Health Tip: What Causes Older People To Fall, And How Can We Reduce Their Risk?

I am the rehab physician for a charming, ninety-year-old woman who is recovering from a broken hip. She is very sharp and independent, and had been living alone until her recent fall at home. She was hurrying to turn off her stove burner when she lost her balance and fell on the linoleum kitchen floor.

Weeks later she is almost pain-free from her hip replacement surgery, but as I watched her stand up from her chair to grab onto her walker, I felt very uneasy. She was still fairly weak and struggling to get up safely. I knew she was still a high fall risk, and we both worried about her falling again. My protective side wanted to keep her in rehab, but then again I knew that we couldn't exactly "hold her hostage" because of something that might happen in the future.

There's no way to prevent people from falling down 100% of the time. However, there are some interventions that have a proven track record for reducing fall risk. The CDC has a nice compendium of research describing what works. I thought I'd summarize it for you here:

1. Exercise - Many studies demonstrate that regular strength, balance, flexibility, and endurance training can reduce fall risks by 50-60%. Classes are often led by physical therapists and last about 60 minutes, 3 times per week to be effective. Tai Chi has also been proven effective for fall reduction. One Swiss study recommended piano music with varied rhythms to challenge stepping speed and balance, and another Japanese study used "Twister-like" colored blocks to improve stepping agility.
    
2. Winter Grips - One study showed that Yaktrax (a traction device that fits over the bottom of shoes, the way chains fit over car tires) reduced falls in snowy Wisconsin by about 60%!
    
3. Home Evaluations - When occupational therapists visit a person's home, they look for specific fall hazards (such as area rugs, cluttered hallways and bathrooms, stairs without railings) and recommend equipment (such as grab bars, walkers, and shower chairs) that can help to make people more steady during everyday activities. Just one visit (lasting an hour or an hour and a half) may reduce falls by 30-40%.
    
4. Stopping Medications - One study showed that stopping sedative medications (such as benzodiazepines for anxiety) reduced fall risks by 67%! It's very important to limit the medications that we take whenever possible. Another study suggested that formally reviewing one's current medication list with a primary care physician could also significantly reduce falls.
    
5. New eye glasses - A vision check by an optometrist, along with new glasses prescription, can improve poor vision and reduce this risk for falls.
    
6. Cataract surgery - Our eye lenses get cloudy as we age, and putting in fresh, clear lenses (a.k.a. cataract surgery) may reduce fall risk by 34%.
    
7. Vitamin D Supplementation- Since low Vitamin D levels can result in weak muscles and thinning bones, the American Geriatrics Society recommends Vitamin D supplementation of 4,000 IUs per day for adults over 65 with low Vitamin D levels.
    
8. Pacemakers - For those with slow heart rates or heart blocks, pacemakers can reduce dizziness from rhythm problems. If the heart is not beating normally, a pacemaker may prevent fainting and falling.
    
9. Foot Checks - One podiatrist visit (with a prescription for well-fitting shoes or sole inserts if needed) can reduce fall risks significantly.

Overall, regular exercise and limited medications are the two most important fall risk reduction strategies that we have. Enlisting the help of physical and occupational therapists, optometrists, ophthalmologists, primary care physicians, cardiologists, rehab physicians and podiatrists can further success!

References
https://www.cdc.gov
https://www.americangeriatrics.org
https://www.medscape.com/viewarticle/819047

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Health Tip: What Causes Older People To Fall, And How Can We Reduce Their Risk?

During the holiday season we often reconnect with our older relatives and friends, and may notice some new deficits in their ability to walk or transfer safely. For this reason, I think it's an opportune time to review a frequently overlooked health topic: are you or your loved one having falls?

Falls are one of the greatest health threats to people over the age of 65. An estimated 37.5% of those who fall sustain injuries severe enough to restrict their mobility or require medical treatment. A recent CDC report suggests that seniors are so embarrassed about their falls (or fear loss of independence), that they fail to report half of them. This can lead to sedentary behavior in an attempt to avoid further incidents. Unfortunately, skimping on exercise only makes the body weaker, which actually increases the risk of toppling over.

Why does our fall risk increase as we age?

1. Balance deficits. As we age, cells responsible for detecting where our bodies are in 3-D begin to die off. This affects the vestibular system in our inner ears, causing a decrease in body awareness during motion.
2. Slower reaction times. Our ability to react quickly to environmental stimuli decreases with age, probably as a factor of impaired vestibular systems, combined with poorer vision, and weaker muscles.
3. Muscle atrophy. Without sustained effort to avoid muscle loss, most people lose 3-5% of muscle mass per decade after age 30. Weaker muscles don't perform as well, particularly in getting up from low surfaces.
4. Neuropathies. Nerve damage is more common with age (especially for those with diabetes), reducing sensation in the feet and leading to stumbles.
5. Medication effects. The average American over age 65 takes about 5 prescription medications per day. Many of these have side effects (such as dizziness or low blood pressure) that can contribute to fall risk.
6. Vision changes. Our eye tissues are less flexible as we age, causing difficulty adjusting our focus (hence the need for "reading glasses.") Cataracts (cloudiness in the lenses of the eye) may also reduce our vision. In fact, internationally-speaking, cataracts are the #1 cause of blindness. We tend to need more light to see well as we age, due to light scatter from aging lenses and corneas or perhaps macular degeneration (vision loss due to cell damage in the back of the retina).
7. Blood pressure variability. As we age, our hearts are a little slower to compensate for changes in body position. So going from sitting to standing too quickly may cause dizzy feelings or fainting spells, leading to falls.
8. Clutter. Ok, this isn't really a factor of aging, but I can tell you that many of the patients I see in my rehab practice have tripped over area rugs or household clutter and fallen down. I suspect that since we tend to collect more worldly items as we age, our risk of falling may increase specifically due to that!
   

Now that we all feel somewhat depressed about the natural aging process and what we are all facing, I have some good news: we can take steps to reduce our (and our loved ones) fall risks. In my next post I'm going to review the CDC recommendations for reducing falls, and call out the practical things you can do that have been proven to work. So stay tuned…

References

https://www.cdc.gov/homeandrecreationalsafety/falls/compendium.html
https://www.wsj.com/articles/falling-is-dangerous-for-the-elderlyand-often-preventable-1510542240
https://www.askdoctork.com/why-does-balance-decline-with-age-201306054928

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What Is Causing My Chronic Diarrhea, Gas, and Bloating?

A dear friend of mine has been suffering with abdominal discomfort for over a decade. She has undergone every study and procedure known to gastroenterology - including tests for infectious disease, autoimmune disorders, and allergies. She has had unremarkable colonoscopies, followed restrictive diets, and felt perpetual embarrassment regarding her ill-behaved intestines.

Although she still has no definitive diagnosis, the answer may be irritable bowel syndrome (IBS). An estimated 25-45 million people in the United States have IBS though many cases go undiagnosed. For those who are diagnosed it may take up to 6 or 7 years for a clinician to figure it out. The reason why it's hard to diagnose is that its course is so unpredictable (it comes and goes in severity, with no obvious pattern), and because embarrassment may cause people not to seek help.

But wait, it gets worse.

The truth is that doctors don't yet know what causes IBS for certain, and there is no reliable cure for it either. In fact, IBS is a general term for what might be several different underlying diseases, yet to be clarified by science and research.

What causes IBS?
We do have some theories, though. First of all, the intestines are stimulated to contract by a complex plexus of nerves. In some people, these nerves may be overactive or triggered by stress. It's not unheard of for people to lose control of their bowels when they are terrified. Imagine that a much smaller stimulus - say, stress at home or at work - could trigger a similar response in more delicate guts. IBS is known to be more common in people with anxiety, depression, or a history of sexual, physical, or emotional abuse.

Secondly, a lot has been learned over the last few years about the importance of gut bacteria. You've probably heard about "good bacteria" and "probiotics" and how important it is to consume foods like yogurt, kefir, or kambucha, especially after a course of antibiotics. Well, it's possible that people with IBS don't have the best bacterial micro-environment, resulting in excessive fermentation of food with gas production and bloating sensations.

Thirdly, some foods may trigger excessive bloating, constipation, diarrhea, and abdominal pain. This is not due to an allergic reaction, but simply an intolerance. Foods known to predispose to IBS symptoms include sugar, wheat, dairy, beans, cabbage, high fiber, artificial sweeteners, and fried foods. These foods are enthusiastically fermented by normal gut bacteria, but for patients with IBS, the action can be overwhelming.

So what can people do about IBS?
The first steps are to address the most common triggers: mental health and diet. If you have symptoms of IBS and know that there is a lot of stress in your life, or perhaps a history of anxiety or depression, start by treating the psychological condition(s). Some people are helped significantly by stress-reduction techniques such as meditation, progressive relaxation, or talk therapy. Others may benefit from medications.

The next step is to avoid foods that are known to make IBS worse. These foods include "high gas" foods such as: carbonated and alcoholic beverages, caffeine, raw fruit, and certain vegetables, like cabbage, broccoli and cauliflower. Some people are sensitive to gluten (without being allergic to it) which is found in wheat, barley, and rye. And others are sensitive to easily fermented carbohydrates. This is sometimes referred to as a low FODMAP (fermentable oligo-, di-, and monosaccharides and polyols) diet. FODMAPs are found in certain grains, vegetables, fruits and dairy products.

Finally, encouraging healthy bacterial colonies to develop may be as simple as taking probiotic tablets or drinking live culture fermented beverages (such as Kambucha). Yogurt may be a good idea, though the fact that dairy is forbidden on the IBS diet may give you pause. For some people, avoiding dairy may be more helpful than getting probiotics through yogurt.

The next level…
There are medications on the market that can help to speed up or slow down the transit time of food through the colon, depending on whether you have diarrhea-predominant or constipation-predominant IBS. Alosetron (Lotronex), and Eluxadoline (Viberzi) are approved for diarrhea-predominant IBS, and Lubiprostone (Amitiza) and Linaclotide (Linzess) are used in constipation-predominant IBS.

When all else fails…
Some studies suggest that slow release peppermint oil pills may help with IBS, and other studies support repopulating the gut flora with someone else's bacteria. This may sound off-putting (fecal transplantation?) but it makes some sense that good bacteria from a healthy gut could make a new happy home elsewhere.
In one small study, 70% of people with IBS symptoms that failed to respond to diet, medication, and mental health treatments, found relief or resolution after a fecal microbiota transplantation (FMT). More research would be helpful in clarifying exactly when this measure (harvesting and cleaning someone's stool sample and transplanting it through an enema to the IBS sufferer) is indicated.

And so, in the final analysis, it may be that the cure for years of intestinal misery (for my friend, or someone you know) is to simply receive a dose of someone else's crap.

I'm sure there's some deeper wisdom in there somewhere. I'd rather take the peppermint oil, though.

References
https://www.mayoclinic.org/diseases-conditions/irritable-bowel-syndrome/symptoms-causes/syc-20360016
https://www.mayoclinic.org/diseases-conditions/irritable-bowel-syndrome/diagnosis-treatment/drc-20360064
https://gi.org/media/press-releases-for-acg-annual-scientific-meeting/fmt-ibd-ibs/

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Health Tip: Weight Maintenance Over The Holidays

Did you know that most Americans gain weight between October and the New Year's Eve, and that it takes about 5 months to lose it again?(1) It doesn't have to be this way, and knowing you're at risk may be the first step in avoiding packing on the holiday pounds.

The over-eating cycle is all too familiar. It starts with Halloween candy, then Thanksgiving feasting, then holiday office parties and pot lucks, culminating in New Year's festivities and then diet and exercise "resolutions" that last a few weeks. The New York Times reports (2) that over a third of people don't stick to their diets through the entire month of January.

But we are going to beat the odds, right? I think we should form a support group or something, don't you? I'm very much prone to winter weight gain, but I thought I'd share some of my strategies with you and see if we might keep each other accountable.

1. Pack your own lunch. It's so easy to grab fast food or high calorie snacks when you're at work. And who knows how many calories are in them? If you do some simple meal prep at the beginning of the week, you can stack up a bunch of healthy lunches in advance. Grab one Tupperware container (I put frozen veggies, brown rice, and grilled chicken in single serving packs and nuke them at work), a fruit, cheese stick, and some nuts and your nutrition day is covered.
2. Don't eat your friend's candy. You know that temptations are all over the place, especially right after Halloween. Remember that you should not eat ANY candy mindlessly - one extra 50-calorie hard candy per day can add up to 5 lbs of extra stored energy (aka fat) per year!
3. Put fruit slices in your water to make it more tasty. So many beverages (especially non-diet sodas) have hidden calories or are high-sugar. I know that water is boring, but if you fill up a jug with some cucumber or fruit slices and pour yourself a big sport bottle of it every day as you leave for work, you'll stay hydrated and feel like you're having a treat to boot.
4. Don't skimp on breakfast. I know you may think that if you skip breakfast you can allocate those calories to sweet treats or a larger lunch. That sounds fair in theory, but what happens is that your hunger gets out of control and you eat a much larger portion later than you normally would, adding up to more calories overall.
5. Eat a small dinner. If you've eaten a good breakfast and lunch, you're probably winding down your day at night and don't need to eat such a large meal, especially before bed. Eating just before you sleep can contribute to reflux and heartburn.
6. Do aerobic activity. The Office of Disease Prevention and Health Promotion recommends (3) that we do one of the following per week:

• 150 minutes (2 hours and 30 minutes) each week of moderate-intensity aerobic physical activity (such as brisk walking or tennis)
• 75 minutes (1 hour and 15 minutes) each week of vigorous-intensity aerobic physical activity (such as jogging or swimming laps)
• An equivalent combination of moderate- and vigorous-intensity aerobic physical activity

7. Lift some weight. Strength training at least twice a week builds muscle, and muscle naturally burns more calories than fat.
8. Be accountable. If you have a friend who also does NOT want to gain weight over the holidays,  create a plan and stick to it together.
9. Don't keep high calorie, low nutrition foods in the house. Have the courage to throw out or donate your "trigger foods" - the snacks you just can't stop eating. Everyone has different favorite junk foods (chips, cookies, ice cream to name a few common ones). Make sure yours are not easily accessible to you. Mine is Nutella.
10. Try on your skinny jeans. Normally I don't recommend weighing yourself too frequently because there are natural gains and losses that can drive you crazy. But if you have a favorite pair of jeans (or other clothing) that you feel good in at the weight that's healthy for you… try on those clothes every now and then to give yourself an early warning signal if they're getting too tight!

Good luck beating the odds this season, my friends. I'm right there with you!

References

1. https://www.realsimple.com/health/nutrition-diet/weight-loss/holiday-weight-gain
2. https://well.blogs.nytimes.com/2007/12/31/will-your-resolutions-last-to-february/
3. https://health.gov/paguidelines/guidelines/adults.aspx

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Could you get altitude sickness at your local ski resort?

As they say in Game of Thrones, "winter is coming." Time to break out the snow gear and prepare for mountain sports (or find some dragon glass to fight off the white walkers - your choice). If you're planning  a trip out west to Colorado, New Mexico, or Utah, however, you may need to think about altitude sickness.

Altitude sickness is also known as "acute mountain sickness" or AMS, and it's caused by lower oxygen levels at higher elevations. AMS gives symptoms similar to a hangover - headache, nausea, dizziness, poor sleep, and fatigue. Most people are not affected by AMS until the altitude is greater than 2,500 meters or 8,200 feet, however, there is wide (and sometimes unpredictable) variation in when and how severely symptoms are felt. Those with kidney, lung, or heart disease may experience symptoms at lower elevations. Some people are genetically predisposed to AMS as their bodies do not adjust as quickly to lower oxygen levels. In moderate altitude (2000-3500 meters or 6,550-11,482 feet) ski resorts, about 10-40% of people experience AMS symptoms.

When AMS becomes more severe (more common at very high altitudes:  3500-5600 meters or 11,200-18,000 feet) it can result in two life-threatening syndromes, causing rapid swelling in the lungs and brain.

High-altitude pulmonary edema (HAPE) is the lung's response to low oxygen pressure over time. Breathing rate, heart rate, and blood pressure all increase as the body attempts to draw in and circulate more oxygen. Interestingly, the lung tissue's response to low oxygen is to clamp down its arteries. With the increased blood flow coming into the lungs, and tight vessels inside, fluid is forced out into the tissue causing swollen lungs that are less effective at oxygen exchange. This can cause suffocation and death in its most severe form.

High-altitude cerebral edema (HACE) occurs when rapid changes in adrenaline (triggered by low oxygen in the air) result in elevations in blood pressure that can swell the brain. Symptoms include changes in personality, emotional outbursts, severe headache, violence, ataxia (discoordination), then drowsiness and eventual coma. Once a coma has developed, death may occur from brain herniation. The usual course is rapid, complete recovery if descent is immediate and treatment is started promptly.

How does the body adjust to higher altitudes?

It takes about 4 days for the body to adjust to lower oxygen levels. It does this by producing more red blood cells to carry oxygen throughout the body, and the kidneys play a major role in adjusting the pH of the bloodstream.  When your breathing rate increases, you expel more carbon dioxide (and natural body acid). The kidneys respond by excreting bicarbonate in the urine to balance the acid loss in your breath, reducing the trigger to breathe rapidly and restoring a normal pH.

How can you reduce your risk of AMS?
 
Ascending no more than 500m (1,640 feet) per day is the best way to become acclimatized to a high altitude.  If you do not have the time for this, some medicines may be helpful.

There is a diuretic medicine called acetazolamide which triggers the kidneys to excrete bicarbonate. Taking this early on can jump start the pH balancing that your body needs to accomplish at higher altitudes. Drinking plenty of water is important to replace the losses as well.

In cases where HAPE and HACE may occur, rapid descent is the best treatment and may resolve the problems within hours. If this is not possible, steroids such as dexamethasone may reduce swelling. Supplemental oxygen is also useful.

Which U.S. ski resorts have the highest elevations?

Sixteen of the top twenty highest elevation ski resorts in the U.S. are in Colorado. Three are in New Mexico, and one in Arizona. For a full list of ski resorts and their elevations, click here: http://www.skiresort.info/ski-resorts/north-america/sorted/mountain-altitude/

The top 5 highest altitude resorts (all with elevations greater than 12,000 feet) are:
  • Breckenridge
  • Loveland
  • Telluride
  • Snowmass
  • Taos

So don't be surprised if you feel yucky for the first few days of your ski vacation. Try to ease into the high elevation, and take along some acetazolamide to combat AMS. The fastest way to feel better, of course, is to get back down to sea level!

References
http://www.altitude.org/altitude_sickness.php
https://emedicine.medscape.com/article/768478-overview#a4

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