Wellness for the Mature Adult

Optimizing Function and Health in our Senior Years

COL John P. Kugler, MD, MPH

Deputy Medical Director (TMA/OCMO) March 2007

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Overview

•The Wellness Paradigm from the Mature Adult Perspective

•Optimization of Function through Balance

•Evidenced-based U.S. Preventive Services Task Force (USPSTF) Recommendations

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Wellness Paradigm with a Mature Adult Focus

• A wellness paradigm of health care is based on prevention and interventions that are meant to maintain a healthy state and avoid crises

• The medical paradigm is based on crisis management and interventions that target individuals whose health have been critically impaired by an event

• The Mature Adult Focus stresses the maintenance of a healthy state that is defined by the optimized function of aging processes

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The Mature Adult Focus of Wellness

• Aging is associated with multiple degenerative failures of complex systems. Disease hastens this process and results in disability and eventually death.

• Successful aging sees the postponement of chronic disability as its primary goal. Extension of life is a secondary goal and is ultimately finite.

• Ultimate goal is to “compress” morbidity towards maximal life expectancy.

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The “Compression” of Morbidity

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now ext. comp.

morbidityonset

life expectancy

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Optimization of Function Through Balance

• Reduce morbidity by optimizing the function of multiple systems/dimensions

• Six critical dimensions requiring optimized function: social, occupational, spiritual, emotional, intellectual, and physical (National Wellness Institute).

• Each dimension requires engagement and practice (exercise): “use or lose”

• Attention to all the dimensions defines “balance” and has the maximal impact on compressing morbidity. (Supported by significant evidence in multiple studies)

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Dimensions of Wellness(Social and Occupational)

• Network of personal friends/active involvement with extended family

• Active group or community involvement

• Solid and non-problematic financial, legal, and personal relationships

• Continued full-time or part-time employment (if preferred and reasonable), volunteer work

http://anthro.palomar.edu/social/images/old_people.jpg

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Dimensions of Wellness(Spiritual and Emotional)

• Self recognition of the importance of spirituality or faith in one’s life. Sense of purpose and meaning

• Seek and utilize spiritual tools in dealing with life’s challenges and crises

• Recognize and seek treatment for depression, substance abuse, dysfunctional coping mechanisms (e.g. prolonged grief)

• Enhance healthy adaptive mechanisms

• Form and sustain healthy relationshipshttp://static.flickr.com/7/6382503_ee69093bd3.jpg

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Dimensions of Wellness(Intellectual)

• Successfully maintain the social and occupational dimensions

• Maximally engage in diverse intellectual pursuits

http://www.giantbrain.com/fc/fc2004/images/bridge-sm.jpg

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Dimensions of Wellness(Physical)

• Comprehensive exercise program that emphasizes: – 1. endurance

– 2. flexibility

– 3. strength

– 4. balance

• Evidenced-based preventive care (see below)

• Evidenced-based disease management that maximizes benefit, minimizes risk, and focuses on functional outcomes that matter

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Comprehensive Exercise Program

• 1. Endurance (e.g. walking, cycling)

• 2. Flexibility (e.g. stretching, yoga)

• 3. Strength (e.g. weight training/isometrics)

• 4. Balance (e.g. Tai Chi, dance)

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USDA Center for Nutrition Policy and Promotion

• http://www.mypyramidtracker.gov/default.htm

• In depth background recommendations for sensible exercise and diet.

• Personal assessment and on-line tracking diary for physical activity.

• Personal assessment and on-line tracking diary for sensible diet.

• NO COST!!!!

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Benefits of Exercise

• Increases physical fitness

• Helps build and maintain healthy bones, muscles, and joints

• Helps weight loss, maintenance of weight loss and prevents weight gain

• Builds lean muscle and may help reduce body fat

• Builds endurance and muscular strength

• Lowers risk for cardiovascular disease, colon cancer, and type 2 diabetes

• Helps control blood pressure

• Can promote psychological well-being and self-esteem

• Reduces feelings of depression and anxiety

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Physical Activity as Part of Everyday Life

• Walk, wheel, or bike more; drive less

• Get up 30 minutes earlier in the morning and take a brisk walk to start your day

• Take the stairs rather than elevators or escalators

• Park at the far end of the parking lot for a longer walk

• Walk around the house, office and yard

• If you are a computer user, give yourself at least 5 minutes of exercise for every hour of computer time

• Lift, push, pull or carry somewhat heavy items such as loaded grocery bags and trash boxes.

• Push your lawn mower instead of using the power-assisted drive or riding mower

• Include endurance or cardio-respiratory activities daily or on most days of the week

• Include flexibility activities at least 3 days per week regardless of age

• Include strength activities 2 to 4 days per week to help your muscles and bones

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Evidenced-based Preventive Care Recommendations

• Recommended preventive services (based on USPSTF assessments)

• Other potentially beneficial services

• Screenings and tests not indicated for mature adults

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All Older Adults Should Be Screened For

• Hypertension and dyslipidemia

• Obesity and malnutrition

• Alcoholism

• Breast, colorectal, and cervical cancers

• Vision and hearing deficits

• Smoking Cessation and Dental Care

• AAA in male smokers age 65-75

• Immunization Status

• Injury Prevention/ Osteoporosis

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Hypertension

• Prevalence increases with age

• Treatment decreases mortality and morbidity from Heart Failure, Heart Attack & Stroke

• Strong evidence for treating Systolic Blood Pressure >160

• Uncertain evidence > age 80

• Action: check BP at least annually (USPSTF ‘A’ Rating)

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Dyslipidemia

• USPSTF strongly recommends screening and treating abnormal lipids for men > age 35 and women > age 45. (‘A’ Rating)

• Screen and treat older adults with Coronary Artery Disease annually: LDL >130, HDL<35, TG>200. (Strong benefit established)

• Target to LDL<100, HDL>40, TG<200

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Obesity and Nutrition

• Measure weight/height routinely and know your BMI– A BMI less than 18.5 is underweight

– A BMI of 18.5 - 24.9 is normal weight

– A BMI of 25.0 - 29.9 is overweight

– A BMI of 30.0 - 39.9 is obese

– A BMI of 40.0 or higher is severely (or morbidly) obese

• Consume a balanced diet high in fruits & vegetables, low in fats, with adequate calcium and Vitamin D

• General Principle: Supply must be less than demand to lose weight and must equal demand to maintain weight.

• http://www.mypyramid.gov/mypyramid/index.aspxhttp://www.texastravesty.com/2004_02/images/breakfast.jpg

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Alcoholism

• Older adults are more susceptible to effects of alcohol

• Screen all adults at least once or whenever a problem is suspected

• http://www.niaaa.nih.gov/Publications/PamphletsBrochuresPosters/English/default.htm

• http://pubs.niaaa.nih.gov/publications/handout.htm

• The CAGE Screen:– C = cut down

– A = annoyed

– G = guilt

– E = eye opener

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Breast Cancer

• Breast cancer prevalence increases with age. Mammography well validated in older adults. Every 1 to 2 years beginning at age 40. Strong evidence of benefit. Medicare/TRICARE coverage.

• Unclear if and at what age mammogram screening should stop: – USPSTF (age 70)– ACP (age 74)– AGS (age 85)– Likely to be beneficial as long as life expectancy 5-10 years

• A normal mammogram does not rule out breast cancer!!!

• Know your personal risk: http://www.cancer.gov/bcrisktool/

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Colorectal Cancer

• USPSTF now gives ‘A’ Rating to colorectal cancer screening–Yearly stool test for blood, Flexible Sigmoidoscopy

every 5 yrs, or colonoscopy every 10 yrs., beginning at age 50 for normal risk persons (earlier for high risk). All ranked as ‘equivalent’.

–All are covered by Medicare/TRICARE.

–Clear evidence of benefit.

• Risk/benefit, provider/patient decision

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Cervical Cancer

• 40% of new cases & deaths in women > 65

• Most cost-effective for women with incomplete screening previously

• Cut-off age remains controversial

• Action: PAP every 1-3 yrs if patient is sexually active and has cervix. Stop after age 65 if h/o normal smears or after 2 normal smears 1 year apart

• Medicare covers PAP/pelvic every 2 years

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Vision and Hearing Deficits

• Routine Eye Check to detect uncorrected refractive errors, glaucoma, cataracts, and macular degeneration

• Routinely consider hearing loss and obtain information about hearing aides if applicable.

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Smoking Cessation

• Leading preventable cause of premature death and disability. Multiple cancers, Emphysema and Chronic Bronchitis, Stroke, Heart Disease.

• There is clear benefit to quitting at any age.

• The more one tries to quit, the more one is likely to succeed.

• http://smokefree.gov/

http://worldofwonder.net/wimages/p1_dentures_ap-tm.jpg

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Oral Health

• Tobacco use in many forms predisposes to oral cancer. Regular oral cancer examinations are an essential part of medical and dental care!

• Receding gums, periodontitis, caries, xerostomia may all be effectively altered by meticulous care and regular dental visits.

http://worldofwonder.net/wimages/p1_dentures_ap-tm.jpg

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Abdominal Aortic Aneursym

• The USPSTF recommends one-time screening for AAA by ultrasound in men age 65-75 who have ever smoked (‘B’ Rating)

• No recommendation for AAA screening for men age 65-75 who have never smoked

• Discouraged screening for AAA screening for women

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Update Immunizations

• Influenza: annually for all >50. Highly effective with a 70% risk reduction for illness and 90% risk reduction for mortality.

• Pneumovax: All >65. At least once. Re-vaccinate high risk q 7-10 yr, or if initial < age 65 in 5 yr.

• Tetanus: Booster q 10 years. 60% of infections occur in persons > age 60, Tdap (18-64).

• New vaccines: Zostavax (“Shingles”)(> age 60)

• http://www.immunize.org/catg.d/p2011b.htm

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Injury Prevention

• Balance (Tai Chi) and strengthening (quad sets) exercises to prevent falls

• Osteoporosis screening and prevention. USPSTF recommends Bone Density at age 65 for normal risk women, earlier for higher risk women. Calcium/vitamin D intake and weight bearing exercise

• Multiple measures to reduce risks for falls and other mishaps, environmental hazards: – driving (seat belts) – alcohol avoidance – polypharmacy reviews– home hazard review (fall avoidance, smoke

detectors, water temperature)

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Other Preventive Services of Potential (but unproven) Benefit

• Dementia and depression screening:

• Prostate Cancer screening: – informed doctor/patient discussion. Medicare covers DRE/PSA

• Diabetes: – Fasting blood sugar for high risk individuals

• Thyroid: – Perhaps useful for older women with TSH every 5 yrs

• Skin Cancer screening and prevention counseling: – target high risk individuals/behaviors– http://www.cancer.gov/melanomarisktool/

• ASA to prevent MI’s in those at risk: – Balance bleeding risk vs benefit. Use low dose (< 325 mgm/day)

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Screening tests not routinely indicated for the adults

• Screenings for: – Bladder cancer– lung cancer– hematologic malignancies– ovarian cancer– pancreatic cancer (if no signs or symptoms)

• Routine lab (if no clinical indication): – CBC – blood chemistries– CXR – EKG– EBCT/Total Body Scans

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General References

• http://www.ahrq.gov/clinic/uspstfix.htm#Recommendations.

• The Cochrane Database of Systematic reviews 2005, Issue 3

• http://www.nationalwellness.org

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QUESTIONS??

John.Kugler@tma.osd.mil.