dementia
have fewer hospitalizations and fewer emergency room visits. The good news is that
as of the beginning of this year Medicare
now covers care planning for cognitively-impaired
individuals. In addition to a
formal care plan, this new Medicare benefit
includes an evaluation of neuropsychiatric
symptoms and safety issues, helping develop advanced
care directives, referral to support services,
and innovatively identifying and assessing the capabilities of an individual’s
primary caregiver — that’s part of this process. An analysis by the non-partisan
healthcare consulting firm Healthsperien concluded
that reimbursing providers for care planning services
would actually save the federal government through Medicare and Medicaid nearly $700
million over ten years. So as I mentioned at the
beginning of my presentation, the new understanding
of Alzheimer’s disease as a continuum from the first
appearance of physical changes or biomarkers to the onset of
symptoms, to the development of dementia — this
continuum creates significant opportunities, I believe,
for public health. Looking at Alzheimer’s disease
this way makes it clear — in fact, make it imperative — that we stop thinking of
Alzheimer’s as a matter of custodial care for someone
once they have developed dementia and start seeing
it in public health terms. And it’s imperative that we
employ the traditional tools of public health
across this continuum, including risk reduction,
early detection and diagnosis, and the management
of co-morbidities, employing those tools
of public health to address the growing
Alzheimer’s crisis. Thank you for listening. And I am now pleased to
introduce Grace Whiting of the National Alliance
for Caregiving. [ Applause ]>>Thank you so much, Matthew. And thank you to the CDC for hosting this amazing
conversation today on healthy aging. I’m really excited
to talk to you about the caregiving
aspect of this. Now, if you’re not familiar
with us, the National Alliance for Caregiving is a nonprofit
organization with more than 50 national members,
including not-for-profit, government agencies,
and corporations. And together we work on caregiving issues
across the lifespan. Today I’m going to talk
in particular about some of the data that we found in our
Caregiving in the US 2015 Report that was conducted with AARP. And I would just note that
when I say family caregiver, I’m talking about families
of choice and relatives, including friends,
family, and neighbors who are providing unpaid care
to someone who needs assistance with activities of daily living. And this would be different than someone who’s a formal
caregiver who’s providing paid care, such as a home
care worker, direct care aide often working
through a defined healthcare or long-term care system. So what is it that — when
we say family caregiving is a public heal issue,
what is we really mean? I think the first thing
here is that we estimate that there’s 44 million
family caregivers in the US — this is roughly the same size
as the population of Argentina. So it’s a huge number of people
who are providing care unpaid to a friend, family,
or a neighbor. And if you were to replace each
one of those family caregivers with a direct care worker, it would cost the US
economy $470 billion a year. Now, we think about caregivers
as typically being a woman who’s in her late 40’s/early 50’s
caring for an older relative, but what we know from the data
is that as time has gone on, caregiving, much like
other older adults, is a group of folks that’s
become increasingly diverse, and it affects people from all
backgrounds and walks of life. And on the right-hand side
here you can see a snapshot of caregivers. One thing I would note is that men are increasingly
becoming caregivers as America ages. And in younger cohorts,
for example, Millennials, men and women are equally as
likely to be caring for someone. Now, what are they doing? We know that they’re spending about 24 hours a week providing
activities of daily living, which is high-touch tasks,
such as helping someone bathe, get dressed, and eat;
instrumental activities of daily living, which would
be coordinating-type skills, such as managing finances, or
running errands, or cooking; and medical or nursing
tasks, which would be things like changing wounds, using a
catheter, giving injections. And at the same time that people
are giving 24 hours a week caring for someone, most
people are also working. So 34% have a full-time job, a
quarter are working part time, and then 28% are in
what we would call the sandwich generation. So they are not only
caring for an older adult, but they’re also raising
children in their household. So you start to get a sense
of how difficult it is to balance both caring for
someone, your own employment and financial needs, and
your own personal needs. This slide is from the
Caregiving in the US data. And what it illustrates is that
caregivers are truly members of the healthcare team. So there’s three activities
here, and we have a comparison on the right-hand
side between your sort of typical caregiver — people
who are caring for someone where the primary reason is
cancer and dementia caregiving. And each of these
cases you can see that caregivers are
communicating with healthcare professionals
about the care plan, they’re monitoring the
severity of a condition, and they’re advocating
for someone not just within the healthcare system
but with long-term care and service providers
and government agencies. And as the intensity
or the complexity of the care situation increases,
caregivers are even more likely to be engaged in
these activities. Additionally, I mentioned that caregivers are doing
medical nursing tasks, and likewise there, the more
hours that you’re caring or the more complex
the care situation, the more likely you’re doing
medical tasks in many cases without any prior preparation
— meaning no one’s shown you or walked you through how
to do these activities. So how is it that caregivers
support the healthy aging of populations? We know that caregivers
help individuals age better by being their advocates and helping them manage
what they need to do on a daily basis, but we
also have seen new research that shows that caregivers
can reduce avoidable hospital readmissions by as much as
a quarter at the 90-day mark and by 24% at 180 days. We also know that for conditions where someone might
have a disability or an older person is having
difficulty living independently in a community, a caregiver
can help them continue to live on their own in their
homes and communities and to avoid costly
institutionalization, such as a nursing home. Now, in order to do this, to
be a true partner in care, caregivers need care, too. And we know that if we neglect
the health, the psychological and financial wellness
of the caregiver, it not only makes it more
difficult for someone to care, but it puts the care
recipient at risk. There is tons of research that
shows that as someone is caring for a person whose
condition is declining, the caregiver’s own
health will decline. Many caregivers experience
psychological stress, such as depression and anxiety. And we know that caregivers
spend a significant amount of income out-of-pocket to
pay for the costs of care. And this last number
here from AARP estimates that it’s nearly $7,000 a year. And for minority populations, many of whom have lower
income thresholds, they spend as much
as $9,000 a year. So what can we do about it? Well, the first thing is health
systems can help support family caregivers by looking at
evidence-based interventions that promote health
and well-being. And this is an example of some
of the programs that we know that science has said works. This first program, the REACH
program was administered through the Department
of Veteran Affairs, but it’s been expanded to
include not only caregiving for dementia, but also other
conditions like ALS and TBI. Powerful tools for caregivers
is a self-care course, enabling caregivers to better
understand how to take care of themselves so that
they can care for others. And next step in care
addresses care transitions, which would enable a
caregiver to help someone move through different settings
of care, for example, from a hospital to the home. Finally, the chronic disease
self-management program is useful not only to a caregiver
who’s helping someone who’s managing multiple chronic
conditions in their loved ones, such as hypertension
and diabetes, but also for many caregivers. We know the average
caregivers are middle-aged, they themselves are aging,
and so it’s important for them to manage those chronic
diseases as they grow older. From a system-level standpoint, providers can also
include family caregivers and the healthcare team. And one of the major
recommendations would be to use caregiver assessments
that identify the willingness, readiness, and ability of an individual
caregiver to provide care. So as Matthew mentioned,
some of this is being done through new Medicare
billing codes. And traditionally, this
has also been done — this idea of assessing
a caregiver — through the Medicaid
program home and community-based
services waivers. We also see when we
look internationally that there is work
to assess caregivers, but it’s not fully prevalent in
our system of healthcare today. The other aspect of this is
just simply including caregivers as members of the
healthcare team, noting them in the
medical records and electronic healthcare
records, and treating them as a member of the
healthcare team. And there is state legislation
in more than 40 states led by AARP called the CARE Act. And the CARE Act actually
does require hospitals to note family caregivers
and to provide training to them upon discharge. The great news is there are
already several wonderful programs from the
federal government that support family caregivers, the biggest of which is the
National Family Caregiver Support Program led
through the Administration on Community Living. It supports 700,000 family
caregivers across the US and is usually disseminated
through the Aging Network. And it provides information
and referral services, as well as access
to respite care. Likewise, the Lifespan Respite
Care Program helps strengthen state networks to
provide respite, and the VA Caregiver Support
Program provides education, information, and
a referral hotline for those caring for veterans. And especially those who might
be older caring for veterans of a post-9/11 conflict
— Iraq or Afghanistan — the VA program even provides
financial stipends based on the level of need. In some places state and federal
tax credits may be available to help caregivers
offset the costs of care. And many working caregivers
are eligible for the Family and Medical Leave Act, which in
some states has been expanded to include new kinds of
caregiving relationships, such as caring for a
grandparent or an in-law. And there are even
a handful of states where you can now get paid
family and medical leave, which can help caregivers
manage that work/life balance. Finally, if people are looking
for resources about caring for an older adult, whether
it’s nutrition, transportation, or the family caregiver program, the Eldercare locator Provides
a registry of what types of resources are available
across the United States. I think all of us have a stake
in supporting family caregivers. If we’re not one now, we either
will be or we’ll need one. And with that, I’d like to turn
things over to Dr. Lisa MacGuire. [ Applause ]>>Thank you, Grace. From our previous
speakers we heard about national efforts related to keeping older
Americans healthy and remaining independent
as long as possible. That is the primary focus
of CDC’s Alzheimer’s Disease and Healthy Aging Program. CDC’s activities touch on each
of these target audiences: Older adults; healthcare
professionals; and caregivers of older adults, especially
those who are caring for a person who has a
cognitive impairment. The types of activities that
CDC’s engaged in are data for action, partnership,
raising awareness, training and education. And I’m going to highlight our
efforts in each of these areas. The goal at CDC’s Healthy
Brain Initiative is to promote cognitive aging,
both brain health and awareness of cognitive decline as part
of public health practice. The roadmap shown on the left
side of this slide is a second in the roadmap series. It outlines 35 action
items for state, local, and public health officials. The national plan to
address Alzheimer’s disease that is updated annually
establishes five ambitious goals to both prevent future cases
of Alzheimer’s disease, to better meet the needs of
millions of American families who are currently
facing this disease. The national plan serves as an additional
driver for CDC’s work. CDC has both the
subjective cognitive decline and caregiving optional
modules included on the Behavioral Risk
Factor Surveillance System. Subjective cognitive decline is
a common precursor to dementia. It is a self-evaluation of
one’s memory functioning. For public health,
this is an indicator of potential future
burden and the needs in a healthcare system,
long-term services and support, and also in communities. This module assesses in
adults 45 years and older, worsening memory problems,
potential difficulties in daily living associated
with those memory problems, and if memory problems
have been discussed with a healthcare provider. This slides shows the states that have administered the
subjective cognitive decline module in 2015, 2016, and 2017. Those states are the combination
of colors of the orange and the purple administer
the module, for example, in both 2015 and in 2016. Based on the 2015 BRFSS data, subjective cognitive
decline appears to be decreasing slightly. Those with SCD tend to report
lower educational levels and are more likely
to live alone. These surveillance results can
be used to target interventions to vulnerable populations,
especially those concerned about cognitive decline,
those who live alone, and those who might
lack caregivers. For the caregiving module,
participants were 18 years old and older who indicated
if they were a caregiver. They also reported on the
intensity and duration of the caregiving situation,
problems that they encounter as a caregiver, and what
their greatest care needs are. Additionally, if they were not
a caregiver, they also indicated if they expect to become a
caregiver in the next two years. This slide once again
shows the states that administered the module
in 2015, 2016, and 2017. So, for example, states
that had the orange and purple together
administered the module in both 2015 and 2016. The results from the 2015
BRFSS module indicate that 22% of respondents 18 years old
and older provide regular care or assistance to a
friend or family member; 9% of caregivers indicate that
dementia is the main reason that they are providing
for the care, so the main reason the
person is needing their caregiving assistance. So what do we know
about the physical and mental health of caregivers? Caregivers are more
likely to report fair to poor physical health,
depression, also more likely to report frequent mental and physical distress,
as well as obesity. However, we do find that
there are no differences between caregivers
and non-caregivers on coronary heart disease,
stroke, CVD in diabetes, and also on receiving
a routine checkup within the past two years. To increase accessibility of BRFSS subjective cognitive
decline and caregiving data in partnership with the
Alzheimer’s Association, a series of state-specific
infographics were developed and released. Additionally, CDC launched a
public data portal on the health of older adults, which provides
access to key indicators of the health and
well-being of older Americans. These indicators
provide a snapshot of currently available
surveillance information and can be useful for
prioritizing or evaluation of public health interventions. Partnerships are the cornerstone
of the Healthy Brain Initiative and the accomplishment of
the roadmap activities. Some of our key partners are
shown here, and I’m going to highlight some
of the activities through the remainder
of the presentation. The Balm in Gilead,
CDC’s newest partner, established the National
Brain Health Center for African-Americans. The goal of the center
is to raise awareness of the issues affecting
brain health through capacity development
within church congregations as an integral partner
in the prevention, disease management,
and caregiving. As a way to raise awareness
of brain health and caregiving in the church congregations, The Balm in Gilead initiated
Memory Sunday in June of 2017. Highlights of Memory
Sunday included 130 churches participated, reaching
approximately 80,000 congregational members. There were 13 related events
in locations shown on the map with nearly 4,000
participants in them as well. To further raise awareness
of brain health issues, the Healthy Brain Research
Center at the University of Pennsylvania, a Healthy
Brain Research Network site, developed a series
of research-based and tested messages targeted to
adult children, encouraging them to accompany their parent to a doctor appointment
regarding memory concerns. Recruiting and training a
workforce that is skilled to work with older
adults is important, given the demographic trends
that we’ve heard about today in changes within
this population. The public health
curriculum is designed to educate public
health students about the growing issues
related to Alzheimer’s disease and dementia, and it is tied
to the core competencies for public health professionals. Healthcare providers are
another important focus of education efforts related
to brain health and dementia. There is a need to increase
the awareness, knowledge, and abilities of healthcare
providers who interact with and support people of
cognitive impairment and also their caregivers. The Balm in Gilead developed
a curriculum and educated over 300 nursing
professionals in 14 chapters of the National Black
Nurses Association in 2016. In 2017 they developed
additional curriculum to educate African-American
physicians about brain health in partnership with the
National Medical Association. In another initiative
for healthcare providers, the KAER toolkit developed
by the Gerontological Society of America helps to
get cognitive screening and assessment resources
into the hands of primary care physicians. The materials in this
toolkit are designed to improve detection of
cognitive impairment, earlier diagnostic evaluation,
and referrals for education and supportive community
services for persons with dementia and also
their family caregivers. The resulting toolkit
provides options to the primary care physicians. Health plans and healthcare
systems can select the approaches and tools
that best fit with their existing
primary care structure. The Alzheimer’s Association
awarded small grants to public health
agencies in seven states. I want to highlight
two of these states that focused their efforts on training healthcare
professionals. Colorado trained
first responders to effectively interact
with people with dementia who are residing in communities. Utah developed dementia-related
competency for primary care providers,
including both medical and nursing students, as well
as other non-health workforces that work with older adults across the continuum
of their care. CDC moving forward with
our partners will continue to support the collection
of data for both the cognitive
decline and caregiving modules on the BRFSS and other
surveillance systems. This data can be
used for action, and innovative tools
facilitating access will be developed. We are currently in the process of analyzing the recently
released 2016 BRFSS data. CDC will continue to increase
awareness about dementia and risk reduction strategies
while reducing conflicting messages for both patients
and healthcare providers, in addition to increasing
supports for caregivers. The key is to improve
the awareness but just improve awareness that
will actually result in action. CDC will also continue to
promote cognitive screening and assessment, and the early
diagnosis and disclosure of Alzheimer’s disease
and related dementias. We will continue to do
this through the training and education of
healthcare providers and public health professionals
and the development and promotion of tools
to facilitate assessment, diagnosis, and disclosure. The ultimate goal is to promote
the health and well-being of persons with a cognitive
impairment and their caregivers. CDC’s Alzheimer’s Disease and Healthy Aging Program will
keep moving the field forward together with our partners to
keep older Americans healthy and remaining as independent
as long as possible. This slide highlights some of the program’s current
collaborations; however, there is a lot that needs
to be done in this field that we can only accomplish
together through collaborations across multiple sectors. Thank you very much. And now I want to open the
session up for questions. If you are participating
remotely, please make sure you submit
your questions electronically. If you’re on site,
please raise your hand or move to a microphone. And I’m going to first ask Susan if we have any questions
remotely. [ Applause ]>>We have several
questions online. In the absence of a sense
of purpose, what can we do to help older adults who have
mobility and sight issues and, thus, cannot volunteer
teaching children how to read and play ball? I’m struggling to
think outside the box, but I’m having difficulty. So what can we help
the aging population do to stay interactive?>>Sarah, do you
want to take that?>>Sure. Thanks for
that question. There are so many opportunities
for people to volunteer and find purpose
in their community. I can recommend AARP’s
Connect2Affect. It’s an initiative
to link older adults with volunteer opportunities in their communities
throughout the country. There are lots of opportunities,
both in-person and remotely to find ways to engage
with your community. And even if you have
certain physical limitations, there are ways around it.>>Thank you very much. Susan, did you want to comment?>>One more. I want to summarize we
have multiple questions on accommodations in housing. What can families plan to
do to adapt their households and how can they find
more information on that?>>That — I’d like to follow
up with you about that. Because there are enormous
opportunities for that. Other aging organizations
and the creation of livable communities is
a big initiative of AARP’s, and that’s to enable people to live independently
in their communities. I’ll be happy to provide a list
of resources and opportunities for you to address
that specific question.>>And we can post that on
our Grand Rounds website.>>Great.>>I would just add to that
very briefly, the Americans with Disabilities Acts does also
protect people who are caring for somebody with limitations. So people who are
caring for families, that should be one thing
that they should think about, is whether they might be able to get accommodations
through the ADA. So, for example, if
you’re heard of hearing, you can actually get a
free caption telephone through the ADA. And a lot of people
aren’t aware of that. And the other would be to
go to the elder care locator because it does provide a
lot of resources for families and for individuals
who may be dealing with functional limitations.>>And then we had a
question in the room.>>Thank you very much for your
commitment to healthy aging and sharing that with us. It seems if we’re going to get
from treatment to prevention, we need really good early
diagnosis so we can separate out it’s not just the
general population in trying to see what seems to be better,
but we have early detection of people who would
otherwise develop and we can tell what’s
working to prevent. What’s the on the horizon
for highly reliable, can be reliably given, and highly specific
ways to diagnose early?>>So one of the things that I think is the most
exciting is something called the IDEAS Study. That’s currently $100 million
study that’s been funded by the Centers for Medicare
and Medicaid Service, CMS. And it’s the American
College of Radiology and the Alzheimer’s
Association are doing it. And what it’s doing
is testing — about 20,000 people
are in this study — testing amyloid PET scans. So there’s an agent
that’s used in a PET scan that can detect amyloid
on the brain. And what the study is looking
at is what is the impact of that on healthcare, and
on the treatment of healthcare, and
on the diagnosis? One of the — the agent has
been approved by the FDA, but CMS said we need more
information on its usefulness, its utility in order to approve
its coverage under Medicare. And the Alzheimer’s Association
believes that this tool, for example, this amyloid PET
scan is particularly relevant in the diagnostic sense
when you’re dealing with differential diagnosis. So you know there’s something
wrong with an individual, and you need to pinpoint
more accurately or you need to pinpoint exactly
what that diagnosis is, and this would be a great tool
to use to enhance that diagnosis and to be able to better make
that diagnosis and potentially at an earlier point
in the process. And so this is a
very exciting study. There were some preliminary
results that were released last summer
that were very, very promising. And so that’s one potential. Another is the ongoing
research for biomarkers. So we know, for example,
on amyloid on the brain — so that’s the plaque that
develops on your brain — if you don’t have the
plaque on the brain, you don’t have Alzheimer’s. But the question remains, if
you do have plaque on the brain, does that mean you
have Alzheimer’s? So does it work both ways? And so can you use amyloid,
which you can now see on this PET scan, can you
use that as a biomarker? And so that’s additional
research that needs to go on. And I’ll mention one more, and that is a study
called the DIAN trial. And this the Dominantly
Inherited Alzheimer’s Network, D-I-A-N, DIAN. This is a group of people
who have a genetic anomaly that guarantees that they
will get Alzheimer’s. This is very rare. So this is less than 1% of all Alzheimer’s cases
have this genetic anomaly and they will get it
at a very young age. But because they are
guaranteed to get it, we know that they will get it
so we can study various means of prevention and whether
certain things can delay the onset of the disease in people that we know are
going to get it. The problem is doing a research
study on preventive measures for this disease is problematic
because it takes a long time for to you get to the point
of being 85 years old and, you know, following
people for 30 or 40 years is extremely
difficult in a study. And so what’s exciting
about the DIAN trial is because you know these
people are going to get it, whereas me, we don’t know that. So those are just a couple of
things that I think are exciting on the horizon about
diagnosis and prevention.>>We’ve had so many
questions, I’m going to go to Susan one more time.>>Yes. And I’ll, again,
summarize from Katie in our Facebook Live stream,
what efforts are being done at the local level to
reach and impact the health of the young old or early
prevention for the young old?>>So I will, again,
mention livable communities. There is an enormous effort
underway in association with local communities all
over the United States, an effort coming out of the
World Health Organization to create livable communities. And that’s to make
sure that streets and housing are accessible, that there are transportation
options, places for healthy eating,
a whole variety of ways of thinking about how
to build communities for people of all ages. You know, the kinds of
innovations that are great for mothers and strollers who
are able to take advantage of curb cuts are the same kinds
of advantages that disabled and older people
find really helpful. So finding local communities who are constructing the
opportunities and the means to transform their
communities into places that promote exercise and
healthy food options are, I think, part of the best way. There’s lots of workplace
and wellness initiatives for the middle-aged folk. And some of the initiatives
that Grace was mentioning around caregiving, kind
of linking the importance of maintaining your
health over age as you age.>>All right. Fascinating session,
a lot of good stuff. Please join me in
thanking the speakers. [ Applause ] And, again, if you
have a moment, please pop down to the
library and see their display. And thank you very
much for joining us. We’ll see you next month for
Public Health Grand Rounds.

Daniel Yohans

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