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Back Pain Should Be A Priority in the Overall Treatment of the Elderly
Sharron Ladd,BSc Managing Editor
"It is clear that the study of back pain has been overlooked in the geriatric community, perhaps relegated to second-class status behind health conditions like diabetes, heart disease and cognitive impairment," says Dr. Hart Bressler, the primary author of the landmark study entitled "The Prevalence of Low Back Pain in the Elderly." The study, co-authored by Dr. Warren Keyes, Dr. Paula Rochon and Dr. Elizabeth Badley appeared in the September 1st issue of the journal Spine. Several reasons are cited for the under-representation of elderly in back pain studies. One of the main reasons is the economic burden of maintaining worker's compensation programs; these programs are necessarily directed at the younger working population. Other reasons are listed in Table 1.
Using the key words low back pain, back pain, elderly, geriatrics and aged for their literature analysis, the researchers found only twelve studies on low back pain in the elderly, between 1966 and the present, that met their final selection criteria! The methodologies underlying some of these studies are dubious. "Many studies have grouped younger and older patients together, such as a 40 year old with an 82 year old.
Social Interaction Improves Mental and Physical Well Being
Thomas Tsirakis, BA
Social isolation is common amongst the elderly. Socially isolated individuals display significantly higher suicide rates, a greater number of physical and cognitive impairments, and a lower life expectancy rate when compared to those who are socially active. European studies have shown that even minor interventions to break social isolation, such as friendly visitors or routine volunteer phone calls, improve survival in the socially isolated elderly. The Baycrest Centre for Geriatric Care in Toronto, Ontario offers a wide range of innovative programs that specifically address problems with withdrawal and social isolation.
Studies show that the elderly population in general feels that their contributions to society are deemed to be insignificant by younger generations. Being able to contribute to the lives of others is important for building self-worth, and ultimately increases the value placed on life itself. For many older persons, various physical ailments (such as osteoporosis, and reduced level of vision and hearing) can cause a reduction in mobility and communication with others, ultimately causing social withdrawal. If the person's withdrawal becomes prolonged, it can become increasingly difficult to break free of this isolation.
Elderly Patients Should be Encouraged to Quit Smoking
Barry Goldlist, MD, FRCPC, FACP
Cigarette smoking remains the leading cause of preventable morbidity and premature death in North America, despite the recent decline in the prevalence of smoking. Data from the United States reveals that in those over age 60, smoking is a major factor in 6 of the 14 leading causes of death, and a complicating factor in three others. The current cohort of elderly includes large numbers of women who never smoked so the overall prevalence of smoking in the elderly is lower than for the population as a whole. However, this gender difference in smoking is shrinking (or even disappearing in some age groups) and the middle-aged cohort of smokers (45 to 64 years of age), has the same proportion of smokers as the population as a whole. This suggests that over the next two decades, we will continue to see large amounts of smoking-associated morbidity among the elderly.
There is now compelling evidence that stopping smoking is a worthwhile endeavor even in old age. It was reported in the British Medical Journal as long ago as 1977, that stopping smoking in old age could slow the progression of chronic airflow obstruction. Loss of physiological reserve is one of the major causes of the common geriatric syndromes that result in functional impairment. It is therefore apparent that maintaining such reserves is frequently the difference between dependence and independence in old age. As well, duration of smoking is a key factor in the development of lung cancer, so it can be expected that stopping smoking, even among the elderly, will also reduce the incidence of lung cancer. There is now data that also shows similar beneficial effects of stopping smoking on complications of vascular disease.
Unfortunately, the perception remains that it is not worthwhile for the elderly to stop smoking, and even if it were, it could not be done. This is incorrect. Not only do the elderly benefit from stopping; the current evidence is that they are just as likely to stop as younger individuals (although specific data is limited).
What does this mean to the practicing physician? First, it is important to determine whether your elderly patients smoke or not. For all those who actively smoke, a formal smoking cessation program should be offered. Although these are successful in the elderly, most patients will prefer to try quitting smoking on their own, at least initially. Their doctor must be available to provide the appropriate counseling and support. It is a misconception that nicotine replacement therapy is unsafe in the elderly. As recently documented in the Ontario Medical Review, smoking is almost always riskier than nicotine replacement therapy.
In summary, there are relatively few interventions physicians can provide their elderly patients with that are as beneficial as helping them stop smoking. It is important that we offer our help in stopping smoking to all our patients, including the elderly.
Cancer and Nutrition: Be Cautious When Making Dietary Recommendations
Cancer and Nutrition: Be Cautious When Making Dietary Recommendations
Eleanor Brownridge, Registered Dietitian
While a number of major dietary components--including fat, total energy, salt, red meat and alcohol--have been implicated as contributing to specific cancers, current case-control and cohort studies do not support some of the predominant hypotheses that are influencing Canadian eating habits. A major reason for the current level of certainty is the challenges inherent in nutrition epidemiology.
Diets are extremely complex. Nutrients are found in a multitude of foods, and their absorption and activity is influenced by other dietary components eaten at the same time. People change their eating habits over time and we have no idea as to the relevant latency period for various diet-related effects.
"The only clear recommendation we can make at this time is to eat more fresh fruits and vegetables.
Seniors Seek Complementary Medicine for Chronic Conditions
David Yap, BSc
The area of complementary medicine in Geriatrics is important, as the use of complementary practices grows along with the expanding elderly population. Complementary medicine consists of a wide range of health care services, which are offered outside the mainstream of orthodox western medicine. Some types of complementary health services are: Acupuncture, T'ai Chi, Herbal Medicine, Homeopathy and Chiropractic.
In complementary medicine, health is viewed as the result of interactions between positive life building forces and negative destructive forces. To treat an illness complementary medicine attempts to improve the positive forces by incorporating a holistic conception of health. Complementary medicine lacks the emphasis on determining a specific pathophysiological diagnosis. The assessment of an individual is based on history and physical exam without a heavy reliance on laboratory tests to confirm a particular diagnosis. Lastly, in complementary medicine the individual actively takes part in their well being and is at least an equal partner in the practitioner-patient relationship.
It is important for family doctors and general internists to have a basic understanding and background in complementary medicine due to the increasing use of complementary services and the potential benefits.
According to the Addiction Research Foundation tobacco use is still considered Canada's greatest public health concern even though the percentage of cigarette smokers is declining. Approximately 35,000 Canadians die prematurely each year due to smoking.1 Despite the increased risk of heart disease, lung cancer, emphysema and other health problems, patients are reluctant to stop smoking and attempts to stop often fail. This is because of nicotine, a naturally occurring alkaloid. It can cause both a physical and psychological dependence that can be compared closely with addiction to substances such as heroin and cocaine.1
Nicotine in the Body
Nicotine is rapidly absorbed into the body through the respiratory tree, buccal membranes, as well as percutaneously. Once in the body, it will mimic the effects of acetylcholine at nicotinic receptors (see Figure 1). These receptors are found at autonomic ganglionic synapses of the sympathetic and parasympathetic branches of the nervous system as well as neuromuscular junctions. Due to the wide distribution of these receptors in the body, nicotine can illicit a wide variety of effects and can act as a stimulant or a depressant.
Nicotine Substitution Therapy
Although the majority of smokers want to reduce or stop smoking, attempts to do so often fail.1 It is the powerful addiction to nicotine that can make quitting so difficult.
The National Council on the Aging in Washington, D.C. recently released the findings of its landmark study entitled Healthy Sexuality and Vital Aging.1 This unprecedented look at older people's sexuality will surely debunk many long-held views about the sexual lives of elderly North Americans. For one, older people appear to be both having sex and enjoying it. Over half of the older people in this study were found to have engaged in sexual activity within the last month, and 40% reported wanting sex more frequently. Only 4% wanted sex less often. Among those who were sexually active, over three-quarters said that maintaining an active sex life is an important aspect of their relationship with their partners. In addition, more than 70% said they were as satisfied or more sexually satisfied than they were in their 40s.
"Healthy sexuality among older women should serve as a benchmark of general health, and assessments of sexual wellness in clinical examination by the practitioner may help diagnose barriers to sexuality."
The findings of The National Council's study provide valuable insight into the sexuality and sexual needs of older women.
Decline in Sexual Desire Not A Normal Part of Aging
Lilia Malkin, BSc
Although many men consider a decline in sexual desire and sexual function a part of the "normal" aging process, this common misconception is being replaced by the increasingly positive outlook on sexuality that is becoming more prevalent among the geriatric population. A large proportion of older men regularly engage in sexual activity and many are addressing physical and emotional barriers, as well as some prevalent myths about sexuality.
A recent study conducted by The National Council On the Aging (NCOA) surveyed 1,300 older Americans and found that 61 percent of American males aged 60 and over are sexually active. The percentage of men who enjoy an active sex life does decline with increasing age; while 71 percent report being sexually active in their sixties, only 27 percent remain so in the 80 and over age group. However, lack of a steady partner presents one of the major barriers to continued sexual activity in the elderly, since 50 percent of men over 80 years of age who do have a partner engage in sex. Furthermore, while 39 percent of American men aged 60 and over stated that they were satisfied with how often they participated in sexual activity, the same percentage of respondents wished to increase the frequency of occasions in which they have sex.
Get Moving and Keep Moving--One Senior’s Perspective on How To Stay Healthy
Jaye Waggoner, BAA
Ms.Waltraud Geisler
The day starts bright and early at 5 a.m. for Ms.Waltraud Geisler. An early riser by nature, the first order of business is a little quiet rest; it is a time when she can take in the news or read. At seven it is time for breakfast and then some writing. Recently, Ms. Geisler's daughter-in-law has asked her to document the family's history all the way back to the days when she left her home land, Czechoslovakia. After working on that for a couple of hours it is time to begin her volunteer work. She spends nine to noon on the 'Safety Line' calling members of her community that are shut-in to make sure they are alright. Then there is time for a quick lunch before heading out for the afternoon. Ms. Geisler is a Peer Councilor for other seniors. Right now she has five clients she visits on a rotating basis, or whenever they need her. She wraps up the day returning home around five for dinner, the news, some knitting perhaps, a little reading, listening to music, relaxing and then off to bed at ten.
It is a rigorous and demanding schedule by anyone's standards, never mind the fact that Ms. Geisler is 76 years old. What is her secret to staying so active and participating fully in her life and the lives of others? Well, according to her the answer is in the question. "I am out everyday, seven days a week." She has a routine that she follows and by doing that and through helping others she is fueled to continue doing the same. "If I sat at home with nothing to look forward to I would get depressed," she said. She went on to say, with a smile, just how important it is to "get moving and keep moving" even if it is just a walk around the block.
The pattern is certainly working for her. In the past she has only had to deal with an ulcer, that has since healed and a hip operation, which has somewhat limited what she can do physically. At 76, she is happy to say, she takes no prescription medications. She believes that physicians should put their foot down and try to limit the drugs they prescribe to seniors and in turn seniors should find other ways to feel good. "Doctors should talk to seniors and listen. Everyone relies too heavily on prescription drugs, especially seniors," she said. "This is not to say that drugs are the enemy, obviously in some cases like heart medication they are very necessary. But some," she went on to list, "like sleeping pills, tranquilizers, and those used to treat depression, may not be."
Ms. Geisler takes a multi-vitamin, vitamins E, C, B complex, calcium and magnesium, and drinks a lot of water, as she does not always feel like shopping and cooking. She also recognizes the value of exercise. She believes you can get exercise in a variety of ways. It does not have to be structured classes. "The only exercise I get is walking, and I feel good," she said. Not only does she bus and walk everywhere, she encourages other seniors, even those with limited mobility, to get out.
Ms. Geisler believes that like herself, if other seniors stay active physically, keep their minds busy, eat reasonably healthy and find someone who will listen and understand them, they could significantly improve their overall long-term health. "They may not find themselves needing so many prescription drugs down the road," she said. The recipe for good health, she says, could be as simple as talking, listening and really living, not simply existing.
As the North American geriatric population steadily increases, a greater emphasis is being placed on primary prevention in the form of screening and counseling, to avoid onset and/or advancement of disease. Treatment of advanced disease often requires much more invasive and time-intensive procedures, and is more stressful and risky for the patient. The periodic health exam is an opportune setting for a primary care physician to screen asymptomatic elderly patients for diseases commonly associated with aging or with a high-risk group. The physician's role is moving from treatment to prevention in our current social climate, since early detection often reduces onset and progression of disease, or at least reduces complications and increases survival rates.
Unlike their younger counterparts and the stronger elderly, when frail elderly become ill, early symptoms of chronic disease are rarely specific and localized ones. Instead, older patients usually manifest nonspecific symptoms, which quickly lead to loss of function. This creates dependency in a previously independent older person without giving any clues as to the cause of the problem. The functional expressions of disease include cessation or reduction of eating and drinking, dizziness, urinary incontinence, falling, weight loss, acute confusion, failure to thrive, and new onset or worsening of previous dementias.
Cancer and Nutrition: Be Cautious When Making Dietary Recommendations