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VA RESEARCH QUARTERLY UPDATE
 

A Chat with Our Expert

Reflections on the VA Normative Aging Study


Dr. Avron Spiro
Dr. Avron Spiro, with VA and Boston University, has been an investigator on VA's Normative Aging Study since 1986, looking at the influences of health and disease on the aging mind, and conducting long-term examinations of personality, well-being, and mental health. (Photo by Steve Miller)

Dr. Avron Spiro, with VA and Boston University, has been an investigator on VA's Normative Aging Study since 1986, looking at the influences of health and disease on the aging mind, and conducting long-term examinations of personality, well-being, and mental health. (Photo by Steve Miller)

Dr. Avron (Ron) Spiro is a senior research career scientist with the Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), and a research professor in epidemiology and psychiatry at the Boston University schools of Public Health and Medicine. In 1986, he joined the VA Normative Aging Study (NAS) as a research psychologist and methodologist. Spiro, who collaborates with researchers at the Center for Healthcare Organization and Implementation Research at the Bedford and Boston VA medical centers, is also the principal investigator for a National Institutes of Health (NIH) grant on Lifespan Outcomes of Military Service, and is co-investigator on several projects funded by NIH and VA that study health, personality, cognition, and aging. He spoke with VARQU about his work with NAS and the Lifespan Outcomes study.

VARQU: The Normative Aging Study began in 1963. Can you tell us about the study and its aims?

Spiro: This study started at what used to be the Boston VA outpatient clinic, which was set up in the 1940s for returning World War II Veterans. Among other things, in the 1960s researchers at the clinic were studying a group of Spanish-American War Veterans who were all in their 80s and 90s. This was a group of about 100 men, and they were all extremely healthy.

And the researchers said: "Isn't it interesting how these men got to be that way. Why don't we look at World War II Veterans (at this time it was 15 or 16 years after the war) and start with a bunch of healthy guys and see what happens to them as they get old?" They wanted to know whether healthy men stay healthy, or whether they get different problems later. Basically, they wanted to know if aging inevitably leads to disease, or if some men could age relatively successfully without getting serious disease.

These World War II Veterans, all of whom fought in the Battle of the Bulge, were interviewed by a media crew at Fort Meade in 2014, for the 70<sup>th</sup> anniversary of the battle.
These World War II Veterans, all of whom fought in the Battle of the Bulge, were interviewed by a media crew at Fort Meade in 2014, for the 70th anniversary of the battle. (Photo by Robert Turtil)

These World War II Veterans, all of whom fought in the Battle of the Bulge, were interviewed by a media crew at Fort Meade in 2014, for the 70th anniversary of the battle. (Photo by Robert Turtil)

So the original objective of the NAS was to look at healthy men—since most Veterans were men at that time—and to take a look from the beginning and see what happened as they got older, so that you could see what made aging different from disease and issues like that. They took a group of mostly Veterans, recruited them through the community, and they were enrolled over a period of 10 years or so, aged 20 to 80. They were all healthy at the time of enrollment. The men aged 65 or older were almost as healthy as the 20-year-olds based on the selection criteria.

We had a super-healthy group of older men, and a typical group of younger men. Over the next 25 years or so, the older group didn't seem to die! The mortality rate was pretty low for the first 15 years of the study. When I joined the group in the mid-'80s, we were trying to do some work looking at mortality, and only 5 to 10 percent of the study group had died, dropped out, or been lost, so we really couldn't do much. At this point, 50 years later, I think we've lost about two-thirds of the cohort, but we also still have a healthy group. We've had a couple of 100-year-olds, and the average age of participants is now in the mid-70s and early 80s.

Ernest Cowell, an Army, Army Air Corps, and Navy Veteran of World War II, Korea, and Vietnam, rings the ceremonial bell during a 2011 Memorial Day commemoration.
Ernest Cowell, an Army, Army Air Corps, and Navy Veteran of World War II, Korea, and Vietnam, rings the ceremonial bell during a 2011 Memorial Day commemoration. (Photo by Paula Berger)

Ernest Cowell, an Army, Army Air Corps, and Navy Veteran of World War II, Korea, and Vietnam, rings the ceremonial bell during a 2011 Memorial Day commemoration. (Photo by Paula Berger) View a musical slideshow tribute to Veterans featuring Cowell and others.

Every few years, study participants would come back for a medical exam and fill out some questionnaires and other things. We'd send them questionnaires in the mail every so often to find out what else was going on in their lives. There are two parts to the study: the biomedical part, which looks at health and disease and other aspects of medical functioning; and the psychosocial part, which looks at how participants think they are doing, how do they feel about things, what makes them happy or sad, what kind of person are they, how many friends do they have, and issues like that. I've mostly been involved in the psychosocial work.

I've done a fair bit of work on the personalities of the men and how that relates to health, and also on cognition and how that relates to health.

VARQU: What sort of things have you found?

Let me tell you about a couple of things I think are interesting, and that we've tried to make the case for. The typical view of personality 15 or 20 years ago, both within the field of psychology and outside of it, was that by adolescence or early adulthood your personality is largely stable. If you are a cranky old man, it's probably because you were a cranky young man. If you are a bit of a free spirit as an older person, it's probably because you have always been that way. We looked to see whether that was the case, and our belief going in was that it's very likely that people change—and they can become more or less extroverted, neurotic, or conscientious as they get older.

Since the mid-80s, we've been collecting data on personality from these men. We've done a number of papers showing that personality does seem to change. People can become—and I think I've noticed this in my own behavior—a little more extroverted and a little less neurotic. It goes the other way for some people. People who became less neurotic in this study were somewhat less likely to die over time. So having what I'd call a healthier outlook on the world is probably a good thing. We've found changes in life satisfaction and well-being—how happy people are with the world and themselves.

Others have had similar findings. All of our subjects are men, almost all of them are Veterans, and all of them are, in some sense, reasonably healthy compared to a general sample of the population. We have a unique group of people in our sample, but it seems that other researchers, once they started looking and thinking that personality might change, started finding similar sorts of things. So that's one of the contributions that we've made to the world of personality and aging.

The other area is cognition. My colleagues and I have been trying to promote a view of cognitive aging. Cognitive aging is the shorthand term we use for the decline in everything that happens when we get older. From your 50s, you probably start forgetting people's names and where the car keys are and so forth—and by the way, it's not dementia until you forget what the car keys are for.

Most people in the field of psychology, in which I was trained, thought cognitive aging was due either to just getting older, or to some more basic mental processes, like memory, that tend to decline with age. The argument we've been making over the last 15 years or so, using the medical data we have as well as the cognitive data we've been collecting, is that you not only have memory problems when you get old, but you also start having respiratory problems, heart problems, often in midlife, all sorts of conditions that can affect the brain, which affects cognition.

So if you look at the prevalence of diseases of aging, something like half the older population has hypertension; somewhere between 20 and 30 percent have diabetes; and some of the imaging data that people have collected in studies of large groups suggests that there are all sorts of things going on in the brain with aging, and all of these are likely to affect thinking and memory and all sorts of cognitive processes.

What we've tried to demonstrate is the notion that it's less aging that causes cognitive declines than it is the fact that people tend to get more illness or diseases as they get older—and that these diseases increase the risk of cognitive declines and account for why older people often have more memory or decision-making problems or other sorts of things.

If you really want to understand what cognitive aging is about, you need to consider the health of the people you're studying, and not just assume health is irrelevant. That's because these diseases reduce blood flow to the brain, or lead to greater inflammation, or all sorts of physiological processes that impair cognitive function. If we all were perfectly healthy, we might all be perfectly cognitively competent.

VARQU: What's the future for the NAS study?

There is a high possibility the study will wind down in the next couple of years, at least in terms of doing the medical exams, because of the retirement of the people who have done that part of the study. What I am hoping is that over the next five or 10 years we can continue to do study activities by mail. The ultimate goal would be to get information on the last man, which sounds kind of morbid, but death is pretty much inevitable for all of us. We can't use the electronic medical record for data, because most of the men are not VA patients, although we did the study in the VA. Only about 20 percent of the cohort use VA on a regular basis.

VARQU: You are also involved in an NIH-funded study on the lifespan outcomes of military service. Would you tell us about that study, and how it complements NAS?

Spiro: Maybe two-thirds of the men in our sample were World War II Veterans, and another third were Korean War-era Vets. What we have learned about in NAS is the aging of those Veteran cohorts. But every war is different, and so are the people who go to fight them. We tried, 15 years ago or so, to set up a comparable study of Vietnam War Vets, who would have been the same age as most of our guys were when they started the study, so that we could find out what happened to this group of Veterans as they aged, but we couldn't get funding.

Now, Vietnam Veterans are the "old guys," and we think they're different from the World War II and Korean War Veterans who used to be the "old guys." For one, they report a lot more mental health problems—maybe because they have them, or maybe just because they are more likely to admit to them. It's not entirely clear. And we've had two wars since Vietnam; the first Gulf War didn't have a particularly sizeable number of participants, and the second one has had a sizeable number with TBI and PTSD.

Some other things have happened to the military as well. One of them is the all-volunteer force, and related to that is the fact that we now deploy many more National Guard and Reserve troops than we did before. So the kinds of things current generations of combat Vets are dealing with and will carry into their old age are different than what the Vietnam or the older guys had.

So the NIH grant funded us to start a research network. What we're doing in this network is getting a group of investigators to study Veterans, using other people's public use data, to find out how Veterans might age differently from the non-Veteran groups in those data. Then, we'll make some suggestions on why we should study Veterans as they age, and how the different wars might affect Veterans' aging differently over time. Without these kinds of data, we're not going to be well-prepared for treating aging Veterans with brain injuries and missing limbs when they get into their 60s or 70s, and we're not going to be able to project what their needs might be and what sorts of providers and health care we would need to provide them.

Everyone seems to be concerned more with the short-term consequences of the current wars, and what we need to do to help Veterans now, but we also need to be thinking about whether there is anything we know about the people who are aging now that might help us understand or begin to get prepared for the Vets who will be aging in 20 years—who they'll be and what kind of services they might need most.

We might begin thinking about what we should do, and how we can work with medical schools to train people in the specialties we might need, and the kinds of service and configurations of care that might be better-suited to Iraq and Afghanistan Veterans as they age. I hope that we can raise some questions that will make people think maybe we ought to do that.

I've had some interactions with VHA's national task group on dementia over the years, trying to project the number of dementia cases VA will see in the future. How will traumatic brain injury [TBI] and posttraumatic stress disorder [PTSD] affect that? They both seem to be risk factors for dementia. We've got a third of the last war's two million plus Veterans coming home with TBIs. The whole notion of "accelerated aging," in which illnesses seem to accelerate aging and cognitive declines—well, TBI may be one of those illnesses. Some of these guys may begin exhibiting dementia symptoms at 55 or 65, instead of 75. This means another 10 years or so of dependency, or respite care, or caregiving.

The projections we make now, such as VetPop [VA's official Veteran population projection], are linear projections. There are things that can modify them and move them up or down—but these projections don't include the disruptive changes that can happen.

What if everyone had a smart phone that woke them up and told them to start exercising? And if exercising results in a 10-percent reduction in cognitive decline and people could live on their own for an extra year and a half without going into nursing care? These small sorts of things can add up and result in large changes. So in some sense, it's important to think about what we know and about what changes might take place in the next 30 years. What if we could find the genetic basis for different kinds of cancer and start curing a couple of them? And if we cut fatalities from lung cancer in half, what's the implication of that? Some people will live longer, but maybe with more impaired health.

I read a lot of science fiction when I was growing up, and a lot of what interested me were disruptors and unintended consequences. When you do straight-line linear projections, everything looks fine—but when someone throws a curve ball, all of a sudden there's a huge difference. If people aren't dying from heart disease or cancer … then they're going to develop dementia [unless we have found cures].

We need to think about what aging Veterans are going to be faced with, and how to better prepare for what they might ask of our system.


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