Public Health Options for Improving Cardiovascular Health Among Older Americans

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.