Select Committee on Science and Technology First Report


CHAPTER 4: AGE-RELATED DISEASES AND DISORDERS

Introduction

4.1.  During this inquiry we have received written and oral evidence from those involved in improving understanding of the major age-related diseases. In this chapter we examine the most important conditions affecting older people on which we have taken evidence. We look at their effect, what treatment is available now and being investigated, and how they interact with other ageing processes. Finally we turn our attention to the interaction between age-related diseases and underlying ageing processes, and how they are both funded.

Conditions affecting older people

4.2.  We saw in Chapter 3 how the age-specific mortality rates in men and women increase very sharply with age. Since death is usually preceded by illness, it will be no surprise that many of the conditions affecting older people show similar sharp increases with age. The fact that illness becomes very much more prevalent with age has led to widespread concern that the increasing numbers of older people will necessarily result in dramatic increases in the costs of healthcare. However, for most people the major lifetime healthcare costs are associated with terminal illness, and this has greatly exaggerated the impression that old age is itself driving up healthcare costs. Everyone is likely to incur such costs regardless of how long they live, but most of us can now expect to incur them in old age. As Sir John Grimley Evans told us:

"The costs in the last five years of life do not derive from predictably futile treatment but from treatments doctors hope will be curative or palliative. With present levels of life expectancy most people experiencing what will prove to be their final illness are aged over 75. This can give the impression that high costs of health care are due to age rather than to being ill, and that any increase in numbers of older people due to lengthening of lifespan will increase NHS expenditure disproportionately. This is not so."[64]

4.3.  Increasing healthcare costs are however likely to arise if the prevalence of chronic age-related conditions rises and if the average duration of these conditions lengthens. For this reason it is important not only to have better information about trends in HLE, as noted in Chapter 2, but also to learn as much as possible about the causes and treatment prospects for conditions affecting older people.

4.4.  In terms of mortality, the three major causes of death, each responsible for more than 10% of all deaths in those aged over 65, are:

  • circulatory diseases,
  • respiratory diseases, and
  • cancer.

The age profile (Figure 4) shows that it is the first two of these which grow most significantly with age. The proportion of deaths from cancer is less age-dependent, being a significant cause at any age.

FIGURE 4

Major Causes of Death by Age



The major causes of death by age. Columns represent the proportion of deaths in that age group due to each disease/disorder.

4.5.  Rates of chronic sickness increase as we get older.[65] The five most prevalent conditions affecting more than 5% of the population over 65 involve:

  • the heart and circulatory system (including heart attack and stroke);
  • the musculoskeletal system;
  • endocrine and metabolic functions (including diabetes);
  • the respiratory system; and
  • the digestive system.

Over the age of 75 eye and ear complaints also become important.

4.6.  Whilst the incidence of all of these conditions in the general population increases with age, those affecting the heart and circulatory system, and eye and ear complaints, stand out as striking older people in particular.

FIGURE 5

Increases in Longstanding Conditions



Rate per thousand reporting one or more longstanding conditions at specific ages

FIGURE 6

Incidence of Specific Conditions



Rate per thousand reporting certain longstanding conditions at specific ages

4.7.  Other specific illnesses affecting predominantly older people include dementia and Parkinson's disease. Both affect about one person in a thousand under the age of 65, and increase with age. Dementia, including Alzheimer's disease, rises to affect 25% of those over 85 (Q 305);[66] Parkinson's disease is less common, affecting around 2% of those over 70.

Stroke

4.8.  A stroke comes from an interruption of blood supply to the brain by either a blood clot in an artery (an ischaemic stroke, the most common form) or a burst blood vessel in the brain (a haemorrhagic stroke). About 125,000 people each year in the UK have a stroke, 90% of whom are over 55. Professor Peter Fentem, Chairman of Research of the Stroke Association, told us that one quarter of the population over the age of 45 will suffer from a stroke. Each year about 70,000 people die following a stroke. Many survive, albeit with severe disabilties: there are about a quarter of a million people who have disability as a consequence of their stroke and those who survive are often affected by serious disability (Q 272). "Stroke is a more powerful cause of disability than musculoskeletal and other chronic disorders".[67]

4.9.  Twenty years ago nothing could be done to heal a stroke, but progress from medical science has led to fewer deaths, and less disability for those who do survive.[68] However, we have been disappointed to learn of the UK's poor record in the treatment of stroke compared with other countries. Professor Fentem informed us that the mortality rate in the UK 30 days after a stroke is 30%, compared with less than 15% in Canada (Q 278). We also note a European study from 1999 which found "significant differences in 3-month outcome in terms of case fatality or dependency for stroke that are unexplained by conventional case mix variable adjustment. The UK centers also appear to have consistently worse outcomes than the rest of Europe."[69]

4.10.  We understood from both Professor Kennedy Lees, Professor of Cerebrovascular Medicine at the University of Glasgow, and Professor Fentem that brain imaging (with MRI or CT scans) immediately a stroke has been diagnosed will improve patient outcomes; countries like Germany and Canada have a far higher proportion of patients making a good recovery. Professor Lees told us that if imaging detected an ischaemic stroke within three hours of its onset, treatment with thrombolytic drugs could have a significant effect by restoring blood supply to areas of the brain. He added that even beyond three hours, imaging would detect salvageable tissue and might allow direct treatment. There are, though, "only half a dozen" centres in the UK that have the rapid access to scanners required for stroke patients, and use these drugs (QQ 276-279).

4.11.  Professor Fentem noted the Royal College of Physicians' guidelines on stroke which state that brain imaging "should be undertaken as soon as possible in all patients, at least within 24 hours of onset". However, in its National Sentinel Stroke Audit 2004, the Royal College of Physicians found that "only 47% of the patients had a scan performed within two calendar days of the stroke."[70]

4.12.  Stroke is a major cause of long-term illness, disability and death, particularly among older people. Yet significant reductions in the long-term health consequences of a stroke can be made if very early assessments and treatments are provided, for example by locating scanners within accident and emergency departments. The Department of Health should make rapid treatment of stroke a priority.

4.13.  The National Audit Office, in collaboration with the Stroke Association, is investigating stroke services in England, focusing on whether the NHS is effectively using its resources to prevent stroke, to provide acute care, to manage rehabilitation of stroke patients, and to integrate health and social care services for people who have suffered a stroke. We look forward to their report.

4.14.  Regarding expenditure on research on stroke, Professor Lees told us that expenditure in the UK on stroke research is about 1% of that on cancer, despite stroke carrying a very similar, if not worse, prognosis than cancer (Q 276). A study comparing costs of illnesses with research funding put total expenditure on stroke at £9.1 million, about 5% of that on cancer. It estimated the annual cost of stroke to the NHS and social services in England to be £2.5 billion, compared to £1.6 billion for cancer. Across age ranges, stroke is responsible for 11% of all deaths each year, compared to 25% of deaths resulting from cancer.[71]

4.15.  Looking ahead 10 or 15 years, Professor Lees saw research opening up the possibility of using stem cells and new drugs to encourage repair mechanisms in the brain. Professor Fentem concentrated on preventative measures, and the importance of lifestyle factors in the development and progress of chronic disease. "A big challenge is going to be to implement Wanless.[72] That will take 20 years" (Q 300).

Heart

4.16.  Coronary heart disease (CHD) results from artery walls becoming narrowed by deposits of cholesterol and cell waste, a process called atherosclerosis. If allowed to build up over time, this blocks the blood supply to the heart, and hence the oxygen supply, and this causes a heart attack. Medical science has allowed many more people to survive severe heart attacks than used to, but the remaining heart tissue after such an attack may be damaged, and this may lead to heart failure. Professor Peter Weissberg, Medical Director of the British Heart Foundation, told us that heart failure is now a rapidly growing problem in the elderly (Q 275).

4.17.  Treatment of heart attack through the use of "clot-busting" drugs has been effective, though it has taken many years for the UK to have developed systems to implement such evidence-based procedures. Professor Weissberg saw the reason for the delay being because of up-front costs: the NHS being concerned with annual budgets rather than the large future savings that may result from the provision of a treatment (QQ 284-285). He saw that applying best practice quickly and efficiently was essential to preventing morbidity in the elderly.

4.18.  Professor Weissberg added that a major focus of research should be on repairing the organs affected by vascular disease using stem cells (Q 275). Studying embryonic stem cells would help improve understanding of the molecular mechanisms and molecular biology of tissue differentiation. This might allow the development of treatments "to start tripping the switches by pharmacological means to induce a mature heart cell to start dividing again, which it would not normally do". (Q 300)

Cancer

4.19.  Although cancer is a significant cause of death at all ages, absolute mortality rates from cancer increase sharply with age. According to Cancer Research UK, over 140,000 people over 70 are diagnosed with cancer every year, amounting to 52% of all cancers diagnosed in the UK; and over 100,000 people over 70 die of cancer every year. In this age range the most common are lung, prostate, breast and colorectal cancers. Survival rates from lung and breast cancer are particularly strongly age-related, diminishing greatly in the over 70 age group. Survival rates for prostate and colorectal cancers begin to diminish markedly only past the age of 80.[73]

4.20.  Cancer is not necessarily more aggressive in older people, but there is evidence showing that a delay in diagnosis is more severe. Professor Robert Souhami, Director of Policy and Communication at Cancer Research UK, saw the need for sociological research to disentangle the factors affecting cancer diagnosis and treatment in older people (Q 513).

4.21.  Whilst expenditure on cancer research is largest by far of all diseases in the UK, it tends not to be specifically targeted at cancers affecting older people. Professor Souhami told us that "If you were to look at the generality of funding in cancer and say, 'How much of that is specifically devoted towards therapeutic and other aspects of cancer as it affects an elderly population?' the answer is a very small proportion" (Q 489), contrasting this with the position in the United States, where more emphasis is given to older people. He also pointed to a gap in research relating DNA damage and cancer: "The issues of whether or not there is a decreased efficiency in repairing DNA damage… as you get older are very under-funded in the UK" (Q 496).

4.22.  It is understandable that research tends to be targeted at younger age-groups, since they (and their families) may be thought to have more to gain from early diagnosis and cure. We do not in any way question the importance of such research, nor do we suggest any decrease in the amount spent on it. But Professor Souhami agreed that "Cancer Research UK and its partners do not invest enough specifically into the questions of cancer as it affects an ageing population" (Q 489). Moreover, if the current incidence of cancer is unchanged, the ageing population will result by 2025 in an extra 100,000 cases being diagnosed annually, and the vast majority of these cases will be in the over 70s.[74] If only for this reason, we believe that this country should follow the lead of the United States and Europe, and emphasise the position of older people.

4.23.  We recommend that the Government and research councils should, when allocating money to cancer research, place more emphasis on those cancers particularly prevalent among the elderly. We encourage Cancer Research UK and other charities to do likewise.

The musculoskeletal system

4.24.  Musculoskeletal disorders include problems with bones, joints and musculature, all of which undergo some progressive deterioration with age. They also include rheumatic diseases, which cover arthritis (inflammation of joints) and rheumatism (more general aches and pains in bones, muscles and joints). About 5 million people in the UK suffer from osteoarthritis, which results from the cartilage protecting joints wearing away, thus affecting older people disproportionately. Osteoporosis describes a condition of reduced bone density, leading to increased susceptibility to fractures. It is most common in the over 50s—one in three women, and one in twelve men, go on to develop it.

4.25.  Professor Cooper described the burden of musculoskeletal disorders: "the prevalence of musculoskeletal disorders in all adults is 25%, the second most frequent cause of medical consultation after psychiatric disorder, and 25% of the total costs of illness in Europe ... Seven million adults in the UK have arthritis with long-term health problems; two million people visit their GP every year with osteoarthritis; and 4.4 million people have X-ray evidence of osteoarthritis" (Q 47).

4.26.  Professor Graham Russell, Norman Collisson Professor of Musculoskeletal Science, Oxford University, told us in evidence that there was a genetic basis underlying most musculoskeletal disorders, particularly osteoarthritis, rheumatoid arthritis, many of the other forms of arthritis, and osteoporosis, but that most of these were not single gene disorders, but more complex genetic disorders with many factors contributing (Q 44).

4.27.  One of the consequences of musculoskeletal deterioration is an increased vulnerability of older people to falling. Because muscles lose their strength and bones their ability to heal, falls often lead to bone fracture, which can result in permanent immobility.[75] Professor Rose Anne Kenny, Head of the Falls and Syncope Unit, University of Newcastle, told us:

  "In the UK, 30% of those over 65 will fall at least once a year, and 40% of those over 75 will fall at least twice a year. Falls are the commonest reason cited for admission to institutional care, and for 40% of admissions to nursing homes or residential homes in the UK the top reason cited is falls." (Q 353)

4.28.  However, there was some good news in terms of hip fracture, a common consequence of falling among older people:

"The mortality rates are improving with hip fracture. I am focusing on hip fracture because that is the expensive one and the one with the heaviest consequences. It is 20% one year mortality now whereas it was about 35% ten years ago. So mortality rates from hip fracture surgery are improving." (Q 354)

4.29.  The decrease in muscle mass and reduced functional capacity of muscle is an important contributor to the reduced quality of life, and loss of independence, among older people. A recent study at the Royal Free Hospital which looked at muscle strength in males and females between 70 and 75 found that 50% of females and 15% of males were unable to mount a 30 cm step without holding on to a handrail. It also found that 80% of females and half of men between 70 and 75 were not able to walk at a pace of three miles per hour, and that 80% of females and half of the men had limitation of their shoulder movement such that they could not comfortably wash their hair (Q 353). We have already stressed the importance of exercise at any age in the prevention of muscle loss.[76]

Parkinson's Disease

4.30.  At any one time, over 100,000 people in the UK have Parkinson's disease, and the great majority of these are older people. The disease affects one person in every thousand of the population, but for the over 70s this rises to one in fifty; the disease is one of the most common neurological conditions affecting older people. For reasons as yet unknown, it affects Caucasian people more than those of Asian or African origin, and the symptoms also tend to be different: Caucasian people are more likely to complain of tremor, while those of Afro-Caribbean origin describe stiffness as the main problem.

4.31.  It is the degeneration of a specific area of the brain which results in the reduction of dopamine, the chemical messenger responsible for the efficient working of the motor coordination centres of the brain. Some loss of dopamine is a normal consequence of the ageing process, but in people with Parkinson's around 80% of dopamine has been lost by the time the disease produces the physical signs associated with it: tremor, slowness, stiffness and speech problems. The cause of this loss of dopamine is unclear, and there is no known cure, although the symptoms can be alleviated by drugs which replace dopamine or mimic its actions.

4.32.  Although the physical consequences of Parkinson's are well known, it is not so widely known that between 20% and 30% of people with Parkinson's will suffer from dementia (Q 304).[77]

Dementia

4.33.  "Dementia" describes symptoms which include memory loss, confusion, and problems with speech and understanding. These are caused by a deterioration of brain function. The deterioration is most commonly caused by the onset of Alzheimer's disease, which progressively kills off brain cells and is characterised by particular pathological markers in brain tissue. However dementia may also be of the "vascular" type, where the damage is linked to impaired blood flow (and which may also be linked to a stroke), or of the "Lewy body" type—Lewy bodies being the pathological markers that are also associated with Parkinson's disease. Indeed, the major difference between Dementia with Lewy Bodies (DLB) and Parkinson's disease appears to be the region of brain tissue that is affected (Q 307).[78]

4.34.  In written evidence, the Alzheimer's Society explained that "dementia is not a natural part of ageing, but age is the most significant known risk factor, and that over the age of 65 "the risk of dementia doubles every five years".[79] Some studies have shown that people with a high blood pressure in middle age have an increased risk of developing dementia. Apart from early-onset Alzheimer's, it does not appear to be a hereditary condition.

4.35.  There is as yet no known cure for dementia. Some treatments have been developed, some of which appear to slow the progress of disease, but in general their clinical and cost effectiveness has not yet been clearly demonstrated. For example, an innovative technique to immunise against the formation of amyloid deposits in brain, which showed promise in animal experiments, caused adverse effects in humans, which have yet to be circumvented in order to allow the efficacy of such an approach to be properly assessed. Professor Carol Brayne, Professor of Public Health Medicine, Cambridge University, told us that "most of the biological lab-based stuff is aimed at providing the bullet cure, and given the mixture of pathologies that we see in the older age groups, I think it is very unlikely that that is going to make an impact on old age dementia, certainly in the near future and maybe in the longer-term". (Q 312)

4.36.  Alzheimer Scotland funded a review of economic costs of diseases and the expenditure on research, which was published in a peer-reviewed journal.[80] They found that the direct cost of Alzheimer's was between £7 billion and £14 billion a year, several times that of stroke, heart disease or cancer. However, research expenditure on Alzheimer's disease was 57% of that on stroke, 10% of that on heart disease and 3% of that on cancer.

Diabetes

4.37.  Glucose from food is absorbed into the blood after digestion. Normally, insulin from the pancreas will regulate the amount of glucose converted by the body into energy. In someone with diabetes the body is unable to metabolise the glucose in the bloodstream, to varying degrees. Three-quarters of people with diabetes have type 2 (where the body produces either insufficient or ineffective insulin), and age is a significant risk factor in developing it. It usually occurs in those over 40, though those from a black or ethnic minority group are at increased risk from age 25. Obesity is also a risk factor for type 2 diabetes. Early diagnosis of diabetes is essential; otherwise it may lead to complications, including blindness. People with diabetes are at increased risk from other health problems, including cardiovascular diseases and stroke.

4.38.  There are links between the causes of type 2 diabetes and dementia. Amyloid plaques—fibrous deposits of protein—have been seen in the pancreas of some diabetics and may stop production of insulin. It is also suspected that amyloid plaques can build up in the brain and kill off cells, leading to Alzheimer's disease. Dr Frans van der Ouderaa told us: "the etiological factors for dementia go from overweight and metabolic dysregulation to diabetes to cardiovascular disease to dementia. If you do not become overweight, if you do not get diabetes, then the risk of dementia is maybe 10% of the risk of you getting it [otherwise]" (Q 123).

4.39.  The Medical Research Council is funding research into amyloid diseases. A team at the National Amyloidosis Centre in London, through MRC funding, have developed a drug that destabilises amyloid deposits, allowing them to be broken down. The new drug offers a new approach to treating a range of amyloid diseases.[81]

Sensory impairments

SIGHT

4.40.  There are in the UK between four and a quarter and four and a half million people with significant loss of vision through macular degeneration. Some 70% of these are over 65 (Q 347).[82] Other common causes of sight loss are cataracts and glaucoma. A study funded by the Thomas Pocklington Trust found that one in 8 people over 75, and one in 3 people over 90, suffer from severe sight loss.[83] Older women are more likely than men to suffer from sight loss, even after adjusting for age differences.

4.41.  Sight loss is often regarded, particularly by those who suffer from it, as an automatic consequence of ageing about which nothing can be done. There is "a singular lack of reliable social research on sight loss,"[84] but it seems that a frequent reaction from older people is that sight loss means "I cannot see and therefore I cannot do"—this despite the fact that there is often an amazing level of ability left which is untapped, unused and un-nurtured (Q 347).[85]

HEARING

4.42.  Professor Karen Steel of the Wellcome Trust Sanger Institute told us that in the UK there are approximately nine million people who have a significant hearing impairment in one ear or the other. Hearing loss is the commonest of the sensory impairments suffered in old age, and is experienced by half of people over 60. Yet, even more than sight loss, it "has long been regarded as an inevitable consequence of growing old, not only among the medical profession but also by the man in the street, and so very often people do not complain about it as much as they should as they are getting older". Social withdrawal is for many people the main tactic deliberately used to avoid embarrassment. There is a stigma attached to hearing impairment which is present to a markedly lesser degree, if indeed at all, in the case of sight impairment; glasses can be regarded as fashion accessories, but the same is not true of hearing aids (Q 351, QQ 361-362). The scale of the problem means that it should be a priority for research, yet the opposite seems to be the case.

4.43.  Professor Steel added:

"We know virtually nothing about the causes of hearing impairment as people get older. We know nothing at a molecular level and practically nothing at a cellular level but we do know some things that are important. For example, there are three independent studies now that have demonstrated that age­related hearing impairment has heritability of about 50%. What that means is that about half of the hearing impairment is something to do with the variants of the genes we carry and the remaining half is probably due to environmental factors. Noise is almost inevitably going to be one of those, but we should not forget drugs, we should not forget infections as well because these can also affect hearing, and I suspect that diet may have an effect. So we actually know very little." (Q 349)

4.44.  One thing however which is perfectly clear is the damage to our hearing caused by excess noise, and that damage is irreversible. "Damage to our hearing is a one­way process because we are born with a set of sensory cells within our inner ear that are not replaced when they die, and any noise damage or any other sort of damage that damages them and makes those cells die leads to irreparable longer term damage. It is a one­way process basically and we never regenerate these sensory hair cells. The level of sound is obviously very important and the length of time of exposure is very important." (Q 348)

4.45.  We asked whether there was evidence that using Walkmans, iPods and other personal amplification systems caused damage to hearing. We were told that at present there is only limited evidence of this, but that this is probably because most such systems are used by young people whose hearing is fairly robust, so that some small amount of physical damage within the ear would not be noticed yet (Q 348). We believe that this is an important topic for research. If evidence does show that the use of such sound systems is going to cause people to lose their hearing ability later on in life, now is the time for the research to be done, so that appropriate precautions may be taken.

4.46.  About 4 million people would probably benefit from using a hearing aid, but only 1.5 million people have one, and it is estimated that half of them find their hearing aids inadequate and do not use them. One of the main challenges is to produce hearing aids which give better frequency resolution and better temporal resolution. We believe that the profits to be made by any company which can produce a markedly improved hearing aid must be very substantial. Yet this is a challenge which industry seems reluctant to take up. We consider this in Chapter 6.

TOUCH

4.47.  The only evidence we received on touch was from Dr R. Conrad, formerly Assistant Director of the MRC's Applied Psychology Unit at Cambridge.[86] He explained the importance to an older person of cutaneous sensation ("Is my finger actually in contact with a surface? Have I actually swallowed the small pill?"). The same was true for proprioception, the exact knowledge of where one's limbs, especially fingers, were in space ("Is my finger solely on the correct button? Have I pressed the button hard enough?"). Yet little was known about this, and whereas there was a great deal of quantitative data available relating to sight and hearing impairment, this was seriously lacking for other sensory systems. In his view there was an urgent need for epidemiological studies to establish the capabilities of older people in different age groups.

THE COST OF SENSORY IMPAIRMENT

4.48.  Leaving aside the loss of faculties caused by sensory impairment, social withdrawal, and the psychological impacts that follow from these, there are direct financial costs. A study in the United States in 1998 suggested that onset of hearing loss to a person in their seventies cost something of the order of $43,000 in hearing aid provision and loss of income. We did not receive comparable figures for sight loss, but it is plain that any intervention that can help reduce those costs, for example by picking up the hearing or sight loss at an earlier stage, will be a benefit accruing not only to the individual but also to society (Q 372).[87]

Oral deterioration

4.49.  Deterioration of oral health is particularly significant for the effect it has on quality of life, not just directly, but also in many other ways. A person's oral health status can affect not just how they chew, taste and enjoy food, but can have more profound physical and psychological influences on how they enjoy life: how they look, how they speak, and how they socialise, as well as their self-esteem, self image and feelings of social well-being.[88] But although oral ill-health has such a profound effect on the psycho-social welfare—particularly of the elderly who have poor oral health—it tends to be a poor relation in terms of the notice the public take of it, and in terms of the research funding it attracts (Q 96).[89]

4.50.  The current shortage of dentists is well-known. We know that the Government is addressing this problem although, given the time needed for training new dentists, this will be a slow process unless more qualified dentists can be encouraged to work in this country. This shortage is however a matter of particular concern in relation to older people, since they need more frequent access to dentists, but are less able to join the queues of people attempting to register with new dentists.

4.51.  We recommend that the Department of Health should continue to take urgent steps to remedy the shortage of dentists, and to encourage a habit of more frequent check-ups, especially among older people.

Conclusion

4.52.  Older people are disproportionately affected by many specific diseases and sensory impairments, and the expenditure directed at these diseases appears to be far lower than would be expected. A population with a growing number of older people will result in an increasing burden on society from some conditions for which age is a significant risk factor.

4.53.  The Government should re-examine their research priorities, and promote expenditure on research into the alleviation of those conditions which disproportionately affect older people.


64   p 357. Back

65   General Household Survey 2003, table 7.13 Back

66   From the evidence of Professor Carol Brayne, p165. Back

67   The Stroke Association, p 142. Back

68   Professor Ian Philp in the Foreword to The National Clinical Guidelines for Stroke, 2nd edition, June 2004. Back

69   Wolfe et al, Variations in Case Fatality and Dependency from Stroke in Western and Central Europe, American Heart Association, February 1999. Back

70   Clinical Effectiveness and Evaluation Unit, Royal College of Physicians, March 2005. Back

71   Lowin et al, Alzheimer's disease in the UK: comparative evidence on cost of illness and volume of health services research funding, International Journal of Geriatric Psychiatry (2001) vol 16, pp 1143 - 1148.  Back

72   Final Report of the Review by Derek Wanless, Securing Our Future Health: Taking A Long-Term View, April 2002. Back

73   Cancer Research UK, p 304. Back

74   Cancer Research UK, p 305. Back

75   Biosciences Federation, p 330. Back

76   Paragraphs 3.21 to 3.26. Back

77   From the evidence of Mrs Linda Kelly, p 164. Back

78   From the evidence of Professor Clive Ballard, p 165. Back

79   p 159. Back

80   Lowin et al, Alzheimer's disease in the UK: comparative evidence on cost of illness and volume of health services research funding, International Journal of Geriatric Psychiatry (2001) vol 16, pp 1143 - 1148. Back

81   Research Councils UK, p 198. Back

82   From the evidence of Mr Mike Brace, Chief Executive, Vision 2020, p 178. Back

83   JR Evans et al, Prevalence of visual impairment in people aged 75 years and older in Britain, British Journal of Ophthalmology 2002;86:795-800 cited in p 408. Back

84   Thomas Pocklington Trust, p 408.  Back

85   From the evidence of Mr Mike Brace , p 178. Back

86   p 355. Back

87   From the evidence of Professor Karen Steel, p 186. Back

88   Professor Aubrey Sheiham and Dr Georgios Tsakos, p 395. Back

89   From the evidence of Professor Elizabeth Kay, p 41. Back


 
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