I can recall how my balance improved remarkably while doing tai chi, and as I notice the declining changes in my balance since I’ve stopped, I think it’s a good time to start up again.  Remember: “Behaviors in mid-life are excellent predictors of success in late-life. “

In another study in long term care residents, Dr. Garfinkel was able to apply the same algorithm and discontinue 332 drugs in 119 disabled residents. What was observed was a lower one-year mortality rate than in the control group, 21% vs. 45%, and a lower rate of referrals to acute care facilities, 11.8% vs. 30% in the control group. This study also measured a substantial decrease in medication costs.

Reducing medication use in the old-old population makes perfect sense since many older adults will suffer from duplicate therapy and resultant toxicity; serious drug-drug interactions; lack of monitoring that leads to drug toxicity; cumulative anticholinergic drug burden with functional and cognitive decline; yet many of these drugs are used with lacking evidence of benefit in this population. It may be that we see a major shift, in a relatively short period of time, in how medications are used in long term care facilities, and the extended impact may be a significant reduction in hospitalizations thereby improving quality of life and helping save the Medicare system. You can find Dr. Garfinkel’s work referenced on his home page at: http://www.dr-g.co.il/.

It may prove fruitful for organizations involved in ACOs to strongly consider utilizing the assistance of those who understand the nuances of medication use in this population to take advantage of an opportunity that pays big dividends. A well thought out approach and launch of a formal program in LTC facilities can lead to a significant lowering of hospitalization rates.

The upper number of blood pressure, also called systolic, is very important in older adults as it tends to rise with age, which was another risk factor from this study that was correlated with stroke risk. In my experience with helping older adults it is common to find isolated systolic hypertension, occurring in about 30% over the age of 80. Isolated systolic hypertension is where the upper number is elevated but the lower (diastolic) number is normal. Treatment of this type of high blood pressure is very effective at preventing strokes in which only 13-18 people need to be treated to prevent one stroke. What is also important to note is that “silent strokes”, in which you have very small strokes that go undetectable but contribute to cognitive decline, can be reduced by better management of your high blood pressure.

My advice, pay attention to your blood pressure and if that upper number is higher than 140, see your doctor and start a conversation. Also keep in mind that self-monitoring of your blood pressure and sharing those recordings with your doctor is more likely to catch high blood pressure, and is also known to be more accurate than the occasional blood pressure check in the doctor’s office.

My quest for a solid explanation started some time ago when reported findings from a couple studies made no sense at all, and I read the statements of “..after adjusting for confounding variables or risk factors..”. I first verified my suspicion in Dr. James DeMuth’s book on pharmaceutical statistics where he states we can not adjust for confounding variables and assume the conclusion is a direct cause and effect. All we can state is a correlation exists, but some authors seem to go much farther in drawing conclusions. In this article, by Dr. John Concato, et al, published in Annals of Internal Medicine, 1993;118:201-210, the author reviews common problems with the use of multivariable analyses, the first being the over-fitting of data, in which too few sample outcomes are applied to a model, and then correlations drawn from those too few outcomes. Other problems involve non-conformity to a linear gradient. For example, the impact of left ventricular ejection fraction on negative outcomes not being linear and is dependent upon where the initial ejection fraction was measured at baseline, e.g. a reduction from 40% to 30% has much lower risk as compared to a reduction from 25% to 15%.

Another problem is what the author says is a “violation of proportional hazards”, in which the risk or hazard of an independent variable is assumed to be constantly proportional. This false assumption is probably where I became suspicious, that a simple “adjusting for confounding variables” assumes all variables to be constant and exist in a simple relationship of direct correlation. The main point I make is that many statistical analyses have limitations and become more limited in their usefulness when they are not applied correctly thereby leading to incorrect conclusions.

Isn’t it true, that on any given day, we can read the summary of a research article which states that a treatment is associated with a negative outcome, after having adjusted for confounding factors, etc. And then one month later we read the opposite results from another study. It begs the question, which article is most accurate in their conclusions, if either? The use of statistics in medical research has accelerated in the last twenty years but not without concerns over the quality of its applications. I, like most human beings, tend to take things at face value. But as more findings hit the news I find myself having to employ discipline and not form any opinion until a detailed analysis of the study can be made to determine if, in fact, the purported conclusions have any meaning at all. The other application of this principle is for the lay person, no matter how educated, do not react to any information in the news.

• Bisphosphonates (Fosamax, Actonel, Bonvia, etc.) suggesting they are of limited help in those with osteopenia and associated with risk for significant side-effects, such as muscle pain, esophageal ulcers, osteonecrosis of the jaw, abnormal heart rhythm. They suggest the benefit of these drugs is even minimal in those with osteoporosis.
• Statins (Lipitor, simvastatin, Crestor, lovastatin, etc.) saying several studies have found these drugs don’t prolong life in women with elevated LDL cholesterol and no other cardiovascular risks. They suggest lifestyle changes to manage high cholesterol in women with no other cardiovascular risk factors.
• Narcotic pain medications (Oxycontin, oxycodone, fentanyl, hydrocodone, etc.) saying women take 50% more of these drugs than men. They also state that long term use of narcotic analgesics can increase sensitivity to pain (hyperalgesia), something for you to think about if you have escalating pain with escalating doses of pain medications. They also state these drugs are associated with falls and fractures and higher hospitalization rates. They also suggest exploring other non-drug pain management options.
• Proton pump inhibitors (Prilosec, omeprazole, Aciphex, Protonix, Nexium, etc.) suggesting these drugs are widely overused and can increase the risk for: fractures, pneumonia, C. diff infectious diarrhea, and that abruptly stopping them can cause rebound hyperacidity giving the person the impression that they need the medication for an underlying cause.

Consumer Reports is a subscription only site and receives good reviews. Here’s the link if you can let go of a few bucks. Remember, your health is your best investment.

http://www.magazine-agent.com-sub.info/Consumer-Reports-On-Health-com/magazine?did=1&page=44&sourcegroup=GOOGLE&gtkw=consumer%20reports%20on%20health.com&crtv=3391194191&source=search&domain=www.magazine-agent.com-sub.info&UMC=2236&mtrack=director-puremagagent&partner=-&xid=1&redirect=no&gclid=CJbo95H6tKwCFUfsKgodjlTOGA

As a result of hearing this PT’s comment I searched the literature again and looked at falls through a different lens, the one that views the null hypothesis of drugs not causing falls. In an article published in 2003 in Pharmacy & Therapeutics, the authors stated: “Beta- blockers do not contribute to falls”. Perhaps they needed to know about the systemic effects of beta blocker eye drops because Australian data have proven timolol eye drops to be the number one risk factor for falls in patients with glaucoma. (One must also understand that any drug that can cause bradycardia or hypotension can cause a fall.) The authors also stated that “Chronic therapy with blood pressure lowering medications rarely cause falls.” They referred to older studies and meta-analyses from the 1990′s, clearly older evidence that conflicts with more recent data.  I found other references that state medications are key contributors to falls, and that is also backed by years of professional experience where changes in antihypertensive medications eliminated dizziness and reduced the incidence of falls. Dr. James Cooper, PharmD, has shown that medications play a key role in causing falls, as reviewed in Medication Interventions for fall prevention in the older adult, Pharmacy Today, 2009 where he referred to his research in reducing the incidence of falls in nursing home residents by 70%. The literature is replete with references showing that alterations in medications reduces the incidence of falls in older adults, and I could fill a few pages with those validated studies.

I am fascinated by the conflicting “evidence” in the literature, and it is now beginning to amuse me. It also shows me that years of reviewing the literature, combined with clinical experience, helps paint a clearer picture that precludes any conclusions from a meta-analysis or retrospective database review that implies cause and effect after “adjusting for confounding factors”. If I followed the advice in some of the literature over the last couple of years I would: Adhere to a complex medication regimen that causes me to be cognitively impaired, dizzy and  to fall down the stairs breaking a hip, all because someone said non-adherence causes falls. I would have also stopped taking my calcium, because it is associated with higher risk of death, for which I then might be at greater risk of fracture. I would also have stopped taking a multivitamin with iron and become anemic, thereby further contributing to my risk of falling by causing weakness, and last but not least, I would be typing this post from my nursing home room.

If you don’t know where to look then you won’t know where to find the truth. It’s also wise to work as a team addressing all the identifiable risk factors for falls.

A good example of how poor data can lead to disastrous results was after the RALES trial was published, which showed that use of a potassium-sparing diuretic (spironolactone) in younger-adult CHF patients reduced CHF exacerbations, hospitalizations and mortality. It appears as if the entire medical community took the results from that trial and transposed them onto the older adult, or geriatric, population. The result was an alarming increase in the rate of hospitalization and mortality from hyperkalemia in older adults with CHF. (Hyperkalemia is a potentially life-threatening elevation of serum potassium.) This was verified by the research of Jurlink et al in studying drug interactions that led to emergency room visits by older adults.

One geriatrician wrote about the transposition of knowledge from one population to another and referred to it as “induction”, a dangerous application of “evidence” by applying it to the wrong population. The reason the adverse outcomes occurred is because the kidneys of older adults work less efficiently than younger adults and tend to be at risk for adverse effects to medications. In this case it would be spironolactone conserving too much potassium, whereas in younger adults this would be far less an issue.

Summary: We must be careful when applying evidence from studies to the older adult population if there is not a substantial number of participants who are truly elderly or old-old, i.e. over 84 years old. Otherwise we may be causing more harm than good. When talking with your doctor, who’s about to write a prescription for you, ask the question: “Is there evidence that this drug is safe and effective in people my age”. That may be the question that keeps you out of the hospital.

What people are looking for is for their physician to listen to them and believe that their complaints are legitimate, that their ideas may have some merit. They are looking to partner with their physician in order to solve a problem that troubles them. People want to be listened to and believed. Referring to a couple of previous posts based on “the evidence”, people actually have a pretty good idea of what’s going on, it’s just that the “experts” think they know it all and shut down the conversation. That’s probably why adverse drug events are the 5th leading cause of death by disease. That’s why 20% of all hospital admissions in older adults are medication-related- because someone’s not listening to the complaints AND doesn’t have the know-how to process that information.  I have learned, when someone comes in and complains about a particular symptom and they believe it’s their medication causing it, I listen to what they have to say! Why? Because it’s proven that people are fairly reliable at detecting when a medication is causing a problem. One study showed that the “patient”, or shall I say the person taking the medication, is right about 90% of the time.

I’ll shorten this up by selling the anecdote: My wife observed the dishwasher leaking and tried to problem solve. She wasn’t certain what was going on and she hypothesized a few different things, but after two “experts” came in, failed to listen, and changed a few parts (thank goodness it wasn’t a hip and a heart valve!) it still leaked. They pushed their theories, yet couldn’t solve the problem. My wife examined it a bit more in depth and Eureka! She was certain it was a clogged drain cap that covers the drain hole. It became calcified so all she did was dissolve the residue with vinegar and scrub it clean. Voila! Problem solved. Now why couldn’t the “experts” fix it? Why did they throw expensive procedures and replacement parts at the problem and hope it “fixed it”? Because they’re truly not experts. Experts are smart enough to listen and gather all the information and then apply deductive reasoning in partnership with their clients.  Here’s a tip: When the health care practitioner you are visiting won’t listen, and throws procedure after procedure at you, yet can’t solve the problem- ask them to listen, and if they don’t, fire them! Find someone who will listen and work in partnership to solve the problem.

Here’s  the NY Times link

http://www.nytimes.com/2011/04/26/health/views/26essay.html?_r=1&emc=eta1

The 8th stage is where the older adult reflects upon their life and either becomes satisfied or develops a sense that it was not a life worth living, hence Despair. Erikson is quoted as saying: “Despair expresses the feeling that time is now short, too short for the attempt to start another life and to try out alternate roads…” He also states that we do have one firm foothold in this stage to fall back on and that is “Basic trust”, and “life without it is simply unthinkable.” He states that Wisdom is the healthy product of the 8th stage where we can develop “an informed and detached concern with life in the face of death itself”. We must also note that those in their later years, long past their “Generative years”, still need a purpose and involvement in society. How can they still be useful and give back? That is the question many older adults have and probably why so many volunteer to form a labor force of unpaid caregivers and doers for others in need, truly purposeful living. However, there is another stage, the 9th.

Erikson also points out that “I am persuaded that if elders can come to terms with the dystonic elements in their life experiences in the 9th stage, they may successfully make headway on the path leading to gerotranscendence.” What is gerotranscendence? Principles regarding gerotranscendence from the Erikson’s book “The Life Cycle Completed” are: Letting go of the material things; gaining the wisdom of humility; defining ourselves by what we give back; to rise above, outdo, go beyond, independent of the universe and time; to leave behind those things we can not carry any longer as they are  too heavy a burden; gaining new spiritual gifts. It’s as if the the older adult in the 9th stage transcends to be a playful child once again, not caring about the material things nor the false pretense of power and stature. Sounds like a nice place to be!

So what’s my point in bringing all this up? My perspective is that the last stage gives us the opportunity to find peace with ourselves and transcend into a different person who is at peace with the world. A loving, caring human being truly of value to the world. That would be by my definition of “successful aging”.

Falls, for example, can be caused by a number of risk factors such as medications, leg weakness, protein malnutrition, vitamin D deficiency and urinary incontinence, all of which can be altered with a little knowledge and effort. If we are protein malnourished we can always eat more protein, and that combined with the proper exercise regimen can improve our leg strength. We can also do balance exercises that help reduce our risk of falling, along with altering some of those medications known to cause falls, such as blood pressure medications, medications for insomnia among many others. Incontinence can be managed with behavioral modifications thereby avoiding medications that can affect our memory and cause falls. Vitamin D deficiency, known to be associated with poor balance, falls, and memory loss in some, can be corrected with the right replenishment of vitamin D. All of these are easy to identify when screened for and easily altered to improve function and quality of life. We all know our body’s organ systems decline with aging but we can slow down that decline and alter the trajectory with these interventions.

What I recommend is to go to the National Institute of Aging web site at: www.nihseniorhealth.gov or www.nia.nih.gov, and go to the Publications section, Age Pages, and search for the condition that affects you or your loved one. The brochures can be printed in PDF format or can be read on line with altering text size for those with low vision. It’s a great way to continue your life-long learning and age well. One other point is that medications themselves can cause geriatric syndromes which are assumed to be a normal part of aging. A medication review with an experienced pharmacist can help identify medications associated with geriatric syndromes and help you age in place. Don’t subscribe to the stereotype that falls, urinary incontinence and memory loss are always a normal part of aging. They may not be in your case!