Category Archives: taking care of your health

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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Taking care of yourself – screening.

This  post is one of several on taking care of your health, and in which I’ll be talking about screening and in a future blog, about prevention (this latter one might be several posts).

The concepts of screening and prevention are related, and sometimes overlapping but different concepts and don’t mean the same things. Screening usually means that one is looking for a disease/disease process that is already occurring. For example, at birth babies are screened for hypothyroidism as well as certain inherited disorders such as phenylketonuria.   The disorders screened for may vary a little from state to state but share the traits of having treatments that PREVENT severe disease or complications of the disease (eg, growth retardation and developmental disability in the case of hypothyroidism). As I’m an internist I’ll focus mostly on adult screening. Screening for colon cancer, breast cancer, aortic aneurysm in older people with other risk factors (a history of smoking and/or hypertension, example) can save lives or reduce the burden of disease.

There’s good evidence for screening for cervical cancer with pap smears in women 21 to 65 (early diagnosis can lead to less invasive treatment) every 3-5 years depending on whether it’s done with testing for human papilloma virus testing or not. History is important in the decision as well  – a woman who’s had a hysterectomy and her cervix removed as well for something other than cervical cancer is in a different category than is someone with a cervix.  Screening for chlamydial infection in young women who are sexually active is another test that has some good evidence behind it (it can lead to PID – pelvic inflammatory disease – which can lead to other issues such as infertility)

For people 50-75 there is good evidence for screening colonoscopy. If a polyp is found it can be biopsied  – which if it’s small enough removes the whole thing. In many cases if it turns out to be a pre-cancerous lesion, having removed the polyp removes the chances of it turning into cancer. Often if there is a history of colon cancer in a patient’s family, a screening colonoscopy will be suggested 10 years before the index case occurred. For example if a patient’s mother had colon cancer at age 49, all of her children and siblings should start screening at age 39 not 50. When and what age to start screening is also affected by other familial syndromes as well and to go through all of them is beyond the scope of this particular blog post.

For other screening tests,  such as screening asymptomatic males for chlamydial infection, older men for prostate cancer, the evidence is less good for routine screening.  As time goes by there will likely be better data to make stronger/more definitive recommendations.

Breast cancer is one area that in the past few years has undergone changes in recommendations. but some organizations recommend recommend screening every two years form 40-50 and then yearly after that. When to start screening and how often is best done in conjunction with your primary care physician.

Screening for proteinuria in patients with hypertension or diabetes might not have the press that some of the screening tests I’ve mentioned (and there are others I haven’t), but can help lead to changing treatment to help prevent or delay kidney disease from getting worse.

For more information you can go to the AHRQ website at http://www.ahrq.gov or the U.S. preventative services website at  http://www.uspreventiveservicestaskforce.org

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Tough conversations and Paperwork.

Two kinds of conversations with patients are particularly tough, and sometimes related. One conversation is delivering bad news, such as the diagnosis of cancer or of a diagnosis such as HIV/AIDS. Sometimes the conversation can be tempered by a positive such as having caught the disease in an early stage, or that enough treatments are available so instead of being a virtual death sentence, it becomes a chronic disease.

The other conversation that can be difficult is talking to patients about end of life issues. Part of it is resistance as facing one’s mortality is difficult. Unfortunately people often wait until it’s too late to have conversations with family and their physician. This can put a person’s physician and family into difficult positions. By this I mean, if a disease such as Alzheimer’s has advanced enough, a patient may not be able to voice an opinion on whether he or she would want CPR, Intubation etc in the case of a heart attack. Anyone who has practiced long enough has seen patients who are unable to live independently due to dementia and have no family or other person to act as a proxy to make decisions on his or her behalf. It can take weeks or months to go through the court system to have a healthcare proxy, guardion or some similar decision maker legally assigned. In other circumstances, someone may be incapacitated by the effects of a disease, stroke, etc and unable to speak for him or herself and end up getting far more treatment at end of life than they would have wanted when they come in unconscious, unable to breath for themselves, etc and end up on a ventilator (breathing machine).

There are several ways around this. All start with conversations with family and/or friends in deciding who will be a health care proxy. There are health care proxy forms that can be filled out. Also a form known as “five wishes” is also a good place to start. The site it can be found at is aging with dignity. The first two pages act as a health care proxy form as well. The pages on the five wishes allow for more narrative as to what one’s wishes are for end of life care. Once either a healthcare proxy form or the five wishes form are filled out, they do no good if left in a drawer where no one can find them. A copy should be given to your primary care physician. Another copy should be kept in a place where you or your proxy can easily access it (preferably he or she should have his own copy as well). As circumstances arise (for example, if your healthcare proxy dies or decides they can’t/wont potentially act as a health care proxy and you appoint a new one), a new form can replace the old. However your doctor should have the updated forms for your chart.

At some point someone might decide that based on whatever set of disorders they have, that should their heart stop or that they require CPR for whatever reason that they want to be “DNR” this stands for “Do Not Resuscitate”. This often is a point of confusion when talked about in a hospital setting. This does not mean stopping treatment for cancer, heart disease, lung disease, etc. It simply means that if some’s heart stops or they stop breathing, that CPR or advanced life support measures won’t be started. There is a form such as the which is used to inform EMTs and other responders about your choice should they be called. Hospitals have their own forms that are used for inpatients.

For people with a disorder or set of disorders where one’s life expectancy is a year or less, a MOLST form can be considered. It delineates what life sustaining interventions (eg, feeding tubes, dialysis, etc) will accept.

Lastly a “File of Life form” can be filled out. I referred to this, perhaps a bit indirectly, in my last post. This is a form that can be filled out indicating whether one has a health care proxy, who that person is, where the form can be found. It also lists medical problems, medication lists, doctors’s names and phone numbers. Often they are put on the the refrigerator door so if one is unable to speak, EMTs and other responders can have important, and perhaps even life saving, information without having to search for it. Some forms are also small enough to be placed in a wallet.

Not all of these forms need to be discussed at one visit with your physician. To find them online you can search for the terms of “health care proxy”, MOLST, DNR, “file of life” and add the state you reside in for forms specific for your state.

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Talking with your doctor.

As this is my first blog post I’d like to start of by saying a few of things. One is thank you for visiting my blog. The other is that I won’t be responding to specific questions on this blog, except perhaps in a relatively generic way. In other words, talk with your primary care physician before you act on anything you read in this blog. For that matter, it’s probably a good idea no matter where you get your medical information from. Lastly, I have yet to decide on a schedule for posting. I don’t know whether it will be once a week, once a month, something in between or even less frequently.

And now to the subject of today: suggestions for talking with your doctor and getting the most out of your visits.

As a practicing physician there are times when I think my patients and I speak different languages even when English the first (and sometimes only) language either of us knows. For example there are times when I’ll be seeing a patient for the first time and I’ll ask what medications he or she is on and the response I get is along the lines of “a heart pill” or “a blue pill, for my heart”.  Other times the patient will know the medication name but not doses so I’ll get the response, for example “metoprolol twice a day”.  This is somewhat better but as medications often comes in multiple doses, knowing the dose is important especially if there is a need to change doses or when a patient calls in for a refill.  This leads me to my first suggestion: make a list of all your medications and include the dose of the medication and frequency. As some medications have more than one use, adding the condition can be useful. For example, some anti seizure medications and a class of blood pressure pills called beta blockers are sometimes used to prevent migraine headaches in people who have them frequently. It also can clue your physician into medications that other physicians you see are prescribing.

A list might look something like this:

Metformin     500 mg twice daily      diabetes

lisinopril    10 mg once daily  high blood pressure, to protect renal function

gabapentin    300 mg three times daily for neuropathic pain

Well, you get the idea. It is also helpful if, heaven forbid, you get sick and need to visit an emergency room on a weekend (your regular doctor might not be covering) or out of state. You might not even be in a position to talk and give information. This last possibility brings up the idea that having a “file of life” – a small document that also lists your name, doctor’s name, health problems, etc – on you in case you can’t speak for yourself.

Another thing that can help you communicate with your doctor is to actually bring a list of written questions/concerns you have to your visit. This is especially important for a few reasons when you have a number of medical problems. One is that even if you’re at a routine office visit, a symptom that you bring up might alert the physician something new is going on, a known condition could be getting worse (or better so now you’re over medicated), or medications might be interacting. Realize however, that if the list is long, your physician might choose to focus on what he or she feels is the most one or two important items on your list (or the one or two that you both agree are the most important). Yes, the knee pain may be making life miserable for you, but if you’re also getting chest discomfort or winded just walking down a hallway or up a flight of stairs, your doctor might feel that focusing more on your heart and lungs might be more important this visit as this could indicate problems with those two organ systems. It also avoids making your visit longer than it needs to be. Often if someone has a lot of issues, a physician will have a patient come back to go over the other issues at a future visit. There are cynics out there that might say we do this to make more money. To counter this I would say that I would not want to miss diagnosing severe heart disease or a potential cancer because someone was coming in for something unrelated. Though I like to believe that all doctors give each patient the time they need to address every issue at each, we also need to keep in mind that there are usually other patients waiting as well!

Having a family member with you can help if you feel overwhelmed by the number of health issues you have, or if you have memory problems. The family member might remember something you forget, for example. I think in general physicians don’t mind when a family member accompanies their patients. There may be some circumstances/questions a patient doesn’t want a family member to know about, this is one of the reasons we shy away from having family (especially young family members) act as translators when a patient has limited – or even no – proficiency in English. For this reason, don’t be surprised if the doctor asks the family member to leave the room for a few moments or chooses/requires the services of a professional translator.

Try not to make a diagnosis yourself. There is a reason that the maxim “doctors who treat themselves have a fool for a patient”. It’s commonly taught that if we listen to our patients, they’ll tell us what they have. However, I know I’d prefer someone saying “I think I have _fill in the blank_ because I have the following symptoms….” than to say “I have _fill in the diagnosis_”. Many disorders have similar symptoms and might be easy to confuse, though many times a patient will be correct, at least with more common or well known disorders. Often I’ll ask a patient why they think they have a particular disorder, as on occasion they will dismiss a symptom that might indicate a different disorder, or be so focused on the diagnosis and the need for particular treatment that it can be a challenge to convince them that something else is wrong or they don’t need treatment. A good example is someone coming in saying that they have “strep throat” and “need an antibiotic” when only a minority of people with a sore throat will have strep throat and a minority of those (I believe it’s only about 1-5%) of adults get complications and all antibiotics are doing is shortening the course of symptoms.

On the other hand there is nothing wrong with looking things up before you go into see your doctor and asking questions.

Anyhow, I hope some of this is helpful to people. Some of the recommendations have been written about elsewhere. If I could recall where I’d be glad to attribute them. If there are other things that come to mind that fit the description of this post, I’ll put them in a part II.

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