Healthy to the end
The first thing that Laura Fratiglioni says is the very thing no-one wants to hear, the thing everyone knows deep inside, but which our entire western society seems to want to ignore.
“Ageing doesn’t start at 65 or 75 years of age. You age day by day, starting in your twenties.” Laura Fratiglioni is a Professor in Medical Epidemiology specialising in dementia at the Department of Neurobiology, Care Sciences and Society. She is also Head of the Aging Research Center (ARC) in Stockholm.
Laura Fratiglioni’s research relates to what makes people age healthily, in a way that allows them to live without functional disabilities and with a high quality of life. She was involved in the Kungsholmen Project on Aging and Dementia, and since then she has been one of the driving forces behind the Swedish National study on Aging and Care (SNAC) in which she is responsible for SNAC-Kungsholmen. The study also includes three other centres, in Blekinge, Skåne and Nordanstig in Gävleborg, which allows it to provide a more general analysis covering both urban and rural areas.
Ageing is a relatively new research field. Really old people have not been an issue until the last 30-40 years. In the 1960s, there were around 200 people in Sweden who were 100 years old or older. Now, five decades later, the number is well over 2,000. A serious academic prognosis, published in the scientific journal The Lancet in 2009, stated that if the increase in life span continued unchanged, half of all the children in countries such as Sweden born in the year 2000 or later would be able to celebrate their 100th birthday. With the current birth rates, the number of 100-year-olds would then be around 50,000 - every year. This is a prognosis, and perhaps not a completely realistic one, as it is not likely that the human life span will continue to increase indefinitely, but it still indicates the dimensions of what is happening.
Many factors determine how healthy your ageing will be
Over the last 50 years, a number of developed western countries have seen the most dramatic increase in average life span that has ever taken place. And if ten times as many reach their 100th birthday than 50 years ago, many more will reach the age of 80 or 90 years. Becoming really old is no longer a rare occurrence. Furthermore, the elderly today are often significantly more lively than they used to be. Mick Jagger and Keith Richards formed the Rolling Stones in 1962 and they still go on tour today. Both Jagger and Richards will be 72 years old this year, and their drummer Charlie Watts is turning 74.
“The most important factors that we can influence, and that increase our chances of healthy ageing, are to be physically active, not to smoke, to drink alcohol in moderation, not to consume an excessive amount of calories and to avoid animal fat,” says Laura Fratiglioni.
To be fair, this does not exactly sound like the Rolling Stones, but at least they are physically active, something to which anyone who has been to their concerts can attest.
“There are many factors that determine how healthy your ageing will be; it’s a combination of factors that interact throughout your lifetime,” says Laura Fratiglioni.
She talks about the interaction between the genetic background that all people have and the biological changes that occur in the body over a lifetime. Things like diseases, accidents and trauma obviously have an impact on the future. The social, physical and psychological environments are then added to these.
“The interaction between genetics, biology, psychology and our physical and social environment is very important. Within each area, there are various influencing factors, and we have managed to identify at least a few that are bad and a few that are good when it comes to achieving good health when you get old,” says Laura Fratiglioni.
Research results difficult to interpret
But many factors remain unknown, or at least insufficiently researched for Laura Fratiglioni to be willing to give any general recommendations. One reason for this is that this research field is still young, but another is that the “elderly” constitute a very mixed group. On the one hand, it spans from 65 years to a bit over 100, a period when much more happens in the body than during the equivalent amount of time during middle age. On the other hand, and this is almost even more important, people get old at very different ages.
“It doesn’t matter what factors you look at. Mental functions, physical functions and biomarkers, everything is more variable in older people than in younger ones,” she says.
This both makes research results more difficult to interpret, and means that values that apply to younger people suddenly become inapplicable. One example of this is high blood pressure. It is generally accepted that systolic blood pressure should be under 140 mmHg and diastolic pressure under 90 mmHg, otherwise it increases the risk of death, but this does not apply to the elderly.
“Blood pressure of 140/90 is not linked to a higher mortality rate in people over the age of 75. This has been proven by us and several other research groups,” says Laura Fratiglioni.
The same is true for being overweight. During middle age, being overweight is a mortality risk factor in terms of cardiovascular disease, stroke and cancer, and a body mass index (BMI) between 22.5 and 25 is ideal. For people over the age of 65, this risk gradually disappears and, after the age of 75, overweight (BMI 25–29.9) no longer increases the mortality risk, whilst obesity (BMI 30–34.9) only leads to a small increase. Instead, for elderly people, it is a low BMI that is dangerous and which increases mortality rates.
Keep both body and mind in shape
In order to increase your chances of a healthy old age, it is important to keep both body and mind in shape. One positive aspect here is that many of the things that activate the body are also good for the brain.
“What is good for the heart is also good for the brain,” says Miia Kivipelto, Professor of Clinical Geriatric Epidemiology at the Department of Neurobiology, Care Sciences and Society, Karolinska Institutet.
She has recently compiled the first results from the world’s first interventional study of protective factors relating to dementia. So far, all research looking at positive and negative factors for a good old age has been based on epidemiological studies. This means that researchers look at people's health and investigate their prior activities. This type of research provides some answers, but cannot provide definite evidence of a causality between a certain factor and an outcome, or whether there are other influences.
This is why interventional studies are necessary. They involve researchers randomly selecting which of the test subjects should do what, and then monitoring them over time. Interventional studies are considered to have the strongest evidentiary value, but they are significantly more costly and time-consuming. Certain obviously unhealthy behaviours, such as smoking, are not ethically justifiable or practically possible to study this way, but many other behaviours can be randomly assigned to the research subjects.
In the current FINGER study (Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability), 1,260 Finnish test subjects aged between 60 and 77 years were randomly assigned either to an intervention programme or to regular health advice. The intervention programme entailed individual diet counselling based on the Nordic Nutrition Recommendations (NNR), individual gym exercise set by a physiotherapist to strengthen the muscles, as well as group activities like walking, aquarobics, jogging or gymnastics, memory training using special computer programmes and regular physical check-ups which focused particularly on monitoring and taking measures against vascular risk factors such as high blood pressure, obesity, diabetes and high cholesterol.
The test subjects have now been monitored for two years, and it is already possible to see certain positive effects on the brain.
“The results are very positive. The people who were part of the intervention group had much better cognitive ability in terms of memory, speed and planning ability,” says Miia Kivipelto.
She and her research group will monitor the subjects of the study for seven years, which will hopefully yield even clearer results.
“Right now, we see differences in cognitive tests, later we may see differences in the number suffering from dementia. But the results already indicate that it is possible to influence the outcome and achieve effects in the brain,” says Miia Kivipelto.
However, it is not yet possible to see which of the different measures in the intervention group have the greatest preventive effect, but she will investigate this issue when the subjects have been monitored a while longer.
Lifestyle changes prevent Alzheimer's
A British-American research group published an estimate last year, however, of the importance of various risk factors in Alzheimer’s disease, and the group is of the opinion that in western countries, with low levels of smoking and a high level of education, physical inactivity is the greatest threat. This is partly because it is so common, and partly because physical activity impacts on so many other risk factors for developing dementia, such as obesity, diabetes and high blood pressure. The same research group also estimates that up to 30 per cent of all Alzheimer’s cases could be prevented through lifestyle changes.
“And if it’s 30 per cent for Alzheimer’s then it’s even more for dementia, since there is a clear vascular component there too,” says Miia Kivipelto.
Reducing the number of Alzheimer’s and dementia cases by 30 per cent or more through lifestyle changes could have an immense effect on the prognosis for healthy ageing. Not to mention how much it would mean for the individuals concerned. A major benefit is that the risk factors are more or less the same as for cardiovascular diseases. These individuals are therefore relatively often already found within the primary care system, but Miia Kivipelto believes that the healthcare centres can do more to help them. She hopes that the new findings will change the view of these risk factors within the health services.
Many people live with high blood pressure, obesity and diabetes. We know that the health services do not always have an ideal approach to these people. Perhaps it would increase the motivation of healthcare providers to take better care of these risk factors if they know that they also have a negative effect on the brain, she says.
To assist the health services, and also to give private individuals a chance to estimate their risk, Miia Kivipelto has created a dementia risk indicator, which allows you to calculate your risk of being affected by dementia within 20 years. The dementia risk score was developed in 2006, and is based on the CAIDE (Cardiovascular Risk Factors, Aging, and Dementia) study.
“Using this score, it is also possible to calculate the reduction of the risk if you manage to decrease a risk factor,” says Miia Kivipelto.
Other than the FINGER study, two other interventional studies are currently under way, one in France and one in the Netherlands, which are looking at ways to prevent Alzheimer’s and dementia. And according to Miia Kivipelto, there is a completely different level of openness between researchers than was previously the case.
“We work very closely with the other research groups, and we will compare our results and also pool our data. This gives us a total of 6,000 individuals, which will allow us to be even more sure in our conclusions of what works and what does not. We have realised that we have to share our data if we want to get results more quickly,” she says.
And they are in a hurry. The number of elderly people is constantly growing, and with it the number who suffer from Alzheimer’s or dementia. There is no cure in sight. There are four approved drug treatments for Alzheimer’s disease, but they have a rather limited effect on the symptoms and none at all on the cause of the illness. Nor has there been any new drug in over ten years, and there does not appear to be any promising research on the subject.
Widen the term "health"
The only thing that can be done instead is to attempt to prevent ill health during old age as far as is possible. But this is not a question of all 80-year-olds being fit as a fiddle. In order to understand the concept of healthy ageing, Laura Fratiglioni feels that we have to widen the term "health" when it comes to the elderly. Normally, we view health as the absence of illness, but this definition no longer works when we get older.
“After the age of 75, very few people are completely free from chronic illnesses, because you will almost certainly encounter a few illnesses over a lifetime. To describe health in the elderly, we must instead consider "function" – how well do we function despite the illnesses. Are we able to manage without help, take care of our personal hygiene, etc.?”
She also argues that it is important, at least from middle age, to assume a healthy lifestyle with physical and mental activity, in order to reduce the risks. Then when you are old, it is important to keep active – physically, mentally and socially.
“You should do things you like to do. Reading a book is great, for example, but it only stimulates your mind. There are other things you can do that are physically, mentally and socially stimulating. Many take a course at a university, or join a health club, where you have to join in with the exercises. I usually bring up dancing as a nice activity that includes all three components,” she says.
She has recently proven that people over the age of 75 who lead a healthy lifestyle live 5.5 years longer than those who do not.
“5.5 years more of life when you are 75 years old; that’s a lot,” she says.
Future healthcare environment
Another discovery made through research is that it is good to live in your own home for as long as possible.
“It is really important to remain at home, surrounded by your own things. But this can also lead to people becoming very isolated. They may lack stimulation, and stop cooking proper meals for themselves. This is something the healthcare systems must also keep in mind. It is great if people can stay at home, but home must not turn into a prison,” she says.
This last part is also the vision of Tore J Larsson, who believes that in the future, the home will not be a prison, but a place where care is administered. He is Professor of Safety Management and Occupational Injury Prevention at the Royal Institute of Technology (KTH), and is the Director of their Centre for Health & Building.
“In the future, we will not have special care homes for the elderly, instead the regular home will provide the healthcare environment. The primary reason for this is that this is the best option for the patients in need of such services,” he says.
Within the Centre for Health & Building, he and his colleagues develop various general and more specific solutions for the future format and organisation of healthcare. He believes that healthcare must be reconstructed from the ground up, to ensure a future healthcare system where the patient's care chain is central, and where health services come to them, instead of patients having to come to the health services as is the case today.
“The local living environment must be adapted for mobile healthcare, and we haven’t yet done that,” he says.
But Tore J Larsson also believes that much can be resolved through new technical solutions.
“Being able to talk to a doctor or nurse via videophone from home would solve a lot of problems. Many matters could also be simplified by having systems in your home that can send vital data to the hospital. You could take blood samples, urine samples, pressure, EEGs and ECGs at home, and send them directly to a lab,” he says.
From the perspective of the home becoming the healthcare environment of the future, it may be good to rethink your housing on an individual level, according to Tore J Larsson.
“All this compact living, and building yourself a loft bed under the ceiling is frankly no good. If you break your leg, you can’t get up there. You definitely want an electric bed with a raisable base. That makes it so much easier to get out of bed by yourself,” he says.
But to go as far as to move into a one-storey house or an apartment at the bottom floor to facilitate future ageing is a mistake, in his opinion.
“No, it’s good to remain agile, so just a few stairs is good for you. But when you can no longer climb the stairs, then it’s good if there's a lift,” he says.
We are becoming older and healthier
At the Centre for Health & Building, they are also developing practical solutions for everyday problems, such as roller shutter doors for the toilet instead of a regular door leaf, or a walker with a built-in hoisting beam that can help a person who has fallen to get up. Laura Fratiglioni is convinced that society as well as the elderly will have to adapt to a new situation with an increasing number of elderly people.
“We have yet to reach a point in our society where we think that an ageing population could be a benefit. So far, we have only considered the downsides, but I don’t believe it has to be that way. Elderly people can contribute both within their own families and society. People want to be involved. If a person is healthy and wants to work, why remove them from the workplace? Or they could start volunteering. Having a new, meaningful purpose can be really important to people.”
So far, it has been somewhat unclear whether the Swedes are really getting older and healthier, or just older. But Laura Fratiglioni has some exciting news.
“I am now one hundred per cent certain that we are becoming older and healthier. We have just published a study in which we were able to prove that a smaller proportion of people have functional disabilities now than ten years ago. And two years ago, we published a study showing that the proportion with dementia also appears to be falling,” she says.
So all that’s left to do now is to get started on a healthier life to increase your chances of ageing healthily. Or as Mick Jagger would have said – “Start me up”.
Text: Fredrik Hedlund, first published in the magazine Medical Science 2015.