THE FUTURE OF OLD AGE: GOOD NEWS OR BAD

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THE FUTURE OF OLD AGE GOOD NEWS OR BAD?

• North West Horizon Scanning Conference
• Raymond Tallis FRCP FMedSci

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Ultimate aims of medicine

• Postpone dying due to disease
• Mitigate suffering due to disease (pain,
  disability, anguish)

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Fundamental questions

• Are the ultimate aims of medicine in conflict?
• Will this conflict become most evident in the
  medicine of old age?
• Will increased life expectancy inevitably be
  associated with increased burden of illness?

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The Future of Medicine An
Ignominious Destiny?

• Extending life becomes feasible, but it may be
  a life exposed to degrading neglect as resources
  grow overstretched and politicians turn mean.
  What an ignominious destiny if the future of
  medicine turns into bestowing meagre increments
  of unenjoyed life. (Italics mine)
• Roy Porter The Greatest Benefit to Mankind,
  1997
• TOO BLOODY RIGHT, MATE!
• Personal Communication, Nice Bloke, in a Pub

5
The Future Achievements of Medicine?

• Bestowing meagre increments ?
• Bestowing unenjoyed increments?

6

• Itinerary
• Old age good news from the present
• Future of old age theoretical gloom
• Future of old age gloomy in practice ?
• Squaring the circle ageing to the rescue
• Future of old age Utopia or apocalypse?

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Good news from the present

• I dont like the thought of getting old
• until I think of the alternative
• W. Allen, personal communication
• There is more chance of living to old age
• Life expectancy in old age is increased
• Seventy years old last December

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Good news demographic trends in the first 50
years of the NHS

• Infant mortality/1000 live births
• 1948 1996
• Girls 39 7
• Boys 30 5
• Remember the NHS?

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Good news demographic trends in the first 50
years of the NHS

• Proportion of deaths below 65 in England Wales
• 1948 1996
• 40 7

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Good news demographic trends in the first 50
years of the NHS

• Population structure of England and Wales
• Overall population increased by 20
• 0-4 increased by 9
• 80 - increased by 240
• Source Kelly et al 1998

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Good news demographic trends in the first 50
years of the NHS

• Life expectancy at birth
• 1948 1996
• Males 66.1 74.4
• Females 70.5 79.6

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Life expectancy at birth UK
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The Big Picture

• Prior to 1800, life expectancy had increased
  little since the days of the Roman Empire
• Age Action 2007
• Life expectancy has increased by 2.5 years per
  decade over the last 160 years
• Oeppen and Vaupel Science 2002

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Increased life expectancy at birth

• Between 1840 and 1950 decline in death in was in
  early life (measures to control infectious
  disease sanitation, housing, nutrition,
  vaccination, clean water, and later, antibiotics)
  most important
• At the end of the 20th century decrease in
  mortality at relatively later ages most important
  with a greater contribution from advances in
  medical care.

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A Major Source of Improved Mortality

• Fall in UK age-specific cardiovascular disease
  mortality in 2005 to 30 of its rate in 1968.
• Deaths from coronary heart disease below 65 have
  fallen by 46 in the UK in the last 10 years
• Source BHF Statistics Website

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The future gifts of Medicine?

• Meagre increments of life?
• Unenjoyed increments?

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The story continues (1) Life expectancy at birth

• 1980 2000
• males 70.8 75.3
• females 76.9 80.1

Source Recent Demographic Developments in Europe
2000 Council of Europe and Office of National
Statistics
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The Story Continues (2)

• At current rates, life expectancy in the UK is
  increasing at the rate of about two years for
  each decade that passes
• Ageing Scientific Aspects
• House of Lords S and T Committee, 2005

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The Story continues (3) Life expectancy in
later life
Source ONS quoted in Leeson, 2004
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The Story Continues Hot News from the
Actuarial Front

• In 1997 65 year old men who have life
  insurance and pensions plans could expect to
  live to 83 years and two months.
• In 2005, they could expect to live to 86 years
  and 7 months.
• By 2015, they could expect to live to 89 years
  10 months
• Continuous Mortality Investigation,
  September 2005

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Trends in 85

• 1900 0.1
• 2000 0.15
• 2050 5.0
• Source Brown, G 2008

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Trends in Centenarians

• 2008 10,000
• 2050 250,000

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Meagre Increments ?

• Lifetime leisure increased since 1870 by between
  50 and 80 waking hours
• This amounts to some extra 130,000 hours (61 due
  to decreased mortality)
• Nicholas Craft. LSE, personal communication

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The future gifts of medicine?

• Meagre increments of life?
• Unenjoyed increments?

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• Itinerary
• Old age good news from the present
• Future of old age theoretical gloom
• Future of old age gloomy in practice
• Squaring the circle ageing to the rescue
• Future of old age Utopia or apocalypse ?

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Theoretical gloom

• Exponential relationship between age and
  prevalence of chronic ill health
• Exponential relationship between age and chronic
  disabling diseases

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Some chronically disabling diseases that have a
steep relationship to age

• Stroke
• Alzheimers disease
• Parkinsons disease
• Osteoarthritis

28
Source Martin et al OPCS, 1988
29
Dependency profile of elderly people by age
(Vetter et al 1990)
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• Itinerary
• Old age good news from the present
• Future of old age theoretical gloom
• Future of old age gloomy in practice ?
• Squaring the circle ageing to the rescue
• Future of old age Utopia or apocalypse ?

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The future of old age gloomy in practice ?
Four scenarios

• 1 year of additional woe for every year of life
  gained
• Less than 1 year of additional woe for one year
  of life gained
• No additional woe for each year of life gained
• Less woe despite life gained Fries Compression
  of morbidity

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Gloomy in practice ?

• Chronic ill health and dependency trends in the
  UK
• Disability and dependency trends in the USA
• Acute hospitals admissions UK

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GLOOMY IN PRACTICE?

• Trends in LE and HLE 1981-2001
• Women Men
• Year 1981 2001 1981 2001
• LE 76.8 80.4 70.9 75.7
• HLE 66.7 68.8 64.4 67.0
• HLE/LE 86.9 85.6 90.0 88.5

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Life expectancy (LE) and healthy life expectancy
(HLE) at 65
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Life and Healthy Life Expectancy1991-2004

• Life expectancy increased by 3.4 years for men
  and by 2.3 years for women
• Healthy life expectancy increased by 1.8 years
  for men and 1.7 years for women
• Source ONS, 2008

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Health trends in UK General Household Survey
1980-2001

• Survey of 3,356 people over 65 living in
  private homes
• Exclude 4 living in local authority homes,
  nursing homes and hospitals

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GHS trends 1980-2001

• No overall change in proportion of elderly
  people reporting their health as good (37)
  fairly good (38) and not good (25)
• Proportion of people reporting long-standing
  illness has not changed significantly

38
GHS trends 1980-2001
Confounding Factors

• Threshold for reporting may have gone down
• Completeness of diagnostic attainment will have
  gone up
• New questions on hearing and eyesight

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Very Recent Trends 2001-2004

• Time men are expected to live in poor health
  decreased by 0.3 year
• Time women can expect to live in poor health
  decreased by 0.2 year
• Source ONS 2008

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Gloomy in practice ?

• Chronic ill health and dependency trends in the
  UK
• Disability and dependency trends in the USA
• Acute hospitals admissions UK

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Trends in USA 1962-1976Life expectancy increases

• Overall life expectancy increase 1.8 years
• In good health - 0.3 years
• With activity restriction - 1.5 years

NHIS data cited by Grundy in Tallis and Fillitt
2003
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Current trends in disability in old age
USAManton 1997

• Prevalence of disability falling at later ages
• Average life span increasing

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USA National Long Term Care Survey (1982-1999)

• Disability in over 65s decreased from 26.2 to
  19.7
• 2 decrease per year
• This is double the decrease in the mortality rate
  (1)
• Rate of decline accelerating
• Manton, cited in Tallis and Fillit, 2003

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Gloomy in practice ?

• Disability and dependency trends in the UK
• Disability and dependency trends in the USA
• Acute hospitals admissions UK

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Himsworth et al. BMJ 1999
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Days spent in hospital in 3 years prior to death

• Median 23 days
• Did not rise with age above 45
• Dixon et al BMJ 2004

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European Perspectives

• Switzerland and Netherlands Dynamic equilibrium
  (Robine et al, 2003)
• Denmark Compression of morbidity
• (Bronnum-Hansen, 2005)

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CONCLUSION

• Trends not as depressing as people expect them
  to be.
• How?
• Surely it stands to reason.?

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Incidence of stroke in 2002-04 (OXVASC) vs
1981-84 (OCSP)
Ratio 0.60 (0.50-0.73) Plt0.0001
Lancet 2004 363 1925-33
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Stroke in Oxford OCSP (1981-84) to OXVASC
(2002-04)

• Incidence expected to rise by 28
• Incidence actually fell by 29
• Rothwell et al, The Lancet 2004

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Projected numbers of people over 65 in UK unable
to perform activities of daily living
No. (Thousands)
Year
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• Itinerary
• Old age good news from the present
• Future of old age theoretical gloom
• Future of old age gloomy in practice
• Squaring the circle ageing to the rescue
• Future of old age Utopia or apocalypse ?

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Squaring in the circleAgeing to the rescue

• Ageing is a harmonious decline of all organ
  systems leading to increased probability of death
• Tom Kirkwood

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Ageings

• Usual
• Ideal
• Optimal
• Physiological
• Pure

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The Boundary between Ageing and Disease

• Clinico-Political against ageism
• Its your age, dear
• Ageing inevitable
• Waste of time treating very old people cant
  buck the Second Law of Thermodynamics
• Biological less clear

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The Biological Boundary between Ageing and
Disease Semi-Permeable?

• Clear distinction between minimal pathological
  processes and deviations associated with ageing?
• Ageing as summed impact of a multitude of
  subclinical diseases?
• Ageing and disease natural kinds?
• At the most fundamental level a convergence of
  ageing and disease processes?

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Frailty A (Biologically Unsophisticated)
Clinicians View

• Homoeostasis
• Homoeostenosis

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Ageing

• Non focal
• Symptom free
• No pain, dyspnoea, nausea etc

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Squaring the circleThe physicians profession de
foi

• By delaying the onset of disabling diseases to
  later ages when intrinsic ageing has raised
  fatality by reducing adaptability, the average
  duration of disability before death will be
  shortened. In brief, we will spend a longer time
  living and a shorter time dying.
• J Grimley Evans 1997

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Dependent life before death

• Age group Men Women
• 65-69 3.8 8.9
• 70-74 3.7 7.9
• 75-79 3.1 6.1
• 80-84 3.4 5.0
• 85 plus 3.2 4.9

J Grimley Evans Philosophical Transactions of
the Royal Society of London. Series B 1997 352
1887-1893.Implications for the Health Service
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THE BOTTOM LINE

• The older the age one attains without becoming
  disabled the shorter the period of dependency to
  be expected before death. This suggests that for
  disability in later life, POSTPONEMENT of age of
  onset would result in PREVENTION of suffering
• J Grimley Evans 1997

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OCSP to OXVASC postponement as well as
reduction of stroke

• Median (IQR ages of stroke)
• OCSP 74
• OXVASC - 75.5

Rothwell P, et al
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Untapped potential for postponing disability in
old age

• Health promotion
• Illness prevention
• Appropriate use of existing technologies
• Technologies around the corner

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Untapped potential for postponing chronic ill
health in old age

• Health promotion
• Illness prevention
• Appropriate use of existing technologies
• Technologies around the corner

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Illness prevention the rule of halves

• Hypertension
• AF
• Cholesterol reduction

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Rule of halves
Of the population qualifying for lipid lowering
treatment
Approximately, half are treated with lipid
lowering therapy
Less than half achieve treatment goals
EUROASPIRE II Study Group. Eur Heart J 2001
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SECONDARY PREVENTION IN ENGLAND (2003)

• 2.4 million patients in 24 localities
• Established CHD in 89, 422
• Analysable data on 78,600
• Cholesterol measured in 37,967 (48)
• Raised cholesterol detected in 20,965
• Cholesterol reached target of lt5 mm/l in 11,161
  (55)

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Untapped potential for postponing disability

• Health promotion
• Illness prevention
• Appropriate use of existing technologies
• Technologies around the corner

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Appropriate use of existing technologies

• Drug treatment
• Under treatment
• Over treatment
• Untailored treatment
• Inappropriate treatment

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Drug treatment of older people

• Admitted to acute hospital
• In residential home
• In long term care ward

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Drug treatment of older people

• 10 on contraindicated drugs
• 6 acute admissions due to inappropriate
  prescriptions
• Refs Tallis, Tully, Paramsothy, Gosney 1984,
  1990, 1991

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Untapped potential for postponing disability

• Health promotion
• Illness prevention
• Appropriate use of existing technologies
• Technologies around the corner

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Technologies around the corner
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Plasticity of the elderly brain
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Untapped potential for preventing or reversing
disability

• Conclusion
• You aint seen nothing yet!

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Disability-Free Life Expectancy Socio-Economic
Determinants

• Hart in Hampshire 68.8 years
• Easington Durham 50.5 years
• Source ONS 2006

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Lifestyle trends favourable and unfavourable

• Smoking down
• Obesity up
• Time on the couch up

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Itinerary

• Old age good news from the present
• Future of old age theoretical gloom
• Future of old age gloomy in practice ?
• Squaring the circle ageing to the rescue
• Future of old age Utopia or Apocalypse ?

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UTOPIA OR APOCALYPSE

• MODELS FOUND ON A SODDEN BEER MAT

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The Possible Futures of Old Age
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Utopia or Apocalypse? Panic in the Treasury

• Type 1 Panic We cant afford to make or keep old
  people healthy
• Type 2 Panic We cant afford healthy old people

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Treating Type 1 Fiscal Panic (Cant afford to
make or keep old people healthy) with
reassurance

• Prevention is cheaper than cure
• Postponement and compression of morbidity is
  cheaper than community or institutional care for
  people with chronic disability

84
Increases in healthcare expenses in old age

• Availability of new treatments
• Appropriate expectation that older people would
  benefit from them
• However
• Age specific need for health care is falling
• Expenditure on health care always maximal in the
  last year, irrespective of age of death

85
Ageing and Healthcare Costs

• Main drivers to increased healthcare costs are
  consumer demand and technological advance
• Ageing population per se adds little
• Turner A Pension Commission Second
  Report 2005
• Shapiro R Futurecast 2020 (2008)

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Health expenditure UK

• Smaller increase in per capita costs for older
  ages compared with younger age groups
• Combined NHS and hospital and community services
  for 85 has decreased in real per capita costs
  between 1985-87 and 1996-99
• Seshanamani and Gray, 2002 quoted in Leeson
  Demographics and economics of UK health and
  social care Oxford Institute of Ageing Working
  Paper 2004

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Treating Type 2 Fiscal Panic (Cant afford to
keep healthy elderly people) with Reason

• Old age is a social construct as well as a
  biological phenomenon
• Older people can be producers as well as
  consumers
• Peg median age of compulsory retirement to median
  age of death

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A very long and healthy life for most people

• Lies within our grasp
• Not a contradiction in terms
• Not unaffordable

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Health Span Approximating to a (Long) Life Span

• Postponement of onset of disease
• Abatement of disease resulting in postponement of
  progression of severity of disease
• Lesser postponement of death

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A healthy old age

• Terminal, not unpleasant, frailty
• A human rather than an animal death
• Memorable last words

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• Bends to the grave with unperceived decay
• While resignation gently slopes the way
• Oliver Goldsmith

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A possible future of old age?

• Bop till you drop
• Mark Ferguson
• Tango to ternity
• Ray Tallis