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It's my pleasure this afternoon to introduce our speaker Dr Lorraine Mion. Dr Mion is the Director of Nursing Research and Geriatric Nursing at Metro Health Medical Centre in Cleveland. Previously she served as the Director of Nursing Research at the Cleveland Clinic Foundation and the Director of Outcomes Research at Mount Sinai Hospital in New York City. She currently holds faculty appointments in Kent State University College of nursing and Ursuline College of Breen School of Nursing where she teaches graduate geriatric nursing and nursing research courses. In the coming years she will be the visiting professor through the Independence Foundation at the Vanderbilt School of Nursing. Dr Mion has focused her research on acute care and geriatric issues, as well as on models of care within the acute care setting. This afternoon's topic will be ageing in the 21st century, living long and well. Support for this lecture today is provided by the Bagony centre at Saint Bonaventure University and the Mari Baker Lau and Catherine Lau Hombre Fund to which we are indebted and now please join me and giving a warm welcome to her first visit to Chautauqua to Dr Lorraine Mion. Thank you. Good afternoon, I am just sorry that it's such a miserable weather time for us all here. And what I was asked to talk about then was what are some other things that we know about not only living longer but living well. And this is certainly isn't a news flash for anyone but we know that our population is living longer and it has been referred to as the Longevity Revolution, the graying of America, the silver Tsunami and that like that one don't you? We are going to hit it like a wave. And when you think about it it's really only been fairly recently in human history that so many individuals have lived to be 65 years of age or older, and in fact it really wasn't until the introduction of Suvar systems that people lived as an average beyond the age of 35. So when we talk about life expectancy well, we are talking about is the average number of years that a human has before death, and conventionally it is at the time of birth that they discuss life expectancy. Lifespan on the other hand is that fixed number of years that a species has, and for human beings the Lifespan has been estimated at a 115 115 to a 120 years. Life expectancy is of what keeps increasing getting closer and closer to that life span and so, in 1900 people born at that time, had an average life expectancy of living until 47 years. Today I am sure you have heard recently in the news that in the United States it's now at 78 years. Now, also I am sure you have heard in the news is that the United States is trailing other industrialized countries that we rank 45th out of all of the countries in in the world in terms of our life expectancy where as the small country of Andorra has a life expectancy of 83 and a half, the poor people in Swazi Land have a life expectancy of 32. So, again looking at what is the type of care and rates of Healthcare that we have in different countries thus impact as a group the population life expectancy. So, the face of America is changing and not only are more people reaching the age of 65 the group that is termed as the oldest old those that are 85 years of age and older that's the group that's the fastest growing group out of any other age span in the United States as compared to a 100 years ago those that are 85 years of age and older are 34 times larger than what we had a 100 years ago. So, it is really the not only those 65 and older but that is just the growing length of time that we have. So what is old? What does it mean to be elderly and why did we even have the age 65 to denote old and just as brief reminder is it that we picked that our country choose that in the 1930's based upon what this mark and pressure choose in the 1880's. It was based on a public policy that in the 1880's only three percent of the population lived to be 65 years of age and older, so setting up a social security system for only three percent of our population made a lot of sense from a public policy perspective in terms of what would be taken out of the covers, but now we know that really not the case of what we mean by older by aging, and there are common traits of the aging process that are the same or universal across all species. The first of them being is it that mortality or death rates increase after the maturation has stopped for the species, the second is it that biochemical composition, changes as we aged, third is that the physiologic capacity decreases and last we have an increase of vulnerability to disease and infection. But we all know that people age at different rates, and I am sure everybody can give stories and I am sure that there is a number of youth here in the audience, people who are in their 90's going into their one hundreds that are still very vibrant, still very active and we probably all can give stories of people that we know who are only in their 50's or 60's and we say, oh my I would have thought they were 20 years older than that. You know, so again we age although we all have a primary aging process the rate of that varies and that's in terms sometimes a secondary aging process, and there is a number of factors that account for that and certainly genetics is one piece, do you remember the old saying that if you want to live long choose your parents wisely, but what we have found with studies is it that really the genetics, or the hereditary piece of whether or not it's slows or it speeds up your rate of aging, we can only a tribute about 20 percent of life expectancy to genetics, so in another words we can't blame up parents, there is other factors such as lifestyle factors that make more of an impact smoking, nutrition, exercise, how you handle stress? All of those can either be protective or they can be more harmful in terms of in addition to the primary aging. As yet we don't have any one definite theory on aging, and that there are several theories and there is a bent made among scientists for years looking at this and certainly a lot of investment by companies because if anybody can come up with that elixir, that founder of youth they are going to make major dollars, no doubt about it. One view, one of the most common views is the Wear and Tear Theory, that as you go on the body starts to have a varying defects in their cells, and if the body can repair this for a while, but eventually we were out, and we die. That's the simple Wear and Tear. Another one that is a fairly common theory and it has a number of evidence or degree of evidence contributing to it is the Oxidative Stress Theory, and what that theory possess is that as we metabolize our oxygen, we have the components that are called free radicals or radicals, that over the years accumulate and it's these radicals than that cause damage to our cells, and there has been some studies that have shown that giving large antioxidants doses of say Vitamin E to animals will delay aging, and there has been now some growing level of evidence that diets rich in anti oxygen do help prevent or delay the unsent of an of a number of diseases, cancer, Parkinson's etcetera. So there is the Oxidative Stress Theory. There is still though that genetic theory, we do know that longevity is greater and people who have family members who are very old again into their one hundreds, now whether or its one single long age gene or whether its several different genes that are for anti disease or disease resistant, they still don't know. But again that's part of the work they are looking at is whether or not gene therapy or alteration with genes may help us with aging. And then there is other various lines of enquiry whether it's with the DNA, the immune system, the endocrine system, certainly you know, that there is the issue of whether or not we should continue to take some hormones to keep us vital and young. But again these are all different trains of science enquiry of what can help us with maintaining our age. So let's go back again, what do we old? And what do we mean by being elderly and what did the elderly look like? So when we are speaking about older people who live healthy, vibrant lives or at the nightmare that we are going to have millions of people who are ferial, disabled and dependent upon their family and society. And these questions truly do have major implications for designating policy. There is two schools of thought in terms of what life increase life expectancy can mean to us as a society. The compression of morbidity from Dr. Fritz back in 1980, and then there is the expansion of morbidity. And I would like to think of these as, well the glass is half full or the glass is half empty approach to this. And by the compression of morbidity, what Dr. Fritz contended was that neither only are we living longer or projected to live longer, we live longer without major disabilities, without having problems with the chronic illnesses that would impact our functional independence. The expansion as to on the other hand say "No disabilities are pretty much going to still come along at the same rate they always have, that means not only are we going to live longer, we are going to live longer with disabling effects". So far, the statistics have been supporting the compression of morbidity theory, thank goodness. And we have had numerous surveys, numerous studies that have follow cohorts, large cohorts of people over several generations, and one major study in the United States is the National long Term Care Survey and the extend and the intend of that is to look at what is the extend in patterns of disabilities among people who are aged 65 and older. So starting in 1982, they started sampling 1000s of people who were 65 years of age and older and every five years, they add on additional people who are over the age of 65, so we can follow people overtime as well as compare as people enter over time against each other in terms of cohorts. The survey looks at what is the person's activity of daily living. You know, in geriatrics in my specialty, our whole concern and our whole major focus is function. Your cognitive function, physical function, we don't look at any one disease or organ like the heart. But we look at what's your function. So the activities of daily living are those that are very that are very necessary to be able to take personal care of yourself bathing, dressing, being able to transfer in and out of bed. The survey also ask what they call "instrumental activities of daily living" the ability to maintain your residence and your ability to interact with the community. So doing housework, cooking, doing shopping being able to manage your medications and your money. And so the Manton group Dr. Manton and his associates, out of Duke University has recently published looking at cross sectional slices of this data from 1982 to 2004. And what they have shown is, is that those rates of disability have kept decreasing. So for each new group coming in at 65 years of age and older there is less a disability among people. And then recently Dr. Jason Connors and his colleagues at Carnegie Mellon actually follow these people overtime. So again looking at 10 years stretches of time with these people and again we have found what we are showing as a population, now this is group statistics. The answer of disability is being pushed back into the later 80s versus when it was in the 70. So again, this compression of morbidity seems to be holding out. So coming back to the question of what do older Americans look like actually quite healthy, we know that from these various surveys that there are no significant disabilities in 90 percent of people who are between the ages of 65 and 74 or in those who are 75 to 84 three out of four people have no significant disabilities and even when you go to the 85 plus we find that 40 percent o f the people have no significant disabilities. So again we are really quite functional, quite able to maintain our ability to live for a long, long periods of time. We also know from large population studies most older people who live in the community you know, for a while they are in the 80's there is all this fear that we were going to need an increase in nursing home beds. What we were finding is we have being closing nursing home beds. People are staying in the community much longer. We also know that most order people are mentally alert and most have a positive perception of their health stating that one asked they have got it to excellent health. We also know that older people are remaining in the work for for greater numbers, a longer periods of time. In 1995 okay, so we are talking about 12 years ago 42 percent of men 27 percent of women who are age 65 and older were in the labor force. So I am talking about under the table, we are talking in the labor force being able to be found by the bearer labor statistics. In 2005, 54 percent of men who are age 65 years of age and older are still engaged in the labor workforce, and now 37 percent of women and I know that there is going to be people who say well they probably have to do it to supplement their incomes, or they have to do it because of health insurance. And I challenge you what is the difference between those people who were in 1995 versus those people in 2005 that we are seeing the sudden huge increase in the amount of people who are staying actively engaged in the workforce, and I do believe that's because more people want to stay engaged in the workforce you know, whether its in their same profession or doing something different, but that that is what did they they choose to do and want to do. Also we know that being able to stay in the workforce is partly do because many of our jobs are less physically taxing but the concern is that right now the baby boomers have comprise half of the workforce, the labor workforce and we don't have the numbers of young people coming and to replace the baby boomers and in the next ten years as the baby boomers do start to retire, and so a lot of companies have starting to look at their work processes, look at their work environment to be able to accommodate us with that. So for the instances an example at Metro Health Medical Center we have been ageing nursing workforce. So we have the double way of a shortage of nurses and that in ageing nursing workforce. One out of five of our nurses are in their 50's and then another third are in their 40's. And we know from studies we know from surveys that as we age we cant tolerate the options as well physically. We can't tolerate the rotating shifts and it is also harder to handle the long hours many young nurses coming out one will work the 12 hours shifts. The older nurse's stamina can't to do that. We also have into generational of differences if that have been cropping up lately in the literature as well as that are on site never before have we had up to four generation of nurses working side by side on the same unit, so we have the veteran nurses those that were born before the '46 the baby boomers the generation Y and the X says and of course I am sure you guys are not going to be surprised, but that the older generations the baby boomers and the veterans they claim that those younger nurses just don't have that same work effect that we did. So again it is trying to find the values and being able to handle that stress and there is many companies that are looking to engage the ageing individuals with the workforce and looking out ways that the environment and the processes can help handle it. We are looking at having for all of our ageing members know lift policies, having the machinery and technology take care of that, but on the other hand then we have some of our maintenance people and house workers they don't want the technology, because they are afraid, then that they loose their positions. So, we have to balance then the needs of the work force but then still not having the injuries that occur with the ageing. For nurses were offering shorter shifts for them, were offering them different carward roles that they can do without the physical taxing. I can certainly say from my own personal experience once in a great while I will help out on the floors if they are really short or trying to cover for vacation, and I still remember going up to the unit and I couldn't read the little pill blister packages. So hearing I am taking my bifocals off and I am holding the pill blister in this hand and the order with this one and a young nurse zipping by me saying although I do feel better that you are helping us out, well that's what I am here for. So, again of you know, what can the environment to be done to help us as we continue with our ageing. Now, one of the things I want to go into now you know, setting the stage of we are here and we are here to stay is there are so many stereotypes I think out there, about ageing and what I want to do is just go through some of those and the first one is most older people are sick, they are disabled they are in poor health. Well we have already discussed this statistics related to physical disabilities and functioning and again staying engaged in the workforce. We know that more than 80 percent state at the young good excellent health. The fact is yes, we do have more chronic illnesses as we age that that's not gong to go away. But they don't necessarily impact our overall quality of life. Second stereotype and I know that there was a speaker earlier about dementia. Second stereotype is dementia is an is inevitable. We are all going to have it if we live long enough. And I think that is one of major concerns we have with ageing. None of us want to have that to happen to us, but it's not normal and it's not inevitable, you have heard probably this statistic that four to five million older Americans have dementia. Have you all heard that number? We will reverse that, that means 35 million don't. You know, so, again with statistics it does help us look with where we have to put in some major policy implications, but it doesn't mean then that this is what is going to happen inevitably to all of us and if dementia was inevitable you would expect to see people in their 90s going into 100 to inevitably have dementia and yet we know that significant proportions of people that are at these advanced stages do not have dementia. Third stereotype, majority of people are socially isolated, well we know that most elder adults live with somebody. Whether it's the spouse, a child, a sibling, a friend we know form these different surveys that most people live with somebody. And recent surveys have shown that most older adults who live alone do sell by choice. So again it's not so much that there is a decline in the social that there is a decline in social activity but that social networks can't stay stable. Fourth stereotype, older adults are depressed and you look like a depressed group. So when you look at it major depression is less prevalent in the older age cohorts than in younger age cohorts and most older adults regardless of their disease or their condition still consider themselves happy or content most of the time. Now obviously we are all going to have down days and times when we think, oh boy you know, I don't know about this but, we we do tend to see that most people stay happy and not in major depression. My favorite aunt I was just hospitalized again this past week for Pneumonia. She is you know, got seal PT and she does have bouts of Pneumonia has to go in for IV antibiotic, so we drilled down to see her on Saturday and she was out of the hospital that day and then started on the oral antibiotics and was very cheaper, very you know, smiling and happy and say how are you doing Rossi? She said she know, she is said the first tonight I am sitting their crying to myself, here I am in the hospital again with Pneumonia and the IV and then I thought well why do I have to be said about, I am in a hospital and they are taking care of me. She said its okay, I got up and wrote a book and put on the TV, so again it's you know in spite of some of the things that you would think to be causing it, many older people do not have major depression. Fifth stereotype, most older adults are poor. Now certainly, there are a number of older adults who were in poverty, but as they grew up they have half of the poverty rate as other age groups, and in fact many of them help out their children or grand children, whether it's with college tuition or other some major purchases. So again as they grew up older adults are not poor. Sixth stereotype older adults are feeble and frail, well we already talked about again maintaining themselves in the workforce, maintaining their social independence and we also know in terms of volunteerism, that people, that 38 million people who are over the age of 55, they estimate that that the volunteer work these people do accounts for 20 million fulltime equivalence in the workforce annually, that's that's impressive. So then the question comes okay, so we have these broad statistics of how long do you want to live? And for most of us when you ask that question, how long do you want to live, you don't necessarily give a number you just say that you want to live well, and that you want to have a very short amount of time, that you would not be living well, and there is a growing body of evidence from a number of studies that have found whether they can help to guide us, and for those of you interested in this certainly any thing by Dr. Thomas Perls, said that P.E.R.L.S, who is at Harvard and heads up the New England study on Centenarians, has done a number of works on this whole aspect. Number of long term cohort studies that have looked at factors that impact functional decline, various diseases such as heart disease, Parkinson's. And we now know a number of risk factors that we can do something about its not genetic, and what I like to do then is to go over just a few of these that these are common factors that they have found in these various studies, and to remember that it's not necessarily about too late, to institute some of these things, and what we talk about them it is certainly that whole combination of physical, mental, spiritual, when we talk about the approaches to this. So just going through first exercise is the top most important preventive factor, followed by diet, to dishes use of supplement, not the size that that two dishes, making sure you stay hydrated drinking water, not smoking, avoiding excessive alcohol intake, and sun exposure, and maintaining relationships. So exercise, we know that exercise even when introduced to people who are in their 80's in nursing homes, the most ferial, that they have improvement in physical function. We know that with exercise you can have reduction in a number of diseases, heart disease, diabetics, osteoporosis, and that it's certainly does help with improvements in a number of not only physical issues, such as bone density and muscle mass, but also in our functional capacity and in our mood. When we talked about diet hydration and judicious use of supplements, it's you know there is much out there about proper nutrition, and it has been pretty much acknowledged that it's very difficult to get exactly all of the minerals and vitamins you need just real a normal diet and so in that regards, that's were the judicious use of supplements come in. And especially for example with women pose menopause needing that additional calcium and vitamin D, so there are certain supplements that probably would be wise to take on a routine basis. We know that with diet that it's certainly does affect not only such conditions such as Osteoporosis it's an important piece of treating or preventing further declined from certain diseases such as diabetes or heart failure. We also know it's important for preventing falls and the injuries subsequent with falls. It also helps in terms of our social functioning, by having that diets or nutrition that we then do with people who are outside of ourselves will also then impact again that whole set. In terms of smoking, is just bad, bad, bad. You know, that that just don't do it. Drinking now however alcohol is a little bit different and when they first came out with these studies about, it was okay to have a drink, I could remember the cardiologist at the Cleveland clinic just having a fit that now we are going to have all these people going out drinking large amounts of alcohol and ruining their liver and ruining their heart in the process. So, where we are now is that again it's the small amounts of wine especially can actually have a protective effect and can be careful as we get older, we metabolize it differently in the same amount that you might drink when you are in your 40s or 50s. you know, when you are in your 70s or 80s, it might be enough to make you fall and break your hip. So you know, you have to again be careful with that. Sun exposure, it's still important. And I don't think we have to worry about that today. Watching the amount of sun exposure that one has and again with the problems with skin cancers. Relationships are very important and I know that for you know those of you who were here yesterday that Dr. Campbell spoke on the importance of maintaining relationships. And we talk about our networks and the social networks with family, with friends and our formal networks you know, whether it's our group organization through church with our professional organization and what they have shown over and over again in so many different studies is that it does predict longevity, the importance of staying connected to one another. It helps decrease depression, helps decrease isolation. It does improve as I said before your nutrition as well as your physical function and cognitive function by staying connected to each other. Pets can help do are any of you pet owners? Okay. There are number of people and they have and what they have shown is that pets can help decrease stress. They have actually drawn Cortisol levels and found that the Cortisol levels associated with stress drop when you are petting a cat or a dog, may can increase our also with lower blood pressure, fewer visits to physicians, maybe more the vets, but fewer to the physicians and they also found there is a study back in the 80s, just a classic that when they followed up people who suffered acute mild cardio infarction and were hospitalized for it filed them up a year later, they found that those who had pets, who were pet owners, their survival rate was 12 percent greater than the non pet owners and this was even after controlling for the sub variety of the heart attack that the person has. We know that you have to maintain your activity with the pets, they do decrease loneliness, they do decrease depression and it encourages nurturing among us. Religion and spirituality, spirituality is important. It isn't the religion, it isn't whether you are Christian, Jewish, Muslim, it is that sense of spirituality and there have been now I mean one review they stated over a 1000 studies, examining that sense of spirituality related to health. And what we know is that it does have a protective effect that sense of having that deep spiritual connectedness can happen then with recovery from whether it's a major trauma event such as hip fracture, whether it's with cancer, blood pressure, again depression that this sense of spirituality can help with recovery but then again in cases where it doesn't help with recovery, it helps with coping. And again, it's a very important piece of what is our quality of life. I am just going to say a few words about fear of forgetting, because I think that that is one of the major concerns that we had as we age. And there are changes that do occur with aging. I mean there is no denying at that we have some changes that occur. It takes longer to process stimuli as they come in you know, I will take just a few seconds longer. Our reflexes aren't as fast, that's why they have mandatory retirement for airline pilots of that not having that same level of reflex action. It does become a little bit more difficult to sustain focus to tension for a long periods of time have any of you with your grand children for instances they are sitting there testing their friends they got the iPod, they are doing there social work paper on the computer and the TV is going on in the back ground and yet they seem to do okay. You know that is harder to do when you get older, and so that's just part of normal ageing. We know that that basically our vocabulary remains the same, our verbal reasoning doesn't change that the normal ageing changes that do occur do occur, do not impair our cognitive function. So when we talk about I acknowledge you had this talk again just to keep in mind what you do to maintain your cognitive function, is that old saying "Use it or lose it", and its been shown all over it has the non- study, you heard about the non-study that those non's I kept being doing new or normal things different types of crossword puzzles, had less cognitive decline that the none that have did the same, activities the same routines over years. So mix it up a little bit, it's good for you. And then of course the diet and exercise that has also been shown to be connected with the mind and how important that is to keep keep of that going. So let's talk now in the last few minutes what are some practical preventive health strategies you could be doing even now and so the first and really I guess you know you could say well or that makes sense is having your routine screening checkups. `You go to the dentist to make sure you don't have period down till disease, that you don't have gum disease. Because that chronic inflammation adds to the stress on the heart as well as the stress on the pancreas and has been shown to be associated with cardiovascular disease and with diabetes, so when he tells to you have to flue more, I just had this yesterday okay I will flue more. You know but again to keep in mind going to the dentist, going for your routine screening for Colon Cancer, for checking your cholesterol, checking for the level of your glucose to see if you are pre-diabetic and whether you need to start putting some interventions in place now. So going for your routine preventive checkups is so important. I come from my background is mostly acute care, there are two thing that I think you need to be doing to keep out of the hospital, I don't want to see any of you in my hospital. Make sure you get your influence of vaccine, it may not prevent you getting the flue but it will help to decrease the severity of symptoms of the flue even if you never had it you don't like it you want to stay away from it you know leisure allergic to it take the flue vaccine very important. The second is watching your own activities and behavior we are at Trauma hospital center we fly people in from counties and some times even from neighboring states to our center because of trauma. We have been seeing as have all other regional trauma centers and increasing number of people coming in because of head injuries and fractures from falling and it isn't what you think of you know when you see the commercials of the little lady with her walker and the she tips over now these are people cleaning out there gutters they are trimming their tree limbs they are doing things that they might have done 20 or 30 years ago and kept there balance but now because remember with the ageing changes we have to acknowledge some changes and some of them are that are centre of balance is of a little bit. We have more sways as we get older. So activities that disrupt the centre of balance can be enough to have your top or lower and then to sustain that trauma and so obviously things again such as exercise to maintain balance Thai Chi is wonderful and I know because my mother was having a problem with falling started Thai Chi and her balance is much better. As well as strengthening exercises are pelvic muscles and quadriceps do become weaker with ageing so if you can get those strengthen your help be able to maintain yourself for a longer period. The other thing I want to talk about is driving. Now this is something none of us ever, ever want to give up, but if you find yourself in increasing number of fender benders, you don't even realize from where that car come from. I didn't even see their post or I didn't even have what was happening. Start to acknowledge your reflexes aren't just fast and that input and stimuli is not as good, and you know it would be an unfortunate thing for you to be killed or harmed or for somebody else to be killed or harmed, and so a very difficult topic and if you have even more ageing parents or relatives, this is something that everybody is uncomfortable about discussing, but again these are the people who are seeing in our hospital settings. So preventive practices of your behaviors that might put you at increased risk think about it because it takes less trauma for you to have a major disability than for a 20 or 30 year old could sustain the same amount of trauma, and not have any disability. Okay so that's it. Now let's talk about life expectancy and I am going to finish this up and I open it up for question. Remember I told you that life expectancy can be calculated basically from any age and then predicting further. So when 2004, the average life expectancy for those and this is on average now okay for the population, was another 19 years, so at this year, 84 years of age, and for those who are 75 years of age and older you can add another 12 years to 87 on average that's the life expectancy. And if you are really curious to know what are your life factors that might impact they do have now a few calculators on the web. So if you were to go in and just typing to Google calculators and life expectancy a whole bunch of them will come up, some from insurance companies. But what that they have done is they have taken this factors from cohort studies and you put in and at the end they will tell you what your adjusted life expectancy is, sometimes its less sometimes its more, and what you might be doing to help yourself. So here is a little bit of a cognitive exercise for us at the very end now, lets hope we are 10 or 65 and start them at age 87, think about your attitude, are you optimistic and this is by the way from Thomas Perls, P.E.R.L.S, as I told you from the Harvard Center, a optimistic generally in good humor let things go that are stressful. If you can say yes keep yourself at 87, don't do anything. If you say no, I do get stressed out easily subtract five. Okay, everybody ready? So keep your your age now in mind, genetics do have at least one thing that you remember that lived into their 90s or longer, if yes add now ten years. Okay, everybody ready? Exercise, do you said exercise at least 30 minutes a day, three days minimum a week to exercise, if you are saying no, subtract five. Interest, do you do things that are did I go too fast?- nothing just keep it at zero. Do you do things that are cognitively challenging on a regular basis? If yes, add five. Okay, nutrition, do you have a diet that facilitates staying alive or my downfall, subtract eight if you do not. Smoking, this is the killer literally, if you are currently smoking subtract fifteen. Do you fall for the anti ageing scams or quackery and he has in this little course if you do, subtract another fifteen. I think he is trying to get this by going across. So add up your total and that would be if you are 65 what your what you would be in terms of the average life expectancy compared to the others. Okay, well and for those of you who are pass that give yourself a pat on the back? Thank you everybody.