Select Committee on Science and Technology Written Evidence


Memorandum by The Royal College of Physicians of Edinburgh

  The Royal College of Physicians of Edinburgh is pleased to respond to the House of Lords Select Committee on Science and Technology's Inquiry to Examine the Scientific Aspects of Ageing.

  The College welcomes this inquiry as one which is much needed. Indeed, hitherto there has been limited research in the field of age and ageing, and there is a concern amongst specialists in geriatric medicine that this is not viewed as a priority by the major bodies funding research in the UK. The demographic trends within the UK population indicate that a high priority in the allocation of research funds should be given to research proposals in this area.

  There are, however, many promising avenues for research. These include aspects of brain function including the role of neuroprotective agents (which may maintain brain function); genetic studies to examine the ability of individual genes to accelerate or to protect against the ageing process; and studies of cardiovascular function in older people. There are excellent opportunities to study the impact of exercise and dietary modification on maintaining good health in later life. However, it is important to emphasise that older people have often been excluded from research studies carried out in the context of a number of medical subspecialties. The College strongly endorses the importance of research in this age group as being a priority, and that older people should not be excluded from such studies. We also suggest that there should be an attempt to facilitate greater of co-ordination of research than hitherto between the public, private and charitable sectors.

  It should also be noted that the specialty of geriatric medicine has had great difficulty in making successful appointments to "academic" posts in the Universities. The lack of funding for research into ageing appears to have been a disincentive to talented researchers from entering the specialty. Conversely, the lack of academics in the specialty has meant that there has not been sufficient emphasis to force research into ageing higher up the priority list. A clear commitment to increase research into ageing may help the specialty to break out of this "chicken and egg" situation.

  The College recognises that one particular problem has been the difficulty in distinguishing the effects of "ageing" from the effects of "disease". Most of the health problems and much of the disability experienced by older people are related to `ill-health' rather than to the ageing process itself. The Inquiry may therefore find it difficult to focus specifically on ageing.

  Current demographic trends raise important issues of how to care for the growing number of old people, but this has been allowed to dominate discussions to the virtual exclusion of a search for strategies which might improve their overall health. The negative tenor of analysis to date has been fuelled in part by a misunderstanding about health in old age. It is true that older people have in general poorer health status than younger people, and this is due in part to the higher rates of disease in old age. The incidence of heart disease, for example, increases with age, but this does not mean that ageing itself is a cause of heart disease. Nor does it mean that heart disease is inevitable in old age. The crucial distinction between the effects of age alone and the effects of disease do require to be reinforced in the minds of both the lay public and health professionals. Finally laying to rest the pervasive misconception that all the ills of old age are "just your age" would represent a major breakthrough for the health care of older people.

  Evidence is beginning to emerge that, certainly for well educated, affluent older people, morbidity is already being compressed and that healthy ageing may be achievable for some. A landmark observational study from the University of Pennsylvania followed graduates from their early 40s to their mid 70s.3 The study focused on the three potentially modifiable risk factors of cigarette smoking, body mass index and exercise patterns. For those with high health risks from these factors in their mid-60s there was both an earlier onset of disability and a greater level of cumulative disability, as well as more disability in the final year of life. In contrast, the age at onset of disability was postponed by more than five years in the low risk group. In this study, adopting low risk habits in later life was associated with not only an increase in lifespan, but also an increase in healthspan. The promise of healthy ageing resurfaced in recent longitudinal data on disability from the US showing that its older population are less disabled and less ill than had been predicted.4 This unexpected finding may be due to a range of factors which include cohort effects, disability-reducing medical interventions and healthier lifestyles. It is telling that no equivalent data exist in the UK.

  Physical activity is the major modifiable influence on health in old age. It is clear that regular physical activity—bodily movement that is produced by the contraction of skeletal muscle and that increases energy expended—is associated with a reduction in the risk of coronary heart disease, diabetes, cancer of the colon and several other chronic diseases. Exercise, a subset of physical activity, may be defined as planned, structured, repetitive movement done with the express purpose of improving or maintaining physical fitness. Demonstrating that exercise can be beneficial is less difficult than persuading people to be more physically active. Part of the problem is the common misconception that to reap health benefits, continuous, vigorous exercise (such as athletics, jogging or squash) is required. This notion has its origins in studies of the effects of endurance exercise training on maximal oxygen uptake in younger adult. This work produced a physical fitness recommendation of 20 to 60 minutes of endurance exercise at 60 per cent to 90 per cent of maximal heart rate, three or more times per week. This advice was so scientific, complex and prescriptive and set such an unattainable goal for sedentary and older people that many must have given up on exercise as a lost cause. However, a reassessment of the original evidence together with a growing body of new research has shown that the majority of health benefits can be gained by performing regular moderate intensity physical activities (the equivalent of brisk walking at three to four miles per hour for most healthy adults) outside of formal exercise programmes. 5,6,7 This good news for couch potatoes of all ages is particularly heartening for older people (who find it is much easier to adopt and maintain more modest activity levels), and it carries the added bonus that low to moderate intensity physical activities are more likely to be continued than high intensity activities.8 It is therefore unfortunate that public health advice has failed to shake off the "high-tech" lycra-clad image of aerobic exercise and physical fitness, instead of embracing the broader concept of health and physical activity—which might include walking, dancing, bowling or gardening etc.9

  Physical capacity peaks in young adulthood and then declines progressively decade by decade at a rate which varies from one individual to another. Part of this physical decline is due to ageing, and is not amenable to intervention. Even healthy ageing is associated with a striking loss of muscle mass and hence muscle strength; by the age of 80 approximately 50 per cent of muscle mass has gone. However, it is now appreciated that some age related changes that were once accepted to be solely the result of the ageing process are actually the result of disuse, and therefore potentially reversible. The practical importance of this is that an older person is often precariously close to the threshold at which a small decline in physical capacity will render basic everyday activities, like rising from an armchair, impossible. The small added loss of fitness which occurs in association with an episode of intercurrent illness may render even a previously healthy 80 year old immobile and dependent. However, there is substantial evidence that lost fitness can be regained with regular physical activity, even in extreme old age. 10 There are a host of other health benefits associated with regular physical activity in old age. Weight bearing exercise may slow the rate of bone loss in older women, balance exercise training makes falls less likely, and regular exercise may be helpful in major depression. 11,12,13

  The social benefits of group exercise activities in later life should not be underestimated in a population where social isolation and loneliness may be common. Clearly there are compelling reasons for old people to be physically active. However, if more old people are to have this opportunity, radical changes in attitude are required. Prevailing cultural expectations that pensioners should "put their feet up" must be challenged. Well-intentioned relatives who take over the household chores should be aware they may be depriving their elderly relative of their main physical activity of the week. Too often, the old person struggling with an aspect of self care in the community is simply provided with social support, when a more appropriate response would have been treatment to help regain the lost skill. The provision of inappropriate social services to old people may simply accelerate the rate at which physical abilities are lost, and low staffing levels in hospitals and homes are likely to create unnecessary dependence because pressure of time means that it is faster for staff to perform a task for the patient than to allow the person to perform it for him/herself. 14

  Technology is already being used to support older people to live in their own homes or in specially adapted "smart" housing. There is an increasing body of evidence of the benefits of such developments, although many of these advances have not been subjected to critical evaluation with randomised trials. It is a matter of regret that "specially" designed houses for older people are sometimes not suitable for disabled people in wheelchairs or who need walking aids. Architects need to be made more aware of these matters and the College strongly endorses the need for proper, randomised, controlled trials of these new technologies before they are implemented on a wide basis, at significant cost. Moreover, many existing technologies eg personal alarms, adapted furniture, the design of special housing, and sensory alarms, have the potential to be upgraded using more modern technology. Again, these should be subject to proper evaluation in appropriate trials.

  A healthy old age depends heavily on luck, genetic and other factors which are not amenable to intervention. However, both lifestyle factors and nutrition in later life are crucial influences on healthspan and disability, and are potentially modifiable. 15 Additional disability free years in later life are precious to individuals and to society, but this prospect should not be overestimated. Disability may be postponed, but it will not be eliminated. Older people will still require longterm care, and many of the chronic disabling diseases of later life will still take their toll. 16 Unfortunately, older people are neglected by most health education campaigns. Older people require access to information about healthy lifestyles, the ability to appraise such information, and a sense of control over their own futures. It is also important to understand more about how and when such knowledge actually influences health behaviours: clinical research is required into incentives and opportunities which would motivate older people to adopt and maintain healthy lifestyles. Such changes are less likely to be achieved by exercise prescription schemes17 than by turning our environment into a more attractive place in which to be physically active, with attention to personal safety, good street lighting and town planning. The ageing of the population is a success story, and although much debate has so far focused on how to care for the growing number of old people, an equally important target is how to maintain their health and to minimise disability.

REFERENCES

  1  Shaw AB. Age as a basis for healthcare rationing: support for agist policies. Drugs Ageing 1996;9:403-05.

  2  Fries JF. Ageing, natural death and the compression of morbidity. N Engl J Med 1980;303:130-35.

  3  Vita AJ, Terry RB, Hubert HB, Fries JF. Ageing, health risks, and cumulative disability N Engl J Med 1998;338 (15):1035-41.

  4  Manton KG, Corder L, Stallard E. Chronic disability trends in the elderly United States populations: 1982-1994. Proc Natl Acad Sci USA 1997;94:2593-2598.

  5  Pate RR, Pratt M, Blair SN, Haskell WL, Macera CA, Bouchard C et al. Physical activity and public health. A recommendation from the Centres for Disease Control and Prevention and the American Colleges of Sports Medicine. JAMA 1995; 273:402-407.

  6  Dunn AL, Marcus BH, Kampert JB, Garcia ME, Kohl HE, Blair SN. Comparison of lifestyle and structures interventions to increase physical activity and cardiorespiratory fitness: a randomized trial. JAMA 1999; 281: 327-334.

  7  Andersen RE, Wadden TA, Bartlett SJ, Zemel B, Verde TJ, Franckowiak BS. Effects of lifestyle activity v. structured aerobic exercise in obese women: a randomized trial. JAMA 1999; 281:335-340.

  8  Pollock ML. Prescribing exercise for fitness and adherence. In: Dishman RK, ed. Exercise Adherence. Champaign, Ill: Human Kinetics Publishers; 1988:259-277.

  9  McMurdo MET. Exercise in old age: time to unwrap the cotton wool. Br J Sports Med 1999; 33:295-296.

  10  Fiatarone MA, Marks EC, Ryan ND, Meredith CN, Lipsitz LA, Evans WJ. High-intensity strength training in nonagenarians. Effects on skeletal muscle. JAMA 1990;263:3029-34.

  11  McMurdo MET, Mole PA, Paterson CR. BMJ 1997;314: 569.

  12  Campbell AJ, Robertson MC, Gardner MM, Morton RN, Tilyard MW, Buchner DM. Randomised controlled trial of a general practice programme of home based exercises to prevent falls in elderly women. BMJ 1997;315: 1095-1069.

  13  Blumenthal JA, Babyak MA, Moore KA, Craighead E, Herman S, Khatri P et al. Effects of exercise training on older patients with major depression. Arch Intern Med 1999;159:2349-2356.

  14  Muir Gray JA, Bassey EJ, Young A. The risks of inactivity. In: Muir Gray JA, (ed). Prevention of Disease in The Elderly. Edinburgh London Melbourne and New York: Churchill Livingstone; 1985:78-94.

  15  Allaire SH, LaValley MP, Evans SR, O'Connor GT, Kelly-Hayes M, Meenan RF et al. Evidence for decline in disability and improved health among persons aged 55 to 70 years: the Framingham Heart Study. Am.J Public Health 1999;89(11):1678-83.

  16  Gordon M. Is the best yet to be? Lancet 1997; 350:1166-1167.

  17  Harland J, White M, Drinkwater C, Chinn D, Farr L, Howel D. The Newcastle exercise project: a randomised controlled trial of methods to promote physical activity in primary care. BMJ 1999;319:828-832.

October 2004




 
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