The Aging Tsunami and Aging Successfully
Sharon Ostwald, PhD and Jennifer Larson, MSE Division of Geriatrics and Palliative MedicineThe University of Texas Health Science Center at Houston
Source: Kinsella, Kevin and Wan He, U.S. Census Bureau, International Population Reports, P95/09-1, An Aging World: 2008, U.S. Government Printing Office, Washington, DC, 2009.
Percent Population Aged 65 and Over: 2008
Source: Kinsella, Kevin and Wan He, U.S. Census Bureau, International Population Reports, P95/09-1, An Aging World: 2008, U.S. Government Printing Office, Washington, DC, 2009.
Percent Increase in Population Aged 65 and Over; 2008 to 2040
(selected countries)
Source: Kinsella, Kevin and Wan He, U.S. Census Bureau, International Population Reports, P95/09-1, An Aging World: 2008, U.S. Government Printing Office, Washington, DC, 2009.
The World’s 25 Oldest Countries: 2008(Percent of population aged 65 and over)
Source: Kinsella, Kevin and Wan He, U.S. Census Bureau, International Population Reports, P95/09-1, An Aging World: 2008, U.S. Government Printing Office, Washington, DC, 2009.
Percent Population Aged 65 and Over: 2040
Source: Kinsella, Kevin and Wan He, U.S. Census Bureau, International Population Reports, P95/09-1, An Aging World: 2008, U.S. Government Printing Office, Washington, DC, 2009.
Young Children & Older People as a Percentage of Global Population: 1950 to 2050
Source: Kinsella, Kevin and Wan He, U.S. Census Bureau, International Population Reports, P95/09-1, An Aging World: 2008, U.S. Government Printing Office, Washington, DC, 2009.
Population in Developed and Developing Countries by Age and Sex- 1960
Source: Kinsella, Kevin and Wan He, U.S. Census Bureau, International Population Reports, P95/09-1, An Aging World: 2008, U.S. Government Printing Office, Washington, DC, 2009.
Population in Developed and Developing Countries by Age and Sex- 2000
Source: Kinsella, Kevin and Wan He, U.S. Census Bureau, International Population Reports, P95/09-1, An Aging World: 2008, U.S. Government Printing Office, Washington, DC, 2009.
Population in Developed and Developing Countries by Age and Sex- 2040
Older Populations Will Increase More Rapidly in Developing than in Developed Countries
Population Aging is Determined by Two Factors: Birth rates Death rates
Population Aging
Singapore, 316%
India, 274%
China, 209%
United States, 107%
United Kingdom, 66%
Japan, 30%
Source: Kinsella, Kevin and Wan He, U.S. Census Bureau, International Population Reports, P95/09-1, An Aging World: 2008, U.S. Government Printing Office, Washington, DC, 2009.
Percent Increase in Population Aged 65 & Over: 2008 to 2040
Source: Kinsella, Kevin and Wan He, U.S. Census Bureau, International Population Reports, P95/09-1, An Aging World: 2008, U.S. Government Printing Office, Washington, DC, 2009.
The Speed of Population Aging in Selected Countries
Life expectancy is a probability estimate of how long individuals can expect to live, given the environmental and disease conditions currently in existence.
Life expectancy is dependent on the interaction of behaviors and exposures that occur over a lifetime with biology and psychology.
Life Expectancy is Increasing
77.477.2
76.576.1
75.873.0
72.572.5
70.470.0
78.1
Costa RicaChile
ArgentinaUruguay
MexicoJamaica
BrazilColombia
PeruGuatemala
United States
Developing CountriesDeveloped Countries
Source: Kinsella, Kevin and Wan He, U.S. Census Bureau, International Population Reports, P95/09-1, An Aging World: 2008, U.S. Government Printing Office, Washington, DC, 2009.
Life Expectancy at Birth for Selected Countries by Region:2008
WOMEN 20 years life expectancy 13.3 in good health 6.7 dependent on others
MEN 17.1 years life expectancy 11.4 in good health 5.6 dependent on others
Age Expectancy at Age 65 in US
Source: Kinsella, Kevin and Wan He, U.S. Census Bureau, International Population Reports, P95/09-1, An Aging World: 2008, U.S. Government Printing Office, Washington, DC, 2009.
Female Advantage in Life Expectancy at Birth for Selected Countries: 2008
Source: Kinsella, Kevin and Wan He, U.S. Census Bureau, International Population Reports, P95/09-1, An Aging World: 2008, U.S. Government Printing Office, Washington, DC, 2009.
Highest National Life Expectancy at Birth: 1840 to 2000
Source: Kinsella, Kevin and Wan He, U.S. Census Bureau, International Population Reports, P95/09-1, An Aging World: 2008, U.S. Government Printing Office, Washington, DC, 2009.
Global Distribution of People Aged 80 and Over(Percent of world total in each country/region- 2008)
Source: Kinsella, Kevin and Wan He, U.S. Census Bureau, International Population Reports, P95/09-1, An Aging World: 2008, U.S. Government Printing Office, Washington, DC, 2009.
Percent Change in the World’s Population: 2005-2040
Source: Kinsella, Kevin and Wan He, U.S. Census Bureau, International Population Reports, P95/09-1, An Aging World: 2008, U.S. Government Printing Office, Washington, DC, 2009.
Survival Curve for U.S. White Females: 1901 and 2003
Source: Kinsella, Kevin and Wan He, U.S. Census Bureau, International Population Reports, P95/09-1, An Aging World: 2008, U.S. Government Printing Office, Washington, DC, 2009.
Proportion of All Deaths Occurring at Age 65 or Overin 29 Countries/Areas: Circa 2001
AGING INDEX is an indicator of theage structure in a country. Higher numbers = more older people China = 31 Northern Africa = 16 Northern America = 65
Disparities Exist Between Urban and Rural People Aged 65 and Over
Source: Kinsella, Kevin and Wan He, U.S. Census Bureau, International Population Reports, P95/09-1, An Aging World: 2008, U.S. Government Printing Office, Washington, DC, 2009.
Major Causes of Death in the European Union by Age:2001
Source: Kinsella, Kevin and Wan He, U.S. Census Bureau, International Population Reports, P95/09-1, An Aging World: 2008, U.S. Government Printing Office, Washington, DC, 2009.
The Increasing Burden of Chronic Noncommunicable Diseases on Low and Middle Income Countries
33.037.0
26.022.5
Cities* Puerto Rice
Poor Health Conditions Good Health Conditions
*Cities include Bridgetown, Barbados; Buenos Aires, Argentina; Havana, Cuba; Mexico City, Mexico; Montevideo, Uruguay; Santiago, Chile; & Sao Paulo, BrazilSource: Kinsella, Kevin and Wan He, U.S. Census Bureau, International Population Reports, P95/09-1, An Aging World: 2008, U.S. Government Printing Office, Washington, DC, 2009.
Chronic Diseases Are Becoming An Increasing Burden
Probability of Being Disabled at Ages 60 and Over Conditional on Early Childhood Health Conditions Latin
American/Caribbean Cities* & in Puerto Rico: Circa 2001
WHO (2002) Active Aging: A Policy Framework. Geneva: World Health Organization.
Important Role of Geriatric Health Professionals is to Maintain Functional Independence
and Prevent Excess Disability
Source: Kinsella, Kevin and Wan He, U.S. Census Bureau, International Population Reports, P95/09-1, An Aging World: 2008, U.S. Government Printing Office, Washington, DC, 2009.
Chronic Disability Decline in the United States: 1982 to 2005
Source: Kinsella, Kevin and Wan He, U.S. Census Bureau, International Population Reports, P95/09-1, An Aging World: 2008, U.S. Government Printing Office, Washington, DC, 2009.
Older Dependency Ratio: 2008
Note: Older dependency ratio is the number of people aged 65 and over per 100 people aged 20 to 64.
Older Dependency Ratio for World Regions:2000, 2020, & 2040
Source: Kinsella, Kevin and Wan He, U.S. Census Bureau, International Population Reports, P95/09-1, An Aging World: 2008, U.S. Government Printing Office, Washington, DC, 2009.
Source: Kinsella, Kevin and Wan He, U.S. Census Bureau, International Population Reports, P95/09-1, An Aging World: 2008, U.S. Government Printing Office, Washington, DC, 2009.
Standard and Alternative Older Dependency Ratios for Five Countries: 2006
Source: Kinsella, Kevin and Wan He, U.S. Census Bureau, International Population Reports, P95/09-1, An Aging World: 2008, U.S. Government Printing Office, Washington, DC, 2009.
Labor Force Participation Rate for Males Aged 55 to 64 in Six Latin American Countries
Source: Kinsella, Kevin and Wan He, U.S. Census Bureau, International Population Reports, P95/09-1, An Aging World: 2008, U.S. Government Printing Office, Washington, DC, 2009.
Labor Force Participation Rate for Females Aged 55 to 64 in Six Latin American Countries
Source: Kinsella, Kevin and Wan He, U.S. Census Bureau, International Population Reports, P95/09-1, An Aging World: 2008, U.S. Government Printing Office, Washington, DC, 2009.
Social Security Coverage in 13 Latin American Countries: Circa 2002
(Percentage of employed population paying contributions)
Regular exercise Healthy diet Avoid tobacco Alcohol in moderation Correct use of medications Screen for disease and treat early Education about caring for chronic illnesses Strengthen social network
Health Promotion Needs to be a Major Focusfor Geriatric Health Professionals
Social, Physical & Economic Environments Affect Healthy Aging
Source: Kinsella, Kevin and Wan He, U.S. Census Bureau, International Population Reports, P95/09-1, An Aging World: 2008, U.S. Government Printing Office, Washington, DC, 2009.
Living Arrangements for People Aged 65 and Over in Japan
(in percent)
Prevention of premature death Delay of the onset of chronic diseases Postponement of disability related to chronic diseases Higher quality of life Greater participation in the life of the family and community in
paid and unpaid roles Reduction in medical care costs, especially hospitalization and
nursing home costs
Reasons for Geriatric Professionals to Focus on Health Promotion and Disease Prevention
Rapid aging of the world’s population, especially in developing countries
Imbalance of people over 65 and under 15 Increasing life expectancy with a rapid increase in numbers
over 80 Geographical inequities between urban and rural dwelling
older people Increasing prevalence of chronic diseases with a burden of
disability Social, physical & economic environments that affect
healthy aging
Warning Signs of the Aging Tsunami
WHO (2002) Active Aging: A Policy Framework. Geneva: World Health Organization.
Global Population Pyramid in 2002 & 2025
What is the difference between a geriatrician and a gerontologist?
Geriatrics- the study of health and disease in later life. The comprehensive health care of older persons. Focuses on medical care and changes that occur with age as a result of disease.
Gerontology- Greek translation literally meaning the study of old men. It is a multidisciplinary field that focuses on the biological, behavioral and social processes individuals go through as they grow from middle age through late life.
Why study aging?
Individual responsibility - Is old age to be lived or endured?Value of healthy behavior - (i.e., smoking, will die anyway) The chance of growing old with disabilities due to poor health is much greater than dying quickly from them.Management of the aged - Your grandparents, parents, older siblings; you may have to be the primary caregiver.Professional careers – With the large number of aging adults, the number of careers working with the elderly will increase dramatically.Enlightened citizens - It is our duty to be knowledgeable. Health care provisions affect everyone. There are critical economic, political and moral issues.
How old is old? The study of health and aging Fact or Fiction? Myths regarding aging and the agedHow long do people live? The biological theories of agingWhat is “normal” aging? The physiology of agingWhat illnesses effect elders most? Common geriatric syndromesCan late life really be enjoyable? The role of behavioral factorsWhat will my quality of life be like? A glimpse at “Successful” Agers
“A prejudice or discrimination against the old because of ignorance,
misconceptions and half-truths. It is an assumption that personal
traits of older individuals and their situations are due to age alone,
not other factors.”
Ferrini &Ferrini, 2000
Ageism
Myth #1: At some point, all elderly people end up living in a nursing home
Myth #2: Dementia is a normal consequence of aging
Myth #3: Depression and suicide is rare in the elderly
Myth #4: Mammograms are no longer necessary after age 70
Myth or Fact?
Myth # 5: If it’s available over-the-counter, it must be safe
Myth # 6: The elderly are immune from domestic violence
Myth # 7: Physical restraints help prevent falls in the elderly
Myth # 8: Caring for the elderly is anything but challenging and rewarding
Myth or Fact?
Normal versus Pathological Aging
Heart & Lungs Brain Kidney & Bladder Body Fat & Bone Sensory Organs
Physiologic Changes Associated with Aging
Heart and Lungs
Heart muscle thickens with age. Maximal oxygen consumption during exercise declines in both
men & women. The body’s ability to extract oxygen from blood diminishes
with age. Arteries tend to stiffen with age. Maximum breathing (vital) capacity may decline by about 40
percent between the ages of 20 and 70.
What is Normal?
The Brain
Brain becomes smaller & lighter with age Reduction of blood to brain Number of neurons decline in parts of the brain Fewer synapses & receptors Grey matter volume shrinkage Pervasive white matter loss
What is Normal?
Kidney and Bladder
Kidneys gradually become less efficient at extracting wastes from the blood.
Bladder capacity declines. Urinary incontinence, which may occur after tissues atrophy, particularly in women, can often be managed through exercise and behavioral techniques.
What is Normal?
Body Fat and Bone Density
Older individuals tend to lose both muscle and body fat.
Fat is redistributed in the body. Bone loss begins to outstrip
replacement around age 35. This loss accelerates in women at
menopause.
What is Normal?
0
10
20
30
40
50
60
70
water fat lean bone
age 29
age 70
AGE
Body Composition Changes with Age
Sensory
Vision lens more transparent; pupils
shrink; optic nerve less efficient Hearing
more difficult to hear higher frequencies with age
Taste & Smell both senses become less
discriminating in old age
What is Normal?
Personality• Personality is extraordinarily stable throughout adulthood. • However, certain individuals facing life-altering circumstances
can and do show signs of personality change during the final years of life.
What is Normal?
• Less time in stage 3 and 4 sleep (deep sleep)
• Increased insomnia• Increased nighttime arousals
Changes in Sleep Associated with Aging
We want a long life, but fear old age.
We have an increased awareness of the blessings of life, yet we fear infirmity, dependence, and death.
The Dichotomy
Section VI: Realities of Longevity
Organ
System
Functions
Age
The Effect of Age on Variability Between Individuals
Arthritis Hypertension Hearing Impairment Heart Disease
Orthopedic Impairment Chronic Sinusitis Diabetes Cataracts Other Visual Impairment
Most Common Chronic Medical Conditions of Older Adults
99105
112120
134
148158
0
20
40
60
80
100
120
140
160
180
1995 2000 2005 2010 2020 2030 2040
Years
Millio
ns
Source: The Robert Wood Johnson Foundation (1996), Chronic Care in America: A 21st Century Challenge
Number of People with Chronic Conditions
610
23
34
43
56
0
10
20
30
40
50
60
70
Per
cent
<18 18-44 45-64 65-74 75-84 85+
Age Groups
Prevalence of chronic illness and likelihood of disability increase with age.
Source: Kaye, H.S., (1997). Disability Watch: The Status of People with Disabilities in the United States. ( Data from the 1994 National Health Interview Survey). Volcano, CA: Volcano Press, Inc.
Percent of Individuals Limited in Activities Because of Chronic Conditions, By Age Group
Multiple coexisting diseases and conditions to manage.
Multisystem geriatric syndromes: e.g., gait instability, dizziness, and weight loss.
How is Health Different for an Older Adult?
Healthy Quality Living: The Role of Exercise and Nutrition
Physiologic Function
Optimal Reserve
Increased margin of reserve with good health care and self care
Age
Usual Reserve
Demand
Physiologic Demand and Reserve
Two thirds of older adults do not exercise regularly.
35% of adults aged sixty-five to seventy-four are completely sedentary.
44% of adults aged seventy-five and older are completely sedentary.
Staying Healthy: Exercise
CDC (2003)
Muscle Wasting
Physical Activity
Morbidity
AGING
Modified from Nair, S. Am J Clin Nutr, 2005.
The Role of Exercise in the Compression of Morbidity
Modified from Nair, S. Am J Clin Nutr, 2005.
Energy Expenditure
Obesity
Insulin Resistance
CVD Type 2 DM Dyslipidemia
Morbidity
Aging
Muscle Wasting
Muscle Weakness
Endurance Capacity
Fatigability
Physical Activity
Two greatest nutritional problems: Malnutrition Obesity
Nutritional needs change in late life Special Considerations Energy Intake
“Tell me what you eat, and I will tell you what you are.”
Jean Anthelme Brillat-Savarin
Staying healthy: Nutrition
Difficulty chewing Upset stomach Shopping & transportation Disease Decreases in olfactory
senses
Difficulty cooking Loss of appetite Medications Finances
Special Considerations
Nutritional Needs: Energy
Food Energy Sources GREAT: fats, oils, avocado, peanut butter GOOD: proteins, meats, custards, Snickers FAIR: cookies, rich breads, fruits POOR: vegetables
Eat with color
Nutritional Needs: Protein
Protein Sources GREAT: Animal products, meats, fish, eggs GOOD: Milk, nuts FAIR: Breads POOR: Fruits, vegetables
Fiber sources: GREAT: Legumes, Beans, Bran GOOD: Fruits and Vegetables,
Whole Grain, Breads and Cereals
FAIR: Cereals (oats) POOR: Chocolate
Nutritional Needs: Fiber
Soluble fiber can be found in such foods as oat bran, barley, nuts, seeds, beans, lentils, fruits (citrus, apples) strawberries and many vegetables
Insoluble fiber is found in foods such as whole wheat and whole grain products, vegetables, and wheat bran
Soluble Fiber Sources
Insoluble Fiber Sources
FLUID Sources GREAT: Beverages, milk, coffee, water GOOD: Fruit juices, soups, ice cream FAIR: Soft drinks, watermelon POOR: Vegetables/fruits
Nutritional Needs: Fluid
Psychological Health
Cognitive function includes Intelligence Language Learning Memory Decision-making Planning
Normal Mental Function in Older Adults
Short-term memory Recall Speed of mental processing Learning involving physical coordination and strength Distractibility
What Changes
Capacity to learn Ability to draw on experience Vocabulary
What Does Not Change
Mental disorders are not a part of normal aging
18-54 yrs 55+ yrsAny anxiety disorder 16.4% 11.4%Any mood disorder 7.1% 4.4%Severe cognitive impairment 1.2% 6.6%Any mental disorder 21.0% 19.8%
http://www.surgeongeneral.gov/library/mentalhealth/home.html
Mental Disorders
Not a normal part of aging Often goes undiagnosed or misdiagnosed Bereavement is not depression
Depression
Signs and symptoms of depression
Tired all the time Sad most of the time Guilty Worthless Unable to think clearly or make decisions No enjoyment in what used to be fun Trouble sleeping Weight gain or loss – hungry or loss of appetite
Depression
Signs and Symptoms —
Symptoms usually occur suddenly or appear with in a short period of time
Close family members or care givers may notice “something just isn’t right” as first symptom
Symptoms vary throughout the day/night
Delirium
Sudden or short time onset
Variation in status throughout the day
Usually has an organic root Treatable
Gradual onset over time Mental status usually
constant No organic causality No curative procedures
Delirium Dementia
Dementia comes from the Latin root for mind, “mens” and the prefix de or out. It means of be literally beside oneself or out of one’s mind.
It results from the death of, or permanent damage of brain cells.
Dementia Is not a Normal Part of Aging
Everyone experiences forgetting Many people exaggerate the importance of forgetting Many also ignore the signs of memory loss and fail to
recognize developing illness
Forgetting vs. Dementia
Education Physical activity and lung function Strong social support High self-efficacy
MacArthur Foundation Study, Rowe & Kahn 1999
We can grow and change throughout life
Old dogs can and do learn new tricks!
Predictors of Strong Mental Function
—Oh, let her drink, she has no other pleasures left in life.
—None of my older clients drink. Seniors just don't drink.
—It's none of my business what my neighbor, Ned, drinks. He isn't hurting anyone.
Substance Abuse and Elders
Memory trouble after having a drink or taking medicine
Loss of coordination (walking unsteadily, frequent falls)
Changes in sleeping habits Unexplained bruises
Difficulty staying in touch with family or friends
Wanting to stay alone a lot of the time
A decline in Grooming Housekeeping & routine chores Eating habits
Signals that may indicate a substance abuse problem:
Trembling hands Smoke burns on clothing and
furniture Increased accidents
Declining health Slurred speech Smell of alcohol on breath
Signals that may indicate a substance abuse problem:
A 70 year oldwho drinks…
Is Equivalent to….
Because Metabolism Slows in the Aging Body:
…a 21 year old who drinks…
A Sobering Fact
NyQuil contains an active ingredient of 25% alcohol, the same as 50 proof booze.
Alcohol comes in many forms
+ = Potential Danger
Mixing Alcohol with Drugs
Why are older adults at risk to abuse substances and/or medications?
Functional Limitations Loneliness Death of Partner or Spouse Retirement Depression Feeling like a Burden to Others Low Self Esteem Physical Pain Changes in Living Situation
Risk Factors
History of Substance Abuse Co-occurring Psychiatric Disorders Decreased Social Support Care Giving Role Custody of Grandchildren Male Living in a Health Care Setting
Blow, 2004
Other Risk Factors
“Age is not a particularly interesting subject. Anyone can get old.
All you have to do is live long enough.”
—Groucho Marx (1890-1977)
Successful Aging
Madame Jeanne Calment-- She is the believed to have lived longer than any other person in recorded history.She was 14 when the Eiffel tower was completed.She sold painting supplies to Vincent Van GoughShe outlived her husband, daughter and only grandson
Centenarians
They were born in 1912 or earlier.
Resiliency Independently functioning In good health at least to
the age of ninety. Few centenarians are obese Substantial smoking history
is rare
Source: Perls T., Silver M., Lauerman J, 1998
Centenarian Characteristics
(30%) had no significant changes in their thinking abilities
Women who have a history of bearing children after the age of 35 years and even 40 years
50% of centenarians have first-degree relatives and/or grandparents who also achieve very old age, and many have exceptionally old siblings
Exceptional longevity runs strongly in families
Photo Credit: Melanie Stetson Freeman
Source: Perls T., Silver M., Lauerman J, 1998
Beating the Odds
This is a splendid trend in the United States Aging is Complex Exercise, Exercise, Exercise You are what you eat Achievements of centenarians demonstrate that it is
possible to not only enjoy life but it relish it.
To Summarize…
Baltes, P.B., Smith, J. Staudinger, U.R.., (1992). U.M. Wisdom and successful Aging. Ferrini, A. F., & Ferrini, R. L. (2000). Health in the later years (3rd ed.). Boston: McGraw Hill. Hetel, L. and Smith , A. U.S. (Oct, 2001). Department of Commerce Economics and Statistics
Administration U.S. CENSUS BUREAU The 65 Years and Over Population: 2000Census 2000 Brief Hobbs, Frank and Nicole Stoops, U.S. Census Bureau, Census 2000 Special Reports, Series
CENSR-4, Demographic Trends in the 20th Century, U.S. Government Printing Office, Washington, DC, 2002.
National Center for Health Statistics Health, United States, 2005 With Chartbook on Trends in the Health of Americans Hyattsville, Maryland: 2005
Perls TT. The Oldest Old. The Scientific American, 1995;272:70-75. Perls T. Centenarians prove the compression of morbidity hypothesis, but what about the rest
of us who are genetically less fortunate? Medical Hypothesis 1997;49:405-407 Perls T, Alpert L, Wager CG, Vijg J, Kruglyak L. Siblings of centenarians live longer. Lancet
1998;351:1560 Perls TT, Bochen K, Freeman M, Alpert L, Silver MH. The New England Centenarian Study:
validity of reported age and prevalence of centenarians in an eight town sample. Age and Ageing (in press).
Perls T., Silver M., Lauerman J. Living to 100: Lessons in Living to Your Maximum Potential at Any Age, March, 1998
References
Baltes, P.B., Smith, J. Staudinger, U.R.., (1992). U.M. Wisdom and successful Aging. Bengtson, V.L. & Scaie, K.W. (1999). Handbook of Theories of Aging. New York: Springer. Centers for Disease Control and Prevention (2001). Healthy Aging: Preventing Disease and
Improving Quality of Life Among Older Americans At A Glance. Centers for Disease Control and Prevention. (2003). Promoting active lifestyles among
older adults. Atlanta: CDC, National Center for Chronic Disease Prevention and Health Promotion. Nutrition and Physical Activity
Ferrini, A. F., & Ferrini, R. L. (2000). Health in the later years (3rd ed.). Boston: McGraw Hill. Gavrilova, N.A. and Gavrilova, L.A. (2002). Evolution Of Aging. In Encyclopedia of Aging.
Editor in chief: Ekerdt, D.J. (1st ed.). New York: Macmillan References USA. P458-467. Geriatric Review Syllabus, American Geriatric Society. 5th edition. 2002-2004 Living to 100: Lessons in Living To Your Maximum Potential at Any Age. TT. Perls,
MH. Silver, 1st edition, Basic Books, New York, NY, 1999
References
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment www.samhsa.gov
Hitt R, Young-Xu Y, Perls T. Centenarians: The older you get, the healthier you’ve been. Lancet, 1999;354 (9179):652
Silver, M.H., Jilinskaia, E., Perls, T.T. Cognitive functional status of age-confirmed centenarians in a population-based study. Journal of Gerontology, Psychol Sci 2001;56B:P134-P140.
Silver MH, Newell K, Brady C, Hedley-Whyte ET, Perls TT. Distinguishing between neurodegenerative disease and disease-free aging: correlating neuropsychological evaluations and neuropathological studies in centenarians. Psychosomatic Medicine 2002;64:493-501.
Perls T, Alpert L, Fretts R. Middle aged mothers live longer. Nature 1997;389:133. Perls T, Kunkel L, Puca A. The Genetics of Exceptional Human Longevity. J Am Geriatr Soc 2002;50:359-
368. Terry DF, Wilcox M, McCormick MA, Lawler E, Perls TT. Cardiovascular Advantages Among the Offspring
of Centenarians. J Gerontol Med Sci 2004;59:M385-389
References
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