Monthly Archives: March 2013

Aging Well

I think that when most people think of aging well, they think of what adults do to become healthy older people. Another line of thinking, which I happen to like, is that successful aging starts  in childhood (may be even in utero) as many things that occur in childhood can affect health as adults. Think of people whose mothers had rubella while pregnant with them. For those of us old enough to have gotten chicken pox rather than the vaccine, we’re at risk for shingles as adults. Severe iodine deficiency can lead to hypothyroidism and developmental delay (a more politically correct term for mental retardation). Growing up bilingual seems to protect against developing dementia, as well as having other beneficial effects on growing brains. The list goes on.

Though many people associate older age with disability and frailty, it doesn’t necessarily have to be that way. One thing I was taught throughout my training is that the older old (people in their 80’s and 90’s) are healthier than those in their 60s. At first this might sound counter intuitive. However, if one considers that those who are sickest die sooner, then it makes sense. The person whose only health issue is well controlled diabetes or well controlled hypertension is much more likely to reach his or her 80s than one who is overweight, diabetic with a glyco-hemoglobin of, for example, 9.5%, high cholesterol and has poorly controlled hypertension.

However, as I am assuming most if not all people reading this are adults, and as a time machine that would let people go back and vaccinate themselves against chicken pox, or somehow convince their parents to make them grow up bilingually (unless they did already)does not exist, I will limit myself to what an adult can do to age successfully. Nothing is guaranteed to prevent illness or frailty but what I suggest below does seem to help protect from or delay such things.

1. Stay Active. Our ancestors did not sit in cubicles all day earning enough money to buy food. They had to do any one of the following to get food: hunt animals, gather food, tend/harvest crops in the field or herd cattle/sheep etc. Only in the past few millennia was it possible for farmers to support a population where everyone didn’t need to be involved with procuring food/housing/etc. Not that getting food was a 24/7 job, but took more physical effort than driving to a supermarket. Even then people walked or rode horses to get places on land. Now it seems like to go more than 50 feet people drive their cars. Our bodies were made to be used. We should all be taking at least 10,000 steps a day (this comes out to walking approximately 5 miles/day).

2) Avoid bad behaviors. By this I mean, don’t do things that can shorten your life. Avoid smoking (not only is it bad for your lungs and increased your risk of lung cancer and of COPD, it raises your risk of bladder cancer, kidney cancer, esophageal cancer, raises your blood pressure and risk of heart disease). Drink in moderation (no more than 1 drink/day). Avoid any street drugs and sharing needles.  If you are sexually active and not in a monogamous relationship, use condoms. Having a discussion about your partners(‘) HIV status isn’t a bad idea either.

Don’t forget to embrace good behaviors. By this I mean not just those things I mention above and below, but also keeping any chronic diseases you have under control as best you can.

3) Be part of a community. Whether it’s a church (or synagogue or mosque), club for a hobby you enjoy, volunteering or any other activity that regularly gets you out with people, do something where you interact with people. The more positively the activity affects your community, the better. Humans are a social species. It helps keep your mind active if you remain part of a community.

4) Watch your diet. Eat healthy. What constitutes a healthy diet could (and likely will) take up a whole other blog post or two. Eat more vegetables. Cut back on meat – processed and otherwise. Eat more fish. Don’t drink to excess.

5) Be curious and educate yourself throughout your lifetime. Whether it’s people with more neural connections that end up in college and graduate school (and that is what makes people with college degrees less likely to develop dementia) or whether the education helps the neural connections stay healthy isn’t known. It could also be that the more educated someone is the more likely it is they will maintain doing healthy behaviors. In any case,  your brain is like a muscle, use it or loose it. If you have the time and inclination, learn another language. Take up a new hobby. Take a course in something you don’t know anything about. Take a refresher course in Italian (or spanish, or multivariable calculus, whatever floats your boat). If it’s another language, try and get good enough you can go to a foreign country where that is the official language and use that without having to speak English.

6) I realize not everyone has as much money as Warren Buffet or Donald Trump, but watch your financial health as best you can. If you retire, you don’t want to have to choose between a co-pay for medication or rent +/- food. If you can afford it, consider getting long term care insurance. If you need long term care, it can mean the difference between being at home with help or needed to go into a nursing home (policies are different, some might pay for nursing home stays as well).

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Screening – part II

In my previous post I wrote about the kinds of screening that could be though of as what you get for having reached a certain age (eg, age 50 for colonoscopy/colon cancer screening) or age +/- behaviors (eg, a sexually active female above a certain age). In future posts I might write about a particular screening test in more depth.

However in this post I’d like to talk about screening for genetic diseases. This is a bit different that the screening I wrote about last time and people can fall into several groups. One group is to see if someone will develop a disease. One disease that fits this mold is Huntington’s Chorea. People who have the mutation do  go on to develop the disease. For Huntington’s Chorea there needs to be a clear family history for testing. For Huntington’s, as well as well as other’s like it, there are multiple things to consider before testing. A big consideration  for Huntington’s Chorea is how one would handle the information if one was found to have the disease (there is no asymptomatic carrier state the same way there is for tay sachs, sickle cell anemia and others). Either you have the mutation and will develop the disease or you don’t and won’t. Someone might choose only to get tested if there is a chance they will have kids and want to know the chances of passing the disease onto their children, or to do prenatal testing, which brings up a whole lot of other issues beyond the scope of this post (what would you do if the test was positive? would you end the pregnancy? Would you go forward knowing you and the child you bring into the world would develop the disease? Would you get tested or do prenatal testing of the child if you were against ending the pregnancy? If you get tested before pregnancy and are positive, would you decide not to have children or would you do some sort of pre-implantation diagnostic testing and then only implant embryos that are free of the disease  – this latter approach might not be something insurance covers which is a whole other discussion/set of issues). Another disorder that fits into this category is Familial Polyposis Coli.  People who inherit this disorder have a virtually 100% chance of developing colon cancer and have an average age of 39 at the time of diagnosis of colon cancer. There are a few mutations associated with this disease which give rise to a somewhat different course of disease (mainly in the average age of diagnosis, # of polyps, etc). To my knowledge the best diagnostic tests for this are family history and colonoscopy rather than genetic testing – it allows for biopsy, quantification of the # of polyps, etc). In this case testing for the disease poses fewer of the issues than say, Huntington’s as there is a treatment available for this disease. If or when there is a treatment for Huntington’s chorea, then some some of the thornier issues mentioned above change.

This brings us to the next group – screening for a carrier state. What disorders one screens/gets screened for depends on one’s family history as people from different parts of the world are at risk for different diseases. Examples of disorders I am thinking of include Sickle Cell Anemia, any of the Thallessemias (and there are several. Some are lethal if inherited. Others are lethal or more symptomatic if two forms are interited together) If one is free (as best as genetic testing can tell), one’s partner might still want to be tested. Their children might not be at risk but grandchildren might and knowing that risk can be helpful. If both partners carry the trait for a particular disease several options exist. Some I mention above (testing pre implantation genetic diagnosis, aka PGD), deciding not to have children, etc. How one might choose to use the information is a matter of conscience.

In the last group of screening, it is to assess whether one is at risk for developing diseases where family history of suggestive of high risk: testing for BRAC1 and BRAC2 mutations in people whose family history includes a high incidence of breast and/or ovarian cancer, for example. This group is similar to the first one. Family history can guide if someone’s high risk. It is unlikely a clinical geneticist would screen for Huntington’s in someone with no family history whatsoever. If the family history shows only sporadic cases of breast or ovarian cancer, for example, testing for BRAC1 and BRAC2 would be less helpful. In these cases it is the person him/herself who’s at risk for the disease.  With some tests such as for BRAC1 and 2, the risk of disease may not be 100%, as it is with Huntington’s. In cases testing, some can decide about, say prophylactic mastectomy and/or oophorectomy, whether to wait after one has had children, etc. Of note, even if the risk is for typically a “womens’ disease” and the risk is on a father’s side of the family it is worth testing for.

Some last thoughts on this issue. If one is thinking of doing any sort of genetic testing, a primary care physician is a good place to start as he or she will at least be able to give some input on how likely one has a hereditary syndrome running in the family. However for actual testing it’s better to go through a clinical geneticist for testing. They have the background to pre and post test counseling.  The clinical geneticist will also be be set up with a lab that would do the testing, as even in a tertiary care center, the laboratories that do the testing are more specialized than  those that do the routine testing physicians do.

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