When Tetyana Shippee was starting her doctorate in gerontology at Purdue University, she skipped pub crawls and student housing in favor of senior activities and a one-bedroom apartment in a continuing care community for seniors. While that might sound like an odd living choice for someone in her twenties, the two-year experience revolutionized Shippee’s views about what matters to people as they age.
“For the residents, these facilities are their universe,” says Shippee, who is now an assistant professor at the University of Minnesota School of Public Health (SPH).
In addition to maintaining an apartment in the long-term care complex, Shippee ate dinner five times a week in the dining room and served on several committees. She listened to stories, looked through photo albums, and made close friends — several of whom later packed their walkers and wheelchairs into a van to travel from Indiana to northern Minnesota where they celebrated Shippee’s marriage to fellow SPH Assistant Professor Nathan Shippee.
What Shippee discovered was that in our desire to make sure older Americans stay safe and medically healthy, we’ve overlooked one very common sense fact: when it comes to aging, the sights, smells, tastes, friendships, and routines of daily life are crucial to a person’s happiness.
“Quality of life is vital to successful aging,” says Shippee. “When I had to eat the same casserole week after week and experienced the shock of the staff coming unannounced into my apartment, it gave me an appreciation for how much these things interrupt your life.”
Naming the Issue
Shippee came to the School of Public Health in 2010 in part because it has long pioneered research about the quality of life in nursing homes, thanks to decades of work by Robert Kane, an SPH professor and the Minnesota Chair in Long-Term Aging, and his wife Rosalie Kane, who is also a professor in the school.
Shippee has strengthened that vital research by looking closely at what truly creates and sustains quality of life (QOL) in nursing homes.
Measures of family satisfaction with nursing home care that she developed with the Minnesota Department of Human Services are used across the state and have been added to the state-wide Nursing Home Report Card. And she broke new ground with a 2015 paper examining racial disparities in nursing home residents’ quality of life.
At a time when people across the world are living longer — the average life expectancy for a person born in 2005 has climbed to 78 years, according to the National Center for Health Statistics — ensuring that these added years are happy and healthy is a public health imperative that grows more urgent by the day. In the next 15 years, the percentage of people in developed countries over the age of 60 will increase by 50 percent and that number rises to 100 percent in less developed nations. In Minnesota, we will have more people who are 65 and older than those aged 5 to 18 by 2025.
That’s a serious challenge when you consider that approximately 92 percent of older adults have at least one chronic disease and that seniors are also more susceptible to infectious diseases and injuries.
SPH is actively devoted to finding real solutions for real people across the aging spectrum. More than 20 percent of SPH faculty members contribute research on what will make life better as we grow older. The challenge for public health professionals, who focus on the health of populations rather than individuals, is to remember that there’s no one-size-fits-all solution to keeping people healthy as they age.
More than a Number
While people’s individual differences matter in all aspects of life, they are particularly important when it comes to making medical assumptions as we get older. “We don’t want to turn people into patients who aren’t really patients,” says Beth Virnig, an SPH professor and senior associate dean for academic affairs and research. “We need to start asking more nuanced questions about healthy aging. Why can some people break their hips and recover, yet others never quite make it back? These are new questions we need to ask.”
Virnig’s research looks at how people should incorporate age into decisions surrounding medical treatment — for example, do you treat prostate cancer the same way for an 85 year old as you do for a 65 year old? In her work, Virnig has found that a high number of seniors are at an increased risk of being either overtreated or undertreated.
When discussing solutions, Virnig stresses that we need to keep in mind that age is a relative concept with many variables. A 77-year-old woman may be capable of flying to Tanzania and camping in the Serengeti. Meanwhile, her best friend back home is learning how to navigate the aisles of a grocery store while using a walker.
To tease out the impact of these differences among people as they age, Virnig points to the work of her colleague Nathan Shippee, who has developed a “cumulative complexity” model that factors in many variables, including social supports, cognitive abilities, and stress levels, to determine a person’s ability to manage his or her health care needs.
Health promotion strategies, long a hallmark of public health initiatives, must take age into account. “We need to make sure our public health messages are also focused on the needs of the elderly,” says Virnig, explaining that many seniors in the Twin Cities are probably not going to feel comfortable using the cities’ new bike lanes, which are placed directly next to traffic on busy streets. But they would enjoy walking to church instead of driving or participating in community gardening projects. Encouraging these types of functional fitness activities, Virnig says, is an effective way to promote healthy aging.
Life After Home
As we age, many of us will need higher levels of care, including assisted living and nursing homes, known in the aging industry as “long-term care.” Perhaps no one in the country knows this territory better than Bob and Rosalie Kane, who, between the two of them, have devoted more than 80 years to the field.
“Aging is not a disease,” says Rosalie Kane. “It’s a process that begins at birth and continues until you die.”
Sitting in her SPH office, which is decorated with framed covers commemorating her years as the editor-in-chief of The Gerontologist, Kane narrates the history of assisted living, from a system dependent on impersonal nursing homes to more recent innovations, such as The Green House Project, a national initiative that emphasizes personal autonomy in intimate home-like environments where every resident has a private bedroom and bathroom. A focus of Kane’s research, The Green House Project has gotten more national attention since the publication of surgeon and public health researcher Atul Gawande’s bestselling book, Being Mortal: Medicine and What Matters in the End.
Both Kanes are openly critical of the current long-term care options available to seniors, which they say are the result of a haphazard combination of payment policies, regulations, and a priority for physical safety that has resulted in a living experience that few people would ever willingly choose.
“It’s a question of ‘Are you in a place where you truly live or are you in a place where you are just following rules?’” says Rosalie Kane. She’d like to see long-term care become a community where older people can test their wings and see what level of independence they can handle, much like 22 year olds do when they strike out on their own after college.
That we don’t view it this way is, the Kanes believe, a by-product of ageism. “We overprotect old people,” says Robert Kane. “If you are 18 years old and want to climb a mountain without a rope, we let you. But we don’t let an 80 year old walk across the room without a safety belt.”
The Kanes propose a number of forward-thinking fixes, including requiring a holding period between a hospital stay and long-term care that would allow families to make a decision, aided by trained counselors, while not in the midst of a crisis. They’d like to see more attention paid to quality of life and care delivered in more flexible settings that allow older people to maintain greater control over their lives, including being able to choose both the level of care they want and the assistants who will help them with whatever needs they have.
Those caregivers, of course, aren’t limited to paid assistants but also include spouses, children, and siblings. “Adult children and families have to make very complex decisions about care for the older adults in their family,” says SPH Assistant Professor Benjamin Capistrant.
One focus of Capistrant’s research is how caregiving has an impact on spouses. His studies have shown that caregiving 14 hours or more a week is associated with an increased risk of cardiovascular disease and hypertension. Caregiving also puts a spouse at a higher risk of developing depression. Capistrant hopes his research will lead to developing interventions for these conditions that caregivers can incorporate into their daily lives, not just in the United States but also in the developing world.
Capistrant has extended his research to India, where he did a pilot study of those who care for older adults. Unlike in the United States, which has a formal care system that includes Medicare, nursing homes, and social policies, in India, the responsibility for care relies almost entirely on the family. “Families may look different in different parts of the world, but when we are sick, they step up and become involved in our care, in one way or another,” he says. “It’s a universal phenomenon.”
“As we face this demographic transition, we need to think much more boldly,” says Robert Kane. “We have to recognize that we are going to require even more caregivers and the ratio of older people to the next generation of caregivers, either paid or family, is much higher than it has ever been. Those caregivers need to be supported and cherished.”
Access to Care
Even the most enlightened support systems for older people and their caregivers won’t matter if you can’t get access to them — a challenge that is especially acute for people of low income and those who call rural parts of Minnesota and the United States home.
“If you live in a remote area, it’s common that you have to leave your community to get the medical care you need,” says Linda Bane Frizzell, an SPH assistant professor and tribal member who researches tribal health and policy, long-term care, health reform, and health policy.
Frizzell says it’s common for rural residents, particularly in the American Indian and Alaskan Native communities, to feel a pressure to move into town as they get older. It’s a pattern that concerns Frizzell because, like the nursing homes that prioritize safety over creature comforts, it overlooks the fact that these people have spent rich and happy lives in small towns or reservations. More troubling, people who can’t afford to move often simply go without care.
Like the rest of the population, American Indians are living longer. But unlike the general public, a lack of access to health services throughout life means they also suffer from higher rates of diseases such as diabetes.
Frizzell wants to change our cultural understanding of aging in the United States, starting when people are in high school, not only to build compassion and knowledge but also to develop critical thinking skills that will help people navigate complex systems such as Medicare as their loved ones age. “I want people to learn to advocate for themselves and others,” she says. “It would be great if people could learn early on how to make smart decisions.”
There are no quick fixes to any of the challenges that come with aging, and that drives SPH researchers to develop strategies that will help people over the long run.
Plus, each of us has to embrace the fact that with every new day, we are all aging. “The public health message about aging should emphasize moderation in all of our daily decisions,” says Robert Kane. “And that to live better, we need to be physically and socially active.”
Avoiding chronic disease: What you can do
Chronic diseases account for most deaths in the United States, and Americans are at a higher risk for these conditions as they age. In 2012, up to 83 percent (depending on age group) of Medicare beneficiaries had multiple chronic conditions, according to the Centers for Disease Control and Prevention. Here’s what SPH is doing to address these challenges.
Long-term SPH studies have followed people as they age to identify risk factors and causes of heart disease so that doctors can spot patients who need interventions. SPH is also a partner in Minnesota’s “Ask About Aspirin” initiative, which promotes the use of a daily low-dose aspirin to lower the risk of first heart attacks and strokes.
What you can do: In addition to talking with your doctor about taking aspirin, SPH Professor Aaron Folsom says it’s important to follow the common sense advice of doctors and public health experts: “Don’t smoke, don’t gain weight, exercise,” he says. “Eat healthy and get your cholesterol under control. And get medication if you have high blood pressure.”
SPH Professor Mark Pereira is researching the role that a more active lifestyle can play in reducing type 2 diabetes. Some people may meet the 30-minute guideline for physical activity, but spend much of the day otherwise sitting or sleeping, he says. His research shows that replacing two hours of sitting with standing or light activity improves blood sugar, blood pressure, and cholesterol levels.
What you can do: Follow the dietary guidelines for eating sensibly, and plan some kind of physical activity every day. “Stop and think about how much time you spend sitting,” he says. “And then try and be up and moving around a little bit more.”
SPH is working to continue the Iowa Women’s Health Study, a cohort of nearly 42,000 women who entered the study in 1986 between the ages of 55 and 69 and were followed for the development of cancer to the present day. SPH Associate Professor DeAnn Lazovich hopes to link the participants’ risk factor information to their Medicare records and to expand the research to include questions about diet and dementia. “With that linkage we would have nearly complete information on most women about their medical
care from the time they turned 65 until they died.”
What you can do: Again, it’s about common sense — stop smoking, eat a healthy diet, and exercise. Because alcohol has been linked to several types of cancer — including breast, colon, and liver — the American Cancer Society recommends limiting alcohol to two drinks a day for men and one drink a day for women. Also, be sure to know the recommendations for screening tests as some recommendations have changed. Keep up to date with cancer screenings, including pap smears, mammograms, and colonoscopies, if appropriate.
Global explorations of healthy aging have Minnesota roots and matching conclusions
By Stacy Richardson
Why do some people suffer illness and die prematurely, and why do some live far into old age?
These questions have absorbed philosophers and scientists since ancient times, and both are looking for the same answer to the eternal question of what makes for a long and healthy life.
Two research efforts — both born in Minnesota and conducted nearly 45 years apart — arrived at a similar conclusion: How long and how well we live are significantly related to the foods we eat and the customs of our cultures.
First came the Seven Countries Study (SCS), led by School of Public Health Professor Ancel Keys. Launched in 1958, the study documented heart-disease risk-factor levels and eating patterns in 14 contrasting areas of the United States, Italy, Greece, Yugoslavia, the Netherlands, Finland, and Japan. During a period when heart attacks had risen to all-time highs, researchers examined thousands of men in these areas over decades and gathered a massive database of comparisons.
Fast forward to 2002 when writer, adventurer, and Twin Cities native Dan Buettner began his search for longevity “hotspots” around the world. With the help of demographers and medical scientists, Buettner identified five “Blue Zones” that were home to unusually high numbers of healthy residents over the age of 100. In Sardinia, Italy; Ikaria, Greece; Okinawa, Japan; Nicoya, Costa Rica; and Loma Linda, California, he interviewed and even lived with these individuals to learn about the surrounding cultures that supported their enduring vitality.
The SCS’s principal conclusion, according to Henry Blackburn, School of Public Health professor emeritus and SCS project officer in its first decade, was that heart attack rates were related to diet, specifically regarding
the types of fat people consumed.
The Japanese, Italians, and Greeks, who had the fewest heart attacks and the most men who lived to age 85 or older, ate predominately plant-based diets in which the percentage of saturated fat was low. By contrast, the meat- and dairy-based American and Finnish diets contained two to six times as much saturated fats, Blackburn says, and men in those countries “were having five to ten times more heart attacks.”
Buettner certainly hadn’t set out to follow in the Seven Countries footsteps. He knew about Ancel Keys as an important figure associated with the Mediterranean Diet, but the Blue Zones journeys were well under way when Buettner decided to “cold call” Keys to talk with him about the pockets of long-lived people he was identifying in areas that included Mediterranean countries. Keys connected Buettner to Robert Kane, Blackburn, and other SPH faculty who had been leading landmark research in the field.
Both Buettner and Blackburn were impressed by the extent to which the results of the studies echoed one another.
Another parallel between the studies lies in the community programs that grew out of them. As health researchers and policy makers around the world recognized their own population profiles in the Seven Countries Study, communities with a high risk of heart disease sought to apply the knowledge in broad-scale public health efforts, not just in counseling for individual patients.
The National Institutes of Health sponsored several long-term interventions in the 1980s that were aimed at promoting healthy lifestyles and preventing heart disease in whole communities. Blackburn was the principal investigator of the School of Public Health’s three-city Minnesota Heart Health Program, and noted that all the communities made visible changes with measureable effects thanks to successful programs that, for example, helped smokers quit and instituted healthy makeovers for school lunch programs.
Buettner’s Blue Zones Projects in 26 American cities are designed to bring about lasting change. In Albert Lea, Minn.; Fort Worth, Tex.; and Hermosa Beach, Calif., civic leaders have committed to a checklist of changes they’re making in policy and the built environment.
Assisted by Blue Zones advisers, the cities are converting streets to make them more pedestrian-friendly and changing food policies “to make junk food more expensive or harder to get,” Buettner says. In one California city, 40 percent of kids — up from “nobody” when the program started five years prior — are walking to school. In addition, childhood obesity dropped from 18 percent to 9 percent.
A half century apart, these two efforts contributed key knowledge to what we know today about how to take care of ourselves: control your weight, eat a diet low in saturated fat, and get exercise.
On top of that, both researchers stress the importance of what we now call wellness, such as finding purpose in life, relieving stress, and investing time and love in the people around us. “Slowing down and the role of family and community are all under-celebrated components of the recipe for longevity,” Buettner says.