All geriatricians know that life expectancy is increasing, but how many know that it is now increasing by five hours a day?

That was the dramatic figure given early on in the BGS’s Spring meeting and in many ways set its tone. For if, by the end of our stay in Gateshead-Newcastle, we would all have ‘clocked up’ the best part of another day on earth, then the questions about how that time would be spent were even more relevant both for our patients - and eventually ourselves.

Those questions – whether old age would be spent in disease and disability or with minimised morbidity and maximised enjoyment – were addressed by virtually every speaker in one way or another. So it was not just those tackling ‘geriatric giants’ like stroke and heart disease who could make all the difference to the quality of later life, but also those with expertise in areas such as nutrition, dentistry and palliative care.

The quality vs quantity debate was summed up by leading geneticist Prof Rudi Westendorp, head of gerontology and geriatrics at Leiden University Medical Centre in the Netherlands. Only the most extreme scientists in his field, he said, believed their research could make us live forever; most were interested in how unlocking the secrets of our genes could help prevent ill health in old age. “If you can identify the biological mechanisms then that allows for personalised intervention.”

Genes are thought to account for about 30 per cent of the variation in lifespan with those of the mother adding more than the father’s, a factor which may be linked to the X chromosome in ways not yet understood. But although some individuals degenerate fast and others more slowly – one of the great mysteries of ageing – everyone is burdened by what Prof Westendorp described as our ‘evolutionary shadow’. What this means is that all that is necessary for the survival of the species is for women to stay alive long enough to raise their daughters to the age when they too can become pregnant.

“Not only does evolution not mind if we die young it has no way of getting rid of genes that might harm us in old age, since it never intended us to live that long. There is no evolutionary reason to have, say, DNA repair mechanisms,” he added. “It may even be that genes which are good in our early years are not useful and may even be a disadvantage in later life.” It is thought, for example, that the same genetic factors which protect against cholera in infancy may also then cause cystic fibrosis.

Two attempts to move out from under this evolutionary shadow were mentioned by Prof Westendorp. One was his team’s research into their ‘collection’ of long lived families, particularly the women, to try to identify the ‘good’ genes which appear to slow down the ageing process at every stage of life and not just the later years. The other was work on mice (illustrated by a photograph of four year-old Yoda, the world’s oldest mouse) and elegans worms where genetic modification had increased lifespans seven-fold. Since our genes and those of other life forms are more similar than previously thought there is the intriguing notion that changing a few letters of the human genome might one day let us live to 700. “We are just at the beginning,” he added.

Genes were also one of the themes of a talk by renown Reith lecturer, Prof Tom Kirkwood, co-director of the Institute for Ageing and Health at Newcastle University in a special extra session on the Saturday morning (see later). Although our genes had settled for maintaining us only long enough to meet our ancient ancestors’ life expectancy, the fact that ageing was not solely genetically determined meant that it was malleable.
“Age related frailty, disability and disease are a result of an accumulation of cellular defects and random molecule damage,” he said, painting a graphic picture of the body as a battlefield where enemies like free radicals clashed with our defence systems – “even as we’re just sitting here quietly.”

“This goes on all through life. Youth and age are a continuum. The good news is that we don’t have to be fatalistic about it. Adverse factors can be offset by good lifestyle and good nutrition. A lot is within our individual power.”

A major attraction of BGS meetings is the chance to hear world-class specialists like Professors Westerndorp and Kirkwood explicate the science which has made them leaders in their field in a way that is accessible to those outside the discipline. This ability to be both highly informative and extremely interesting was a common attribute of most of the guest lecturers although they set about it in a variety of ways, including the use of video, photographs and other illustrations, humour and audience participation.

Living to see the other side of the wall
Prof Kaare Christensen, professor of epidemiology at the University of Southern Denmark in Odense, for example, illustrated his talk ‘Why do we age so differently?’ with pictures of elderly twins. The photographs were part of a fascinating experiment to see whether instinctive assessments of someone’s age-related well-being were borne out by science. For although there are formal ways of measuring the relationship between biological age and perceived age – whether one looks old or young for one’s years – many health professionals do that already.

In the experiment, nurses were asked to look at the photos of 400 twins and guess their ages. Their mortality rates were then followed up, allowing at least a two year interval to remove any contemporaneous illness as a factor in appearance. In each case the older looking twin died first. “Looking older is more dangerous than being older,” he said. Asked in the discussion afterwards whether changing one’s appearance might reverse the process, Prof Christensen said that there had been some interest from cosmetic surgeons in his findings.

“There’s no indication of that as yet. However it may be that looking better has a positive influence. You start taking more care of yourself and having a better lifestyle.”

Earlier he had described how mortality rates can be shifted quickly even at advanced ages. Before the unification of Germany, people in the East died significantly earlier than those in the West. Once the Berlin Wall came down however, the old people from the East rapidly caught up with their Western counterparts. “Questions are still being asked as to whether this was better food and better health care or whether it was psychological: they’d been waiting for 45 years to see what was on the other side and they weren’t going to die now.”

Sit when you wee
Another attention-grabbing illustration came from Prof Lewis Lipsitz, professor of medicine at Harvard Medical School and chief of gerontology at Beth Israel Deaconess Medical Centre in Boston, who showed a slide of President George Bush slumped across the banquet table during a state visit to Japan.

Could it have been, wondered Prof Lewis, an expert in abnormal blood pressure regulation and its relationship to falls and fainting in the elderly, a case of postprandial syncope?

Athough the question brought laughter from the audience it did underline a serious point: many fainting spells remain unexplained even after tests. Where causes were found they were often situational rather than due to disease: elderly patients were often at high risk of hypotension during their daily activities. A useful way of gauging such risks was to ask patients to keep a diary and measure their blood pressure at different times using an ambulatory monitor or portable machine.

“This way we can often identify the situation or the combination of factors that cause it to occur.” The problem does not always need drug therapy; sometimes coping strategies such as spreading out food intake, taking a walk after meals, eating less carbohydrate, even telling men to sit down while urinating, can be effective.

The power of appropriate audio-visual input was apparent right from the start of the meeting. In the inaugural symposium on the Wednesday evening Margaret Jackson, consultant neurologist at Newcastle General Hospital, showed videos taken of patients with suspected epilepsy. Falls, blackouts, confusional episodes and sleep related phenonemena in later life can all be caused by epilepsy but they can also be caused by a whole range of other factors.

Mind over physiology
A proper history can be as effective as any tests in establishing the truth but getting that may be difficult with patients who live alone or whose partner is hearing impaired, partially sighted or still fearful that the disease is a stigma. Hence the use of video recordings which can capture the episodes for subsequent analysis. One example showed that a woman’s blackouts were happening in response to terrible life traumas rather than any pathology.

At the moment such recordings are carried out in clinics but Margaret Jackson envisages a time when everyday technology might help. “Videos on mobile phones could be a very valuable resource. One can envisage a time when a young person captures on screen, a grandparent having an attack as it happens.”

Text-thumb
In a session on pain management Fraser Birrell, honorary clinical senior lecturer in rheumatology at Newcastle University, linked slides of X-rays to thumbnail sketches of patients and invited audience members to suggest both diagnoses and treatments. Suggestions included throwing away her mobile after excessive text messaging had caused one woman to develop problems with her thumb.

The pain management symposium was chaired by BGS president Jeremy Playfer, consultant physician in geriatric medicine at the Royal Liverpool University Hospital, who made the vital point that the issue of pain was raised on almost every ward round and was an area in which geriatricians could profitably learn from other specialities.

That drawing from other disciplines was echoed in many sessions of the meeting: after all, geriatrics is a broad church and one of its attractions is the sheer breadth and variety of the conditions our members can encounter almost on a daily basis. So speakers were not just geriatricians but experts from the fields of oncology, psychiatry, public health, nutrition, dentistry, cardiology, endocrinology and anaesthetics as well as the neurology, epidemiology, genetics and rheumatology, as already mentioned.

Their presentations included: a practical ‘toolkit’ to help recognise and diagnose Alzheimer’s disease; advances in cancer treatment; early manifestations of Lewy body disease; the ‘honeymoon’ period in Parkinson’s disease and how to maximise therapy to manage it; the latest thinking in hypertension management; future directions in osteoporosis care; dealing with incontinence; the ageing brain; bone health and new approaches to falls and fractures.

Glass half full or half empty
Some speakers’ messages were optimistic: they revealed valuable new research or promising new medication. Others used the forum to issue warnings or call for action. Clive Bowman, medical director of BUPA care services, said that the lack of control over antibiotics and infections such as MRSA in many institutions was a ‘tinder box waiting to go bang’. Roger Bullock, consultant in old age psychiatry at Victoria Hospital, Swindon, said that although two thirds of acute hospital patients are elderly and a third of those have mental illness, the system was still failing them. “Cognitive issues are still not being addressed. They’re falling between too many stools.” One member summed it up neatly from the floor. As well as patients’ well-being, he said, there were long term economic benefits from getting it right. “It costs an awful lot to treat someone badly.”

Some talks centred on the new: drug developments, technological innovation or better understanding of existing phenomena. An example of the latter was the metabolic syndrome as explained by Prof Mark Walker, head of Newcastle diabetes research group. Although the syndrome of a clustering of cardiovascular risk factors, including insulin resistance or raised insulin levels, has been recognised for some time, there is now increasing interest in the risk factors associated with abnormal fat distribution around the waist.

We are what we can eat
Other talks looked at more traditional areas in a new way. Advances in dentistry, for instance, are reducing edentulism almost by the day. Although about 50 per cent of 75 year-olds and over currently have no natural teeth, that proportion could soon drop to 20, even 15 per cent. But that will bring its own problems according to Prof Angus Walls, professor of restorative dentistry at Newcastle University, in his cleverly titled ‘We are what we can eat’ lecture. Natural teeth are not an unmitigated benefit: they can be a source of pain, inflammation and sensitivity. The ability to chew properly or a decline in saliva production then affects food choice which in turn affects nutrition.

Dental problems, however, are only one reason why the elderly may have a bad diet. In the same session Ashley Adamson senior lecturer at the Human Nutrition Research Centre at Newcastle University, cited loss of appetite, poverty, isolation, disability and access to food as other causes. Unrecognised malnutrition in hospitals, he said, remained a major problem.

The venue for the meeting was the new Sage building, Norman Foster’s magnificent steel and curved glass creation on the south bank of the Tyne in Gateshead which has already become a symbol of the area’s regeneration. With its massive state-of-the-art main auditorium, substantial seminar rooms, airy common spaces and views of the river with the city of Newcastle beyond, it proved an appealing and successful setting.

Finding a balance
(While on the subject of the pharmaceutical industry, the BGS is aware that there has been growing unease about the sponsored symposia at our meetings. Although we need sponsorship and are grateful for it, the feeling among members is that when the sponsors select the speakers who in turn may endorse their products, then the relationship may be getting a little too cosy. The Society is looking into this issue and members will be kept informed).

The regeneration of Tyneside is a source of tremendous civic pride both to native Geordies and to those who’ve made it their home and this feeling was very much in evidence at the meeting. Not only were a large proportion of the speakers and chairs from local institutions, both academic and clinical, but the welcome address was shared between BGS president Jeremy Playfer and Newcastle University’s vice-chancellor Christopher Edwards.

His appearance on the platform was entirely appropriate, said Dr Playfer, since the university was one of the few in the country to buck the trend in the ‘catastrophic decline’ in academic geriatrics: indeed it had more professors of the subject than anywhere in Europe

The interest is set to continue said the vice-chancellor. The university’s Institute for Ageing and Health already has a world-class reputation and the city has been recently designated one of the UK’s six ‘science cities’ with the aim of translating intellectual property into economic and social benefit.

The party city
The place’s reputation as a ‘party city’ was no doubt tested by many members but even those who didn’t venture across the river could experience two highly enjoyable social events.

On Thursday evening there was a welcome reception with canapés and drinks at the Baltic Centre, the former flour mill now an international arts centre. The highlight of the evening was undoubtedly the raising of the already iconic Millenium bridge, specially for the BGS.

On Friday there was a dinner at the Hilton Hotel, enjoyed to the backing of a jazz band and followed by the presentation of the president’s medals and an amusing talk by John Burn, medical director and head of the Institute of Human Genetics at Newcastle University. A highlight of the event for more energetic members was the Northumbrian ceilidh where they could clear their brains and shake their legs in the traditional dances as instructed by the bowler-hatted caller.

Those who drank the bubbly beforehand, wine during and brandy after the meal had no doubt been heartened by that afternoon’s lecture from Oliver James, provost of the Medical Sciences Faculty at the University. Speaking on alcohol and older people, he presented the cheering news that in terms of drinking, life begins at 60. Moderate consumption of any type of booze has a beneficial effect on heart attacks, stroke, osteoporosis, dementia and Alzheimer’s and overall mortality.

There were around 440 participants at the meeting including a large number of younger geriatricans as well as 30 visitors from overseas. Holland had the largest representation, followed by Australia with seven. Other visitors were from India, Kuwait, Denmark, America, New Zealand and Canada.

Posters
There were nearly a hundred posters at the meeting with subjects ranging not just across a wide range of illnesses and conditions but also into areas such as the law and medical ethics. Some concentrated on pure science; others looked at issues that might affect the daily lives of older people and their care: did they like shared hospital wards, for instance; should they see copies of their consultant’s letters.

The meeting ended with an extra session on the Saturday morning – a joint venture between the BGS and Years Head, the North East Regional Forum on Ageing. Members who stayed on for it were rewarded by a highly informative and interesting look at some of the wider issues affecting older people.

Speakers included Tom Ross, chairman of the Pensions Policy Institute who gave a succinct summary of the Turner report and its implications; Prof Peter Lansley, professor of construction management at Reading University who described some of the benefits technology could deliver; and Prof Ian Philp, the old people’s ‘tsar’ at the Department of Health.

As well as speaking of the major issues that still need to be addressed Prof Philp paid tribute to examples of good practice which already exist. At one home where residents were encouraged to live life to the full right to the end, a nonogenerian had told him :” I know I’m going to die soon but I consider myself lucky to be able to die here because this is a place where dreams come true.”

As she left the Sage, one member who has been attending BGS scientific meetings for 20 years gave a long term perspective on the meeting .“ I remember how it used to be just a couple of rooms with junior doctors presenting their research. The fact that we now have four days at a major venue like this shows how far we’ve come. Now it’s a world-class event.”

Liz Gill
Freelance Journalist