Professor Peter Gore – Written evidence (INQ0063)
Professor Peter Gore CEng FIMechE FRSA,
Professor of Practice in Ageing & Vitality at Newcastle University
1. How complete is the scientific understanding of the biological processes of ageing and their epidemiologies (including the relative roles of genetics, epigenetics, lifestyle, environment, etc.)?
It is widely accepted that around 25% of how we age is genetic, and around 75% is about the choices we can and do make. (1) At least some of the difference in health span between areas of different socio-economic status seem to be explained by less good choices being available to people from more deprived communities, and lower educational attainment.
The loss of independence with age can be considered as a hierarchical progression of impairments that cause functional decline resulting in the loss of abilities to perform Activities (& Instrumental Activities) of Daily Living. This is understood at a high level – but the detailed progression of underlying impairments and specifically their drivers, and the interactions with chronic conditions, cognitive decline, poor sleep, oral health, education etc, are not yet well understood.
Increasingly small pieces of evidence are emerging around biological responses to environmental and ‘lifestyle’ factors e.g. brain volume as a proxy for ‘Brain Age’ (BA) which has been shown to correlate to years of education and Flights Of Stairs Climbed (FOSC) daily (2). There is also some evidence around how certain biological ageing processes can be at least partially reversed (e.g. growing and strengthening a muscle can – at least for a time – alter the glucose tolerance of that muscle). However, this doesn’t seem to be available in a systematic overview that could be used to support targeted interventions.
2. How firm is the scientific basis for public health advice about healthy lifestyles as a way to increase health span, including physical health and mental health?
a. What are the practical impediments for this advice being acted on?
One of the interesting implications of the LIFE study (3) which intervened with people at the point of losing the ability to walk 400 yards, was that the control group were given good general public health advice – however group and individual exercises were dramatically more effective – delaying further decline for at least 2.6 years longer than general public health advice (the length of the study was approx. 3 years). This was a very thorough and large multi-centre RCT. This suggests that more direct interventions are significantly more effective than general advice.
My own work in trying to engage directly with members of the public around healthy ageing, is that there is a general lack of understanding of the relevance of the phrase ‘healthy ageing’ to individuals. However, we and others have found articulating ageing in terms of maintaining personal independence to be much more effective.
The Irish Longitudinal Study on Ageing (TILDA) demonstrated some years ago that – adjusting for all other factors, simply having a negative stereotype of ageing versus a positive one, is associated with walking slower and being more cognitively declined 2 years later. However, much of the public dialogue and rhetoric around ageing is still very negative and informed by ignorance and prejudice rather than evidence. In my experience, the general level of understanding around ageing is at best poor, and vastly out of date.
It is my view that however much evidence we have, unless we address these negative stereotypes which pervade society in general (including some in the medical profession), we will not achieve the gains in health span that are already within our grasp. We certainly need more evidence, but do not lack the evidence to make significant improvements now.
There is a move in health to encourage much better ‘patient activation’ which is associated with better outcomes, but still very little engagement with the aspirations of older people that might drive better outcomes around ageing (and better health spans).
Perhaps engaging with different socio-economic groups on their own terms, in their communities, might help to improve the impact of the evidence-based interventions that we do have. In an evidence based Healthy Life Simulation undertaken in Newcastle some years ago (https://www.ncl.ac.uk/ageing/ageing_projects/simulation/#thesimulation), it became clear that despite their best efforts, well educated professionals were not always engaging effectively with the right messages in the right way for more deprived communities. A somewhat surprising piece of learning alongside this, was the passion with which 16-17-year olds could be engaged around the subject. Perhaps we could engage young people as the motivators around healthy ageing in their own communities?
b. Are there examples of good practice in the UK/devolved nations, or elsewhere?
In 2017 the Scottish Government introduced an Active Independent Living Programme which started to have some real impact on services across Scotland, however like so many similar programmes this has now been discontinued.
It is my view that we would benefit from a communication programme such as this for an extended period. A recent review of demonstrator programmes by Professors Harper and Rouse at Oxford University for the ISCF Ageing programme, found a widely held view that these types of programmes should run for at least 5 years to achieve lasting impact.
4. How complete is the understanding of behavioural determinants and social determinants of health in old age, and of demographic differences?
It is my opinion that whilst many of the biomedical science innovations show real promise, it is unlikely we will have sufficient time to generate a high level of evidence around impact, and see widespread adoption in time to achieve the goal of 5 more years of healthy & independent impact by 2035 and narrowing of the gap between good and less-good ageing.
However, I believe we already have sufficient evidence around the impact of attitude and the role of functional stage-specific flexibility, balance, endurance & strength, along with addressing loneliness and polypharmacy etc, to achieve the 2035 target. Whilst not a medical framework, Compression of Functional Decline (4) is showing promise in helping a wide range of stakeholders to understand how their independence is changing and why – which allows better targeting of appropriate interventions, and better ownership of the ageing process by individuals.
5. What technologies will be needed to facilitate treatments for ageing and ageing-related diseases, and what is their current state of readiness?
There seems to be a widespread belief amongst technologists that if we measure enough parameters of older people – particularly in real-time, and analyse this with ‘AI’, that we will be able to predict and intervene in a timely manner and avoid adverse health & other events. Many such technologies are already on the market; however, they often measure parameters in ways we already know evidentially is not accurate. Much of this work in my opinion is underpinned by well-meaning aspiration rather than a proper understanding of how people change with age, but this will hopefully improve in the future.
However, there is no question that empowering people to understand and take informed decisions to improve how they age, is deliverable through digital technologies. An early example of a such technology is the ADL Lifecurve™ App (downloadable from App stores) which takes people through an evidential hierarchy of functional loss, and makes suggestions for evidence-based exercises that will help them maintain targeted functional capabilities for longer. There are many Apps to help manage chronic conditions effectively already, however the adoption models are still not nearly as successful as required for mass impact. This was highlighted in a recent Harvard Business Review article (https://hbr.org/2018/04/why-apps-for-managing-chronic-disease-havent-been-widely-used-and-how-to-fix-it).
6. What technologies will be needed to help people to live independently for longer, with better health and wellbeing? What is the current state of readiness of these technologies, and what should be done to help older people to engage with them? For example:
Devices, machines, etc. for daily living in the home
There are very many devices/technologies that can help people maintain their independence for longer, however these devices are typically unpopular and are seen as stigmatising. Most of these designs date back many decades, and are very utilitarian in design. Some limited studies in this area has shown high levels of non-use (and therefore no impact). Psychosocial evaluations have helped to unpack many of the reasons, but a high proportion of what is available – and especially that provided by public services – is not of a good-enough standard of design. In defence of the industry, margins on these products are wholly inadequate to fund better designs, and the very few attempts at addressing this have been very short-lived.
There are a wide variety of smart devices that have potential to support independent living better, however the true potential for a more connected and coherent system of support is undermined by the wide variety of standards, and the perceived (and real) challenges of security and data privacy. As the Internet of Things matures further, many of these issues are beginning to be addressed – but the maintenance and configuration of much of this technology is still the preserve of experts and enthusiasts.
There are a number of proprietary systems and standards which offer various levels of function, but there are many issues still with inter-operability with other devices (from different manufacturers) in practice.
9. What opportunities are there for industry in the development of new technologies to help increase health span? In which areas of medical research and technology development does the UK excel?
We have some excellent research around healthy ageing in the UK, and in the National Innovation Centres for Ageing & Data some great resources to help innovators to understand health span better, which can underpin both further research and medical & technology development.
10. What more is required for the UK to benefit from commercialisation of its discoveries and inventions relating to healthy ageing, as envisioned by the Government’s Industrial Strategy?
Although public sector bodies in the UK are potentially large customers for UK businesses, in my experience many small businesses particularly (often the source of many innovations) find health & social care very difficult organisations with which to engage. I know of no-one in my experience and field of operation that would think of health & social care in general (of course there is always individual variation) as being anything other than late adopters. I believe the disconnect between the often-stated ambition of many public bodies to be innovative – and the practice on the ground, to be a serious impediment to the UK benefitting from its discoveries.
11. How feasible is the Government’s aim to provide five more years of health and independence in old age by 2035?
a. What strategies will be needed to achieve the Government’s aim?
In my opinion we have enough knowledge already to start making an impact as most of the 5 year gain in healthy life expectancy by 2035 will have to come from those doing less well improving significantly
b. What policies would be required, and what are their potential costs and benefits?
c. Which organisations need to be involved?
I think much of the understanding from the Healthy Life Simulation (https://www.ncl.ac.uk/ageing/ageing_projects/simulation/#thesimulation ) can inform this.
d. Who should lead the work?
I believe the Government can influence the poor understanding of ageing through the type of campaigns that have been used for smoking cessation – but this needs to be a long-term campaign, perhaps leveraged by investment from industries with a vested interest?
To change communities that are ageing less well, we need to empower those communities.
12. To what extent are inequalities in healthy ageing, as well as differences in acceptance of technologies, a barrier to achieving the aims of the Government’s Ageing Society Grand Challenge?
a. To what extent could achieving the Government’s aim of five more years of healthy and independent life exacerbate, or reduce, these inequalities?
13. What would be the implications of a paradigm shift to people leading healthier lives for longer, and spending less time suffering ill health?
There are many calculations that can be offered here; however, I would offer a few simple examples:
The WHO produced a report in 2005 which highlighted a common misunderstanding around the preventability of chronic diseases, they pointed out that “at least 80% of all heart disease, stroke & type 2 diabetes could be prevented – along with 40% of cancer. In the House of Commons Health Committee “Managing the care of people with long-term conditions” 2nd report of session 2014-2015 Volume 1: 222 pages, it was estimated 70% of total expenditure on health & care in England is spent on 30% of pop with LTC. They further highlighted that this represented 55% of GP appointments, 68% of outpatient and A&E appointments, 77% inpatient bed-days. Preventing 40% of cancer might very roughly save a further £2bn.
Data from a Scottish AILP Survey in 2017 analysed by Strathclyde University, showed each stage of further functional decline (against 15 markers), was associated with ~£640/person/year of secondary care costs, and other data shows about the same again on domiciliary care costs.
The current average length of stay in residential in the UK is ~ 27.6 months, we believe that by empowering people to stay independent for longer and therefore remain in their community of longer, this could potentially be reduced to 2-4 months. A typical cost might be ~ £30k/person/pa.
1. Passarino G, De Rango F, Montesanto A. Human longevity: Genetics or Lifestyle? It takes two to tango. Immunity & Ageing. 2016;13.
2. Steffener J, Habeck C, O'Shea D, Razlighi Q, Bherer L, Stern Y. Differences between chronological and brain age are related to education and self-reported physical activity. Neurobiol Aging. 2016;40:138-44.
3. Pahor M, Guralnik JM, Ambrosius WT, Blair S, Bonds DE, Church TS, et al. Effect of Structured Physical Activity on Prevention of Major Mobility Disability in Older Adults The LIFE Study Randomized Clinical Trial. Jama-J Am Med Assoc. 2014;311(23):2387-96.
4. Gore PG, Kingston A, Johnson GR, Kirkwood TBL, Jagger C. New horizons in the compression of functional decline. Age Ageing. 2018;47(6):764-8.
20 September 2019