 Good evening, everybody. We might make a start. I've been told I have to keep everybody to time tonight. Welcome, everybody. It's wonderful to see such a large audience for our presentations tonight. I'm Alexandra McCarthy, head of the School of Nursing. And tonight we are actually going to hear about the inevitable. Aging is something that none of us can avoid, but I'm sure we're going to hear some very sound advice tonight as to how to deal with it the best way that we can. We've got a very, very stellar lineup for you tonight, starting with an overview of what aging currently looks like in New Zealand. And then we're going to move into the intricacies of sight and hearing as we grow older and conclude with a discussion of the consequences for our generation in particular of living longer. I think the alarming thing about the presentations tonight is that we are the first, and with the rising obesity in all Western countries, probably the last generation to live as long as we are going to. So we're here tonight to actually understand how to make the best of it. I'm going to, in the interest of time as well, because the presentations are going to be very captivating. You'll have a lot of questions, but we'll save them for the end, where we'll have a little bit of time to actually take a few questions from the audience. And we're going to start with a brief word from Sue Brewster, who is Executive Director of the AMRF. Where is Sue? Oh, there you are. My side's going. Off to the side. Oh, look, good evening, everybody, as introduced. Sue Brewster, and I'm the Executive Director of Auckland Medical Research Foundation. And I'm really, really delighted with how many of you have turned out tonight. We're a bit worried when we saw the weather. The rain does tend to put a few people off. So thank you very much for coming out. And the range of presentations tonight are going to be all worth your while. So a big thank you. I think the topic tonight is a subject here to my heart. My mother lives with us, and mum is 85. And, funnily enough, I met up with Cliff this week, and I was talking to Cliff about mum, and he said to me, well, is your mum 85 years young or is she 85 years old? And I think that's a really good distinction, because I think ageing well and living well for an older population is all key to that quality of life. So, and on that note, I would like to pay special tribute to Emeritus Professor Kay Ibbitson, who passed away on the 12th of July at the age of 91. So for those of you who know Kay, and extraordinary man who lived life well and made amazing advances in medical research and all of our quality of life and health, so special tribute to Kay. But once again, and I think from our perspective, I would love to thank all of our supporters here tonight. I think since 1955, we've funded $71 million worth of medical research in the greater Auckland region. So it's only you supporters that are here tonight that have made that possible, and I guess continue investing in the quality of life for everybody. So a massive thank you. I really know you'll enjoy tonight's presentations and I will hand back over so you can enjoy the lectures. Thank you. Thank you. Thank you, sir. Our first speaker tonight is Professor Alastair Woodward, fresh from Barcelona. Alastair is a public health medicine specialist who graduated from the University of Adelaide and has studied and worked in universities in Britain and the U.S. and obviously in New Zealand. He was the first head of the School of Population Health after its move to the Tamaki campus. He works on environmental health issues such as air pollution, physical activity and climate change and is presently head of the section of epidemiology and biostatistics of particular relevance to tonight's lecture. He recently published a book The Healthy Country, question mark, A History of Life and Death in New Zealand. So please welcome Alastair. Thank you very much, Sandy. And it's great to see the lecture theatre full. Wonderful. The topic for tonight is the social revolution that we face as a consequence of the population living longer. It really is a revolution because it's something that's happened that's unprecedented and I believe it's going to have implications for every aspect of our life. We've got a section on the data to start with because I think that many people don't appreciate just how substantial the changes are that have occurred, how significant they are, just what the consequences are going to be. And as a result, I think people either are sort of not aware of what's happening or they are frightened by it because they don't understand it fully but think it may be leading us into a new ice age. It's important to understand what's happening in order to appreciate the challenges and I think you'll see tonight that there certainly are challenges in front of us. But it's not the ice age that's coming over the horizon. There are new opportunities as well as a consequence of people living longer and as I'll make the case, not only living longer but living better, living healthier for longer than they have in the past. So that's my job really to tell you a little bit about the basis for this social revolution and other speakers are going to talk to you about some of the implications, the clinical implications of this enormous change in survival in demographics. Now, this as you know is part of a series of lectures celebrating 50 years at the University of Auckland Medical School and those 50 years have seen enormous change. Here we have the class of 68. Now, I wasn't, I didn't graduate from the University of Auckland as I said and I'm not quite old enough to have been in the class of 68 but close too. And one of the things that was drilled into me as a medical student around this time was that the job of medicine was to add life to years not years to life. And the basis for that was the view that the human lifespan was more or less fixed. You know, the Bible had laid it all out as it laid out many things a long time ago three score years and ten was what you could expect and indeed that was what people were living. And it wasn't going to change and so the job of medicine and the healthcare system generally was to ensure that you got as much quality in that 70 years as you possibly could. I was told many things in medical school that were subsequently proven to be absolutely wrong and that was one of them because that's not the way it's turned out and I think it's really important that we appreciate how it has turned out and just what the implications might be. So here we have life expectancy at birth. This is for men, the pattern for women is similar but not exactly the same. In New Zealand, going back to the 1940s but if you have a look at 1968 or roughly where 1968 might sit on this graph 1965-1968 here and the New Zealand non-Mari is the green, Maori is the purple let's just look for the time being at the non-Mari life expectancy so look at the green line here so what was happening to male life expectancy in New Zealand in the 1960s and early 1970s it was not changing was it? and it's about 70 a little bit under 70 so that was why my lecturers said to me, we've got three score years in ten that's pretty much where it's going to sit but look what happened subsequently the line's going up up up up up and for the non-Mari men in New Zealand, life expectancy now is about 80 bit over 80 it's very close to world best for men which is the blue line at the top and it is nudging ahead of the Australian figures not that that matters in the slightest now the story for Maori is different and I'm going to come back to that shortly but the point I wanted to make here is that what appeared to be the picture in 1968 when this medical school got going appeared to be the case in the early 70s when I was a medical student is proven to be quite wrong and instead added 10, 15 years of life expectancy on top of what applied in 1968 indeed as I'm going to show you just as a rule of thumb, a way of thinking about it in recent in the last 30 years New Zealand has added three years of life to every decade so every 10 years life expectancy's gone up by three, three years almost the same as you know, every day getting another eight hours of life, you know, in the day and all of a sudden you've got eight hours more in front of you than you did before so that is extraordinary what could possibly cause it where is it leading us those are the sorts of questions that follow just to give you a sense of what I talk about and I talk about life expectancy which is, you know, a statistical term it's a convenient way of summarizing mortality across the lifespan here I've got death rates by age in 1901 and 2011 for New Zealand and the 1901 graph is the one at the top here with the fainter line and the 2011 is here showing that the curve has been shifted to the right and the peak that applied in 1901 in infancy when mortality rates are extremely high in the first year of life has reduced enormously you know, one of the enormous great achievements of the last 100 years is overcoming infant mortality life expectancy is LE, that's what it stands for that's the average years of life lived you remember, I'm not sure if you remember statistics some of you may have studied it at some stage, you know, there's a difference between average or mean and median and mode so median means the 50th percentile so halfway through the distribution and mode, what does mode mean most common yeah so you can see the average life expectancy or the average has gone up from 57 to about 83 that's in the space of 110 years the median so that's what 50% of the population could expect has gone up from 66 to 86 and the most common age at death now is into the early 90s so the difference between the mean, which is the average and the common is important if we're thinking about the implications for healthcare amongst other things now I said that life expectancy is a way of sort of condensing into one figure a quite complex picture and just to give you a sense of the complexity I'm showing here mortality rates for the most common causes of death in New Zealand cancer, ischemic heart disease cardiovascular disease or stroke chronic lower which is sort of pneumonia they are the major ones and this is again going back to the sort of end of the Second World War taking us up to the current day and you can see that in each instance these deaths from these diseases have fallen from cancer many people don't appreciate that substantial year on year improvements in cancer mortality cardiovascular disease, look at that you know when I was a medical student we were at the peak and indeed that was the reason that male life expectancy had stalled because we were going through the peak of the epidemic of heart disease since then since I graduated mortality from heart disease has fallen by over 80% that's really changed the world of medicine and healthcare and all the other causes that you can see there I think without exception have reduced so when we talk about a social revolution a healthcare revolution you know we're looking at this picture where the world is different to the way it was now the question of how far it can go is this going to continue this was the question that got Tony Blakley and I interested in writing the book that Sandy referred to the healthy country because for 80 years New Zealand non Maori were the healthiest in the world we were highest average life expectancy 1860 to 1940 nobody had written about it before or looked very closely at it so that was the impetus of our book but you can see the line here the straight line is drawn through world maximum average life expectancy which has gone from 45 so the healthiest population in the world had lived on average for 45 years in 1850 160 years later you've had 40 years added to life expectancy 40 years in 160 that's the same as 3 months every year being added to life expectancy and the remarkable thing about it is that it's linear you know it's just going and going and going and going so for individual countries of course there have been perturbations and that's apparent in the coloured graphs there that show for different countries the effects of flu epidemics, of world wars of other disasters but in terms of what humans can aspire to at present we don't know what the limit is countries like Japan which are the longest lived in the world still year on year their mortality rates are improving mind boggling now the question of what the explanation for this might be is partly captured in this table which shows you the age specific contribution so which of the age groups that have been responsible for this remarkable improvement in mortality in New Zealand and elsewhere and it began with infant survival so to begin with the top left-hand corner of the graph of the table it was children improvements in mortality in children that were responsible for driving increased longevity but that's no longer the case across to the last 20 years mortality in childhood has fallen so far that there are not many gains still to be made where the improvement is coming from is reducing mortality in the elderly and not just in what you might call the young elderly 65 to 79 but the older elderly over 80 more than half the reduction more than half of the improvement in life expectancy is now coming from reductions in mortality amongst people in their 80s and 90s now there are some other things that were regarded as certainties that are not certainties and one of them is this question of differences between men and women and again I remember being instructed that men were the weaker sex and that they would never expect to live as long as women did and there was a five or a six year gap now that as you can see here is not fixed in concrete over time the difference between men and women has changed and continues to change as you can see here the gap between male and female life expectancy in New Zealand is currently declining men are catching up on women and we believe that's a consequence of several things one of which is men were first to take up cigarettes and they gave them up earlier than women did cardiovascular epidemic has receded and that bore particularly on men the story is different for Maori as you can see when statistics were first available Maori men lived longer than Maori women and that was a consequence largely of the appalling maternal mortality and mortality related to reproduction that Maori women suffered at the time now I'd like to just lean a bit on this notion of variations in life expectancy because the average very much hides a widespread of experience here in New Zealand and this is important in terms of what we should do in terms of priorities and in terms also of what we could achieve Daniel Sir Calum is an honours student who worked with Dan Exeter and I last year and I'd suggest that he look at life expectancy across the Auckland Transport Network and so what Daniel did was to take the bus stations on the northern busway and the train stations on the southern side of the bridge and look at life expectancy of the populations within 2 kilometres of each station you can understand how that might be done and what he has shown is this startling variation within one city as you travel from Albany to Otahuhu life expectancy falls 11 years now it's not an even gradient you know you can see the colours are mixed up here but the point I'd like to make is that we talk about an average of 82 years life expectancy that hides an enormous variation the Maori non-Mauri differential I've already referred to but there are other differences in terms of socioeconomic status and in terms of other ethnicities so this tells us that we have some work to do people say how could we live longer well it's not a question I believe of technology or treatments it's a question of working out how everybody in New Zealand could have the same experiences the people who live in Albany does anybody here live in Albany so what is it about being in Albany that enables you to live so long the experience of Maori I mentioned that is something that is of great importance to us here in New Zealand for many reasons it's a very sad history in terms of the effects of colonisation and loss and deprivation on Maori health they started from a long way back it wasn't any of their doing it certainly wasn't biologically determined it was a consequence of our history the good news so that's the bad news the good news is that that gap is not widening and we believe there's some evidence that it's narrowing here in Auckland the life expectancy for Maori is increasing currently at twice the rate of non-Mauri this was reported by Waitemata DHB last year so bad news, good news story, bad news that we have these gaps, good news that they certainly not fixed in stone that they can be changed and at least in Auckland they appear to be changing in the right direction now the big question when you talk about living longer is whether it's a good idea I mean is this something we should really aspire to and behind that lies a fear of aging people associated I think with loss with misery, with unhappiness with separation but of course there's absolutely no reason why that should be so and the question of whether the improvement in life expectancy has been accompanied by an improvement in healthy life expectancy is a really important one at the same time it's a very difficult one to answer because what defines a healthy life expectancy it's easy enough by and large to tell whether somebody's alive or not but to tell whether they're healthy or not is that something that people decide for themselves is that something that you determine on the basis of a blood test how do you do it well this is work from the Ministry of Health it's a bit old now but it was a good stab at answering this question which looked at that years of life lived independently or years of life lived in various ways judged in various ways to be dependent and you can see here that we're talking remember I said about three years and every decade improvement in life expectancy a bit more for men than for women so that's the height of the bars here and the proportion of the blue is the extra years lived independently not dependent so good news bad news story bad news is that there is extra years of life lived independently but the good news is that they are outnumbered two to one by years lived with healthy and a healthy life expectancy so an extra three years every ten one of those three is lived in compromised health two of those three is lived in good health is that a good story or is that a bad story well I'm an optimist I would see that as a desirable state of affairs there are other indications that people who reach the age of 70, 80, 90 these days are in better shape than people in the past reaching the same age that's important for cognitive decline which is a major issue for us in terms of aging where it's observed that in later birth cohorts people born at later times the frequency of cognitive decline of dementia of other mental conditions of that kind is lower than it was previously so it's not to say that we can turn back the effects of aging but the effect is less amongst individuals of a certain age now than it was in the past a good way of describing this is this remarkable man Don Pellman so this is two years ago he repeated the achievement of Jesse Owens you may remember Jesse Owens at the Berlin Olympics he broke four world records in the space of an afternoon that had not been done again until Don Pellman fronted up at the Masters Games in 2015 and he broke four world records in the space of an afternoon in his age group his age group was 100 to 104 he was born only two years after Jesse Owen he's a contemporary of Jesse Owen and so my point being obviously he's an extraordinary man but there's a bigger picture here which says that people are living longer and they're generally living longer in better shape than they had in the past now why would that be I'm not going to go into that because I've almost used up my time but I can I think we can point to some important things that have happened recently you know since 1968 which have contributed in terms of having a better environment enlightened social legislation and as I've already mentioned better medical care what's missing in this picture of the Southern motorway well it's different in many ways from how it looks these days I suppose but you might notice the very effective median barrier that's located here which was introduced by the way as a consequence of agitation by the doctors in the emergency department at Auckland Hospital who were fed up with having to deal with the damage resulting so you know just an example of the environmental changes that have occurred and what about social policy you know could you imagine travelling like this in an aeroplane it was once the way we went got around and as I've mentioned here a truly smoke-free childhood once a rarity is now commonplace so you know there have been huge changes in the world in the last 50 years and it's not too difficult to draw the dots in terms of how those changes have led to the kinds of improvement in survival that I've talked about and maybe we can pursue that later in the question time if you like where are we heading I think we might get to a century of life expectancy by the end of this century it's a daunting thought maybe but as you can see present trends continue we're likely to have life expectancy for women of about 95 which means you'll have a 50% chance women born in that in 2100 of getting close to 100 so I've more than used up my time this is what I want to tell you average life expectancy increasing by about 3 months every year that is absolutely remarkable it's earth moving it's social revolution indeed substantial social inequalities don't forget that map of the Auckland Transport Network but some signs that they're closing healthy life expectancy is also rising two years of every three that we gain each decade is good life the causes I've touched on that very lightly no sign yet of a slowdown and if you've got a chance to see a movie and you haven't seen this one go and see Michael Cain in going in style absolutely wonderful you're never too old to get even that's his message thank you very much I wish we had an hour to listen to you Alastair that was fascinating thank you now we're going to delve into hearing as we age with Professor Peter Thorn Peter is an auditory neuroscientist from the University of Auckland he directs the I'd sell more centre for research on hearing and balance disorders and is a co-director of brain research New Zealand which is a national centre of research excellence that's focused on the ageing brain he's published widely on cochlear pathophysiology and sensio neural hearing loss and he established the clinical audiology training program at the university here Peter contributes substantially to the hearing impaired community and is a companion of the New Zealand Order of Merit in 2009 thank you Peter thanks Andy thank you very much Alastair's given you a wonderful talk about life expectancy and what I'm going to talk a little bit about is I suppose maintaining good health or some aspect of good health as we get older and my area is in the area of hearing and what I was asked to do really was just to delve into a little bit of this story particularly thinking about some of the impacts on cognition and some of the data which is coming out that suggests that hearing loss might actually be a contributor to cognitive decline and potentially a risk factor or a modifiable factor for dementia what I thought I'd do first of all was just to talk a bit about what our sense of hearing is and I think that we tend to take our sense of hearing for granted it's a very, very important sense we just perhaps don't realize what it's capable of and its importance and in fact if you go back to some of the writings of Helen Keller and this is just a paraphrase from her the view that with hearing loss and in this case a profound deafness actually cuts you off from people so the issue here is about maintaining a connection with people and I would just add to that it also separates you from your environment and what I'd just like to talk a bit about is how important your sense of hearing is not only to communication but also to your place in the world and your connection with your environment so perhaps this whole idea is about hearing is really if you think about it is actually staying connected with various aspects of living for example it's really important in terms of learning and taking opportunities that might be presented to us as we need to it's about staying connected with each other through communication and it's very importantly about staying connected to the world around us through awareness of sound in our environment so we think about some of these different things and think about hearing in terms of interaction and communication we can understand this, the importance of it for social engagement the importance of it for emotion particularly that comes from that social engagement of enjoyment the issues of sadness all those sort of emotions that might come through social engagement important key element to developing and maintaining relationships to work and to learning and I think this little image here of a young boy at school who has a hearing loss in this case completely tuned out just not able to in this environment take part and it's not clear what's going on so it has a huge impact on learning and we can all appreciate how important our sense of hearing is and how important it is to into enjoyment and to emotional aspects of life and whether we appreciate music whether it be a blues band or it's an orchestra the more these days the idea of being tuned into your iPod or your cell phone for hours on end listening to music or to podcasts and so forth but also just remembering the importance of being out in nature listening to the whistling of the birds or chipping of birds and obviously you know things like the rustling of leaves and so forth which give a lot to our enjoyment of our life but also our hearing is really important for awareness and for safety so if you think about your hearing system enables you to have contact through a three-dimensional world to environmental sounds that provide that real-world contact and areas for example in terms of safety that being able to listen for warning signals are very important in this case in the sort of traffic environment or even in your own home where you may need to know about warning signals about fire or so forth it's very important for maintaining your safety and one of the things about your auditory system is it never ever turns off you tune out but it's always on we don't like the visual system you have an eyelid you can turn it out you can reduce the light it might have an ear-lid your system is on constantly but it can be stimulated it can tune itself down but it doesn't turn itself off so it's constantly sensing the environment the other thing we can just think about is obviously our hearing starts with our ears I mean that's where the sound is coming in it's being detected and it's being passed into nerve impulses that go to various parts of the brain which are the auditory centres in the brain which are responsible for detection of speech and sound for complex sounds I just want to make this point here that you might not be aware but you have two ears and they're very important that we have two because even if you have a loss of hearing in one ear you're actually quite seriously disadvantaged but the other thing about our auditory system and these are just showing the pathways here going from our ear through to the part of the brain in the auditory cortex out here on the temporal lobe which are responsible for receiving information from our ears but our auditory system is also connected with our emotion centres it's connected with our memory centres deep into the hippocampus for example which is very very important for memory so our auditory system is not just dealing with the access to sound but also the consequences of that sound to life and we also have a lot of interaction a lot of our different sensory systems they're not all working independently they're all working together to give us once again an ability to sense our environment and to communicate so in many ways we now know that by staying connected and we might hear a little bit more about this later on but by staying connected and hearing is a very very important part of this you can sort of see is we know that staying connected is very important for healthy aging relationship with our environment and additionally now we know that if you have a hearing loss as we age that that has a considerable impact on your health and well-being and I'll just go through some of these issues very briefly so let's think about age-related hearing loss well the deficits in hearing is quite substantial in our population and if you look at the graph here showing the percentage of people with hearing loss in the population it's really something for those people in older age particularly over about the age of 50 and what you see is not only is that the amount of hearing loss is increasing but also the severity so as we get older we're also becoming more severely hearing impaired and so the impact of that on healthy living is quite substantial and as Alice was talking about aging population there are some statistical modelling which is now being done to show that the proportion of the population that might having severe hearing loss will be rising quite dramatically over the next few decades so what can we do about it I mean this is a very very important health and probably a social problem which we need to think about we need to improve our awareness of the implications to general health and well-being so it's not just focusing particularly amongst older people to diagnose and provide those interventions early enough and there's a number of things which we need to think about equitable and accessible services limited disease and so forth and access to technology but particularly is around the sort of prevention and public health strategies which are really important to try and prevent the hearing loss and for this at the University of Auckland we've now established a centre which focuses on research into hearing loss disorders and this is a centre that includes a lot of groups around the country and the focus of this is really to try and work with clinical groups, with research groups and with the community to start thinking about how we can really develop interventions and community interventions in particular to reduce the impact of hearing loss so what is it just coming back to thinking about this relationship with healthy aging obviously from what I've been saying so far keeping socially active for hearing is very important for that I'll show in a few minutes that seems to be particularly important around cognitive vitality and avoiding dementia it may be particularly important in terms of avoiding injury so that you can be aware of warning signals and so forth and so it seems to be tied clearly to a lot of different aspects of trying to maintain healthy brain and then healthy aging as we age and now we have another issue which has emerged from a number of longitudinal studies which is showing that there is a link between hearing loss and cognitive decline and developmental dementia and so if you look at some of the data that's come out of the US, the risk of developing dementia increases quite substantially in this case close to a fourfold increase with severe hearing loss when these people have been followed over time there's been an increase in that and what might this be related to so there's a suggestion that maybe it's to do with changes in brain structure which might be common across these two, the age-related hearing loss and cognitive decline perhaps a big part of it is that withdrawal the social isolation that occurs so that connectedness may have an impact and there may be some common features which are sort of common pathology and pathological processes that affect both parts and so there may be some sort of common mechanistic process which we don't fully understand yet and just to show you that, some of the work which we've been doing looking at the auditory part of the brain, this part of the brain which is the cortex which is associated with with audition if you look at some of the pathological changes which are associated with Alzheimer's disease they're clearly present for example this particular protein tau and amyloid beta which are proteins associated with pathology of Alzheimer's are clearly more present inside the auditory part of the brain in Alzheimer's patients and if you look at that, even the number of neurons inside the part of the brain which is actually involved in audition in people with Alzheimer's is really severely reduced so that the processes which are possible within the auditory brain are going to be severely compromised in people with Alzheimer's and interestingly is that the part of the brain which seems to be more affected in Alzheimer's in the auditory part is actually in the left hemisphere which is that part of your auditory brain which is associated with speech and language and pitch perception which are areas which are quite considerable with people with dementia we've got a long way to prove whether these are associated with or causative but at least we're starting to see that there are changes in the auditory brain another piece of work which we're doing is asking questions using our dementia prevention research clinics which are part of the brain research news and a series of clinics right around the country where we're recruiting people who have early cognitive decline and following them over time and we're investigating here under the direction of Suzanne Purdy here looking at the sensory status of these people as they enter into the clinic and asking questions whether these sensory changes might be maybe a biomarker maybe they're early changes of cognitive decline that may tell us something about the progression for these patients and just in that just to sort of show you very quickly the data we have is that yes people with early cognitive decline against an age match controls they show difficulties in conversation, localising sound poor processing of complex sounds and they also show very poor processing of motion within the in their visual field as well so it seems as if these are measures that are sensitive to changes and we now need to think about and we're piloting whether we can perhaps train people in their auditory and visual domains to try and improve the development of cognitive impairment and just very very quickly out of time here but very quickly there is now the Lancet commission last year came out looking at the risk factors for dementia and they have suggested that one of the most predominant risk factors or dominant risk factors is hearing loss and that if you can treat that hearing loss as they suggest in early years, mid years here perhaps you can reduce the rate at which dementia develops and so there is a clinical trial going on now to look at the impact of hearing aids on cognitive decline and we're going to wait to see the outcome and it's a very big study in the US to see whether this has an impact which will be very important for the progression of these conditions and just finally there is a piece of work going on here supported by the Health Research Council and led by Grant Searchfield in audiology and what's interesting here is he's looking at is if you're going to fit these hearing aids you're fitting quite complex devices to people who might have cognitive problems and so the devices are actually more advanced than the cognitive processing of the person that you're fitting them to and so what he's looking at is if you actually alter these hearing aids so they have a very much slower cognitive processing power will that optimize or improve the the influence I suppose on hearing for these for people with cognitive problems and so what I just wanted to try and show you is that number one hearing is very important for good brain health it's very important for your well-being we need awareness campaigns and we need ways to be able to provide hearing interventions which are equitable and accessible almost along the same lines as Alice was talking about strong prevention and public health programs to encourage people to use their hearing and remain connected so as I say look after your hearing and stay connected it's maybe far more important than you actually realize thank you I'm sure you'll have many questions for Peter at the end of the session in the interest of time we'll move on to Professor Helen Danesh-Mayer who is a professor in the department of ophthalmology she's a clinician scientist and Helen divides her time equally between patient care surgery and research Helen graduated from the University of Otago and undertook her subspecialty training at Will's High Eye Hospital in Philadelphia in 2008 she was appointed as the Sir William and Lady Steven professor of ophthalmology making her the youngest professor in the medical school and the first female professor of ophthalmology in New Zealand she is head of academic glaucoma and neuroophthalmology and the founder and director of the optic nerve research unit she's also chair of Glaucoma in New Zealand which is a charitable trust that focuses on preventing blindness from glaucoma thank you Helen good evening good evening ophthalmology is all about vision and most of you will have at some stage feasted on visually feasted on masterpieces such as Rembrandt's paintings and perhaps even this one which is the blinding of Samson the story is told that Samson had invincible powers and he told the secret of his powers to his lover Delilah and that was that his powers came from the fact that his hair had never been cut since he was born Delilah betrayed him and told the Philistines the secret and so you can see from this picture Delilah running away with his hair the Philistines pinning down Samson getting ready to blind him now several questions can emerge from this looking at this painting the first could be why did Delilah betray him but I would say the more important question is why are they blinding him why are they not cutting off a leg or an arm or cutting out his tongue why are they choosing to blind him and that is because they wanted to inflict the greatest cruelty upon him and blindness is considered to be the greatest cruelty and in fact in 2016 when in the United States Chapman University surveyed to look at what Americans fear they found that they feared several things 60% feared corrupt governments 41% feared terrorist attacks 35% feared Obamacare and 47% feared blindness saying that this possible health problem someone could go through and when they explored this further they found that blindness was ranked as the most dreaded health complaint worse than memory loss of speech loss of a limb or contracting HIV and AIDS and when they explored why they said it was because blindness is associated with loss of independence and quality of life and certainly this is an important issue as we age visual impairment increases as we age in fact 33% of visual impairment occurs over the age of 65 and if you look at this graph you'll see that the spike starts about the age of 50 so what are the common causes of blindness well there's cataracts, glaucoma diabetes and age related macular degeneration so what I'd like to do in the next 10 to 12 minutes is to do a historical journey through our understanding of vision and then secondly to focus on some of the research we have done at the University of Otago Auckland one of the common threads that goes through both themes historically as well as our research here at Auckland is that research and progress is not made just through advances in technology but it requires fresh approaches and looking at things with new eyes in the words of Marcel Proust the real voyage of discovery consists not in seeking new landscapes but in having new eyes so the research I'm presenting to you is part of a team work and these are some of my students who all four are now doctors and three are ophthalmologists the research I'm giving you is an essence of the work that's been published in papers so if you would like more details let me know afterwards and I'll be focusing on the optic nerve which is my area of research and arguably the most important aspect of the eye so the optic nerve well initially our understanding of the optic nerve comes from Galen and Galen thought that when someone wanted to see spiritual humor was passed through the optic nerves which he thought were hollow onto what we wanted to look at for our mind through the optic nerves again so we can see and in fact this is where the concept of the evil eye comes from so therefore if the soul is looking upon something evil the evil humor is then transmitted to the person making them sick so the optic nerve was thought to be hollow and then in the 1700s we had the invention of the microscope and at that stage despite looking at the optic nerve through the microscope people were afraid to overturn Galen's theory so despite seeing these little tubules they still concluded that the tubules were hollow allowing the flow of spiritual humor and in fact it took a medical student in 1755 who was brave enough to go against current dogma at the time and say that these fibres actually did not have a cavity inside them and now we know that the optic nerve is very much like a cable a telephone cable or the wire that connects your iPhone to the brain and that it sends multiple millions of messages through these little nerve fibres connecting the eye to the brain and here at the top you can see the histology of the optic nerve and again you can see the cable and see the remarkable resemblance between the two the next step came for us to be able to look at the optic nerve in vivo in the actual person and this was happened through the development of the ophthalmoscope in the 1850s with the development of the ophthalmoscope the optic nerve became the only nerve in the body that could be looked at under physiological conditions so if a neurosurgeon wants to see what they're interested in they have to take out their blacken and drill a hole through the skull while as ophthalmologists all we have to do is pick up the ophthalmoscope and we can see the nerve in action during life and therefore we have developed many different techniques and toys so that we can actually look at the optic nerve in three dimensions but the next challenge came is how do we share what we're actually looking at and this was primarily done through these sophisticated drawings which we would do after we looked at the optic nerve and of course you can I don't have to explain to you the limitations of this of these drawings so the next major advance in ophthalmology came when photography met ophthalmology so that we can now take photographs of the back of the eye and here you can see a photograph of the optic nerve and therefore we all knew what we were looking at and we could share our knowledge however it soon became very clear that although we were all looking at the same thing we all had very different interpretations of what we were looking at and this kind of muddied a lot of the research that we were doing in fact studies have shown that ophthalmologists correlated with what they were looking at as well as anglers who do who are describing the same fish they caught and it really did very significantly from the different perspectives that you came into things so the next challenge was how do we measure objectively what we can see subjectively in these pictures and this is where laser technology now meets ophthalmology and with that came the new revolution and evolution of many of the techniques that we now use in our practice so one is the Heidelberg retinal tomograph which is a scanning laser camera which allows a three dimensional quantitative image of the optic nerve from all 360 degrees the other important technology is optical coherence tomography an OCT as we call it uses light waves very similar to ultrasound using sound waves so it allows us to look and quantitatively measure the thickness of the optic nerve and here at the University of Auckland we've been using these technologies for various conditions the first one is glaucoma glaucoma is the leading cause of preventable blindness it affects one out of every 10 adults over the age of 70 the visual loss is silent but once it occurs it's irreversible it occurs because of a problem with the drainage of fluid in the front of the eye and this results in a buildup of pressure inside the eye this pressure is then transmitted to the optic nerve and then you see you get an excavation in the head of the nerve and you can see that normally there's a nice shallow head to the optic nerve but with a buildup of pressure you get loss of nerve tissue there's an excavation that occurs as this excavation occurs of the nerve you start to lose your peripheral nerve fibers first and the world becomes darker dimmer and more constricted until ultimately you're left with very little vision left in glaucoma and this is an example of the OCT scan that we now can use to analyze and evaluate people with glaucoma and what you can see up here are these black spots that are determined by a peripheral visual field test in someone and you can see that with the OCT scan we can measure microns of change in the optic nerve so this is the head of the optic nerve as we look at it and the areas of red or abnormal areas or areas where the tissue has been dropped out and the areas of green are normal tissue so now we can use this technology to monitor people with glaucoma and determine how they are deteriorating or if they're stable and so here's an example of a patient who has, remember that hollowing that I described to you and you can now look at the quantitative hollowing that we can now measure and we can do this test every time they come and overlap their optic nerve on one visit from another and exquisitely tell them whether their treatment is accurate or whether it needs to be further intensified so the advances in glaucoma met with this technology we can diagnose glaucoma earlier we can identify deterioration earlier and we can better differentiate between glaucoma and other disease that mimics it but glaucoma is not the only area that we've used this technology because you have to remember the optic nerve is the back of the eye but it's also the front of the brain so it allows us to look at a window of what's happening deep inside the brain and our group here in Auckland to try to use the optic nerve as a biomarker to see what's happening in various neurodegenerative disorders and the first group of patients we looked at were patients with Alzheimer's disease and this is a graph from our table and you can see that this here shows you the increase in the size of the optic cup or that excavation that I spoke about or the loss of nerve tissue it's a surrogate for loss of nerve tissue so you can see as you lose nerve tissue in the optic nerve the minimental status examination which is the score of the severity of glaucoma the lower the number the more severity of the Alzheimer's the lower the number the more severe the disease you can see that this is severity of Alzheimer's and that's loss of tissue so the more nerve tissue we were able to show the more nerve tissue you lose in the optic nerve and that was the first study that was able to show the optic nerve can be used as a biomarker for neurodegenerative disease since then many investigators internationally have also been looking at this in various other conditions and in fact the FDA now requires in multiple sclerosis for an OCT scan to be done and all these patients to help monitor disease with any new treatments that have been developed and here in Auckland we're looking at Huntington's Korea Frontotemporal dementia and also brain tumors and the role of OCT in these studies so why brain tumors is because brain tumors can cause blindness because the optic nerve extends deep into the brain and you can see from this yellow diagram here those are the pathway fibres of the optic nerve and their extensions so a brain tumor as you see in the other neuroimaging slide does push on the optic nerve fibres and can cause blindness so one possible area we wanted to look at is can we use this technology to predict if someone is going to recover from their vision when they have a brain tumor after they undergo surgery but what we noticed and in fact it was noticed internationally is if you look back at this visual field test you can see that all these black spots here are someone's blind spots so they can't see when they have all these blind spots but look at the OCT it's green and you will remember I told you that red is bad, green is good so how can someone who has this have this technology so the traditional interpretation was the machine is limited the technology is limited because it doesn't allow you to interpret what's happening into the brain but here in Auckland we looked at it differently we said that maybe this is a clue to whether the person is going to recover or not and so in our paper what we did is we correlated those who recover from vision following surgery with their OCT and we found that if they have a healthy retinal nerve fibro layer or an optic nerve prior to surgery as measured by the OCT even if they were blind their chances of recovery were excellent and you can see that's from these group of patients here who recovered while those who had a poor retinal nerve fibro layer thickness and were blind didn't change much in their post-operative tests and therefore they didn't recover so I will end with this 39 year old woman who is 24 weeks pregnant because she came in towards the end of the study just as soon as we had made this observation and so she had this significant tumor which and the question was really whether she should have surgery at 24 weeks pregnant or whether she should wait and this was her OCT so you can see it was green so we discussed with the neurosurgeons and we said we think she's fine she has time you can wait a few weeks and let the baby develop because the optic nerve fibres are not stressed so they waited six weeks so the baby could be more fully developed and then this is the change in her vision that we saw after the surgery and then three months afterwards she came into the post-operative check with a very healthy baby and a very normal visual field so in conclusion longer life expectancy is associated with greater needs in maintaining quality of life and vision is critical to maintaining this quality of life technological advances in ophthalmology allow earlier diagnosis in more precise management of conditions that occur in aging and cos blindness thank you thank you Helen I'm sure again there will be many more questions for Helen once we conclude but we're now going to our final speaker Professor Martin Connolly Martin trained in medicine at Newcastle of Pontine in the UK and he qualified in 1980 he was for 15 years consultant at Manchester Royal Infirmary and senior lecturer in geriatric medicine at the University of Manchester he was appointed as Freemason's Professor of Geriatric Medicine at Auckland and geriatrician at Whiteamarta DHB in 2006 Martin's research centres around healthcare provision for older people with emphasis on those living in residential aged care and in retirement villages he has published over 130 peer reviewed original research papers and last month he became a New Zealand citizen thank you I'm hoping that my voice will hold out because I'm full of cold and sore throat the consequences that sounds bad doesn't it the pros and the consequences I'm hoping to present I'll continue to present an optimistic view rather than a pessimistic one it's the truth the university acknowledged the single man in possession of a good fortune must be in want of a wife first line of Pride and Prejudice 1813 Jane Austen what's that got to do with the demography of aging well quite a lot Jane died four years later at the ripe young age of 41 great loss to English literature but as you've already seen not particularly epidemiologically surprising this line this graph that you've already seen if you follow it further back it plateaus at around about 41 from about 1817 backwards so 1817 the average age of death in England where Jane died was 41 so I hope I'm not going to insult people here hands up please if you are 41 years old or younger keep your hands up hands up please if you're 42 years old or older so everybody should now have their hands up good keep them up put them down and you hope you die before you're 42 put them down if you're in the second group and you wish you'd died before you were 42 so you've all still got your hands up if you are in though is it either of those groups and you have concerns that demographic aging is a problem you are the epidemiological equivalent of a nimby not in my backyard you know that sewerage running through the streets is a bad thing but you don't want a sewerage farm next door to your house you know you think that aging of the population might be causing problems but you don't want to die young you're a nimby so am I I therefore say to you is a truth which should be universally acknowledged that the so called demographic time bomb is in fact man's greatest achievement because nobody in the room wants to die at 41 or younger demographic time bomb silver tsunami, grey tsunami if you google just those three terms you get 90 million a bit google hits is this the object of giddy conspiracism and internet myth making as Simon Seabrook Montefiore said about Jerusalem or are these legitimate concerns before we go on to talk about that just a few examples of people who died young by today's standards in times past think what they could have done had they lived another 10 or 20 or 30 years longer and few examples of people who did live a bit longer either by their standards at the time or by modern standards and did great things when they were older so Churchill was war prime minister until he was 71 and Nelson Mandela whose birth anniversary 100th anniversary was yesterday was 73 at the end of apartheid is there a glass half empty or is it half full this is my oldest son Robert with his glass half empty or half full notice a beer glass not a milk glass Robertson engineer is the glass twice as size it needs to be that's not a perfect analogy but it does suggest that the problem may not be quite as simple as the glass half being half full or half empty if only it were UK tobacco tax in 2016 raised 13 billion pounds when 70% of people smoked my working lifetime as you've already heard tobacco tax is equated at today's equivalent of 52 billion to smoking related healthcare costs in the UK and those costs and the total healthcare costs not just smoking related was 116 billion in 2016 but also they saved pensions at 92 billion and social care costs at 17 billion because the age of death in smokers in 1980 was 66 and the age of death in the average population including smokers was 75 now most people don't smoke if they did we wouldn't have a problem the modern equivalent is fat tax fat tax has been brought in in the UK and brought out again because everybody hated it sugar tax has just been brought in everybody hates that and that's probably going to go we've not tried salt tax yet perhaps we should think about that one too but it isn't simple I'm going to show quite a few slides from work that have been done in my department by a team of us many people in that team I'd like to particularly acknowledge Jo Broad who's part of that team Dr. Jo Broad and she's present here today this is one of her slides the number of the problem or the number of the perceived problem is that as we get older the number of chronic medical conditions that we have gets greater so when you're 20 on average 80% of them have no chronic conditions at all like heavens and only 15% or less have one chronic condition but by the time you get to 80 15% of people have six or more chronic conditions and less than 10% have not at all we've heard a bit about healthy lifespan versus unhealthy lifespan we've heard it from Alice in terms of disability and dependency another way of looking at healthy lifespan and unhealthy lifespan is morbidity, illnesses what symptoms and the jury's out really whether in terms of illnesses and symptoms as opposed to dependency we are compressing morbidity I don't know what I'm speaking to as I'm looking at this but there is some evidence in some this is UK data, there's some evidence in some countries that we are compressing morbidity so we're having a longer lifespan being healthy there's some evidence in other countries that we're not but in any case in any country there's not a lot of movement in terms of compression or morbidity this is New Zealand data another study that I was involved in and this is a prevalence of the most common medical conditions in very old people 80 to 90 year olds, Maori and non Maori in the north island of New Zealand and these are the conditions high blood pressure and heart disease and heart failure they're pretty nasty conditions that you wouldn't want to have and these are the percentage of people in each of these groups with them quite a lot of morbidity note the relatively low prevalence of dementia in this very advanced age group perhaps a bit more of that later so another show of hands what proportion of these very old people described their health as poor was it hands up 50% was it 35% hands up was it 20% was it 10% it was 7 to 8% and when you asked them to compare that to their own age it was 1 to 2% 45% of these people with all these horrible symptomatic things wrong with them said their health was good or excellent and you may be surprised we weren't surprised because this is replicated by lots of international data that says the same thing another study from Belgium note I'm not biased, they beat us in the World Cup but I'm still going to talk about their study this is 131 people with the median age of 83 ranging from 80 to 90 years old who had been admitted to the intensive care unit because they were very sick and they'd not died and they'd survived to be discharged from hospital and they were surveyed 3 months after discharge, a year after discharge and 7 years after discharge their one year mortality was 50% and their 7 year mortality was 84% not surprisingly because they were pretty old and they'd been very very sick they themselves felt their disability independence at a time and indeed nearly 40% of them by the time they got to 7 years of the survivors were living in rest homes or private hospitals there was an overall decrease in quality of life they told us, although they told the investigators as reported by them on a validated quality of life scales however quality of life was still regarded as acceptable by all of them 20 of 21 7 year survivors were glad to be alive 82% of one year survivors and 72% of 7 year survivors would say, said if I was sick again I'd want to go back to ICU these are very old people remember the oldest was 97 by the time they got to the 7 years so compression of comorbidity might be a bridge to our step too far should we be happy as older people seem to be with maintenance of comorbidity I'm not saying we should, I'm just posing the question so what are our chances, we've been hearing about this already 85 on 90, well life expectancy at birth, 78 for men and H2 for women in New Zealand is not the same as life expectancy at 60 or 65 and that's called the survivor effect so this is a slightly complicated slide these are people of a certain age, 70 or 75 or 95 this is how many years of life you've got left when you are 70 forget, just look at the medium colour blue thing this is the average, the medium so on average if you're a man in New Zealand and you're 70 you can expect to live another 17.2 years but if you get to 85 15 years later you can't expect to live another 2.2 years you can expect to live another 5.5 years and it goes on and goes on and goes on so theoretically, mathematically we all live forever but it's not quite as simple as that but that's the survivor effect we've already seen this from Alastair in a non-graphical form most of that increased expectation of longevity currently is in older people so you don't stand a much greater chance of making it to 65 than you're 50 years older than I did 50 years ago but if you make it to 65 you stand a much greater chance of living to 75 or 85 or 95 so it really is all these older people that are living longer the story just published this year that shows that if you get beyond 100 your chances of dying in the next year are less than the chances of an average 90 year old dying in the next year these are super survivors these are the really high perfect people that make it to 100 and as you've already heard there's a very major socio-economic effect so my daughter here is 28 from a high socio-economic group stands a 50-50 chance of living to 90 and my granddaughter her niece who is 3 now she wasn't 3 then also from a high socio-economic group stands a better than 50-50 chance of living to 95 but improvements do come with potential problems and I'd like to introduce the term dependency ratio to you this is a well-recognised international term note the loaded terminology dependency the dependency ratio is for every 100 people in the population age 15 to 64 which are said to be productive people how many dependent people are there how many kids under 15 and how many adults over 65 and I'd just like to talk about the adults over 65 so currently in New Zealand for every 100 people age 15 to 64 there are 23 people over 65 but in the working lifetime of our current medical students that number will have doubled there will be 45 roughly over 65 year olds for every person of productive age but are they really dependent in New Zealand almost 35% of over 65 people paid work and 20% do voluntary work the net intergenerational transfer older to younger of money does not reverse until the older generation gets to 82 so why because we older people give our kids deposits for their houses or loan them then do we expect to get it back well perhaps we do and we look after their kids for free we look after our grandchildren babysitting for free etc and we've paid their student loans or paid their university fees and we don't expect to get that back either 90% of the caring of so called dependent and indeed these people are dependent or very old people is carried up by their families so they may be dependent but they don't depend on the state and 50% of that is carried out by their spouses so they may be dependent but they're not dependent on the younger generation so there's lots of buts in the dependency ratio however what is not a but is that the number of acute medical hospitalizations medical and surgical hospitalizations unexpected I don't mean you go in for routinely expected operation the number of acute unexpected operations over 85 this is the red line has doubled in a relatively short period of time this is the northern region the four northern DHBs from northland down to counties Manukau for every one person that was admitted to hospital as an emergency over 85 in 1999 there were just over two people admitted in 2009 11 years later New Zealand is very generous when it comes to health care expenditure it's very old this is just health care expenditure this is slightly old data for every dollar New Zealand spends on health care of people under the age of 65 it spends six dollars on people over the age of 75 and in relative terms that's the highest in the OECD even higher than the states for example and the bottom line is we spend 41% of our public health expenditure on the 15% of the population currently 65 in over that doesn't sound good does it when we're going to get lots more people age 65 in over well here's the good news guys what this actually equates to is that we use most of our personal health care expenditure in the last year over two of our lives trying to keep us alive at whatever age we die so if you die at 41 you use most of your personal lifetime health care expenditure between the age of 39 and 41 if you died 101 99 to 101 and beyond a certain age and that age depends on the jurisdiction where you're living so far when we die the less actual money is spent on us trying to keep us alive so this is the EU and this is increasing age and this is money spent trying to keep people alive the total lifetime health care expenditure and as you see it drops at about 87 that's the EU well the country is 85 whether it's 89 but it falls off so it's cheaper for health care for people to live longer not for everything care but for health care further problems for the future medical advances more can be done more should be done new older generations have increased expectations anyway further reductions in ageism will increase costs further so when I was a registrar in 1990 if you were 66 and you had a heart attack you couldn't go to coronary care you were too old if you were 66 and your kidneys failed and you needed renal dialysis tough you were too old that's what I mean by ageism in health care we don't have that now but we still have some so I explained all this to one of my older son got all my kids into this thing this is Simon he was then aged 11 he's now 22 and 6 foot 2 and hates me showing this slide and I explained it in slightly simple terms and I said so Simon what do we think for the future and that was his answer I think he was wrong we don't know what we don't know when we don't know it so this is a map of the world in 1750 very accurate what we knew about bit missing bit missing lot of missing this is a map of the world of course drawn in Europe this is the Royal Victorian Firmary in Newcastle upon time where I trained Pavilion Ward the ward was called Pavilion Ward this is 1911 I'm not in the picture that is not me it looked a bit like that in 1981 where I worked there but it doesn't look like that now hospital wards do not look like this anymore medical care is advancing and it always has I love this quote this is the first time anybody in the world that we know of ever said that doing research is a good thing Seneca the Roman philosopher there's another one of Joe Broad's slides as how many people in New Zealand are living in residential aged care what are your chances of living in rest homes and private hospitals as you age well one way of measuring that very accurate way is where you are physically located geographically located at the time that you die and in New Zealand if you die over the age of 85 there's a 55% chance that you are physically, geographically in a rest home or a private hospital when you die we're only just overtaken by Iceland on that table on that graph and as you can see in other OECD conferences a wide range New Zealand is very good at institutionalising these older people but it's getting better so this is another study that I was involved in including Joe but many other people on this study we were involved in this one 2008 this is the Opal study and this is Greater Auckland the three Auckland DHBs this happens to be for people over the age of 85 a bit lower than the age of 94 so for every 100 people in Greater Auckland in that age group in 1988 43 of them, if they were women lived in a rest home or a private hospital by 2008 that had fallen to 27 same for men, same for other age groups I want to show you in the one slide busy slide but just look at this line here this is the actual number of rest home or private hospital places available in those four years spread over 20 years no change despite the fact that there have been a 43% increase in the population over the age of 65 people were older living in residential aged care and they were more disabled they were less mobile and they were on many more drugs than there had been 20 years ago is all that a bad thing? residents were entering residential aged care later in life and only when they were more disabled they were staying independent at their own homes for longer and that's where they want to be they're also not occupying hospital beds so this is the time they entered residential aged care on the first day they entered residential aged care this is a year before that time this is a year after that time this is the chances of acute hospitalisation each of the dots represents a week and as you can see, increasing chance particularly in that last six months before they move into a rest home or a private hospital as soon as they enter drops off a cliff so it isn't all these old people in rest homes that are blocking the medical beds in hospitals pensions, Bismarck Germany, New Zealand 10 years later UK is 10 years after that UK pension in current terms then was $30 a week and it was given to those over 65 when the average age of death was 59 not many people got a pension if we were equally generous as UK Liberals 100 years ago we'd start to pay pensions at about 90 not a great idea but even a slight increase in the pension age is not going to be very popular and probably not very fair to manual workers but pensions take up a very high proportion of spending on older people housing occupancy has fallen in New Zealand quite dramatically it's not fallen as much in older people but it has fallen in younger older people not in the very old as yet why is that relevant because the amount of pension that New Zealand and any other country older people is affected by the assumption that they don't have to pay rent because they own their own homes they don't have to pay a mortgage because they paid it off and in fact that's less likely to be true pensions are rising anyway even in the crash there is a current transfer of family capital to the state and the private sector retirement bill is all going to Y and some people have to pay rest open private hospital costs and thus resentment has arisen in younger generations there's no money going when you got free education we have to pay for it but older people have paid their taxes and their superannuation for a long time and those taxes and superannuation have actually built up the healthcare system and the social care system that we currently have these things do not happen straight away overnight so a reasonable question might be do we agree with Margaret Thatcher who said in 1980 there is no such thing as society I very rarely find myself agreeing with Margaret Thatcher but I hear you ask what about dementia, well you've already heard so I won't do the show of hands because you know the answer this is the actual data from the studies that Alistair was referring to two studies both published as one paper in the Lancet in 2013 data from the UK the prevalence of dementia in 85 to 90 years old essentially 25 years ago was 20% in men and it formed a 30%, 13% 20 years later and in women it was 27% and it formed to 18% 20 years later that was a massive fall, it was a 35% fall in the age specific prevalence of dementia in that period in the UK why might that be we've heard various reasons why that might be but an important reason is the fall in vascular risk smoking high blood pressure control of cholesterol reducing the risk of stroke and heart disease but also reducing the risk of vascular dementia 25% of dementia is due we think, or we used to think to lots of little mini strokes impairing brain function but if it's only 25% of dementia that's caused by that even if you eliminate all of it how can you get a 35% reduction in the prevalence of dementia well we now think that Alzheimer's disease in order to become manifest doesn't just need those proteins that you were hearing about earlier on to be deposited in the brain yes it needs those before you get Alzheimer's disease but it also needs, we think an unhealthy arterial blood supply to the brain so if you eliminate or reduce vascular risk you also reduce Alzheimer's disease risk if so then again as we've already heard there are some concerns in the future regarding obesity diabetes and vascular risk so evolution versus revolution so mapping Europe and mapping Africa was evolution, it happened gradually Europeans finding this bit of the world was revolution Europeans finding this bit of the world was revolution Fleming finding penicillin was revolution we need another Fleming when it comes to Alzheimer's disease we can't do it all with evolution it's probable and increasingly likely that many of us will live to be a hundred or possibly our kids or our grandkids a hundred and ten, a hundred and twenty should we want to, do we want to is our perspective at least partially dependent on society's perspective started with the first line famous one, here's another famous one Joel's Dickens tale of two cities best of times, worst of times spring of hope, winter of despair take your choice do you believe in hope or despair this lady believed in hope Jean Calment who died in 1997 at the age of one hundred and twenty and a half she was the oldest person that we know with a birth certificate to prove it she knew Vincent van Gogh she described him as a dirty smelly unpleasant individual she started fencing on guard fencing at the age of 85 she was still cycling on a pedal cycle in Paris at the age of a hundred and a half you should drive in Paris when she was just about, or just approaching her a hundred and twentieth birthday she was interviewed by a junior reporter from Le Figaro in France a French national newspaper about the secrets of a healthy and long life red wine, garlic, all that sort of thing at the end of the interview we stood up and said so do you think Madame Calment I'll be coming to see you again next year when you're a hundred and twenty one and she looked at him and she said thank you