“Enlightened Aging: Building Resilience for a Long, Active Life” - Eric Larson, MD, MPH
Kaiser Permanente Center for Health Research
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528 views Jan 11, 2018
Kaiser Permanente Center for Health Research
Speaker Series
Portland, Oregon
January 2, 2018
Dr. Eric Larson is the Executive Director of the Kaiser Permanente Washington Health Research Institute, and Vice President for Research and Health Care Innovation at Kaiser Foundation Health Plan of Washington. He is also a professor of medicine and health services at the University of Washington, a primary care physician specializing in internal medicine, and a member of the National Academy of Medicine.
The title of Dr. Larson’s talk is taken from his 2017 book, published by Rowman & Littlefield and available for purchase online.
Intro music courtesy of www.bensound.com
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Intro
0:07
[Music]
0:13
[Music] what I'd like to do is sort of tell you
0:19
the story that led up to the book and this notion of the kind of research that
0:24
we did I've been in this area for quite a long time so I'm gonna say a little bit about the background of the topic I
0:31
think this will be probably very familiar to all of you then what I call the act study journey will take up the
0:38
majority of the talk and then some selected findings and I have a ton of
0:43
backup slides because we've been doing this for a long time and then a little bit at the end about about the book
0:49
itself so what is enlightened aging why did we choose this title when I got into
What is Enlightened Aging
0:57
this field the most seminal thought was paper by Jack Rowe and Ron Caan called
1:05
successful aging and this was based on the Baltimore longitudinal study and a
1:10
bunch of other studies and if you read the book carefully what it is it's about not aging it's avoiding chronic disease
1:19
of waiting bad things are supposedly bad things that happen to people to get older and in fact that is is not what
1:28
happens if we're not aging what are we yeah very simple you know one of the
1:35
basic facts of life so I have been working in this area for a while and
1:42
went off to to try to figure out a different approach based on what we'd
1:48
seen in our research and it's the idea of knowledge of healthy aging and the
1:54
foresight to use it and especially geared to boomers I was born in 1946 so
2:01
how are we going to have this giant bulge go through our population and have
2:07
a better go of it and this is one of the main characters in the book
Van
2:13
m'angil and Schuler we talked about man you know about van so in 2006 I'd come
2:21
to group health three or four years earlier and we published a paper on exercise
2:27
and the risk of Alzheimer's disease in the annals of internal medicine and it ended up being the paper that got as
2:32
much public attention as anything ever published in the annals so they TV stations had we gotta film
2:40
something and can we find a subject to to film and I did not know this person
2:47
because she had not graduated to to needing a medical evaluation but she'd been into the study for a number of
2:53
years she was a hundred years old and we called her the staff said wow what vans
2:59
she'd be perfect so we called her and asked her would you be willing to to be
3:06
on TV and talk about your life and the study and she said yeah and the
3:12
producers wanted to do it like on Monday and she said no it's got to be tomorrow
3:17
or and so I said well why why do white
3:22
amaro well because I'm taking a trip oh where you going I'm going to boil his
3:28
arse for a tango festival and she got on the bus the TV people came down to that
3:34
as a center that Center for Health Studies and filmed her in her red tangled dressing shoes dancing she's a
3:41
short person and just charmed the heck out of them and her daughter told me after she died that on this trip the
3:48
male Argentinians in their attractive tango carbon were much more interested
3:55
in dancing with her mother and depend the mother's daughter who is a bore their age so it's a great story and
4:01
we'll come back and so that's that's the research part of it and then then there's just living this is my mom and
The Greatest Generation
4:10
dad coming back around the time of the Korean War to Portland and my sister
4:15
myself and they they taught us a lot that generation called the greatest
4:25
generation because of what they did I mean they got us through the war they didn't
4:32
care of a lot of the problems we'd had in civil rights and other debacles they were part of American culture and they
My parents died at 97
4:39
showed us how they could live but none of them ever thought they would live to
4:45
be as long as they lived both my parents died at 97 and in my research I often
4:50
ask people did you ever expect to live this long and almost everybody says no and or I say how old your parents when
4:59
they died and all the subjects are older than their parents when they died so there's a phenomena going on in our
5:05
society that we can learn from and some of the things that we've studied over the years are what's normal on which
How can we successfully adapt
5:13
variation is usual how can you avoid decline and so on and so forth but at
5:18
the bottom of the list there are how can we successfully adapt and remain independent as long as possible which is
5:25
what a lot of people see as their goal as they hate you why does it matter the
5:31
numbers I think are pretty familiar to all of you but it's really staggering to
Why does it matter
5:36
think that that the 90 and older population is going to jump 70 percent in the decade if the current trends
5:43
continue and you can see these numbers even more striking if you look at a
5:50
population curve like this those of you who look at graphs carefully we used to
Population curve
5:56
show this curve from birth to 100 now it's starting at 35 to 100 so the
6:04
rectangular ization went from an earlier part of the so-called coke-bottle
6:11
population curve to now all the growth is happening above the age of 65 and
6:17
especially above the age of 80 and 90s this population just burns here's an
6:23
even easier way to see this so in Sweden there were three people in 1860 who lived
Subpopulations
6:28
Ondra in 2008 there were 750 and they're expecting fifty thousand of those born
6:35
in 2007 to live to be a hundred and every older sub population that you look
6:43
at is the fastest growing or growing faster than the sub population that's
6:48
younger than that if you look at these numbers and this is the one that really really floors me and I wanted I want to
6:55
point this out this is James low poll two people know his work he's a demographer in Denmark and northern
7:02
Germany now but also in this country I think he may have been in North Carolina or Duke he calls these the two Scourge
7:10
ha's of old-age Alzheimer's and sensory deprivation and that I think is really the way it is but here's what he's
Trends
7:17
written in nature of all the babies born in 2000 if current trends continue half
7:24
will live to see the next century III don't know that these trends will
7:29
continue because trends are just that you know what happened to be previously isn't necessarily what's going to happen
7:35
next but just think about that because among other things these are the
7:41
scourges old age those are the numbers from some of our research in Seattle
Dementia
7:48
about rates of dementia these are general rates and you go down to five
7:55
and older and it's somewhere around two-thirds to three-quarters in
8:01
population studies of people are demented so you think about half the people born
8:06
in 2000 or 2007 or whenever it is living to be a hundred we've got a some work to
8:12
do I think and especially it's a good area for people to be involved in research this is a study we did which
8:18
I'll come back to a little bit this is the camee project study in in of japanese-americans in King County
8:24
showing the the race and you can see these are prevalence rates you can see that they they start to spike up in the
8:32
late 70s and this is why it's so important study older people not younger people
8:38
with this disease because this condition is a condition of aging not of 1557 it's
8:44
a rare condition in young people and this is our incident study from the axe study and you can see ours are that are
Incident Study
8:52
the open circles but you can't see them very well but look at the scale on the
8:58
y-axis it's a log scale there's an incidence rates and we can't use regular
9:04
scale we have to use the log scales to capture the increase that occurs over time so I started in this area I had
9:15
trained in internal medicine and in 1977
9:20
to 78 I was the chief resident at University Hospital and I thought I knew
9:26
everything you know I'd been managing all the residents and all of care on the
9:31
internal medicine service and having a noon conference every week and gosh I
9:37
was smart and this colleague of mine is another clinical scholar Berger Eifler
9:42
said I need an internist to help me start the first ever outpatient clinic
9:47
for evaluation of people and their family members dealing with suspected
9:52
dementia and so we started this and this picture is looking at the south campus
9:57
of the University it's just where we started our work and what I found there
10:04
was I really didn't know anything about what we were dealing with and why didn't
10:10
I know anything because all the research was done on highly specialized population of younger people with
10:18
dementia there was a paper in the annals of internal medicine the dementia in the elderly the silent epidemic and the four
10:26
studies they cited in one of the table did not have anybody over the age of 60
10:31
dementia in the elderly the silent epidemic very silent in that case so we started seeing these people and I
Collecting Data
10:40
began to realize I since I didn't know probably a lot of other people didn't know either so we literally started with
10:47
5 by 8 cards and eventually 8 by 11 pieces of paper that I put in my lab coat in my back pocket and we developed
10:54
a very sophisticated paper paper and pencil database on these people and
11:02
collected data in a standard way and we were able to find things in this first
Early Findings
11:08
couple years that that kind of launched my career I I never thought I would be doing this now what almost 40 years
11:14
later because it seemed like a kind of a backwater internist didn't weren't
11:20
really that interested in dementia and in fact nobody was interested in to mention all the people but we found
11:27
important things I think and among other things there's a second bullet there's a lot of treatable medical conditions in
11:34
people who are demented and why is that what happens when you're demented they
11:40
can't remember or you can't report things and so we're finding an undiagnosed heart failure undiagnosed
11:48
urinary tract infections adverse drug reactions really advanced cases of
11:53
hypothyroidism we also learned a lot about depression and there in those days there was
12:01
something called pseudo dementia versus dementia and pseudo dementia was depression and we now know that the to
12:07
actually occur together and each one of these findings that are listed here have have endured in part because I think
12:15
like you we were studying a representative population so in nineteen
Early NIH Research
12:20
eighty got my first research grant from NIH we'd actually done all the research
12:27
in the first two years of the clinic that we were doing in the grant which made it easy to meet our specific aims I
12:34
didn't tell a project officer that obviously but we looked at the dementia
12:40
workup and we found that the there were work after what had certain
12:45
yields and we wrote papers on that but we also found these other aspects of
12:50
dementia research that were I think really interesting and important and for
12:56
example a David Buckner and I think some of you probably worked with David on something Falls exercise Gerry geriatric
13:05
researcher we showed just how common it was for persons with dementia to fall
13:11
break their hip that the rate is about three to five times higher if you're demented and you are going to have an
13:16
injury as well and at that time that really wasn't appreciated and these sensory impairments that James Vogel
13:22
talked about they really do add to the morbidity of dementia if you can't hear
13:29
or can't see well especially if it's reversible you're far worse off so
13:35
here's some other examples and I don't think we need to go through that I've already talked about the fracture rate
13:41
here adverse drug reactions in those days were the most common cause of reversible dementia not a brain tumor not a
13:47
subdural hematoma but a drug that was affecting the brain and causing people
13:53
to look like they were demented and recently we we've come back to anticholinergics and it's shown that
13:59
they're not just reversible effects of any cholinergic sand all older people but actually it increases your baseline
14:05
risk for being demented and not not in an irreversible way so we did this wrote
14:13
a lot of papers started getting research grants and then the niña said what we
14:19
need for Alzheimer's disease research is something like they have at NCI Cancer Registry so they put out an info a and
14:26
said can you develop an ideal a dementia registry for studies of markers and for
14:36
clinical trials so we colleague but Kukla and I wrote a
14:42
incident case finding grant and got the best score but we moved from
14:50
a convenient sample at the University and the specialized clinic to group
14:55
health and that was one of the smartest things I ever did in my career was start to work with group health and folks like
15:01
Ed Wagner and others at the Center for Health Study and our goal was to find every case we could who within a year of
15:10
their onset just the way you would a Cancer Registry but as you can imagine
15:16
there is no tissue that draws a person into it you have to have a surveillance
15:21
strategy and that's that's what we develop and then we got a study called
15:33
genetic differences and we established essentially a case control study with with the population being the area
15:42
served by the Central Hospital Group Health which means it's kind of West King County East
15:49
I mean west of the of Lake Union and Lake Washington and south of Edmonds and
15:55
north of Renton and that was our that was our study and those days group
16:01
health at a hospital now now we don't so during that time we again got very close
Survival and Decline
16:09
to a truly population-based study and case control kind of design established
16:15
a database and began to study survival and decline and again polish papers and
16:23
uh that are that were used by by insurance companies actually to try to figure out what at what's normal for
16:29
people with dementia versus not in terms of survival and decline and then we began to working with our pathologists
16:35
which in in the long run was going to be an extremely important for us so those
16:42
were kind of lean years why because
16:47
everything we found seemed well that was really interesting was
16:53
essentially not confirming findings that were even more interesting that findings
Platelet Membrane Fluidity
16:59
platelet membrane fluidity that was a marker discovered at the University of
17:04
Pittsburgh nobody ever remembers that but me anymore but we we looked at that and we could not reproduce the finding
17:10
and it was done in especially a clinic we did it in a generalized population skin biopsies for amyloid same thing
17:18
findings would come out ni a would just you know celebrate luckily found science
17:24
New York Times those kinds of things now nobody even remembers them other than the people that had done the work
17:31
we just couldn't replicate we did replicate the things that have endured for the last 3040 years so the April
17:38
before we show that that worked and we also realized that if you're gonna do
17:45
great epidemiology and health services research it's wonderful to have a cohort
17:52
study all kinds of problems with case control that you can overcome with with
17:58
a cohort study so in this third
18:03
iteration of this grant that's been funded since 1986 we slipped in an aim
18:09
to recruit a cohort sample and the sample was people over the age of 65
18:15
without dementia who agreed to participate in a follow-up study and so
Living Learning Laboratory of Aging
18:21
this is how we how we started and this is where we are today we started in 94
18:27
to 96 getting our first cohort two thousand five hundred and eighty people and we want to be a living learning
18:35
laboratory of Aging and I hope that I can convince you as this study goes
18:40
along that we're that we are I think we're the longest-running study of our content worldwide there are other
18:45
studies that have established cohorts that are longer but none of them have the richness of the data
18:52
you have when you're part of an HMO and you know that the median number of years
18:58
that people have been in group health before they come into our study is over 30 so that means especially with
19:05
electronic medical records you have this vast trove and a group health has started having computerized records of
19:14
drug fills back in 1977 and and then labs in the 80s and that are full-on
19:21
electronic medical record in the early 2000s now what we do is as you know when
19:30
you're doing an aging study what's the first thing that you realize the sample
19:36
gets smaller really smaller in a hurry and the events accumulate especially if
19:43
you've got a random sample of a population so we've devised a replacement strategy so we recruit about
19:51
two hundred and fifty people a year to replace the people that have either become demented died or for some reason
19:57
or they have dropped out so we have this constant recruitment strategy we do it exactly the same we draw the population
20:04
using the same algorithms as the years go by and and this is what we end up
20:10
with this is where we are today are pretty close to today might have been a week before last I don't know but we
20:17
call this a living laboratory and we are now part of our University's atrc we
20:24
help them with with certain certain subjects who are willing to be more
20:30
intensely followed if you will scan and
20:35
so forth but we have about five hundred and thirty four five thousand three hundred forty people in the cohort at
20:41
present of that over two thousand are alive and not demented
20:47
and seen every two years we have been collecting autopsies and this slide said
20:53
seven hundred twenty the we are now up to seven hundred forty and that's been a
20:58
huge huge important part of our work and you can see on the right side we we do work
21:06
in genetics the emerged study who came out of the act study because we had a
21:13
bio bank and neuroimaging pharmaco epi we've gotten very involved in traumatic
21:19
brain injury which always surprised me and I'll say more about that later the neuro path piece we're having a
21:24
conference on Friday bringing together about 40 neural pathologists to begin to
21:30
think how can we use these brains from a population-based study to learn more about the aging brain in ways that
21:36
nobody can duplicate plus the the brilliance of neuroscience has all these
21:44
new ways of looking at tissue in cells we just some treatment trials and I'm
21:51
going to talk later about resilience and you can see on the on the Left these are the sources of our data so what has
21:59
emerged in my own mind that I this is not a very well done slide but this is a
22:06
dream come true for me David Sackett some of you know that name is a giant founder of clinical
22:13
epidemiology great force and evidence-based medicine this is linked
22:19
off lecture he gave in 1986 published in 1987 and what he exposed me and the
22:28
audience to and then wrote it up as a paper was this notion of you have biology human biology on one side you
Population Science
22:36
have epidemiology on the other side and I think today we would call this population science or quantitative
22:46
biology if you will and his belief was that these two should come together to
22:52
bring a research program together and the bridge for this could be a clinical
22:59
epidemiologist to health services so a person like ourselves I presume and the
23:05
idea is there's so much going on in the science of human biology especially
23:10
around aging and computational work and and population that we have to study are
23:18
also we're getting better at that all the time and he thought let's bring this together and work across this spectrum
23:26
of from human biology to epidemiology and outcomes and so on and so forth he
23:33
did that those of you who remember the the programs in vascular medicine
23:41
especially clotting thrombin Wallach disease at McMasters that's what they did they had people studying smooth
23:47
muscle cells and platelets and they also had some of the most elegant clinical
23:53
trials and epidemiologic studies of the time and that work has withstood the
23:59
test of time a lot of the evidence base that we use today was developed with this kind of a vision I believe so where
24:07
we are today is we just started our next five-year cycle back in 2015 and we're
24:15
working on two main aims our first aim is to look at cardiovascular risk
24:21
factors that we know have some relationship to brain aging and
24:28
Alzheimer's disease high blood pressure high blood glucose or higher blood
24:34
glucose and and and lipids to try to understand how those were lately shown
24:40
in a paper in the New England Journal a couple of years ago how any level of higher blood sugar is associated with a
24:47
higher risk of dementia regardless of whether a person is diabetes diabetic or
24:52
not and so we're trying to sort through those three well-known cardiovascular
24:58
risk areas and then we've turned our paradigm for study on its head
25:05
we've always studied the adverse outcome dementia Alzheimer's disease and done
25:11
our work in that space one of the things we've realized with all these brains is
25:16
there are people who live to be ninety ninety five and have all the plaques and
25:21
tangles which would say that person should have advanced clinical findings
25:27
of Alzheimer's but they died in our study sometimes with 20 years of follow-up and they're not demented so
25:34
what is it about those people that causes them to be more more likely or in
25:43
in fact resilient to these effects is it physical activity versus sedentary
25:49
behavior we're looking at that with accelerometers and them kilometers as a genetics for dealing deeper and deeper
25:56
with the Allen Brain Institute and and some of the genetic areas and other risk factors and then of course we've always
26:02
said aim 3 which is data sharing how can
26:08
we use this laboratory to advance the science of brain aging or often the
26:14
science of somebody else's area of interest but we have the resources to do data sharing so here's an example of
Traumatic Brain Injury
26:23
something that came along this is a what kind of a team is this an old football
26:30
team look at that look at the helmets and think today about traumatic brain
26:35
injury and football players well we learned in the 80s and 90s that traumatic brain injury is not a good
26:43
thing and we know that traumatic brain injuries increase your risk of getting dementia in late life and I thought to
26:49
myself you know one just is any more well Paul Allen National Football League
26:54
head injuries all of a sudden everybody's interested in traumatic brain injury we have a huge program now
27:00
with colleagues from Mount Sinai traumatic brain injury and Boston
27:06
University so all of those stories that you heard yesterday when you're watching the football games about these guys that
27:11
are just frying their brains we're trying to look at the mechanisms and
27:17
some of those those findings because among other things we have great history
27:22
of head injury and we can get more from our subjects and and their survivors and
27:29
we have this 740 brains that we can look at so it's been very interesting to say
27:36
there's always more to learn when you when you want to drill down on a topic beyond just a huge public health
27:42
implications so we have mentioned the
Emerge
27:47
emerge a study where we we got funded to show to show how you can link electronic
27:54
medical records to a bio bank and and we do a lot of work in genetics male
28:00
through the Alzheimer's disease genetics consortium and the ad sequencing project
28:05
and some international studies and we I don't know that have a slide for it but
28:11
we finally got collaboration with the Allen Brain Institute where they're doing some of the most I think deep
28:19
genomic proteomic and in metabolic work
28:25
and we started doing that work around hit injury but now we've just put out a big paper on in in by all in a by
28:33
electronic biology to looking at that these deep genetics we do a lot of data
Data Sharing
28:39
sharing we have 71 funded grants since we started in 86 that use our data as
28:48
best we can tell and then since 2010 we've done 100 or 150 episodes of data
28:56
sharing and we've now got a grant to codify how we how we do that and make it
29:01
as easy as possible for people to get our data this is a list and I'll keep
External Research
29:07
the slide up here because I don't want to read everything but we have 16 studies that are using
29:15
the laboratory of the ACT study for externally funded research a few of
29:21
these are not as external as you might think but we've got grants on on air
29:28
pollution with the University of Washington some work on machine learning
29:33
and and so on and so forth the early
29:39
environment studies come back to that a little bit later but there's really a
29:44
life course approach to the risk of Alzheimer's disease and dementia but I think we should think about some
29:51
adherence studies and then this third bullet up here current and future costs
Current and Future Costs
29:58
of l-tyrosine dementia care Norma Coe is an economist and they was it the
30:03
University of Washington School of Public Health now she's back at Penn and we're very interested in the cost of
30:09
dementia care and especially with with Katie Washington will have excellent
30:15
ability to study that and we're just starting to publish papers in that sphere so you can see it's been it's
30:23
been a tremendous place to work and some
30:28
of you probably know Aaron Bowles from cancer research Network she and I have
30:34
begun to create ways to get the data out so we have a data query tool so if you
30:40
come to our website and you're interested in research in this area you can just log in to tell who you are what
30:48
are you doing this and and go to know what kind of subjects might be available for for research using the act database
Reducing Risk of Dementia
30:57
and then this is a dream come true for me Mars is the multi-domain Alzheimers risk
31:05
reduction randomised trial it's a study that we're doing with the University of
31:12
California in San Francisco to attempt
31:17
to show that these multiple risk factors that we studied over the years that are
31:22
modifiable if they are modified could lead to a reduction in the person's risk
31:28
of Alzheimer's a season and we're doing it in a very I think innovative way rather than just throwing the facts at a
31:37
population of cases and you're exposed
31:42
and unexposed we're trying to develop a menu and select people based on their
31:51
individual risk and then offer them what do you want to work on to try to reduce
31:57
your risk of late life dementia rather than say everybody gets everything we're
32:03
gonna try to do it with a fairly intensive but personalized effort to
32:09
reduce we reduce risk and the elements are up here I'm missing our our staff
32:14
meeting today but we're gonna get it going and we're gonna get on time and there are studies like this all over the
32:21
world but as far as I know there's nobody that's taking an individualized approach that you can do in a delivery
32:27
system like ours so this is a more on
32:33
the study itself and I'll come back to this but it's said that if somewhere around maybe 40 to 50 percent of risk is
32:41
what this is modifiable potentially what a lot of file based on on descriptive
32:47
trials like like we do so this is what has emerged and it doesn't project very
32:54
well but this is from The Lancet Commission on dementia so this summer in
33:02
July there were two major reports that came out on dementia the first was at first but they came out
33:11
at Saint John but the first to start was the Institute of Medicine now National
33:18
Academy of medicines HR qni funded what
33:24
is the evidence base that we can prevent dementia and the end the study was pretty discouraging there were only a
33:29
couple things that that met criteria for an evidence-based Practice Center and
33:35
you know you do a lot of that here it's very high criteria and some of the things you think you could study are
33:41
very hard to study in in the context of a randomized trial because they're mostly common sense things that lead to
33:47
better health anyway and and this this is The Lancet a version of that which is
33:55
the Lancet Commission on dementia which I worked on both of them and what we came up with which i think is very
34:01
important is that there's a series of risk factors that accumulate over the
Lancet Commission on Dementia
34:06
life course starting from the at Birth socio-economic well-being and and and
34:13
factors of the environment when a baby is still in gestation and an early life
34:19
which had you can you can make an estimate of how much that contributes to dementia and if you follow these lines
34:26
down here you'll see early life midlife and then of course late life and and the Commission
34:33
concluded and you know the numbers I would take them to the bank but about
34:38
thirty five percent of this risk is potentially modifiable and it happens across the life course and again you can
34:45
kind of relate this back to - to some of the things we wrote about in the book so
34:50
here's a few selected findings and my goal for those of you who are kind of
34:55
wondering what is this guy going to stop is to try to finish this part and then
35:01
we have plenty of times to just talk about the studies and the book and some of your observations
35:07
so these are some of our selected findings this is pre-act
Selected Findings
35:13
this list of things about depression and caregivers and how these disturbing
35:20
behaviors are the kind of things that make life miserable for families and
35:25
over time the second name here Lyndon Terry and I and others have developed
35:31
something called the Seattle protocols which are designed to help people figure
35:37
out how to deal with difficult behaviors and one of our papers in JAMA quite a
35:43
long time ago showed that just teaching caregiver dyads about daily walking and
35:51
some of the ways not to accelerate
35:57
behavioural problems can make a huge difference and in physical well-being at
36:03
the end of a couple years and also it reduced the rates at which people were
36:08
admitted to nursing homes for behavior problems that's this second trial in
36:14
2003 and the Seattle protocols Falls and Footwear I mentioned early on that one
Falls and Footwear
36:21
of the things we discovered before a DPR
36:27
enact was that Falls are devastating and there were contributing factors and then
36:34
a few years ago some of you probably know Tom capsule I'm sure from from our place we got a grant to study the
36:42
question of are you more likely to trip or slip as the cause of a ball and and
36:50
there was an RFA and Tom and another epidemiologist in public health said can
36:57
we can we use your study to study this so we had we had people with these
37:03
little three by five cards and we asked them every month to tell us if they fell
37:08
or not and then we asked him to call us they ever fell and we would send somebody out
37:14
to measure the coefficient of friction on the bottom of the shoe or on the
37:20
surface that they fill on and one of the persons who was still skiing and up in
37:28
Snoqualmie Pass he would call us when he fell and that was that was kind of fun
37:34
for a while and they say women but there's too much staff time driving because their quality measure would it's
37:41
gonna be the same no matter what inventors of the spectrum oh where that was but it turns out that that being
37:48
barefoot or walking around in stocking feet yes of his is a highest risk for falling it's higher than even wearing
37:54
high-heeled shoes and the safest kind of shoe to wear is a like a tennis shoe
37:59
with a nice non-slip a sole and when this study came out does anybody
38:06
remember her no Sid Wolfe from citizens Public Citizen and he was their health
38:13
research group had he want he wrote to tommy Thompson when this paper came out who's then the Secretary of Health I
38:20
believe and said you should put this in every social security check it's finding and think of all the the hip fractures
38:27
you might save people change their behavior my I had my mom and dad always have a slippers with a hard sole next to
38:35
their bed so when they get up and go to the bathroom at night they would you know fallen slip drugs we talked a lot
Drugs and Dementia
38:43
about that in early on one of the most important papers I think I ever wrote
38:48
was the adverse drug reactions causing dementia in the elderly and and in those
38:54
days it was in Seattle and he went I'm sure it was true in Portland a lot of people were taking long-acting events
39:02
our days of peds or any hypertensives like al de menthe or methyl dopa and those drugs interfered with various
39:10
aspects of brain transmission and overtime I think that's kind of gone away but it's still a very prominent
39:17
in geriatric medicine in the care of older people the amount of drugs people are taking that and can cause them to
39:24
become less alert or to lose their balance we showed in one study that
39:30
statins and Steve you might be interested in this people that were
39:35
taking statins had less Alzheimer's ation in their brains at autopsy and you
39:44
know kind of hard to interpret that but it was it was another feature of perhaps the way you can reduce the risk of this
39:52
disease by controlling cardiovascular risk factors and then this study is a really important one and I did my
40:00
sabbatical in 2014 in January a paper by
40:05
Shelly gray and our group came out showing that not only do any cholinergic s-- cause short-term cognitive
40:14
impairment but they actually increase a person's risk of dementia over time and
40:19
as I left England this paper was just coming out it made the front page of all
40:26
the tabloids and they talked about these abandoned real drugs that people use for
40:32
for sleeping the challenge was the version that they had in England didn't
40:39
contain finish so maybe makes a front page of the tabloids the NHS is deluged
40:44
with calls and they have to do a public relations campaign to you know to
40:49
contradict the way the tabloids had interpreted the study in America versus
40:55
versus in in Great Britain physical activities we talked a little bit about that in the
Physical Activities
41:01
context of then and the real interesting thing about this is that if you look at
41:08
the data real carefully the thing that drives us is inactivity not not you know
41:15
anything above less than three times a week 15 minutes is relatively protective
41:23
compared to the being in that lower quartile or quintile of activity and
Inactivity
41:29
physical function may actually start to
41:34
decline before Cobble cognitive function occurs and a great number of people with
41:41
this condition and I think you can see that if you've been around or people they often start to slow down before
41:47
their cognition begins to slow down or recover apparently slow to slow down and
41:53
then some of you may remember silver sneakers lifetime fitness that's a
42:00
benefit guys are benefiting this grew out of some work that we did at the Center for Health Studies on preventing
42:06
Falls led to silver sneakers lifetime fitness and some of the work that we did
42:12
on that program showed that if you participate in this program you have lower health care costs and so you can
42:19
kind of understand why it's a covered benefit it's smart business to give people this is an access to staying
42:27
physically fit this is our exercise study that that appeared in the annals
42:34
of internal medicine and you can see that the curves start to separate around
42:40
late 70s especially into the 80s which is when the disease becomes so much more
42:46
prevalent which is what you might expect and this is the finding that that shows
Vascular Dementia
42:53
you how things are always going to change in medicine and medical research
42:59
when I started out in this field we were trying to distinguish between
43:04
vascular dementia or multi-infarct dementia and Alzheimer's disease there were scales that we looked at we tallied
43:11
up poison the schinsky scale was if you're above such as such a dish it's a skill you have multi-infarct if you're
43:18
less than such-and-such well it's gotta be Alzheimer's disease well early on we found that in fact mixed dementia was
43:26
much more common in our population and we published this and nobody believed it
43:33
but then now I think everybody knows that in an older population your brain
43:38
is more likely to have plaques and tangles which are the markers of Alzheimer's Lewy bodies which are seen
43:44
in Parkinson's disease and and vascular injuries but then we got very interested
43:51
in what about people that are supposedly false negatives in the two-by-two chart
43:59
they're not demented but they have no pathologic findings and there was a
44:05
neurologist named Fred plum who told me and our team in Seattle early on that's
44:12
the really interesting part of a two by two classic happy table who are those
44:17
people that are false negatives are not demented but they have these kind of
44:22
changes so we were able to put together our our brains with the organ brain Bank
44:28
the nun study and one other study
44:36
therefore studies the lots of brains and what we found was that there are these
44:41
people with plaques and tangles those do live to be 90 and 95 and they're not
44:46
demented and it's very interesting to to
44:51
see how we can learn from that group this is the actual studies or the other
Hana Little Asian Aging Study
44:57
one was the hana little asian aging study this this is our our set of brains and
45:03
or debris bank I think is right here maybe yeah and not really important what
45:11
is important is that that blue is people who died with no dementia and have
45:19
significant Alzheimer's findings the red is a vascular brain injury and the other
45:25
color are people that have Lewy body disease so this is and you can see that
45:30
as as as you get older that's it's it's it's very very interesting how much of
45:38
this is present so the other thing that
45:43
I think is worth knowing is this this has nothing to do with act per se but
45:50
there's we beginning to look at data on existing rates of dementia there was a
Data on Existing Rates of Dementia
45:56
demographer named Anton who again was also out in your neck of the woods probably knew him he looked at national
46:03
long-term care data and showed in a paper published in a very obscure Journal who my project officer told me
46:10
about that the rates of severe cognitive impairment over this period of time had gone from five point seven to two point
46:16
nine percent and Ken langa a colleague of mine at Michigan who works with the
46:23
hrs the US health and retirement study began to look at these data and what we found in our paper was that there was a
46:31
compression of cognitive morbidity over these two cycles of the health retirement study from twelve point to
46:38
28.7% in a cohort that was essentially established in the same way and the
46:45
people who became demented at a shorter period before they died so their mortality over
46:52
two years was higher than it had been earlier so there now are a bunch of
46:58
papers from other studies in Rotterdam in England and and this slide right here
Other Studies on Dementia
47:10
this paper I wrote for the New England Journal of Medicine a couple of years ago listing them all and this is why the
47:18
life course approach is so important to studying this disease as if you look at this this by far right column higher
47:26
education level over the course of the last century better medical care decline
47:33
in stroke prevalence better prevention of vascular diseases these were all associated in these five studies and
47:39
there's since been a paper by Prince Martin Prince felt a very prominent
47:46
researcher in England where he's taken all these studies from all over the world and what he's shown his rates have
47:53
come down in countries like these or social well-being and progress and
48:04
prosperity I guess you call it has rained the rates are going down little by little it was they were going down
48:10
enough in England this is the study by Matthews here that the NHS had to revise
48:17
their there their expense estimates for dementia haiya do go back to the drawing board
48:23
being based on a Fiona Matthews and Carroll brains work there but worldwide
48:29
you can see these rates come down but they also go up they're going up in
48:34
China and going up in other countries which are industrializing and not paying attention to cardiovascular risk
48:40
especially smoking and so there's something about these conditions that
48:47
has to be amenable to public health efforts so what are these advances I'm really
What are the Advances
48:55
optimistic because of these findings that are listed here they were pulled
49:01
out of the table but there are also other other other features that could could reverse these trends and in this
49:08
case I cite the oh the obesity epidemic but you could also cite at the international level some of the things
49:15
that are that are undesirable that are happening so now the book how how what
49:24
leads to well-being in ageing and one of the concepts that in the book is this
49:31
notion of resilience and if you look up resilience it's there's all kinds of
Resilience
49:36
definitions but the most important one I think is it's the ability to bend but not break when something adverse happens
49:44
and this is the key I think to one of the concepts that dries enlightened
49:49
ageing we call this the path to resilience which is proactivity meaning
The Path to Resilience
49:58
you approach aging with an activist not attitude but also a set of actions you
50:05
realize that you have to accept through the things about age you can't deny the
50:10
changes that occur with aging but you can accept them and begin to be mindful about them and and not the discourage
50:18
but but accept them with equanimity and and activism and then build reservoirs
50:24
and the three reservoirs we talk about our mental physical and social and I'll
50:29
just say a few words about this approach so the one thing about aging that we we
50:39
always think it's a it's a downward spiral that's just not the case it's a
50:45
period of changes yes some things are downward spiral but the key feature of aging that I learned when I first
50:51
started getting interested in geriatrics is the range of normal the variability
50:57
is far greater as we age and I got this realization when I was on my sabbatical
51:03
riding by junior high school in in Cambridge and looking at the difference
51:10
in maturity size shape activity in that
51:16
stage of development that's what aging is like if you look around at older people you'll see
51:21
compared to say 20 to 65 there's just a lot more variability and
51:27
that variability is is a key to understanding things and so it's not
51:34
just a downward spiral and we talk here about the risk factors which I mentioned earlier
51:39
and then acceptance we did some work with a Elisabeth Phelan gerontologist
51:47
debt and UW looking at our act subjects
51:53
and comi a subject and asked what is successful aging being to you and we had
52:00
a scale that people could respond to and we were sure that the Japanese American
52:06
population would be from the Caucasian population in group health they were exactly the same there
52:12
was you couldn't distinguish any differences between the two populations even though one is supposedly revering
52:19
aging more than the other but the lowest feature was longevity most people didn't
52:24
put longevity as their definition over what would successful aging mean but
52:29
these are the others that are there meaning fulfillment purpose relationships not necessarily many but
52:37
some that are meaningful ability to contribute to keep active in your life
52:43
as you get older and to not be a burden on others and we think that this this is
52:51
one of the ways we can accept the fact that we are aging and it's not just a
52:56
race to see how long we can live but how well we can live this is a study that
53:03
some of you may have read I would guess that anybody read the journal with happiness research in 2006 well a very
53:13
clever guy block out his name right now but Peter you will wrote this paper and
53:20
he's up in North Carolina - they used to be anyway he asked people in their 30s
53:26
and people in their late 60s who do you think is happiest younger people or older people and then rates your own
Happiness
53:33
happiness and what he found was everybody thought they aren't people
53:39
were happier but when you measured level of happiness older people had a higher measured Klose of happiness and this
53:48
this kind of shocked me when I first heard about this paper but in fact now there's tons of data at least in
53:55
population surveys showing that there's a u-shaped happiness curve or happiness
Happiness Curve
54:01
is highest down in the late teens
54:07
and raise your hand if you're at the low point of the happiness no but but it
54:13
actually declines and then at some time in the and and this is average of course
54:19
not you're all above average right but the
54:25
minoo age at which is not higher than the age that precedes it and so I think
54:31
that's that's that's really retelling us about acceptance and the ability to to
54:37
to begin to understand by experiencing aging that it's not that bad Pete
54:44
Townsend who knows Pete Townsend somebody knows Pete Townsend in Portland
54:50
you know I think I thought rock and roll was not very popular here but what did
54:56
people what did Pete Townsend say in one of his song boy it sure looks awful cold
55:02
out there I hope I die before I don't get old what is Pete Townsend do we know
55:08
he's blogging on Aging in a very positive way so we have these attitudes
55:14
that are very important so these are some of the features that why people
Maintaining Happiness
55:20
might be happier when they're when they're aging and also some of the
55:26
things one can do I think to maintain happiness and especially this last piece
55:31
of the happiest people really are those that have an interest in others and are trying to contribute to their community
The Three Reserves
55:38
the the three reserves mental physical and social I think there's just a lot of
55:46
evidence that trying to maintain independence is maintaining your brain
55:53
maintaining your mobility especially balance bone strength and muscle strength preserving your hearing and
55:59
vision and we talked earlier about the study of vans Schuler that lady I told
56:04
you about Makai say there's not any good evidence that dancing is good it's mixed evidence
56:11
well there's now a paper that just came out comparing people who participated in
56:16
a dance intervention with controls and what it showed is that the hippocampus
56:22
in these people didn't shrink it got bigger and their mental their cognitive
56:28
function improved and that's because they're working on all three reserves cognitive physical and social so it's
56:37
it's like a marathon we say in the book and you need the resources to get all the way the flame finish line this is
56:45
the biggest mistake people make and every time I give a talk like this somebody says what's the one thing
56:53
what's the Magic Bullet well these are a series of studies that we've done or
The Magic Bullet
56:58
have occurred up to the time when I when I when I made this slide of the magic
57:05
bullets that don't work and there's just endless numbers of magic bullets out there starting from the Fountain of
57:11
Youth and Ponce de Leon back in in the early days of the discovery of this
57:17
continent exercise is probably the closest thing and this is an interesting slide this is work that I did with Bob
Exercise and aging
57:24
Bruce do people know about Bruce Bruce protocol treadmill this is he's a cardiologist
57:30
many years my senior and helped me a tremendous amount in my earlier career we were interested in in exercise and
57:37
aging and this is a from an old textbook that we wrote a chapter for showing why
57:42
it's important to build reserve because as you as you as you compared acting to
57:48
sedentary people that and these are data pulled from the literature that we published you can see how as you get
57:57
further down these curves in life your Delta between functional Reserve and
58:07
active versus sedentary is far greater and one of the things that is the
58:13
biggest setback for people when they get a pneumonia or they fall and hurt themselves is they have so little
58:20
functional reserve this minimum is this is the amount of vo2 max you need to
58:26
breathe and eat and excrete and and you
58:32
fall below that and you either die or you or you don't recover so you want to build this functional reserve to recover
58:38
from the illnesses that are eventually going to happen here's a a study that is not ours but it shows how exercise
Exercise and the brain
58:47
affects the brain this is a group back in University of Illinois that has done
58:52
a lot of work on exercise in the brain and this study showed that you can exercise people and and see that not
59:02
only do they improve cognitively but the change over time in the hippocampus is
59:08
such that these people's hippocampus actually yeah their volume increased
59:14
when they exercised and this brain-derived neurotropic factor was
59:19
hired to go along with that there's been some work now that is that has confirmed this several times the other thing that
59:25
I think is going to be really important is to realize that some aspects of our
59:33
social policy could affect how we age there's a book called the long baby boom
The Long Baby Boom
59:40
that showed that if you can keep working if we had social policies we didn't
59:47
penalize people to stop working because of the way Social Security or taxes are
59:52
involved we could create a very nice workforce most people want to quit
59:58
working because of the drudgery well why do we need to make work so
1:00:04
as much stretch drudgery why not give people some some flexibility and when
1:00:11
they can can work in my book by former father-in-law started a volunteer
1:00:17
program for retired doctors and what they do is they came together and started essentially a free clinic and
1:00:24
that clinic turned into the the clinic that that now bears his name but it's it
1:00:31
was a it was a high point in his career it was a urologist they learned a general practice essentially to do this
1:00:38
and I can't tell you how important it is
1:00:43
for our society to work on the importance of high quality early
1:00:50
education and some of these other aspects all of these contribute to
1:00:55
either the obverse of successful aging or or actually successful aging when
1:01:01
when we address these at the at at the societal level so I like to conclude
1:01:06
with a with a quote here as a Simone de Beauvoir only one solution if old age is
1:01:14
not to be absurd parity of our former life and that is to go on pursuing ends
1:01:19
that give our existence meaning devotion to individuals groups to causes societal
1:01:25
political or intellectual one with that I can close my presentation I think we have plenty of time for opinions and
1:01:33
questions and I also have more slides but I'm not going to
1:01:38
[Applause]
===
