WELCOME TO THE FIRST BSSR SEMINAR SERIES 2014, FALL START. MY NAME IS AMY WASIM AND I'M AN OFFICER IN BEHAVIORAL SOCIAL SCIENTIST RESEARCH AND I'M HERE TO INTRODUCE THE SPEAKER. SO THANK YOU ALL FOR COMING AND I HOPE THAT YOU CHECK US OUT THE REST OF THE SEMESTER, TOO. SO TODAY WE'RE GOING TO HAVE DR. JOHN HAGA INTRODUCE OUR SPEAKER. DR. HAGA IS /THE DEPUTY DIRECTOR OF THE BEHAVIORAL AND SOCIAL SCIENTISTS AT THE NATIONAL INSTITUTE OF AGING AND I ASKED HIM IF THERE WAS ANYTHING INTERESTING TO TELL YOU GUYS AND HE WAS A STARTER ON HIS HIGH SCHOOL BASKETBALL TEAM AND THAT'S AN INTERESTING THING ABOUT DR. HAGA TODAY AND HE DID GET A LETTER SO YOU CAN CONGRATULATE HIM ON THAT AND WITH THAT, I'LL GIVE YOU DR. HAGA. >> THANKS. IT EMERGED THAT OUR SPEAKER HAS THE SAME CREDENTIALS. KEN LANGA IS PROFESSOR IN THE DEPARTMENT OF INTERNAL MEDICINE AND THE INSTITUTE OF SOCIAL RESEARCH AT THE UNIVERSITY OF MICHIGAN. HE'S ALSO A RESEARCH SCIENTIST IN THE VA CENTER FOR CLINICAL MANAGEMENT RESEARCH. AND ACTIVELY DOING CLINICAL WORK REGULARLY. HE'S WORKED FOR -- HIS WORK NOR -- FOR ANY OTHERA IS CENTERED ON HIS ROLE FOR THE CENTER OF DIRECTOR OF RETIREMENT STUDY, WHICH LABOR SOURCE OF THE LOT OF THE IM/PEMPIRICAL RESULT THAT HE'S GOING TO PRESENT. KEN IS -- HAS GOT A LOT /OF /STKEUPBGSS BUT ONE /OF THEM IS HE'S BOTH A BOARD-CERTIFIED GENERAL INTERNIST AND A PH.D, IN THIS CASE IN PUBLIC POLICY, BOTH FROM THE UNIVERSITY OF CHICAGO. AND WHAT HE'S GOING TO TALK TO US TODAY IS IN/TREUPTRINSICICALLY ABOUT IS IMPORTANT A TOPIC AS WE CAN THINK ABOUT HERE AND I ALSO FIND IT VERY INTERESTING AS /AA GREAT EXAMPLE OF THE BENEFITS THAT COME FROM BEING A POPULATION PERCESPECTIVE PERSPECTIVE^-- BRINGING A POPULATION PERCESPECTIVE TO SOME OF THE ISSUES THAT WE STUDY TYPICAL LY FROM LOWER DOWN LEVELS OF ANALYSIS SO BOTH ON THE IN/TREUPTRINSIC INTEREST AND THE METHOD LODGICAL WORK, I THINK GETS TO GO TO BE VERY INSIGHTFUL AND INTERESTING. THANK YOU. KEN. >> ALL RIGHT, THANK YOU, JOHN, FOR THAT INTRODUCTION AND THANK YOU TO AMY AND GREAT TO BE HERE TO TALK ABOUT SOMETHING NEAR AND DEAR TO MY HEART, THE HEALTH AND RETIREMENT STUDY AND AS JOHN SAID, I ALSO PLAYED HIGH SCHOOL BASKETBALL, SO FOR THE BSR FOLKS WHO ARE IN THE PROCESS OF ORGANIZING THE PICKUP BASKETBALL GAME, THE H /R-FPRS, VERSUS THE BSR IS COMING -- GOING TO COME UP IN THE NEXT FEW WEEKS. TKPWEUI AM GOING TO TALK ABOUT THE SOCIAL AND ECONOMIC IM/PABPACT OF DEMENTIA IN THE UNITED STATES WITH A FOCUS ON DATA FROM THE HEALTH AND RETIREMENT STUDY. I HAVE NO FINANCIAL CONFLICTS OF INTEREST. AND JUST AS AN OVERVIEW -- I SHOULD SAY IF ANYONE HAS QUESTIONS ALONG THE WAY, IF I AM UNCLEAR ABOUT ANYTHING, FEEL FREE TO INTERRUPT AND RAISE YOUR HAND. I'M HAPPY TO TAKE QUESTIONS ALONG THE WAY, AS WELL IF WE HAVE SOME TIME AT THE END FOR QUESTIONS. SO JUST TO GIVE YOU -- TO START WITH SOME OF THE MAIN POINTS I WANT TO MAKE. DEMENTIA CURRENTLY HAS A SOCIAL AND ECONOMIC IM/PABPACT AS LARGE AS OTHER COMMON DISEASES SUCH AS HEART DISEASE AND CANCER AND NEW EFFECT /KWREUIVE INTERVENTIONS, WE THINK A SOCIETAL IM/PABGPACT OF DEMENTIA WILL LIKELY GROW THREE TO FOUR-FOLD DUE TO THE AGING OF THE POPULATION. WE THINK THE BURDEN OF DEMENTIA AFFECTS FAMILIES, ESPECIALLY WOMEN MORE THAN OTHER COMMON CHRONIC DISEASES. AND FOCUSING AGAIN ON THE FAMILY FAMILY. THE CAREGIVERS IN THE DECADE AHEAD MAY LEAD TO A PEST STORM WITH /EUINCREASING CARE GIVING NEEDS AND DECLINING CARE GIVING SUPPLY. CIVIL STRAINING FAMILIES AND PUBLIC PROGRAMS, AS DEMENTIA CASES GROW AND THEN AGAIN I'LL TURN MORE SPECIFICALLY TO THE HEALTH AND RETIREMENT STUDY, AND WE'VE BEEN USING THE HEALTH AND RETIREMENT STUDY TO TRACK TRENDS IN DEMENTIA AND BRAIN HEALTH IN THE UNITED STATES POPULATION AND THEN END WITH SOME MORE OPT OPTIMISTIC NEWS THEN THAN SOME OF THE EARLIER TOPICS THAT I JUST MENTIONED. AND THAT POTENTIALLY OPTIMISTIC NEWS IS THERE SEEMS TO BE GROWING EVIDENCE THAT THE RISK FOR ALZHEIMER'S DISEASE AND DEMENTIA, THEY HAVE DECLINED OVER /THE /HRAFLAST 25 YEARS OR SO IN HIGH-INCOME COUNTRIES. BIG GROWTH IN THE NUMBER OF CASE CASES AND GROWTH IN THE ELDERLY POPULATION BUT AN 85-YEAR-OLD TODAY MIGHT HAVE A LOWER RISK OF HAVING ALZHEIMER'S DISEASE FOR -- OR DEMENTIA COMPARED TO AN 85 85-YEAR-OLD 20 YEARS AGO AND AGAIN, I'LL HOPEFULLY EXPLAIN THAT IN MORE DETAIL AS WE GO FORWARD. JUST SO WE'RE ALL ON THE SAME PAGE. HERE IS WHAT DEMENTIA IS. THIS IS FROM THE D /S-FPSM 4 CRY TIER IA. SO THE DEFINITION OF DEMENTIA IS "IMPAIRMENT IN SHORT AND LONG TERM MEMORY AS WELL AS OTHER COG NITIVE PROBLEMS." YOU CAN SEE SOME OF THE POTENTIAL PROBLEMS, EXECUTIVE FUNCTIONS. SO MEMORY, AS WELL AS SOME OTHER COG /TPHENITIVE PROBLEMS. AND THE COG /TPHENITIVE DEFICITS CAUSE SIGNIFICANT IMPAIRMENT IN SOCIAL OR OCCUPATIONAL FUNCTIONING AND REPRESENT A SIGNIFICANT DE GUIDELINE PREVIOUS LEVEL OF FUNCTIONING . SO THE KEY ISSUES OR CRY /TAOITERIA ARE DECLINE IN COG /TPHENITIVE FUNCTION, ESPECIALLY MEMORY AND THAT DECLINE IS SEVERE ENOUGH THAT I PERSON CAN NO LONGER TAKE CARE OF THEMSELVES AND NEEDS HELP DURING THE DAY IMPOST PARTUM IN SOCIAL OR OCCUPATIONAL FUNCTION. IT'S A FUZZY DEFINITION, AS I THINK YOU PROBABLY CAN GET A SENSE. ACTUALLY, CLINICAL DIAGNOSIS IS NOT STRAIGHTFORWARD. THERE IS OBVIOUSLY SOME SUBJECT SUBJECTIVITY ABOUT WHEN SOMEONE BECOMES SOCIALLY OR OCCUPATIONAL OCCUPATIONALLY IMPAIRED, WHEN DO PEOPLE START NEEDING HELPING -- HELP DURING THE DAY? PEOPLE CAN -- ACTUALLY, YOU CAN GO UP /SAND DOWN ALONG THOSE CRY TIER IA, AS PEOPLE AGE ALSO. SO IT'S NOT STRAIGHTFORWARD, AS MANY OF YOU KNOW. MUCH RESEARCH NOW IS AIMED AT DEVELOPING BIOMARKERS, BOTH SER SERUM-BASED, SPINAL FLUID-BASED AND IMAGING-BASED MARKERS TO GIVE US A BETTER SENSE OF WHO IS AT RISK FOR FURTHER DECLINE AND WHO WILL GET ALZHEIMER'S DISEASE IN THE FUTURE. AND AGAIN, I'LL TALK ABOUT THAT AS WE GO ALONG. THE SOCIAL AND ECONOMIC IM/PABPACT OF DEMENTIA. THERE ARE TWO MAIN COMPONENTS OF THE LARGE ECONOMIC IMIM/PABPACT THAT DEMENTIA IMPOSES, AND AGAIN, THOSE ARE CARE GIVING TIME AND NURSING HOME CARE. HERE ARE SOME OF THE FIRST DATA FROM THE HEALTH AND RETIREMENT STUDY. AND SUBSTUDY, THE AGING, DEM DEMOGRAPHICS AND MEMORY STUDY, OR ADAMS, THAT WAS FIELDED IN SORT OF 2002 THROUGH 2010. AND WE FOUND IN THE ADAMS ABOUT 15% OF THE 71 PLUS U.S. POPULATION, WE THINK, HAS DEMENTIA AND ABOUT 22% HAS THIS INTERESTING COG /TPHENITIVE IMPAIRMENT IMPAIRMENT, NOT DEMENTED OR CIN D HAS -- THAT'S DEEMED PART OF IT. MYOCOG /TPHEUNITIVE IMPAIRMENT, OR MCI, WHICH IS WHERE PEOPLE HAVE SOME COG /TPHENITIVE IMPAIRMENT OR COG NIT NITIVE FUNCTION IS NOT AS GOOD AS IT USED TO BE. BUT THEY HAVEN'T HIT THAT THRESHOLD WHERE THEY'RE HAVING SIGNIFICANT DIFFICULTIES WITH ACTIVITIES OF DAILY LIVING SO THEY'RE STILL ABLE TO GET YOU THROUGH THE DAY. THEY MIGHT NOT BE DOING IT AS WELL AS OR EFFICIENT LY BUT THEY HAVEN'T MITT -- HIT THAT DEMENTIA THRESHOLD. THAT'S EVEN A LARGER PROPORTION OF THE 71 PLUS POPULATION. YOU CAN SEE THE TOTAL NUMBERS HERE, IF YOU THINK ABOUT 4 MILLIONOR -- OR SO PEOPLE. YOU ADDED IN THE PEOPLE LESS THAN 71 WITH DEMENTIA, THIS NUMBER IS OUR ESTIMATE FROM THE ADAMS IS ABOUT 4.2 MILLION PEOPLE WITH DEMENTIA IN THE UNITED STATES IN 2010. AND YOU CAN SEE THE OTHER NUMBERS THERE. AND THEN AGAIN THE IM/PABPACT OF DEMENTIA AND THE FAMILY AND TURNING TOWARD THIS CARE GIVING ISSUE. WE'VE FOUND A BUNCH OF STUDIES EARLY ON USING DATA FROM THE HEALTH AND RETIREMENT STUDY ON CARE GIVING TIME. HOW MANY HOURS FAMILIES SPEND PROVIDING HERE OR HELP WITH ACTIVITY OF DAILY LIVING TO PEOPLE WITH VARIOUS CHRONIC DISEASES AND YOU CAN SEE THAT WE'VE AGAIN LOOKED AT A WHOLE BUNCH OF THE COMMON CHRONIC DISEASES AND DEMENTIA WHEN WE SPLIT THIS OUT AND TRY TO GET A SENSE /OF WHAT THE ADDITIONAL CARE GIVING TIME RELATED TO EACH OF THESE CHRONIC DISEASE, DEMENTIA WAS THE LARGEST PIECE OF THE PIE, ABOUT 30% DEPRESSION AND STROKES. SO ASSISTANT BRAIN-RELATED PROBLEMS SEEMED TO HAVE THE LARGEST IMPACT ON FAMILY MEMBERS IN TERMS /TPH-PLZ OF CARE GIVING TIME FOR HELPING PEOPLE GET THROUGH THE DAY. IN TERMS. AGAIN, THERE WAS A STUDY USING DATA TRYING TO ESTIMATE THE QUANTITY OF TIME THAT PEOPLE ARE SPENDING PROVIDING CARE AND THESE ARE WEEKLY HOURS OF CARE GIVING AND PEOPLE WITH NORMAL COG KNITTINGIVE DEMENTIA, YOU CAN SEE THE SURPRISING INCREASE IN CARE GIVING TIME AT ABOUT LITERAL LY A FULL-TIME JOB FOR TAKING CARE OF PEOPLE WITH SEVERE DEMENTIA AND ADDITIONAL 4 41 HOURS PER WEEK OF CARE GIVING TIME THAT FAMILIES PROVIDE. HERE IS ANOTHER ECONOMIC IM IM/PABIMPACT OF DEMENTIA. OUT-OF-POCKET EXPENDITURES FOR DEMENTIA THAT THAT FAMILIES IN INCURE AND THIS AGAIN -- THESE ARE DATA FROM THE AGING STUDY AND DEMOGRAPHICS AND FOLKS WITH NORMAL COG /TPHENITIVE AVERAGE, BIG IN INCREASE IN OUT-OF-POCKET EXPENDITURES WITH THE MAIN COMPONENT BEING OUT-OF-POCKET EXPENDITURES, OR NURSING HOME CARE. OTHER EXPENDITURES ARE ACTUALLY NOT TOO SIGNIFICANTLY DIFFERENT BUT AGAIN, PERHAPS NOT -- SURPRISING LY IT'S EXPENDITURES FOR NURSING HOME CARE WHERE THE IM/PABPACT ON OUT-OF-POCKET EXPENDITURES IS REALLY SEEN. AND DEMENTIA CARE GIVING FALLS MORE HEAVILY ON WOMEN. ABOUT 15 MILLION AMERICANS PROVIDE UNPAID CARE IN STKPWAOEUPB NEARLY TWO-THIRDS OF THOSE CAREGIVERSS WERE WOMEN. ABOUT 55% OF CAREGIVERS ARE ACTUALLY THE PRIMARY BREAD WINNERS AND 26% HAVE CHILDREN YOUNGER THAN 18 LIVING WITH THEM THEM. SO THE EXAMPLE OF THE SO-CALLED IS SANDWICH GENERATION, WHERE TAKING CARE OF BOTH KIDS AS WELL AS OLDER ADULTS WITH DEMENTIA. AND THEN JUST BECAUSE OF THE TYPICAL COURSE OF DEMENTIA AND THE LENGTHY COURSE COURSE THAT IT OFTEN HAS, DEMENTIA CARE GIVING OFTEN EXTENDS MUCH LONGER THAN CARE GIVING FOR OTHER CHRONIC DISEASE. AND THIS WAS ACTUALLY ONE OF THE FIRST STUDIES I WAS INVOLVED WITH HEALTH AND RETIREMENT STUDY DATA PUBLISHED BACK IN 2000. AND WE WERE LOOKING AT /THIS IDEA THAT WOMEN BEAR MORE OF THE CARE GIVING BURDEN THAN MEN. AND THIS IS ACTUALLY NOT SPECIFICALLY FOR DEMENTIA BUT THESE ARE CARE GIVING VALUES FOR ANYONE WITH A DISABILITY SO YOU CAN SEE FIRST OF ALL, THAT OLDER DISABLED WOMEN SIGNIFICANTLY LESS LIKELY TO BE MARRIED, ONLY ABOUT 28% VERSUS 7 74% AND MORE LIKELY TO BE LIVING ALONE. THAT'S MAINLY AS A RESULT OF THE FACT THAT WOMEN LIVE LONGER THAN MEN. SO IN THE FIRST IN [INDISCERNABLE] FAN IS WOMEN HAVE FEWER CARE CAREGIVERS. THEY ARE MUCH MORE UN-- LIKELY TO BE UNMARRIED THAN LIVING A ALONE THEY ARE MOST LIKELY ATO HAVE A LOW NETWORK AND HAVE MORE DIFFICULTY GOING OUT AND BUYING CARE GIVING. BUT EVEN WHEN MARRIED, SO AGAIN, WOMEN HAVE FEWER CARE GIVING RESOURCES AROUND THEM. BUT EVEN WHEN MARRIED, DISABLED WOMEN RECEIVE LESS CARE FROM THEIR HUSBANDS THAN DISABLED MEN RECEIVE FROM THEIR WIVES AND DISABLED WOMEN THERE YOU SEE SIGNIFICANTLY FEWER HOURS OF IN INFORMAL CARE FROM THEIR SPOUSE AND FAMILY THAN MEN DO. AND MY WIFE HAS STILL FOUND IT AMAZING THAT JAMA WAS INTERESTED IN /AA PAPER THAT SAID WOMEN HELPED MEN MORE THAN MEN HELPED WOMEN. SHE DIDN'T THINK THAT THAT WAS SIGNIFICANT IN/TPFO THAT EVERYONE DIDN'T ALREADY KNOW THAT ALREADY ALREADY. HERE IS ANOTHER ASPECT OF THE GREATER BURDEN OF ALZHEIMER'S DISEASE AND DEMENTIA ON WOMEN. JUST TALKED ABOUT THE CARE GIVING SIDE OF THINGS. THIS IS THE ACTUAL PREVALENCE OF DEMENTIA. AGAIN, THESE ARE DATA FROM THE AGING DEMOGRAPHICS STUDY AND VIEWED DATA A WHILE AGO AND SHOWING THE GENDER DIFFERENCE IN LIVING ARRANGEMENTS FOR PEOPLE WITH DEMENTIA SO THERE WERE ABOUT 34 -- 3.4 MILLION OR SO PEOPLE WITH DEMENTIA BACK IN 2002. FIRST OF ALL, YOU CAN SEE THAT THERE IS A LOT MORE GREEN THAN RED. GREEN IS REPRESENTING WOMEN. WOMEN REPRESENTED ABOUT TWO THIRD OF THE DEMENTIA CASES. AND THEN YOU CAN ALSO SEE THE SIGNIFICANT DIFFERENCE IN WHERE PEOPLE ARE LIVING AND HOW THEY ARE BEING CARED FOR. SO FOR MEN IN THE RED BARS, THE MOST COMMON SITUATION IS TO BE LIVING IN THE COMMUNITY WITH A SPOUSE. AND LEAST COMMON SITUATION IS TO BE IN /AA NURSING HOME. YOU CAN SEE IT'S VERY DIFFERENT FOR WOMEN. THE LEAST COMMON SITUATION IS TO BE LIVING IN THE COMMUNITY WITH A SPOUSE, MUCH MUCH MORE COMMON TO BE IN THE COMMUNITY WITH NO SPOUSE AND ALSO TO BE IN /AA NURSE NURSING HOME. SO VERY DIFFERENT CARE GIVING ENVIRONMENT FOR WOMEN COMPARED TO MEN, BECAUSE AGAIN, MAINLY BECAUSE OF THOSE DIFFERENCE IN LIFE EXPECT ANANCY. WE THINK THAT THE MAIN REASON THAT WOMEN ARE MAKING UP TWO THIRD OF THE DEMENTIA CASES COMPARED TO MEN IS MAINLY THE LENGTH /OF LIFE. THERE IS STILL SOME INTERESTING RESEARCH GOING ON, IS THERE A BIOLOGICAL REASON FOR THIS /TKEUFG IN PREVALENCE? BUT I THINK MY READING OF LITERATURE SO FAR IS THAT IT'S MORE LIKELY THIS LIFE EXPECT ANANCY DIFFERENCE. AND THEN TURNING TO NURSING HOME CARE, AGAIN, NOT SURPRISING LY RISK OF NURSING HOME ENTRY INCREASES SIGNIFICANTLY FROM ABOUT 10% MILD DEMENTIA, 50% TO SEVERE DEMENTIA IS. THESE DATA ARE FROM ADAMS AND THE H /R-FPRS. RISK IS INFLUENCED BY BOTH PATIENT AND CAREGIVER CHARACTERISTICS. LIVING SITUATION, MARRIED FOLKS ARE OBVIOUSLY LESS LIKELY TO ENTER NURSING HOME THAN PEOPLE THAT ARE LIVING ALONE. HERE IS SOME INTERESTING RACIAL AND ETHNIC DIFFERENCES WITH AFRICAN-AMERICANS, HISS /PAPANIC ELDERS AT LOWER RISK FOR NURSING HOME ENTRY THAN WHITES. AND THEN ALSO CERTAIN SYMPTOMS, FOR INSTANCE, DEPRESSION, DELUSION, INCREASES THE RISK FOR MOVING FROM HOME TO A NURSING HOME FOR WOMEN WITH DEMENTIA NURSING HOME ARE EXPENSIVE, AS WE TALKED ABOUT BEFORE. ON AVERAGE ABOUT $80,000 A YEAR AND NURSING HOME COSTS LIKELY ACCOUNT FOR ABOUT 40% OF THE TOTAL DIRECT COST OF DEMENTIA CARE. SO A LARGE CHUNK OF WHY DEMENTIA HAS A BIG IM-- ECONOMIC IM/PABPACT IS LONG TERM SATURDAY AND A EXPENSE OF NURSING HOME CARE. WE'VE ALSO AGAIN USED THE HEALTH AND RETIREMENT STUDY TO GET A BETTER SENSE OF THE FULL ECONOMIC IM/PABPACT OF DEMENTIA ON SOCIETY, ON FAMILIES. THIS WAS A PAPER BY MICHAEL HERD HERD, ONE. COLLEAGUES INVESTIGATORS FROM THE START. OF THE H /R-FPRS. AND AGAIN WE USED H /R-FPRS DATA AND ADAMS DATA TO GET A SENSE OF WHAT THE FULL ECONOMIC IM/PABPACT OF WHAT DEMENTIA WAS IT WAS. THIS WAS SORT OF THE BUNCHLINE GRAPH HERE. THIS IS IN 2010 /TW-PB DOLLARS WE THINK ABOUT $56,000 PER PERSON. SO THE ADDITIONAL COST THAT DEMENTIA IMPOSES COMPARED TO ALL THE OTHER CHRONIC CONDITION THAT'S OLDER FOLKS HAVE. AGAIN, THE LARGEST PIECE OF THE PIE, ABOUT HALF OF THE TOTAL ECONOMIC IM/PABPACT WAS THE TIME THAT CAREGIVERS SPEND, THE UNPAID VALUE OF THE TIME THAT CAREGIVERS SPEND, EVEN THOUGH IT'S NOT REIMBURSED FINANCIALLY. NURSING HOMES, ANOTHER LARGE CHUNK OF THE THE PIE, OUT-OF- OUT-OF-POCKET EXPENDITURES AND THEN YOU CAN SEE HERE. INTERESTINGLY MEDICARE EXPENDITURES THEMSELVES, A SMALL PIECE OF THE PIE. AGAIN, LIKELY BECAUSE LONG TERM CARE IS /THE IMPORTANT PIECE HERE, AND IT'S MEDICAID THAT PAYS FOR THE LARGEST CHUNK OF NURSING HOME CARE. THESE WERE THE FEW -- IF YOU AG AGGREGATE TUP, THOSE PER-PERSON COSTS TO THE UNITED STATES IN 2010. HERE /TIN /TTHIS FIRST COLUMN HERE, HERE IS THE 2010 NUMBERS HERE. WE'LL FOCUS ON THOSE FIRST. IN TERMS OF DIRECT COSTS PAID FOR IN THE MARKETPLACE -- SO THINGS LIKE DOCTOR FEES, NURSING HOME EXPENSE ESPNS -- THINGS LIKE THAT, WAS ABOUT $109 BILLION. AND THEN DEPENDING ON HOW YOU VALUE INFORMAL CARE, WE DID SORT OF A RANGE OF ESTIMATES, A RE REPLACEMENT COST IS JUST IF YOU HAD TO GO OUT AND BUY THAT AMOUNT OF CARE IN THE HOME CARE MARKET IF YOU HAD TO HIRE SOMEONE. YOU GET AN ESTIMATE OF ABOUT $2 $215 BILLION IN CARE GIVING COSTS,IZING MORE CONSERVATIVE ESTIMATE OF WHAT'S THE VALUE OF A CAREGIVER'S PEOPLE -- TIME, YOU GET A MORE CONSERVATIVE ESTIMATE BECAUSE MAINLY OF THE -- -- MANY OF THE CAREGIVERS ARE OUT /-OF THE LABOR FORCE /SKAND THEIR TIME IS SORT OF VALUED RELAT RELATIVELY LESS. BUT SOMEWHERE BETWEEN 16 /0 AND $1 $115 BILLION PER YEAR -- I'M SORRY. WHEN YOU ADD THAT TO THE DIRECT COST, THAT'S THE TOTAL COST OF DEMENTIA. SO AGAIN, $215, MINUS 109. SO $106 BILLION JUST FOR THE IN INFORMAL CARE. AND THEN IN ORDER TO GET A PROJECTION GOING FORWARD, WE USED THE PREVALENCE ESTIMATES FROM THE ADDSON AND RAN THOSE FORWARD TO 2030, 2040, ASSUMING THAT THE RISK OF DEMENTIA -- THE AGE-SPECIFIC RISKS ARE THE SAME AND YOU COME UP WITH AGAIN, MORE THAN A DOUBLING OF COSTS FROM ABOUT 215 TO 511 BILLION OR THE MORE CONSERVATIVE ESTIMATES HERE IN TERMS OF THE TOTAL ECONOMIC COST OF DEMENTIA IN THE UNITED STATES. SO COMPARE THAT SOCIAL AND ECONOMIC IM/PABPACT TO SOME OF THE OTHER IMPORTANT AND COMMON CHRONIC DISEASES, YOU CAN SEE THE DIRECT COST ESTIMATES HERE THAT THESE ARE FROM MEDICAL EXPENDITURE PANEL SURVEY DATA THAT $102 BILLION FOR HEART DISEASE, AND THIS WAS THE SAME YEAR AS THE ESTIMATES FOR DEMENTIA $80 BILLION AND $109 BILLION TOTAL IN DIRECT COSTS. INFORMAL CARE GIVING COSTS PROBABLY GREATEST FOR DEMENTIA SO THAT'S WHY WE THINK THAT DEMENTIA HAS A LARGE IM/PABPACT, GREATER ECONOMIC IM/PABPACT THAN HEART DISEASE CANCER OVERALL. ALL RIGHT, GOING TO TURN NOW TO THIS QUESTION OF THE CHANGING AVAILABILITY OF CAREGIVERS, AS THE NUMBER OF OLDER FOLKS IN INCREASES GOING FORWARD. SO HERE'S -- I'M SURE EVERYONE HAS SEEN A ZILLION TIMES BUT AGAIN TO PUT IT IN BLACK /SAND WHITE HERE. THE LARGE INCREASE IN THE ELDERLY POPULATION FROM 40 MILLION PEOPLE IN 2010 UP TO 90 MILLION PEOPLE IN 2050, FROM ABOUT P 13% OF THE POPULATION TO 20% OF THE POPULATION IN 2050. PERHAPS MORE IMPORTANT, FROM THE PERCESPECTIVE OF WHAT'S GOING TO HAPPEN TO DEMENTIA IS /THE POPULATION OF THE OLDEST TO OLDER 85 PLUS. YOU CAN SEE JUST FROM ABOUT 6 MILLION PEOPLE HERE /TIN 2010 UP TO ALMOST 20 MILLION IN 2050. SO A HUGE RELATIVE INCREASE OBVIOUSLY IN THE NUMBER OF PEOPLE WHO ARE OBVIOUSLY AT THE GREATEST RISK FOR DEMENTIA. OTHER FOLKS -- MARTIN PRINCE AND COLLEAGUES IN LONDON HAVE TRIED TO DO THESE KINDS /OF ESTIMATES -- PREVALENCE ESTIMATES FOR OTHER COUNTRIES AROUND /THE WORLD WORLD. THEY ESTIMATE THAT THERE ARE ABOUT 36 MILLION PEOPLE WORLD WORLDWIDE THAT HAVE DEMENTIA NOW AND THAT WILL INCREASE TO ABOUT MORE THAN 100 MILLION IN 2050. WE TALKED ABOUT IN THE UNITED STATES FROM ABOUT 4 TO 5 MILLION UP TO 10 TO 16 MILLION SO AGAIN, EFFECT /KWREUIVE INTERVENTION INTERVENTIONS TO PREVENT OR DELAY ONSET. WE THINK THERE WILL BE A FOUR FOUR-FOLD INCREASE IN THE NEXT 40 YEARS DUE TO THIS LARGE IN INCREASE IN THE OLDER POPULATION POPULATION. AND AGAIN, AS YOU KNOW, THE NUMBER OF YOUNGER PEOPLE IN THE UNITED STATES AVAILABLE WORKING AGE PEOPLE AVAILABLE TO PROVIDE CARE FOR THE GROWING NUMBER OF PEOPLE WITH DEMENTIA IS DE DECLINING AND SO THIS IS ONE WAY TO SHOW THAT THE OLD AGE DEPENDENCY RATIO, MEANING THAT THERE ARE 22 PEOPLE, 65 PLUS FOR EVERY 100 PEOPLE AGE 20 TO 64 IN THE UNITED STATES RIGHT NOW. THAT IS GOING TO INCREASE SIGNIFICANTLY ABOUT 37 PEOPLE 65 PLUS FOR FEM IN 2050. SO A LARGE INCREASE IN OLDER ADULTS. LARGE RELATIVE INCREASE IN PEOPLE WITH DEMENTIA. LESS SIGNIFICANT INCREASE IN THE CARE GIVING SUPPLY, IF YOU WILL. SO THAT'S THE CONCERN ABOUT THIS MISMATCH AND NEED AND SUPPLY GOING FORWARD OVER /THE NEXT 35 YEARS OR SO. IN ADDITION TO /TTHAT, THERE IS THIS QUESTION OF THE HEALTH OF THE FUTURE CAREGIVERS. AS MANY OF YOU MAY KNOW, WITH THE LARGE INCREASE IN OBESITY AND DIABETES, THERE SEEMS TO BE GROWING EVIDENCE THAT DISABILITY DISABILITY, ESPECIALLY MOBILITY DIFFICULTIES AMONG PEOPLE 50 TO 64 IS ACTUALLY INCREASED OVER THE LAST -- BETWEEN 19/THE /1K3-7 2007. OBESITY HAS BECOME MUCH MORE COMMON. SO THE QUESTION AND CONCERN IS THE FUTURE SUPPLY OF CAREGIVERS ACTUALLY NOT ONLY GOING TO BE SMALLER BUT ALSO UNABLE TO HELP BECAUSE OF SOME OF THESE IN INCREASING DISABILITIES OR THE PUSHING BACK EARLIER IN THE AGE OF WHEN PEOPLE BECOME DISABLED. A NEW YORKER CARTOON ABOUT CARE CAREGIVER BURDEN THERE. 77 -- HOW ABOUT YOURS? JUST ONE OTHER IMPORTANT ISSUE, I THINK /STKWHRARBGS WE'VE STUDY STUDIED A BIT WOULD BE THE HEALTH AND RETIREMENT STUDY IS THE IM/PABPACT OF COG /TPHEUNITIVE IM IMPAIRMENT AT THE END OF LIFE. USING THE H /R-FPRS, WE'VE FOUND THAT ABOUT 25% OF OLDER ADULTS REQUIRE MEDICAL DECISION MAKING IN THE LAST DAYS /OF LIFE. BUT ARE NOT COG /TPHENITIVELY ABLE TO MAKE THOSE DECISIONS. AND THIS AGAIN IS IMPORTANT RELATED TOP /KWREUIC ABOUT THE IMPORTANCE OF ADVANCED DRESSES AND DISCUSSING -- DIRECTIVES AND DISCUSSING WHAT KINDS /OF PREFERENCES /R-FPZ OLDER ADULTS HAVE MORE CARE, GIVEN THE FACT THAT WE ESTIMATE ABOUT ONE QUARTER OF OLD OLDER ADULTS WON'T BE ABLE TO MAKE THESE KINDS /OF DECISIONS AT THE END OF LIFE. ALL RIGHT, SO NOW AFTER THAT SOMEWHAT POSSEESSIMISTIC OR SAD NEWS NEWS, HERE LET'S TRY TO TURN TO MAYBE SOME OF THE OPTIMISTIC TRENDS THAT I TALKED ABOUT JUST A LITTLE WHILE AGO. SO AGE-SPECIFIC DEMENTIA RISK DECREASING.^ A NUMBER OF STUDIES I'LL TELL YOU THE ONE WE'VE DONE WITH THE HEALTH AND RETIREMENT STUDY. EIGHT OR NINE STUDIES OVER /THE LAST TEN YEARS HAVE SUGGESTED THAT THE AGE-SPECIFIC DEMENTIA RISK IS ACTUALLY DECLINED. AND AGAIN I'LL TALK ABOUT IN MORE DETAIL GOING FORWARD. TWO SORT OF LEADING CONTENDERS OR REASONS THAT WE THINK THIS MIGHT BE HAPPENING ARE HUGE IN INCREASES IN THE LEVEL OF EDUCATION, THE NUMBER OF YEARS THAT PEOPLE ARE GOING TO SCHOOL, BOTH THE UNITED STATES AS WELL AS AROUND /THE WORLD. AND BETTER CONTROL OF CARD /KWIO VASC LAR RISK FACTORS. RELATED TO RISKS AND I'LL TALK ABOUT THAT IN JUST A LITTLE BIT ALSO. ONE STUDY THAT'S ESPECIALLY POWERFUL, I THINK, IS /THE RAT EER RATERDAM STUDY BECAUSE THEY HAD BRAIN IMAGING DATA BACK IN 2001 AND THEY FOUND IN THE CARD /KWIO VASC LAR RISK OR THE SER REBO VASCULAR REGIONS OF THE BRAIN DE DECREASEDED IN THEIR STUDY IN ROD ER DAM DURING THAT TIME PERIOD AND SUGGESTING CARD /KWIO VASC LAR RISK FACTOR CONTROL MIGHT BE VERY IMPORTANT. DEB BARNES /SAND CRISTINE PUBLISHED A PAPER A FEW YEARS AGO THAT ESTIMATED IN TERMS OF MODIFYABLE RISKS AGAIN SPECIFICALLY LOW EDUCATION AND CARD /KWRO /SRAFIOVASCULAR RISK FACTORS AN D DEPRESSION MIGHT ACCOUNT FOR UP TO 50% OF THE RISKS FOR DEMENTIA SO IF WE FIXED ALL OF THOSE PROBLEMS, WE MIGHT BE ABLE TO DE DECREASE PREVALENCE BY 50%. THEY PUBLISHED WITHIN THE /HRALAST FEW MONTHS AN UPDATE TO THIS ANALYSIS THAT'S A LITTLE MORE CONSERVATIVE. PART OF ISSUE HERE IS THERE IS OVERLAP IN MANY OF THESE RISKS FACTORS. SO IF YOU SORT OF VIEW THAT THOUGHT EXPERIMENT FACTOR AT A TIME, YOU MIGHT GET TWO -- TOO LARGE A NUMBER. SO THEY'VE ACTUALLY IN A MORE CONSERVATIVE, STATISTICAL METHOD ABOUT 30 TO 35% OF DEMENTIA MIGHT BE MODIFYABLE. SO AGAIN, THIS 50% NUMBER. BUT OBVIOUSLY, STILL A LARGE 30% OF 140 MILLION IN 2050 IS STILL A SIGNIFICANT NUMBER OF PEOPLE. SO WE PUBLISHED A REVIEW OF SOME OF THESE PAPERS. COLLEAGUE ERIC LARSON AND MYSELF PUBLISHED THIS REVIEW LAST YEAR. I SHOULD SAY THAT ANDERSON WAS VERY INSTRUMENTAL IN NUDGEING US ALONG TO DO THIS PAPER. SO I THANK HIM FOR THAT. AND AGAIN, WE LOOKED AT A FEW OF THESE DIFFERENT PAPERS. KEN MATEN USING AN LTCS, PUBLISHED A PAPER IN I BELIEVE 2005 WAS ONE OF THE FIRST ONES AND WE PUBLISHED A PAPER IN 2008 WITH HEALTH AND RETIREMENT STUDY DATA AND I'LL SHOW YOU THAT IN MORE DETAIL. I TALKED ABOUT THE RUDDER DAM STUDY. THERE IS A STUDY FROM STOCKHOLM AND MOST RECENTLY AND PRETTY PER WAY ISIVELY FOLKS IN ENGLAND, CAROL BRAIN AND TEAM IN THE COG NITIVE FUNCTION AND AGING STUDY PUBLISHED A PAPER LAST YEAR SHOWING A SIGNIFICANT DECREASE IN DEMENTIA RISK IN ENGLAND FROM 1990 TO 2010. SO FROM A DEMENTIA PREVALENCE OF ABOUT 8.3% AND I'VE GOT THIS RED BAR HERE UNDERLYING EDUCATION'S KEY FROM COG /TPHENITIVE FACTOR AND LARGE INCREASE S S IN EDUCATION IN ALL OF THESE COUNTRIES. ALL RIGHT, JUST TO LAY OUT AGAIN SOME OF THESE RECENT TRENDS THAT MIGHT BE IMPROVING BRAIN HEALTH OVER TIME. JUST TO FOCUS ON THE CARD /KWRIO VASC LAR RISKS FOR /AA MINUTE. SO ON THE ONE HAND YOU KNOW THERE HAS BEEN AN /EUINCREASING PREVALENCE OF OBESITY, DIABETES AND HYPERTENSION. BUT MUCH MORE WIDESPREAD AND INTENSIVE TREATMENT OF DIABETES, HYPERTENSION AND HIGH CHOLESTEROL OVER /THE /HRAFLAST 20 YEARS. HERE ARE SOME OF THE NUMBERS FROM THE CD IDEA.^ CDC AND OTHER PUBLICATIONS. A BIG IN/KHRAES IN DIABETES. 23% TO 35% IN ADULT BETWEEN THESE TIME PERIODS.^ A HUGE INCREASE IN DIABETES PREVALENCE. MORE MODEST INCREASE IN HYPER HYPERTENSION PREVALENCE ALSO. BUT THEN AGAIN, WE'RE TREATING THINGS MORE AGGRESSIVE LY AND ACTUALLY MAKING SOME HEAD WWAY IN TERMS OF CONTROL. AGAIN, THESE ARE FROM LAYER IS CDC AND OTHER PAPERS, THESE DATE DATA. SO HYPERTENSION TREATMENT FROM ABOUT 58% TO 75% OF THOSE WHO HAVE DIAGNOSED HYPERTENSION. CONTROL ALMOST DOUBLED FROM 27% TO 50%. OBVIOUSLY, STILL CAN DIE LOT BETTER. BUT ALMOST A DOUBLING IN THE PERCENTAGE OF THE HYPERTENSIVE POPULATION CONTROLLED ON MEDICATIONS. YOU CAN SEE THE SIMILAR TRENDS IN CHOLESTEROL AND DIABETES TREATMENT, TOO. SO IS THIS BETTER TREATMENT HAVING AN IM/PABPACT ON HEALTH OUT OUTCOMES? THE EVIDENCE SEEMS TO SHOW DEFINITELY YES. THIS IS ACTUALLY -- I THINK ONE OF THE MOST /STRAOEUPBGING GRAPHS FROM THE MEDICAL LITERATURE I'VE SEEN IN THE LAST FIVE YEARS OR SO. STRIKING. THIS WAS FROM A PAPER BY GREG -- GREG AND COLLEAGUES THIS /KWRAYEAR AND THESE ARE THE EVENTS FOR 10 10,000 ADULT POPULATION WITH DIABETES. SO THESE ARE ALL FOLKS WITH DIAGNOSED DIABETES. AND THEN THESE ARE THE RATES OF THE KEY DIABETES-RELATED OUT OUTCOMES, BAD OUTCOMES FROM DIABETES -- HEART ATTACKS, STROKES, AND YOU CAN SEE THESE PRETTY AMAZING DECLINES IN THE LAST 25 YEARS OR SO FROM 1995 -- HEART ATTACK, ALMOST A 70% DE DECLINE. STROKE, AMPUTATION. SO IT DOES SEEM AS THOUGH THIS MORE AGGRESSIVE TREATMENT IS DOING SOME GOOD. THIS OBVIOUSLY ISN'T ALL MEDICATIONS SMOKING DECLINES AND OTHER THINGS GOING ON DURING THIS TIME PERIOD. BUT OVERALL THIS GRAPH SEEMS TO SAY TO ME THAT THE VASCULAR ENVIRONMENT WITHIN ADULTS' BODY IN THE UNITED STATES HAS CHANGED FOR THE BETTER BETWEEN 1990 AND 2010. AGAIN, I THINK PART OF THAT IS DUE TO THIS MORE AGGRESSIVE TREATMENT OF HYPERTENSION AND CHOLESTEROL AND OTHER CARD /KWIO VASC LAR RISKS. AND THE OTHER KEY THING WE THINK THE -- THINK MIGHT BE GOING ON -- LARGE RISE IN EDUCATIONAL A ATTAINMENT IN THE UNITED STATES AND ACTUALLY AROUND /THE WORLD. YOU CAN SEE THE NUMBERS HERE THAT ABOUT 53% OF 65 PLUS FOLKS FINISHED HIGH SCHOOL IN 1990. UP TO 80% IN 2010. 11% HAD COLLEGE EDUCATION IN 199 1990. AND 23% IN 2010. SIMILAR TRENDS IN LOWER AND MIDDLE-INCOME COUNTRIES AROUND THE WORLD. AND WE THINK THAT EDUCATION PROTECT AGAINST DEMENTIA PROBABLY THROUGH LOT /OF DIFFERENT COMPLEX PATHWAYS. AGAIN, ONE THAT WE'VE BEEN FOCUS FOCUSING ON /OR INTERESTED IN /AAS OUR OTHER RESEARCHERS, THIS IDEA OF BRAIN OR COG /TPHENITIVE RESERVE, THE IDEA THAT HOW YOU USE YOUR BRAIN AND THE MORE FORMAL EDUCATION AND OTHER KINDS /OF COG NITIVE STIMULATION YOU HAVE FROM BIRTH THROUGH ACTUALLY ADULTHOOD AND MAYBE INTO OLDER AGE BUT CERTAINLY AS THE BRAIN IS GETTING WIRED UP IN THE EARLY YEARS, THAT HOW YOU USE YOUR BRAIN ACTUALLY CHANGES THE BIOLOGICAL -- BIOLOGY OF THE BRAIN AND CREATES DENSER CONNECTIONS BETWEEN NEWURONS AND GIVES YOU THE ABILITY TO SORT OF ACCOMMODATE AND ADJUST TO THE TO THE LESIONS THAT EVERYONE GETS WHEN THEY AGE SO THE PROTEINS OF ALZHEIMER'S DISEASE, FOR INSTANCE, OR VASC VASCULAR PROBLEMS. SO EDUCATION, BETWEEN, SEEMS TO HAVE THIS HUGE IMPORTANT EFFECT ON THE BIOLOGY OF THE BRAIN THAT PERHAPS MIGHT DECREASE DEMENTIA RISKS BY ALLOWING YOU TO ADJUST AND ACCOMMODATE BETTER. BUT AGAIN, THERE IS ALSO SOME OTHER THINGS THAT EDUCATION BRINGS YOU -- DIFFERENT HEALTH BEHAVES, OCCUPATION, HOW YOU USE YOUR BRAIN DURING YOUR ENTIRE WORKING LIFE IS DIFFERENT FOR PEOPLE WITH MORE EDUCATION. LEISURE ACTIVITIES AND SOCIAL NETWORK, ET CETERA. SO I DON'T THINK IT'S ALL ATTRIBUTABLE JUST TO THIS IDEA OF COG /TPHENITIVE RESERVE. THERE IS CERTAINLY LOTS OF OTHER THINGS GOING ON. BUT IT DOES SEEM THAT EDUCATION IS VERY PROTECTIVE AGAINST OR DECREASES DEMENTIA RISKS. SO WITH THAT IN MIND, JUST IN THE LAST TEN MINUTES SOR O-- OR SO /TTELL YOU THE STUDY WE'VE DONE TO LOOK AT /THIS ISSUE, THAT CHANGE IN DEMENTIA RISK OVER TIME. THESE ARE OUR QUESTIONS. WHAT'S THE TREND OF PREVALENCE IN THE COG /TPHENITIVE IMPAIRMENT IN THE U.S. AMONG THE 70 PLUS POPULATION? AND ALSO WHAT'S THE TREND IN MOR MORTALITY AMONG THOSE WITH COG NITIVE IMPAIRMENT? SO ONE OF THE ASPECTS OF THE COG NITIVE RESERVE HYPOTHESIS IS THAT NOT ONLY DO YOU DECREASE YOUR RISK BUT YOU ACTUALLY PUSH OUT -- YOU DECREASE THE AMOUNT OF TIME WITH DEMENTIA. SO YOU SORT OF PUSH OUT OR COMPRESS TOWARD THE END OF LIFE THE ONSET OF DEMENTIA SO THE TEST -- TO TEST THAT HYPOTHESIS, WE LOOKED AT THE QUESTION OF AMONG THOSE PEOPLE WITH COG /TPHENITIVE IMPAIRMENT, ARE MORE EDUCATED PEOPLE OR IS THERE A TREND TOWARD QUICKER DEATH ONCE THEY HAVE COG /TPHENITIVE IM IMPAIRMENT ONSET LATER BUT LESS TOTAL TIME WITH DEATH? I'LL SHOW YOU SOME OF THE DATA ABOUT THAT. SO AGAIN, I THINK MOST PEOPLE IN THE ROOM KNOW ABOUT THE HEALTH AND RETIREMENT STUDY BUT FOR THOSE OF YOU THAT DON'T, ABOUT 25,000 AMERICAN AGED 51 PLUS ACTUALLY THAT WE'VE BEEN FOLLOWING FAIR WHILE BASED AT THE INSTITUTE FOR SOCIAL RESEARCH, AS YOU KNOW AGAIN FUND FUNDED BY NIAA SINCE 1990 WITH SOME FUNDING FROM THE SOCIAL SECURITY ADMINISTRATION. WE COLLECTED LOTS OF DATA AND DID HALF OF THE INTERVIEWS FACE TO-TO-FACE, HALF BY TELEPHONE. ALL THE DATA ARE PUBLICLY AVAILABLE. PEOPLE CAN DOWNLOAD THE DATA DIRECTLY TO THEIR COMPUTER. THERE HAS BEEN MORE THAN 2,000 PUBLICATIONS. THIS MIGHT BE A LITTLE OUT OF DATE NOW. 1500 AUTHORS, MORE THAN 14,000 DATA USERS. AND FOR SOME OF THE SURVEY CONTENT, FOR THOSE OF YOU WHO DON'T KNOW, RELEVANT TO /THE PRESENTATION HERE, WE ASK ABOUT PHYSICAL AND FUNCTIONAL HEALTH, DO COG /TPHENITIVE TESTING IN ADDITION TO /TTHAT MORE INTENSIVE COG NIT NITIVE ASSESSMENT, WE DID AN ADAMS. THERE IS GREAT LINKS TO ADMINISTRATIVE DATA, THE MED MEDICARE NATIONAL DEATH INDEX ACTUALLY LINKING TO THE VA HEALTHCARE SYSTEM FOR ABOUT 7 7,000 VETERANS IN THE H /R-FPRS. AND THEN SINCE 2006, BECOME A LOT MORE BIOLOGICAL. WE'VE COLLECTED BLOOD SPOTS AND GENETICS -- GENETIC INFORMATION ON THE SAMPLE. AGAIN, A LITTLE -- MOST OF YOU KNOW THIS. HERE IS THE DESIGN OF THE SAMPLE SAMPLE. ACTUALLY STARTED IN 1992 AS THE STUDY JUST OF PEOPLE 51 TO 61 AND ADDED AN OLDER COHORT IN '93 '93. BY 1998, SORT OF FILLED IN THE MISSING AGE THERE. SO SINCE 1998 HAS BEEN REPRESENTATIVE OF THE 51 POPULATION AND HAVE BEEN FOLLOWING PEOPLE EVERY OTHER YEAR, ENROLLING IN NEW 41 TO 60 60-YEAR-OLD COHORT. EVERY SIX YEARS WE DID THAT IN 2010 WITH THE MID BOOMERS AND WILL DO THAT AGAIN IN 20 IT 16 WITH THE LATE BOOMERS. I STARTED WORKING WITH FOLKS WITH THE DATA IN 1997 WHEN I WAS 34 AND I THOUGHT OF EVERYONE AS OLD PEOPLE THAT I WAS STUDYING. AND FOUR MONTHS AGO I BECAME HE WILL GIBLE FOR THE H /R-FPRS SAMPLE SO I'M NOW 51 YEARS OLD. HERE IS WHAT WE HAVE IN THE HRS THAT ALLOWS US TO FOLLOW BRAIN HEALTH OR HOW PEOPLE ARE THINKING OVER TIME. AGAIN, WE DO A COG /TPHENITIVE ASSESS ASSESSMENT AT EVERY WAVE THAT HAS THOSE COG /TPHENITIVE TESTS THAT ARE THERE. ALSO DO SOME THERMAL FLUENCY TESTING NUMBERS HERE AND HOW QUICKLY PEOPLE PROCESS SOME OF THESE THINGS. IMPORTANT, ABOUT 10% OF THE HRS SAMPLE INTERVIEWS ARE DONE BY PROXY, BECAUSE SOMEONE EITHER WON'T OR CAN'T DO THE INTERVIEW THEMSELVES. THAT'S OBVIOUSLY AN IMPORTANT ASPECT OF DATA COLLECTION FOR PEOPLE WITH DEMENTIA SO WE USE INSTRUMENTS, THE IQ CODE IN ADA THAT INDICATE WHETHER WE ASK SOMEONE ELSE YOU WHO -- HOW THEIR MEMORY IS DOING AND HOW THEY ARE ABLE TO GET THROUGH THE DAY THROUGH VALIDATE VALIDATEED PROXY INSTRUMENTS AND THEN SOME OF THE OTHER INFORMATION THAT IS AVAILABLE TO TRACK THE BRAIN HEALTH. WE ASK PEOPLE TO ACCESS -- ASSESS IT THEMSELVES. HOW THEIR MEMORY HAS CHANGED OVER /THE /HRAFLAST COUPLE /-OF YEARS? HAS THE DOCTOR TOLD YOU THAT YOU HAD ALZHEIMER'S DISEASE? SOME OF THESE PROTECTIVE AND RISK FACTORS. CARD /KWRO /SRAFIOVASCULAR RISKS WE TALKED ABOUT. ACUTE MEDICAL EVENTS. HOW DO SERIOUS ILLNESS ACUTE AFFECT THE BRAIN AND COGNITION LONG TERM? WE'VE GOT INFORMATION FROM THE DATA THAT ALLOWS US TO DO THOSE KINDS /OF ASSESSMENTS ALSO. AGAIN, AS MANY OF YOU KNOW, THIS QUESTION OF WHAT IS HAPPENING TO THE DEMENTIA TRENDS AROUND /THE WORLD AND LOW AND MIDDLE-INCOME COUNTRIES? THERE HAS A STUDY PATTERNED AARP THE H /R-FPRS. SO /-MANY OF THESE STUDIES ARE STARTING TO LOOK MORE COG NITIVE DATA AND DEMENTIA TRENDS WILL. JUST BRIEFLY AGAIN TO TELL ABOUT OUR STUDY THAT TRIED /TO COMPARE COG /TPHENITIVE -- THE PREVALENCE OR RISK OF COG /TPHENITIVE IMPAIRMENT IN 1993 AND 2002. I SHOULD SAY WE'RE IN THE PROFESS UPDATING THIS NOW THROUGH 2010. AGAIN, A BIT OF NUDGEING AND OTHERS /TPHUPLG ING ING TO LOOK AT THE MORE RECENT DATA. BUT BASICALLY WHAT WE DID WAS POOLED DATA FROM 19/-THE 3 AND 2002. WE DIE /REGRESSION MODEL WHERE THE INDICATOR IS WHETHER OR NOT SOMEONE HAS COG /TPHENITIVE IMPAIRMENT IMPAIRMENT. THEN WE BASICALLY HAVE AN INDICATOR VARIABLE ABOUT WHAT YEAR THEIR DATA COMES FROM. 1993 AND 2002 AND LOOK FOR SIGNIFICANT CHANGE IN /THIS TREND VARIABLE, THE YEAR VARIABLE BETWEEN 1993 AND 2002. AND THEN WE ADD VARIABLES TO SEE IF THERE IS A CHANGE, WHAT VARIABLES SEEM TOOK -- TO BE ACCOUNTING FOR THAT AGAIN, EDUCATION AND CARD /KWRO /SRAFIOVASCULAR RISKS ARE THE THINGS THAT WE ARE MOST THERE HAD IN. AND AGAIN WE LOOKED AT WHAT'S THE RISK OF MORTALITY, THE TWO TWO-YEAR MORTALITY AMONG THOSE WITH COG /TPHENITIVE IMPAIRMENT AND HAS THAT CHANGED BETWEEN 1993 AND 2002? HERE IS JUST THE BIG PICTURE OF THE DATA THAT WE USED. ABOUT 7400 PEOPLE IN 1993. 7100 IN 2002. AND YOU CAN SEE THE RESPONSE RATES, DEATH RATES, VERY LITTLE. LOTS TO FOLLOW UP BETWEEN THOSE OR IN THOSE COHORTS. AND THEN THIS IS PUNCHLINE. IN THE INTEREST OF TIME I AM GOING TO SHOW YOU SOME OF THE BRIEF RESULT. THIS IS IN YELLOW THE 1993 DATA. PEOPLE WITH MILD COG /TPHENITIVE IM IMPAIRMENT, MODERATE TO SEVERE COG /TPHENITIVE IMPAIRMENT. AND YOU CAN SEE BETWEEN 1993 AND 2002, THERE WAS A SIGNIFICANT DE DECLINE SO IN TOTAL FROM ABOUT 12% DOWN TO ABOUT 9% IN THE PEOPLE THAT MET OUR COG /TPHENITIVE IMPAIRMENT THRESHOLD BASED ON THE COG NIT NITIVE TESTING IN THE H /R-FPRS. IN TERMS OF THAT MORTALITY ANALYSIS, THESE ARE THE DATA HERE. IN 1993 HERE AND 2002 HERE. THE FIRST THING YOU CAN SEE IS THAT COG /TPHENITIVE IMPAIRMENT IS ASSOCIATED WITH UNCREASED RISK OF DEATHS SO GOING DOWN THE ROAD HERE, -- ROWS HERE, SOMEONE IN OUR MOD MODERATE-TO-SEVERE COG /TPHENITIVE IM IMPAIRMENT CATEGORY, OR -- ARE ABOUT TWO AND A HALF TIMES MORE LIKELY TO DIE IN THE NEXT TWO YEARS, COMPARED TO NORMAL COGNITION. AND THEN YOU CAN SEE THAT THERE WAS AN INCREASE IN THAT RISK OF DEATH AMONG THOSE WITH COG NIT NITIVE IMPAIRMENT BETWEEN 1939 AND 2002. SO FROM ABOUT TWO AND A HALF TIMES UP TO 3.1 TIMES WAS THE HAZARD RATIO. THESE WERE NOT, I SHOULD SAY, THESE WERE SORT OF BOARDERLINE STATISTICALLY SIGNIFICANT. BUT DO SORT OF AT LEAST SUGGEST THAT THERE WAS THIS DEPRESSION -- COMPRESSION IRE BIT OF COMPRESSION OF COG /TPHENITIVE MORBID MORBIDITY, THAT PEOPLE ARE -- ONCE THEY HAVE SIGNIFICANT IM IMPAIRMENT, ARE MORE LIKELY TO DIE IN THE NEXT TWO YEARS. AND THEN FINALLY, THIS WAS A TEST OF THE COG /TPHENITIVE RESERVE HYPOTHESIS. ? -- IN SOME WAYS KIND OF A BUSY SLIDE HERE. WHAT WE WERE WONDERING -- WONDERING IS THAT ARE MORE EDUCATED PEOPLE WHO ARE IN /THIS MODERATE-TO-SEVERE GROUP EVEN MORE LIKE I THINK DIE IN THE NEXT TWO YEARS COMPARED TO MOD MODERATELY-TO-SEVERELY IMPAIRED PEOPLE WHO HAVE LESS EDUCATION? AND THAT DID BECOME -- THAT PATTERN DID STRENGTHEN BETWEEN 1993 AND 2002 SO SOMEONE WITH A COLLEGE EDUCATION WAS TWO AND A HALF TIMES MORE LIKELY TO DIE -- MORE LIKELY THAN SOMEONE WITH LOWER LEVELS OF EDUCATION. SO AGAIN, AT LEAST INDIRECT SUPPORT FOR THIS COG /TPHENITIVE RESERVE HYPOTHESIS. ALL RIGHT, SO TO CONCLUDE ON OUR STUDY, I THINK WHAT WE CONCLUDE ED FROM THAT /WWAS THAT BOTH THE PREVALENCE IN MORTALITY RESULTS TOGETHER DO RUG -- SUGGEST THIS COMPRESSION OF COG /TPHENITIVE MORBID MORBIDITY BETWEEN 1993 AND 2002 -- 2004 WITH FEWER OLDER AMERICANS REACHING A THRESHOLD OF SIGNIFICANT COG /TPHENITIVE IM IMPAIRMENT AND MORE RAPID DE DECLINE. COG /TPHENITIVE FUNCTION APPEARED TO IMPROVE FACING THE CASKIO VASC VASCULAR RISKS. AS THOSE OTHER TRENDS, THERE WAS INCREASING PREVALENCE OF DIABETES AND OBESITY. BUT STILL THIS DECREASE IN COG NITIVE IMPAIRMENT DURING THIS TIME. SO WE THINK THAT MORE WIDESPREAD AND MORE EFFECT /KWREUIVE TREATMENT OF HYPERTENSION AND HIGH CHOLESTEROL MAY BE HELPING TO PROTECT BRAIN HEALTH THE IN THE UNITED STATES. THE IMPORTANCE OF EDUCATION FOR COG /TPHENITIVE HEALTH SUGGESTS THAT EARLY LIFE NON-MEDICAL FACTORS MAY BE IMPORTANT IN LIMITING DEMENTIA AMONG THE GROWING NUMBER OF OLDER ADULTS. I SEEM TO BE RUNNING OUT /OF TIME TIME. BUT I WILL SHOW YOU REAL BRIEFLY SOME WORK PEEVE -- WE'VE DONE TO SHOW, LOOKING AT THE ACUTE ILLNESSES AND HOW THEY MIGHT AFFECT COG /TPHENITIVE IMPAIRMENT, ALSO I THINK SHOWS THE VALUE OF THE HEALTH AND RETIREMENT STUDY WITH THESE LINKED /H-PGD DATA TO HAVE A LONGITUDINAL DESTROYED.^ WE HAVE INFORMATION FROM MED MEDICARE ABOUT ACUTE ILLNESSES. WE TRIED /TO LOOK AT AND A COLLEAGUE OF MINE IN MICHIGAN LED THIS WORK, WAS LONG TERM COG NITIVE IMPAIRMENT AND FUNCTIONAL DISABILITY AMONG SURVIVORS OF SEVERE ACCEPTANSEPSIS, WHICH RESULTS FROM AN OVERWHELMING INFECTION THAT SORT OF MANY OF THE ORGANIORGAN SYSTEMS OUT /-OF THE -- OF THE BODY OUT /OF WHACK. ABOUT 50% DIE SO AMONG THE 50% THAT SURVIVE, HOW ARE THEIR BRAINS AND BODIES WORKING LONG TERM? AND SO WE USED THE LINKED DATE WRFROM THE HEALTH AND RETIREMENT /STKPOEUTD COG NITIVE DATA HERE. SO WHAT'S GOING ON HERE IS THAT AGAIN, THESE ARE FOLKS WHO HAVE MILD COG /TPHENITIVE IMPAIRMENT, MOD MODERATE-TO-SEVERE IMPAIRMENT. THESE ARE THE WAVES BEFORE ACCEPTANSEPSIS, THE TWO WAVES HERE IN THE GRAY BOX ARE THE WAVES AFTER ACCEPTANSEPSIS. AND WE DEFINE ACCEPTANSEPSIS USING THE MEDICARE DATA THAT ARE LINKED IN WITH THE H /R-FPRS. SO THERE IS THIS HUGE INCREASE IN PREVALENCE OF COG /TPHENITIVE IM IMPAIRMENT AMONG THE PEOPLE THAT HAVE ACCEPTANSEPSIS BEFORE AND AFTER. AND THEN ALSO DID SOME MODELS HERE /TO FOLLOW PEOPLE BEFORE AND AFTER THEIR ACCEPTANSEPSIS EPISODE, LOOTING THEIR RATES OF COG NIT NITIVE IMPAIRMENT. SO BEFORE ACCEPTANSEPSIS, AS PEOPLE PAGE -- AGE, THERE WAS AN /EUINCREASING LIKELIHOOD OF COG /TPHENITIVE IM IMPAIRMENT. BUT THEN YOU CAN SEE AT THE SIM -- TIME OF ACCEPTANSEPSIS, THIS BIG HIT TO THE /SPWRAOEUPB GET THIS A ACUTE INCREASE IN RISK RELATED TO ACCEPTANSEPSIS OF COG /TPHEUNITIVE IM IMPAIRMENT. BUT THEN AGAIN INTERESTINGLY AFTER ACCEPTANSEPSIS, FOR PEOPLE THAT HAVE RECOVERED, EVEN OUT FOUR OR FIVE OR SIX YEARS, THERE SEEMS TO BE AN ONGOING RISK OF IM IMPAIRMENT /SWROFPLT YOU HAVE A SORT OF STEEP ER DECLINE COG NIT NITIVE FUNCTION POST ACCEPTANSEPSIS. DYING LOT /OF RESEARCH AS TO WHAT PUT SOMEONE ON THAT KIND OF TRA TRA/SKWREBJECTORY AFTERWARD /SWROFPLT TO CONCLUDE, WE THINK THAT DEMENTIA HAS A SOCIAL AND ECONOMIC IM/PABPACT AS LARGE AS HEART DISEASE CANCER AND IM/PABIMPACT WILL LIKELY CLEOD -- EXPLODE IN THE NEXT 40 YEARS DUE TO THIS LARGE INCREASE IN OLDER ADULTS AROUND /THE WORLD. IT DEMENTIA AFFECTS FAMILIES, ESPECIALLY WOMEN MORE THAN OTHER CHRONIC DISEASE. THE DECLINE IN THE /TPAEFAMILY CARE CAREGIVERS MAY LEAD IT A CARE GIVING PERFECT /STRORPL SEVERELY STRAINING TEAMS AND PUBLIC PROGRAMS AS DEMENTIA CASES GROW. INCREASING LIFE-LONG EDUCATIONAL OPPORTUNITIES, MAY HELP LIMIT THE GROWING SOCIETAL IM/PABGPACT OF DEMENTIA OBVIOUSLY, I WANT TO THANK OUR ANIAA FAMILY FOR ALL THE YEARS OF SUPPORT ON THE HEALTH RETIREMENT STUDY AND FUNDING THAT WE'VE GOTTEN FROM NIAA THAT SUPPORT AID LOT OF WORK HERE AND OTHERS THERE. THANK YOU VERY MUCH FOR YOUR ATTENTION. WE'VE GOT TIME FOR QUESTIONS, IF ANYONE HAS THEM. /PHRA [APPLAUSE] >> THANKS. AND I AM GOING TO HAND THIS AND ASK PEOPLE BECAUSE THIS IS BEING RECORDED FOR WEB. IF I GET TO START OFF, YOU MENTIONED THE ISSUE OF DIFFERENT INCIDENTS FOR MEN AND WOMEN, AND OBVIOUSLY, THE MAJOR THING IS THE DEMOGRAPHIC DIFFERENCE OF WHO LIVES LONGER. BUT ARE AT ANY GIVEN AGE ARE WOMEN MORE LIKE I THINK GET DEMENTIA THAN MEN? >> THERE HAS BEEN A LOT /OF PUBLICITY ABOUT THIS. >> I DON'T THINK I'M THE BEST EXPERT IN /THIS AREA. AGAIN, MY SENSE RIGHT NOW IS THAT THE DATA SUGGESTS THAT THERE ISN'T A SIGNIFICANT GENDER RISK. ALTHOUGH I KNOW THERE IS SOME STUDIES ARE SHOWING. I THINK THERE ARE SOME ENDOCRINE HYPOTHESES ABOUT WOMEN'S RISKS, CARD /KWRO /SRAFIOVASCULAR. WHAT'S YOUR SENSE RIGHT NOW? >> WELL, THERE HAS ALWAYS BEEN A DIFFERENCE BETWEEN WHAT'S GOING ON IN EUROPE AND WHAT HAS BEEN GOING ON IN THE UNITED STATES. MANY OF THE EP STUDIES HERE HAVE NOT SHOWN IMPORTANT SEX GENDER DIFFERENCE IN RISK. BUT I THINK THERE IS MORE SENSE WRIST TO THE TOP /KWREUIC AND WHAT WE MIGHT LOOK TO IS WHETHER THERE IS A NON-STATISTICAL SIGNIFICANTLY. AND FOR EXAMPLE, ERIC LARSON, WHO JUST PUBLISHED AN ARTICLE IN THE AMERICAN PUBLIC OF JOURNAL HEALTH IN JULY. AND IF YOU LOOK AT THE RESULTS THERE, IT DOES SHOW A HIGHER AGE AGE-SPECIFIC RISK FOR AL ALZHEIMER'S IN WOMEN. IT'S -- AS FAR AS I CAN TELL, IT'S NOT STATISTICALLY SIGNIFICANT BUT IT HOLD FOR 80 TO 85, 85 TO 9 1K30 90 AND ABOVE. AND SO IT WOULD BE INTERESTING TO SEE WHETHER WE HAVE THOSE KINDS /OF SIGNALS IN OTHER STUDIES. WE'RE BASICALLY SAYING WELL, THE STATISTICAL SIGNIFICANCE IS NOT THERE, BUT WE'RE FINDING THE SIGNAL EVERYWHERE AND I THINK WE SHOULD PAY ATTENTION TO THEM. >> JUST TO /ADD ONE THING. IN A COUPLE OF THE EUROPEAN, IN PARTICULAR, WHERE WE'VE BEEN ABLE TO LOOK AT VARIOUS COHORT DIFFERENCES OUTCOMES OF COG NIT NITIVE LEVEL IN MIDDLE AND OLDER AGE, THERE ARE SOME OF THE DIFFERENCES PREVIOUSLY SEEN BETWEEN MEN AND WOMEN AND COLLAPSED OAF TIME. THIS ACTUALLY IS DUE TO DIFFERENCE S S IN EDUCATIONAL A ATTAINMENTMENT SO IF THAT WERE THE STORY, THEN WE WOULD BE EXPECTING TO SEE KIND OF THE DATA THAT YOU WERE SUGGESTING TO /TTHAT LARSON WAS FINDING THAT SOME OF THE DIFFERENCES IN THE U.S. BUT ALSO MOSTLY IN OLDER AGES. >> RIGHT. THAT REMINDS ME. JING COOK LI LED A PAPER USING THE PILOT DATA FROM LASSI /SKWHRORBGS LOOKED AT COG NITIVE FUNCTION IN /EUPINDIA. FEMALE EDUCATIONAL ATTAINMENT IS SIGNIFICANTLY DIFFERENT THAN MEN MEN, ESPECIALLY IN /THIS COHORT AND DID SEE AGAIN THIS GREATER RISK AMONG WHIM YOU CONTROL FOR EDUCATION, MOST OF THAT GOES A AWAY. THERE IS ALSO A QUESTION OF DISCRIMINATION AGAINST WOMEN IN DIFFERENT PARTS OF INDIA. SO LOOKING AT /TTHAT WITH SOME OF THE LASSI DATA. YEAH, IMPORTANT TOP /KWREUIC, I THINK. >> THANK YOU FOR THE SPEEDY DELIVERY. >> THOSE BASKETBALL SKILLS /STKWHROEURBGS. >> IN THE NEW ENGLAND JOURNAL PAPER, ONE OF THE KEY ISSUES WAS HOW /TO VALUE INFORMAL CARE GIVING TIME. AT AN INDIVIDUAL CAREGIVER'S OWN RATE OF EARNINGS OR THE RE REPLACEMENT COSTS OF GETTING THAT SERVICE IN THE PRIVATE SECTOR. THAT'S AN IMPORTANT ISSUE IN ITSELF. IT'S KIND OF AN INTERESTING QUESTION. HOW SHOULD WE VALUE IT? IF WE ASSUME THAT THE LOW RATE OF VALUE RATE IS /THE REPLACEMENT COST OF THE SERVICES, THEN A RELEVANT THING I WANT TO EMPHASIZE FOR ANY WORK IN THE FUTURE, IF WE ARE PROJECTING FUTURE COSTS OR FUTURE ECONOMIC BURDENS, OF CARING FOR /AA DEMENT DEMENTED PERSON, WE SHOULD EXPECT A RELATIVE PRICE OF THOSE SERVICES TO CRANIUS AT A DIFFERENTIAL LY RAPID RATE. SIMPLY BECAUSE IT'S A VERY LOW PRODUCTIVITY GAIN ACTIVITY. IT DOESN'T -- DOESN'T LEND ITSELF TO INCREASES THAT ALLOW US TO THINK OF /AA DECLINE IN PRICES. SO I THINK IN SOME WAYS WE POSSIBLY UNDERSTATE, EVEN IF WE ENTER A GOLDEN ERA WITH LOWER INCIDENCE OF DEMENTIA ON AN AGE- AGE-ADJUSTED BASIS, WE SHOULD EXPECT THE COST TO POSSIBLY SPIRAL IN WAYS JUST BECAUSE -- THINK OF IT AS THE SPOT PRICE OF ATTRACTING WORKERS. >> YEAH. GREAT POINT. >> SO I HAVE A QUESTION. SO GIVEN ALL THE WORK YOU'VE BEEN DOING, WHAT WOULD YOU REALLY RECOMMEND THAT WE PUT IN PLACE POLICY WIWISE TO MITIGATE THE RISKS AS WE ALL AGE WITH HIGH EDUCATIONAL LEVEL? >> YEAH, GREAT QUESTION. WE WERE HAVING THOSE KINDS OF DISCUSSIONS THE /HRALAST DAY /OOR SO. I WAS SAYING TODAY THAT I WOULD GIVE A GRAND ROUNDS AT THE MEDICAL CENTER AT THE UNIVERSITY OF /PHUFPD EARLIER THIS /KWRAYEAR AND DIDN'T MAKE A LOT /OF FRIENDS RAISING THE POSSIBILITY THAT MAYBE WE SHOULD BE REALLOCATING A GOOD CHUNK OF HEALTHCARE DOLLARS TOWARDS EARLY LIFE EDUCATION AND KEEPING EVERYONE'S BRAINS, BOTH EXPENDING OPPORTUNITIES ACROSS THE SOBCIO SOCIOECONOMIC SPECTRUM FOR EDUCATION. BUT WE WERE TALKING ABOUT LAST NIGHT ALSO SOME OF THE EARLY LIFE TRAINING PROGRAMS THAT SEEM TO ALSO BE -- SEEM TO HAVE SOME LONG TERM, BOTH HEALTH, PHYSICAL HEALTH, MENTAL HEALTH BENEFITS LONG TERM SO THAT'S A REAL EASY POLICY THING TO DO. JUST PICK HALF A TRILLION DOLLARS FOR HEALTHCARE AND PUT IT INTO EDUCATION. I'M SURE THAT ONE -- WOULD BE ONE THING. I MEAN MORE SERIOUSLY, I DO THINK STARTING TO THINK ABOUT EDUCATION TRAINING, COG /TPHENITIVE TRAINING THROUGHOUT THE LIFE AS A HEALTHCARE INTERVENTION AND THINKING ABOUT -- THE QUESTION, WHICH I SORT OF WAVED MY HAND AT A LOT HERE, WHICH IS WHAT IS ACTUALLY EDUCATION? WE COUNTED UP THE YEARS SOMEONE SAID THEY WERE IN SCHOOL. WHAT WERE THE ACTIVE INGREDIENTS OF EDUCATION ARE THOSE THINGS THAT WE CAN DELIVER, AGAIN BOTH TO LOW SOBCIOECONOMIC STATUS BOTH THE UNITED STATES AND MIDDLE MIDDLE-INCOME COUNTRIES. BUT I DO THINK, AGAIN, TO ME THE EVIDENCE IS GETTING CLEARER THAT THAT IS AN IMPORTANT PREVENTED MEASURE FOR AND FOR IMPROVING BRAIN HEALTH AS WELL AS PHYSICAL HEALTH, TOO.^ SO AGAIN THE POLITICS OF THAT I'LL LEAVE TO YOU ALL FOR FOLKS IN THE OTHER PART OF THE CITY. BUT I THINK A DEBATE ABOUT THAT OR THINKING ABOUT THAT IS IMPORTANT. I ALSO TALK ABOUT THIS OVER /THE LAST DAY, PHYSICAL ACTIVITY IN THE CARD /KWRO /SRAFIOVASCULAR RISK FACTOR WITH MY PATIENTS THAT REALLY EMPHASIZED PHYSICAL ACTIVITIES IS /THE ONLY GOLDEN BULLET I THINK THAT WE HAVE IN HEALTHCARE HEALTHCARE. THERE IS ALMOST NO SIDE EFFECTS, OTHER THAN PEOPLE FALLING AND BREAKING THEIR HIP OR SOMETHING LIKE THAT. BUT I DO THINK CREATING ENVIRONMENTS, NEIGHBORHOODS WHERE PEOPLE ARE ABLE TO WALK MORE AND JUST INCREASING OVER A LEVEL OF PHYSICAL ACTIVITY WOULD HAVE A HUGE BANG FOR THE BUCK. >> TWO MORE QUICK QUESTIONS. ONE FROM BARBARA? >> I'M INTERESTED, GIVEN YOUR RESULTS SO /TPFAR. WHAT DO YOU THINK NIH SHOULD BE FUNDING IN THE NEXT TEN YEARS, GIVEN WHAT YOU'VE ALREADY DONE? >> AGAIN, I DO BELIEVE THE RESULTS ABOUT THE ECONOMIC IM/PABPACT AND QUALITY OF LIFE OF AGING-RELATED DISEASE, SPECIFICALLY DEMENTIA. TO ME, THIS LONG TERM CARE -- THIS QUESTION OF LONG TERM CARE OF WHAT -- HOW WE'RE GOING TO BE TAKING CARE OF THESE OLDER FOLKS TO ME IS JUST THE PUBLIC POLICY ISSUE SO SORT OF RESEARCH-RELATED TO -- AND HOW DO FAMILIES ALLOCATE CARE? HOW ARE THEY DEALING WITH GROWING CARE GIVING NEEDS? WHAT'S THE IM/PABPACT ON THEM, BOTH POSITIVE AND NEGATIVE? WHAT ARE THE FUNDING MECHANISMS? WHAT'S THE PUBLIC POLICY RESPONSE WE NEED TO THINK ABOUT FOR BOTH HOME-BASED AND INSTITUTIONAL CARE? TO ME THOSE ARE THE -- ON THE POLICY SIDE, THOSE ARE HUGE LY IMPORTANT THINGS. AND JUST FROM THE BIOLOGY SIDE, AGAIN THIS IDEA OF WHAT IS THIS LINK BETWEEN CARD /KWRO /SRAFIOVASCULAR RISKS AND DISEASE AND THE BRAIN JUST GROWING THROUGH OCCUPANCY -- AUTOPSY STUDIES AND POPULATION BASED OF AUTOPSY STUDIES? WE'VE GOTTEN A BETTER SENSE /OF THIS EFFECT THAT MOST DEMENTIA IN OLDER FOLKS IS NOT JUST AL ALZHEIMER'S DISEASE, BUT A MIX MIXTURE AND THE INTER/AOBACTION, I THINK, SORTING OUT THOSE COMPLEX INTER/AOBACTIONS, WOULD AGAIN PAY OFF SIGNIFICANTLY, TOO. >> THANK YOU. AND DALLAS ANDERSON IS GOING TO END ON A LITTLE EASY QUESTION. >> WELL, I WAS JUST THINKING ABOUT THE FACT THAT WE ALL HAVE TO DIE OF SOMETHING, RIGHT? AND IF YOU STARTED THINKING ABOUT LEADING CAUSES OF DEATH AND WHAT HAPPENS IF WE WIN THE WAR ON /SKPAERPBTS WAR ON HEART DISEASE AND THE WAR ON STROKE? CANCER. WHERE DOES THAT LEAVE US IN TERMS OF ALZHEIMER'S? >> YEAH. AND AGAIN, WE WERE TALKING ABOUT THIS A BIT AT LUNCH. TO ME IS THAT -- THE QUESTION OF THE COMPRESSION OF MORBIDITY. WHAT ARE THE STRATEGIES? DOES EDUCATION IM/PABPACT OR PUSH DEMENTIA OR ALZHEIMER'S DISEASE OUT CLOSER WITH WITH THE TIME OF DEATH? IF WE DO SHALL DID TWO OF THESE OTHER THINGS, WOULD THAT STILL BE THE CASE OR WOULD PEOPLE STILL BE LIVING LONGER YEARS WITH DEMENTIA? I DON'T HAVE A PERFECT ANSWER FOR THAT, OTHER THAN TO SAY IF WE DO FIND, WE SHOULD BE SEARCHING FOR THOSE KINDS /OF INTERVENTIONS -- AND THIS IS PRETTY OBVIOUS, BUT LONGER LIFE WITH THE SAME AGE OF ONSET OF DEMENTIA WOULD BE PROBABLY PRETTY BAD IN MANY WAYS, BOTH FROM QUALITY OF LIFE AND COST. SO AGAIN, KEEPING THAT COMPRESSION -- IS DISABILITY BEING COMPRESSED OR -- BOTH FROM THE FUNDING OF RESEARCH AND THE RESEARCH THAT WE'RE DOING BUT YEAH, SO IT WILL BE A COMPLICATED BUT INTERESTING, FAS FASCINATING RIDE OVER /THE NEXT 2020 YEARS, AS THESE THINGS PLAY OUT, I THINK. >> KEN, THANK YOU VERY MUCH FIRE WONDERFUL TALK AND FOR ENDING ON A GREAT NOTE FOR US, STARTING THE WEEKEND. AND I HAVE TO SAY IN FUTURE WE'RE GOING BACK TO THE OLD POLICY OF PEOPLE WITH QUESTIONS, WALK DOWN AND ASK IT THERE. THANK YOU. /PHRA