University College London (UCL) – Written evidence (INQ0027)

A: Summary:

1. Scientific basis

• Common cellular hallmarks of ageing e.g. cell senescence, are well documented in animal studies however their role in human ageing is less well documented.
• Anticipated biomedical developments to contribute to the Government’s 2035 goal include imaging with other biomarkers for e.g. neurodegeneration, trials of established drugs (e.g. metformin), indication expansion of licenced drugs that are geroprotective (slow ageing and extend life span) in animals and wider use of senolytics (drugs to selectively induce death of senescent cells). Research to understand the ageing systemic (blood and lymph) environment is also likely to yield new approaches.
• Modifiable lifestyle factors and environment clearly have a role in ageing, however direct evidence quantifying the role of each, for example, is less clear.

• Practical impediments to the public health advice being acted on include difficulties in making lifestyle changes once habits are entrenched, and the adverse impact of commercial interests. Population level policy is likely to have a greater effect than individually targeted interventions.

2. Technologies

• Technologies to deliver therapies for home use are developing e.g. home haemodialysis, however further work is needed ensure they are used safely and effectively in people’s lived lives. For technologies monitoring healthy living issues to be addressed include why (older) people engage with them and how the data are monitored and used.
• Assistive Technologies (AT) can help people to stay healthy, productive and independent for longer, however more work is needed to improve development and access to AT. This will require a global mission-led approach, research and better data and testing and piloting. In addition, work by investors and governments will be needed to bring products to market and make them accessible, while community participation is required to ensure the AT solutions developed fit with the needs of users.
• Technology, including AT, is an enabler not a solution and implementation must be done with care. It can help a person understand and maintain or improve their physical and emotional functioning, thereby reducing the need for formal health support services and burden on carers.
• With regards to transport, older people need services within a reasonable distance and frequency and good infrastructure e.g. bus stops, pavements, benches, and public toilets, to ensure they can continue to be involved in the community and maintain their physical, and thereby mental, wellbeing.

3. Industrial strategy

• As illustrated for AT above, need activity at many levels to improve the pathway to impact.

4. Healthier ageing

• To achieve its 2030 goal, the Government will need to undertake early and sustained engagement with all stakeholders, and find new ways of working across professions and disciplines. There is a risk that a commercially driven model for technologies for older people may exacerbate existing digital and socio-economic divides. Involving local communities from the outset may help mitigate against this risk.
• The culture shift, whereby older people are seen as a full part of society, needs to start in education. Once achieved, it will be easier to encourage industry to modify its approach to careers. This would make working later in life easier and, for those able to and wanting to work, help their physical and mental wellbeing. The paradigm shift will require policies to enhance health across the whole of life.

B: Introduction

1. UCL is London’s leading multi-faculty university, with more than 13,000 staff and 42,000 students from 150 countries. UCL has a number of institutes, centres and individual research groups taking an active interest in understanding the ageing process, diseases of ageing and identifying interventions to prevent or improve the conditions and issues faced by the UK’s ageing population.
2. This document is based on contributions from the following members of the UCL community: Professors Ann Blandford, Yvonne Rogers, Nadia Berthouze, Dr Catherine Holloway and Felipe Ramos Barajas from the UCL Interaction Centre and the UCL Global Disability Innovation Hub; Professors Linda Partridge, Nishi Chaturvedi and David Gems from the MRC Centre for Lifelong Health and Ageing (LHA) and the UCL Institute for Healthy Ageing; Professor Diana Kuh, founder and former director of the LHA; and Professor Nick Tyler from the UCL Person-Environment-Activity Research Laboratory and Director of the UCL Centre for Transport Studies.

C: Scientific basis

1. Understanding of biological processes and epidemiology

1.1 Common cellular hallmarks of ageing, including genomic instability, cell senescence, disordered nutrient signalling, mitochondrial and stem cell dysfunction and altered cellular communication, have wide support from animal studies. The role of these mechanisms in human ageing is less well documented, but they clearly play a role in the aetiology (cause) of multiple age-related diseases.

1.2 Marked socioeconomic differences in longevity and healthy life expectancy highlight the important role of modifiable lifestyle factors (smoking, physical activity etc.), and environment on ageing, diseases of ageing and the potential for general improvement. Direct evidence, quantifying the role of each, the optimal timing of interventions, and the role of individual differences in response, is less clear.

1.3 Capabilities change as a person’s calendar age increases, but not all of these changes are downwards e.g. experience, coping etc. can rise. Collaborative research across disciplines to look at brain, body and mind plasticity with a view to understanding how coping and experience later in life is achieved and/or improved would be beneficial.

2. Understanding of effectiveness of healthy lifestyle public health advice

2.1 Observational data across the life course clearly indicate that healthy lifestyles are associated with longer life and health span. They also indicate the importance of the whole life course, i.e. optimising early-life reserve (e.g. cognitive, exercise capacity, respiratory function), maintenance of reserve in mid-life, and promoting resilience in later life to enhance healthy ageing.

2.2 Gold standard trial evidence, focussed on interventions in older age, is limited and conflicting, as a consequence of small sample size. It is also limited by a focus on short term mental and physical health outcomes, rather than longer term effects, and on treatment of well-established disease, rather than prevention.

2.3 Practical impediments to the advice being acted on include:

• Socially constructed expectations of what is “normal” as people age which can limit people’s expectations of themselves, and difficulties in making lifestyle changes once habits are entrenched in late youth/early adulthood.
• Adverse impact of commercial interests acting against the public health interest (e.g. smoking, alcohol, diet) and a widespread focus on short term pleasures over long term benefits.
• The mentality of policy makers is still in the era of the heavy industrial working life where life expectancy after retirement was very short. We need to facilitate a continuing active life, whether this is in work or not, and enable people to have the capabilities to be able to fulfil their ambitions throughout their life-course, retaining ownership of their life choices.
• Examples of good practice include: UK smoking policy (particularly since 2007), UK government policy/Food Standards Agency actions on dietary salt intake (2004-8); UK Soft Drinks Industry Levy; Ageing Well in Wales and social prescribing which is focussed on life quality rather than disease.

3. Anticipated biomedical science developments

3.1 We anticipate the developments to include:

• Biomarkers of the progress of ageing and risk of age-related diseases including methylation clock, changes in gene expression and levels of metabolites.
• Imaging with other biomarkers for various conditions including neurodegeneration, cancers, diseases related to vision.
• Trials of established drugs (e.g. metformin) with composite (multiple, combined) healthy ageing outcomes, as proposed in the US.
• Indication expansion of licenced drugs that are clearly geroprotective (slow ageing and extend life span) in animals, such as sirolimus. These have started for specific conditions such as the poor response of elderly people to immunisation against influenza. Such trials are likely to be extended to other conditions e.g. dementia.
• Senolytics (drugs to selectively induce death of senescent cells), in the first instance, are likely to be used for improvement of quality of organs for transplant and locally applied for osteoarthritis.
• The importance of the ageing systemic (blood and lymph) environment is being increasingly recognised and analysed experimentally, and is likely to yield new approaches in the medium future.
• Observational life-course data suggest that treatment of co-morbidity needs to start earlier, and possibly be more aggressive, to fully impact on downstream target organ damage. To date trial data to support this however are limited. In addition there is no evidence, as yet, that early diagnosis of disease will result in preservation of function and enhancement of lifespan, and there have been no clear successes in stratified medicine (i.e. identifying groups of people at high risk of multi-morbidity, or who particularly stand to benefit).

4. Behavioural determinants and social determinants of health in old age

4.1 There is fairly strong evidence that differences in lifespan by socioeconomic status, ethnicity and geographic region are at least in part due to health behaviours and environment, acting across the life-course. However understanding of the pathways responsible for social determinants of health is incomplete.

4.2 The current focus on individually targeted advice to change behaviour has limited potential for success – population level (government) policy is a far more effective tool.

D: Technologies

5. Technology needs and state of readiness of new technologies

5.1 There are ongoing developments in e.g. home haemodialysis[1] but much greater attention needs to be paid to developing devices for delivering drugs, and other therapies that fit well with people’s lifestyles/circumstances and are safe and easy to troubleshoot. Patients and lay carers have been found to adapt technology[2], sometimes inappropriately, to fit their lifestyles. Therefore better design, deployment and education is needed to minimise such adaptations. People also wish to communicate more seamlessly with their clinical teams2 e.g. sharing data from monitoring devices.

5.2 There are many ongoing research projects focusing on different contexts and health conditions monitoring and providing advice[3]. There is a growing body of literature showing that people need to both make sense of their clinical conditions (requiring personalised medical information/advice) and internalise what it means for them (requiring information exchange with “people like me”)[4]; this applies across the life-course, but particularly for chronic conditions, and is particularly challenging for people managing multiple comorbidities, and their families.

5.3 Monitoring of some kinds of physical activity (e.g. walking, cycling) is maturing, and include studies on older people[5]. The ‘Get A Move On’ network report also included a focus on older people[6]. Monitoring of other aspects of lifestyle (e.g. other sports/activities, diet, social engagement) are less mature and there are important issues to be addressed around what might motivate individuals to engage in/agree to monitoring, who does the monitoring and how insights are used, particularly where cognitive decline may limit the active involvement or informed consent of an individual.

5.4 Affective technology: There is a need for technologies to monitor affective states, and perceived physical and functional capabilities, in everyday life. This can: enable the application of self-management strategies to remain functional, despite chronic conditions (e.g. chronic pain[7], stroke) or simply ageing; increase self-efficacy and self-esteem; and ensure social engagement.

5.5 Assistive Technology (AT) - such as wheelchairs, hearing aids, eyeglasses, prostheses, and increasingly, mobile technologies - enable people to live healthy, productive, independent and dignified lives. Older people particularly benefit from AT[8]. The UK DFID AT2030 Programme[9] led by the Global Disability Innovation Hub[10], UCL, is currently testing “what works” to improve access to AT. The programme will invest and support solutions to scale, with a focus on innovative products, new service delivery models, and global capacity support.

6. Readiness and engagement with technologies to help people to live independently for longer

6.1 Technology is an enabler, not a complete solution. It is important to identify real problems and address them, understanding that one size will not fit all (or even fit the same person at different stages of ageing).

6.2 Technology has to match the user’s self-identity. Many older people do not identify as such, and do not want products for “older people”. What is needed is products that work for all (that are accessible to all, and potentially useful for all). There also needs to be a support structure for people who are unable to access services independently through digital communications.

6.3 Older people are strong uptakers of digital communications[11]. The use of software, such as Facebook or Skype, to keep in touch with family, friends and past acquaintances is high. However take up of devices/machines for daily living in the home is much lower.

6.4 Technology should help understand one’s physical and emotional capabilities and enable the application or development of strategies to improve those capabilities rather than only compensate for the lack of them[12].

6.5 AT and its related services help maintain/improve functioning and thereby promote physical and mental wellbeing and independence reducing the need for formal health and support services, long-term care, and the burden on carers.

6.6 London’s Freedom Pass, management of public transport and its density is better than other cities and rural areas in the UK, which plays well for older people who need services within a reasonable distance and at a reasonable frequency. However the associated infrastructure is less good e.g. bus stops and footways, and their installation, are often poor. The provision and design of benches and other amenities including public toilets are also particularly important for older people, as they support older people to go out and become involved in the community, in turn reducing loneliness and the consequences of mental ill health.

7. Technology to improve mental health and loneliness for older people

7.1 Digitally enabled communications need to add value rather than being used as a superficial substitute for meaningful interpersonal engagement. Voice interfaces and agents offer a new kind of intervention for being informative about health, providing companionship and connecting people but more research is needed to see how socially acceptable they are.

7.2 Affective Sensory Technology can increase confidence in one’s body and capabilities and self-esteem[13].

8. Barriers to the development and implementation of technologies

8.1 Barriers include: insufficient focus on the variety of “problems” that digital technologies are designed to address; insufficient consideration of the needs/values/situations of individuals and communities; awareness of the complexities of lives as lived and the places where technologies can add value.

8.2 To overcome these barriers we need to:

• Find better ways to engage with people in hard-to-reach and vulnerable groups and simplify the ethics process to generate opportunities to engage with these groups ensuring that the interests of patients are protected while also valuing the benefits of better understanding patient needs and experiences.
• Rethink data privacy and data sharing, including how individuals can manage data that relates to them for their own benefit.
• Support science, engineering and technology communities to better communicate outside their own domain and across age ranges to support uptake of new technologies

8.3 Innovations in AT often fail due to a lack of the following: R&D funding, investors willing to engage in developing new AT, early adopters and clinical trials and access to user testing. AT2030 launched the Innovate Now project[14] to help support AT innovators. The Scoping Study[15] found that cost is not the only barrier to use of AT. Issues, in the UK and elsewhere, include undeveloped policy frameworks, inefficient/non-existent markets, poorly resourced services, and stigma and discrimination.

8.4 To overcome these barriers in AT, as summarised in the Scoping Study report15, we need:

• A global, mission-led approach with measurable outcomes
• Research and better data to enable countries to understand the return on investment for AT.
• Testing and piloting market shaping
• Determined work on systemic interventions with national governments
• Harnessing innovation and new market entrants with a focus on leapfrog technology
• Community participation and capacity building

8.5 There is a situation where expenditure on policies for older people by one government department (Work & Pensions) benefits another department (NHS/local authorities) – this imbalance needs to be addressed.

E: Industrial strategy

9. Opportunities for industry in the development of new technologies and UK areas of excellence

9.1 The UK has excellent technical capability and entrepreneurship culture, supported by incubators, innovation hubs, etc. It is world-leading in areas including Human-Computer Interaction, imaging, AI and Human Factors. The UK science base in biomedicine of ageing is quite strong however exploitation of discoveries about mechanisms of ageing is predominantly led by the US.

9.2 Understanding what older people can do well, enabling people to do what they are good at, and designing work practices so that these can be utilised to the best effect, including flexible working hours, would be a huge gain in terms of enabling older people to work and bring in an income.

9.3 Developing the concept of a ‘career profile’ in which the aptitudes of people are regarded as malleable – some things become better as people become older and some things become worse. Working later in life should be made easier and less stressful, not just necessary until pensionable age, but because it is better for the person’s mental and physical wellbeing. For those who cannot, or choose not to, work for ever, this should be possible too.

10. Requirements for the commercialisation of the UK’s discoveries

10.1        The “pathway to impact” is difficult for companies to navigate when those companies are start-ups and SMEs. Companies need support in:

• Understanding and complying with regulations and standards (including GDPR and medical devices regulation, including developments in “software as a medical device” and techniques for validating novel algorithms)
• Developing products that are usable, fit for purpose and sustainable (e.g., following guidance in British Standards Institution PAS 277[16])
• Developing viable financial models, whether based on purchasing products or selling services, where it is clear who the purchaser is.

10.2        Scientists need support to engage with tech transfer and venture capital organisations in order to identify and develop opportunities for the commercialisation of discoveries/inventions.

10.3        In the case of AT what is needed are the factors highlighted in the AT2030 report (see bullet 8.4 above).

F: Healthier ageing

11. Strategies needed to achieve the Government’s aim

11.1        Success will depend on early and sustained engagement with all stakeholder groups, including local communities across the country. It also depends on finding new ways of working across professions and disciplines in ways that are courageous, agile and disruptive without being destructive.

11.2        Policies to enhance health across the whole of life will be required, including investment in education in early life, improved interventions to prevent and treat ill health in mid-life, and maintenance of physical, cognitive and social function in later life. The improvements in education are vital not only to improve individual health but also to equip our future workforce with the skills it needs to support an ageing population in a rapidly changing society.

11.3        Ageing in the future will take place in a very different context from the past and will be profoundly affected by phenomena such as climate change, air pollution, antibiotic resistance and social change. Policies around ageing will only be successful if they accommodate these changes[17].

11.4        Organisations to involve are those that have the capacity to make a difference and the openness to work together; for example AT2030 programme, GDI Hub, ATscale, World Health Organization as well as the Government as this is a cross-departmental issue. The work should be led by a trusted party with the longevity, resources and authority to provide coherent leadership over such a timescale

12. Inequalities in healthy ageing and differences in acceptance of technologies

12.1        There is a risk that a strong commercially driven model may exacerbate existing digital and socio-economic divides, leading to even greater health inequalities. There needs to be grass-roots engagement, involving local communities, from the outset to mitigate the risk of extending the divides that already exist and a focus on population-level interventions as individual-based interventions will likely widen inequalities in older age.

13. Implications of an ageing paradigm shift

13.1        A culture shift is needed to see older people as a full part of society where, just like in all other age groups, some will be engaged through working, others through volunteering, others in other ways, but all are seen to contribute to society. This culture shift needs to start in education, from school age onwards. Having achieved the culture shift it will be much easier to encourage industry to modify its approach to the career profile so that the best can be achieved by everyone throughout their working life.

13.2        It should be easier to ‘volunteer’ for things, and for bodies (e.g. charities and other social organisations) to employ older people in suitable roles without negatively affecting their pensions or tax situations. Organisations to be involved in supporting the changes as a result of the culture shift include human resources organisations, Age UK and HMRC.

19 September 2019