[Senate Hearing 116-542]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 116-542

                  PROMOTING HEALTHY AGING: LIVING YOUR
                 BEST LIFE LONG INTO YOUR GOLDEN YEARS

=======================================================================

                                HEARING

                               BEFORE THE

                       SPECIAL COMMITTEE ON AGING

                          UNITED STATES SENATE

                     ONE HUNDRED SIXTEENTH CONGRESS


                             FIRST SESSION

                               __________

                             WASHINGTON, DC

                               __________

                           SEPTEMBER 25, 2019

                               __________

                           Serial No. 116-12

         Printed for the use of the Special Committee on Aging
         
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]         


        Available via the World Wide Web: http://www.govinfo.gov
        
                                __________

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
47-292 PDF                 WASHINGTON : 2022                     
          
-----------------------------------------------------------------------------------   
       
                       SPECIAL COMMITTEE ON AGING

                   SUSAN M. COLLINS, Maine, Chairman

TIM SCOTT, South Carolina            ROBERT P. CASEY, JR., Pennsylvania
RICHARD BURR, North Carolina         KIRSTEN E. GILLIBRAND, New York
MARTHA McSALLY, Arizona              RICHARD BLUMENTHAL, Connecticut
MARCO RUBIO, Florida                 ELIZABETH WARREN, Massachusetts
JOSH HAWLEY, Missouri                DOUG JONES, Alabama
MIKE BRAUN, Indiana                  KYRSTEN SINEMA, Arizona
RICK SCOTT, Florida                  JACKY ROSEN, Nevada
                              ----------                              
            Sarah Khasawinah, Majority Acting Staff Director
                 Kathryn Mevis, Minority Staff Director
                        
                        
                        C  O  N  T  E  N  T  S

                              ----------                              

                                                                   Page

Opening Statement of Senator Susan M. Collins, Chairman..........     1
Opening Statement of Senator Robert P. Casey, Jr., Ranking Member     2

                           PANEL OF WITNESSES

Rudolph Tanzi, Ph.D., Director, Genetics and Aging Research Unit 
  at Massachusetts General Hospital, and Professor of Neurology, 
  Harvard Medical School, Boston, Massachusetts..................     5
Susan Hughes, Ph.D., DSW, Co-Director, Center for Research on 
  Health and Aging, University of Illinois-Chicago, Chicago, 
  Illinois.......................................................     7
Diane Dickerson, Chief Executive Officer, Bangor Regional YMCA, 
  Bangor, Maine..................................................     8
Brian L. Long, Lead Coordinator, Pennsylvania Link to Aging and 
  Disability Resources Service Area 13, and Volunteer 
  Representative, Southcentral Regional Council on Aging, 
  Lancaster, Pennsylvania........................................    10

                                APPENDIX
                      Prepared Witness Statements

Rudolph Tanzi, Ph.D., Director, Genetics and Aging Research Unit 
  at Massachusetts General Hospital, and Professor of Neurology, 
  Harvard Medical School, Boston, Massachusetts..................    29
Susan Hughes, Ph.D., DSW, Co-Director, Center for Research on 
  Health and Aging, University of Illinois-Chicago, Chicago, 
  Illinois.......................................................    33
Diane Dickerson, Chief Executive Officer, Bangor Regional YMCA, 
  Bangor, Maine..................................................    40
Brian L. Long, Lead Coordinator, Pennsylvania Link to Aging and 
  Disability Resources Service Area 13, and Volunteer 
  Representative, Southcentral Regional Council on Aging, 
  Lancaster, Pennsylvania........................................    43

                        Questions for the Record

Rudolph Tanzi, Ph.D., Director, Genetics and Aging Research Unit 
  at Massachusetts General Hospital, and Professor of Neurology, 
  Harvard Medical School, Boston, Massachusetts..................    51
Susan Hughes, Ph.D., DSW, Co-Director, Center for Research on 
  Health and Aging, University of Illinois-Chicago, Chicago, 
  Illinois.......................................................    52

                        Statement for the Record

Helen Sheehy, letter regarding Medicare coverage.................    55

 
                  PROMOTING HEALTHY AGING: LIVING YOUR
                 BEST LIFE LONG INTO YOUR GOLDEN YEARS

                              ----------                              


                     WEDNESDAY, SEPTEMBER 25, 2019

                                       U.S. Senate,
                                Special Committee on Aging,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:17 a.m., in 
Room 562, Dirksen Senate Office Building, Hon. Susan Collins 
(Chairman of the Committee) presiding.
    Present: Senators Collins, Hawley, Braun, Rick Scott, 
Casey, and Sinema.

                  OPENING STATEMENT OF SENATOR
                   SUSAN M. COLLINS, CHAIRMAN

    The Chairman. The Committee will come to order.
    Good morning. First, let me thank our witnesses for 
accommodating our change in schedule. There happens to be quite 
a bit going on--on Capitol Hill today, as you may have heard, 
but I think it is important that we continue with important 
work that we are doing on this and other committees as well.
    By the year 2030, one out of five Americans will be over 
the age of 65. These Americans represent the fastest-growing 
demographic segment of our population. They are independent. 
They are diverse and they are often still working.
    Today the Aging Committee is convening this hearing, during 
Healthy Aging Month, to make healthy aging a goal that all 
Americans can strive to achieve.
    Hospitals are required to conduct community health needs 
assessment surveys every 3 years to identify priorities. Last 
week, the MaineHealth hospital system, my State's largest 
health care network, published a report with the results from 
the 2019 survey. Five local health care systems identified 
``healthy aging'' as a top priority for the coming years. For 
MaineHealth, this means improving access to quality health care 
as well as the physical and social environment that promote 
healthy lifestyles. While this may come as no surprise to the 
State of Maine, where older adults outnumber children, healthy 
aging ought to be a priority for every State.
    Healthy aging starts with community. Last Congress, we held 
a hearing on the increasing epidemic of social isolation among 
older adults and uncovered the startling fact that prolonged 
isolation and loneliness are comparable to smoking 15 
cigarettes a day. Staying connected with family and friends 
helps to stave off physical illness and mental decline. It adds 
years to life and life to years.
    Aging with community means staying engaged, physically, 
socially, and cognitively. Mounting evidence indicates that 
this trifecta can help reduce the risk for serious age-related 
diseases from Alzheimer's disease to cardiovascular conditions. 
Physical activity, for example, promotes healthy aging and 
fights chronic diseases from the cellular to the systems 
levels. During exercise, mitochondria, the energy powerhouses 
within cells, grow stronger and proliferate, improving the 
function of the entire body from head to toe. While we have 
long known the benefits of exercise, today's research is 
shedding new light on the mechanisms through which exercise 
supports healthy aging, and the results are truly impressive. 
Exercise can actually change the way that genes are regulated, 
reducing risk for age-related degenerative diseases.
    In fact, growing research shows that several lifestyle 
factors can modify gene expression. Today we will learn that 
approximately 95 percent of gene mutations linked with certain 
age-related diseases can be modified in their expression 
through changes in lifestyle. This gene modification can 
decrease the risk of certain diseases. In addition to physical, 
social, and cognitive activity, other key factors include diet, 
sleep, and stress management, so I am in real trouble.
    A new study published this month in the Proceedings of the 
National Academy of Sciences found another remarkable lifestyle 
factor that promotes healthy aging, and that is optimism. In 
this study, researchers followed more than 70,000 seniors for 
10 to 30 years and found that the most optimistic demonstrated 
on average an 11 to 15 percent longer life span. Research has 
already shown that optimistic individuals tend to have a 
reduced risk of depression, heart disease, and other chronic 
illnesses. This new report shows that people who ``usually 
expect to succeed in things that they do'' tend to live longer, 
too. The more we learn about healthy aging, the more we can do 
to help make it possible.
    Routine preventive and maintenance care is another 
important part of healthy aging. The Medicare annual wellness 
visit provides critical screenings from cardiovascular health 
to cognitive function, as well as medication reconciliation. 
With more than 42 percent of seniors taking five or more 
prescription drugs, reconciling these medications can help to 
reduce adverse drug events, such as dizziness, which can lead 
to falls and injuries.
    From the individual to the community level, from the 
doctor's office to the home, there are steps that we can take 
right now to improve prospects for healthy aging. Today we will 
hear from a great panel of experts on how to add health and 
well-being to life's golden years.
    I want to thank all of our witnesses for being here today. 
I will introduce them shortly, but now I would like to turn to 
our Ranking Member, Senator Casey, for his opening statement.

                  OPENING STATEMENT OF SENATOR
              ROBERT P. CASEY, JR., RANKING MEMBER

    Senator Casey. Chairman Collins, thank you for holding this 
hearing, and thank you for your opening statement.
    When it comes to healthy aging, we have news to celebrate. 
On average, people are living longer and as life expectancy has 
increased, health has improved. We can attribute much of this 
success to advances in medical research and treatment, 
dedicated health professionals, and, of course, programs like 
Social Security, Medicare, Medicaid, and the Older Americans 
Act.
    I spent a significant amount of my time thinking about how 
these federally funded programs promote health security and 
financial security and even more time fighting for policies to 
protect and strengthen them.
    During our hearing today, I would like to highlight the 
important role of Medicare and discuss ways that we can improve 
the program in order to further promote healthy aging. Medicare 
is the only game in town when it comes to health insurance for 
most people 65 years of age and older. In Pennsylvania, for 
example, over 2.7 million people receive their coverage through 
Medicare. It ensures that individuals have coverage for 
preventive care, necessary medical care, and prescription 
drugs.
    However, Medicare is not required to cover dental, hearing, 
or vision services. To expand upon a tweet from Gretchen 
Jacobson, a Medicare expert from the Kaiser Family Foundation, 
while every single individual on Medicare has teeth and/or 
gums, eyes, and ears, they do not--they do not--all have 
insurance to help cover the cost of dental, vision, and hearing 
services. This is a barrier to healthy aging.
    I received a letter recently from Helen Sheehy of Tyrone, 
Pennsylvania, about this very issue. Chairman Collins, I would 
ask consent to have this letter from Helen Sheehy entered into 
the record.
    The Chairman. Without objection.
    Senator Casey. Thank you. Helen's letter begins, ``I am 
writing to you about serious gaps in Medicare coverage that I 
hope you, through the Special Committee on Aging, could begin 
to address.''
    Helen goes on to write about how Medicare covered the care 
her husband, Jim, received following a cancer diagnosis: 
surgery, chemotherapy, and radiation. As a result of Jim's 
treatment, his teeth were seriously damaged, and most of them 
had to be removed. Helen goes on to explain that the medical 
bill for this care was $31,000.
    Helen Sheehy closes the letter to me by writing as follows: 
``Apparently, the dental exclusions have been in place for 
decades. We now know that there is a direct connection between 
dental health and an individual's overall health, I am hoping 
that you will think the time is ripe to rethink these 
provisions.''
    I agree with Helen. The time is ripe to rethink these 
provisions. It is for this reason that I have introduced 
legislation, the Medicare and Medicaid Dental, Vision, and 
Hearing Benefits Act to expand Medicare and Medicaid coverage 
not just for dental services but for hearing and vision care as 
well.
    We can find story after story about the need for these 
basic benefits. We know that a simple eye exam can lead to 
early detection of hypertension and high cholesterol. If 
someone has trouble conversing with others due to hearing loss, 
research tells us that there will be a greater likelihood of 
mental health issues, dementia, and social isolation and the 
list of examples goes on from there.
    We have a responsibility to ensure that our aging loved 
ones receive the critical health care services they need to 
lead the most active and healthy lifestyle possible.
    Again, I look forward to hearing from our witnesses today, 
thank them for their testimony, and also look forward to a 
discussion about this important topic.
    Thank you, Chairman Collins.
    The Chairman. I now would like to turn to our panel of 
witnesses. We have a great panel of witnesses today.
    First, I would like to introduce Dr. Rudolph Tanzi, the co-
director of the Center for Brain Health and vice chair of 
neurology at Massachusetts General Hospital. He is also a 
professor of neurology at Harvard Medical School. Of particular 
interest to me, Dr. Tanzi discovered several Alzheimer's 
disease genes, and he serves as director of the Alzheimer's 
Genome Project. He has published more than 500 scientific 
papers and co-authored several New York Times best-selling 
books, including ``Super Brain,'' ``Super Genes,'' and ``The 
Healing Self.'' I had the pleasure of meeting Dr. Tanzi when I 
went to Harvard to learn more about the work that its 
laboratory was doing on Alzheimer's research, and I remember 
leaving not only impressed but encouraged at the research that 
is ongoing. I appreciate your being here today, Doctor.
    Our second witness will be Dr. Susan Hughes. She is the co-
director of the Center for Research on Health and Aging at the 
University of Illinois at Chicago. She is also the principal 
investigator of the Midwest Roybal Center for Translation and a 
founding member of the Evidence Based Leadership Collaborative. 
Her research focuses on physical activity to help older adults 
maintain individual functioning and age well.
    Next, I am delighted that we will hear from Diane 
Dickerson, who is the CEO of the Bangor, Maine, YMCA. Diane 
came to the Y with a lifetime of business experience and 
community building. Prior to coming to Maine and leading the Y 
in 2013, she held a variety of responsible leadership positions 
for three decades in Nevada and California. We are glad she has 
finally gotten to the State where she belongs. At the Bangor Y, 
she has been instrumental in developing programs designed to 
support healthy aging in Bangor and across the State. We are 
very proud that you could be with us today.
    I would now turn to our Ranking Member to introduce our 
final witness on the panel.
    Senator Casey. Thanks, Chairman Collins. I am pleased to 
introduce Brian Long of West Hempfield Township, Pennsylvania. 
West Hempfield Township is in the western part of Lancaster 
County. Brian Long is the lead coordinator for the Pennsylvania 
Link to Aging and Disability Resources--did I get all that 
right?--for the Berks, Lancaster, and Lebanon service area. 
That is three of our counties in the south-central part of our 
State. He is also a volunteer representative for Pennsylvania's 
Southcentral Regional Council on Aging.
    Brian is no stranger to service. He is a veteran of the 
United States Army. He also has served in the U.S. Army Reserve 
and in the Pennsylvania Army National Guard. Mr. Long is a 
proud parent to two adult children and grandparent to three 
grandchildren.
    Brian, thank you for your service to our Nation and older 
residents of Lancaster, Berks, and Lebanon counties and for 
your willingness to testify today.
    Thank you.
    The Chairman. Thank you very much.
    We will begin with Dr. Tanzi.

          STATEMENT OF RUDOLPH TANZI, Ph.D., DIRECTOR,

       GENETICS AND AGING RESEARCH UNIT AT MASSACHUSETTS

         GENERAL HOSPITAL, AND PROFESSOR OF NEUROLOGY,

         HARVARD MEDICAL SCHOOL, BOSTON, MASSACHUSETTS

    Dr. Tanzi. Thank you. Good morning. I want to thank 
Chairman Collins, Ranking Member Casey, and other members of 
the Special Committee on Aging, including Senator Warren from 
my home State of Massachusetts, for the opportunity and 
privilege of discussing the role of genetics and lifestyle in 
promoting healthy aging into our golden years.
    My name is Rudolph Tanzi. I serve as the Joseph P. and Rose 
F. Kennedy Professor of Neurology at Harvard Medical School, 
vice chair of Neurology, and co-director of the McCance Center 
for Brain Health at Massachusetts General Hospital, and serve 
as the director of the Alzheimer's Genome Project supported by 
the Cure Alzheimer's Fund, one of the highest impact 
Alzheimer's disease research foundations in the world.
    I have dedicated my entire career to studies aimed at 
preserving and promoting brain health and preventing brain 
disease. Over the past four decades, my lab has discovered and 
characterized numerous genes influencing susceptibility for 
Alzheimer's disease, including the first three and we have used 
knowledge gained from these genes to develop new therapies for 
treating and preventing Alzheimer's disease. Some of these new 
drugs are already in clinical trials in Alzheimer's patients. 
We have also published over 500 original research papers on 
Alzheimer's disease and brain health and have written three 
best-selling books on brain health, genetics, and immunity.
    I will focus my remarks today on how we can best maintain 
brain health and resilience against age-related diseases, 
including neurological diseases such as Alzheimer's, as well as 
other chronic diseases including diabetes, heart disease, and 
cancer. Approximately 8 in 10 older adults in the United States 
have a chronic disease, and 7 in 10 have two or more. Chronic 
diseases are the leading cause of death and disability and the 
leading drivers of the Nation's $3.3 trillion in annual health 
care costs. Alzheimer's, the most common form of dementia in 
the elderly, currently affects nearly 6 million Americans. The 
cost of this disease to our country is approaching $300 billion 
per year. Half of Americans over 85 years old exhibit 
Alzheimer's symptoms; two-thirds are women. With the American 
life span now nearly up to 80 years, this disease is a 
burgeoning epidemic that will someday single-handedly collapse 
our health care system if we do not do something about it.
    As modern medicine has extended life span, unfortunately, 
our health span has not kept up, and this has resulted in 
rampant increases in the incidence of age-related diseases. How 
can we stem the tide of Alzheimer's and other chronic diseases? 
The research is promising and has turned traditional notions 
about disease upside down. Not too long ago, we were taught 
that the effects of the genes you inherited from Mom and Dad 
were fixed, unchangeable, but new research in the burgeoning 
field of epigenetics has demonstrated that the activity of the 
genes or, as we call it, the ``expression'' of the genes is 
fluid, dynamic, and responsive to everything we do and think.
    Every choice we make leads to experiences that change the 
expression of our genes, and gene expression is actually 
controlled by our habits. A healthy lifestyle of good habits 
leads to beneficial gene programs and good health. The opposite 
is also true. You may currently have bad habits, like too much 
junk food, which induce gene expression programs that promote 
risk for age-related disease, but with repetition, the 
establishment of new, ``good habits,'' like a plant-rich diet, 
will change gene expression programs that promote health and I 
wrote about this at length in my books ``Super Genes'' and 
``The Healing Self.''
    At the end of the day, by altering our gene expression 
programs through our daily conscious choices, we have the power 
to slow the aging process, improve our mood, stave off anxiety 
and depression, aches, pains, get better sleep, et cetera.
    The genetics of Alzheimer's disease is very interesting. It 
exhibits a clear dichotomy. On one hand, we first discovered 
these gene mutations that guarantee the disease, usually under 
60 years old. Fortunately, these so-called fully penetrant gene 
mutations only account for 3 to 5 percent of Alzheimer's. 
Meanwhile, we also found 30 other genes where the mutations do 
not guarantee the disease, so lifestyle interventions make a 
difference in 95 percent of those at risk for Alzheimer's. In 
support of this statement, a large study was recently published 
by Lourida et al. in JAMA that concluded: ``A favorable 
lifestyle was associated with a lower dementia risk [even] 
among participants with high genetic risk.''
    The same is true for other age-related chronic diseases, 
and it is generally the case that on common, age-related, 
complex genetic disorders such as Alzheimer's disease, heart 
disease, diabetes that 3 to 5 percent involve mutations that 
guarantee the disease, but 95 to 97 percent are genetic factors 
that are modifiable by lifestyle.
    I will now conclude with brief recommendations for 
lifestyle that have the potential to reduce age-related chronic 
diseases. For this I use the acronym SHIELD, which has gotten a 
lot of popularity lately. It was just on the ``Today'' show and 
``NBC Nightly News'' a couple of weeks ago, so, briefly, S 
stands for sleep, 7 to 8 hours sleep, helps clean the brain.
    H is handling stress, taking on a meditation practice, also 
great for the brain and body.
    I is staying interactive with friends, staying socially 
engaged with friends.
    E is for exercise, which induces new nerve cell growth to 
strengthen brain regions affected in Alzheimer's.
    L is for learning new things, not just playing brain game 
but learning new things and making new synapses. The more 
synapses you make in your brain, the more you can lose before 
you get into trouble.
    Finally, D is for diet. The Mediterranean diet has been 
shown to be most advantageous for preventing Alzheimer's 
disease. It feeds your gut microbiome with plant fiber, and 
your gut microbiome helps keep your brain healthy from 
inflammation.
    In summary, while we await the medicines that will prevent 
and treat Alzheimer's disease and other chronic diseases, it is 
my hope that research will be accelerated into lifestyle 
interventions. I also hope that we can proactively educate the 
American public about using plans like SHIELD to improve their 
brain health and reduce risk for brain disease and we need to 
let the American population know that, despite their family 
history and personal genetics, in the vast majority of cases, 
lifestyle and behavioral changes have the potential to preserve 
and promote brain health and prevent age-related diseases--not 
only Alzheimer's, but also heart disease, diabetes, and cancer.
    Thank you for your attention.
    The Chairman. Thank you, Doctor.
    Dr. Hughes, welcome.

          STATEMENT OF SUSAN HUGHES, Ph.D., DIRECTOR,

            CENTER FOR RESEARCH ON HEALTH AND AGING,

      UNIVERSITY OF ILLINOIS AT CHICAGO, CHICAGO, ILLINOIS

    Dr. Hughes. Good morning. I am Dr. Susan Hughes. I direct 
the Center for Research on Health and Aging at the University 
of Illinois at Chicago. Am I on?
    The Chairman. Doctor, forgive me. If you could just----
    Dr. Hughes. Talk into----
    The Chairman. Right, just bring it in a bit.
    Dr. Hughes. All right. I also direct our Midwest Center for 
Health Promotion that is funded by the National Institute on 
Aging, and I am a founding director of the Evidence Based 
Leadership Collaborative. I would like to thank you so much for 
this opportunity to talk with you today about healthy aging.
    Today I would like to address physical activity, describer 
our Fit & Strong! exercise program, our experience translating 
Fit & Strong! into practice, and the importance of the Older 
Americans Act renewal for maintaining advances in healthy 
aging.
    Substantial evidence currently supports the importance of 
physical activity for healthy aging, yet engagement in exercise 
among older adults is still sub-optimal. Currently, 35.8 
percent of seniors engage in recommended levels of aerobic 
exercise and 16.7 percent in resistance training. Engagement is 
considerably lower in minority seniors.
    We also know that 27.5 percent of older adults are 
sedentary, a development that is highly correlated with 
increased levels of obesity, incidence of Type 2 diabetes, 
cardiovascular disease incidence and mortality, and all-cause 
mortality.
    On a more positive note, a recent meta-analysis found that 
any physical activity, regardless of intensity, is associated 
with a lower risk of mortality. We also know that short bouts 
of exercise are as effective as spending hours on a treadmill. 
Both findings matter because the current CDC physical activity 
guidelines may be daunting for older adults.
    What can we do to change the situation? Understanding why 
older adults are sedentary could help. I began my research 
career working with homebound older adults in Chicago who 
reported that arthritis was their most common chronic condition 
and the condition that interfered most frequently with their 
functioning. I then examined the relationship between joint 
impairment and function over time in 600 older adults and found 
that lower-extremity joint impairment was the pathway through 
which disability developed.
    To disrupt this cycle, we designed Fit & Strong! for 
persons with lower-extremity osteoarthritis, or OA. The program 
meets three times a week for 90 minutes. Each session 
incorporates flexibility, aerobics, and lower-extremity 
strength training, followed by health education to help 
participants manage OA with physical activity. Our clinical 
trial of Fit & Strong! found that it improved physical activity 
engagement at 8 weeks, the end of the program. Participants 
maintained this improvement at 6, 12, and 18 months, and also 
experienced improved joint pain and function as well as 
improved mobility and strength. These effects matter because 
impaired lower-extremity strength is a major risk factor for 
falls, and impaired mobility is a risk factor for both falls 
and mortality.
    These findings indicate that persons with OA clearly 
benefit from the program. They raised the question of a 
possible impact on hip and knee total joint replacement surgery 
on which we currently spend $72.5 billion annually. If we could 
delay the surgery, this could potentially save millions of 
dollars and keep people with OA active. Fit & Strong! is now 
being offered in 32 States. This happened because of health 
promotion funds in the Older Americans Act.
    Title III D funding is vital and should be increased in the 
future, if possible. Unlike chronic disease management or falls 
prevention programs, physical activity programs do not have 
designated funding and must compete for Title III D funds. I 
recommend, given the fundamental power of physical activity 
programs to improve healthy aging, that they be assigned their 
own funding stream in the future.
    To summarize, physical activity is essential for healthy 
aging. I urge you to support the reauthorization of the Older 
Americans Act with increased funding for Title III D and new 
set-aside funds for evidence-based physical activity programs. 
I know that you are both strong supporters of the renewal 
legislation, and I want to thank you for your leadership.
    The Chairman. Thank you very much, Dr. Hughes. I was going 
to point out that I am the chief sponsor of the reauthorization 
of the Older Americans Act, and I very much appreciate having 
your specific recommendations.
    Ms. Dickerson, welcome.

         STATEMENT OF DIANE DICKERSON, CHIEF EXECUTIVE

          OFFICER, BANGOR REGIONAL YMCA, BANGOR, MAINE

    Ms. Dickerson. Thank you, Chairman Collins and Ranking 
Member Casey, for the honor of speaking to you today on a 
subject that is very near and dear to my heart, both personally 
and professionally, and that is for three specific reasons.
    Number one is that I lived with aging parents up until 6 
months ago when they passed away at 91 and 96 years old. I know 
the joys of the aging process. I also know the heartache of the 
aging process. They passed away 18 days apart from each other 
after 70 years of being married.
    My second reason is because, as of 2 days ago, I turned 65, 
and so I am now a legitimate card-holding member of the aging 
population, and number three, and most importantly for today, 
is I am the proud CEO of the Bangor Region YMCA, and I am 
honored each and every day to serve the community, from babies 
all the way to our senior citizens. It is absolutely joyous to 
see our multi-generational efforts at our Y and watch a 2-year-
old shuffle across our lobby to the pool for a swim lesson 
while passing a 92-year-old shuffling across our lobby going 
the other way to a chair yoga and balance class and they smile 
at each other and literally give each other a high five along 
the way. It is quite an experience to watch.
    As you know, Maine is the oldest State in the country, and 
so all of our YMCAs throughout the State have a social 
responsibility to the needs of our senior community. Our Y 
serving the Bangor region is focused on the mental, the 
physical, and the spiritual side, and how all are 
interconnected to the aging process.
    We have more than 100 group fitness classes a week on land 
and in our pools that will keep seniors feeling physically 
healthy, increase their strength, improve their mobility and 
their balance and their flexibility and decrease their stress 
and certainly encourage a very important social network.
    We also offer programs for individuals with specific 
conditions and ailments. Our Phase III Cardiac Rehab Program is 
a community-based program in partnership with our local 
hospital, Northern Light Eastern Maine Medical Center, and is 
for those who have been affected by a cardiac event and is 
designed to further strengthen their aerobic capacity, their 
flexibility, and overall movement for participants. We have had 
this program for over 45 years, as I said, and it has been 
extremely successful.
    Our LIVESTRONG program is an evidence-based fitness program 
to promote the importance of physical activity with those with 
a cancer diagnosis. This is a free 12-week program that we 
provide to people, and it truly increases their ability to deal 
with the cancer diagnosis and the medication that they must go 
through along the way. The best news about that is that after 
the 12-week program is over, 98 percent of them join the Y to 
continue that process because they felt and lived the positive 
impact of it.
    For those seniors suffering with arthritis or similar 
conditions that may limit their movement, we have a joint 
venture class and others that are designed specifically to 
reduce pain and increase the range of motion through all the 
joints in the body in an effort to improve overall wellness.
    Then we have our Pedal for Parkinson's and other special 
programs that are designed for this very devastating disease. 
It is a debilitating disease that we really work to increase 
the activity and stimulate the movement, increase their 
balance, and help them live as normal a life as possible. I 
submitted to Senator Collins' staff a video of a gentleman who 
has Parkinson's in our Y, and he expresses how much the Y has 
changed his life in that process.
    Our newest addition, one that I am very, very close to, is 
our Alzheimer's Program. We are in partnership with the 
Alzheimer's Association of Maine and Jackson Lab who is doing 
amazing work on the Alzheimer's process, thanks to you, Senator 
Collins, for your funding efforts, so we at the Y will be 
introducing in 2020 The Bangor Y's Brain Health Initiative. 
This will be designed to help the person afflicted with this 
disease, as well as the caretakers and the families. I know 
firsthand how devastating this disease is to a family. As I 
told you earlier, I lost my Mom 6 months ago, but I did not 
tell you that I lost her to Alzheimer's and the truth is that I 
really started losing her 6 years ago when this disease took 
away the strongest, the kindest, the funniest, and the most 
engaging person that I have ever known in my life whom I so 
honored and proud to call my Mom.
    All of these health initiatives cannot stand on their own, 
however. We must have the social and educational component to 
really maximize what we provide to our seniors. We have a 
Second Wind Social Club that does all kinds of things from 
parties to card playing to movie nights to dinners to special 
excursions to our national parks and so on. We work with our 
Bangor Historical Society, and they provide tours and special 
events and, most recently, we have just aligned with the Senior 
College of Maine so that our seniors will be able to take 
classes right at our Y and to expand their knowledge base.
    We at the Y believe that aging is not losing your youth 
but, rather, a new stage of opportunity and strength. We 
believe that it is our duty to provide that opportunity, to 
relish and to flourish, to move and to dance, to laugh and to 
learn, and, most of all, to know how important they are and how 
valued they are as members of our Y family.
    Thank you so much.
    The Chairman. Thank you very much for sharing your personal 
story and for the great job you do at the Bangor Y.
    Ms. Dickerson. Thank you.
    The Chairman. Mr. Long.

         STATEMENT OF BRIAN L. LONG, LEAD COORDINATOR,

           PENNSYLVANIA LINK TO AGING AND DISABILITY

            RESOURCES SERVICE AREA 13, AND VOLUNTEER

         REPRESENTATIVE, SOUTHCENTRAL REGIONAL COUNCIL

               ON AGING, LANCASTER, PENNSYLVANIA

    Mr. Long. Well, good day, Chairman Collins, Ranking Member 
Casey, and members of the Committee. My name is Brian Long. I 
serve as the lead coordinator for the Pennsylvania Link to 
Aging and Disability Resources in the service area of Berks, 
Lancaster, and Lebanon counties in south-central Pennsylvania.
    Pennsylvania calls its Aging and Disability Resource Center 
Program the ``Link to Aging and Disability Resources,'' but you 
all have it in every State in this country, thankfully.
    Thank you for the opportunity you are giving me to testify 
before the Committee about my experiences and observations 
about ``healthy aging'' issues.
    I am one of the coordinators of the 15 service areas who is 
in regular contact with persons who are age 60 and older, 
persons with a disability, veterans, family members, and 
caregivers.
    I am also a volunteer on one of the regional councils of 
the Pennsylvania Council on Aging, which serves as an advocate 
for older individuals and advises the Governor of the State and 
the Department of Aging on planning, coordination, and delivery 
of services to older Pennsylvanians. In these roles, I listen 
to people's stories. I ask for their opinions. I connect with 
them, and I connect them with resource providers in our ADRC 
network.
    As a person over age 60 by a long shot, a person with a 
disability, and a veteran, I feel I relate and empathize with 
persons who need long-term living resources and information.
    I am more fortunate than many of the people I work with. 
The cases that are most challenging for me are the ones also 
where I have limited ability to help.
    Most of the time, if someone requires additional help like 
putting food on the table or getting a ride to the doctor, I 
can help connect that person with resources, but there are 
certain barriers that make it difficult for me to do my job of 
helping others.
    Hearing loss, for one, is faced by nearly two of three 
older Americans. Many returning veterans have or will have 
hearing loss, as I do, but the Veterans Affairs Medical Center 
in Lebanon provided hearing devices, hearing assistance for me. 
That is not the case for so many people over age 60. I always 
will remember the face on the gentleman, a 60-something-year-
old guy, when a senior center manager called me and said, ``Can 
you help us by getting hearing aids for this person?''
    Well, one of our ADRC partner agencies provided a set of 
previously owned hearing aids, and the senior center manager 
and I went outside with him and put the hearing aids in. He 
said, ``I can hear the birds.'' He said, ``I can hear you 
breathe.'' I mean, it was so emotional for all of us. We went 
outside because we did not want to be in the senior center with 
other people as well. Hearing aids are out of reach for so many 
people because there is no coverage requirement in Medicare or 
Medicaid.
    Vision acuity is another disability that many people reckon 
with as they age. I know a 76-year-old woman who lives on 
minimum Social Security. She needs cataract surgery, but she 
cannot afford it, and Medicare will not cover all of the 
surgery charges, and she does not have the finances to do it, 
so many seniors struggle to afford vision care. Our eyes are 
our windows to the world. We should not be shuttered in old 
age.
    Partial and total tooth loss affects a larger number of 
people, particularly if they come from disadvantaged 
populations. We know that the absence of regular dental care 
and treatment can lead to disastrous health consequences.
    Again, affordability is the factor.
    The issue of coverage for dental, vision, and hearing 
services is about healthy aging. Without access to these 
services, we know that older adults have a greater likelihood 
of experiencing social isolation or connected mental health 
issues, becoming a victim of scams, having difficulty accessing 
transportation resources, struggling to adhere to their 
prescription medicines, encountering hazards in the home. Every 
contact between a person with a disability, every conversation 
with somebody about aging challenges, every call, every email, 
or every text message from a family member looking for 
resources presents an opportunity for one of our ADRC partners, 
a Council on Aging volunteer, or an ADRC coordinator to step up 
and find the resources that will help people with healthy aging 
assistance. I can only do so much from where I work, but there 
are changes that can be made at the Federal level that would 
help me serve older Americans and people with disabilities.
    I know that Senator Casey has introduced legislation that 
would expand Medicare and Medicaid coverage to include dental, 
hearing, and vision care. This, in my judgment, is a must-do. 
There is no reason to delay. With the growing baby boomer 
population, as you identified, Senator Collins, these issues 
are going to become more and more prevalent.
    We must also ensure that the network of ADRCs have the 
resources necessary to serve everyone. Most people have never 
really heard of ADRCs, but they are so thankful to know that 
there is a network out there that can help. ADRCs are a 
lifeline to healthy aging for millions of people across the 
country. I know for sure that is true in Pennsylvania.
    In closing, Chairman Collins and Ranking Member Casey, I am 
honored to have had the opportunity to present this testimony 
before the Committee today. I am happy to respond to any 
questions or concerns you may have. Thank you.
    The Chairman. Thank you very much.
    Dr. Tanzi and Dr. Hughes, let me start with both of you. 
Biomedical research funding has been a real passion and 
priority of mine. Over the last 4 years, Congress has increased 
funding by 30 percent for the National Institutes of Health. 
Building on that success, this year's appropriations bill, 
which we have approved in the Appropriations Committee, would 
increase NIH funding by another $3 billion.
    Could you explain to us why this investment is so 
important? I know you get other sources of funding as well, but 
if you could talk about NIH funding and what it means to your 
ability to come up with the extraordinary findings that you 
have outlined for us today. Dr. Tanzi and then Dr. Hughes.
    Dr. Tanzi. Yes, you know, in research, we learn as we go. 
We are challenged by a lot of unknowns, and so we make a lot of 
mistakes and a good scientist learns from mistakes.
    For example, in Alzheimer's disease, the first genes we 
found all told us amyloid was the target, the plaques and they 
still are, but over the last two decades, we targeted them too 
late. They initiate the disease 10 years before symptoms. By 
the time a person has symptoms of dementia, it is 
neuroinflammation that is killing most of the neurons, and you 
are trying to put out a forest fire by blowing out the match 
that started it. We had to learn that along the way with many 
trials and lots of research.
    I think cancer, heart disease, and AIDS has shown us that 
the more money you put into research on a disease, the faster 
you will beat it and for a long time, for example, Alzheimer's 
was, you know, very underfunded and we are so grateful that now 
funding is almost up to $3 billion and we are seeing the 
differences, because now we are seeing the research that looks 
into neuroinflammation and other pathways so that we do not 
throw amyloid away, we will target that early, but what can we 
do with patients right now? We are learning from genes we 
discovered for neuroinflammation how to track that.
    I think it is very important to have funding for many, many 
backup plans so that we have as many shots on goal as we can.
    The Chairman. Thank you.
    Dr. Hughes?
    Dr. Hughes. Thank you. I am delighted to have this 
opportunity to respond to that question. I think it is 
important for everybody to understand that the National 
Institutes of Health are basically our engine in the United 
States for innovation and, you know, without the funding for 
those institutes, all of the incredible research that we are 
currently doing would stall, you know, and it would be 
disastrous.
    We have been very fortunate to have our Roybal Center re-
funded five times by the National Institute on Aging. We 
develop evidence-based health promotion programs with those 
funds. Some of them include--one is Fit & Strong! Another one 
is Health Matters. That is for people with intellectual 
disabilities. It is currently also being offered all over the 
country and in many countries outside the U.S.
    The funding that we provide to young investigators at UIC 
from the Roybal Center is absolutely pivotal to getting them 
interested in aging and launching them on a lifetime career of 
commitment to and engagement in aging research, so it is 
incredibly important. The ADRC, no funding for it. The National 
Institute on Aging is incredible. We got a supplement to our 
Roybal Center, and it basically has enabled us--we now do 
physical activity programs. We look at the impact on cognition. 
We are also now able to do MRI imaging so that we can compare, 
you know, what is happening in terms of function to what is 
actually happening, you know, in the brain. It is just kind of 
a leap forward, and it would not have been possible without 
that increased funding.
    The Chairman. Thank you.
    Ms. Dickerson, I feel like you are on the front lines. You 
are translating the research into practice in many ways. By 
giving seniors the opportunity to participate in physical and 
social activities in an enjoyable, safe, and friendly 
environment, the Y represents all that we are talking about 
with healthy aging and it also represents community.
    In Maine, like many other States, we have a lot of seniors 
who are isolated. They may live alone. Their health may not be 
very good. They may be on a back road. How do you reach those 
seniors who are living alone who may have limited mobility?
    Ms. Dickerson. One of the things that I can say is that 
word spreads fast amongst seniors. Giving you an example, I was 
having a focus group and chose 15 seniors, and all of a sudden, 
75 showed up because they all wanted to tell me what they 
needed to say.
    What we have started was a buddy system amongst our 
seniors, and we have also incorporated our teen center into 
that and what that is - is that another senior will make the 
effort to bring another senior into the YMCA.
    We also have vans that we will pick up those seniors that 
are in isolated areas because, you are so right, transportation 
is a critical issue and we even now have been having our 
teenagers go through a training program so that they know how 
to drive the buses so that they can also pick up seniors, so 
that they have that multigenerational mentoring aspect along 
the way.
    We reach out to doctors. We reach out to every senior group 
possible. We reach out to churches and other groups to get the 
word out there that we have these programs to offer at the Y 
and that we will absolutely get them there one way or another 
to serve their needs.
    The Chairman. That is great. Thank you.
    Senator Casey. Thank you, Chairman Collins. I will start 
with Brian Long.
    Brian, your work connecting older adults and people with 
disabilities to the services and supports they need is 
critically important. We commend you for that work. In your 
very moving story about that one older adult who received the 
hearing aid for the first time, saying, ``I can hear the birds. 
I can hear you breathe,'' it must have been a powerful moment 
for you and it was a moving story for us to hear, and we need 
stories like that to bring--it becomes much more than a policy 
discussion when you talk about that kind of reaction. I guess 
you probably bring similar success stories along the way, and 
your work at the Council on Aging is important for us to learn 
more about.
    I guess I wanted to stay with that issue of just hearing 
loss. Can you share with us more about that issue itself as 
discussed through the council?
    Mr. Long. Sure. I think that what happens with hearing 
loss, as a person who has hearing loss, I had known I had 
hearing loss for years; it is just that I chose to ignore it, 
because if you are in a big room and there are a lot of people 
talking, you do not really hear. You just nod your head and 
agree, so many people really live that life.
    I talked with a guy just last week, actually, who was in a 
car crash, and he asked me about hearing loss because he lost 
hearing in one ear as a result of a car crash, going through 
his life, and it is just like that, but we talk with so many 
people in municipal meetings, school board meetings. The people 
who attend, for the most part, are older Americans--in 
Pennsylvania, anyway, that is true and many of them just cannot 
hear what is happening because you know what the council 
chambers are like in school boards. They are cavernous things, 
and they do not have audio systems.
    I find that people do not go out as a result of having 
hearing loss. They do not go places because they do not want--
they do not want to appear to be looked at or looked down on. 
It is a stigma that is attached with hearing loss in many 
cases.
    Senator Casey. I guess the other part of it is it can lead 
to other issues. I do not know if you want to highlight that, 
but that is significant as well, that it is not just something 
isolated to that one problem. It can lead to other issues.
    Mr. Long. Yes, what happens--I mean, I visit and we do 
trainings for a number of--for any population, frankly, but I 
visit a lot of affordable housing units; I visit a lot of 
personal care homes and nursing homes and one of the things 
that we find with folks there is they do not want to go out. 
They do not even want to go out of their rooms sometimes 
because they feel embarrassed because they have got no teeth. I 
talk with so many people who do this all the time and these 
physical handicaps that come into play for people at later 
points in life, they are debilitating, and they are also 
embarrassing for many of them.
    We want to make sure that we--nobody should have to live 
sequestered in a cave or a cavernous environment because they 
cannot participate. I look at hearing and I look at vision and 
teeth as participative assets.
    Senator Casey. Dr. Tanzi, I want to go back to your SHIELD 
model. You mentioned the importance of staying socially active 
and keeping one's mind engaged. However, as people are losing 
their hearing, they may be less able to converse with others, 
as I just highlighted.
    The same is true for people who have a vision loss. That as 
well can lead to other issues, including social isolation, and 
it is also connected to higher rates of depression and 
dementia.
    I wanted to ask you to speak about the intersection between 
the three--dental, vision, and hearing loss--and cognitive 
function.
    Dr. Tanzi. Yes, the connection is huge. If we think about 
hearing loss, I cannot tell you how many talks I give when I 
give public lectures. After I give the lecture, folks will come 
up to me from the audience and say their loved one has 
Alzheimer's and it began with hearing loss and you try to think 
about. I have talked about that connection for years, and then 
it comes down to what you just pointed out and Chairman Collins 
pointed out earlier in the opening remarks, that loneliness--
not being alone. If you are alone and like it, that is fine. 
Loneliness is a stress, and it increases risk for Alzheimer's 
disease twofold and that has been shown in meta analyses. It is 
a pretty valid result. If you cannot hear very well--and I 
think, you know, Mr. Long made the point--you are less likely 
to be social. You do not want to go out. You are in a crowd; 
you feel isolated and now you are not getting that stimulation 
and intellectual input to build new synapses.
    When we think about what Alzheimer's disease is, we talk 
about plaques and tangles and inflammation. What correlates 
with the degree of dementia is loss of the connections between 
nerve cells, the synapses, so you have 100 billion neurons and 
about 10 trillion synapses. I tell people, ``When you are going 
to retire, do not just think about your financial reserves. 
Think about your synaptic reserves. Build more synapses, learn 
new things,'' because that reinforces your brain and neural 
networks, and that means that, you know, when you start to lose 
synapses, you have more in the bank, so to speak.
    Now, if you cannot hear very well or you are being socially 
isolated and you are not engaging with others, you are not 
going out to the local community center to be stimulated, that 
is bad for the brain, and a lot of people do not realize that.
    You also mentioned about dental care. Well, you know, our 
mouth is the main source of pathogenic bacteria in our body, 
and there is a clear link between periodontal disease and heart 
disease. Now, as we have learned, much of the pathology in 
Alzheimer's, our lab has shown, particularly the work of Rob 
Moyer, that the plaques and the tangles, why are they forming 
in the first place? It is looking like they may be trying to 
fight infection in the brain. We think about our brains as 
sterile, but if you look in the brain, there is actually 
bacteria there, viruses, fungus and it looks like the plaques 
and tangles are trying to fight that and it is possible for 
periodontal bacteria to make its way not only down to your 
heart and cause cardio issues, but into your brain and now you 
have to make more of that Alzheimer's pathology to fight it 
that is eventually going to trigger inflammation and lead to 
symptoms.
    I think the points you raise are not really stressed enough 
or really understood enough, and we need to make people 
understand them more in this country.
    Senator Casey. Thanks very much.
    Dr. Tanzi. You are welcome.
    The Chairman. Senator Braun.
    Senator Braun. Thank you, Madam Chair, and thanks for 
another great topic of discussion.
    I want to make a statement about health care in general and 
why this is important to me. I am now in that category of being 
somewhat aged, and what a blessing it is when you have taken a 
holistic approach to life to where somewhere back in the 
distance I knew how you treat your body and how you feed it is 
going to be an investment for when you have the time to enjoy 
life, you are able to do it.
    I want to also talk about the fact that our health care 
system in general is broken. It is monopolized by an industry 
that has evolved not toward well-being but toward remediation 
and until we change the whole mind-set, we are going to sadly 
be spending so much money remediating to where the single 
biggest thing we could do is to preach at an early age, you 
know, what you are talking about.
    I will give you a little example of how it works. For me, I 
was still trying to play basketball into my early 30's and 
popped up with a form of arthritis, and I knew that was the 
vector of what was making me feel pain each evening, but then I 
quit doing that, was attentive to mild exercise every day and 
healthy eating, and knock on wood, you know, it has put me in a 
place now where I feel as good as I did in my 20's.
    Let us get back to the industry itself. Until we start at 
an early age promoting a holistic way, I do not think we are 
ever going to break the cost curve that currently besets 
everyone's well-being. In my own company, 11 years ago I 
drastically changed how we address health care, and that was to 
change it from remediation to prevention, and also in no other 
way to get my employees engaged in their own well-being, 
created the incentive so that they do have some skin in the 
game from dollar one in the system that I built.
    In that system, my employees have not had a premium 
increase--I had to resign as CEO, by the way, on December 31st 
of 2018, but that is the experience I bring here to talk about 
every day, whether it is in agriculture, health care, 
infrastructure, or whatever. We found a way to cut costs, and 
by doing it and having our employees engage in their own well-
being, there has not been a premium increase in now 11 years. 
We cut costs out of the gate roughly 50 percent. I require that 
you take a free biometric screening, or you are going to pay 
more for your health insurance and I discourage you from doing 
bad things like smoking; you are going to pay more for your 
health insurance.
    I would like the opinion of--I think I want to start with--
first of all, Mr. Long, thank you for your service. I notice 
that you served your country and then segued into an important 
category. How do we keep people healthy into their later years?
    My question is for Dr. Hughes. Do you think we have got 
enough time to change the system to do the things you are 
talking about to where the industry itself will embrace 
prevention, not remediation?, because in a sense it shrinks the 
size of what we have got in terms of the health care industry. 
Do you see inroads being made?
    Dr. Hughes. I think we have the time and I think we have an 
imperative. I mean, we absolutely have to do this, and we have 
to do it now. We do not have an alternative. With all of the 
people who are coming down the pike and aging, we absolutely 
have to keep people healthy. We have to shift our focus. You 
are tracking somebody who is in a school of public health, so 
no question but prevention is the answer.
    Just look at arthritis. We are spending $73 billion on 
total hip and knee replacement surgery that helps people, but 
why let them get to that point, you know, where they need that 
when we can give them preventive services like physical 
activity programs that can really help them maintain their 
functioning at an incredibly lower cost?
    At the same time, we are not investing in these exercise 
programs. The amount of money that is currently going into 
Title III D, when you look at it on a per State basis, is very 
small, certainly very small compared to what is happening with 
respect to, you know, the Medicare funding that goes into acute 
care.
    No question, we have to turn the system around. We have to 
fund prevention first, and we have to do it now. You know, we 
have to really work on this now because--yes.
    Senator Braun. The main stakeholder should be the 
individual, and I found until we changed our insurance system 
and basically radically changed how we deliver it to emphasize 
that, we were not getting people to do it naturally. Employers, 
who are the biggest financial stakeholders in the whole current 
health care system, have got to wake up and start doing things 
that are different from what they are being sold by an industry 
that is increasingly dominated by large corporations that I do 
not think really have the incentive to change the dynamic. I 
know when I wrestled with it, I did not see that happening. I 
just have got to vent that because I think we have got a long 
way to go. I see them digging in here through all the 
committees that are trying to fix the current system to where 
it is going to be a battle.
    Dr. Hughes. I think Medicare Advantage programs could 
definitely be encouraged in terms of incentives, regulations, 
whatever; they can be encouraged to cover programs like Fit & 
Strong!, other evidence-based programs. It is a win-win in 
terms of, you know, they save money; their beneficiaries have 
better outcomes. They can use it for marketing purposes, and it 
is such a win-win. They can get a gold star for quality.
    Senator Braun. Thank you.
    Madam Chair, I have got to jump to another committee 
meeting. Anybody else want to jump in?
    Dr. Tanzi. Yes, a quick comment. You know, when I meet with 
insurance companies about the importance of lifestyle 
interventions, for example, along the lines of SHIELD, they 
say, ``Where are the clinical trials?'' and, you know, we have 
a lot of biological data about what exercise does for new 
neurons being born in the brain and all of these things, but 
who is going to do the clinical trials on a lifestyle 
intervention?
    At McCance Center, we are doing an exercise and sleep 
trial, but we really need NIH funding to start funding trials 
no one else is going to do to show the evidence to health 
insurance companies. Yes, in a clinical trial, sleep, 
meditation, exercise, diet does make a difference, and that is 
something you are not going to get companies to do, and so I 
think the Government maybe could pick that up and help us to do 
it.
    Senator Braun. Go ahead.
    Ms. Dickerson. One of the reasons why we are working so 
closely with Jackson Lab and putting together this Alzheimer's 
Initiative at the Bangor YMCA is because we have been told that 
the Alzheimer's actually started 20 years before it becomes 
apparent. We want to be able to do whatever we can with our 
community during that 20-year period of time to find out what 
can we do differently. We know exercise can help. We know diet 
can help. We know socialization can help. We know optimism can 
help. We want to be a part of that during that period of time, 
and so we need to work together as a group--the Jackson Lab, 
the Alzheimer's Association--to try to find every way possible 
to curb what can happen during that 20-year period of time.
    Senator Braun. Thank you. Brian?
    Mr. Long. As an older American, I have tried to practice 
and I try to encourage people I talk with that they can do 
anything. We are just going to do it a little slower than we 
did before, but we try to get our--I work with a group of 
people at one facility where we used a tai chi video, and I 
engaged in tai chi with them just to get them started on this 
thing, because some of these folks had a difficult time walking 
10 feet.
    Now, you know, you can say, can we undo some of the things? 
Yes, we can. We can undo things with coaching, with positive 
messages for many of the people who are there right now and 
have these difficulties, I think. I agree with you, when it 
comes to the imperative that employers have to use with their 
staff, that if we are going to have substance abuse--and that 
includes tobacco--then insurance is just not going to be there 
for you, or it is going to be really expensive.
    Senator Braun. Thank you, all of you. Keep up the efforts.
    The Chairman. Thank you, Senator. I know that you have to 
leave, so I tried to give you a bit more time since you will 
not be here for the second round. Thank you for being here.
    Dr. Tanzi, in your book ``Super Genes,'' you challenge the 
conventional wisdom that genes are your destiny, and you wrote, 
``In the vast majority of cases, your genetic destiny is not 
set in stone.'' That idea challenges the basic biology that a 
lot of us were taught over the years.
    In light of the growing evidence that you have accumulated, 
I want to probe more deeply on this issue. If an individual is 
genetically predisposed to an age-related disease like 
Alzheimer's due to carrying a specific gene, to what extent do 
you believe that lifestyle factors can delay the onset? Are we 
talking about just changes around the edges, maybe a little bit 
of a delay? Or is this really a significant breakthrough that 
that senior should adopt?
    Dr. Tanzi. Yes, so the idea behind ``Super Genes'' was to 
explain to the public about epigenetics, and that means that, 
you know, you are not going to change the DNA you are born with 
and you are inheriting around 50 or 60 million variations in 
the DNA versus everyone else from your Mom and Dad, and some of 
those will directly cause disease, so about 2 or 3 percent of 
disease gene variation is causative. We say ``fully 
penetrant.'' It guarantees disease, and those are the very 
unfortunate cases in Alzheimer's and heart disease. It means 
you are going to get onset earlier, too, usually under 60. It 
has a familial pattern.
    The vast majority of genes we have discovered--for example, 
all the ones we discovered for neuroinflammation, which is the 
biggest killer of nerve cells in the brain, those gene variants 
do not guarantee the disease. They just kind of put the immune 
system in your brain on a hair trigger or the knife's edge, so 
they are ready to--your threshold is lower, so that once you 
eat too much junk food or do not get enough sleep or you are 
not exercising, those genes will say you are more likely to now 
get inflammation and start to go downhill, but you can do 
something about it. It is good to know that you are on the 
knife's edge, and you get the kick in the pants to say, ``Wow, 
I do need to exercise more. I do need to get 7 to 8 hours of 
sleep,'' even if it with naps during the day. ``I need to 
change my diet to be more healthy.''
    When we started the Cure Alzheimer's Fund, for example, our 
mantra then and now is: Early prediction of disease, early 
detection, early intervention. Early prediction means know your 
family history, know your genetic risk so you know what you are 
up against. Early detection, know at what age you need to start 
looking at where the pathology is creeping up, for example, as 
Ms. Dickerson said, about 20 years before symptoms Alzheimer's 
begins. Then early intervention, so hopefully someday we will 
have the meds for our lab and other labs that will nip this 
pathology in the bud, but in the meantime, it is lifestyle that 
will make a difference for 95 to 97 percent of gene variants 
that you inherit from Mom and Dad that says the disease runs in 
your family, and if the American public knows that, they will 
not give up hope. They will be incentivized to do what they 
need to do to stave off disease.
    The Chairman. Well, that is just an extraordinary statistic 
and is one of the reasons we wanted to hold this hearing today 
to get the word out.
    You made a comment about amyloid plaque earlier, and, you 
know, so much of the research has focused on amyloid plaque and 
tau, and I think we need to broaden the horizon, which we are 
able to do now because, when I first founded the Alzheimer's 
Task Force in the Senate, we were spending only $400 million a 
year on the most costly disease that we have, not to mention 
one of the most devastating. If this bill goes through, the 
appropriations bill goes through, we will be up to almost $2.7 
billion a year, and what a difference I think that will make.
    I also cannot help but think that a lot of those clinical 
trials might not have failed if the pharmaceutical drug were 
tried much earlier in the disease----
    Dr. Tanzi. Yes, that is right.
    The Chairman [continuing]. rather than with people who 
already had so much cell death in their brains and were at the 
stage of moderate to severe, but I am not a scientist, 
obviously, but I do think that we can make a difference.
    Ms. Dickerson, I am curious because, as you know, we share 
a common commitment to defeating Alzheimer's disease. How did 
you decide to develop an Alzheimer's Program at the Y?, and how 
do you envision it working?
    Ms. Dickerson. Again, being in a State with such an older 
population and we do know that Alzheimer's can come to those 
that are older, and we also are in a State that in the past--I 
like not to say in the present or the future, but I do not 
think that healthy diet was a real long suit of the State of 
Maine. We are just seeing more and more of our population 
leaning toward that Alzheimer's direction.
    Of course, my own personal experience certainly gave me the 
fire and the passion, and I have several members on our board 
of directors, one of them Mary Hart, who I know spoke to you as 
well, whose husband has early onset Alzheimer's. There is a 
fire in all of us to try to bring more knowledge and 
information and education to this process.
    The reason we are partnering with Jackson Lab and with the 
Maine Alzheimer's Association is because we are not the 
scientists and we are not the brains behind this disease, but 
we want to work with them to help us know what we can do every 
single day to try to bring a reduction of the onset of 
Alzheimer's in our individuals.
    We know that physical activity is critically helpful. We do 
that so well. We know that socialization is critical. We do 
that so well. We know that diet is to helpful. We do seminars 
all of the time about this area of focus. We believe that this 
is one of the most important things that we can be doing in our 
Y to help serve our community.
    The Chairman. Thank you.
    Senator Casey. Thanks so much.
    Dr. Hughes, I wanted to start with you. The Chairman and I 
represent States that have a high senior population. Her State 
of Maine is a little bit ahead of Pennsylvania, but we are not 
far behind. We encounter a lot of these issues on a regular 
basis, even if we were not members of this Committee.
    One thing we know--and we all experience this or see this 
no matter what State we are from--is that seniors as they age 
are more likely to develop issues with both hearing and vision, 
as we have highlighted today. We are told that something like 
one-third of Americans 65 to 74 have hearing loss. In a future 
hearing, we hope to hear from a Pennsylvanian who is in her 
80's and who is legally blind. She will explain to us that she 
is very physically active through programs like Fit & Strong! 
As you outline in your testimony, research shows that people 
with vision and hearing loss have lower levels of physical 
activity. You have developed a model of your own specifically 
for people with low or no vision.
    Here is my question: If Medicare offered a standard hearing 
and vision benefit to seniors, do you think that more people 
would participate in evidence-based programming like Fit & 
Strong!?
    Dr. Hughes. I do not think there is any question but, you 
know, that there would be greater participation. When we 
developed the low-vision/no-vision version of Fit & Strong! 
working with the Lighthouse for the Blind in Chicago, the first 
thing we did was to do focus groups with potential users, and 
when we did the focus groups, we found that the folks with low 
vision felt very, very challenged by existing physical activity 
programs. They would go to senior centers. None of the staff 
there would pay any attention to them. Nobody helped them to 
use the equipment. They were basically just kind of--they would 
stumble around, and they even had difficulty getting to the 
senior center in the first place because even negotiating their 
neighborhoods and traveling and so on and so forth is a huge 
access issue. We asked them, you know, where do they usually 
exercise, and usually they exercise in the hallways of their 
apartment buildings because they are safe.
    We think that vision loss is a very, very important 
barrier. No question, it should be included--we should be 
addressing it. These are very, very basic impairments--vision, 
hearing, dental--that should be included in Medicare going 
forward.
    Senator Casey. Doctor, thanks very much.
    Mr. Long, I wanted to come back to you. I do not want to 
take you through a geographic recitation of the parts of our 
State you work in, but if you are traveling through Berks 
County, Lebanon County, and Lancaster County, you have got 
serious territory to cover and a lot of diversity. We have got 
significant-sized cities in those communities like Reading in 
Berks County and Lancaster in Lancaster County. Lebanon County 
has smaller towns, but still Lebanon itself, the city, is 
significant and then you also have vast rural areas, a lot of 
agricultural communities, and a lot of small towns.
    When you are traveling through that vast region of 
Pennsylvania and you are delivering presentations on healthy 
aging, can you share with us some of what you both hear and 
what you talk about, the topics that you talk about and how 
they are related to promoting healthy aging, and what you hear 
in response?
    Mr. Long. I hear things from people talking about 
affordability of medication for one. I just heard that one 
yesterday a couple of times.
    I hear things, particularly in the rural parts, about the 
absence of reliable transportation, particularly for people who 
have vision loss or mobility loss or hearing loss, because it 
is really difficult to get to services and to get to providers 
of services. I mean, in our partners, we have YMCAs, YWCAs, rec 
centers as partners, but, you know, if you just do not feel 
comfortable or you cannot get there, you cannot participate. 
That is the killer in rural parts of the world and as you know, 
I mean, Lancaster and Berks counties have been high-growth, and 
it is difficult getting from one to the other. I now allocate 
almost an hour just to get to meetings.
    I hear all of those things, and I hear--I go to a great 
deal of Alzheimer's support meetings, too. I need to hear what 
people are saying all the time. In fact, 1 day I went to 
volunteer at a memory care unit just to help and find out what 
people are dealing with and talk with people. I have a number 
of friends who have dementia, so I hear all of the things, but 
I hear the things that lead up to these things--access and 
hearing loss and vision loss. These are things that are 
impediments that are out there that will lead to a worsening 
outcome as you age. They just do.
    I would like to find transportation assistance, I would 
like to find medication assistance, I would like to find 
hearing and vision and dental assistance for the folks that 
talk with me. I am kind of nosy. I ask everybody questions all 
the time.
    Senator Casey. Thank you for that.
    The Chairman. Thank you, Senator Casey.
    I want to once again thank all of our witnesses for sharing 
your expertise and experience with us today. We have learned a 
lot about the importance of living and maintaining a healthy 
lifestyle to stave away declines associated with aging. We have 
also learned the critical importance of having resources to 
support that mission.
    I find it so exciting to learn that each of us controls our 
own destiny to a certain extent, and that the programs, whether 
it is Fit & Strong! or the Y's programs or Mr. Long's programs, 
can really make a difference in our communities.
    I do not think, however, that most Americans know that, and 
that is why during Healthy Aging Month, which this is, I wanted 
to hold this hearing. Awareness is increasing, but I hope as 
the BOLD Act, which is a bipartisan law that I wrote, goes into 
effect and gets funded with grants to State public health 
departments, that we can have more public education around the 
country on the need--on what we can do to stave off these 
degenerative diseases and live healthier lives, but also the 
importance of early diagnosis, treatment, assistance to 
caregivers, all of that I believe is so important and will be 
enhanced by our taking a public health approach to what is a 
real crisis since Alzheimer's, if we go on the current 
trajectory, is going to bankrupt our country, and not to 
mention the devastation that it causes for so many families. 
Like Diane, I lost my father last year to the ravages of that 
disease, and it runs very heavily in my family, having lost my 
grandfather and two uncles to Alzheimer's also. As you 
poignantly put it, it really starts many years before that you 
start losing your loved ones. It has been interesting to do 
comparisons in my own family and differences in diet and the 
age of onset, and there does seem to be a link there since they 
all exercised.
    I think we can learn so much from the research that is 
ongoing, and the programs that you are doing at the State and 
local level are just so important.
    This also is important given the aging trends in our 
population. Maine is the oldest State by median age in the 
country. As you mentioned, Pennsylvania is not far behind, but 
that is true of virtually every State except Utah, which has a 
very young population. We need to accept that this is a 
challenge that is going to affect our entire country as people 
are living longer, which is a good thing.
    Thank you for increasing our understanding. Thank you for 
the work that you are doing. It really matters.
    Senator Casey. Thank you, Chairman Collins. I want to thank 
you for holding this hearing, and we all received reminders, 
and certainly reminders that I needed, about, just by way of 
example, diet and exercise. I was----
    The Chairman. Sleep.
    Senator Casey. And sleep. I was paying attention to all of 
them, so I have got to try to get a head start here, but we are 
grateful because we know the challenges that folks face when we 
are aging, and we also know what we can do to provide 
opportunities for healthy aging. Part of that is programmatic 
and policy in terms of Medicare, Medicaid, Social Security, and 
the Older Americans Act, as I mentioned, how important that 
programs are for healthy aging, but this is not the case for 
everyone. Our witnesses today have given us evidence that we 
need to support policy improvements that will allow even more 
individuals to reach that milestone age of 100. May it be said 
that we have--we are having more people reach that age. I hope 
we are able to turn these policy recommendations into reality.
    I think, Ms. Dickerson, you said it well in the last part 
of your testimony when you said, ``Aging is not losing your 
youth but, rather, a new stage of opportunity and strength.'' 
That is a darn good summation of, I hope, the work that we do 
in this Committee and the work that we should be doing going 
forward, not just on aging itself but, of course, on healthy 
aging, approaching these issues with that attitude, that it is 
a new opportunity, a new stage of life.
    Madam Chair, thank you for this hearing, and I thank our 
witnesses.
    The Chairman. Thank you.
    Committee members will have until Friday, October 4th, to 
submit questions for the record, so you may find some 
additional questions coming your way.
    Again, my thanks to our great witnesses, to the Ranking 
Member, and to the Committee members who were able to come 
today. Unfortunately, there was an awful lot going on today, 
but I can assure you that many of them will look at your 
testimony and have received the materials.
    I also want to thank our staff without whose assistance we 
would be unable to put on these hearings and do these 
investigations. Thank you.
    This concludes the hearing.
    [Whereupon, at 11:42 a.m., the Committee was adjourned.]

   
=======================================================================


                                APPENDIX

     
=======================================================================


                      Prepared Witness Statements

=======================================================================

[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
      
=======================================================================


                        Questions for the Record

=======================================================================

[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
=======================================================================


                        Statement for the Record

=======================================================================

[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

                           [all]