Lifestyle, social factors, and survival after age 75: population based study

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e5568 (Published 30 August 2012)
Cite this as: BMJ 2012;345:e5568

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There are studies that reveal that self- forgiveness and conditional forgiveness of others are associated with longevity/ mortality1,2. Studies also show that yoga breathing can diminish many of the physical sufferings3. Health care access and spiritual health also relieve mental and physical sufferings4,5.

References:

1. Krause N and Hayward R D. Self-forgiveness and mortality in late life. Soc Indic Res. DOI 10.1007/s 11205-012-0010-3.

2. Toussaint LL, Owen AD, Cheadle A. Forgive to live: forgiveness, health, and longevity. J Behav Med. 2012 Aug;35(4):375-86. Epub 2011 Jun 25.

3. Brown RP, Gerbarg PL. Yoga breathing, meditation, and longevity. Ann N Y Acad Sci. 2009 Aug;1172:54-62.

4. Gilbert PD. Spirituality and mental health: a very preliminary overview.
Nurse Pract. 1996 Aug;21(8):60, 65-70.

5. Leetun MC. Wellness spirituality in the older adult. Assessment and intervention protocol. Curr Opin Psychiatry. 2007 Nov;20(6):594-8.

Competing interests: None declared

Neeru Gupta, Scientist E

KK Jani

Indian Council of Medical Reserch, Ansari Nagar, New Delhi-110029

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It kind of depends what they were doing with their time. Many older people enjoy mainly sedentary pursuits and value these more than two years of life gained by what may be considered tedious physical activity.

Competing interests: None declared

susanne stevens, retired

none, cf24

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After an 18 year follow up of a cohort of 1810 persons who were over the age of 75 years, Rizzuto et al. observed physical activity to be one of the factors for survival. Those who were physically active survived more than two years longer than those who were physically inactive.

Our knowledge base would be enhanced if we systematically study the effects of physical activity on the biology of the central nervous system at cellular - subcellular level in chemical and electro-magnetic parameters.

Competing interests: Age : 77 years. Peachtree Road Race Runner.

A.A.W. Amarasinghe,M.D.,, Psychiatrist

none, 102 Bayberry Hills, Mcdonough,Ga 30253-4005, USA.

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Once again, this research assesses the important need of prevention at every age.

However, we have to talk about how this prevention should be done in practice. From the right to health to the right to health care [1], the question is: who should realize this prevention? This question is not so simple considering the increasing proportion of older people.

Geriatricians seem to be the most pertinent. Nevertheless, the geriatricians we have interviewed [2] told us they could not undertake this prevention because of there are too few of them. In this situation they clearly ask general practitioners to undertake this job. [3]. The other reason is the necessity to anticipate this prevention before the age of 75. It should begin earlier. But are general practitioners sensitive to this job? Some studies show that prevention is concentrated on risk factors [4]. Lifestyle and social factors are too often forgotten because doctors do not have a direct impact on them. The consideration of these factors is an ethical obligation to efficient health care.

Above all, this study shows the necessity of investing in social medicine. It is one of the reasons for medical schools to respond to social accountability [5].

[1] Kentikelenis A, Karanikolos M, Papanicolas I, Basu S, McKee M, Stuckler D. Health effects of financial crisis: omens of a Greek tragedy. The Lancet. 2011 oct;378:1457–8.
[2] Tudrej B. Re: Fall assessment in older people [Internet]. 2011 Nov 9 [cited 2012 Jan 12];Available from: http://www.bmj.com/content/343/bmj.d5153?tab=responses
[3 ]Trumble S, Naccarella L, Brooks P. The future of the primary medical workforce. BMJ. 2011 août 22;343:d5006–d5006.
[4] Blanquet M. - Measuring preventive procedures by french GPs - an observational survey – British Journal of General Practice – January 2011
[5] Boelen C, Woollard R. Social accountability: the extra leap to excellence for educational institutions. Med Teach. 2011;33(8):614–9.

Competing interests: None declared

Benoit V. TUDREJ, Junior Doctor, PHD Student

Christan HERVE

Laboratoire d'Ethique Médicale et de Médecine Légale, EA4569, Université Paris Descartes, Université de Poitiers, Faculté de médecine, Centre Universitaire des Saints-Pères 45 rue des Saints-Pères. Paris 75006

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Older people, particularly those above the age of sixty five, have a high likelihood to suffer from a chronic disease or a functional disability. The appropriate place of prevention in elimination or minimizing such problems is extremely hard to evaluate. Usually, preventive steps that are taken during adulthood are targeted at the diseases, as well as conditions of old age (Thomas et al, 2003). Furthermore, application of efficient preventive must be done at the youthful age thus requiring intergenerational transfer in resource utilization. On the other hand, evidence shows that health education programs that are designed to delay or prevent problem onset in daily occupations for the reason of health promotion, as well as an independent living among elders are essential

Figure 3: Annual Medical Costs of Active and Inactive Women (Aged 45 or Older) Without Physical Limitations http://www.ahrq.gov/ppip/activity.htm

Although the study has some limitations affecting its generalisabilty, the limitations and strengths are clearly acknowledge by the authors. In my opinion this study has good implications in the care of elderly in many institutions.

This study also supports evidence behind OT activities in care homes. Reduction in the budgets of these institutions can affect the frequency of leisure activities offered to their residents.

The limitations of this study in my opinion can be addressed by further research through an international and multicentre study design. This approach will also clarify the relationship between survival and other variables: ethnicity, for example.

Prevention and health education in elderly is a significant aspect in caring for the old. It is thus indispensable for the elderly to involve themselves in physical activities, in addition to getting educated on how to take care of themselves.

1.Thomas P. Gullotta and Martin Bloom (2003). Encyclopedia of primaryprevention and health promotion. New York: Kluwer Academic/Plenum

Competing interests: None declared

ngongang paulin, senior house officer

Hwel Dda Health Board, prince phlip hospital SA14 8QF

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Towards evidence based prevention in elderly persons

The intriguing study of Rizzo et al. on the determinants of old age survival suggests that we have to actively approach elderly persons and convince them to quit smoking, drink alcohol, keep on weight and to intermingle with others.1 It shows that life style factors are still associated with mortality risk at old age.

However, the core question is if changing one’s lifestyle at old age will still result in a survival benefit. Observational studies, such as the one of Rizzo et al. cannot answer this question. Evidence on the implementation of public health interventions for the elderly is currently lacking.2 This necessitates a complete novel domain of research: evidence based prevention in old age, to study the implementation of the results from association studies like the study of Rizzo et al. Demographic studies give a hopeful perspective, as they indicate that end-of-life trajectories are far more plastic than most people think.3,4

With populations increasingly ageing all over the globe it is of major importance to get a better understanding of how we should implement the current knowledge from observational studies into daily clinical practice.5 We have to go for the next step in public health. This ‘new’ public health agenda is amazing in various aspects. Who had ever thought to go ‘preventive’ at an age where most of us think it is time to consider palliative care?

References:
1. Rizzuto D., Orsini N., Qiu C., Wang H. and Fratiglioni L. Lifestyle, social factors, and survival after age 75: population based study. BMJ, 2012,345e5568.
2. Drewes YM et al. Assessment of appropriateness of screening community-dwelling older people to prevent functional decline. J Am Geriatr Soc. 2012,60(1):42-50. doi: 10.1111/j.1532-5415.2011.03775.
3. Vaupel, J.W., Biodemography of human ageing. Nature 2010, 464:25
4. Vaupel, J.W., Carey J.R. and Christensen K. It’s never too late. Science, 2003,301, 1679-1681.
5. Christensen K., Doblhammer G., Rau R. and Vaupel J.W. Ageing populations: the challenges ahead Lancet 2009,374(9696):1196-1208.

Competing interests: None declared

Frouke M Engelaer, PhD candidate

David van Bodegom and Rudi G. J. Westendorp

Leyden Academy on Vitality and Ageing, Rijnsburgerweg 10, 2333 AA, Leiden, the Netherlands

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This article gives a scientific basis for life style and social factors in influencing the life span of an individual. Yet it is important that in certain traditions having the company of one's spouse, being wanted, being useful and having a family environment play an active role in promoting and prolonging one's life span. When compared to nuclear societies joint family systems provide respect and the importance an elder needs to have. He or she is not left alone seeking psychiatric help to boost one's morale or finding a purpose to live. Reduced smoking and alcohol intake may promote vital functions to be healthy. Above all what an elder needs is attention and care, which many societies do not give. Many a time an elder is left alone to live in the past with very little time spent with his or her children as a part of their lives. The most important social factor is that the elder needs his/her family to recognize and reinvigorate their spirit to live.

Competing interests: None declared

Dhastagir S sheriff, Professor

FAculty of Medicine, Benghazi University, Benghazi, Libya

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Editor

Public health messages are of critical importance in guiding both policy makers and clinicians. Although cohort studies are invaluable in exploring the role of lifestyle factors in survival, there are considerable limitations in extrapolating the findings from the role of alcohol consumption in this study. The authors point out the 32% missing covariate data, but this also hides additional underlying associations. The cohort which participated in this study was born in the early 1920s. The Bratt system of rationing in Sweden in 1955 led to a sudden increase in alcohol consumption in subsequent years. This had a greater influence on subsequent alcohol related mortality born in the 1930s and early 1940s than on the 1920s birth cohort, but alcohol related mortality in all of these cohorts peaked at 60 years of age and declined significantly thereafter, particularly in the 75+ age group(1).

There are also problems with the external validity of this study. Without further drilling down into patterns alcohol consumption, it is problematic to draw firm conclusions from a categorical ‘yes/no’ system of classifying drinking. In addition, the definition of heavy drinking in older people still lacks reliability, given the influence of co-morbidity and polypharmacy(2).

There remains considerable scope for examining the role of alcohol in health and social outcomes among older people. To be better informed, clinical services will benefit from similar studies incorporating a wider range of drinking parameters in the 50+ ‘baby boomer’ cohort, who currently represent the cohort at greatest risk of alcohol misuse (3). Such studies should also widen their scope to include mental health outcomes. Only then can clinical services move forward in a developing a targeted approach to service development for older people with alcohol misuse.

References

1. Rosén M, Haglund B. Trends in alcohol-related mortality in Sweden 1969–2002: an age-period-cohort analysis. Addiction 2006;101:835-40.

2. Crome I, Ting-Kai, Rao R, Wu Li-Tzy. Alcohol limits in older people. Addiction 2012;107: 1541-1543.

3 Crome I, Dar K, Janikiewicz S, Rao T, Tarbuck A. 2011. Our invisible addicts (College Report CR165), London: Royal College of Psychiatrists. http://www.rcpsych.ac.uk/files/pdfversion/CR165.pdf

Competing interests: None declared

Rahul (Tony) Rao, Consultant Old Age Psychiatrist

South London and Maudsley NHS Foundation Trust, Rotherhithe, London SE16

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Lifestyle is an important factor for survival; this study clearly highlights this statement.

Although the study has some limitations affecting its generalisabilty, the limitations and strengths are clearly acknowledge by the authors. In my opinion this study has good implications in the care of elderly in many institutions.

This study also supports evidence behind OT activities in care homes. Reduction in the budgets of these institutions can affect the frequency of leisure activities offered to their residents.

The limitations of this study in my opinion can be addressed by further research through an international and multicentre study design. This approach will also clarify the relationship between survival and other variables: ethnicity, for example.

Competing interests: None declared

ngongang paulin, Senior House Officer

hwel Dda Health Board, prince philip hospital

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Have the authors considered how religious activities may fit into their classification system? The categories of mental, physical, social, and productive activities could arguably all be covered by a churchgoer who walks to Church on a Sunday morning, sings in the choir, listens to the sermon and chats to her friends over a cup of tea after the service.

Can the authors make any comment on whether religous activities and the mental/productive/social stimulation they provide are any more beneficial than non-religious activities?

Competing interests: None declared

Tom Roberts, F1 Doctor

Princess of Wwales Hospital, Bridgend

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