Geriatric Medicine: Getting Old Isn’t for Sissies

There’s plenty we can do to help our bodies feel their best at any age. Here are a few helpful hints from our area physicians.

Wine, cheese and beef improve with age. Sadly, the same can’t be said of the human body.
The older we grow, the more likely it becomes that we’ll be confronted with health challenges. Some conditions don’t develop until we reach our seventh and eighth decades; others are a culmination of diseases we’ve had for many years. But no matter what, we can improve our odds of enjoying good health longer if we participate in the prevention of disease by eating well, exercising and changing bad habits.
“I have patients who are young in their eighties, while others are old at 60,” says Dr. Monica Simionescu, a board-certified neurologist at OSF Saint Anthony Medical Center, in Rockford.
Along with good health habits, age and family history are the most important risk factors for dementia, one of the most terrifying conditions common among the elderly.
The National Institute on Aging defines dementia as the loss of cognitive functioning – thinking, remembering, and reasoning – to such an extent that it interferes with a person’s daily life and activities. Dementia ranges in severity from mild, when it just begins to affect a person’s functioning, to the most severe stage, when a person completely depends upon others to accomplish the basic activities of daily living.
Alzheimer’s disease is an irreversible, progressive brain disease that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks. For most people with Alzheimer’s, symptoms first appear after age 60. Estimates vary, but experts suggest that as many as 5.1 million Americans have Alzheimer’s disease. It’s the most common cause of dementia among older people.
“If a patient has a family history of Alzheimer’s, his or her risk is higher,” Simionescu explains. “As far as age is concerned, that’s a hard question. In general, however, the older the age group, the higher the percentage of people diagnosed with dementia.
“I’ve seen patients with signs of dementia in their late 40s,” she says. “Of course, that’s very rare and usually is associated with a genetic predisposition.”
Simionescu explains that there are several kinds of dementia.
Alzheimer’s dementia is the most common, and typically takes a slow but progressive course.
Vascular dementia can be the result of multiple tiny strokes that adversely affect blood vessels in the brain. In the past, this condition was often referred to as “hardening of the arteries.”
“As each stroke happens, the patient gets measurably worse,” says Simionescu. “This is the opposite of Alzheimer’s, which progresses gradually at a different pace in each patient.”
Dementia treatment begins immediately after diagnosis, based on a battery of psychological tests that evaluate both memory and cognitive decline.
“We examine closely the patient’s anxiety levels, mood swings, short- and long-term memory loss, as well as any medications they’re taking,” Simionescu says. “Once the results are assessed, we start the appropriate medications. We can’t cure dementia, but we can slow it down. We monitor the patient and make any necessary adjustments.”
Simionescu adds that, in early stages, dementia patients are scheduled for assessments every three to six months, depending on their type of dementia and the speed at which it’s advancing. After that, a patient may go as long as a year between visits.
“We cannot intervene in swift-moving dementia,” she explains. “But certain physical conditions, such as delirium, can be caused by other health conditions including pneumonia, urinary tract infections and dehydration. We treat those and see if the patient gets better. If the dementia progresses despite treatment, there really isn’t much we can do.”
The impact of dementia may be devastating to the patient and to the patient’s loved ones and caregivers. Dementia patients have difficulty finding words and may stop trying to communicate altogether. They may even hallucinate and “see” deceased family members.
“This is much harder on the caregivers than on the patient, who doesn’t know there’s a problem,” Simionescu says.
If at all possible, Simionescu recommends that dementia patients remain at home or in familiar environments.
“They’re better off if they keep the same routines,” she says. “They can become very agitated if changes in their daily schedule or living conditions occur. It ends up making things worse for the patient and the family.”
Education may be one key to helping caregivers cope with dementia patients. “They need to better understand what is happening to their loved ones and know what to expect as the disease progresses,” she says.
While the onset of dementia is most commonly associated with the aging process, other diseases are so much a part of daily life, for some elderly people, that their long-term effects are often underplayed. Diabetes may be one of the most insidious. This disease relentlessly attacks the entire body, from eyes to toes. Sadly, many people who don’t see a primary physician on a regular basis may not be diagnosed with diabetes until symptoms are obvious, or they simply may not take their diabetic condition seriously.
Diabetes occurs when the pancreas either slows down production of the insulin needed to regulate blood sugar, or completely fails. Diabetes is hard enough to deal with on a daily basis, but the cumulative effect, if left untreated, can be devastating. Dr. Vijay G. Eranki, a board-certified endocrinologist practicing at SwedishAmerican Hospital in Rockford, says blood glucose control is the key to avoiding or postponing the long-term effects of the disease.
“People can be diagnosed with diabetes at pretty much any age,” Eranki explains. “But its complications may not manifest for as long as 10 to 15 years.”
For a patient diagnosed with diabetes, an A1C blood test every three months is the best way to evaluate how well his or her blood sugar is being controlled. An A1C measures blood sugar levels over a three-month period. For normal, healthy patients who don’t have diabetes, the ideal A1C is 5.7 or lower. Diabetic patients, however, can have significantly elevated A1C levels, a sure indicator that their blood sugars are not being controlled sufficiently.
“An A1C below 7 is OK, with fasting glucose tests around 100 and non-fasting tests around 140. But when it begins to creep up, we need to look at the patient’s medication and diet to see where adjustments must be made,” Eranki says. “For elderly patients, we may relax that A1C goal to between 7 and 7.5.”
Diet is the main method for controlling diabetes. Patients may need to test their blood sugars with a glucose monitor one to six times daily, depending on how high their A1C level is and the kind of diabetes medication they take. Because every patient is unique, the way in which food, especially carbohydrates, affects glucose tests demands that patients watch their diets closely and make adjustments when their A1Cs climb.
“There’s really no hard and fast rule for how uncontrolled diabetes can affect the body or when,” Eranki says. “The disease’s influence can be so subtle that it takes years before it becomes diagnosable. Diabetes can damage eyesight, causing decreased vision. It can weaken or totally destroy kidney function so that the patient ends up on dialysis. Diabetes also can lead to heart disease, including myocardial infarction – a heart attack.”
The challenges that diabetic seniors face is often complicated by the other ailments they have developed, Eranki adds.
“When the primary doctor sees signs that a patient has diabetes, usually with complications, he or she is referred to us,” Eranki explains. “We perform a detailed examination based on the patient’s A1C, blood glucose levels and other symptoms, and make recommendations for medication. This can be in oral or injectable form, or both, depending on the individual’s needs.”
Balancing diet and medication is tricky. Eranki points out that insufficient medication, coupled with a high-calorie diet, can send the patient’s blood glucose soaring into the 400- to 600-point range.
Conversely, too much insulin-based medication and not enough food intake can drop the patient’s glucose levels dangerously low, leading to shakes, a needle-and-pins feeling in the hands and feet, and dizziness, followed by belligerence, delirium and potentially a coma that may or may not be reversible.
“The keys to successfully controlling diabetes are diet, exercise, healthy lifestyle, consistent glucose monitoring and taking their medications,” Eranki says.
He adds that becoming educated on the effects and control of diabetes, along with keeping regular appointments with primary doctors, goes a long way toward preventing or postponing long-term effects.
Heart disease remains the No. 1 cause of death in the U.S. The prospect of a heart attack may worry an older person, especially because these events are sudden, often deadly, and may cause permanent disability. But an actual heart attack is only one threat. Congestive heart failure (CHF) can be equally devastating.
The term “heart failure” sounds very alarming. While it does not mean the heart has “failed” or stopped working, it is a serious condition. The Johns Hopkins Heart and Vascular Institute explains that CHF means the heart does not pump as well as it should to meet the body’s oxygen demands, often due to heart diseases such as cardiomyopathy or cardiovascular disease. CHF can result from either a reduced ability of the heart muscle to contract or a mechanical problem that limits the ability of the heart’s chambers to fill with blood. When weakened, the heart is unable to keep up with the demands placed upon it; blood returns to the heart faster than it can be pumped out, so the heart gets backed up or congested – hence the name of the disorder. CHF is the leading cause of hospitalization and death. In more than 50 percent of cases, sudden death occurs because of cardiac arrhythmia.
CHF has long been considered a disease of the elderly. Recently, however, that has changed. Dr. Haroon Chughtai, a board-certified interventional cardiologist with Beloit Health System, reports that patients are being diagnosed with this disease at earlier ages.
“We are seeing more patients in middle age and younger. Where patients were normally in their 70s or older, now they’re in their 60s, 50s or even 40s,” Chughtai says. “There are two types of congestive heart failure. The first one is caused by pumping problems in the heart, referred to as systolic heart failure. The other one is caused by a relaxation abnormality of the heart called diastolic heart failure, or heart failure due to stiffening of the heart.”
Chughtai says that early symptoms of CHF include shortness of breath during exertion, lack of energy, leg swelling and difficulty climbing stairs or carrying items such as grocery bags or laundry baskets. Many patients have trouble sleeping and get up often during the night gasping for air. Along with that, they may experience an inability to lie flat on their backs, making it necessary for them to sleep with their heads raised.
“Many sleep in recliners because they get uncomfortable in bed,” Chughtai says. “Unfortunately, many of these symptoms are blamed on other conditions. But when the patient’s symptoms become really bothersome, that’s usually when the patient’s primary doctor hears about these symptoms. Early referral to specialized care is the key for achieving a good outcome.”
Traditionally, it was thought that heart failure only happened in people with the pumping problem (systolic dysfunction), but now an increasing number of patients experience relaxation abnormality (diastolic dysfunction).
Pumping capacity in the heart is measured by “ejection fraction,” a measure of the percentage of blood the heart pumps out with each beat. In a normal, healthy heart, the ejection fraction is between 55 and 65 percent. In diseased hearts, that percentage can drop to as low as 5 percent.
This inability of the heart to pump efficiently results in lack of oxygen and nutrients to vital organs such as the brain, kidneys and the heart itself.
Treatment begins with a search for the cause of the failure, which can include blocked arteries and previous heart attacks. Chughtai says an echocardiogram helps to determine the cause.
“Each patient’s treatment is based on the cause, but we may prescribe diuretics to reduce fluid buildup in the lungs and legs. Other medications include beta blockers, ACE inhibitors and agents such as digoxin,” he adds. “If medications don’t control the patient’s symptoms, advanced treatments such as specialized types of pacemakers, artificial pumps (left ventricular assist devices), and ultimately heart transplantation can be helpful to patients.”
The good news is that, caught early, it’s possible to halt or even reverse CHF.
“Early diagnosis, along with making certain the patient does all of the right things to support treatment, can make a huge difference,” Chughtai says. “A change in lifestyle may be necessary. A healthy diet low in salt and cholesterol, along with regular physical activity, can go a long way to improving congestive heart disease.”
The Johns Hopkins Institute adds that patients with CHF can enjoy better health if they treat the underlying cause, if possible. For many patients the outlook is uncertain and depends on the extent of the disease and the patient’s response to therapy. However, in other cases, restricted salt intake and medication are used to ease the strain on the heart and to relieve symptoms. While CHF is a serious health risk, it’s possible for patients to live with CHF and manage many symptoms effectively, with proper treatment, if they adhere to prescribed regimens. Noncompliance with a doctor’s recommendations regarding diet or medication increases the risk that the disease will worsen.
You’ve heard the expression, “getting old isn’t for sissies.” You may also have heard old age referred to as the “golden years.” It may be because it’s so expensive. The soaring cost of treating an aging population has placed an ever-increasing burden on Medicare. The best possible solution would be to do what our parents always told us to do: eat right, exercise, refrain from unhealthy habits, take medications consistently and as prescribed, and schedule regular physical examinations.
Establish good habits now, and there’s every possibility that you will avoid or postpone many of the diseases and conditions commonly associated with aging.