Public Health Options for Improving Cardiovascular Health Among Older Americans

Abstract

Life expectancy at birth has increased from 74 years in 1980 to 78 years in 2006. Older adults (aged 65 years and older) are living longer with cardiovascular conditions, which are leading causes of death and disability and thus an important public health concern. We describe several major issues, including the impact of comorbidities, the role of cognitive health, prevention and intervention approaches, and opportunities for collaboration to strengthen the public health system. Prevention can be effective at any age, including for older adults. Public health models focusing on policy, systems, and environmental change approaches have the goal of providing social and physical environments and promoting healthy choices.

Public health and medical advances continue to beneficially affect the health of Americans. Life expectancy at birth increased from 74 years in 1980 to 78 years in 2006.¹ In 2006, people at age 65 could expect to live an average of 17 to 20 additional years, an increase of about 1 year since 2000.¹ The percentage of the US population older than 65 years is expected to grow from about 12% in 2007 to about 20% by 2050, with a doubling of the population older than 75 years.¹ Furthermore, the older adult population is becoming more ethnically and racially diverse through changing demographics and increased life expectancy for all Americans.

Despite significant improvements in treatment and prevention, heart diseases and stroke have been leading causes of death in the United States for almost a century.² They also are leading causes of disability and poor health-related quality of life,^3,4 and cost an estimated $273 billion in direct medical costs per year.⁵ The majority of those who die from heart disease and stroke are 65 years old or older.⁶ Furthermore, as life expectancy increases, greater numbers of older adults are living with cardiovascular (CV) conditions,⁷ which are frequently experienced with comorbid physical and mental conditions as well as social challenges. In their efforts to prevent and control CV conditions among older Americans, public health workers must consider these additional factors.

Although the prevalence of CV disease in the US population increases with age, it is not a normal process of aging. For those who survive to older adult years, health status is the result of cumulative exposures and health conditions throughout one’s life. The associations between risk factors and health and illness may be different for older versus younger cohorts because of the effects of survivor biases or comorbid conditions. These elements suggest that a lifespan approach is useful to investigating and improving CV health and reducing disease burden, since prevention can occur at all ages.

As increasing numbers of older adults live with CV disease and other chronic conditions, their physical, mental, and social functioning, as well as quality of life, are affected. For older adults in particular, a goal of public health has been to postpone and reduce years of ill health into fewer years before death, a “compression of morbidity.”^8,9 Factors affecting successful aging that intersect with promoting and maintaining CV health include disability and comorbidity, independence and functional ability, and cognitive health. Challenges associated with the prevention and treatment of CV conditions in older adults include attitudes about the value of medical expenditures for people with limited life years remaining, decisions about extending life versus maintaining optimum quality of life, competing risks, greater medication use leading to potential drug interactions, changes in the risk-to-benefit ratio of interventions for older vs younger adults, and insufficient evidence of the effectiveness of particular interventions in older populations.

We discuss several issues of health and healthy aging for older adults. Although we focus on those aged 65 years and older, we also discuss some issues for those at younger ages, since health in earlier years affects outcomes in later years of life. We focus on heart diseases and stroke as major CV conditions. Although peripheral vascular conditions are included as CV diseases, we do not discuss them. CV health is more difficult to define from a public health perspective. Recent American Heart Association health goals refer to CV health as optimal risk factor levels and the absence of CV conditions.¹⁰ Public health approaches for improving CV health and healthy aging will benefit from a multilevel, multisectoral approach at the state and local public health level that includes consideration of these multiple issues.

PUBLIC HEALTH BURDEN

Among the issues related to the burden of CV conditions and risk factors among older adults are mortality, heart failure, racial/ethnic and socioeconomic disparities, continued risk factor burden, and comorbidities, including physical conditions and cognitive health, that can negatively affect social functioning. Table 1 provides recent summary national data regarding CV health issues among adults aged 65 years and older. These data, which provide only an overview of health status for older adults, are discussed here.

TABLE 1—

Cardiovascular Health–Related Indicators for Adults Aged 65 Years and Older: United States, 2003–2009

Indicator and Year	Women ≥65 Years	Men ≥65 Years	Adults ≥65 Years	Adults ≥18 Years
Life expectancy at age 65 y, 20051	19.7	17.0
Heart disease deaths per 100000 population, 20061				211.0
65–74 y	346.3	660.5
75–84 y	1136.7	1743.5
≥85 y	4322.1	4819.9
Stroke deaths per 100000 population, 20061				45.8
65–74 y	86.5	108.0
75–84 y	328.0	345.5
≥85 y	1089.8	932.4
Heart disease hospitalizations, discharges per 10000 population, 20061				171.7a
65–74 y	396.5	598.4
75–84 y	735.3	936.9
≥85 y	1173.6	1238.5
Stroke hospitalizations, discharges per 10000 population, 20061				31.5a
65–74 y	102.6	121.4
75–84 y	172.3	214.0
≥85 y	372.1	487.2
Heart failure hospitalizations, discharges per 1000 population, 200711
65–74 y			9.8
75–84 y			22.4
≥85 y			42.9
Persons with reported heart attack, %, 20097				6.5
65–74 y			16.8
≥75 y			25.4
Persons with reported stroke, %, 20097				2.6
65–74 y			6.4
≥75 y			12.1
Hypertension, %, 2003–20061				17.9b
65–74 y	40.8	29.2
≥75 y	55.4	38.2
High cholesterol, %, 2003–20061				16.4
65–74 y	24.2	10.9
≥75 y	18.6	9.6
Current smoker, %, 20071	7.6	9.3		19.8
Obesity, %, 2003–20061				33.5b
65–74 y	36.4	33.0
≥75 y	24.2	24.0
Regular leisure-time activity, %, 20071				30.8
65–74 y	21.5	28.7
≥75 y	13.9	24.3
Other selected conditions
Diabetes (diagnosed and undiagnosed), %, 2003–20061			22.9c	10.3b
Vision trouble, even with glasses or contacts, %, 20071				10.0
65–74 y			12.9
≥75 y			17.9
Trouble hearing or deaf, %, 20071				2.3
65–74 y			4.7
≥75 y			13.3
Serious psychological distress, %, 2006–20071				2.9
65–74 y			2.1
≥75 y			2.0
Difficulty in physical functioning, %, 20097				15.7
65–74 y			27.9
≥75 y			48.4
Other characteristics
Fair or poor health status, %, 20071				9.8
65–74 y			23.4
≥75 y			30.7
≥10 health care visits in prior 12 mo, 20071			23.6	12.9
Received influenza vaccination, 20071			66.7	30.1
Pneumococcal vaccination, 20071			57.7	16.7
≥1 hospital stays in prior y, 20071			17.4	7.5

Note. Detailed information is provided by sex and age as available, otherwise for all men and women aged 65 and older, older adults by age group, or all adults aged 65 and older.

Source. Health, United States,¹ National Health Interview Survey,⁷ and National Hospital Discharge Survey, as reported for Healthy People 2020.¹¹

^aAges 45 to 64 years.

^bAges 20 years and older.

^cAges 60 years and older.

Heart Disease Mortality Rates

Mortality rates for heart disease have significantly declined since the late 1950s, but it remains a leading cause of death and disability for older adults.^1,3 Stroke has been the third overall leading cause of death since about 1938.¹² Chronic lower respiratory disease (CLRD) recently surpassed stroke as the third leading cause of death, partly as a result of coding changes that include more cases as CLRD.¹³ In any case, stroke also remains a leading cause of death and disability for older Americans. CV conditions are also major causes of health care visits to hospitals and physician offices. Adults aged 65 years and older make up about 12% of the US population but accounted for 25% of physician office visits in 2008.¹⁴

Heart Failure

Usually the result of other conditions (such as heart attack, hypertension, valvular heart disease and pulmonary hypertension), heart failure—also called congestive heart failure—is a chronic condition in which weakened heart muscles cannot effectively pump blood out of the heart, resulting in less oxygen-rich blood being sent to the rest of the body. About 92% of deaths with heart failure as the underlying cause of death are among persons aged 65 years and older.⁶ Heart failure hospitalization rates among adults 65 years and older have increased since 1980; by contrast, hospitalization rates for coronary heart disease and stroke have decreased.¹⁵ The increase in prevalence of heart failure hospitalizations is partly due to improved survival time after a CV event such as a heart attack. The aging population, with CV-associated age-related vascular changes such as arterial stiffness and increased systolic blood pressure, is another factor in the increasing numbers of heart failure, as are age-related increases in hypertension and diabetes. The only CV-related objective for Healthy People that is specific for people aged 65 years and older is a reduction in heart failure hospitalizations. The target rates of 6.5, 13.5, and 26.5 per 1000 for those aged 65 to 74, 75 to 84, and 85 years and older, respectively, in Healthy People 2010, based on the “better than the best” target setting method, were not met.¹¹ For Healthy People 2020, target rates for heart failure hospitalizations were set at a more realistic level—a 10% decrease from baseline values of 2007 for all 3 subobjectives of 3 age groups (65–74, 75–84, and ≥85 years), using data from the Centers for Medicare and Medicaid Services Chronic Conditions Warehouse.¹¹

Racial and Ethnic Disparities

The burden of heart diseases and stroke is unequally distributed across racial/ethnic groups in the United States. Age-adjusted 2006 mortality rates for coronary heart disease per 100000 standard population were higher for Blacks (161.6) than for Whites (134.2), American Indians/Alaska Natives (97.4), and Asians/Pacific Islanders (77.1).¹⁶ Hispanic men and women had lower rates of heart disease and stroke mortality than non-Hispanic White men and women, respectively.¹ Blacks also experienced a greater proportion of premature mortality (death before age 75 years) than other racial groups. The proportion of deaths from coronary heart disease occurring among people aged 45 to 74 years was higher for Black men (61.5%) than for White men (41.5%) and higher for Black women (37.9%) than for White women (19.4%). Patterns for stroke mortality rates were similar to those for coronary heart disease, with rates for Blacks about 32% higher than rates for Whites.¹⁶ Premature mortality highlights not only disparities in health but also issues of successful aging.

Prevention and Control

Prevention and control of risk factors among older adults remain important public health priorities. The prevalence of hypertension increases with age; more than 60% of men and more than 70% of women aged 65 years and older have hypertension (i.e., they have high blood pressure or are taking medication for it).¹ On the other hand, the prevalence of high blood cholesterol (serum total cholesterol≥240 mg/dL) is comparable or lower in older adults than in people aged 45 to 64 years. More than one third of older adults take a statin medication for lowering cholesterol,¹ and this contributes to the lower prevalence among older compared with younger adults. Although the prevalence is much lower than in the general adult population, some 9% of older men and 8% of older women still smoke. About 3% of older adults are heavy drinkers (more than 14 alcoholic drinks per week for men and 7 for women), compared with 5.7% in the general adult US population.¹

Older adults tend to report lower caloric intake than other age groups, but energy intake has increased since 1971.¹ Additionally, more than half of older adults report no leisure-time physical activity, although about one quarter of older men and fewer than 20% of older women report regular leisure-time activity. Consequently, the prevalence of overweight (body mass index [BMI]≥25 kg/m²) and obesity (BMI≥30 kg/m²) has increased among older adults as it has for Americans in other age groups, with more than two thirds of older adults being overweight or obese.

Although mean daily sodium intake is somewhat lower for adults aged 70 years than for younger adults, the mean energy intake is also lower, resulting in a sodium density (mg sodium/1000 kcal) comparable to that of other age groups.¹⁷ Older adults also may be more sensitive to the effects of salt and may benefit more from sodium reduction.^8,18

For older adults, nutrition concerns related to CV health should also take into account potential adverse effects on muscle mass, bone density, and other factors that may be related to conditions in older life such as frailty and falls.¹⁹ The normal aging process can affect nutritional status through mechanisms such as taste sensitivity and thirst, immune function, and oxidative stress.²⁰

Comorbid Conditions

Often overlooked, comorbid conditions can affect health outcomes by influencing treatment considerations, producing potential drug interactions,^21,22 affecting patients’ ability to manage multiple conditions and to afford treatments, and complicating other care and caregiver needs. It is estimated that 82% of Medicare beneficiaries have 1 or more chronic conditions, and 65% have 2 or more.²³ About one third of people with diabetes also have a CV condition for which treatment must be considered.²⁴ About half of adults with heart disease also have arthritis,²⁵ which can affect risk factors such as physical inactivity through fear of pain or joint injury. Treatment of individuals with multiple chronic conditions accounts for 66% of the country’s health care budget.²⁶ Additionally, cognitive and social issues may complicate how older adults manage and deal with their health. For example, more than 60% of older adults report some limitation in basic actions such as sensory or cognitive actions and movement.¹

Cognitive Health

Frequently assumed to be a normal or inevitable part of aging, cognitive decline with aging ranges from no or mild cognitive impairment to severe impairment and diagnosed Alzheimer’s disease and vascular dementia. In 2007, Alzheimer’s was the sixth overall leading cause of death in the United States.⁶ An estimated 1 in 10 Americans older than 65 years and nearly half of those aged 85 years and older have Alzheimer’s disease.²⁷ Memory impairment is the most common cognitive change associated with aging,²⁸ although other capabilities such as processing speed, reasoning, and executive function can also be affected.²⁹ Heart disease, stroke, and heart failure are associated with Alzheimer’s disease and vascular cognitive impairment. Vascular cognitive impairment refers to the spectrum of cognitive impairment related to stroke and subclinical cerebrovascular and CV conditions.³⁰ Vascular dementia, the most severe form of vascular cognitive impairment, is estimated to account for up to 20% of dementia cases in the United States.²⁷ Because of the frequent co-occurrence of either overt or subclinical cerebrovascular disease and signs of Alzheimer’s disease in older adults, the specific contributions of vascular conditions versus Alzheimer’s disease processes to cognitive impairment are often difficult to determine.³⁰ Mechanisms by which cognitive health may be affected by CV and cerebrovascular conditions include physical events (e.g., hemorrhage), degenerative processes, oxidative stress, and inflammatory processes.²⁹ Associations between CV conditions and cognitive health may partly be through common risk factors such as hypertension, obesity, or cholesterol.^31–34 Conversely, cognitive decline and Alzheimer’s disease may also affect risk factor levels. Studies have suggested that high systolic blood pressure and high blood cholesterol in midlife are associated with greater risk of Alzheimer’s disease in late life, particularly when these conditions occur together.³⁵ However, dementia itself has been associated with low blood pressure.³⁶ Therefore, the temporality of risk factor and Alzheimer’s disease progression with cognitive outcomes is unclear. Further research is needed on the associations between CV risk factors and disease and cognitive health and conditions such as vascular dementia and Alzheimer’s disease to determine causal pathways and longitudinal associations.

PUBLIC HEALTH APPROACHES

A number of approaches are being used to improve CV health in the general population and among older adults. These approaches include efforts targeted to the general population as well as to individuals at high risk for illness, death, and disability; effective identification, treatment, and management for those with existing chronic conditions to prevent or delay additional effects of disease and maintain quality of life; and individual as well as systems- or environmental-level approaches in both the clinical and community environments. The American Heart Association recently developed its organizational goals for 2020¹⁰ and is actively promoting CV health through healthy lifestyles and reduction and control of risk factors across the lifespan. This method combines the population-wide approach to reduce risk factor levels in the entire population, while still treating high-risk groups. The following options may help to improve CV health for older adults.

Health Promotion and Risk Reduction

CV health promotion and disease risk reduction can occur at any age. In recent years, declines in CV disease mortality and improvements in life years gained were as much the result of prevention as they were of medical treatment.^37,38 A number of longitudinal studies have documented that a low-risk or healthier CV profile in midlife is related to more positive outcomes in later life, including lower mortality rates,^39–42 lower average annual Medicare costs,^43,44 and better health-related quality of life.^41,45 CV risk factor prevention and control strategies at all ages—including among older adults—may benefit not only CV health, but also overall health and a lower likelihood of, or delay in, disability in later life.⁴⁶ A recent review suggested that, on the basis of existing evidence, maintaining CV health, abstaining from tobacco and heavy alcohol use, and following a heart-healthy diet in midlife may help to maintain cognitive health in later life.³⁶ Control of risk factors is generally recommended for older adults as it is for younger adults, especially among those with existing CV disease or those at high risk. For older adults, concerns related to risk factor control include poor nutrition and undernutrition, comorbidity and medication interactions, and secondary factors (such as falls).⁴⁷ For older adults, the benefits of risk factor control and disease management include not only considerations of life expectancy and preventing further events but also quality-of-life issues.

Risk factor control for disease management and risk reduction can occur in both the medical and community setting. A recent meta-analysis of community-based programs for CV risk prevention concluded that these types of programs have had a positive effect on overall CV risk.⁴⁸ Results of a study carried out in 39 Canadian communities found that hospital admissions for acute myocardial infarction among those aged 65 and older were significantly lower in intervention than in control communities after an intervention program that included CV risk assessment and the use of peer volunteers.⁴⁹

Early Identification and Treatment

Early identification and timely treatment of heart attack or stroke may help reduce mortality and the lasting effects of acute events on individuals who survive. For older adults with existing conditions, prevention includes efforts that prevent or delay death or further disability or loss of quality of life. For example, early treatment of stroke with timely administration of clot-busting agents can help to reduce the adverse effects of stroke among survivors.⁵⁰ Increased use of automatic external defibrillators in communities has been reported to be associated with improved survival after out-of-hospital cardiac arrest.⁵¹ Initiatives such as the Centers for Disease Control and Prevention (CDC) Paul Coverdell National Acute Stroke Registry,⁵² the American Heart Association’s Get With the Guidelines—Stroke,⁵³ Joint Commission–certified primary stroke centers, clinical practice guideline development, and quality-of-care improvement efforts have been established to increase system responsiveness and to optimize patient care and outcomes after acute ischemic stroke. Awareness and action may be critical in the chain of events from stroke onset to treatment and outcome, although awareness remains suboptimal.^54–57

Integrated Programs

Integrated programs are essential for the effective management of multiple conditions. The US Department of Health and Human Services recently published its Strategic Framework on Multiple Chronic Conditions to address the large burden of multiple chronic conditions on the health and health care of Americans.⁵⁸ The framework outlines several strategies, including integrated chronic disease management and prevention programs that are essential to addressing comorbid conditions. Several ongoing examples can be noted that support this framework. For example, 9 states (Alaska, Illinois, Indiana, Iowa, Kentucky, Maryland, Massachusetts, Mississippi, and New York) recently received funding through the National Association of Chronic Disease Directors, with CDC support, to integrate arthritis intervention activities into other chronic disease and health promotion programs, including CV programs. Using a systems approach to integrate arthritis interventions into other existing chronic disease delivery systems, program staff will be able to expand access to, and use of, effective interventions for arthritis and other conditions.⁵⁹

The National Association of Chronic Disease Directors also supports state chronic disease programs to collaboratively engage state programs on aging to examine state and local policies that serve to support evidence-based chronic disease self-management programs. For example, in partnership with the Kansas Department on Aging, the Kansas Department of Health and Environment is exploring policy options to support ready access to chronic disease self-management programs to keep pace with the demographic shift toward an older population.

With diabetes being a significant comorbidity with CV diseases, state health departments have teamed with health care providers to implement system changes to better treat and manage diabetes and common conditions such as hypertension and hypercholesterolemia. More than 20 state health departments are supporting clinical providers in applying lessons learned from a Health Resources and Services Administration–CDC Diabetes Collaborative conducted in the late 1990s. The collaborative demonstrated the benefits of a systems-level approach to managing and treating diabetes. It used an electronic data management system to monitor improvements in disease management and guidance in implementing the Planned Care Model in provider settings. Clinicians are reaching out to state diabetes prevention and control programs for assistance in implementing the model, assisting with clinic- and patient-level evaluation of progress, and bridging connections between clinic providers and community supports, such as referral sources for chronic disease self-management.

The Kansas Diabetes and Cardiovascular Programs, for example, have combined efforts to support 40 private and nonprofit clinics in 95 sites across the state to implement policy and systems change, using the Planned Care Model framework. The establishment of a robust data collection system to support comprehensive program evaluations has been an important achievement that allows programs to report on key outcome-oriented evaluation indicators for diabetes, hypertension, and hypercholesterolemia. Such indicators have been identified by the CDC’s Division of Diabetes Translation and Division for Heart Disease and Stroke Prevention. Kansas program data from 2009 showed that 49% of current diabetes patients had achieved targets for blood sugar levels (hemoglobin A1c<7.0%), and that 40% of current diabetes patients had reached a target blood pressure (<130/80 mm Hg). By comparison, an earlier study reported that 49.8% of adults aged 18 years or older with diabetes were at goal for hemoglobin A1c (i.e., <7.0%) and 47% were at goal for blood pressure (<130/80 mm Hg).⁶¹ For the 11 clinics that submitted data on high blood pressure as part of a hypertension pilot project, 63% of patients being treated for hypertension had achieved a target blood pressure (<140/90 mm Hg),⁶¹ comparable to control rates from large clinical and community trials such as the Hypertension Detection and Follow-Up⁶² and the ALLHAT trial.⁶³

Clinical–Community Linkages

Some successful models move services to where those who need them can easily access them, sometimes in nonmedical settings. The Sickness Prevention Achieved Through Regional Collaboration (SPARC) program, for example, coordinates among several agencies, including local health department, area agencies on aging, health care providers, and other partners to deliver a set of recommended immunization, cancer, and CV screening services to older adults. This program focuses on influenza and pneumococcal vaccinations, cancer (breast, cervical, and colorectal) screening, and blood pressure and cholesterol screening—all services recommended by the US Preventive Services Task Force. SPARC does not provide services but facilitates the coordination and delivery of services in places where they can be easily accessed; traditional service partners provide the services.⁶⁴

Systems- and Environmental-Level Approaches

In addition to focusing on high-risk groups, public health approaches that focus on policy, systems, and environmental (PSE) changes facilitate prevention of CV diseases by producing sustainable improvements in the physical and social environment to promote choices, availability, accessibility, information, and resources for healthful behavior.^65,66 Successful policy-level approaches have included seatbelt laws and tobacco- and alcohol-use laws. A recent example of local and state CV-relevant policy-level approaches is reducing the amount of sodium in processed and restaurant foods. In 2010, the Institute of Medicine recommended mandatory national standards for the sodium content of foods.¹⁷ The vast majority of sodium consumed comes from prepared and processed foods. Two strategies to help reduce the amount of sodium in Americans’ diets are reducing the amount in prepared and processed foods and informing the public about recommended sodium intake levels and the sodium content of the foods they purchase. As requested by Congress in 2009, the CDC began working with food manufacturers and chain restaurants to reduce sodium levels in their products. Historically, the food industry and governmental agencies have worked together to address nutritional problems by fortifying foods with minerals and vitamins (e.g., vitamin D fortification of milk to prevent rickets, niacin fortification of flour to prevent pellagra, and folic acid fortification of flour to prevent neural tube defects).

At the local level, 3 state health departments, on behalf of Shasta County (California), Shawnee County (Kansas), and Broome and Schenectady County (New York); 1 county health department (Los Angeles); and 1 city health department (New York City) are currently engaged in cooperative agreements with the CDC in a “sodium reduction in communities” project.⁶⁷ In Kansas, where more than half of adults aged 65 years and older (59.1%) report having hypertension,⁶⁸ the state health department is partnering with a local health department and a community coalition to increase public understanding of the link between sodium and CV diseases. As partners, they will apply evidence-based practices to reduce sodium consumption at a population level. With the backing and active engagement of medical providers, city and county officials are exploring strategies for applying worksite procurement practices, aimed at reducing the sodium content in purchased foods, along with providing incentives to food retailers to promote the consumption of fruits and vegetables through competitive pricing strategies. Media strategies to communicate the purpose of community changes will be used to drive public engagement and generate support for worksite and procurement policies aimed at reducing sodium intake.

State health departments are applying best practices for affecting PSE change in every aspect of their approach to slowing the development of CV diseases. Chronic disease and health promotion directors convene and facilitate broadly representative coalitions to focus on the primary prevention of risk factors for CV conditions across the lifespan. First and foremost, slowing the uptake of tobacco use among youths and reducing exposure to secondhand smoke are paramount to long-term reduction of tobacco-related CV diseases in the population. In 2010, 5 states enacted clean indoor-air laws; 35 states now have taken action to protect their publics from the deadly effects of tobacco smoke. Since the first statewide smoking-restriction legislation, adopted by California in 1994, clean indoor-air protection has expanded. By 2010, such laws covered 79% of the US population. Equally important is the renewed effort across the country to support smokers who are attempting to quit tobacco use. All states use the national tobacco Quitline (1-800-QUIT-NOW). States offer varying levels of free counseling for quitting tobacco. Quitting is especially important for older adults, given their high prevalence of multiple chronic conditions.

Much of the evidence regarding PSE approaches focuses on whole communities or populations. Over the long term, these efforts can improve the health status of adults as they enter middle and older age, thereby affecting health and health outcomes even later in life. However, evidence on the more immediate effects of these approaches on specific population groups such as older adults is sparse, and their effects may not be similar across age groups. For example, a meta-analysis of the effects of smoking bans in public places noted that the bans had a greater effect on incidence of acute myocardial infarction among young adults than older adults.⁶⁹ Further research and evaluation on the effects of PSE approaches should include assessment of their effects on particular groups such as older adults or other vulnerable groups as well as on particular disease-related outcomes, including health status, access to and quality of care, treatment and control, and morbidity and mortality.

OPTIONS FOR PRIORITY PUBLIC HEALTH ACTIONS

Public health approaches to CV health and disease in older adults must address the entire individual. Because of frequent comorbidity in older adults, the odds of successfully managing one condition are dependent on other conditions present, which may include physical, mental, and social challenges. Although advances in treatment may help to reduce mortality and poor outcomes, prevention and risk reduction across the lifespan are also necessary so that individuals reach older adult life in a healthier state and optimal quality of life.

Our premise is that CV health promotion and risk factor reduction and control can occur at any age. A number of priorities for CV health among older adults can be considered, including data needs, PSE approaches, and partnerships. Strengthened efforts in these areas can help to improve the capacity of public health systems to address CV health at the local, state, tribal, and federal levels.

Tracking the Health of Older Adults

For older adults, data needs include disease status and comorbidities, behavioral and risk factor status, functioning and disability, medication use, support (social support, as well as economic and social resources), and cognitive health, among others. The relationships among cognitive health, CV disease, and risk factors need further elucidation. A recent National Institutes of Health State-of-Science Conference noted that the science—particularly for the prevention or delay of Alzheimer’s disease and cognitive decline—is currently insufficient.⁷⁰ However, a number of activities can help support public health approaches in maintaining cognitive health, as mentioned in the Healthy Brain Initiative, including dissemination of the latest science to increase public understanding of cognitive health, systematic literature reviews, controlled clinical trials, and population-wide surveillance.⁷¹

CV conditions and risk factors vary by region and state, and the prevalence of many risk factors can be monitored at the state level. The Behavioral Risk Factor Surveillance System (BRFSS), a large telephone-based survey of adults conducted by states in collaboration with the CDC, provides important information for state-level public health planning. Detailed data, including state-specific data by age, are available on the CDC’s Web site.⁶⁸ Reports regarding health and receipt of clinical preventive services for older adults that provide comparison with Healthy People 2010 goals are also available.^72,73

Community-Based Research

Community-based research can identify the most effective and adoptable interventions, policies, and systems to improve health and move research from academics to community practice. The Prevention Research Centers⁷⁴ are a network of community, academic, and public health partners that conduct prevention research and promote wide use of best practices proven to promote good health. Through the Prevention Research Centers, the Healthy Aging Research Network brings together researchers and diverse communities to improve the lives of older adults. The network’s goal is to deliver, into community settings, healthy aging practices, programs, and policies. Network members are engaging in individual and collaborative projects that test measures, interventions, and dissemination strategies for healthy aging. Issues addressed include physical activity, fall prevention, cognitive health, and nutrition. For example, the network developed an environmental audit tool to assess community-level factors associated with mobility and physical activity in older adults, available on the network’s Web site (http://www.prc-han.org).

Linking Local, State, and National Data

In 2007 and 2008, 3 state health departments (Washington, Arkansas, and Kansas), with funding from the CDC, tested the feasibility of conducting state CV Health Examination Surveys that included physical and laboratory measures. Such data are important to collect and link to other available sources at the local and state level, such as that from the BRFSS. All 3 states successfully collected clinical measures to obtain state estimates of hypertension prevalence. The Kansas CV Health Examination Survey provided a more rigorous analysis of the prevalence of CV-related risk factors in minority populations. Such analyses are especially important in evaluating the disproportionate impact of hypertension in the population.

In addition to linkage of surveillance systems, statistical methods have developed to allow linkage of data reflecting individual, family, community, and societal factors that may affect health. Although individual level factors such as lifestyles, education, income, and health care coverage have immediate impacts on health outcomes, community-level factors, such as availability of places for physical activity, smoking restrictions, or levels of social capital, and state-level factors, such as Medicaid coverage or statewide insurance coverage, may also affect health.^75,76 Statistical methods have been developed to incorporate the various levels of variables into models that can assess their individual effects on individual health. For example, a study of the effects of neighborhood stress on ischemic heart disease among adults aged 40 to 79 years in 33 communities in Japan observed associations of community stress with a greater likelihood of ischemic heart disease in men, after adjustment for individual-level factors associated with disease.⁷⁷

Population-Wide Approaches

The research literature and evidence base on effective community-level preventive practices is accumulating—for example, through the Guide to Community Preventive Services⁷⁸ and other practice- and evidence-based initiatives.^79–81 Policy approaches that can be promoted by health departments and public health officials might include use of local zoning and regulatory levers to modify the community environment relative to food and nutrition and to mobility, physical activity, and exercise, which can affect the population as a whole and, in particular, the older adult population. Integral to societal-level approaches to preventing CV disease are public health law–related opportunities and models that can address CV disease at the local, state, and national levels.⁸² Such models can go beyond direct regulation and can help to promote physical and social environments that are conducive to CV health. The impact of such PSE approaches for specific vulnerable populations such as older adults needs to be assessed further to ensure that benefits reach all groups. Furthermore, as the older adult population becomes more racially and ethnically diverse, health disparities make assessment of PSE changes even more complex.

Strengthening Partnerships

Public health agencies at the local, state, tribal, and national level can improve coordination—both among one another and with aging services networks—on innovative programs to prevent the progression of CV disease and maintain optimal quality of life among older adults with CV disease. In addition to improving systems of care, engaging with nontraditional partners such as those involved in transportation, parks and recreation, and community services—who may not see how their work includes health—can also help to improve and integrate prevention.

New national initiatives seek to reinforce partnerships across levels and sectors involved in promoting health for all Americans. For example, Million Hearts (http://millionhearts.hhs.gov) is a new initiative of the Department of Health and Human Services that seeks to improve health and prevent 1 million heart attacks and strokes over the next 5 years by incorporating changes in new technology (e.g., electronic medical records), coverage and reimbursement, and comprehensive policy and environmental approaches to improve health and health outcomes.⁸³ Local community initiatives such as the Community Transformation Grants program (http://www.cdc.gov/communitytransformation) aim to prevent chronic disease by producing sustainable, positive, and improved health outcomes through the implementation of change at the policy, infrastructure, program, and environment levels. National network partners will help to support, disseminate, and amplify the successful evidence-based community strategies. The community-level initiatives are grounded on a solid evidence and practice base from the CDC’s Racial and Ethnic Approaches to Community Health, Healthy Communities, and Communities Putting Prevention to Work community health programs (http://www.cdc.gov/nccdphp/dach). A newly funded Coordinated Chronic Disease Prevention and Health Promotion Program seeks to strengthen and better coordinate activities within state and territorial health departments aimed at preventing chronic diseases and promoting health, with a focus on 5 leading chronic disease–related causes of death and disability: heart disease, cancer, stroke, diabetes, and arthritis (http://www.cdc.gov/chronicdisease/about/prev-pubhealth-fund.htm). Because leading chronic diseases have many similar risk factors, coordination and integration of activities for maximum public health impact is logical. These programs tend to focus on the American population as a whole but should affect older Americans as well. Monitoring specific groups such as older adults and specific disease outcomes will be necessary for evaluating and adjusting the course of these programs for maximum impact.

CONCLUSIONS

To advance CV health and healthy aging, we must focus on multiple approaches and at multiple levels (individual, community, health care, societal). This approach will require successful partnerships among local, state, and national organizations and the communities they serve. Given that some 10000 baby boomers reach age 65 every day,⁸⁴ public health has an important and immediate imperative to focus on older adult health.