How long do you want to live? How do you want to live those years? And which is more important, a long life or a healthy life? Or could we possibly enjoy both health and longevity as medical science continues to make advances in our understanding of human life and death?
These fundamental questions are moving centre stage in Ireland as our society grows collectively older. After decades of rejoicing in our relative youth – remember our boasts about being the youngest people in Europe – we now have to grapple with the challenges posed by an increasingly older, and potentially dependent, population.
They are also at the heart of the work of Mercer's Institute for Successful Ageing, an ambitious new project on the campus of St James's Hospital which is being opened by the President Michael D Higgins, on Wednesday (December 7th).
Funded by €17 million in capital support from Chuck Feeney’s Atlantic Philanthropies along with backing from the Department of Health, the institute is unlike anything that has gone before it in the health service. It isn’t just about size – the clean lines of the building rise seven storeys and offer fabulous 360-degree views over Dublin. The clue is in the name, one that signals a positive, all-embracing approach to providing services based on a person’s biological age rather than their chronological tally of years.
The first myth it seeks to slay is that ageing is a matter solely for the old. We are all ageing from the moment we are born. As the director, Prof Rose Anne Kenny, points out, the most dramatic changes in our cells start at the age of just 38.
“We need to be aware of this. Ten years on from this point in our lives, high blood pressure or arthritic changes or weakening muscles start to kick in so it’s important that people realise the things you need to do at this age to ensure healthy productive ageing almost to the end.”
Add to this the fact that the vast bulk of caring is done by family members and it is clear we all have a vested interest in healthy ageing.
“It’s great that people are living longer but the challenge is for people to live longer without disability. We’re not great on that in Ireland,” says Kenny. Over the age of 65, for example, only 30 per cent of women, and 45 per cent of men, are disability-free for the rest of their lives. In Sweden, this figure is 75 per cent.
She points out that 70 per cent of people aged over 50 are not taking adequate physical exercise (150 minutes a week), while 70 per cent are obese or overweight. Let alone the problems this causes with heart disease, stroke and cancer, these are also risk factors for dementia.
Meanwhile, most men aged 50-64 are not aware they have high blood pressure. “These are easily modifiable things, they don’t cost anything. It’s up to the public to be aware that once you hit 50 you have to have these things evaluated.”
Kenny says we all have a personal responsibility to manage these risks. “It shouldn’t all be dependent on the State. We all need to ensure we have screening assessments at regular intervals.”
If you manage blood pressure, obesity, physical exercise and diabetes in mid-life, you reduce your chances of getting dementia in later life by over one-third, more than the impact of any single drug.
Most of the patients coming through the acute beds and the day services at the institute are indeed older people, but the institute’s services are not age-specific and the patient cohort also includes younger people who may have suffered a stroke, memory issues or fainting.
Ireland beat off stiff competition from the US and other European countries to gain funding from Feeney for a centre that combines the daily practise of medicine with a slew of research activities.
“Atlantic wanted something that would have an impact on service delivery and people’s health nationally. We are the national lead for new services, so we develop and evaluate new models of service delivery and then work with hospitals.”
The idea is that clinical practice and research are constantly learning from each other. The problems surfacing on the wards are the issues that need researching, and the results of that research feeds back into medicine through new devices, guidelines or training.
Prevention is often crucial. More than half of all women aged over 50 will suffer a bone fracture, for example. That has implications for other medical conditions, and the likelihood of suffering a further fracture.
"Hip fracture is an absolute medical disaster, especially for men," says Prof Bernard Walsh of the institute's bone health unit. "One-third of patients who suffer it can be dead within a year. One-third get back to independent living but the remaining one-third are left dependent, and many end up with multiple medical problems, such as heart failure, embolism, DVTs and clots."
Falls, fits and faints
The institute has responded by developing a new way of evaluating the “falls, fits and faints” staff were seeing, and from this came a training programme for doctors and nurses, including a diploma in syncope (fainting) and related disorders.
Falling or having a blackout is the commonest single reason for emergency department visits, often as a result of a heart issue, so the institute also checks patients with a “head-up tilt test”, a device for examining a patient’s susceptibility to fainting. Kenny developed the apparatus while working in London and it is now used worldwide.
At-risk patients can then be monitored using a tiny device, no bigger than a short lollipop stick, which is injected in under the skin, from where it provides heart rate measurements for up to three years. The data is transmitted to the computer system via Bluetooth.
The device allows for continuous monitoring of the patient’s heart for 250 patients a year. Kenny says 70 per cent of people coming to the emergency department with an unexplained fall were found through this testing to have a heart irregularity that wasn’t previously known.
Age-related medicine used to be the “Cinderella” of medicine, she says, but this is no longer so. “When I came back to Ireland 10 years ago there was a lack of awareness of ageing issues, of the coming demographic wave, and of the contribution made to society by older people. There has been a huge change since, including among doctors.”
As a result, more nurses are now trained in specific age-related issues. In addition, dedicated cubicles have been provided for older people in the emergency department at St James’s, providing some relief against an environment that can often be overcrowded and chaotic.
Decline, Walsh says, is not an inevitable part of ageing, though it is frequently assumed. He cites a case of an elderly woman who was admitted to him with double incontinence, dementia, severe pain and who was completely immobile. He was requested to find long-term care for her, yet simple tests established she had severe vitamin D deficiency.
“All we had to do was replace the vitamin D. The pain went away gradually, the pelvis healed and there was no more incontinence after we removed the catheter. The woman went from being immobile to being totally active and went on to organise and make the dress for her granddaughter’s wedding.”
A device that tests rugby players for concussion by measuring tiny movements of the eye is one of the more unexpected spinoffs from the age-related research being carried out at Mercer’s Institute of Successful Ageing.
The device uses ocular micro-tremor measurement technology to monitor the movement of the eye, by a distance as short as the breadth of a human hair. Variations of this movement can be used to detect whether patients are emerging from coma, or how deeply they are anaesthetised, researcher Mindaugas Norkas, from Lithuania, explains.
Another potential application is as a pitchside test for concussion in sport. Unlike existing equipment, it does not require contact with the cornea, he says, as it relies on a light shone on the white part of the eye.
The project is just one of a number of promising research activities at the institute, which aims to translate medical findings into usable technology of benefit to patients.
In the social area, the best-known project is the ongoing survey of over-50s known as Tilda, which has informed almost 60 policy documents over the past five years.
Tilda has filled in many of the blanks that previously existed in our knowledge of older people but it has also sparked trials aimed at preventive measure and more fundamental research.
For example, after it found that only half of over-50s were aware of their blood pressure levels, a campaign began to target middle-aged men for screening. Two-thirds of those who were found to have atrial fibrillation, the most common cause of stroke, were unaware of this.
It was also found that nurses working in primary care, mostly for private GPs, were unaware of up-to-date guidelines for measuring blood pressure, so training was organised.
Of course, many patients' needs are immediate. In the occupational therapy department, Thomas Payne is stepping out of a "half-car" which has been installed in order to help recovering stroke patients re-adapt to life in the outside world.
Payne, from Crumlin, is making a good recovery after suffering a stroke six weeks earlier that affected his sight and his movement on one side. Over this time, staff have worked intensively to help him regain his movement and to adapt to his new situation.
The model, comprising the passenger side half of a Toyota, allows the patients practise alighting from the car. The department is also equipped with a model kitchen, including a counter that can be moved up and down to suit the requirements of patients and anticipate their needs when they move back home.
Staff visits to Payne’s home have confirmed the need for alterations and repairs. “It’s coming back,” he says of his movement, “I think I’m starting to look forward to Christmas at home now.”
The approach of the institute to research is inclusive. “Design for the aged and you include the young. Design for the young and you exclude the old,” Prof Bernard Walsh. “So if you design for the elderly you cater for everyone.”
Keys to growing older healthily
Physical exercise, social engagement, early screening and good diet are the keys to growing older healthily, according to Prof Rose Kenny, director of the Mercer’s Institute for Successful Ageing.
Friends are more important than family in many cases, she says, as they may be easier to engage with and confide in, she counsels.
“Friends are more important than physical exercise, smoking and alcohol combined. If you experience loneliness, that is a bigger risk factor for your heart than the other three.”
People can alter their diet at any age and still enjoy positive benefits, she says. Her dietary recommendation: “Dark fruit and vegetables, fish and chicken. The darker the fruit the better.”
By the age of 50, people should be having their blood pressure, blood sugars and bone health screened, so as to minimise ill-health in older life. In the US, she notes, dementia rates have fallen sharply due to the earlier identification and management of the cardiovascular risks.
Kenny also stresses the importance of creativity throughout life, which is why the new institute has a strand devoted to “creative life” alongside its clinical and research activities. Concerts, art displays and other artistic events will take place regularly in dedicated central areas on the ground floor of the building, it is envisaged.