Ageing as a cross-cutting themeDr Miles D Witham

Clinical Reader in Ageing and Health

Ageing – why bother?

Core business of the NHS Growth area… Current healthcare systems not

equipped to deal with ageing populations and their attendant issues

Underdeveloped evidence base Lot of ill-conceived ‘innovation’ Very little evaluation

Healthy ageing – why bother?

Dramatic increases in longevity over last century

Debatable as to whether this is accompanied by increase in healthy life expectancy

So plenty of work still to do here!

‘adding life to years’ – common, but still useful adage

Christensen K et al. Lancet. 2009; 374: 1196–1208

Crimmins EL et al. J Gerontol B Psychol Sci Soc Sci. 2011; 66B(1): 75–86.

Why focus on ageing as a College?

Impact Natural home for collaborative working Some strengths in this area already Historically under-resourced area of

endeavour (but this is changing)

FuturAGE roadmap

FuturAGE report 2011

So what’s wrong with ageing research at the moment?

Basic science in ageing is divorced from clinical practice

Social science (gerontology) is also divorced from clinical practice

Clinical practice lacks an evidence base relevant to older people

Clinical research is often small-scale, single centre, lacking critical mass and lacking the right multidisciplinary ingredients

Lack of ‘follow through’ from discovery, intervention development, testing to implementation and dissemination

The evidence mismatch

Most clinical studies look at young people with single diseases

Older people typically have multiple diseases, and are taking multiple drugs

They lack homeostatic reserve, are highly prone to decompensation, and have multiple functional impairments (the state of frailty)

Older people are highly heterogeneous

So evidence accumulated in younger people may not apply to older people

This leads either to:

- Inappropriate use of interventions in older people that may be either useless or harmful

- Ignoring potentially efficacious interventions in older people because practitioners don’t think the evidence applies to their patient

Health care systems

All this is delivered in healthcare systems set up for:

Single diseases Episodic care And increasingly…Mobile, articulate, IT-

savvy people

Which is not very useful for older people!

So how do we change this?

We need more of:

a) Interventions that target underlying pathological processes common to multiple disorders

b) Studies that deliver evidence that is relevant to older, frail people with multimorbidity

c) Healthcare delivery systems designed for (and by!) older people, which are flexible enough to deal with the heterogeneity of age

We need less of:

Single organ studies Highly selected populations

And also less of: Small pieces of disjointed work Small, isolated teams

Where could we target?

Multiple points in the lifecourse:

In utero Childhood Young adulthood Healthy ageing Ameliorating disease and decline End of life care

Danger of an embarrassment of riches…

What would an effective research strategy look like?

Multidisciplinary – just like good clinical care

Involve older people in priority setting and design

Spectrum of methodological expertise: Qualitative

Systematic reviews

Basic science

Epidemiology

Complex intervention development

Trials

Implementation science

Focus – no point starting a line of enquiry unless you are going to take it through to definitive trials and implementation

The UK picture

Historically, lack of join up between basic science, gerontology and clinical geriatric medicine

Lack of capacity in clinical geriatric medicine

Multidisciplinary work is common Lot of observational work Few small trials Very few large trials

Lack of critical mass until recently

Some good work, but lacking multicentre / UK-wide approach

Dundee: small trials

Edinburgh: delirium and dementia

Bradford, Notts: Health services research

Southampton, Cambridge: Epidemiology

Newcastle: Basic science, epidemiology

Local expertise

Ageing and Health

Oxidative stress (CVDM)

Trials (TCTU)

Epidemiology (DEBU)

Qualitative expertise (SNM)

Some systematic review expertise (scattered)

Implementation science (SISCC) – early stages

Examples from A+H

Health and Social care data integration:

Team from A+H, Clin Pharm, DEBU, HIC, SCPHRP

Now ESRC / Scottish Govt funded PhD (cosupervised by A+H / SNM / PHS / Napier)

Adherence in older HF patients:

Team from A+H, SNM, Health psychology (from Galway)

CSO-funded PhD

Physical activity in older people

Team from A+H, DEBU (PACS cohort); newer collaborations with SNM (PhD on care home physical activity); Computing and Design (BeSIDE project)

Pharmaceutical interventions to improve physical function in older people

Teams from A+H, Clin Pharm, Imaging, IMAR, Health economics (Aberdeen), trials (TCTU and HSRU Aberdeen)

Multicentre trials (BiCARB, LACE);

Single centre trials (PREFACE, SPIROA, ALFIE)

Pitfalls of cross-cutting themes

1) Getting Ageing and Health to do all the work

2) Tacking the word ‘Ageing’ onto work in a superficial way

3) Chasing grant calls with the word Ageing in them, rather than pursuing a coherent programme of work

4) Keeping the same structures and expecting cross-cutting work to magically happen

Conclusion

Ageing is a natural home for interdisciplinary, cross-cutting research

There is a lot of work that needs to be done The funding and structures nationally are

improving UoD has several inherent strengths in this area A joined-up, focussed approach may be the best

way to develop critical mass in selected areas Local examples of collaboration give a good

basis for future growth