Chronic disease begins in childhood

22 July 2013

A conference report from the BGS Spring Meeting in Belfast, by Liz Gill. Research is increasingly suggesting that old age is influenced by conditions and events in early life, a concept supported by data from The Irish Longitudinal Study on Ageing, TILDA, which has studied 8,500 people aged 50 and over for the past ten years. Opening a special session on the last morning of the conference, its principal investigator Prof Rose-Anne Kenny of Trinity College Dublin, described the process. Participants were given an initial comprehensive assessment which included physical health, cognition, psychology, behaviour, family background and use of health care. They were then revisited every two years providing a rich set of data involving almost one in every 140 people in Ireland. The study was already shedding light on the biology of ageing as well as allowing for the rapid transfer of findings into policy. For example, it had unearthed a huge discrepancy between reported health and objective health in conditions such as atrial fibrillation, hypertension, osteoporosis and the risk of polypharmacy,  prompting new awareness campaigns. One of its most interesting findings was the influence of the early years, as Dr Cathal McCrory, TILDA research fellow, explained. “Poor health in childhood increases the risk of cardiovascular disease, arthritis, cancer, lung disease and psychiatric disorders. The lower the social class in childhood the higher the blood pressure and body mass index in adulthood. Parental illness, family dysfunction, neglect, abuse and poverty which probably means poor nutrition and overcrowding, all chip away at physical and mental health. They may even influence the foetus: developing systems may be particularly vulnerable to adversity.” What happened was that stress hormones were released as a fight or flight reaction to perceived threats increasing blood pressure and heart rate. A young body could cope over a short period but chronic activation could lead to long term problems. “Childhood really is a critical period. The more challenges a child faces the more likelihood he or she is to develop disease later in life.” The TILDA session was followed by the Marjory Warren lecture given this year by Prof Peter Langhorne  professor of stroke care at Glasgow University, who covered the development of specialist stroke units both in the UK and overseas and their success in increasing survival rates and the numbers of patients who were able to return home and regain their independence.  Key factors included dedicated wards with acute management by a multi-disciplinary team followed by rehabilitation and planned discharge. Benefits were   achieved with only marginal increase and sometimes even a reduction in costs. Early discharge where patients could have more of their rehabilitation and  nursing in their own homes was found to be helpful in mild to moderate cases. Economic analysis showed that the consequent reduction in hospital costs was cancelled out by increased costs to the community. What this had to do with geriatrics was that stroke units and specialist geriatric units had the same underpinning philosophy - in fact stroke services had evolved out of some of the notions governing geriatric services – and had similar successes: a reduction in mortality and long term institutionalisation. “So why is this not happening universally?” he asked, and urged BGS members, “You should be trumpeting the benefits of this model”. The complexity of geriatric medicine was highlighted in the session on the critically ill older patient by Dr Brian Mullan, consultant in critical care medicine at the Royal Victoria Hospital in Belfast. Today’s intensive care was highly sophisticated with state of the art monitoring and organ support but it still placed enormous demands on the body. Mortality in ICUs increased with age because the older body often had co-morbidities, its immune system was more vulnerable to sepsis and infection, delirium was more likely and arterial stiffness made complications more likely. Moreover ICU capacity was very limited with fewer than five beds per 100,000 population and very expensive costing up to £1700 a day compared to £250 on an ordinary ward, so the question always arose as to whether it should be limited to those most likely to benefit. “There is no limit by age and no clear guidelines,” said Dr Mullan. “We have to use clinical judgement and that’s not easy. There has to be a case by case assessment looking at co-morbidities, the acuity of the illness and the patient’s  pre hospital admission functional status.” The same session on the critically ill older patient heard from Prof Steve Allen of the University of Bournemouth on adjunct treatments for respiratory disease and from Dr Tom Esmonde, consultant neurologist with the Northern Trust, on neurological emergencies.  Other sessions covered cerebrovascular disease, pain management, dietary strategies, blood dyscrasias, gastroenterology and health service research. There were two on dementia: one with presentations on cognitive exercise, dementia pharmacology and autism in maturity and another on various aspects of managing it within a general hospital.  There were clinical updates on pain management and renal disease. There were nearly a hundred posters with topics covering pharmacology, education and training and epidemiology as well as a wide range of physical and mental illnesses. Other reports from the conference include:

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