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Sociology 120
Introduction to Gerontology

Transcript - Lesson 3

Maximizing Physical Potential of Older Adults

Maintaining health

After all, I’m 88 years old. I hope I have many more years. If I reach 90, that would be a triumph. Imagine being 90 years old. I've only got two more years to go. Ha ha ha! I have always thought people aged 80 had one foot in the grave and the other on a banana peel. I still do, but my banana peel isn't slipping.

How can we maintain health and prevent disease in our later years? How can we compensate for inevitable age changes and adapt to disability when illness strikes? What are the effects of the environment and society on the health of older people?

Next, on growing old in a new age. Older adults rate good health as vital to life satisfaction. As people live longer, they are concerned about maximizing their physical health so they can enjoy their later years. Individuals pursue this in different ways. One 70-year-old might run a marathon. Another might be compensating for changes in vision with large-print books, while a third might be wheelchair liberated from the bed to enjoy a more active, independent life.

Old age does not necessarily mean ill health. Researchers have found that many health problems often attributed to aging could be prevented by changes in health habits, life style, environment, or societal factors. How can we improve the odds of good health in old age? We think regular exercise certainly puts more life in your years. There's some suggestive data that it may even prolong life. Certainly most muscular systems are kind of in a use-or-lose type of situation, where if you don't exercise the particular muscle set regularly, you tend to lose some of the capacity of that system. I think that in terms of, for instance, cardiovascular fitness, regular exercise may actually increase one's maximal oxygen consumption anywhere from 10% to 25%, but an older, fit individual may actually have an aerobic capacity or an oxygen consumption that's as high as that of a person 20 or 25 years younger.

Other benefits of good physical fitness include reduction in blood pressure, improved sugar and fat metabolism, weight control, changes in cholesterol levels, and increase in bone mass and muscle tone. High levels of fitness in older people yield lower death rates from cancer and heart disease. Health benefits are found even when a program is begun late in life. It's now known that even in older ages, like in the 60s, um, late 50s, middle 60s, people that begin an exercise program, an active life style, can improve and increase their life expectancy. Some studies have shown people in their early 60s can improve their life expectancy almost two years with starting an active life style. When I say active life style, I don't necessarily mean lifting heavy weights and becoming musclebound. I mean walking, jogging, dancing, swimming-- this kind of a thing. So it really isn't ever too late to begin an active program.

That, in contrast with the fact that 13% of people that are 60 to 65 can't even lift 10 pounds, is quite dramatic. There's a tremendous amount of potential. I've had people that have said to me, "i haven't walked for a long time." of course you can walk. This one lady said, "i haven't walked outside for a long time," and I said, "just go two doors away. "just walk down two doors, come back. "and the next day, walk three doors down-- three houses down." she actually started doing that and actually has been making some progress.

The Danvers walkers of the Danvers senior center walk for different reasons and derive different benefits. Upon retirement, I found that i-- I was arthritic, and I thought the best way to get rid of it so it wouldn't cripple me was to keep walking. So I started in because it was a group here that was going every day, and that was it in the beginning, but I changed it a little because one day-- I bowl, and I decided that doing both was too much, so now we walk one day and bowl the next.

I walk because I had a stroke, and I went to cardiac rehab for three years. Then when I stopped that, walking has just helped me. I had to put my husband in a nursing home. As a result, I couldn't sleep. I’m up at 5:00, ready to walk. She's a very energetic walker. I took a toss last Friday. I got a big bump on my chin. See it? I’m all black and blue, but I got up, and I finished the walk. I think that's one reason I didn't have any bad effects from it-- just keeping my body mobile.

Cross-training with both aerobic and resistance activities is important for older adults, especially as people become frail. Better muscle tone and strength can help to prevent falls and promote independence in the activities of daily living. Many activities that we do in daily living actually involve resistance-type exercise, whether we realize it or not. Getting out of a chair is a resistance exercise, where we're lifting our own weight out of a chair. Now, it's very possible that one could be, uh, relatively fit aerobically and still have relatively, uh, low muscle strength, so I think that because-- particularly because of the fact that there is significant loss of muscle fibers with age that, uh, it's probably very worthwhile to do exercise that also involves muscle strength training as well as aerobic training to strike a nice balance between the two. We have even better ways of combining exercise with drugs that don't have the side effects that the steroids do that people use in athletics that are natural factors that stimulate the production of muscle and maintain muscle. And these things need to be put into older populations to directly attack the problem of frailty.

Stress management is another important benefit of exercise. I would think that certainly in terms of stress reduction for all ages--that exercise is very beneficial, uh, very therapeutic, and makes a lot more sense than popping a pill, which many people feel is much simpler. It doesn't have the same benefit that exercise does.

Jane potter describes the role of exercise in her adjustment to the stress of the sudden death of her husband. One thing I found I needed right after cal died-- um, I swim at the y every day. I did not swim the day he died, but the next day, I did, and I needed that both for my emotional... Uh... Healing...as well as keeping my body agile-- keeping my muscles going. And lots of times, when I feel down, I go down to the y for a swim. I always feel better afterwards--always.

Adjustment of exercise habits over time is sometimes necessary. Walter Morris is 74. It's been a gradual type of change... Uh, in my physical activity obviously. I’m getting to the point where arthritis-- a little arthritis is setting in. I’m not as flexible, and my knees are wearing down. My menisci are almost bone on bone, so it's been necessary for me to modify my tennis playing-- whereas I have the energy right now to play three or four hours, but I’m limited by the fact that my knees can't take it, so I’m changing and doing more swimming and stationary bike riding and walking, and then i've attempted to play golf, which is quite a challenge at my age.

A schedule of about 15 to 30 minutes of aerobic exercise, three times a week, combined with stretching for flexibility and weight training for strength, can yield significant health benefits for older adults. A balanced program for strength, flexibility, and endurance should be discussed with a physician. Now, the important thing about swimming, my physician tells me, is not how fast I swim or the stroke I use-- the fact that I do it regularly. I swim a quarter of a mile a day, which takes 20 minutes. That's all my physician says I have to do.

In contrast, poorly planned exercise can have disastrous effects. Sudden death is sometimes a problem. People exercise too much. People play racquetball-- weekend warriors-- "I’m going to exercise a lot." they get out and try to win a game of racquetball and they drop dead because they had silent ischemia-- they had decreased blood flow to their coronary arteries. You have to really balance everything. Know yourself. Know your history. Have the appropriate tests if you're going to do anything dramatic.

Exercise can hasten recovery from serious illness. An exercise program was prescribed for David Reese to maintain his cardiac health after quintuple bypass heart surgery. I go 3 miles a day walking every day, and then I will take 15 or 20 minutes of just ordinary calisthenics, so I’m getting my exercise. All of the exercises I do are designed to, uh... To keep me in good shape. I feel like... As if I’m in good shape, considering the fact that a year ago, I was in bad shape.

I think if we exercise, we improve our functional abilities, we improve our emotional state, our quality of life improves, but we need to do something to incorporate it into a realistic life style. Life styles are very difficult to change when you've been accustomed to kind of doing one thing. In the area I live in and the work I do, there's a certain format that people kind of live by. They work during the day. In the afternoon, they typically have cocktails, which is o.k. If you're balancing that off with other things. There has to be some balance. It took me a while to break away from a steady routine of doing what everybody else is doing. Of course, any time you change something, it's somewhat difficult because maybe many of your friends are doing something a little different.

The social support of family and friends can help in behavior change. The social context in which we place ourselves can help us maintain life style changes. I picked up another set of friends, and mostly, these men tended to be younger than me. I could look around the health club that I typically go to, and on any given day, I’m probably one of the older people there. I’m wondering, where are the other men my age-- in their late 40s or early 50s? I got a feeling many are still sitting in the bars having cocktails. At some point, they'll probably realize they'll have to change if they want to maintain their health into their later years.

Nutrition is a vital factor in maintaining health. Information about nutritional needs of older adults is incomplete and sometimes contradictory, but it's clear that the nutrition of elders can be affected by physical aging changes, by illness, and by social factors such as widowhood, isolation, and poverty. Older adults vary in their ideas about nutrition.

I’m very pleased that we are healthy enough. I think it's probably because I keep a good diet-- scotch, vodka, and vegetables. I try to watch my diet. Sometimes I’m eating all day-- very small meals... And I find that that works better than-- than three big meals or three regular meals, so i've changed my eating habits. I eat a lot of raw fruits and vegetables and then small quantities of meat-- all the things they're talking about now, but I was already clipping those articles in 1975 about low cholesterol.

Sensory changes in taste and smell may reduce the enjoyment of food for elders, resulting in loss of appetite or the tendency to oversalt meals. Using spices instead of salt can make meals appealing again. Loose teeth or poorly fitting dentures can lead to difficulty chewing, poor digestion, and reduced intake of food. Proper dental care is important. Digestive system changes affect the absorption and use of nutrients in the body. These changes make knowledge of proper nutrition important for older people.

When illness strikes, a person's ability to shop for and prepare food may be compromised. Slicing foods or opening containers may be difficult or impossible for arthritis sufferers, but these people may be aided by devices such as reachers, food processors, or openers. Some chronic illnesses, such as cancer, directly affect nutrition. Patients may lack appetite, have a digestive system malfunction, or find drugs they're taking affect the way nutrients are used by their bodies.

Even living alone is a major risk factor for poor nutrition in some elders. It's a mighty lonesome life. Don't let anybody tell you it's not. I can do any kind of housework-- help Dorothy do any kind of housework-- cook, bake bread, bake pies, cakes, and all that stuff. Today, I can't go in the kitchen to do that. I have to go up to the restaurant and get me something to eat up there. Maybe some of these times-- we have two freezers out there full of frozen stuff. It's hard to--ahem-- to go in there and get that, knowing who helped me put it there.

Living in rural areas with poor transportation may affect an older person’s ability to reach a grocery store. Reduced or fixed incomes, coupled with soaring food prices, may make the purchase of nutritious food impossible, even if elders are able to shop. Innovative programs, such as the rural elderly enhancement program, keep people in their own homes and improve their nutrition through use of home health workers, who shop and prepare meals.

Other aspects of nutrition are cultural and ethnic food preferences. Dr. Percil Stanford describes how successful meal-site programs have addressed cultural needs. What they have done is to develop a nutrition program, whereby the older people have an opportunity to get food which is related to or more specific to their own backgrounds, and it doesn't have to be all processed food. It can be natural foods, for example. This program has been very successful.

Because of changes in the body and decreasing physical activity, older people usually need fewer calories. For many, weight control requires constant vigilance. Sensible weight control is important because excessive weight is related to diabetes, heart disease, high blood pressure, and certain forms of cancer. Some older adults have found successful ways to stay off the dietary roller coaster. I try to maintain sensible eating habits. I belonged to a group called tops, which stands for take off pounds sensibly. While I never had that much weight to lose, I did lose the extra I did have. Now I’m a member of kops, which is keep off pounds sensibly. I work very hard at maintaining a normal, sensible weight. Uh...that doesn't mean I deprive myself. I do have occasional binges, but if I have a food binge, I know that the very next day i'll go back.

From studies in the Baltimore longitudinal study on aging, it's very clear that over the last 30 years there have been major changes in dietary intake. There has been a big fall-off in the amount of fats. Over the same time period, there's been an actual increase in the amount of fiber intake. We're learning that nutrition can be a valuable adjunct to promoting health and well-being in the later years. That simply by modifying our diet, increasing our intake of fruits and vegetables, which have high levels of antioxidants, we can not only increase longevity, but prevent tumor growth, possibly prevent cancers, or at least some cancers, and improve the quality of life.

Sleep is also crucial to vitality. As we age, sleep patterns change. Although some older adults report that sleeping difficulties are disruptive to their health and well-being, most adjust to changes in sleep patterns. My sleeping habits have always been the same. I like to stay up, and I like to sleep late in the morning, but I have to get up for medication. I don't think anything of going to bed at 2 a.m. Because I’m watching tv. Even when I worked, I went to bed late. I used to wake at 5:30. I don't sleep as well as I used to. I don't sleep during the daytime unless I’m sick. If I’m sick, I will sleep it off, you know. However, I’m up a lot at night. I have difficulty sleeping at night lots of times, and I’m up two and three hours sometimes-- get up and get a hot drink, just try to relax. Why I can't sleep, I don't know. As long as you're not in stress. If you're stressful under those times, in those periods, uh, I would say that then you have need for getting to a specialist, but if you're not under stress, just pick up a book. Forget that it's 2 a.m. Read until you get sleepy and then sleep.

About 1/3 of people who have serious sleep problems have sleep apnea, a condition when breathing is interrupted during sleep. Respiratory problems, sleeping pills, and alcohol contribute to this problem. Interrupted breathing contributes to less rapid eye movement in sleep, to changes in intellectual function and memory, and stress on the cardiovascular system. Sleep clinics can evaluate problems such as apnea and other sleep disturbances and suggest treatments. Sleep study centers are located at medical facilities around the country.

Preventing illness

Appropriate self-monitoring and medical checkups can help maintain health and also prevent serious illness by detecting problems early. I’m very fortunate in that I have maintained my health, except for the minor things like a little hearing loss and some arthritis pain, but I do have annual checkups. My heart's in good condition. I get a yearly mammogram because there's a history of breast cancer in my family, and thank god that's o.k. I still feel energetic, although perhaps not quite as much as I did 10 or 20 years ago, but I use my energy to its fullest. I discovered there was, uh, cancer cells, but they discovered it early, so I was very fortunate, but I had had the mammogram a year before that, and...between that time... And the--and the last mammogram, I must have started cells growing, so then I had the operation, but my general health-- very good, and as far as the operation, it was a breeze. I’m still very active. I was just as active afterwards as before. I probably feel better now because I’m not as tired. I used to get quite tired at times.

Other things people should be aware of are things such as blood in the stool. If there is blood, is this more than hemorrhoids? Could this individual have an early colonic cancer? My recommendation-- very high recommendation-- is that people take it upon themselves to take advantage of all, again, the tests that they have perfected and that they have today, and these tests will show whether or not you have or don't have or could be coming down with cancer. So if everybody would catch it early and don't be afraid of that, I think they can add a lot of years to their life. So, for me, it's a total uphill battle because it was not caught early, so, uh, you know, prognosis is not going to be as good. So that is a--if everybody can learn from that, and I’m speaking from experience, so that is, you know, straight from the horse's mouth, as they say, and I think that's important.

Early detection of diabetes is especially important because diabetes becomes increasingly common with age. Diabetes is characterized by above-normal levels of glucose or sugar in the blood and urine. Symptoms of diabetes include frequent urination, excessive thirst, fatigue, tingling in the hands and feet, reduced resistance to infections, blurred vision, and impotence in men. Early detection of diabetes led to early treatment and behavior change for Donald McClure. Many people walk around with diabetes-- they don't know they have it. Of course that's the most dangerous kind because you're not doing anything for it. I found that out and took control-- got right into not only medication, but the physical workout and the weights and all this stuff. That has been very beneficial.

This is healthy bone. This is bone ravaged by osteoporosis. This condition causes more than a million fractures a year, including 250,000 fractures of the hip. Known as a silent epidemic, osteoporosis often causes no symptoms. People often don't know they have it until their bones become so brittle that a sudden bump or a fall causes a break. Broken bones, especially broken hips, cause major problems, such as the loss of independence and huge medical bills for stays in the hospital or nursing homes. Half of those with hip fractures never walk on their own again. Women are more susceptible to osteoporosis than men because they have less total bone mass. Beginning around age 35, women's bone mass starts to decrease. Around 50, declining female hormones speed the rate of bone loss, and by the time they're 70, many have lost as much as 1/3 of their bone mass.

The national institute on aging launched a research program called stop it to find the most promising ways to stop hip fractures. More than 1,000 men and women over the age of 65 are participating at five sites across the country. We're hoping that stop it will lead to reduced health care costs and maintain the health of older people and maintaining their long-term independence. Stop it will test weight-bearing exercises, such as climbing steps, nutritional supplements of calcium and vitamin d, and hormone therapy. To evaluate the success of these interventions, scientists will use a special instrument that measures bone. If any of these treatments is successful, the next generation of men and women may have strong and healthy bones for a lifetime.

Medication plays an important role in preventing and treating illness. When drugs are prescribed to elders, full understanding of their effects is important to regaining and retaining health. Older people use more medications than any other part of the population. At least 30% of the prescribed medications are utilized by older adults, and perhaps as much as 40% of over-the-counter medications are used by older adults. It's not only the quantity of medications, but the number of medications many are using concurrently. It's not unusual to find different older people taking six or seven different medications. Any one by itself may be fine. To the extent that you put different medications together, you increase the likelihood of drug interactions that could have adverse side effects, so one always needs to be diligent about that. That's why I encourage older people when they see any physician for a follow-up, to write down all the medications they have, both over-the-counter and prescription so that one can see the full range. There are also other drugs we don't think about such as alcohol, and that, too, can interact with medications. It can affect the way the liver metabolizes different drugs and alter the way the body handles it, and so it can make a safe medicine unsafe. One has to always be diligent about the range of medications, the combinations, and... How else they're carrying out their everyday activities in the use of that medicine.

Compensating for age changes

As we age, changes occur in our senses. Particularly important to independent living are vision and hearing. Despite many age changes in vision, about 80% of older people have vision changes which are correctable by surgery or glasses. Therefore, most older people enjoy adequate vision for the activities of daily living. However, when changes occur, it can be very disturbing. A few years back, I was suffering-- my eyes-- with cataracts, and little did I realize what it did to my health. It drained me. My grandparents had died in Greece of blindness, which compounded the anxiety and the feeling that one had.

During that time, I found that john had been depressed. I didn't know what was wrong with him, because he was-- he was so frightened by what was happening to him, that he just-- he just couldn't understand, and, uh, once he found out that it was his cataracts and something that was taken care of, it certainly helped his, uh, his outlook and his whole mental attitude.

My vision was always rather poor in that I was very, very nearsighted and had to wear pretty thick glasses, and I had sort of a progressive myopia until--which stopped when I was about 19 or--18 or 19, but going without glasses was-- which I did once in a while, on a date or, uh, just because I got sick of wearing glasses, which was terrible. I didn't know people and got lost and so forth, but five years ago, I had my first cataract surgery, and they-- now they give you implants, and so I see much better, and I can go without my glasses if I’m not going to read, and my eyesight is about 20 times better than it's ever been, since I remember. So my vision has improved with age due to medical advances.

Changes we notice in vision are a reduction in sharpness near and far, sensitivity to glare, slower adaptation from light to dark, reduced depth perception, and changes in our ability to detect colors. A yellowed lens makes blue-green distinctions more difficult. These changes are especially noticed while driving at night or emerging from a dark building into bright sunlight. Adapting to these changes involves regular eye examinations to correct vision and timely treatment for cataracts and other conditions.

Community resources help people to adapt when vision is limited. Volunteers make it possible for blanche woodbury to attend church and senior center activities. There's a group of young girls that range from 20 to 30 years old, but they're in that category, and every single Sunday morning at 9:00, she's outside my door waiting for me, brings me down to church, and we, you know, have the service at church, and I think that's pretty darn nice because I couldn't go if not for that. I wouldn't even cross the street. I think every church and synagogue should have prayer books and bibles with large printing, which people can read, and all of us who are growing older and find the newspaper print gets smaller and smaller, that there are prayer books, there are bibles, and we also make a statement that we value you, we want you to come, and we want you to be present.

Technology is also helping people to cope with reduced vision. Computer scanning and voice reading of written material and enlargement of letters on the computer screen can help people read.

Physical age changes in hearing include loss of hair cells in the corti, changes in the eardrum and middle ear bones, altered blood flow serving the inner ear, and decreased fluid in the inner ear, which is related to balance. Occupational exposure to loud noise, certain drugs, and chronic ear infections can cause changes similar to aging. I'd have to start with the period when I had no hearing aids, and I was losing hearing gradually. I had been losing it since I was a gunnery officer in World War II, and I think all that noise started this out.

Perceptual changes include difficulty distinguishing speech from background noise and problems comprehending certain consonants or word forms and rapid or out-of-context speech. Communication with a person who is hard of hearing can be helped by several simple measures. When someone has hearing loss, we want to talk to them slowly, we want to speak in complete sentences, we don't want to shout, but instead, talk in a low range of, uh, tone, and, uh, speak distinctly and clearly. Another thing that's very important is to cut out background noise.

About 25% of people over age of 65 have moderate to severe hearing loss. Over the years, I started to lose hearing ability, and my wife, of course, was putting up with it until the point when I decided that I was going to take the step to have hearing aids, and I got both. It was like a miracle. He put them in. The technician adjusted them and told him to stand in a corner facing the wall. He said, "say something to him." I said, "David, come here." he turned around and came over. I almost cried. He heard me. Before i'd had to scream.

Dr. Reese has developed strategies for adjusting to the amplified sound of his hearing aids. At times I have to become antisocial because if you get a group of 20 or 30 people in a small room, there's so much noise. One person talks. The next one talks above that. First thing you know, you can't hear a thing. What I tend to do, then, is find myself on one of the areas on the extreme edges so that you're not in all that clamor. Hearing aids are a distinct advantage for me. Many people object to them, but for me it's an aid. It makes me more comfortable in many situations.

Even slight changes in vision and hearing make the coordination of these senses especially important. Because the total amount of information available to older persons via the senses is reduced and central nervous system processing of input is slower, coordination of senses to obtain as many contextual cues as possible is vital to driving, speech perception, and other complex tasks. Compensating for losses and returning to adequate functioning is a challenging but gratifying experience. One gets to be, uh, intelligent enough, uh, to compensate for whatever your losses may be in the, uh, sensory areas. Uh, you just move to compensate for that, and it's a happy period. I want to go to 100, and I’m going to make it.

Person/environment fit

The importance of a supportive, energizing environment increases as we age. A good fit between the person and the environment can help to maximize physical potential. For the most part, the individual's major lifetime is going to be spent in a house, in an apartment-- an individual's residence, and not in an institutional environment, and if so, what we have to think about is how can we enrich the quality of that environment so that the individual can live there for a long time.

Safety is an important consideration for older adults. They tend to live in more cluttered houses. There are more older things around-- throw rugs, wires in the way-- and the normal changes of age that would prevent them from having an accident, like better vision, quicker muscle reaction time, um, quicker nerve reaction time-- all of those factors change to make them more prone to having a fall. Area throw rugs become very important problems and things we should notice. A person may trip from a small throw rug, break their hip, which leads to a situation with prolonged immobility. About half the people that fracture the hip never walk independently again. So looking at these risk factors are key.

we had those bars installed in the--in the showers, bathtubs, whatever they would be, and, uh, that's--that's one of the most hazardous pieces of equipment in the house. If the individual cannot climb in and out of the bathtub within their own home, and for that reason they cannot bathe, there needs to be some kind of an accommodation to that bathing area so that the individual can bathe comfortably. We're doing research right now looking at tools that are developed and on the market for older people, like reachers or dressing aids-- those kinds of things-- even things like a frame for your toilet so you can have arms to get up more easily, or a seat.

None of these were developed with older people in mind. So we're looking at each of these instruments and seeing what problems an older person has utilizing them, both in terms of installing them and utilizing them after they learned how to. I think that will be the wave of the future in technology in geriatrics is looking more at the kinds of home safety types of apparatus that might be used.

However, sometimes technology doesn’t reach far enough. Dr. Koff illustrates the problem of placing an emergency call button in only two places in an apartment. The great anxiety in our interviews with people who live in these institutions is "what happens if I fall in the living room "or in the kitchen? "how do I design my fall to be appropriate to the designer of this space?" well, the electronic device that you can carry with you, that pushing a button wherever you are, tripping a signal into the telephone that then goes into some kind of a call box is a very simple system, and, uh, it is not any more costly-- maybe even less costly because you avoid all the wiring that is so essential to the fixed wired system.

We know that social support is important to health. Environmental design can encourage or discourage social interaction in older adult housing projects. When you look at the design of all of the facilities developed all over the country, you see that the least amount of space per person is allocated within the apartment, and you get enormous dining rooms and enormous lobbies and enormous social halls, which in some ways are marketing tools for the developer, but it denies the very significance-- that which is most important to the individual, and that is their own space. That's where socialization could go on, and not in the large meeting rooms. The environment and the design of the environment is extremely important, as it talks to the needs of the individual.

The proper environment can make the difference between community and institutional living when older people become disabled. On lok in San Fransco has developed a comprehensive set of medical, social, economic, and housing services to provide a supportive environment for disabled elders. We provide all the health and social services to a nursing home-certified group of people-- those who would otherwise go to nursing homes-- and provide these services in their homes or in this community, essentially. I have, uh, retired. I quit the elks club. I lost my girlfriend. My father committed suicide and all that, so I took a little drinking, and I was pretty depressed. I broke my hip, and while I was in the hospital, on lok people came. I didn't know what on lok was. I think one of the problems in the traditional system-- uh, it is very difficult to mobilize all the forces to help people to maintain-- to live on an even keel even if they have illnesses. At on lok, we're able to do that because we know people well. We assess them regularly and know where they are. We have the freedom to get our treatment plan to the needs of the people rather than just look at what's being paid for. Various people come in to dress me. I can do some myself, but my shoes... Once a week I get a shower. They have regular eating-- 9:00 for breakfast, 12:00 lunch, and then 5:00 dinner. As time goes on, I’m pretty near cured now. I’m taking exercises and, uh, my--they watch the diet. They watch your diet-- so many calories, and a lot of things you can't do. You go by the program, and it's been beneficial. Technology also plays a role in altering the environment. I think technology is important, and when we start defining disability-- we start defining handicaps-- often we think of the individual with the disability or impairment or handicap. Sometimes these things can be compensated where they're no longer disabilities if we can modify our environment. By modifying our environment through technology, we can reduce many things commonly thought of as impairments and disabilities, so technology plays an extremely important role. It's not their problem. It's the environment's problem that are limiting these older or disabled people-- people with handicaps-- from doing things.

Technology's contribution to mobility and communication provides support, allowing people to remain at home. A lot of technology that's being used in rehabilitation is, um, not being used quite so much with older people. Some is. For instance, the person who is at risk for falling can now be, um, analyzed through a very complex computer-assisted model to look at their gait, to look at their balance, to look at their ability to counteract changes in their balance. Those sorts of things are really on the forefront of the technological diagnostic applications to geriatrics and to function.

It's terrible when you see patients with locked-in syndromes where their brain and their cognitive statuses are intact, but they can't communicate with you. They're basically in a living jail. There are many people working at different augmentive communicative devices trying to do this, whether it's eye movement to signal yes and nos, finger movements, or sweat responses. There's many innovative ways that are trying to improve communication that people may have. So these high-technology things are geared to understand and translate little movements that appear random at first into meaningful responses.

You have the technological advance, but you also need trained personnel to teach this patient who's depressed, who's locked in, to use this to be able to communicate with the outside world and to be able to accept it, as well. So technology's important, but without that human element, the technology really wouldn't have any hope of helping anybody.

A stimulating environment can actually affect structures in the brain. Many years ago, people with a brain injury, they would feel the brain itself has no capacity of regeneration. It has no capacity of development after you are born, and there's research now that shows with complex environments and complex situations that you can actually change the brain's structure. You can increase the number of synapses in the brain. You can increase electrical connections of the synapses. You can improve and increase actual brain thickness. Some evidence says you can even increase the number of neurons. So basic science research is generally important because with that kind of concept, you don't take grandma, grandpa, or the brain-injured patient to a back room and say, "this is their maximum potential." you can expect more of people with problems. The community and wider society also have a stake in the environmental factors important to older persons' health.

Planned communities such as leisure world have attempted to maximize the physical environments for older adults. One of the most important things we did is the improvement that we have provided in the health care center on the premises. The social need and the health care need has changed over the years where people are interested in that, and this life-line system is available to those residents who need it. They can push a button, and the message comes to the health care center, and immediately a representative or nurse is sent for their attention.

Simple changes like larger street signs and longer yellow lights contribute to the health and safety of older drivers and pedestrians. Environmental design can be crucial to maintaining health and mobility when chronic illness or disability strikes. As long as the person, though, is appropriately treated so they can get around that and adapt to that disability, then they're not handicapped. For instance, if the person is a wheelchair user and has a good wheelchair and can go into a restaurant because there's a ramp built that enables them to use the wheelchair, then they're not handicapped, but if the restaurant won't build that ramp, then they become handicapped. So really, there are no handicapped people. There are only handicapping societies. Environmental features such as pollution, noise levels, and perceptions of crime affect the physical well-being of older adults.

Hayward King describes his neighborhood in the tenderloin district in San Francisco. Even though--i mean, young people hiss various, um... Expressions in dialect at the kind of narcotics they could supply you with as you walk by, and I want to turn and slap somebody, but that would start something I don't need to get into, but I’m insulted that that's going on. That brings violence in. I won't mail letters on that street because it's important mail, and violence just comes at you in so many different ways, but the older people have to have escorts. They...choose not to, and they end up with broken arms and...crushed organs and... They're just bait for those people, and they'll just take anything. Although statistics show that younger groups are victimized more often in our society, older people feel especially vulnerable to crime. As a result, isolation occurs when people are afraid to leave their homes.

Dr. Minkler describes an innovative program in the tenderloin district. About 10 years ago, 3 of my students got the idea of going into a low-income, inner-city area with many elderly, isolated people to start a support group, getting people out of rooms, talking one morning a week, and seeing if that wouldn't affect their health. From this tiny beginning began a project that has involved 300 students and hundreds and hundreds of elderly people who have worked together and formed an organizing project. They've established 80 safe houses where people can go for help in a police emergency. They've worked on nutrition-- published a little cookbook of recipes you can cook in your room without having a stove, and most important, they've supported each other. They have really learned the value of friendship, and previously isolated people now are looking out for one another in a way that not only helps them in terms of mental health, but physically, as well. We know socially isolated people have higher rates of illness and disease. These people are breaking down barriers of social isolation, and we're seeing the consequences in healthier and happier old age. Societal attitudes evolving from the recent interest in health and life style changes sometimes dictate that people accept personal responsibility for their health status. The result may be that the victim is blamed when illness strikes. Elderly don't need to be blamed for the fact that they're reaching an age in which physical infirmities happen, in which there are losses that are inevitable that happens to them, and blaming them for what's occurring. They have reached this age. Let's celebrate their life. Let's not blame them.

Ethnic group, income status, and other factors can play a role in the health status of our later years. If we look at our health status and the health status of older people across groups, we're going to find that there are some very, very broad differences. The actuarial tables, for example, tell us that the American Indian is still dying at a much younger age than most other persons-- 49, 50, 51 is still somewhat the--the average. The black male, for example, is still dying at a younger age than the average expectation. What are the health implications? We need to have some better understanding of whether it's just environmental or whether it's somehow social or whether there are some political implications in terms of whether or not we can do some things to prevent the environmental situations to bring about longer life for some of these groups. One in four is estimated among the Hispanic population has health insurance. There's also some health conditions that are prevalent among our population group, and that includes diabetes. It includes cardiovascular disease and all kinds of heart-connected or related diseases, uh, which, again, are preventable if they only got health-- access to health care early in their lives. If you can't pay for them, you can't access the services. We have programs specifically designed for low-income people, but the poverty line drawn in this country is very low, so you can be quite poor and still not qualify.

People in rural areas find themselves at a particular disadvantage because the services often are not available in their areas. Gender also plays a role in health status. Older women aren't treated as aggressively for breast cancer as younger women or as intensively for heart disease as men. In the past, women were omitted from longitudinal studies of health. Women experience heart disease at almost the same level as men, but they experience it 10 years later than men do in their lives, but yet, women have not been included in those studies. So heart disease and cancer and osteoporosis are the three primary, um, causes of death among women, and disabling diseases, and if we could get greater research done in those areas, it would be a real asset to women. It's critical that we spend more money on prevention and health promotion for the elderly. We know that elderly people can benefit tremendously from things like smoking cessation programs, substance abuse prevention programs, and yet we focus these programs, by and large, on younger people. My ambition is to help develop programs so that everybody will live until they all of a sudden wear out at the age of 95 or 100 or 110 by their vital organs just stopping. It only takes a couple of them to stop, and if they stop simultaneously, that's it. That's a very nice way to go. I've seen people do that. They were usually people with a very positive attitude. I knew a Methodist bishop-- bishop Welch, who worked vigorously to the age of 106, and his heart and brain suddenly stopped at his desk at work in New York City, and he was healthy, you see. So we do have a limit. It may be genetic, but most of us never reach that limit of healthy aging, and I think that can be done. It's a matter of education.

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