HEALTHY AGEING & PREVENTION SUMMIT

Action to sustain wellbeing in later life

25th November 2015

Welcome

Dr Liz Robin

Summit Chair

Director of Public Health

Cambridgeshire & Peterborough

Housekeeping

Programme

9.00 am Welcome & Background

9.20 am Session 1: Healthy Ageing – the bigger picture • Keynote presentations

• Panel discussion

10.45 am Refreshments & Networking • Prevention into practice

11.15 am Session 2: A system-wide agenda for action • Group discussions

• Plenary

12.45 pm Closing remarks

1.00 pm Finish

Changing demographics

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

50,000

18-24 25-34 35-44 45-54 55-64 65-74 75+

Nu

mb

er

of

pe

op

le

1 longstanding illness 2 3 4 or more

Source: Health Survey for England (2012)

The number of people with one, two, three or four or more longstanding illnesses by age group, C&P CCG, 2015

Changing priorities

Changing systems

• New solutions to meet changing needs

• Opportunities

• System redesign - new structures

• Focus on healthy ageing and prevention

Aims of the day

• Develop a system-wide Agenda for Healthy Ageing and Prevention across Cambridgeshire and Peterborough

• Commitment to embed preventative principles and healthy ageing vision across our organisations

Current position

Dr Angelique Mavrodaris

Consultant in Public Health Medicine

Cambridgeshire & Peterborough

30.7%

3.4%

37.6%

28.4%

18-64, HSE

Two or more LTCs only

Two or more LTCs,mental ill health only

Two or more LTCs,limitation

Two or more LTCs,limitation + mental illhealth

Source: Health Survey for England (2012) survey estimates. Note: count of illnesses excludes self-reported mental health conditions and probable mental ill health is based on GHQ-12 score of four or more

Proportion of people aged 18 – 64 years with multiple (two or more) long standing illnesses with and without limitation and/or mental ill health (based on GHQ-12 score of four or more)

Health, care & complexity

A lifecourse approach

CC

G O

utco

me

s Frame

wo

rk Do

main

1

Collab

care

Interventions

to reduce admissions

Carer support

Targeted interventions

Regular medication reviews

Early identification/awareness/assessment of health risks

Vaccination

Environment & Community Comfortable and secure homes, adequate income, safe neighbourhoods, getting out and about and engaging

with community, friendships and opportunities for learning and leisure, keeping active and healthy, access

to good & relevant information

PLACE-BASED APPROACHES

LTCs JSNA

Prevention of Ill health in

older people JSNA

Primary Prevention

JSNA

PHYSICAL ACTIVITY & FALLS

LONG-TERM CONDITIONS & COMPLEX NEEDS

OLD

ER P

EOP

LE M

ENTA

L HEA

LTH

MDT evaluation

etc

HEALTHY AGEING & PRVENTION

Incontinence & UTIs

Dementia & MH

falls

Isolation & loneliness

PA & nutrition

multimorbidity

SESSION 1: HEALTHY AGEING – Are we seeing the Bigger Picture?

30 Wasted Years

Professor Ian Philp CBE

Cambridgeshire Summit on Preventive Care for Older People

25th November 2015

Segmenting the Population of Older People

Frail

At-Risk

Free-Range

The Young Ones

Self Esteem Friendship Active minds and bodies

Preventive care

EASYCareHealth:

25 Years,

44 Countries,

80 Publications

History and Development

EASYCare Assessment

1 •Seeing, hearing, communicating

2 •Looking after yourself

3 •Getting around

4 •Your safety

5 •Accommodation and finance

6 •Staying healthy

7 •Your mental health and well-being

Top Four Concerns

Loneliness

Finance

Memory

Pain

Cutting the Costs of Frailty

Chose to admit Specialist Acute Care

Discharge to Assess

Recovery Before Placement

Every Moment Counts

www.easycarehealth.org.uk

Healthy Ageing – are we seeing the bigger picture?

Carol Brayne

Cambridge Institute of Public Health

How is our perception of the bigger picture influenced?

• Routine information • Opinion (may or may not be evidence based, or

mixture) • Media • Personal experience • Systematically collected data that would not

otherwise be available (audit/research) and in the public domain or available to relevant parties (commercial, third sector, public sector)

• Integration of multiple sources (e.g. systematic and synthetic reviews)

• ….more on research with dementia as example

WHOLE

POPULATION Primary

care

Psychiatry

services

Institutional

care

Neurology

services

End of

life care

Secondary

care

Young,

no major

psychiatric

disorder

Memory problem,

worried well,

relatively fit

Acutely unwell,

Chronic disorders

and/or disability

Frail, may have Cognitive impairment, variable proportion with formal dementia diagnosis

End stage

disease,

likely

excluded

From

dementia

trials

Anticholinesterase RCTs (mean ages 72 to 75)

Antipsychotics in dementia RCTs

(mean ages 70 to 80)

National Dementia Audit in General Hospitals

(mean age 83)

Alzheimer’s Disease Neuroimaging Initiative

(mean age 75)

HTA-SADD Trial (mean age 79)

Example of research output

Example of

why we need

population

perspective to

understand

bigger picture

What is seen from local

authorities (and CCG’s)

perspectives

Who is the evidence based created from? For whom is it relevant?

Dementia distribution for people over 65 years old in 2010

Source: Population size come from ONS Statistics. Prevalence of Dementia come from Dementia UK full report 2007.

Some of the structures that can generate new knowledge locally

(apologies for abbreviations)

• NIHR investments: BRC, CLAHRC, SPHR, RfPB, other programmes (all will be explained!)

• Other: MRC, Wellcome, specific disorder charities, general local charities (e.g. Evelyn)

• Co-investment approaches e.g. LA and Univ. • All have work relevant to understanding Healthy

(Optimal) Ageing • Jigsaw of evidence to assemble • All new work should be framed within population

perspective to allow interpretation of meaning

No disease Asymptomatic disease Clinical disease

PRIMARY

Prevention

of risk

SECONDARY

Early detection

and treatment

TERTIARY

Reduce

complications

Onset of disease Onset of symptoms

Prevention terminology

(widest sense, ph definition)

Interplay between these is important in relation to populations

surviving with differential risk for future chronic disease and our

approaches to best bang for buck in societal action

What do we know from locally led work on Health Ageing?

• Population based work: general mid life to older populations

• EPIC Norfolk and the Cognitive Function and Ageing Studies

• Evidence reviews

EPIC NORFOLK and the survival advantage of healthy behaviour score people aged 45-74 followed for 6 years*

From Plos Medicine Khaw 2008

*Current non smoking Physical inactivity Moderate alcohol intake Blood vit C (5 fruit/veg)

Healthy behaviours

· Physical activity / Sedentary behaviours

· Diet

· Tobacco smoking

· Alcohol consumption

· Cognitive activities

· Noise exposure

· Work / Social activities / Participation

REVIEW 1

Uptake &

maintenance of

healthy

behaviours in mid-

life

Barriers Facilitators

· Personal factors (e.g. gender, SES, ethnicity, employment, family, previous

experiences, expectations)

· Social factors (e.g. norms, support)

· Environmental factors (e.g. access to resources/interventions; residential &

work environment)

· Organisational factors (e.g. design & delivery of intervention, resources)

REVIEW 2

Association between

behavioural risk factors and

ageing well outcomes &

common chronic conditions

Effect on ageing Well Outcomes

· Disability (ADL, IALD, independence,

mobility)

· Dementia

· Frailty

· Healthy life span

· Quality of life

· Participation

Effect on non-communicable conditions

· Cardiovascular diseases& stroke

· Renal disease

· Life style related cancers

· COPD

· Type II diabetes

· Osteoporosis / Bone health

· Hearing & Sight Loss

Primary prevention of preconditions

· Impaired glucose intolerance

· High blood pressure

· High cholesterol

· Overweight / Obesity (weight loss or control)

· Impaired cognitive function (MCI)

· Mood disorders & mental health

· Functional limitations

Other relevant outcomes

· Resource use, costs, cost effectiveness

Effect on healthy behaviours

· Increase/maintain “good” levels of physical activity OR

decrease sedentary life styles OR maintain balance, strength and weight-bearing functions

· Improve/maintain good diet & nutrition

· Reduce/prevent/stop tobacco consumption

· Decrease/prevent excessive alcohol consumption

· Maintain/increase cognitive and social activities, and participation

· Prevent / decrease excessive noise/ sun exposure

· Improve/modify multiple behavioural risk factors

· Remove barriers / facilitate uptake & maintenance of any life style behaviours WITH demonstration of

impact.

Intervention

Effectiveness & cost effectiveness…

REVIEW 3

Summary of NICE reviews (Lafortune and team)

E.g. Physical Activity (n= 45) √ = improved outcomes; 0 = no significant association; X = poorer outcomes

Successful

ageing

Disability

& Frailty

Dementia Total mortality CVD

(events &

mortality)

Diabetes

(MetS)

Cancer

(cancer

mortality)

Mental

health

√√√

√√√√√0

(√√)(√√)√√ 00

(√√)√√√

(√√)(√√√)√√√√

√√ (√√√)

0(√0X)0√

√ 0

[+][++][++]

[+][+][-

][+][-]

[+][+][+][-

][++][-]

All [+]

All [+]

All [+]

All [+]

[+] [-]

UK,UK,US

UK,It,Ice,Fi

n, US/ Fin

UK,Swe,US,Ice

/ Swe, US

UK,Fin,Den,G

er

UK,Fin,Swe,G

er,Gre,Den

UK,Nor

UK,UK,UK

,Fin

UK, Aust

E.g. Smoking (n=57) √ = improved outcomes; 0 = no significant association; X = poorer outcomes

Successful

ageing

Disability

& Frailty

Dementia Total

mortality

CVD

(events &

mortality)

Diabetes

(MetS)

Cancer

(cancer

mortality)

Mental

health

XXX

XX

(mobility)

0X0X (fract)

XXXXXX /00

(dem)

XXX (cognition)

X(XXX)XXX

(Ex-smokers)

√√√√√√

XXXXXX/0

(mortality)

XXXXXXXXXXX

/0(CVD)

XXX/0

(X0 MetS)

XXXXXX

none

ALL [+]

5[+] 1[-]

ALL [+]

ALL [+]

3[++] 9[+]

ALL [+]

ALL [+]

UK,Fin,US

Swe,US/Swe,S

we,UK,Aust

US,US,US,Kor,US,US

s US/Nor

UK,UK,NL

UK,3Fin,Jp,

Sing,Is

US,Cz,Jp,Jp,Is,Sin

g/Ch

UK,UK,Jp,Jp,Swe

,Jp,Swe,Swe,US,

US,Swe

UK,Fin,Jp/

Nor (Diab)

UK,UK,Jp,Jp,

Jp,Sing

E.g. Alcohol (n=54) √ = improved outcomes; 0 = no significant association; X = poorer outcomes

Successf

ul ageing

Disability &

frailty

Dementia Total

mortality

CVD

(events &

mortality)

Diabetes

(MetS)

Cancer &

cancer

mortality

Other

NDCs

Men

tal

heal

th

√X

X ADL

0X Fract

X0 Dem APOE4

0 Cognition

XX Abstain vs mod

XXX Heavy drinkers

X

000

XX Heavy

√ (Regular cf occ)

X

Diab

mod/high

X0√ MetS

000X

0

COPD

√

[++][+]

[-]

[+][+]

ALL [+] [++]

[+][++][+]

[++][+]

[+]

[+]

[+][+][+]

[+][+][++][+]

[-]

[-]

US US

US Swe,UK

Fin, UK, Fr

UK UK, Ch, NL

UK, Jp

Jp

UK,UK,US

UK,UK,US,J

p

Europe

Aust

Barriers and Facilitators - example

Uptake &

maintenance

Smoking

Barriers Facilitators

HEALTH & QUALITY OUTCOMES

• Experience of iIl health

• Health check-ups

• Physical activity

• Medicine use

SOCIOCULTURAL

• Support

• Occupation

• Current practice

• Age at initiation

PHYSICAL ENVIRONMENT • None found ACCESS • Information

PSYCHOLOGICAL • None found SUBPOPULATIONS Unemployed young adults • Lack of motivation

HEALTH & QUALITY OUTCOMES

• None found SOCIOCULTURAL

• Cultural and social acceptance

• Misperception of benefits

• Relaxation

• Concentration

PHYSICAL ENVIRONMENT

• Easy availability

ACCESS

• Low cost

• Marketing strategies

PSYCHOLOGICAL • Lack of motivation

SUBPOPULATIONS • None found

Findings from Barrier and Facilitator review

Across health behaviours

• Lack of time (family/childcare/work/household)

• Financial costs

• Access/availability (to programmes)

• Transport issues (access to programmes)

• Lack of knowledge

• Low SES

• Co-existing poor health behaviours

• Personal attitudes and beliefs in midlife (entrenched)

• Social support/environment

• Enjoyment

• Health benefits/prevention of illness/body image

• Integration into lifestyle/swapping/routine

• Health check-ups/ appointment arrangements

• Clear accurate health messages/tools

Original MRC Cognitive Function and Ageing Study

Prevalence (%) of dementia early 90s

0

5

10

15

20

25

30

64-69 70-74 75-79 80-84 85+

men

women

Continua of all measures, not dichotomies (cognitive -

CAMCOG norms)

50

55

60

65

70

75

80

85

90

95

100

65-69 70-74 75-79 80-84 85-89 90+

Age group

CA

MC

OG

sco

re

.

95th, 90th

75th

50th

25th

10th

5th

Williams 2003

Dementia and severe cognitive impairment before death by age in CFAS (dying within one year of interview)

0

10

20

30

40

50

60

70

65-69 70-74 75-79 80-84 85-89 90-94 95+Age group

% D

em

en

ted

at

de

ath

NEJM 2009; 360:2302-2309

Inconvenient findings Age-Effect on Relationship Of Pathology to Dementia

Sodukos, blueberries and a bit of exercise – is healthy (brain) ageing that easy? Reducing risk….

Education mitigates effect of pathology

Formal years of education reduces dementia risk: why?

1. Less pathology in the brain? “neuroprotection”

2. Better able to cope with pathology in the brain? “compensation”

We found no relationship between education and burden of pathology (i.e. education was not neuroprotective)

Those with high education

were able to compensate for

pathological burden

Example: cortical tangles

0

20

40

60

80

100

0-3 4-7 8-11 12+

Education

% d

em

en

ted

None

Mild

Mod/sev

Opportunities for risk reduction for dementia (and other conditions) - modelling prevention with caveats (Norton et al, Lancet Neurol 2014)

Repeat look at Seven risk factors for dementia

• Potential proportion of dementia (AD) in the population that might be prevented through tackling seven linked risk factors

• 30% attributable to diabetes, midlife hypertension, midlife obesity, physical inactivity, depression, smoking, and low educational attainment taking into account inter-relationship between these variables

Testing change over time: CFAS I and II • Building on MRC CFAS (6 sites)

• Three areas taken forward for new study

Cambridgeshire

Newcastle

Nottingham

• CFAS II Repeated methods

• Health profiles changed

• Ageing of population

The present: CFAS II* & change over time

* + other Europeand/US studies

Deprivation and differences in age structures – CFAS II estimates applied to UK (prevalence %)

Men Women

Value

3.30 - 4.32

4.33 - 5.24

5.25 - 6.38

6.39 - 6.96

6.97 - 8.38

Prevalence of Dementia (%)Upper Tier Local Authorities

© Crown copyright. All rights reserved. Public Health England, 100016969, 2013.

Lifecourse approach

Kindersley, 7 Ages

Henry Moore, sketches on 7 ages, Tate archive

Synthesis

• Change in populations is ‘in our time’ and possible • Lifecourse scrutiny of what can be done, what is the

evidence base of possible actions at different ages • Social deprivation captures things that matter for brain

health (and will do for disability as well) • Some positives being seen for brain health in CFAS • Other data sources suggest mild disability has increased,

new data to come soon from CFAS • Embedded research integrating routine data sources and

research data will be valuable to guide and evaluate any new activities

• We are keen to continue to work with you and whole communities to co-produce healthy ageing lifecourse plans

Thank you!

PANEL DISCUSSION

Ian Philp, Carol Brayne, Liz Robin and Adrian Loades

Break

9.00 am Welcome & Background

9.20 am Session 1: Healthy Ageing – the bigger picture • Keynote presentations

• Panel discussion

10.45 am Refreshments & Networking • Prevention into practice

11.15 am Session 2: A system-wide agenda for action • Group discussions

• Plenary

12.45 pm Closing remarks

1.00 pm Finish

SESSION 2: A SYSTEM-WIDE AGENDA FOR HEALTHY AGEING - How can Healthy Ageing be actioned locally?

Priorities for local action

Group discussions 1) Increasing physical activity and reducing injurious falls

2) Ensuring holistic approaches and care for older peoples’ mental health

3) Strengthening a place-based approach to healthy ageing

4) Avoiding admissions for people with multiple conditions and complex needs

Plenary session: prioritisation exercise

Closing remarks

• A way forward – next steps

• Action and deliverables

• Continuity and collaboration

• Sustainability and integration

• What we hope to achieve

Keeping in touch

• Contact:

angelique.mavrodaris@cambridgeshire.gov.uk

Thank you very much for your attendance & participation today