Exercise at any Age, with any Chronic Condition (Part 3)

Steven C. Castle, MD

Republished from: http://www.aginglifecarejournal.org/exercise-at-any-age-with-any-chronic-condition/

What this Geriatrician learned from the Gerofit program

The following describes an exercise program, Gerofit, and its proven benefits for its participants. The Gerofit program was started by Dr. Miriam Morey at the Durham VA and for the past 30 years has successfully provided an exercise venue for older adults with chronic conditions (Morey MC, 2007). The program requires a referral from the primary care provider, with a chart review and telephone interview. Then baseline and quarterly Senior Fitness Test assessments (Rikli RE 2013) tell you your percentile ranking by gender and five year age group.  This allows a prescribed individualized exercise program that includes exercises for aerobic/cardio, weight resistance, and balance.  Program participants demonstrated a 25% reduction in mortality over five years, and in a related study, those that showed a 0.1m/sec increase in usual gait speed had less hospital days and reduced one-year costs (Purser JL 2005).

This author was skeptical of this program and had concerns about its safety. What I learned from exercising with older Veterans, doing assessments, and adjusting exercise protocols was this:  besides being a lot of fun, the gym is a true respite from illness.  Everybody has chronic conditions, and instead of focusing on them, everyone is working to improve their fitness.  Second, I realized I was biased against exercise because I was fearful someone would get hurt.  Instead, what I have learned is to assess their fitness, then prescribe an appropriate starting place for cardio, weight-resistance training, and balance based on that assessment. Third, older adults need guidance/reminders to do exercises correctly and to adapt exercise to chronic musculoskeletal conditions, and most importantly, to progress the intensity of the exercises.  I also learned it is very hard to predict in whom exercise will really take hold and become life changing.  Prior history of some physical fitness training provides a clue, but is not a guarantee; while many with no background in exercise can just as readily take off.  Exercise is life changing in this cohort.

What do we do about exercise in the significant portion of older adults with varying forms of cognitive impairment?

How do we implement an exercise program that includes cardio, muscle strengthening, and some balance exercise in this population?  What I have learned from Gerofit is that some of the older adults in a program will develop cognitive decline, some will be unrecognized at time of enrollment but become more obvious when they do not learn exercise routines or technique; and in both cases, they will exercise effectively but need supervision and coaching. Those with moderate dementia can fit well into a group exercise program if there is enough staff support or their caregivers are trained and supervised as well.  Folding cognitive impairment participants into a fitness program really provides optimal socialization and engagement when the focus is on fitness and set exercise routines.  

Participants with dementia with past history of physical activity will have motor memory that exceeds cognitive memory.  Regardless, improvement in fitness assessment is the norm if participants engage in the exercise, and there is significant benefit to mood and reduced anxiety.

How can an Aging Life Care Manager™ help?

Aging Life Care Managers have an important role in promoting exercise for their older clients. Care managers can facilitate the interaction of older adults, families, and health care providers, making the initiation of an exercise program more possible.  Care managers can recommend exercise programs for their clients for fall prevention, but can also help to identify clients that have already fallen that could benefit from exercise as an intervention.

The recommendation by the CDC is that if someone has had two or more falls or a fall with injury in the past year, has decreased activities due to changes in their balance, or has demonstrated at-risk screening measures mentioned above, then the following should be done:

• Address chronic medical conditions that may be contributing to changes in balance, including inadequately controlled hypertension.
• Review possible risky medications that may impair balance for indication, efficacy, and safer alternatives.  A careful review of how medications are being administered for adequate adherence, and if a blood thinning medication is appropriate given the falls risk, adherence with meds and risk/benefit of the blood thinner.
• Have a thorough mobility and balance assessment, including drop in blood pressure with standing, vision (acuity and peripheral fields) cognition, and gait assessment.
• Be encouraged to participate in a balance exercise program.
• Address vision, appropriate shoes (no barefoot or socks), lighting and environmental risks.

An Aging Life Care Professional™ is in a unique position to encourage clients and their families to follow through with these recommendations, and begin or continue exercise programs that meet the guidelines.

We, as care managers and health care providers, need to address our own bias about exercise for older adults, in order to become effective advocates for this essential component of health and wellness.

Exercise at any Age, with any Chronic Condition (Part 2)

Steven C. Castle, MD

Republished from: http://www.aginglifecarejournal.org/exercise-at-any-age-with-any-chronic-condition/

Why should Grandma and Grandpa perform muscle strengthening (weight resistance) training?

In the paper “Exercise is the Real Polypill” (Fiuza-Luces C 2013), the evidence of the impact of exercise in comparison with medications on reducing chronic conditions such as  glucose intolerance, lipids, blood pressure, and risk of thrombosis-related cardiovascular events (heart attacks and stroke) is discussed.  The paper reviews a meta-analysis which demonstrates that weight resistance training in particular was equivalent to the polypill (1-3 blood pressure lowering meds, a lipid lowering med, and aspirin), while other types of exercise had a more modest effect on lowering blood pressure in particular. It also identified that there was lower dropout rates in exercise groups (10%) versus the polypill group (20% dropout versus 10% for placebo pill).

In addition, the paper discusses the release of beneficial myokines and anti-inflammatory substances secreted as a result of muscle strengthening exercise, as well as possible substances associated with longevity and reduced risk of colon cancer.  Muscle strengthening exercise provides something different than the more traditional aerobic or cardio-fitness exercises we think of older adults actively engaged in.

What are the components of exercise that help improve balance, reduce falls, and achieve mindful awareness? (Rose D, 2010)

The following are descriptions of the positive outcomes exercise can provide for older adults and how these outcomes can improve balance, reduce falls, and increase safety awareness.

1. Posture and control of Center of Gravity

Older adults who experience a decline in posture often develop inaccurate perceptions of true vertical. Curvature of the spine with decline in flexibility was significantly associated with falls (Kasukawa Y 2010). Mindful awareness of vertical targets (doors, windows, corners) is helpful in restoring postural alignment. Progressive improvement in balance from exercises can start with seated, progress to standing activities, and utilize compliant (foam) or irregular surfaces. In addition, posture control strategies using the ankle, knee, or hip should be included in the exercise training.

2. Strength and Endurance

Muscle strength declines as much as 20-40% between age 30 and 80. Weakness in the body core (alignment of low back, pelvis, hips) contributes to poor balance, and weakness of the muscles in the legs can cause significant challenge in going from a seated to standing position. Strength becomes of increasing importance in individuals with poor balance control. More strength is needed to correct posture to prevent a fall because inappropriate weight shift results in moving the center of gravity off the base of support.

3. Flexibility

Joint range of motion and muscle flexibility decline with age and are associated with impairment in function. Loss of flexibility to perform shoulder or spinal rotation is directly related to functional limitations and increased susceptibility to falls. Reduced flexibility in legs results in less efficient gait (limits endurance) and a decline in balance control (leaning) that also contributes to falls.

4. Gait speed and efficiency

Because of many of the changes described above, stride length and decreased height of each step results in a decline in gait speed. Slow gait results in less stability and shorter steps: shuffling increases the risk of tripping or catching a toe. Exercise programs that require negotiating obstacles and vary surface conditions allow participants to develop a walking pattern that is more efficient, flexible, and adaptive, with more speed to improve stability.

What else can we do to improve mobility and balance?

Falls prevention is difficult to achieve, while mobility and balance awareness should not be.  For the needed behavior changes for exercise and adaption to changes, mobility and balance awareness provides a platform for patients, family, and care managers.  One way to better address mobility and balance awareness is by doing balance assessments, including the 8 foot up and go as part of the Senior Fitness Test, or the more balance-focused Short Form of the Fullerton Advanced Balance Scale (Hernandez D 2008).  These objective measures provide the opportunity to discuss changes in balance which most of us are not cognizant or aware.  Most 80-year-olds will recognize their balance is not like when they were 30, but all 60 and most 70-year-olds are not aware of decline at all; and all older adults are not aware of the size of the risk or that they have the ability to improve their balance through a formal balance exercise program or the need to adjust their lifestyle to match.

Once aware of their change in mobility and balance, the next step is to try and have older adults work with their providers to figure out the cause of mobility and balance changes. A practical approach to identifying the underlying causes is by symptom categories:

• D:  Dizziness/Vestibular:  Benign positional vertigo, vestibular neuronitis, Meniere’s Disease, brainstem infarcts
• LH:  Light headed/Postural Hypotension: drop in blood pressure with standing
• BB:  Bad Balance
• Frame – kyphoscoliosis, leg length discrepancy
• Central – infarcts in basal ganglia, central microvascular infarcts, Parkinson’s, cerebellar
• Peripheral – Peripheral neuropathies, spinal stenosis
• Impaired vision – especially discrepancy between eyes
• Meds – sleep aids, neuropathic pain meds, psychotropics
• Barefoot or socks increases the risk of falls 10-13 times vs. wearing shoes w/heel; poor weight transfer to balls of feet (studies have shown that wearing socks or walking barefoot inside increases the risk of falling 10-14 fold.)
• W:  Weakness – MS, focal weakness (stroke, motor neuropathy)
• PA:  Poor awareness – all of us as we age, dementia (Lewy Body & Vascular in particular)

Visit www.DrBalance.com for more information.

Exercise at any Age, with any Chronic Condition (Part 1)

Steven C. Castle, MD

Republished from: http://www.aginglifecarejournal.org/exercise-at-any-age-with-any-chronic-condition/

Introduction

Exercise and physical activity for older adults was an important theme discussed at the 2015 White House Conference on Aging.  Specific initiatives discussed included the NIH Go4Life campaign and the YMCA initiative to provide intergenerational physical activity.  The implementation of exercise and fall prevention programs on state and national levels sheds light on the importance of physical activity as being viewed as the core to healthy aging and preventing and lessening the impact of chronic disease.  Exercise is now known as an essential component of falls prevention, demonstrated by the fact that $5 million of President Obama’s budget is targeted for the National Falls Prevention Resource Center. Moreover, the CDC has also recognized its importance by providing free online webinars on falls prevention, which are currently being used by health care providers like Kaiser Permanente.  The reduced health care costs as a result of physical activity as well as the reduction of the most common form of accidental injury (falls) may also reduce the need for long-term services prematurely.

Everyone has heard that exercise is good for you, right?  Of us older adults, how many are heeding that advice?  How many of our primary care providers have spent the time to find out and help us do more exercise to the degree that they prescribe or monitor lipid lowering meds and follow cholesterol levels?  One reason why we as a society are falling short, as described below, is because there is a bias AGAINST exercise in older adults that no one is talking about.

Why Exercise?

Exercise is essential to improving balance and reducing risk of falls.  While the National Council on Aging (NCOA) has made a list of evidence-based programs, the evidence is not equal, and there may be other programs in the community which are actually more robust in improving balance.  A recent review on efficacy of exercise programs in preventing falls identified that 32 multicomponent exercises demonstrated reduction in falls by an average of 30%, while three single component (either walking or strength training) programs were not effective (Gillespie LD 2012).  The multicomponent programs target activities that address balance, strength, endurance, and walking.  Among successful programs, total weekly exercise time ranged from 80 minutes to more than seven hours. The duration of programs ranged from eight weeks to two years, while one review suggested a minimal dose of 50 hours of balance exercise is needed to be effective. Participation was improved by having a convenient location, incorporating social activities, and reimbursement for travel costs (Ganz DA personal communication).

In addition, engaging in physical activity is essential for maintaining mobility as we age. Dr. Debra Rose, Director of the Center for Successful Aging at Cal State Fullerton, defines mobility as “the ability to move oneself independently and safely from one place to another.”  The ability to walk 400 meters has been defined as an excellent proxy for community ambulation, which is central to aging in place and quality of life. This became the primary outcome measure of the LIFE (Lifestyle Interventions and Independence for Elders) Study (Pahor J, 2014).  This study randomized 818 (mean age 78.7 years) to physical activity (2x/week in a center and 3-4x/week at home) with 817 (mean age 79.1 years) to a health coaching group.  Of the physical activity group, 85.3% remained independent in community mobility versus only 80.2% of the health coaching group, for a 28% reduction in the risk of becoming dependent (p=.006).

How well are we doing?

Data from the National Health Interview Survey and the Centers for Disease Control (CDC) from interviews of the civilian and non-civilian population show that 42.4% of adults age 65-74 are reporting achieving aerobic activity goals as are 28.1% of adults age 75 and over (goal >50%).  Not bad.

However, only 14.4% of adults age 65-74 and only 7.9% of adults age 75 and over are achieving the goal of both the aerobic and muscle-strengthening activities.  Why aren’t older adults doing more muscle strengthening exercise? Probably because we are not aware of the benefits and have a bias that it will do harm. This is also due to the lack of resources, training, and coaching / supervision needed.

How much exercise should older adults participate in?

The US Office of Disease Prevention and Health Promotion established physical activity guidelines for “Healthy People 2020” to gain substantial public health benefits:

• Avoid inactivity, some physical activity will provide some health benefits (goal <33%)
• For substantial health benefits, older adults should do aerobic activity.
• At least 150 minutes (2 hours and 30 minutes) a week of moderate intensity (goal >50%)
• Or 75 minutes (1 hour and 15 minutes) of vigorous intensity (goal > 33%)
• Or an equivalent combination, performed in 10 minute increments
• Extensive health benefits occur when increased to 300 minutes (5 hours) of moderate intensity or 150 minutes of vigorous activity.
• Muscle strengthening exercises should be done 2 or more days per week of 8-10 exercises that train all major muscle groups (goal >25%)

Additional Recommendations for older adults from the American College of Sports Medicine:

• Maintain or increase flexibility (stretching) for at least 10 minutes a day, twice a week
• To reduce the risk of injury from falls, perform exercises that maintain or improve balance

In the paper “Exercise is the Real Polypill” (Fiuza-Luces C 2013), the evidence of the impact of exercise in comparison with medications on reducing chronic conditions such as  glucose intolerance, lipids, blood pressure, and risk of thrombosis-related cardiovascular events (heart attacks and stroke) is discussed.  The paper reviews a meta-analysis which demonstrates that weight resistance training in particular was equivalent to the polypill (1-3 blood pressure lowering meds, a lipid lowering med, and aspirin), while other types of exercise had a more modest effect on lowering blood pressure in particular. It also identified that there was lower dropout rates in exercise groups (10%) versus the polypill group (20% dropout versus 10% for placebo pill).

In addition, the paper discusses the release of beneficial myokines and anti-inflammatory substances secreted as a result of muscle strengthening exercise, as well as possible substances associated with longevity and reduced risk of colon cancer.  Muscle strengthening exercise provides something different than the more traditional aerobic or cardio-fitness exercises we think of older adults actively engaged in.

A 1-Hour Walk, 3 Times a Week, Has Benefits for Dementia

By GRETCHEN REYNOLDS MAY 24, 2017

Exercise may bolster the brain function and thinking skills of people with dementia, according to a new report. The study’s findings suggest that walking a few times per week might alter the trajectory of the disease and improve the physical well-being of people who develop a common form of age-related memory loss that otherwise has few treatments.

The study looked at vascular cognitive impairment, the second most frequent form of dementia worldwide, after the better-known Alzheimer’s disease. The condition arises when someone’s blood vessels become damaged and blood no longer flows well to the brain. It is often associated with high blood pressure and heart disease.

One of the particular hallmarks of vascular dementia in its early stages, researchers have found, is that it tends to make the brain function less efficiently. In past brain-scan studies, people with a diagnosis of vascular cognitive impairment generally showed more neural activity in parts of their brains that are involved with memory, decision-making and attention than did people without the disease, indicating that their brains had to work harder during normal thinking than healthier brains did.

But while a great deal of research attention has been devoted to Alzheimer’s disease, less has been known about the progression of and potential curbs on vascular dementia. Some research has indicated that reducing blood pressure lessens the symptoms of the disease.

Exercise can likewise improve blood pressure and cardiovascular health. And some research suggests that frequent, brisk walks may improve memory and physical abilities in those in the early stages of Alzheimer’s disease. But, rather surprisingly, few past studies had examined whether exercise might also improve brain function in people with vascular dementia.

So for the new study, which was published in April in The British Journal of Sports Medicine, researchers at the University of British Columbia in Canada and other institutions decided to look into the effects of walking on this type of dementia.

They began by recruiting 38 older people in British Columbia who had been given diagnoses of a mild, early form of vascular cognitive impairment. None currently exercised. All agreed to visit the university’s lab frequently for six months.

On the participants’ first lab visit, the scientists measured their general health and also memory and thinking skills.

They then scanned each volunteer’s brain while he or she concentrated on a computerized test of attention and decision-making skills that involved rapidly clicking keys to indicate the direction that an arrow should point. This scan was designed to reveal neural activity and how hard different parts of the brain were working during the task.

Finally, the scientists randomly assigned their volunteers to start either walking or, as a control group, to visit the lab for weekly education sessions about nutrition and healthy living.

The walking program was simple, consisting of supervised one-hour sessions at the lab three times a week. The walkers were asked to move briskly enough during workouts to raise their heart rates to about 65 percent of their maximum capacity.

“We wanted to have some intensity” in the exercise, says Teresa Liu-Ambrose, the director of the Aging, Mobility and Cognitive Neuroscience Lab at the University of British Columbia and the lead author. Most of the walkers completed all of the sessions and “seemed to be enjoying the exercise” by the end of the six months, she says.

At that point, the volunteers in both groups repeated the physical and cognitive tests from six months earlier, as well as the brain scan. The results showed that the two groups had drifted apart, in terms of the functions of their bodies and brains. Most obviously, the walkers generally had lower blood pressures now than the volunteers in the control group.

But more striking, their brains also were working differently. The walkers’ brains showed less activation in portions of the brain required for attention and rapid decision-making than did the brains of those in the control group.

The differences were subtle, Dr. Liu-Ambrose says, but they correlated neatly with improvements on the cognitive tests. The less someone’s brain had to work to maintain attention and make quick decisions, the better that person typically performed on the tests of general thinking ability.

In essence, the walkers had more efficient brains and better thinking skills now than the control group did, she says.

Of course, this study was short term, lasting only six months, after which the volunteers were free to stop exercising — and most did. Dr. Liu-Ambrose and her colleagues hope in the future to study whether and how rapidly the brains and bodies of exercisers lose any gains if they become sedentary again. They also want to look into different “doses” of exercise and whether shorter or easier workouts would have an effect on brain function in people with vascular dementia.

Obviously, anyone with memory or other cognitive problems should consult with a doctor before starting to exercise and should probably not exercise alone, Dr. Liu-Ambrose says.

But even with so many questions remaining, the results of this study are encouraging, she says. They show that in the early states of vascular dementia, “something as simple and accessible as walking may make a meaningful difference” in how well the brain works.

Reprinted from: https://www.nytimes.com/2017/05/24/well/move/a-1-hour-walk-3-times-a-week-has-benefits-for-dementia.html?_r=1

5 Red Flags That Could Signal Neglect, Mistreatment, or Abuse

By Judy Speicher, Caring.com author | Last updated: Mar 08, 2017

Have you ever worried whether an elderly person is really all right?

Sometimes it's a loved one we're worried about -- we're concerned about whether she's being treated well by her caregiver, friends, or family members. Sometimes it's just a worry about a senior we know casually -- someone we see around the neighborhood, at church or synagogue, or at local gatherings. We wonder whether we should worry; we wonder whether we should say something.

The fact is, far too many of our elders are not all right. The Senate Special Committee on Aging says there are as many as 5 million victims every year, while the National Center on Elder Abuse cites recent studies that estimate that up to 3 to 5 percent of the elderly population in the U.S. have suffered abuse.

Unfortunately, this type of appears to be on the rise, according to Elizabeth Loewy, former chief of the Elder Abuse Unit in the Manhattan District Attorney’s Office, where she oversaw thousands of elder abuse cases. Despite the prevalence of the problem, Loewy says it remains signicantly underreported.

That may be partly because neglect, mistreatment and abuse aren't always easy to spot. Some signs are obvious, some not so much. The New York City Elder Abuse Center defines elder abuse as an act that causes harm or distress to an individual 60 years or older. It happens most often in relationships based on trust. And it can be intentional or unintentional. Elders with cognitive impairment are particularly vulnerable, both because dementia behaviors can be extremely frustrating to caregivers, and because elders with dementia can lose the ability to recognize abuse and defend themselves.

Here are five signs to look for:

1. Signs of Physical Abuse

·         Bruises

·         Broken bones

·         Burns

·         Abrasions

·         Pressure marks

Hearing odd explanations for injuries -- "Oh, she ran into a wall."

Common signs of physical abuse against an elderly person include unexplained signs of injury such as those listed above, says Anne Sansevero, a registered nurse and member of the board of directors of the Aging Life Care Association.

“Be alert for a history of broken bones, sprains, or dislocations and sudden hair or tooth loss especially if the injuries are unexplained or explanations do not ‘fit’ with the findings,” she says.

Sansevero also advises looking out for behavioral indicators on the part of the elderly person’s primary caregivers. Not allowing you to visit with the elderly person alone, inconsistent explanations for injuries or taking the elder to multiple medical facilities for treatment can all be red flags that abuse is occurring.

2. Signs of Neglect

·         Dirty clothes

·         Soiled diapers

·         Bedsores

·         Unusual weight loss

·         A home that's unusually messy -- especially if it wasn't before

·         Lack of needed medical aids, such as hearing aid, cane, glasses

If the elder is disabled, especially cognitively disabled, and needs help taking medication or getting dressed, it can be considered neglect if their caregiver is not providing assistance. Alternatively, passive neglect occurs when the abuse is unintentional, often as the result of an overburdened or untrained caregiver.

3. Signs of Verbal or Emotional Abuse

·         Withdrawal and apathy

·         Unusual behavior, such as biting or rocking

·         Nervous or fearful behavior, especially around the caregiver

·         Strained or tense relationship between caregiver and elder

·         Caregiver who is snapping or yelling at the elder

·         Forced isolation by the family member/caregiver

Emotional abuse is one of the most difficult problems to spot, since the victim may be unable to convey what's happening because of illness, dementia, or fear of being neglected. "The elderly person is unable to fight back," says Dr. Irene Deitch, professor emeritus of psychology at the College of Staten Island, part of the City University of New York.

Emotional abuse can range from a simple verbal insult to an aggressive verbal attack. It can also include threats of physical harm or isolation.

Deitch says verbal attacks include a caregiver or family member yelling or cursing at the person, or using phrases such as, "I can't wait till you die and I have my life back again."

Often in cases of emotional abuse, Deitch adds, a spouse or adult child will isolate the senior, not allowing calls or visitors, so no one else gets a sense of what's happening in the house.

4. Signs of Sexual Abuse

·         Bruises around the breasts

·         Bruises around the genital area

·         Evidence of venereal disease

·         Vaginal or rectal bleeding

·         Difficulty walking or standing

·         Depressed or withdrawn behavior

·         Flirtation or touchiness by the caregiver

We don't even want to think about it, but it happens. Attackers look for vulnerable people to victimize. Seniors can be perceived as easy to overpower. They may also be less likely to report abuse because of their dependency on others for care.

5. Signs of Financial Exploitation

·         Bills not being paid

·         Money disappearing and unaccounted for

·         Caregiver taking money for a purchase that doesn't arrive

·         Unusual purchases that your loved one didn't used to make

·         Increased use of credit cards

·         More frequent withdrawls of cash

·         Adding someone new to bank accounts or credit cards

Financial exploitation of elders is all too common. Older adults may be particularly vulnerable to this type of abuse for a number of reasons, says Loewy, who now serves as general counsel and senior vice president for industry relations at EverSafe, a financial monitoring service for older adults.

Loewy says it may be that financial exploiters are simply following the money, and seniors tend to have a higher net worth than younger adults. And some older adults are at greater risk of exploitation due to cognitive impairment.

Financial exploitation can also happen when a professional caregiver takes advantage of the elder. Both family caregivers and paid caregivers are in a unique position to perpetrate this crime, Loewy notes. This is why background checks are especially important when hiring a professional caregiver.

What to Do if You Suspect Elder Abuse

The National Center on Elder Abuse (NCEA) recommends calling 911 immediately if you believe an elderly friend, relative, or neighbor is in immediate, life-threatening danger.

If the danger is not immediate but you suspect that abuse has occurred or is occurring, relay your concerns to the local adult protective services agency, long-term care ombudsman, or police.

To find the right helpline, hotline, or elder abuse resources in your local area, visit the NCEA webite.

Reprinted from: https://www.caring.com/articles/signs-of-elder-abuse

Eat well, drink lots of water, exercise and socialize for brain health

In my last column, I wrote about Brain Health Awareness month. The brain, the most complicated system in our bodies is often the most overlooked. When most of us think of health we may think of overall health or we may think of heart health but how often do we think in terms of brain health?

I would speculate that many of us change habits or behaviors based on the fear factor. We wait until there is a health crisis to take notice and adopt healthier patterns. For many of us it may be stepping on the scale that provides the impetus to eat better or healthier. Most of us don't think in terms of brain health unless we are fearful of developing Alzheimer's disease or one of the related dementias.

As a part of normal aging our brains change. Our brains begin the gradual process of decreasing in volume as we age. Short-term memory may decline, reaction time increases, cognitive processing time increases, cognitive inflexibility increases, and the filter between our thoughts and words can become less inhibited. While these may be normal effects of aging we can try to minimize the progression of the effects of normal aging and potentially ward off the effects of "abnormal" brain changes such as the effects of dementia.

According to brainhealth.gov, brain health refers to the ability to remember, learn, plan, concentrate and maintain a clear, active mind. How do we achieve brain health? Maintaining overall health is the best way to protect the brain and minimize the overall effects of normal aging.

Improving overall health, minimizing risk factors and following simple steps can keep the brain active and sharp. Following a heart healthy regime also contributes to a healthy brain. Nutrition and eating smart, exercise, staying social, managing stress and continuing to learn and discover new interests are important to maintaining a healthy brain.

Here are some interesting facts about the brain that may help keep things in perspective: The brain is made up of 77-78 percent water, 10-12 percent fats and 8 percent proteins.

So here is where we begin to keep our brains as healthy as possible — water! Most of us are walking around chronically dehydrated and it takes its toll on our brains. In fact, as we age, dehydration may in fact cause confusion and memory loss. In a person living with dementia the effects of dehydration can be devastating.

Diet contributes a huge part in keeping a healthy brain. Our brains need healthy fats to function. However, maintaining a balance is so important. If you consider what is good for the heart is ultimately good for the brain, then eat a diet high in antioxidants found in fruits and vegetables and moderate in lean proteins and carbohydrates. The brain needs fats so some fat in the diet is therapeutic.

There is an ongoing debate about the use of cholesterol lowering drugs and the effect on the brain. The conundrum is to that to protect the blood vessels from plaque build-up that causes heart disease there may be some adverse effect on the brain. People are living longer due to the control of heart disease — although it is still the No. 1 killer of both women and men — thus living to the age when Alzheimer's disease and related dementias typically become obvious. Keep in mind the greatest risk for Alzheimer's disease is age. Also keep in mind the biggest risk associated with vascular dementia is hypertension, stroke and heart disease. So I am not advocating for anyone to stop their cholesterol-lowering medications because who wants to weigh those odds of a heart attack at a younger age versus an unhealthy brain at an advanced age?

The bottom line is to eat well and in moderation! And here comes the bombshell … just adding 30 minutes of exercise (like taking a walk) to drinking plenty of water, and eating reasonably well can significantly contribute to overall brain health.

While eating well, drinking plenty of fluids and walking are hallmarks of good overall health, the effects of socialization on the brain are undeniable. Those who are socially isolated and have very little contact and stimulation through relationships are known to have an increase in cognitive decline. Laura Carstensen, professor and founding director of the Stanford Center on Longevity, reported in 2009 that our social arena "influences not only our happiness in everyday life but the ways in which our brains process information, the levels of hormones circulating in our bodies and our physiological responses to stress."

Stress, the other culprit adversely affecting brain health, leads to increased levels of cortisol, which essentially kills brain cells, decreases the production of new brain cells and can lead to shrinking of the brain, which leads to cognitive impairments. Controlling stress comes in the package with eating well (including foods high in antioxidants), exercising and socializing.

Finally, add something new and fun to your routine. Changing it up and learning something new has been found to be great for the brain. Try a new activity such as ladder ball, add knitting to your bucket list of things to learn or go buy a new, grown-up coloring book and don't worry about staying in the lines!

Eat well, drink your water, go take a walk with a friend, and come home to relax with a new activity and your brain will thank you! I'm on vacation and I'm going to the front porch to color!

Jill Rosner is a registered nurse, certified geriatric care manager and owner of Rosner Healthcare Navigation. She provides patient advocacy and care management services to clients with health and aging issues. Contact her at JillRosnerRN@aol.com.

Reprinted from: http://www.carrollcountytimes.com/columnists/ph-cc-nav-health-0717-20160716-story.html

How Many Pills Are Too Many?

By Austin Frakt
THE NEW HEALTH CARE APRIL 10, 2017

The point of prescription drugs is to help us get or feel well. Yet so many Americans take multiple medications that doctors are being encouraged to pause before prescribing and think about “deprescribing” as well.

The idea of dropping unnecessary medications started cropping up in the medical literature a decade ago. In recent years, evidence has mounted about the dangers of taking multiple, perhaps unnecessary, medications.

Deprescribing will work only if patients also get involved in the process. Only they can report adverse effects that they sense but that are not apparent to clinicians. And they need to be comfortable weaning from or dropping drugs that they are accustomed to and believe to be helpful.

Yet an increasing number of Americans — typically older ones with multiple chronic conditions — are taking drugs and supplements they don’t need, or so many of them that those substances are interacting with one another in harmful ways. Studies show that some patients can improve their health with fewer drugs.

Though many prescription drugs are highly valuable, taking them can also be dangerous, particularly taking a lot of them at once. The vast majority of higher-quality studies summarized in a systematic review on polypharmacy — the taking of multiple medications — found an association with a bad health event, like a fall, hospitalization or death.

About one-third of adverse events in hospitalizations include a drug-related harm, leading to longer hospital stays and greater expense. The Institute of Medicine estimated that there are 400,000 preventable adverse drug events in hospitals each year, costing $3.5 billion. One-fifth of patients discharged from the hospital have a drug-related complication after returning home, many of which are preventable.

Not every adverse drug event means a patient has been prescribed an unnecessary and harmful drug. But older patients are at greater risk because they tend to have more chronic conditions and take a multiplicity of medications for them. Two-thirds of Medicare beneficiaries have two or more chronic conditions, and almost half take five or more medications. Over a year, almost 20 percent take 10 or more drugs or supplements.

Some are unnecessary. At least one in five older patients are on an inappropriate medication — one that they can do without or that can be switched to a different, safer drug. One study found that 44 percent of frail, older patients were prescribed at least one drug unnecessarily. A study of over 200,000 older veterans with diabetes found that over half were candidates for dropping a blood pressure or blood sugar control medication. Some studies cite even higher numbers — 60 percent of older Americans may be on a drug they don’t need.

Though studies have found a correlation between the number of drugs a patient takes and the risk of an adverse event, the problem may not be the number of drugs, but the wrong ones. Some medications have been identified as more likely to contribute to adverse events, particularly for older patients.

For example, if you’re taking psychotropic agents, such as benzodiazepines or sleep-aid drugs, you may be at increased risk of falling and cognitive impairment. Diuretics and antihypertensives have also been identified as potentially problematic. (The Agency for Healthcare Research and Quality has published a longer list of drugs that are potentially inappropriate for older patients. Note that, even if they are problematic for some patients, they are appropriate for many.)

Relative to the mountain of evidence on the effects of taking prescription drugs, there are very few clinical trials on the effects of not taking them.

Among them is one randomized trial that found that careful evaluation and weekly management of medications taken by older patients reduced unnecessary or inappropriate drug use. Adverse drug reactions fell by 35 percent. Medication use was reduced, along with the risk of falls among a group of older, community-dwelling patients through a program that included a review of medications.

Several other studies also found that withdrawal of psychotropic medications reduced falls. A comprehensive review of deprescribing studies found that some approaches to it can reduce the risk of death. Another recent randomized trial found that frail and older people could drop an average of two drugs from a 10-drug regimen with no adverse effects.

So why isn’t deprescribing more widely considered? According to a systematic review of research on the question, some physicians are not aware that they’re prescribing inappropriately. Other doctors may have difficulty identifying which drugs are inappropriate, in part because of lack of evidence. In other cases, doctors believe that adverse effects of drug interactions are outweighed by benefits.

Physicians also report that some patients resist changing medications, fearing that alternatives — including lifestyle changes — will not be as effective. Other studies found that many doctors are concerned about liability if something should go wrong or worry they’ll fail to meet performance benchmarks — like the proportion of diabetic patients with adequate blood sugar control.

To reduce the chances of problems with medications, experts advocate that physicians more routinely review the medication regimens of their patients, particularly those with many prescriptions. At hospital discharge — when patients leave the hospital, often on more medications than when they entered it — is a particularly important time for such a review. Including nurses and pharmacists in the process can reduce the burden on physicians and the risks to patients.

Patients can play an important role as well. Walid Gellad, a physician in the Veterans Health Administration and at the University of Pittsburgh School of Medicine, advises that at every visit with a doctor, “patients should ask, ‘Are there any medications that I am on that I don’t need anymore, or that I could try going without?’ ”

Patients, of course, should not try weaning themselves off medication without consulting their doctors — but deprescribing is an idea for all parties to keep in mind.

Reprinted from: https://www.nytimes.com/2017/04/10/upshot/how-many-pills-are-too-many.html?smprod=nytcore-iphone&smid=nytcore-iphone-share&_r=0