Sharon Ostwald, PhD and Jennifer Larson, MSE Division of Geriatrics and Palliative Medicine The University of Texas Health Science Center at Houston

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 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 Aging Older Populations Will Increase More Rapidly in Developing than in Developed Countries Population Aging is Determined by Two Factors:  Birth rates  Death rates

Percent Increase in Population Aged 65 & Over: 2008 to 2040 Japan, 30% United Kingdom, 66% United States, 107% China, 209% India, 274% Singapore, 316% 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 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 is Increasing 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 at Birth for Selected Countries by Region: 2008 Costa Rica Chile Argentina Uruguay Mexico Jamaica Brazil Colombia Peru Guatemala United States 70.4
70.0
76.5
76.1
75.8
77.4
77.2
73.0
72.5
72.5
Developing Countries Developed Countries 78.1
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.

Age Expectancy at Age 65 in US 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

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 Over in 29 Countries/Areas: Circa 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.

Disparities Exist Between Urban and Rural People Aged 65 and Over AGING INDEX is an indicator of the age structure in a country. Higher numbers = more older people  China = 31   Northern Africa = 16 Northern America = 65

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 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 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 33.0
Poor Health Conditions 26.0
Good Health Conditions 37.0
22.5
Cities* Puerto Rice *Cities include Bridgetown, Barbados; Buenos Aires, Argentina; Havana, Cuba; Mexico City, Mexico; Montevideo, Uruguay; Santiago, Chile; & Sao Paulo, Brazil 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.

Important Role of Geriatric Health Professionals is to Maintain Functional Independence and Prevent Excess Disability WHO (2002) Active Aging: A Policy Framework. Geneva: World Health Organization .

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. 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 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.

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) 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.

Health Promotion Needs to be a Major Focus for Geriatric Health Professionals         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

Social, Physical & Economic Environments Affect Healthy Aging

Living Arrangements for People Aged 65 and Over in Japan (in percent) 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.

Reasons for Geriatric Professionals to Focus on Health Promotion and Disease Prevention       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

Warning Signs of the Aging Tsunami       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

Global Population Pyramid in 2002 & 2025 WHO (2002) Active Aging: A Policy Framework. Geneva: World Health Organization.

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 aged How long do people live? The biological theories
of aging
What is “normal” aging? The physiology of aging What illnesses effect elders most? Common
geriatric syndromes
Can late life really be enjoyable? The role of
behavioral factors
What will my quality of life be like? A glimpse at
“Successful” Agers

Ageism “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

Myth or Fact?
 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

Normal versus Pathological Aging

Physiologic Changes Associated with Aging      Heart & Lungs Brain Kidney & Bladder Body Fat & Bone Sensory Organs

What is Normal?
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

Kidney and Bladder What is Normal?
  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.

Body Composition Changes with Age
70 60
AGE
50 40 30 20 10 0 water fat lean bone age 29 age 70

What is Normal?
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.

Changes in Sleep Associated with Aging • Less time in stage 3 and 4 sleep (deep sleep) • Increased insomnia • Increased nighttime arousals

The Dichotomy 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 Effect of Age on Variability Between Individuals    Organ System Functions Age 

Most Common Chronic Medical Conditions of Older Adults     Arthritis Hypertension Hearing Impairment Heart Disease      Orthopedic Impairment Chronic Sinusitis Diabetes Cataracts Other Visual Impairment

Number of People with Chronic Conditions
180 160 140 120 100 80 60 40 20 0 99 105 112 120 134 148 158 1995 2000 2005 2010
Years
2020 2030 2040
Source: The Robert Wood Johnson Foundation (1996), Chronic Care in America: A 21
st Century Challenge

Percent of Individuals Limited in Activities Because of Chronic Conditions, By Age Group
70 60 50 40 30 20 10 6 10 23 34 43 56
Prevalence of chronic illness and likelihood of disability increase with age.
0 <18 18-44 45-64 65-74 75-84 85+ Age Groups
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.

Healthy Quality Living: The Role of Exercise and Nutrition How is Health Different for an Older Adult?
 Multiple coexisting diseases and conditions to manage.
 Multisystem geriatric syndromes: e.g., gait instability, dizziness, and weight loss.

Physiologic Demand and Reserve Physiologic Function Usual Reserve Demand Optimal Reserve Increased margin of reserve with good health care and self care Age

Staying Healthy: Exercise  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.
CDC (2003)

The Role of Exercise in the Compression of Morbidity AGING Muscle Wasting Physical Activity Morbidity Modified from Nair, S. Am J Clin Nutr, 2005.

Muscle Wasting Muscle Weakness CVD
Modified from Nair, S. Am J Clin Nutr, 2005.
Fatigability Endurance Capacity Physical Activity
Energy Expenditure Obesity Insulin Resistance
Type 2 DM Dyslipidemia

Staying healthy: Nutrition “
Jean Anthelme Brillat-Savarin   Two greatest nutritional problems:  Malnutrition  Obesity Nutritional needs change in late life  Special Considerations  Energy Intake

Special Considerations      Difficulty chewing Upset stomach Shopping & transportation Disease Decreases in olfactory senses     Difficulty cooking Loss of appetite Medications Finances

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

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 Soluble Fiber Sources Insoluble fiber is found in foods such as whole wheat and whole grain products, vegetables, and wheat bran Insoluble Fiber Sources     Fiber sources: GREAT: Legumes, Beans, Bran GOOD: Fruits and Vegetables, Whole Grain, Breads and Cereals FAIR: Cereals (oats) POOR: Chocolate

Nutritional Needs: Fluid FLUID Sources  GREAT: Beverages, milk, coffee, water  GOOD: Fruit juices, soups, ice cream   FAIR: Soft drinks, watermelon POOR: Vegetables/fruits

Psychological Health

Normal Mental Function in Older Adults Cognitive function includes    Intelligence Language Learning    Memory Decision-making Planning

What Changes      Short-term memory Recall Speed of mental processing Learning involving physical coordination and strength Distractibility

What Does Not Change    Capacity to learn Ability to draw on experience Vocabulary

Mental Disorders Mental disorders are not a part of normal aging Any anxiety disorder Any mood disorder Severe cognitive impairment Any mental disorder 18-54 yrs 16.4% 7.1% 1.2% 21.0% 55+ yrs 11.4% 4.4% 6.6% 19.8% http://www.surgeongeneral.gov/library/mentalhealth/home.html

Depression    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

Delirium 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 Dementia     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

Dementia Is not a Normal Part of Aging  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.

Forgetting vs. Dementia    Everyone experiences forgetting Many people exaggerate the importance of forgetting Many also ignore the signs of memory loss and fail to recognize developing illness

Predictors of Strong Mental Function     Education Physical activity and lung function Strong social support High self-efficacy We can grow and change throughout life Old dogs can and do learn new tricks!
MacArthur Foundation Study, Rowe & Kahn 1999

Substance Abuse and Elders —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.

Signals that may indicate a substance abuse problem:     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

Because Metabolism Slows in the Aging Body :

Alcohol comes in many forms
NyQuil contains an active ingredient of 25% alcohol, the same as 50 proof booze.

Mixing Alcohol with Drugs
+ =

Why are older adults at risk to abuse substances and/or medications?

Risk Factors          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

Other 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

Successful Aging
“Age is not a particularly interesting subject. Anyone can get old.
All you have to do is live long enough.” —Groucho Marx (1890-1977)

Centenarians 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 Gough She outlived her husband, daughter and only grandson

Centenarian Characteristics       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

Photo Credit: Melanie Stetson Freeman Beating the Odds     (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 Source: Perls T., Silver M., Lauerman J, 1998

To Summarize…      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.

References           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 (3 rd 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 (3 rd 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. (1 st ed.). New York: Macmillan References USA. P458-467.
Geriatric Review Syllabus, American Geriatric Society. 5 th 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

Credits Photographs use for the cover are allowed by the morgueFile free photo agreement and the Royalty Free usage agreement at Stock.xchng. They appear on the cover in this order: Wallyir at morguefile.com/archive/display/221205 Mokra at www.sxc.hu/photo/572286 Clarita at morguefile.com/archive/display/33743 MorgueFile images used: Slide 35: http://morguefile.com/archive/display/151713 Microsoft Powerpoint Images and Clipart: Slides: 22, 41, 45,46,47,52, 54, 65, 71, 73, 84, 85, 88, 89, 91, 95, 100 Stock.xchng imaged used: Slide 40: http://mrg.bz/kc2j3F Slide 98: http://www.sxc.hu/photo/1124775 All other images are credited with the photograph.