Transcript Successful Aging: what is in a name?

Successful Aging
Knut Engedal, Professor, MD, PhD
Director for Research,
Norwegian Centre for Ageing and Health
Oslo University hospital, University of Oslo, Norway
The lecture
 Longevity – is longevity successful ageing?
 Centenarians – the prototype of successful ageing?
 Frailty - the opposite of successful ageing?
 Definitions of successful ageing
 Factors associated with successful ageing
 Interventions
 Concluding remarks
Genetics of longevity
 Hundreds of study have been carried out to find associations of specific
genes, polymorphisms and longevity. Many polymorphisms have been
found and some of them are also associated with factors that influenced on
health such as cardiovascular disorders.
Example
The Mac Arthur Network study of successful ageing studies found and
interaction between ApoE genotype, beta-carotene and inflammation
 The neuroprotective effect of beta-carotene was not seen in ApoE e4
individuals
Longevity
 The maximum life expectancy is today about 120 -130 years, and has
increased just a little during the last 1000 years
 The mean life expectancy varies across countries. It has increased
enormously during the last 100 years (decreased death in early
childhood and better treatment of diseases )
 Genetic factors are more important for the maximum life
expectancy in a person (30-50%) than for biological ageing (2030%) and above all for the mean life expectancy
Obesity could decline life expectancy
Olshansky et al. NEJM, 2010
Centenarians- successful ageing?
Results from a study of 602 centenarians in Italy
(Motta et al, Archives of gerontology and geriatrics 2005; 40: 241-51)
 Good: medium: poor health status
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20% : 33.4% : 46.6%
Only 5.7% were totally independent in ADL
13.4% had cognitive disorders
35.2% had hypertension
But only 0.9% had Parkinson’s disease; 4.9% had diabetes and 6.4% had
thyreopathies
Little social engagement
The authors conclude that the centenarians represent the extreme limit of
life span, but they do not represent the prototype of successful ageing
Centenarians- successful ageing?
 Genetic factors of great importance
 More women than men, except for southern Italy (no explanation)
 Less Parkinson’s disease, diabetes, thyreopathies, myocardial infarction
 More persons with cognitive impairment, but with a delay of 10-20 years
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of the development of dementia and hip fracture
Low level of insulin resistance
Favourable levels of cholesterol (LDL and HDL), triglycerides, BP
inflammatory and antioxidant profiles
The immune system is well preserved, with a good balance between antiand pro inflammatory processes
Many have followed a healthy life style in younger age
Cevenini et al. Expert Opin Biol Ther 2008; 8(9):1393-1405
Frailty - the opposite of successful ageing?
 Frailty is a term related to ageing, but no clear consensus definition
exists.
 Most agree that frailty is a condition that increases the risk for
adverse health events as a consequence of diminished ability to
respond to stress
 A recent published review found 22 article, suing various
definitions of frailty that physical function, gait speed and
cognition were the most reported components of the definitions of
frailty (Shelley et al, JAGS 200)
Frailty - the opposite of successful ageing?
Frailty - outcomes
Frailty is not the opposite of successful ageing
Most authors will conclude that frailty is not the opposite
of successful ageing, because the concept of frailty is a
concept related mostly to physical and cognitive function.
Social engagement and mood is not part of this concept
Successful Aging –what it is?
 The term “successful aging” was first introduced by Havinghurst,RJ
in 1961, but not well defined (Gerontologist 1961; 1:8-13)
 In 1987 Rowe JR and Kahn RL published a paper (Science, 1987; 237:
143-49), that for the first time made a definition that separated
successful aging from usual aging, instead of separating usual aging
from pathological aging.
 Later on various terms have be used for the same concept such as
“healthy aging”, “productive aging”, “aging well” and “compression
of morbidity”
 Today there is no consensus how to define the concept and no
consensus whether the concept should be defined by health and
social care workers or by the older persons themselves.
The two most cited definitions of successful aging
Rowe and Kahn’s definition (Science 1987; 237: 143-49):
• Free from diseases and disability
• Maintenance of cognitive capacity
• Active engagement in life
Baltes and Baltes definition (Successful aging, Cambridge university press , 1990 pp1-36):
• Selection (to adjust the expectations in relation to losses)
• Optimization (training and practice)
• Adaptation (to find compensatory strategies)
More definitions....
 In the literature you can however, find more than 30 various definitions of
the term successful aging
 Most of them are similar to those of Rowe and Kahn focussing on physical
disabilities and dysfunction in activities of daily living as well as in
cognition. Some focus on mood, and others on self perception of health,
satisfaction with life, well-being and some on longevity and social
engagement.
 However, there is a general agreement in the literature that successful
aging is not the same as longevity, but a concept beyond longevity and not
the opposite of frailty.
(Depp A and Jeste DV. AJGP 2006; 14: 6-20)
Successful ageing
It seems to be concept that includes absence of physical
disorder, good function in ADL, absence of cognitive
impairment and depression, engagement in social life in a
persons with good abilities to adapt to and cope with
Everyday challenges
How many are ‘successful agers’?
 Due to different definitions of successful aging it is impossible to
report on the prevalence of this condition
 If you focus on preserved cognition and good mental health the
majority of person aged 80-85 years will be defined as “successful
agers” ( 76% reported by Almeida et al. AJGP 2006; 14: 27-35)
 If you focus on physical function and disability the prevalence of
‘successful agers ‘will be not more than 20-30 % (Depp and Jeste.
AJGP 2006; 14: 6-20).
 If you take another position and ask the old persons themselves if
they are ‘successful agers’ most of them will say YES (Vahia et al.
2010; 18: 212-20)
A process of adaptation? (Baltes and Baltes definition)
In a study of 599 persons of 85 years+ in Leiden (The Netherlands) 45%
had optimal scores of well-being. Only 10% could be defined as
successful ager according to their physical, mental and social functioning
BUT
“An analysis of 27 persons that were interviewed revealed that the old
persons perception of successful aging was equivalent to well-being.
The ability to adjust to circumstances and focusing and gains
instead of losses was important to feel well. But adjustments had to be
within the limits and to be in line with the person’s self-image”
Von Faber , Arch Intern Med 2001; 161: 2694-2700
1.979 women aged 60 and above – Self perception as
successful agers (Vahia et al, 2010)
Prevalence of factors related to the biomedical
definition of successful ageing in the same women
 Absence of disease
 Freedom of disabilities
 Normal cognition
 Active engagement in life
 Mastery/growth
 Positive adaptation
 Life satisfaction
 Self-rated successful ageing
 Independent living
15%
38%
71%
74%
81%
81%
84%
90%
94%
Other studies on self perception of successful ageing
 Montross et al, 2006 found that 92% of 205 community dwelling old people
rated themselves as successful ager, even though the majority did not meet
the Rowe and Kahn’s definition
 Bowling and Dieppe, 2005 in a BMJ paper found that old people rated
social integration and well-being (like von Fabre’s paper) more important
for successful aging than biomedical factors
 Eisenman, 2006 reported that most old people (in a study of 239 former
Yale students )found their QoL to be good despite the presence of diseases
and disabilities.
This kind of “resilience” to age-related diseases seems to play a role for how
successful ageing is defined and who defines it!
What are the determinants for the various
biomedical definitions?
As the definitions of successful aging are different various determinants
have been reported. Most frequently reported are:
 Physical exercise (effect size 1.27 – 3.09)
 No smoking(effect size 1.2 – 4.5)
 No obesity (effect size 1.58 – 3.05)
 No diabetes and arthritis
 Absence of depression
 Absence of cognitive impairment
 Many social contacts
 Better self-rated health
 Positive view of ageing
Peel et al, AmJ Prev Med 2005; 28(3): 298-304 and Depp and Jeste. AJGP 2006; 14: 6-20)
Lupien AJ and Wan N. Phil Trans R Soc Lond B 2004; 359:1413-26
Will intervention have effect on successful aging?
 As many life style factors influence on successful aging it should be
obvious that both life style factor intervention as well as optimal
treatment (and rehabilitation) of mental and physical diseases will
influence positively on successful aging.
 However, this does not mean that interventions that will increase
the numbers of ‘successful agers’ will influence on the maximal life
expectancy in every person in the same way. Genetic factors seem to
have a stronger influence on a person’s maximal life expectancy
compared to the genetic impact on successful aging (Lupien and
Wan. The Royal Society; 2004; 359: 1413-26)
Interventions
Good evidence
 Physical exercise
 Caloric restriction (at least in animals)
Interventions that could enhance successful ageing
 Optimal prevention and treatment for cardiovascular disorders, diabetes
 Optimal prevention and treatment of depression
 Optimal prevention and treatment of dementia
 Increased social engagement
Example – Alzheimer’s disease
Risk factors
 Heredity
 Ageing (biological)
 Down syndrome
(3,5)
(25)
 Hypertension
(2)
 High cholesterol
 Diabetes
 Obesity
 Head trauma
Protective factors
 Physical activity
 Mental and social activity
 Diet ?
(0,5)
Life style factors and dementia
Dementia
Physical activity
Mental activity
Social activity
pos
6
6
3
neg
3
1
3
Fratiglioni L et al. Lancet Neurol 2004; 3: 343-53
Prevention of AD
4.5
4.0
3.5
5-year delay of onset
3.0
2.5
2.0
1.5
1.0
0.5
1-year delay of onset
0
2007
2027
Year
2047
Number of AD cases in millions that could be prevented in the USA if an
intervention programme could dealy onset with 1 or 5 years
Reduced prevalence of cognitive impairment in USA
Langa KM et al, Alzheimer and Dementia 2008;
Examination
1993 - 95 (n= 7 406), 70 ys+
2002 - 04 (n= 7 104), 70 ys+
Cognitive impairment
12,2 %
8,7 %
Explanation
In the cohort examined between 2002- 04 there were more people with higher
education that continued cognitive stimulation during work and leisure activities.
More participants had adequately treated diabetes and hypertension,
Physical activity at work and as leisure activity
A 21 years follow-up study in Finland
Dementia
OR (95% CI)
Twice a week (Leisure)
.48 (.25-.91)
AD
OR (95% CI)
.38 (.17-.85)
Rovio S et al. Lancet Neurol 2005; 4: 701-11
Physical activity at work
No effect
Rovio S et al.Int J Geriatrc Psychiatry 2007; 22: 874-82.
Physical exercise in elderly persons with
memory problems (SCI/MCI,(n=170)
Physical exercise= fast walking for 24 weeks
ADAS-COG (24 weeks)
Intervention
+ 0,26
Control
- 1,04
Physical exercise and cognition
n= 3.863; 65år+; follow-up period 10 years
Number of activities
Number Weekly > 20 minutes
Walking >20 min
Gardening > 20 min
Mistakes on dementia test
beta
p-value
-0.189
0.002
-0.0045
0.007
-0.041
0.081
-0.095
0.026
(linear regresjon)
Jedrziewski et al, Alzheimer and Dementia 2010
Physical exercise and dependency
In-home nursing
beta
p value
NH admittance
beta
p-value
Number of activities
-0.77
0.000
-0.65
0000
Number Weekly > 20 minutes
-0.89
0.013
-0.94
0.022
Walking >20 min
-0.95
0.033
-0.93
0.046
Gardening > 20 min
-0.99
0.71
-0.93
0.299
(linear regression)
Jedrziewski et al, Alzheimer and Dementia 2010
Physical exercise and mortality
Death
Number of activities
-0.534
0.000
Number Weekly > 20 minutes
-0.912
0.000
Walking >20 min
-0.914
0.000
Gardening > 20 min
-0.934
0.000
(linear regression)
Jedrziewski et al, Alzheimer and Dementia 2010
Physical exercise to prevent cognitive impairment
 Regular walking 2-3 timers a week
> 20 min
 Regular gardening 2-3 times a week
> 20 min
 Regular training 2-3 times a week
> 20 min
 Any physical activity 2-3 times a week > 20 min
Jedrziewski M, et al, 2010
Lautenschlager, N, 2009
Physical exercise - meta-analysis including old person
with and without cognitive impairment
Kramer et al 2006 included studies of old persons with normal cognition
 Increased executive functioning
Heyn et al, 2004 included studies of old persons with cognitive impairment
 Increased fitness
 Increased physical function
 Increased cognition
 Increased positive behaviour in demented patients
Caloric restriction
 Caloric restriction can in rodents lengthen the life span with 40%.
The mechanisms behind this is unclear (better cardiovascular
status?, neuroprotection?, mild stress?)
 It is unclear whether caloric restriction can prolong life in human,
but due to the fact that obesity shorten the life span it could be
possible. .....
Engagement in social life for successful ageing
One study reported an association between social engagement
among persons 70-79 years and lower levels of proinflammatory markers
Loucks et al Am, J Cardiol 2006; 97: 1010-16.
Treatment of depression, high BP and diabetes
to improve successful ageing
A 12 months RCT (IG=106 vs CG=108) to improve depression, glycemic
control and BP and lipid control. Outcome: disability, QoL and ADL
Results
 Disability:
 QoL
 ADL
IG vs CG
IG vs CG
IG vs CG
difference -0.9 (-1.5 - 0.2; p 0.006)
difference +0.7 (0.2 – 1.2; p 0.005)
difference -1.5 (-3.3 – 0.4; p 0.1)
Von Korff et al BMJ, 2011:343:d612doi
Conclusions
 Successful ageing is more than longevity and not the opposite of
frailty
 Successful ageing is a multidimensional phenotype. It is a concept
that describe old people with good physical and mental (cognition
and mood) function and that are active in social life
 There is a discrepancy between the biomedical and the lay
definition. The self perception of successful ageing is more or less
equivalent with the concept of well-being. Old persons that adapt
to losses and have a positive view on own ageing have greater
tendency to rate themselves as successful ager.
Conclusions
 Our knowledge about genetic markers for successful ageing in a
biomedical perspective is sparse
 A healthy life style including regular physical exercise , avoiding
obesity, and smoking and misuse of alcohol may increase the
probability to be among the successful agers.
 Optimal treatment of cardiovascular disorders, diabetes, depression
and cognitive disorders will also increase the odds of successful ageing
 Lastly, social engagement seems to be of importance for a successful
life in old age