Woody Allen and ageing

"In my next life I want to live my life backwards. You start out dead and get that out of the way. Then you wake up in an old people's home feeling better every day. You get kicked out for being too healthy, go collect your pension, and then when you start work, you get a gold watch and a party on your first day. You work for 40 years until you're young enough to enjoy your retirement. You party, drink alcohol, and are generally promiscuous, then you are ready for high school. You then go to primary school, you become a kid, you play. You have no responsibilities, you become a baby until you are born. And then you spend your last 9 months floating in luxurious spa-like conditions with central heating and room service on tap, larger quarters every day and then.. Voila! You finish off as an orgasm! I rest my case."

This quote is from Woody Allen and was sent to me by one of the participants to our meeting. It is very timely as at my work I was joking earlier this week about the possibility of deageing. Especially deageing after reproduction seems a real option to me, meaning that when the kids grow older, you have more energy again. I must admit that I am a bit obsessed with growing older, approaching 50, and want to do everything to stop the process. And to find out that I have a bit more energy again, because my kids can pee, eat and move on their own gives a feeling of, well, comfort (and living in Geneva for most of the week also helps in this respect, although I miss them a lot at the same time).

But on a more serious side, it is also something we should deal with at WHO. In our discussions on how to structure the meeting, we are struggling with finding an alternative for the old models where you relate age and disease to various forms of care. If you have chronic diseases, find some disease management programme, If you are frail, you need to have home or institutional care, and if you are dying, the palliative care guys are waiting for you. As I said already in my earlier blog, it is all a bit sad and focused on the average patient.

What we really want is to find the right mix of support, assistive devices and care for you to remain longer independent. If your functions decline, and that is going to happen to all of us, how can we compensate for that as much as possible? I am not going to tell you what is our new model (will be released soon), but it is going to radically alter the lives of older people worldwide (ok, this may be an exaggeration).

However, I am convinced that you can start already now in trying to shift the age where you become dependent and frail. By taking care of the FIELDS of ageing (Food, Intake, Exercise, Liquids, Drugs and Stress, see earlier blog) it must be possible to stay in better shape and to be better able to cope with getting older. Just like people who are in good shape often recover faster after an operation, fitter people will probably face serious decline much later in life.

A word on dependency, as we struggle with that as well. What is it after all? There is much written about this in the literature. Dependent is often explained in terms of dependency on other people with performing activities of daily living. But can you be dependent on assistive devices as well? Are more resilient people with similar declined functions less dependent? And how to define the border line? Does frailty implies that you are also dependent? And is the wording (dependent) not a terrible way to speak about people?

Enough questions and I am not qualified enough to answer them. But we will address them during our meeting in April.

For now I wish everybody a happy Easter. After all, Easter always represents a new beginning, and the start of spring. In fact Easter is THE feast of deageing. Or as Woody Allen says "I don't want to achieve immortality through my work... I want to achieve it through not dying."

Old people, joy is coming

This week I went to a small art cinema in Eaux Vives, the area I live in Geneva, to see the movie "No" by Pablo Lorrain. The film is about the referendum that the dictator Pinochet in Chile was forced to organise under international pressure, asking the people for a mandate to continue another 8 years. The people in the No camp, a diverse group ranging from communists, dissidents and Christian democrats, had little time to design a campaign, but were allowed to broadcast 15 minutes each day on national television. They first made short movies about the misery of the Pinochet regime, the people that disappeared and with as concluding message that this should never happen again and that you should vote no. A young marketing professional joins the group and tells them it will not work. People will not want to jeopardize their increase in welfare, will be afraid to vote or will think that change will not happen anyway. The only chance for change is to look at the future and come with a message of hope and humor. After a lot of opposition from within the party (it is not easy to be joyful when your relatives were killed) and from outside (secret police) they do a campaign with the slogan 'Chile joy is coming'. They win, Pinochet has to leave and the rest is history.

Ok, nice story, but what has this to do with ageing and care you might ask? I will come to that in a moment. The first step to explain this is to have a look at the new health policy of the Dutch government.

Essential element of the newest health reforms in the Netherlands is a transition from looking at systems to looking at people. There are not only big differences in health status between people, but also in their social environment and the degree to which they have control over their own life. Despite the fact that different people need different care, we often still give them equal treatments.

The Dutch health ministry wants to solve that by integrating the existing systems for curative care, long term care and social support and to have a much more local and people centred approach in care.

I brought up this policy in an interesting discussion I had in Geneva with a close colleague. As I wrote before, we are organising a meeting with the title "building systems to address functional decline and dependence in ageing populations". For this meeting we write few papers, one of which on functional decline when people get older. The paper summarises the various definitions of frailty, functional decline and disability and how they relate to the different forms of care. There are already nice chronological schemes in the literature connecting different phases in your life to for example chronic diseases management, long term care and palliative care. In other words, your degree of dependency determines what care you need.

In our discussion we had the feeling that this does not reflect the recent developments, for example in the Netherlands, to a more patient centred and integrated care approach. It may be a better way to start not only from health status but also from the social environment and personal characteristics of people to get the full picture. You may then better understand what they need and together decide on the mix of care that will give best results. The mix of care must be such that it will contribute to the overall aim of maximising independence of people over their life course. After all, it is about people's ability to adapt to ageing.

During the meeting we may ask participants to reflect on these issues. But even if we come up with a different format, for me it is interesting to see that there are many similarities to the new health policy back home. We could even radically change the title of the meeting. Not building systems to address decline in people, but building people to address their decline.

But what is the link to the film I started with? Well, you need an optimistic message to change systems. Saying that you will decline later in life, that you are not able to perform functions anymore, that you therefore need care and at the very end maybe even palliative care is not really a hopeful message. Doesn't it sound so much better that it is wonderful to grow older and that our health care and support systems will contribute via a personalized approach to you being as long as possible independent and joyful later in life. As in the film, the dictator/top down approach should make place for the benefit of democracy/ the power of people to have more control over their own lifes. That would be a real revolution! Old people of the world, joy is coming!

Stress in old age

This week we had a visiting professor from Israel specialised in ageing and stress. To some extent this is rocket science in this country, as part of the research focuses on the anxiety of people when faced with rocket attacks. But they also use American research from people exposed to hurricanes.

The key question is whether older people are better able to cope with this kind of stress than young people. Is resilience getting stronger with age? And what dimensions of stress may change with age? You would expect that old people have more experience and know what to do in stressful situations. On the other hand, they may be a bit less flexible.

The theory of coping with stress goes back to the flight or fight response. There are many videos on Youtube explaining this. I like the one with the guy jumping away when a car suddenly drives into the pavement. It is then explained how you react in an emergency situation like that, what will happen to your muscles and to your hormone production.

http://www.youtube.com/watch?v=m2GywoS77qc

But going back to the question whether older people react differently. The evidence is mixed. For both hurricanes and rockets it was found that older groups experience less post traumatic symptoms than younger people, especially the middle aged groups. That is not completely surprising, as people in middle age have to cope with jobs and families. There is a difference if you just have to get the newspaper in the morning when there is a hurricane raging outside or you have to bring the kids to the nursery school and be in time for work. The professor herself experienced it when having to go for lectures to the university when there was an imminent rocket threat. Still old people seem to deal a bit better with psychological aspects and accompanying negative emotions. They report stress less often when they experience it (instead, they complain about the weather).

On the other hand, in old age stress is more often experienced through somatic symptoms, like slipping away and falling down more often. Existing health problems in old people like high blood pressure,cardiovascular disease, osteoporosis and digestive problems are intensified by stress. Stress hormones are released and absorbed slower and have a longer impact. Both ageing and stress hormones will impact immune functions. Old adults experiencing stress are vulnerable to infections and viruses like flu even when they are vaccinated.

So we are not sure about the relationship between old age and stress. But we know that over time stress can even be passed on to next generations. The classic example is post traumatic symptoms in a second or third generation holocaust survivors. Remarkable enough it can be shown that this is also the case for any positive effects. Resilience is also often higher in third generation holocaust survivors. The big question is how to pass the good things and block the bad.

Finally, is it possible to be happy and stressed at the same time? Yes, according to the professor. That is good news for me, as the coming weeks will be busy. I will be a happy, stressed and little bit old man.

Overmedicalisation

"Fred, you suffer from Self talking syndrome type 2". I turn around, a bit surprised, to my room mate, a doctor from Singapore. He is also a philosopher by nature and I wait for the daily question or theory that he wants me to react on. He continues "You are talking to your computer and that is maybe treatable". And then he starts to explain that this is an example of overmedicalisation, more a joke by him and that we have to find a balance in life. We divert the discussion to long term care - as we are both dealing with that - and conclude that there may even exist something like oversocialisation in some countries. And in other countries undersocialisation (not enough attention for social care) in the aim to come to universal coverage for medical care.

After our discussion, I thank him for finding the topic for my next flight blog (I usually write these blogs in the airplane back home on late Friday afternoons). Last week I already wrote about the danger of using too many medicines, especially when getting older, but the problem of overmedicalization is broader. The overtreatment of the attention deficit hyperactivity disorder (adhd) in kids may be the most well known example, but examples can also be found in fields like depression, sleeping disorders and, hm ok, talking to yourself.

How to define overmedicalisation exactly? Or rather medicalisation because this is how the term was first devised by sociologists in the 1970s. They viewed medicalisation as a form of social control in which medical authority expanded into domains of everyday existence. Doctors were seen as agents of social control. Ivan Illich, a philosopher, in his book "Limits to medicine: medical nemesis", elaborated on this. He stated that the medical profession harms people through iatrogenesis, a process in which illness and social problems increase due to medical intervention. He saw it on 3 levels: the clinical, involving serious side effects worse than the original condition; the social, whereby the public is made docile and reliant on the medical profession to cope with life in society; and the structural; whereby the idea of aging and dying as medical illnesses effectively "medicalized" human life and left individuals and society less able to deal with these "natural" processes (source: wikipedia).

Nowadays and after the roaring sixties and seventies, the criticism has become less sharp and a far cry from the earlier calls for a revolution against the biomedical establishment. Even scholars who critique the societal implications of brandname drugs remain open to these drugs' curative effects. That is probably why we now call it "overmedicalisation" rather than just "medicalisation". But recently the trend is to become more critical again. With the information revolution, more and more people want hard evidence for effective treatments and more and more is known about adverse effects of medicines. Our trust that big companies in banking, food industry and pharmaceuticals are acting in the interest of their customers is under fire with all this new information.

But before turning a revolutionary myself, let me turn back to overmedicalisation and ageing. As Illich already said, ageing should not be seen as an illness in itself. We too often use the words "frail" and "elderly" in one sentence, just because old people react a bit slower and tend to forget things more easy. Of course, they may have more diseases than when they were younger, but ageing itself is not (yet) curable. To make the distinction more clear, I propose that professional care workers who assist old people with activities of daily living (for example washing) are not allowed to wear white or green nursing uniforms. Pink, red or yellow, it does not matter, as long as it is colorfull, showing that ageing is not a disease.

Finally, should I worry about my talking to machines? Probably not as I am just ahead of my time. Computers and mobile devices are already able to deal with spoken comments and that will only increase in future. Whether it is desirable that computers in WHO will learn all types of Dutch dirty words is another matter. After I have left, they will probably need some treatment....

The holy grail of healthy ageing

One of the interesting advantages of my work on healthy ageing in Geneva is that I learn how to live longer. I am now reading an interesting book on the 10 secrets of healthy ageing: “Live longer, look younger and feel great” by Patrick Holford and Jerome Burne. Holford is CEO of the British Food for Brain Foundation and expert in nutrition therapy. Burne is a health journalist and expert on adverse effects of medicines.

I usually donot recommend books and I must be extra careful working for WHO now (so once and for all blogs, I am not a real expert, these are just personal thoughts and certainly not WHO guidelines). However, the more I read the more I feel that there are some valuable and even doable lessons on how to age better. Ageing is a bit like raising kids. It just happens to you but nobody learns you how to do it properly.

The interesting aspect of this book is that the authors start as much as possible from scientific evidence, but also use common sense. It is definitely not alternative medicine, but they recognise and show convincingly that there are many perverse incentives in prescribing medicines and modern medicine. It is indeed insane that old people sometimes have to use multiple prescription drugs with often more adverse than beneficial effects. So how to avoid that and avoid old age illnesses as much as possible from the very beginning?

The book starts by how to check your biological age. You can do that in a simple way by checking your BMI, blood pressure, pulse and waist/hip ratio. But they have also included more advance tests including some blood tests. They then address the ten secrets of healthy ageing, or rather 9 ways of addressing most common issues for old people: Alzheimer, joints & bones, diabetes, stress, skin issues, cancer, high blood pressure, digestive problems, eyesight and one for discovering the natural anti-ageing hormones that perk us up. Based on all this information you can develop your own anti ageing action plan.

Despite all these issues and illnesses addressed, there are basically just a few main recommendations in the book. Easier to remember: it is all about the FIELDS of ageing.

F: for Food. Most of us know or feel that food and ageing are interrelated. And indeed, there is something like an anti-ageing diet. Some of it is well known (not much fat and sugar) but they go much deeper in the book. They introduce the glycemic index of food, telling whether the carbohydrates are fast or slow releasing. And of course the antioxidant rich foods (chocolate and carrots) and food with omega-3 fats such as oily fish and seeds are good for you as well.

There are many things that at least I did not yet know. The Geneva diet: coffee with croissant is a deadly combination as far as blood sugar is concerned. I also didn't know that eating little and often is better than three big meals a day. And that muesli bars are deceptively unhealthy, with refined sugar and fat.

I for extra Intake: as you get older, the case for taking nutritional supplements on a regular basis gets stronger, as nutrients from food are less well absorbed later in life. And with less physical activity you also eat less (so you get even less nutrients). I must admit that I was always very reluctant to take extra vitamins, as they are expensive and I had the feeling that it was more profitable for industry than for my health. But after reading this chapter I partly changed my mind. They warn against too high doses but in general, they state, it is wise to have extra multivitamins, Vitamin C with zinc, omega-3 and 6, and antioxidants plus some additional stuff depending on specific diseases that you may already have. That sounds like a lot and maybe it is. But the main point is that when you get older, you can't get all the necessary nutrients from food anymore – even with the best diet – and you better have some additional Intake.

E for Exercise. As the authors state, modern life is one big conspiracy against physical activity. If governments wanted to do just one thing that would have a major impact on obesity, heart disease, stress and dementia, it would be to get everyone on a regular exercise programme. Exercise is the closest thing to an anti-ageing pill. It makes you less hungry, it boosts your metabolic rate (how fast you burn food), increases your hormone production and so on.

L for Liquids. Most of discussions are about alcohol, but that is not so important. Too much is harmful and one glas of good quality red wine is probably beneficial. Also sugary drinks are clearly wrong, including sugared coffee and tea. But the key issue is water. Start drinking a glass when getting up, with each meal, with each coffee and with each glass of alcohol. Our bodies consist of 85% water so you need it (I mean the water and not the alcohol). 8 glasses of water or herbal tea a day keeps your body in better shape.

D for Drugs, Do not take too many medicines. Medicines can be very useful and sometimes indispensable. One of the authors mentions that both his wife and his kids would be probably dead if they would not have had anti-biotics. But they also quite convincingly argue that medicines do not work that well in elderly patients, that side effects are often underestimated for this group and that side effects often lead to a chain effect (medicines prescribed to address side effects of other medicines). There are many examples in the book of diabetes drugs that raise the risk of heart disease, ineffective prescribing of anti psychotic medication to deal with dementia and the doubtful benefits of the use of statins to people without any heart disease. In a sense many pharmaceuticals follow the agrochemical approach that knocks out weeds and bugs with pesticides or of the preventive use of antibiotics in meat production. That is often not necessary as biological farming shows. Similarly, many drugs are not necessary when you adjust your lifestyle.

S for Stress, feel fine, avoid stress, sleep well and develop a healthy mind style. One useful recommendation is to have a notebook near your bed and write down anything you want to deal with tomorrow. That helps you to let it go during the night. Happy and flexible people live longer. And the worst emotion for longevity is not depression or stress – it's cynicism.

So don't be cynical after reading my blog or you will die earlier. It is so easy: eat well, drink well, sleep well, exercise well and well, take some vitamins and less drugs when you get older. The only thing is that I have to start doing it myself as well.

High tech & old

This week my new computer arrived after I was ageing for a few weeks. Most computers at WHO are small laptops that you can connect to a working station and disconnect when you have to travel. You even have two screens where you can split tasks. And you can install Skype and other useful tools. The help desk is in Kuala Lumpur as is most of WHO administrative support. But it works and I already phoned them late at night (at least for them).

So it is a good week to write a bit about technology and ageing. For example, this week I learnt more about the possibilities of big data / data mining to better treat old people. Up till now, treatment protocols are mostly based on the average patient. Of course there is no such thing as an average patient so decisions on treatment, placements in nursing homes and prioritization with waiting lines are often wrong. But if you use big cohort studies and try to match patients with similar patients in the past, you can better forecast what will happen to them. Due to the large data sets, there will always be a set of patients that had similar diseases and symtoms at any given point of time. As you know what happened to these other patients, you can better predict whether you are better off with home care or in a nursing home. Or doctors can forecast that given your present condition, how much will your ADL score change when you will get a certain intervention (ADL stands for activities of daily living). That will lead to better and more cost effective decisions and may also save a lot of money.

There are many other interesting applications of technology for the eldery. For example health mobile phone apps can monitor whether an old person is still active (moving around or communicating as usual). If not, the device will inform a care giver who can call or visit the immobile older person. A bit inpersonal maybe but very effective. EU research projects have mapped the opportunities for various high tech applications for the different diseases.

 A bit less age specific technology development, but worth mentioning is that this week the three global intergovernmental bodies dealing with health, intellectual property and trade have issued a study of the mix of policies needed to advance medical and health technologies and to ensure that they reach the people who need them. The book, “Promoting Access to Medical Technologies and Innovation: Intersections between Public Health, Intellectual Property and Trade,” was launched on 5 February 2013, by the heads of the three bodies — the World Health Organization (WHO), World Intellectual Property Organization (WIPO) and World Trade Organization (WTO).

The book covers a broad range of complex, yet linked, issues relating to public health and innovation in medical technologies, with the ultimate goal of accessibility — making medical advances available globally to all who are sick.

The book looks in some depth at the development of medical technologies, modern research and development, ways of providing incentives for innovation, and ways of dealing with market failures, in particular with new products for treating neglected diseases. I was involved in this proces some years ago when the topic was on the agenda of the World Health Assembly, leading to negotiations that lasted till deep in the night.

To read the two-page summary of the book, click here: www.wto.org/english/tratop_e/trips_e/trilat_5feb13_e.html

So much about ageing and technology. Probably I will come back to this issue again, as there are so many developments in this field. It will also be a topic that will be addressed during our high level meeting.

Independent or frail?

What is the difference between frailty, disability, dependence and comorbidity (having multiple diseases at the same time)? That is not so very easy to say. The similarity is not difficult. These words are all used to describe the heath status of older people. But there is much discussion in the scientific community about the precise definitions and how to measure them.

Ok, let them discuss it, I was always inclined to say. After all, if you are old why bother whether you are frail or dependent? But there is more to that. If you want to provide the right care to old people, you need to know what their problems are. Hence, you first have to measure their health status. To be able to measure, you must know what to measure. And for this you need good definitions. So, the scientists are right in this case.

After this week in Geneva, I learnt a bit more about the definitions. First we had a visit to WHO by Prof. Linda Fried, a world authority on frailty and now dean at Colombia University. In 2000 she already identified a definition and way to measure frailty. She defined it (in my own shorter version) as a state of high vulnerability for adverse health outcomes that results from decreased physiological reserves. In other words, your life reserves come to an end and your are less able to cope with health threats. Note that it is probable but not absolutely necessary that you have (mutiple) diseases when frail.

She also proposed how to measure it, When you have 3 out of 5 following symptoms you are frail:

1. Unintentional weight loss
2. Self reported exhaustion
3. Weakness (measured by grip strength)
4. Slow walking speed
5. Low physical activity

Later in the week, we had a retreat with the whole department where we elaborated on the issue. That was very pleasant a we had our meeting somewhere in the Alps in a chalet owned by one of the team members. Many people in te team had prepared delicious dishes and cakes so I felt a bit frail when coming back. Especially as I had to postpone my flight back and am now flying at 6 in the morning, while typing this blog

But it was worth it. During our discussion it became clear that the definitions sometimes overlap. You can be disabled, have multiple diseases and be frail at the same time. But also be only disabled, only frail and only have few chronic diseases. Or any combination in between. That is important to know when organising a long term care system.

Then dependence. Instead of measuring the health status, you can also measure what people can still do. To do this we identify activities of daily living (for example eating and personal hygiene) and instrumental activities of daily living (for example shopping and housework). When people cannot perform these activities without help, they are dependent and need help or care. This is a more functional approach to ageing.

Of course dependency is a difficult concept and varies per individual, by country and over time. One old person will be dependent when not being able to do the groceries any more, whereas the other person is not and already solved it one way or another. And in 2030 people will probably be less dependent than in 1980 due to more assistive devices. There are even people who would like to redefine the whole definition of health so that it would focus on the ability to adept.

Anyhow, a very interesting week that made me a bit more frail, but also more independent in my thinking on the topic.