1
Introduction

Living is not the good, but living well. The wise man therefore lives as long as he should, not as long as he can. He will observe where he is to live, with whom, how, and what he is to do. He will always think of life in terms of quality, not quantity.

— Seneca

The United States is an aging society. The elderly (aged 65 and older) constituted 12.4 percent of the population in 1988, and this proportion is projected to rise to approximately 14 percent in 2010, accelerating to nearly 22 percent by 2030.49 Today, this age group comprises some 30 million people; it is expected to grow to 39 million in 2010 and 66 million in 2030. Paralleling this growth is an overall increase in the median age of the U.S. population. From the present all-time high of 32.1 years the median age is projected to rise to 36 years in the year 2000 and to 42 years in 2030. The bolus effect of the baby boom cohort is less influential after 2030, and the median age rises more slowly thereafter. Nevertheless, it continues to rise.

Although the human life span has not changed, human life expectancy has changed dramatically. Life expectancy at birth is now 74.8 years—78.3 for females and 71.3 for males.39 Moreover, the elderly population itself is becoming older. Of those over the age of 65, 9.6 percent are aged 85 or older, and that percentage will reach 15.5 percent in 2010.

The implications of these demographics for health care in a society with finite resources are enormous, involving medical, social, and economic dilemmas that cannot be ignored. Already the nation's annual expenditures for health approach a half trillion dollars, and the public portion of that figure, reflected in Medicare and Medicaid expenditures, is more than 50 percent and rising. More telling, 30 percent of Medicare costs are for care in the last year of



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The Second Fifty Years: Promoting Health and Preventing Disability 1 Introduction Living is not the good, but living well. The wise man therefore lives as long as he should, not as long as he can. He will observe where he is to live, with whom, how, and what he is to do. He will always think of life in terms of quality, not quantity. — Seneca The United States is an aging society. The elderly (aged 65 and older) constituted 12.4 percent of the population in 1988, and this proportion is projected to rise to approximately 14 percent in 2010, accelerating to nearly 22 percent by 2030.49 Today, this age group comprises some 30 million people; it is expected to grow to 39 million in 2010 and 66 million in 2030. Paralleling this growth is an overall increase in the median age of the U.S. population. From the present all-time high of 32.1 years the median age is projected to rise to 36 years in the year 2000 and to 42 years in 2030. The bolus effect of the baby boom cohort is less influential after 2030, and the median age rises more slowly thereafter. Nevertheless, it continues to rise. Although the human life span has not changed, human life expectancy has changed dramatically. Life expectancy at birth is now 74.8 years—78.3 for females and 71.3 for males.39 Moreover, the elderly population itself is becoming older. Of those over the age of 65, 9.6 percent are aged 85 or older, and that percentage will reach 15.5 percent in 2010. The implications of these demographics for health care in a society with finite resources are enormous, involving medical, social, and economic dilemmas that cannot be ignored. Already the nation's annual expenditures for health approach a half trillion dollars, and the public portion of that figure, reflected in Medicare and Medicaid expenditures, is more than 50 percent and rising. More telling, 30 percent of Medicare costs are for care in the last year of

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The Second Fifty Years: Promoting Health and Preventing Disability life. Should we continue to devote these resources to the provision of acute care, or should we allocate more of them to prolong independent functioning in a community setting? A major factor in whether prolonged well-being can be achieved will be the success of programs for health promotion and disease and disability prevention. Typically, such programs have been targeted at the young and the middle-aged, but there is increasing evidence to suggest that they are useful to older individuals as well.24,35,40 In particular, these programs bring a valuable perspective to chronic illness in the over-50 population. Older individuals are more likely than younger persons to experience such illness, which often triggers processes that begin with physical impairment but that may progress into a myriad of limitations: the loss of independent function, emotional difficulties, and impediments to daily, work-related, and social activities. Many older persons can be spared all or part of this progression to dependency and diminished function, but reversing such a course requires attention by health professionals not only to the disease itself but also to its consequences. Health promotion and disability prevention supports and encourages healthful behavior and the prevention of chronic and acute conditions through risk reduction. This approach also makes room for broader notions of disability care and prevention, departing from traditional disease model frameworks in the care of the elderly in a number of ways. With this new perspective, prevention is more comprehensive; that is, points of prevention for chronic illness and disability are defined throughout life, including periods after the onset of these difficulties. Rehabilitation and social supports that recognize the heterogeneity of the older population are also an important part of this approach. Chronic illness and disability are constant companions of the elderly today and are likely to remain so, at least for the near term. Whatever progress is made in the prolongation of functional independence will come slowly and will depend heavily on research in the basic biology of aging and the genetic determinants of age and predisposition to disease. With that reality in mind, common sense dictates moving from the traditional primary prevention/''cure" model to a framework that incorporates the reduction of morbidity and the maintenance of maximal functioning as its goal. Intuitively, such a shift makes economic sense as well. But are there interventions that will produce these outcomes? This report attempts to address some of these issues. It has been prepared by the Committee on Health Promotion and Disability Prevention for the Second Fifty. Why the "second fifty?" The

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The Second Fifty Years: Promoting Health and Preventing Disability human life span is about 100 years, and there is evidence that around the 50th birthday, people begin to consider their mortality and pay more attention to their health.34 Improvements in methods of health promotion and disability prevention for people over the age of 50—including improvements in the car and advice given by health professionals—could yield major dividends in the form of physical, mental, and social well-being with reduced functional disability, a shortened term of expensive medical services, and a postponement of long-term care. It is only within recent years that older populations have been the focus of research in the field of health promotion and disease and disability prevention.7,20,25,35,38 Indeed, there is little agreement about what health promotion and disability prevention means for the health of persons over the age of 50. Even when related data have been available, there have been few analyses that draw inferences for older populations, little effort to quantify the benefits of such programs, and no consensus on what the evidence might mean for research and clinical practice among those aged 50 and older.9,13,48 In addition, there has been no systematic consolidation of the literature on rehabilitation practices in older populations with that on health promotion and disability prevention. As a result, there is little information on a number of difficult questions for the over-50 age group.6,21,45 For example, what age groupings or functional categories should be developed for this group to target health promotion and disability prevention interventions more effectively? What is known about the effects of such risk factors as smoking, high blood pressure, oral diseases, poor nutrition, and inactivity on different age segments of this population? What are the mechanisms and intervening processes that result in undesirable health effects or losses of functional ability? Prevention of premature disability and mortality for older individuals requires greater understanding of the changes in risk factors for these groups. Thus, one of the most significant problems facing those who would design interventions for the older population is the lack of an updated risk factor knowledge base. Most risk factor research has involved either the general population, the young, or the middle-aged.7,38,56 There have been few systematic studies of special risks, high or low, among those aged 50 and older.9,12 In addition, there are serious shortcomings in knowledge about the mutability of behaviors already classified as risks.10,32 The relative lack of knowledge on risk factors for those over 50 had led to several major efforts to acquire more longitudinal cohort data. The ongoing Framingham studies33 and the longitudinal research known as the Alameda County studies are being used to

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The Second Fifty Years: Promoting Health and Preventing Disability address some of the questions about risk factors for older persons. Ongoing work at the National Cancer Institute (NCI) exploring the risk of occurrence and reoccurrence of malignancy in those over the age of 50 will further strengthen this knowledge base.32 Findings from the Centers for Disease Control (CDC) risk factor update project and statewide risk factor surveys14 and the National Health and Nutrition Examination Survey (NHANES) follow-up studies15 are other important additions to understanding. Over the past decade the Public Health Service (PHS) has begun to identify priorities in health promotion and disease prevention for the general population.1,52,53,54 In addition, the recently released U.S. Preventive Services Task Force report on clinical preventive services18 and the Carter Center Health Policy Project2 have developed listings of priority health conditions. Of the two earlier noteworthy attempts to set health priorities for older populations, one dates from 1981,19 and the other covers chronic conditions only.40 The Health Objectives for the Year 2000 project will be particularly helpful in updating these priorities. A forthcoming Institute of Medicine report on a national research agenda on aging will add substantially to the knowledge base as well. Information is still lacking on a number of important aspects of risk for older persons. Research designs for examining the effects of risk factors on older persons should include social epidemiological as well as medical factors.5,8,11,29,32,37,42,47,56 Questions such as the specific impacts of social isolation and socioeconomic status, as well as the effects of other social epidemiologic variables, on the health status28 of older persons warrant careful attention. Answers to such questions may be found in part through review and classification of the evidence on both the physiological correlates of psychosocial changes44 and the interaction between biological and behavioral risk factors. Another area that requires greater understanding is the severity or strength of particular risk factors for older individuals. Although much is known, for example, about a number of factors of coronary heart disease risk (e.g., cigarette smoking, high blood pressure, high blood cholesterol17, the strength of other such factors (e.g., high dietary sodium,27,43 obesity3,17) is currently under challenge. A key task involves determining which methods are most valid for revealing the strength of risk factors for the over-50 population. In short, an integrated, coherent synthesis of existing findings, in the form of an updated knowledge base, must be developed to enable the required advances in research and clinical practice. Although the National Institutes of Health consensus development conferences17

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The Second Fifty Years: Promoting Health and Preventing Disability and the U.S. Preventive Services Task Force18 offer models for assessing what is known, these approaches have not yet systematically focused on currently available information on risk factors among older persons. Merely assembling the risk factor literature poses formidable problems because the information is scattered and lacks any consensus on key terms. Although researchers typically keep abreast of the literature on risk factors in the realm of their disciplinary interests, the limited scope of their work often fails to take account of the interactive nature of multiple risk factor problems in older persons. More important, there seems to be little agreement on the form of informational structures such as key word indices. Just as more integrated, coherent knowledge of risk factors is basic to continuing reassessment of their effects on the over-50 population, so evidence from health promotion and disability prevention research is important in assessing the effectiveness and benefits of approaches currently in use (both those that target the highest risk groups and those that reflect a more integrated strategy) to guide the development of future interventions. This body of knowledge, however, suffers from some of the same problems that characterize risk factor research for the elderly—for example, the lack of agreement about what health promotion and disability prevention means for those aged 50 and older.23 That lack reflects a relatively undeveloped conceptual base for such programs, a problem that impedes efforts to develop a systematic framework for understanding. Even the traditional classifications of prevention are difficult to apply to older people.32 The distinctions between primary, secondary, and tertiary prevention fit so poorly into the language of chronic disease that numerous efforts have been launched to develop uniform classifications of functional status. Prevention in rehabilitation terms is focused on preventing, maintaining, and modifying the loss of function as a result of physical, mental, or social impairments. Rather than disease prevention, the focus becomes disability prevention, an emphasis that seems a particularly important conceptual approach to studies of older people. The heterogeneity of the over-50 population is another issue that must be addressed for both risk factor and intervention research and implementation. All individuals over the age of 50 cannot be grouped into a single category. Development of a conceptual basis and a classification system for health promotion and disability prevention must take into account where older individuals are in the life course. Two major problems currently impede the delivery of preventive services for older persons. First, Medicare reimbursement primarily

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The Second Fifty Years: Promoting Health and Preventing Disability covers acute care and prohibits payment for preventive services except immunizations against pneumococcal pneumonia and hepatitis B and short-term rehabilitation.46,52 Second, and perhaps more critical, there is a lack of agreement about what kinds of interventions really work because there have been few rigorous evaluations of prevention strategies. (The debate over whether to intervene to control moderate high blood pressure is an example of the prevailing uncertainties regarding the use of certain high-risk versus integrated strategies.16,22,31,50) Consensus regarding the effectiveness of particular interventions is needed to target resources efficiently and to support the development of reimbursement policies for preventive services. Evaluation research is also necessary to assess the value of public and private experiments in prepayment arrangements that provide incentives for health promotion and disability prevention, such as Health Care Financing Administration (HCFA) and CDC demonstrations,26 and the INSURE30 and On Lok4 projects. Congressional interest in such questions51 appears to be growing as legislators seek solutions to budget problems. The absence of widely accepted criteria for determining the type and strength of the scientific evidence necessary for formulating preventive interventions is a serious barrier to progress in this arena, as is the inadequate assimilation into practice and action of comprehensive "state-of-the-art" reviews. Two related questions also apply: What evidence is appropriate for the decision to implement one or another intervention, and what measures of outcome may be accepted as surrogates for the traditional measures? The second question usually evokes suggestions of randomized clinical trials and other cumbersome and expensive experimental methods. The first may eventually be answered by the U.S. Preventive Services Task Force,18 building on the work of the Canadian Task Force on the Periodic Health Exam.13 Currently, however, the growth of the number of interventions and the mix of preventive health services continues to outpace the translation of firm research evidence into sound prevention recommendations. This report addresses some of these issues as they relate to a selected groups of specific risk factors. As part of their preparation for the study the committee members received the list of priorities prepared by the Division of Health Promotion and Disease Prevention of the Institute of Medicine and the Committee of Prevention Coordinators of the National Institutes of Health as well as others.19,40 The committee agreed that the following matters should receive specific attention.

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The Second Fifty Years: Promoting Health and Preventing Disability An integrated, coherent synthesis of new material and findings about risk factors and interventions should be prepared and made available to policymakers, the public, and practitioners on a periodic basis. The elderly themselves need to be the focus of a separate, targeted educational program concerning risk factors and interventions. Research should be conducted to find better ways to measure the strength of risk factors and less cumbersome and costly methods for measuring and comparing the benefits of interventions. The impact and effectiveness of intervention strategies should be measured and the results compared to identify the best approach, one that targets the highest or higher risk group(s) or one applied to the entire population. A better conceptual base should be developed and a more uniform system of classification should be defined and implemented for describing the body of knowledge on risk factors and interventions in the population aged 50 and older. Intervention outcomes should be examined not only in terms of lives prolonged but also of morbidities and disabilities slowed or reversed and quality of lives enhanced. Progress should be gauged both by advancements in promoting health and by improvements in managing chronic illness, particularly in the patient's capacity to cope with illness and disability. There is a need for more sensitive measures of quality of life in the years saved and new methods to assess the outcomes of health promotion and disability prevention programs. Several policy issues clamor for resolution. What type of health promotion benefit should be considered under Medicare and other payment mechanisms? What are the overall benefits of health promotion and disability prevention for persons aged 50 and older? What definitions, measures of impact, or terms should be used to support policy analysis in this area? Early in its work the committee recognized the large number of risk or causative factors that could be explored and decided to use three criteria to prioritize those it would address: prevalence, burden, and measurable mutability through the use of possible interventions. Thus, Chapters 3 through 15 examine the knowledge base of each of the following risk factors: high blood pressure, medication use, specific infectious diseases, osteoporosis, sensory deprivation, oral health problems, screening for cancer, nutrition, smoking, depression,

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The Second Fifty Years: Promoting Health and Preventing Disability physical inactivity, social isolation, and falls. The chapters review the prevalence of each factor in the over-50 population and its burden in terms of mortality, morbidity, and functional disability. Interventions to prevent, detect, treat, or modify the effect of these risk factors on the health and functional independence of older people are discussed, and the effectiveness of these interventions is examined both for the entire population above age 50, and for specific subgroups of that population. Based on these reviews, specific recommendations are proposed—for individuals, providers, advocacy groups, policymakers, and third-party payers. In addition, recognizing the gap between what is known and what needs to be known, the committee where appropriate proposes a research agenda to bridge that gap. These research recommendations complement the work of another Institute of Medicine committee that is developing a national research agenda on aging in all its aspects. Despite the burden of chronic illness and associated disabilities experienced by the aging in this society, the committee recognizes the great heterogeneity of this population and emphasizes that healthy aging is not an oxymoron. More important, the committee urges an expansion of elder care that looks beyond the primary prevention and cure model toward the maintenance or restoration of maximal functioning in the face of chronic illness. REFERENCES 1. Abdellah, F. G., and Moore, S. R. (eds.). Proceedings of the Surgeon General's Workshop: Health Promotion and Aging. Washington, D.C.: Department of Health and Human Services, Public Health Service, 1988. 2. Amler, R. W., White, C. C., et al. Closing the Gap: Cross-Sectional Analysis of Unnecessary Morbidity and Mortality in the United States. The Carter Center of Emory University, Health Policy Consultation, Nov. 26-28, 1984, Atlanta, Ga. 3. Andres, R. Presentation at the conference, Aging in the 21st Century, Montefiore Centennial Series, Rockefeller University, New York City, October 12, 1984. 4. Ansak, M. L., and Lindhein, R. On Lok: Housing and Adult Day Health Care for the Frail Elderly. Berkeley: Center for Environmental Design Research, College of Environmental Design, University of California at Berkeley, 1983. 5. Badura, B. Lifestyles and health: Some remarks on different viewpoints. Social Science and Medicine 1984; 19:341-347. 6. Berg, R. L. The prevention of disability in the aged. In: John M. Last (ed.), Public Health and Preventive Medicine. New York: Appleton-Century-Crofts, 1980, pp. 1283-1299. 7. Berkman, L., and Breslow, L. Health and Ways of Living: The Alameda County Study. New York: Oxford University Press, 1983. 8. Berkman, L. F., and Syme, S. L. Social networks, host resistance and mortality:

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The Second Fifty Years: Promoting Health and Preventing Disability A 9-year follow-up study of Alameda County residents. American Journal of Epidemiology 1979; 109:186-204. 9. Besdine, R. W. The database of geriatric medicine. In: J. W. Rowe and R. W. Besdine (eds.), Health and Disease in Old Age. Boston: Little, Brown, 1982, pp. 1-15. 10. Black, J. S., and Kapoor, W. Health promotion and disease prevention in older people: Our current state of ignorance. Journal of the American Geriatrics Society 1990; 38(2):168-172. 11. Blazer, D. Social support and mortality in an elderly community population. American Journal of Epidemiology 1982; 115:684-694. 12. Branch, L. G., and Jette, A. M. Personal health practices and mortality among the elderly. American Journal of Public Health 1984; 74(10):1126-1129. 13. Canadian Task Force on the Periodic Health Examination. The periodic health examination. Canadian Medical Association Journal 1979; 121:1193-1254. 14. Centers for Disease Control. Risk Factor Update Project: Final Report (under Contract USPHS 200-80-0527). Atlanta, Ga., February 1982. 15. Cornoni-Huntley, J., Barbano, H. E., Brody, J. A., et al. National Health and Nutrition Examination I—Epidemiologic follow-up survey. Public Health Reports 1983; 98:245-252. 16. Curb, J. D., Bohani, N. O., Schnaper, H., et al. Detection and treatment of hypertension in older individuals. American Journal of Epidemiology 1985; 121(3):371-376. 17. Department of Health and Human Services, National Institutes of Health. OMAR, Consensus Development Conference Statement, Vol. 5, No. 7, 1984. 18. Department of Health and Human Services, Public Health Service. Guide to Clinical Preventive Services: Report of the U. S. Preventive Services Task Force. Washington, D.C., 1989. 19. Department of Health and Human Services, Public Health Service. Strategies for Promoting Health for Specific Populations. Publ. No. 81-50169. Washington, D.C., 1981. 20. Donahue, R. P., Abbott, R. D., Reed, D. M., and K. Yano. Physical activity and coronary heart disease in middle-aged and elderly men: The Honolulu heart program. American Journal of Public Health 1988; 78:683,685. 21. Dychtwald, K. (ed.) Health promotion and disease prevention for elders. Generations 1983; 7(3):5-7. 22. Fries, E. D. Should mild hypertension be treated? New England Journal of Medicine 1982; 307:306-309. 23. Fries, J. F., Green, L. W., and S. Levine. Health promotion and the compression of morbidity. Lancet 1989; 1(8636):481-483. 24. German, P. S., and Fried, L. P. Prevention and the elderly: Public health issues and strategies. Annual Review of Public Health (United States) 1989; 10:319-332. 25. Green, L. W., and Gottlieb, N. H. Health promotion for the aging population: Approaches to extending active life expectancy. In: J. R. Hogress (ed.), Health care for an aging society. New York: Churchill Livingstone, 1989, pp. 139-154. 26. Greenlick, M., Lamb, S., Carpenter, T., et al. A successful Medicare prospective payment demonstration. Health Care Financing Review 1983; 4(4):85-97. 27. Gruchow, H. W., Sobscinski, K. A., and Barboriak, J. J. Alcohol, nutrient

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The Second Fifty Years: Promoting Health and Preventing Disability intake and hypertension in U.S. adults. Journal of the American Medical Association 1985; 253(11):1567-1570. 28. Hamburg, D. A., Elliott, G. R., and Parron, D. L. (eds.) Health and Behavior. Washington, D.C.: National Academy Press, 1982. 29. Hodgson, J. L., and Buskird, E. R. Effects of environmental factors and life patterns on life span. In: D. Danon, N. W. Shock, and M. Marois (eds.), Aging: A Challenge to Science and Society. Vol. 1: Biology. Oxford: Oxford University Press, 1981. 30. The INSURE Project on Life-cycle Preventive Health Services. Industrywide Network for Social, Urban and Rural Efforts. Washington, D.C., 1980. 31. Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. The 1980 report of the treatment of high blood pressure. Archives of Internal Medicine 1980; 140:1280-1285. 32. Kane, R. L., Kane, R. A., and Arnold, S. B. Prevention in the Elderly: Risk Factors. Paper prepared for the Conference on Health Promotion and Disease Prevention for Children and the Elderly, Foundation for Health Services Research, September 16, 1983. 33. Kannel, W. B., and Gordon, T. Cardiovascular risk factors in the aged: The Framingham study. In: S. G. Haynes and M. Feinlieb (eds.), Second Conference in the Epidemiology of Aging. Publ. No. 80-969. Bethesda: National Institutes of Health, 1980. 34. Karp, D. A. A decade of reminders: Changing age consciousness between fifty and sixty years old. The Gerontologist 1988; 28(6):727-738. 35. Larson, E. B. Health promotion and disease prevention in the older adult. Geriatrics 1988; 43(Suppl.):31-39. 36. McCormick, J., and Skrabanek, P. Coronary heart disease is not preventable by population interventions. Lancet 1988; 2:839-841. 37. McCoy, J. L., and Edwards, B. E. Contextual and sociodemographic antecedents of institutionalization among aged welfare recipients. Medical Care 1981; 19:907-921. 38. Multiple Risk Factor Intervention Trial Research Group. Multiple risk factor intervention trial: Risk factor changes and mortality results. Journal of the American Medical Association 1984; 248(2):1465-1477. 39. National Center for Health Statistics. Health, United States, 1988. Department of Health and Human Services Publ. No. (PHS)87-1232. Washington, D.C.: Department of Health and Human Services, December 1988. 40. Office of Technology Assessment. Technology and Aging in America. Washington, D.C., June 1985. 41. Oliver, M. F. Reducing cholesterol does not reduce mortality. Journal of the American College of Cardiology 1988; 12:814-817. 42. Paffenberger, R. S. Early predictors of chronic disease. In: R. C. Jackson, J. Morton, and M. Sierra-Franco (eds.), Social Factors in Prevention. Berkeley: University of California Public Health Social Work Program, 1979. 43. Phillips, K., Holm, K., and Wu, A. Contemporary table salt practices and blood pressure. American Journal of Public Health 1985; 75:405-406. 44. Riley, M. W., and Bond, K. Beyond ageism: Postponing the onset of disability. In: M. W. Riley, B. B. Bess, and K. Bond (eds.), Aging in Society: Selected Reviews of Recent Research. Hillsdale, N.J.: Lawrence Erlbaum Associates, 1983. 45. Rowe, J. W. Health care for the elderly. New England Journal of Medicine 1985; 312(13):827-835.

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The Second Fifty Years: Promoting Health and Preventing Disability 46. Smith, S. A. Patient education: Financing under Medicare. Patient Education and Counseling 1986; 8:299-309. 47. Solomon, K. The depressed patient: Social antecedents of psychologic changes in the elderly. Journal of the American Geriatrics Society 1981; 29:14-18. 48. Somers, A. R., Kleinmen, L., and Clark, W. D. Preventive health services for the elderly: The Rutgers Medical School project. Inquiry 1982; 19:190-198. 49. Spencer, G. (U.S. Bureau of the Census). Projections of the population of the United States, by age, sex, and race: 1988 to 2080. Current Population Reports Series P-25, No. 1018. Washington, D.C., January 1989. 50. Stegman, M. R., and Williams, G. O. The elderly hypertensive: A neglected patient. Journal of Family Practice 1983; 16:259-262. 51. U.S. Congressional Record. January 31, 1985:S919-922. Washington, D.C.: U.S. Government Printing Office. 52. U.S. Department of Health, Education and Welfare, Public Health Service. Promoting Health, Preventing Disease: Objectives for the Nation. Washington, D.C.: U.S. Government Printing Office, 1980. 53. U.S. Department of Health, Education and Welfare, Public Health Service. Healthy People. Washington, D.C.: U.S. Government Printing Office, 1979. 54. U.S. Department of Health, Education and Welfare, Public Health Service. Implementation plans for attaining objectives for the nation. Public Health Reports 1983; 98(5—Suppl.):2-177. 55. Wingard, D., Berkman, L., and Brand, R. A multivariate analysis of health related practices. American Journal of Epidemiology 1982; 116:765-775. 56. Zuckerman, D. M., Kasl, S. V., and Ostfeld, A. M. Psychosocial predictors of mortality among elderly poor. The role of religion, well-being, and social contacts. American Journal of Epidemiology 1984; 119:(3):410-423.