Geriatric Medicine in India

 Like many other developing countries, India did not realise the impact of population ageing till the 1970s. The need for geriatric medicine as a separate speciality was not appreciated, and it had a late beginning. In 1978, the outpatient service in geriatric medicine was started in Madras Medical College and Hospital, Chennai was started. The inpatient service was established in 1988, and the postgraduate program in geriatric medicine was formed in 1996, under the aegis of Dr MGR Medical University of Tamil Nadu. The National Policy on Older Persons (NPOP) (1999) mandated the establishment of geriatric medicine in all medical colleges. Responding to NPOP, the Medical Council of India developed the postgraduate training curriculum in geriatric medicine in 1999. Madras Medical College was the first medical college to establish postgraduate training in India. In 2004, a Postgraduate diploma in geriatric medicine was launched by the Indira Gandhi National Open University, Delhi, to equip the primary doctor with knowledge and skill in geriatrics and deal with older people's unique problems. After the initial enthusiasm, the program lost its importance due to a lack of hands-on training facilities and non-recognition by licensing authorities. Subsequently, Amrita Institute of Medical Science in Kochi, Kerala, Christian Medical College, Vellore, Tamil Nadu and Mahatma Gandhi Mission Medical College, New Mumbai, All India Institute of Medical Sciences, New Delhi have started a postgraduate (MD) training programme in geriatric medicine.

There is limited exposure to old-age care in the undergraduate medical curriculum and nearly non-existent in nursing and paraprofessional training. To address these issues, the Government of India launched an intensive training programme with sponsorship from the World Health Organization (WHO). The programme was managed by the All India Institute of Medical Sciences, New Delhi and reached 100 medical colleges between 1998 and 2001. More than 200 primary care physicians were trained in workshops conducted in medical colleges across the country. This initiative, with focused operational inputs from WHO, led to creating a critical mass of teachers and specialists trained in old age care and the evidence base required for more significant initiative. The National Programme for Health Care of the Elderly (NPHCE) was launched in 2010 by the Ministry of Health and Family Welfare, Government of India. The programme has a two-pronged strategy: capacity building through PG training in medical colleges and expansion of service from district hospitals to the peripheral most dispensary.

During the 12^th five year plan, it was proposed that 12 medical colleges would be added for setting up Regional Geriatric Centres. The Position paper by the Indian Academy of Geriatric's states that we need 27,600 geriatricians for a 138 crore population(1). Assuming that all the RGC'c become fully functional with adequate staff, we would still have only 120 geriatricians, far below the minimum requirement. The key measures enumerated to develop the health workforce included:

·         Training primary care physicians and internists

·         Mid-career training of family physicians and general practitioners

·         Mandatory addition of geriatric medicine in the medical curriculum

·         Incentives for institutes to implement geriatric medicine postgraduation programmes

·         Making geriatric medicine a mandatory department for medical colleges

Through these measures, we can aspire to achieve the goal of healthy ageing and health for all in India.

Acknowledgement:

An extract from a chapter titled "Evolution of Geriatric Medicine in India" by Dr A B Dey

 

References

1.       Rao AR, Mathur A, Dey A B. Health workforce development for geriatric services in India. J Indian Acad Geriatr 2020;16:176-9

Frailty

 Ageing is associated with a gradual decline in physical functioning. However, the rate of decrease varies, and hence ageing is not always coupled with frailty. Frailty is defined as an ageing-related physiological decline syndrome characterized by significant vulnerability to adverse health outcomes. Multiple protective and risk factors influence frailty during the life course, and these factors have complex interactions among one another. Older frail people experience a dramatic decline in physical and mental functions and have poorer outcomes after apparently minor stressors such as mild physical disorders and anxiety.

 

Frail adults are at increased risk of adverse health outcomes, including falls, fractures, disability, dementia, low quality of life, increased cost of care, hospitalization and premature death. Several studies have shown that the health care costs of frail individuals are several-fold higher than non-frail adults. The prevalence of frailty among 65 years and older adults ranged from 4% to 59% in different communities. Advanced age is a significant risk factor for frailty, with one-fourth of those aged 80 and above being frail. The prevalence is even higher in those with renal disease, heart failure, Alzheimer's disease, cancer etc.

How to identify a frail individual

Various tools are available, but there is no one gold standard method. Fried criteria define frailty as the presence of three out of five phenotypic criteria: low grip strength, low energy, slowed walking speed, low physical activity and/or unintentional weight loss. A pre-frail stage, in which one or two criteria are present, identifies people at high risk of progressing to frailty.

 

A risk index by counting the number of deficits accumulated over time termed as Frailty index (FI), developed by Rockwood and Mitnitski, is available. FI is a more sensitive predictor of adverse health outcomes. Other scales include frailty/vigor assessment, clinical frailty scale, brief frailty instrument, vulnerable elders survey (VES-13) etc. These tools have their advantages and disadvantages. Few are easy to use, not time-consuming, sensitive, and can be used in an OPD setting or community, whereas others require special tools, are complicated and time-consuming.

Why identify Frail individuals

It is understood that the treatment outcomes depend not on the chronological age but the biological age of the individual. By identifying frail individuals, the treatment goals can be set accordingly, including treatment (medical, surgical etc.), the intention of therapy (curative, palliative etc.). Also, by understanding the impact of frailty on treatment outcomes, the patient and their family members can make a better, informed decision.

 

 

CGA Part IV: Functional status

 

Functional Status

Intrinsic capacity (IC) is the combination of all the physical and mental capabilities of an individual. Functional ability is dependent on the IC (of the person himself/herself), the environment (external things which help improve function, Eg: spectacles, hearing aid, walker, wheelchair etc.) and the interactions between the two. This model proposed by the World Health Organization can modify how clinical practice is currently conducted, shifting from disease-centred towards function-centred paradigms.  

Measurement of functional status is an essential part of the evaluation of an older person. A person's capability to perform functional tasks can be considered as a comprehensive measure of the overall impact of age-related impairment and health conditions. Functional status is a powerful prognostic factor and an essential indicator of the quality of life.

Many tools have been proposed and used to assess functional status in older adults, some are objective measures, and others are self-reported. Self-report measures are based on questionnaires asking how people function in their environment to evaluate their ability to remain independent. Using the self-report tool, functional status can be assessed at different levels: basic activities of daily living (BADL), instrumental activities of daily living (IADL) and advanced activities of daily living (AADL). The latter is seldom used in routine clinical practice.

Basic activities of daily living (BADL)

Basic activities of daily living include fundamental skills typically needed to manage basic physical needs. They have the following categories:

·         Ambulation: the extent of a persons ability to move from one position to another and walk independently.

·         Feeding: the ability of a person to feed oneself.

·         Dressing: the ability to select appropriate clothes and to put the clothes on.

·         Personal hygiene: the ability to bathe and groom oneself and maintain dental hygiene, nail and hair care.

·         Continence: the ability to control bladder and bowel function.

·         Toileting: the ability to get to and from the toilet, using it appropriately, and cleaning oneself.

The Katz index of independence and the Barthel index is commonly used for BADL evaluation. The Katz index ranks performance in the six functions. A score of 6 indicates full function, 4 indicates moderate impairment, two or less indicates severe functional impairment. The Barthel index assesses ten activities. The total score ranges from 0 to 100 points, with higher scores indicating better performance.

Instrumental activities of daily living (IADL)

The instrumental ADLs are those that require more complex thinking skills, including organizational skills. IADLs are those activities that allow an individual to live independently in a community. The Lawton IADL scale includes eight domains:

·         Using the telephone

·         Shopping

·         Preparing food

·         Housekeeping

·         Laundry

·         Mode of transportation

·         Responsibility for their medications

·         Ability to handle finances

The scoring should be individualized, as not everyone performs all the above eight activities. Hence a more appropriate scoring method would be first asking if the person performed an activity and has he/she stopped doing it recently.

Advanced activities of daily living (AADL)

AADL is based on intentional conducts involving the physical, mental and social functioning that allow the individual to develop multiple social roles and maintain good mental health and quality of life. It is also of interest in establishing the diagnosis of Alzheimer's disease in an earlier stage, as these activities require high cognitive functioning and are responsive to subtle changes. Common AADLs are:

·         Participating in a meeting

·         Giving advice to family

·         Reading a newspaper

·         Shopping on special occasions

·         Socializing with others

·         Taking a walk

·         Care of a grandchild

 

Objective measures of physical function might be superior to self-report tools in people who are in general healthy. The measure includes short physical performance battery (SPPB), gait speed or 400 m walking test or 6- minute walk test. This is the best strategy to detect early limitations and stratify the risk of future health outcomes in otherwise fully independent people. Learning how each ADL affects an individual to care for themselves can help determine whether a patient would need daily assistance.

With the advancement in technology, we can provide support to people with impaired ADLs. Assistive devices are external devices that are designed to assist a person in performing a particular task. With the use of appropriate devices of good-quality, it is possible to improve the quality of life by enabling a person to participate in life at home, work, and the community.

COVID-19 and Older adults –Your Questions and Our answers

 

Dr. Prabha Adhikari M.R.

Professor and HOD Geriatric Medicine

Yenepoya Medical College, Mangalore

Everybody knows that COVID-19 had a devastating effect on older adults (age 60 years and above). Data from the Centre for Disease Control USA, WHO and published data from China have shown that age is an independent risk factor for COVID-19  hospitalization and death. Out of 10 people who have died due to COVID -19, 8 are above 60 years. Also, older individuals have multiple comorbidities which further predispose them to hospitalizations and death. The atypical presentation and hyperimmune response also contribute to the development of complicated COVID.

As a complication, patients with COVID have suffered from a stroke, heart attacks and other life-threatening complications and succumbed. Few of these complications have occurred as a delayed complication when the standard test for COVID become negative.

Similarly, we have witnessed COVID affecting the brain, intestines, liver, kidneys and other organs in older adults. This is because they already have an organ which is weak and such organs are affected earlier. This is called a weak link system. A person with chronic kidney failure will abruptly present with worsening of the kidney disease needing dialysis. An individual with dementia or Parkinson's disease will present with worsening of their symptoms. Same is the status with liver disorder. These cases are not recognized as COVID, and they succumb to the illness as -due to kidney failure, heart failure or brain failure.

With the release of COVID-19 vaccine, the elderly have the dilemma of taking it and exposing them to side effects or not taking it and taking the risk of COVID morbidity or mortality. Here are answers to a few of their questions and dilemma.

1.      Should I take COVID-19 Vaccine?

If you are a fit older adult, you must take the COVID-19 vaccine.

If you have a comorbidity, you have to take it.

2.      The vaccine has side effects. I am scared. My children are not allowing me to take the vaccine.

Vaccine side effect so far has been expected reactions. About one third will experience pain at the injection site, fever, body ache. These are rarely severe enough to confine one to bed. I was the first to be vaccinated in our institution, and I was fine after the injection. Younger people did develop a fever and pain. However, these symptoms will subside with paracetamol and ice pack.

3.      What about anaphylaxis, a sudden allergic reaction?

It is a 1 in 1,00,000 reaction. All the centres are well equipped with anaphylaxis kit which contains the antidote for the same. This reaction causes difficulty in breathing and low blood pressure, but this is reversible with treatment.

After vaccination, everybody is observed for 30 minutes by the medical team as the reaction occurs within 30 minutes.

Also, the emergency team will always be ready.

4.      We heard that two health care professionals developed a heart attack and died after vaccinations in Karnataka.

They were investigated. They did not die immediately after vaccination. They died after two days, and both had confirmed heart attacks. They were not elderly.

5.      We heard that in Norway as many as 33 elderly died after vaccination.

Two lakh nursing home residents were vaccinated. They were frail, weak, dependent elderly. They were anyway too sick to live as the weekly death rate among them were at least two deaths. It so happened that they died after vaccination.

They were cleared as natural deaths by WHO

However, we will not venture and vaccinate frail elderly who are bedridden and suffering from end-stage diseases whose life is limited anyway

6.      Which vaccine is better?

We have two vaccines at the moment in India. Covishield made by Serum Institute of India with the transfer of technology from Oxford University and Astra Zeneca and Covaxin by Bharath Biotech. Both are given as two doses Intramuscularly 28 day apart.

Antibody response and side effect profile are similar

7.      How long will I get Immunity?

At the moment for six months for sure. It is predicted that immunity may last up to 6 years. We are happy if immunity lasts for one year. Studies are still ongoing

8.      If I have had COVID and if I am living, why should I take?

If you had a mild disease in the past, there is no guarantee that the next one will also be mild .mutations are occurring, and you can have any number of attacks

9.      If I had COVID when is safe to take the vaccine?

I would recommend that you had mild  COVID- you can take vaccine after 14 days after you became COVID negative which is almost a month

If you have severe COVID-19 safer to wait for three months for all the activated cytokines to settle

10.  If I am on a blood thinner, can I take vaccination?

Suppose you are on aspirin or clopidogrel or an antiplatelet drug you can take the vaccination. If you are on a drug called an anticoagulant, IM Injections can make a haematoma. Hence please consult your doctor about the safety of stopping the same

11.  I have an allergy. Can I Take the vaccination?

If you have an allergy, you are at high risk of COVID complications. However, if you had a severe allergy to any COVID Vaccination or any other vaccination, you may opt-out of vaccination

12.  Today we read that five doctors of Karnataka developed COVID after vaccination?

Vaccination will start protection only after the second dose, that too 45 days after the second dose. Although we may upload pictures in the media that I am safe, I am vaccinated, we need to be cautious. Vaccine efficacy is not 100%. In studies, it will be 70-80 per cent efficacious. In the field, it is around 60 per cent protection. All the five people were front line workers

Kindly continue to wear Mask and maintain Physical distancing although you feel good and protected after vaccination. We have prayed and hoped that we will get the vaccine soon. When the vaccine has been produced by the efforts of so many, doubting rumours are going around. All the developing countries are towards universal vaccination. We being a vast country with a huge population we have completed  3 million vaccinations and are almost completing the first phase, and the second phase is about to start. In the 3^rd phase, those above 50 will get the vaccination by February, March.

You will get a call and a message about the centre before the date of your vaccination. Do not miss this opportunity. I wish you all a Happy and safe Vaccination. Let us all be proud of the privilege of getting vaccinated at no cost.

 

 

 

 

Comprehensive Geriatric Assessment Part II

 Identifying individuals who are frail or at risk of poor health outcomes, followed by appropriate evaluation and intervention is the cornerstone of geriatric medicine and quality care for the ever-growing elderly population.  However, in older adults, clinical decision making, including diagnosis, treatment, and outcome selection may be challenging. The complexity is due to the interplay of multisystemic effects of the ageing process with multimorbidity and polytherapy and the contribution of psychological, social, economic and environmental factors as key determinants of the health status.

 

Many models of care and multiple instruments have been developed over the last 40 years. The majority of CGA tools include similar measurable dimensions that can be grouped into physical health, functional status, psychological health and socio-environmental status.

1.      Physical Health

CGA does not substitute the traditional clinical workup based on patient’s medical history and clinical examination. But clinicians need to extend beyond standard evaluation and focus on a systematic search for specific conditions that are common among older people. This is because older patients fail to report conditions such as visual and hearing impairment and frequent falls. The dimensions assessed as part of physical health include vision, hearing, multimorbidity, polypharmacy, nutrition and balance.

·         Vision

One in three older adults aged 65 years and above have vision-reducing eye disease. The prevalent conditions with increasing age are presbyopia, cataract, macular degeneration, glaucoma and diabetic retinopathy. Many older adults do not report visual loss assuming it to be a normal part of ageing. Intact vision is essential to maintain functional independence, and impaired vision is associated with mobility restriction, recurrent falls, increased risk of delirium etc.

Simple questions to screen for visual impairment:

o   Do you have trouble recognizing faces?

o   Do you have problems reading a book or a newspaper?

o   Do you have problems watching television?

A positive response should prompt further detailed evaluation, including assessing visual acuity using a Snellen chart and ophthalmologic reference. Correction of visual impairment using spectacles, cataract surgery can improve the quality of life of these individuals.

·         Hearing

After hypertension and arthritis, presbycusis is the third most common chronic condition in older adults. Hearing impairment can significantly impact the functional abilities and reduce participation in social activities. Individuals with hearing impairment are also at an increased risk for cognitive decline (dementia). Health care providers must screen for hearing loss as most older adults don’t self-report decreased hearing.

Screening questions include:

o   Do you feel you have a hearing deficit?

o   Do you have trouble speaking over the telephone?

People who give a positive answer to screening questions should be referred for audiology examination. Rectification of hearing impairment by removing ear wax, or using hearing aids (when indicated) can improve their participation in social life.

·         Multimorbidity and Polypharmacy

Presence of two or more long term conditions is called as multimorbidity. Multimorbidity becomes more common as people age. Two-thirds of people aged 65 years and above have multimorbidity. And the Longitudinal Ageing Study in India (LASI) reported that cardiovascular diseases, diabetes mellitus and respiratory diseases contribute to a significant share of chronic health conditions.

But the presence of two illnesses may not be of much significance. For example, a person with well-controlled hypertension and mild osteoarthritis will also be considered to have multimorbidity (by definition). Still, it is not relevant as his/her condition is well controlled and not requiring much medical attention. Many tools have been developed, such as the cumulative illness rating scale and the Charlson comorbidity index, to assess multimorbidity severity. Presence of multimorbidity matters when associated with disability, reduced quality of life, higher mortality and increased health service utilization, including emergency hospital visits. 

Multimorbidity is associated with polypharmacy, increased treatment burden and higher rates of adverse drug events. Older adults take more medications than other age groups. Severe adverse drug reactions may lead to hospital admissions, delirium precipitation, functional decline and increased mortality. Self-management of drugs and correct adherence by the patient is a demanding task requiring good cognitive performance. Medication assessment, reconciliation and comprehensive medication review are a cornerstone of geriatric evaluation and patient safety.

The clinician needs to determine what medications that patient is taking and how he/she takes them. For this process, called “medication reconciliation”, multiple pieces of information from the patient, caregiver and medical record should be gathered. After establishing the medication, its safety and appropriateness are assessed. Beers criteria and the STOPP and START criteria help clinicians identify potentially inappropriate medications and the right treatment for a specific patient. By following these essential steps, the pill-burden and use of improper prescriptions can be reduced. 

Next week I will describe the assessment of nutritional status, balance and functional status.

Comprehensive Geriatric Assessment Part I

It has been observed that chronologically we all age at the same speed, but the rate of biological ageing is heterogeneous across individuals. The research focus has been identifying the individuals who accumulate multiple comorbidities and have an excess risk of physical and cognitive frailty due to accelerated ageing. The initial work in this area recognized that the typical medical approach to diagnose and treat based on specific diseases is not sufficient.

What do we mean by this?

If a person has diabetes, a physician will assess a few physical and laboratory parameters. Measure blood pressure to screen for hypertension, a fundoscopy for retinopathy (disease of the retina), a monofilament test to screen for neuropathy, fasting and post food blood glucose levels, serum creatinine and spot urine protein and creatinine to look for nephropathy (disease of the kidney), serum cholesterol levels etc. These tests look at specific parameters that revolve around diabetes and are very important in delivering optimum medical care of diabetes. These assessments do not comment on the health, functional status and quality of life of older persons, which is of immense importance.  

To assess and manage older people's unmet needs, geriatricians have developed and used the Comprehensive Geriatric Assessment (CGA).  Larry Rubenstein defined is as a multidimensional, interdisciplinary diagnostic process focused on determining a frail older person’s medical, psychological and functional capability to develop a coordinated and integrated plan for treatment and long-term follow-up. Let me try to break down each term.

Multidimensional: The unidimensional approach was disease-oriented. It included diagnosing an illness, identifying its severity and prescribing medications to treat the disease. Though suitable in younger adults who often have one condition, this approach does not work well for frail older adults with multimorbidity. It has been identified that there is a loss of harmonic interaction between multiple domains which include a functional, cognitive, psychological and socio-economic domain that ultimately leads to illness. Hence an assessment of older adult needs to be multidimensional.

Interdisciplinary: This term refers to a process of care that integrates the specialized knowledge of multiple disciplines. The complexities of the care needs of older adults require the expertise of various disciplines. For example, a 70-year-old male, a case of hypertension, diabetes presenting with recurrent falls was assessed by a geriatrician, physiotherapist and clinical pharmacist. They found that the factors contributing to his falls were his benign prostatic hypertrophy (BPH) and a diuretic (given for his BP) he took at night, which made him wake up multiple times at night. A sedative prescribed to him for his sleep disturbance (which was because of frequent urination). The interdisciplinary team is not restricted to the members mentioned above. It can include a neuropsychologist (in case of declining memory), a dietitian, an occupational therapist, an orthopaedician (in case of fragility fracture) etc.

Diagnostic process: performing a CGA is to identify the problems in various domains that affect the patients and their illness.

Frail older person: This answers the question “Who should undergo a comprehensive assessment?”. An older adult who is healthy, with no comorbidities and fully independent should not undergo comprehensive assessment as he/she might not benefit from such an extensive evaluation. Similarly, it is not beneficial to assess older patients suffering from acute illness such as pneumonia, acute heart failure, fracture etc. The ideal candidate who would benefit is a frail older person.

Medical, psychological and functional capacity: The focus of CGA is not a particular disease, but the person in entirety. The assessment involves identifying all the comorbidities (diabetes, hypertension, osteoarthritis etc.), geriatric syndromes (urinary incontinence, mobility issues, polypharmacy, visual and hearing impairments etc.), cognitive and psychological capacity (cognitive reserve, depression, anxiety etc.), functional capacity (ability to perform activities of daily living) along with other domains.

Develop a coordinated and integrated plan: After an extensive assessment, it is essential to list the problems and develop a treatment plan. The management usually includes a multidisciplinary team (geriatrician, physiotherapist, nutritionist, occupational therapist etc.). The management plan contains medications for the management of comorbidities, assistive devices (such as spectacles, hearing aid, walking stick etc.), environmental modifications (appropriate lighting, railings) and support from the family member. Hence it is important to involve family members during assessment and planning management.

Long-term follow-up: Unlike acute illnesses that resolve completely with appropriate medications, older adults' needs are complex. A care plan made will not be suitable for the same person after a few years. A long term follow-up with a re-evaluation of the situation and development of management plans is a continuous process.

The benefits of CGA has been demonstrated in multiple studies across multiple settings. I will describe the various domains and their use in different locations in the upcoming parts

 

 

Geriatric Medicine

Good evening everyone.

Being a Geriatrician, I am frequently asked many questions regarding Geriatric medicine, the requirement and how senior citizens are different from younger adults. Here I try to answer a few of them.

What is Geriatric Medicine?

Geriatric medicine is a branch of medicine concerned with all aspects of health and illness in older adults (Individuals 60 years and above)

 

Who is a Geriatrician?

A Geriatrician is a physician who specializes in treating conditions that affect senior citizens. Geriatricians have an interesting and varied job which includes providing comprehensive medical care to senior citizens who may have several medical conditions (multimorbidity) and are often taking multiple medications (polypharmacy).

 

Why do older people/senior citizens need specialized care?

Older individuals differ from the younger ones in many ways.

A.    Difference between person to person increases with age

As people age, they become more and more different from the standard population due to different health and medical needs. Most adults aged 30 years don’t have a chronic disease, don’t need to see doctors regularly and don’t take long term medications. But few, if not many, people aged 60 years and above have one or two chronic medical conditions (eg: Diabetes, Hypertension, chronic heart and lung diseases, joint pains, memory complains etc), they are on multiple medications and may be dependent on the young ones to perform their activities of daily living.  The disease pattern and combination varies drastically in this group making them different from the younger population.

 

B.     Decreased reserve capacity

As people get older or develop chronic disease, there is a narrowing of their reserve capacity. This phenomenon has been called homeostenosis, a decreased ability to maintain homeostasis (balance) under stress. The stress can be in the form of infection, trauma, falls, pain, and even medications. A young person has a high capacity to maintain health and prevent the consequences of dehydration well. Whereas an older person is increasingly susceptible, a very short duration of decreased appetite can lead to dehydration which can, in turn, lead to kidney damage (termed as acute kidney injury). Being bedridden for even a few days can make an older person noticeably weaker.

C.    Comorbidities

The recently released LASI (Longitudinal Ageing Study in India) reports that a third (35%) of people aged 60 years and above had diagnosed Cardiovascular diseases, 14% had diagnosed diabetes, 5.9% had asthma, one in five (20%) had chronic bone and joint diseases. Hence, older people don’t come to doctors with a single problem, they often have multimorbidities (two or more medical conditions). And treatment of one condition may interfere with another, or in some instances make it worse. A specialist who works towards combining the treatments safely and effectively is essential.

 

D.    Atypical disease presentation

This was initially observed in children and is now true for senior citizens as well. Unlike younger adults who have typical presentations, senior citizens may not have similar features. For example, high-grade fever, cough with sputum and shortness of breath are classical symptoms of pneumonia. But this is not so for older people, they often present with no fever, or low-grade fever, no to mild sputum production, altered mental status (decreased speech, increased drowsiness, confusion etc) and loss of appetite. 

 

E.    Polypharmacy

It is not uncommon to see an older person take 5 or more medicines per day. As we go old, the number of diseases and disabilities go on adding up. In many cases, it is necessary to take medicines for these conditions. But at the same time, the function of our liver and kidneys deteriorates. And these organs help remove these medicines from our blood. Also, the multiple medicines taken together can interact with each other and cause harmful effects. A Geriatrician ensures that the patient is receiving medications at optimum doses, with minimal harmful effects, and eliminated the possibility of duplication of medicine.

 

F.     The attitude of the relatives

Most often the symptoms of older persons are ignored by the person himself/herself and their relatives. Symptoms such as urinary incontinence, decreased memory, decreased physical activity, reducing vision, joint pains are considered as part of ageing and hence ignored. Hence, these troubles increase and impair the daily activities of senior citizens. A Geriatrician not only screens and treats an older person for these conditions, but he also educates the patient as well as the family members regarding the preventive measures.

 

G.    Geriatric giants

These are major categories of impairment that appear in older people. Traditionally these include immobility, instability, incontinence (lack of control on urine and stool) and impaired intellect/memory. More recently, four more syndromes of frailty (weakness), sarcopenia (loss of muscles), anorexia (lack of appetite), and cognitive impairment (loss of memory and mental function) have been termed as modern geriatric giants. A Geriatrician who is trained in the care of older persons can properly assess all these issues in totally and advise appropriate management to improve the functionality and quality of life.

To conclude, senior citizens, differ not only from younger adults but also differ among people of the same age group. They need special attention and specialised care plans based on individual needs, and Geriatricians are trained to achieve this goal.

Keep Dementia at Bay. Act now

Greetings of the day !

Mr. Kapoor (name changed) the 76 year old retired officer , nicknamed as 'Raj Kapoor' in his youth for he used to be well dressed and a highly polished gentleman of the locality.

He had been living with his wife and children happily till 2017 . Mr & Mrs Kapoor once upon love birds were ageing gracefully and were enjoying life to its full but now they were fighting on simple and pity issues.

One day on a sunny day, while returning from a shopping mall ,Mr Kapoor could not find his way back home. He went on moving from one corner to the another for almost an hour till a passerby helped him out and accompanied him back home.

Mr Raj (name changed) his son felt happy to see his father back but surprisingly Mr. Kapoor shouted at him , ''you are the one who did black magic on me' otherwise I never experienced this before . Mrs Kapoor looked at her husband and strengthened his belief .Both felt that their son was no more a sincere person .

Next day Mr Kapoor was taken to a doctor and he was diagnosed as Alzheimer’s disease. Various investigations were done to rule out any treatable cause but all in vain. The doctor had an elaborate discussion with the family. Mr Kapoor was not allowed to visit marketplaces alone and he started to live indoors much to his dissatisfaction .

The disease is unfortunately progressive and till date there is no specific treatment . Social circle of Mr Kapoor progressively declined as he would repeat his past stories again and again. To deal with such people one needs a loving heart and caring ears which are unfortunately rare .

A year later, one day , Mr Raj was seen shouting at his wife as his father Mr Kapoor blamed that lot of people are coming to their residence no sooner Mr Raj goes out for duties which was not a fact. Finally Dr Adit (name changed) explained his son, Mr Raj that this was the delusion of persecution his beloved father has developed ,as part of natural history of the disease thus none of his faults. This needs to be understood by caregivers of such patients.

With these developments the sweet Kapoor family became a group of villains living under one roof, all suspecting one another . It is easy said than done ,to take care of a dementia person. It starts with memory impairment and difficulty in planning. Hence we must focus to reduce the development of dementia right from the beginning as there is no treatment .While non modifiable factors like age & family history are unalterable but certain factors can be controlled when taken care at an early age.

Coming back to Mr Kapoor 's family one day as the dawn was breaking Mrs Kapoor   developed severe chest pain and she was rushed to a hospital where she breathed her last . Her husband once upon a loving partner was least bothered about this unfortunate incident due to his disease process . He had an inappropriate affect .He started singing and continued his irrelevant ,difficult to understand discussions .

Day by day Mr Kapoor 's talkative behaviour and irrelevant singing became a big problem in their home. He lost his facial sheen and became very weak. Mrs Bunti (Raj's wife) was concerned about the education of her children and would frequently complain about it to her husband who seemed to have got sandwiched between the two parties .The lady seemed to have become fed up with a person who had given blood to the home. The bitter story of life.

Months later Mr Kapoor was unable to dress himself and needed a person to support .A full time helper was hired by Mr Raj to look after his beloved father.

October 2020 , Mr Kapoor is bed bound, recognise none .The Raj Kapoor of yester years is living as an untidy weak person who has forgotten everything around.

Dear Reader : Dementia and Alzheimer’s disease are thought to be caused by a combination of genetic, environmental, and lifestyle factors including diet and nutrition. While people after the age of 65 years are more prone to develop dementia , younger people are no way immune to these disorders, hence ACT NOW 

How to prevent ?

1. Patients with chronic health conditions like hypertension , heart disease, diabetes, and obesity must focus a meticulous control of their disease as these preclude dementia in old age .
2. Exercise regularly: 150 minutes /week 
3. Keep your brain very active , learn new things , read a book, solve a puzzle etc. 
4. Sleep apnea. People who snore and have episodes where they frequently stop breathing while asleep may have reversible memory loss.
5.Vitamin and nutritional deficiencies. Low levels of vitamin D, vitamin B-6, vitamin B-12 and folate may increase the risk of dementia.
6. Be socially active. Meet people , greet people and avoid all types of stresses . We live once live happily and the key to happiness is no expectations. Never try to change the behavior of your spouse , never compare yourself with others . 
Come on, from a Billionaire to a beggar the final outcome of our life is ZERO, No profit and no loss 
7. Quit smoking 
8.Sleep well 
9. Practicing good nutrition and eating lots of healthy foods is shown to help reduce the risk of dementia and Alzheimer’s disease .

Here are 7 foods that can fight off cognitive decline and help you stay healthy as you age:

1. Leafy Greens
These are high in essential B vitamins like folate and B9 that can help reduce depression, while also boosting cognition. 

2. Berries
The anthocyanin present in Raspberries, blueberries, blackberries, and cherries helps to stop the progression of brain damage triggered by free radicals. 

3. Nuts
Almonds, walnuts, and peanuts are loaded with healthy fats, magnesium, vitamin E, and B vitamins — all of which are shown to promote good cognition and ward off signs of dementia. 

4. Omega-3s
Olive oil, flax seeds, and fatty fish like tuna, salmon, are examples of foods high in omega-3 fatty acids .These help your brain stay healthy. Studies have shown that omega-3s are effective at fighting and preventing dementia . 

5. Cruciferous Vegetables
Broccoli, cauliflower, are high in vitamin B and carotenoids that have the ability to reduce levels of homocysteine — an amino acid linked to cognitive decline, brain atrophy, and dementia. 

6. Spices
Spices like , Turmeric and cinnamon contain lot of polyphenols — compounds that offer numerous benefits for memory and brain health. Add Turmeric to rice and take cinnamon regularly 

7. Seeds
Sunflower seeds, flax seeds, and pumpkin seeds all contain antioxidants and nutrients like vitamin E, zinc, omega-3s, and choline that reduce cognitive decline. 

Foods That Are Risk Factors for Alzheimer’s disease

Many foods like RED MEAT , processed meats, refined grains, sweets, and desserts are shown to be risk factors of dementia .

Excess alcohol intake, saturated fatty acids, and foods with a high number of calories are also risk factors for Alzheimer’s.

Keep Dementia at Bay SO ACT NOW 
Have a good day!

References:


https://www.ncbi.nlm.nih.gov/pubmed/24500933

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4105147/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4019002/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5293796/

https://www.ncbi.nlm.nih.gov/pubmed/27431367

https://www.ncbi.nlm.nih.gov/pubmed/23092406

Nip the evil in the bud

Dear Friends Today Nip the evil in the bud. 

Screening for HBV and HCV

Chronic hepatitis B and C continue to be endemic in our region affecting millions. 

We must actively screen infected people and treat them so that its complications like cirrhosis and hepatocellular carcinoma are averted.  

Why is screening important.? 

Having HBV or HCV is  no  more a taboo, as affordable treatment options are  now  available. 

The positive person can  learn proper precautions and transmission can easily be halted.

 The patient can be followed up, to prevent complications like liver cirrhosis & liver  cancer. 

The same person if not screened now can present with cirrhosis and in that setting doctors  do  not offer much to the patient .Thus screening is beneficial. 

The  liver transplant remains a distant dream so nip the evil in the bud  IDENTIFY THE PATIENT & TREAT  

 

Few suggestions:

1.All students must be screened before admission to a school / college for HBV and HCV. 

Hepatitis B vaccine should be given at the entry-level to all students. 

2. Pre marital screening of HBV and HCV can be started. Infected persons can be easily treated and they can happily marry there after.

 In Fact we must add drug screen to pre marital screening as well to discourage drug abuse which is so rampant now.

The best model of pre marital screening is provided by Saudi Arabia .

 Before marriage boys and girls  need to have clearance from ministry of health.  There  is long list of  disorders which they screen including viral hepatitis , drug abuse etc

This way they  have curbed so many genetic disorders and identified HBV & HCV patients and treated them well. 

Another side of the coin is that by creating such centers at all places we can increase job opportunities for our youth.

3.Pregnant ladies must be screened for HBV and HCV. They should be vaccinated in 2nd trimester. If HBV is positive they can be treated and risk of transmission to newborn can be stopped. 

4. Our dental surgeons need to be careful and take extra precautions while sterilization of their equipment

5. Our blood banks and Dialysis centers should take stringent precautions so that seroconversion of HBV & HCV   is prevented .

6.Our Barber brothers must use disposable shaving kits without fail. 

7.Screening should be made compulsory before employment whether in Government or private.

8. Avoid tattooing , not really needed , it is a source of infection of HBV,HCV

9. Awareness regarding HBV and HCV should increase in the society only then we can curb its disastrous effects .

To conclude mass screening of HBV and HCV can go a long way to curb these diseases. Vaccinate your self for HBV 

Treat HBV and HCV and stop Liver cancers. These are no more incurable 

Reference: 

Blum HE. History and Global Burden of Viral Hepatitis. Dig Dis. 2016;34(4):293-302. doi: 10.1159/000444466. Epub 2016 May 11. PMID: 27170381.

Exercise a free Medicine without side effects

Dear Friends : In my previous posts I have emphasized less oil , lesser salt and a plant based diet .

Today I want to discuss a free medicine without side effects .

Yes, it is #EXERCISE 

Benefits of exercise

It can reduce your risk of major illnesses, such as heart disease, stroke, type 2 diabetes and cancer by up to 50% .

Exercise is the only proven treatment for Fatty liver  

Our health is now suffering as a consequence of reduced exercise .

There's strong scientific evidence that being physically active can help you lead a healthier and even happier life.

Research shows that physical activity can also boost self-esteem, mood, sleep quality and energy, as well as reduce your risk of stress, depression, dementia and Alzheimer’s disease.

What counts?

To stay healthy, adults should try to be active daily and aim to achieve at least 150 minutes of physical activity over a week through a variety of activities.

For most people, the easiest way to get moving is to make activity part of everyday life, like walking or cycling instead of using the car to get around. 

Play any out door game regularly. 

Walk faster, avoid going up by lifts, use stairs instead. 

For any type of activity to benefit your health, you need to be moving quickly enough to raise your heart rate, breathe faster and feel warmer.  

 

A modern problem

People are less active nowadays, partly because technology has made our lives easier. 

We drive cars or take public transport for short distances. 

We entertain ourselves in front of a TV or computer screen.

Fewer people are doing manual work, and most of us have jobs that involve little physical effort.

We move around less and burn off less energy leadlng to obesity 

Sedentary lifestyles

 

Common examples of sedentary behaviour include watching TV, using a computer, using the car for short journeys and sitting.

such behaviour is thought to increase the risk of many chronic diseases, such as heart disease, stroke, type 2 diabetes obesity.

Previous generations were active more naturally through work and manual labour, but today we have to find ways of integrating activity into our daily lives.

Friends keep exercising and shun off your fat ..stay healthy.Have a good day !

Salt, the white POISON

 Greetings of the day !

Today about  Common salt. Continuing NUTRITION series 

 We have been consuming common salt since ages . Studies have shown that high salt consumption is a major cause of high blood pressure .There is a strong link between high salt consumption and risk of stroke, left ventricular hypertrophy, renal disease, obesity, renal stones and stomach cancer. 

What does excessive  salt do to  our body ?

It has been shown to reduce the activity of superoxide dismutase which is a very powerful antioxidant enzyme working tirelessly  to  detoxify a million free radicals per second .Once we cripple our very own antioxidant  machinery our arterial functions get crippled .Further, excessive salt intake leads to stiffness of arteries  and its consequent effects . 

It has been observed that people consuming high salt their blood pressure never gets controlled despite  multiple drugs  and the nasty game of hypertension is set free. 

Salt intake is especially deleterious  for kidney and liver disease patients. 

High Sodium intake has been shown to reduce nitric oxide release known to relax blood vessels .Thus by consuming  one salty meal  not only does our blood pressure go up, but our arteries literally stiffen.

Can reduction in salt intake help us ?

 If we would cut our salt intake by a half teaspoon a day we might prevent 22% of strokes and 16 % of fatal heart attacks. 

Your  kitchen master could help you more than pharmacy. 

Do we really need salt ?

Yes, we  do need salt in our body and it  should come naturally from food (fruit and vegetables) 

Stop   adding table salt, avoid salty preparations from  the market .We don't need  more than 2.3gm/day (1/4 tea spoon) 

We should reduce salt in cooking and avoid hidden sources of salt  like that found in Bread, Pizza, Burgers bakery, processed foods , fast foods, potato chips. Salted nuts etc 

Sounds strange! 

There  are no deleterious effects associated with reducing salt consumption and it is also very cost-effective.

It has been observed that our taste buds get acclimatized to NO SALT within 2 -3 weeks and you won't have salt cravings later at all. 

How to have salt alternatives for our naughty taste buds ?

Be creative and season your foods with spices, lemon ginger garlic. Vinegar 

To conclude common salt is a white poison World over 4 million deaths are linked to high salt intake. 

Gradually stop salt intake from today.Train your taste buds  SALT FREE FOODS, it needs just 3 WEEKS to adapt and live a healthy Life. 

References : 

1.McCord JM. Analysis of superoxide dismutase activity. Curr Protoc Toxicol. 2001 May;Chapter 7:Unit7.3. doi: 10.1002/0471140856.tx0703s00. PMID: 23045062.

2.Delahaye F. Should we eat less salt? Arch Cardiovasc Dis. 2013 May;106(5):324-32. doi: 10.1016/j.acvd.2013.01.003. Epub 2013 Apr 11. PMID: 23769406.

3. Jablonski KL, Racine ML, Geolfos CJ, Gates PE, Chonchol M, McQueen MB, Seals DR. Dietary sodium restriction reverses vascular endothelial dysfunction in middle-aged/older adults with moderately elevated systolic blood pressure. J Am Coll Cardiol. 2013 Jan 22;61(3):335-43.