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Constipation is not a glamorous topic, but it’s certainly important, especially in older adults.

As anyone who has experienced occasional — or even chronic — constipation can tell you, it can really put a damper on quality of life and well-being.

Constipation can also cause more substantial problems, such as:

  • Severe abdominal pain, which can lead to emergency room visits
  • Hemorrhoids, which can bleed or be painful
  • Increased irritability, agitation, or even aggression, in people with Alzheimer’s disease or other forms of dementia
  • Stress and/or pain that can contribute to delirium (a state of new or worse confusion that often happens when older adults are hospitalized)
  • Fecal incontinence, which can be caused or worsened by having a hard lump of stool lodged in the lower bowel
  • Avoidance of needed pain medication, due to fear of constipation

Fortunately, it’s usually possible to help older adults effectively manage and prevent constipation. This helps maintain well-being and quality of life, and can also improve difficult behaviors related to dementia.

The trouble is that constipation is often either overlooked or sub-optimally managed by busy healthcare providers who aren’t trained in geriatrics. They are often focused on more “serious” health issues. Also, since many laxatives are available over-the-counter, some providers may assume that people will treat themselves if necessary.

Personally, I don’t like this hands-off approach to constipation. Although several useful laxatives are indeed available over-the-counter (OTC), I’ve found that the average person doesn’t know enough to correctly choose among them.

Also, although in geriatrics we often do end up recommending or prescribing laxatives, it’s vital to start by figuring out what is likely to be causing — or worsening — an older person’s constipation.

For instance, many medications can make constipation worse, so we usually make an attempt to identify and perhaps deprescribe those.

In short, if you’re an older adult, or if you’re helping an older loved one with health issues, it’s worthwhile to learn the basics of how constipation should be evaluated and managed. This way, you’ll be better equipped to get help from your health providers, and if it seems advisable, choose among OTC laxative options.

Here’s what I’ll cover in this article:

  • Common signs and symptoms of constipation
  • Common causes of constipation in older adults
  • Medications that can cause or worsen constipation
  • How constipation should be evaluated, and treated
  • The laxative myth you shouldn’t believe
  • 3 types of over-the-counter laxative that work (and one type that doesn’t)
  • My approach to constipation in my older patients

I’ll end with a summary of key take-home points, to summarize what you should know if you’re concerned about constipation for yourself or another older person.

Common signs and symptoms

Constipation can generally be diagnosed when people experience two or more of the following signs, related to at least 25% of their bowel movements:

  • straining
  • hard or lumpy stools
  • a sense of incomplete evacuation
  • the need for “manual maneuvers” (some people find they need to help their stools come out)
  • fewer than 3 bowel movements per week

People often want to know what is considered “normal” or “ideal,” when it comes to bowel movements. Although it’s probably ideal to have a bowel movement every day, it’s generally considered acceptable to have them every 2-3 days, provided they aren’t hard, painful, or difficult to pass.

The handy Bristol Stool Scale can be used to describe the consistency of a bowel movement, with Type 4 stool often being considered the “ideal” (formed but soft).

Constipation is pretty common in the general population and becomes even more so as people get older.  Experts estimate that over 65% of people over age 65 experience constipation, with straining being an especially common symptom.

Other symptoms that may be caused by constipation in older adults

Constipation may be associated with a feeling of fullness, bloating, or even pain in the belly. In some people, this may interfere with appetite.

Although most older adults will admit to symptoms of constipation when asked, a person with Alzheimer’s or a related dementia may be unable to remember or relay these symptoms. Instead, they might just act out or become more irritable when they are constipated.

Prolonged constipation can also lead to a more urgent problem called “fecal impaction.” This means having a hard mass of stool stuck in the rectum or colon. It happens because the longer stool remains in the colon, the dryer it tends to get (which makes it harder to pass).

Impaction tends to be very uncomfortable, and can even provoke a full-on crisis of belly pain. It can also be associated with diarrhea and fecal incontinence.

Clearing out impacted stool can be hard to do with oral laxatives; these can even make things worse by creating more pressure and movement upstream from the blockage.

Fecal impactions are usually dislodged using treatments “from below” to soften and break up the lump, such as suppositories and/or enemas. (I address what type of enema is safest below.) They sometimes require help from clinicians in urgent care or even the emergency room.

Common causes of constipation in older adults

Like many problems that affect older adults, constipation is often “multifactorial,” or due to multiple causes and risk factors.

To have a normal bowel movement, the body needs to do the following:

  • Move fecal material through the colon without excess delay (stool gets dryer and harder, the longer it stays in the colon).
  • Coordinate a defecation response when stool moves down to the rectum, which requires properly working nerves and pelvic muscles.

As people get older, it becomes increasingly common to develop difficulties with one or both of these physical processes. Such problems can be caused or worsened by:

  • Medication side-effects (more on those below)
  • Insufficient dietary fiber
  • Insufficient water intake
  • Electrolyte imbalances, including abnormal levels of blood calcium, potassium, or magnesium
  • Endocrine disorders, including hypothyroidism
  • Slow transit due to chronic nerve dysfunction, which can be due to neurological conditions (including Parkinson’s disease) or can be caused by long-standing conditions that eventually damage nerves, such as diabetes
  • Irritable bowel syndrome
  • Pelvic floor dysfunction
  • Psychological factors, such as anxiety, depression, or even fear of pain during the bowel movement
  • Very low levels of physical activity
  • “Mechanical obstruction,” which means that the colon or rectum — or their proper function — is impaired by some kind of mass, lump, narrowing, or another physical factor
    • A tumor can cause this problem, but there are also non-cancerous reasons that a person can develop a mechanical obstruction affecting the bowels.
Medications associated with constipation

Several commonly used medications can cause or worsen constipation in older adults. They include:

  • Anticholinergics, a broad class which includes sedating antihistamines, medications for overactive bladder, muscle relaxants, anti-nausea medications, and more. (This group of medications is also associated with worse brain function; they block acetylcholine, which is used by brain cells and by the nerves in the gut.)
  • Opiate painkillers, such as codeine, morphine, oxycodone
  • Diuretics
  • Some forms of calcium supplementation
  • Some forms of iron supplementation

It’s not always possible or desirable to stop every medication associated with constipation. If a medication is otherwise providing an important health benefit and there’s no less constipating alternative, we can continue the medication and look for other ways to improve bowel function.

Still, it’s important to consider whether any current medications can be deprescribed, before deciding to use laxatives and other management approaches.

If opioids are absolutely necessary to manage pain (such as in someone with cancer, for instance), a special type of medication can be used, to counter the constipating effect of opioids in the bowel. This is generally better than depriving a person of much-needed pain medication.

How to evaluate constipation

How to treat constipation basically depends on what appear to be the main causes and contributors to a person’s symptoms.

An evaluation should start with the health provider asking for more information regarding the symptoms, including how long they’ve been going on, as well as the frequency and consistency of stools.

It’s also important for the clinician to ask about “red flags” that might indicate something more serious, such as colon cancer. These include:

  • Blood in the stool (which can be red, or black and “tarry” in appearance)
  • Weight loss
  • New or rapidly worsening symptoms

The next steps of the evaluation will depend on a person’s medical history and symptoms. It’s generally reasonable for a healthcare provider to check for these common causes of constipation:

  • Medication side-effects
  • Low intake of dietary fiber
  • Low fluid intake
  • Common causes of painful defecation, such as hemorrhoids or anal fissures

Evaluation for possible mechanical obstruction will depend on what the clinician sees on physical examination, the presence of potential red flags, and other factors. Generally, a rectal exam is a good idea.

In a 2013 review, the American Society for Gastroenterology recommends that clinicians evaluate for possible pelvic floor dysfunction mainly in those people whose constipation doesn’t improve with lifestyle changes and over-the-counter (OTC) laxatives.

They also recommend diagnostic colonoscopy only for people with alarm symptoms, or who are overdue for colorectal cancer screening.

How to treat constipation

In most older adults with constipation, there are no red flags or signs of mechanical obstruction.

To treat these cases of “garden-variety” constipation, geriatricians usually use a step-wise approach:

  • Identify and reduce constipating medications if possible.
  • Increase dietary fiber intake and fluid intake, if indicated.
  • Encourage a regular toilet routine, with time on the toilet after meals and/or physical activity.
  • If necessary — which it often is — use over-the-counter laxatives to establish and maintain regular bowel movements.

The American Society of Gastroenterology recommends more in-depth constipation evaluation for older adults who fail to improve from this type of first-round treatment. Some older adults do have pelvic floor disorders, which can be effectively treated through biofeedback.

The laxative myth you shouldn’t believe

People often have concerns about using laxatives more than occasionally, because they’ve heard this can be dangerous, or risky.

This is a myth that really should be dispelled. Although medical experts used to worry that chronic use of laxatives would result in a “lazy” bowel, there is no scientific evidence to support this concern.

In fact, in their technical review covering constipation, the American Society of Gastroenterology notes that “Contrary to earlier studies, stimulant laxatives (senna, bisacodyl) do not appear to damage the enteric nervous system.”

(FYI: the “enteric nervous system” means the system of nerves controlling the digestive tract.)

Lifestyle changes and over-the-counter oral laxatives are the approaches endorsed as the first-line of constipation therapy, by the American Gastroenterology Society and others. There are no evidence-based guidelines that caution clinicians to only use laxatives for a limited time period.

The four types of OTC laxatives that I’ll cover in the next section have been used by clinicians and older adults for decades, and when used correctly, are considered safe and do not seem to cause any long-term problems.

That’s not to say that they should be used willy-nilly, or in any which way. You absolutely should understand the basics of how each type works, so let’s cover that now.

Three types of laxative that work (and one that doesn’t)

There are basically four categories of oral over-the-counter (OTC) laxative available. Three of them are proven to work. A fourth type is commonly used but actually does not appear to be very effective. Each has a different main mechanism of action.

The three types of OTC laxative that work are:

  • Osmotic agents: These include polyethylene glycol (brand name Miralax), sorbitol, and lactulose. Magnesium-based laxatives also mostly work through this mechanism.
    • These work by drawing extra water into the stool, which keeps it softer and easier to move through the bowel.
    • Studies have shown osmotic agents to be effective, even for 6-24 months. Research suggests that polyethylene glycol tends to be better tolerated than the other agents.
    • Magnesium-based agents should be used with caution in older adults, mainly because it’s possible to build up risky levels of magnesium if one has decreased kidney function, and mild-to-moderately decreased kidney function is quite common in older adults.
  • Stimulant agents: These include senna (brand name Senakot) and bisacodyl (brand name Dulcolax).
    • These work by stimulating the colon to squeeze and move things along more quickly.
    • Studies have shown stimulant laxatives to be effective. They can be used as “rescue agents” (e.g. to prompt a bowel movement if there has been none for two days) or daily, if needed.
    • Bisacodyl is also available in suppository form, and can be used this way as a “rescue agent.”
  • Bulking agents: These include soluble fiber supplements such as psyllium (brand name Metamucil) and methylcellulose (brand name Citrucel).
    • These work by making the stool bigger. Provided the stool doesn’t get too dried out and stiff, a bulkier stool is easier for the colon to move along.
    • Bulking agents have been shown to improve constipation symptoms, but they must be taken with lots of water. Older adults who take bulking agents without enough hydration — or who otherwise have very slow bowels — can become impacted by the extra fiber.
    • People with drug-induced constipation or slow transit are not likely to benefit from bulking agents.

(For more details regarding the scientific evidence on these laxatives, see this 2013 technical review.)

And now, let’s address the type of OTC laxative that is least likely to work.

The type of OTC laxative that isn’t really effective is a “stool softener”, such as docusate sodium (brand name Colace).

These create some extra lubrication and slipperiness around the stool. They actually have often been prescribed by doctors; when I was a medical student, almost all of our hospitalized patients were put on some Colace.

But, the scientific evidence just isn’t there! Because this type of laxative is so commonly prescribed, despite a weak evidence base, the Canadian Agency for Drugs and Technologies in Health completed a comprehensive review in 2014. Their conclusion was:

Docusate appears to be no more effective than placebo for increasing stool frequency or softening stool consistency.”

So, save your money and your time. Don’t bother buying docusate or taking it. And if a clinician suggests it or prescribes it, politely speak up and say you’ve heard that the scientific evidence indicates this type of laxative is less effective than other types.

Laxatives do work and are often appropriate to use, but you need to use one of the ones that has been shown to work.

About prescription laxatives

Newer prescription laxatives are also available, and may be an option for those who remain constipated despite implementing lifestyle changes and correctly used over-the-counter laxatives. These include lubiprostone (brand name Amitiza) and linaclotide (brand name Linzess).

But, it’s not clear, from the scientific research, that they are more effective than older over-the-counter laxatives. In its technical review, the American Society of Gastroenterology noted that “meta-analyses, systematic reviews, and the only head-to-head comparative study suggested that some traditional approaches are as effective as newer agents for treating patients with chronic constipation.”

Since these newer medications have a more limited safety record and are also expensive, they probably should only be used after an older person has undergone careful evaluation, including evaluation for possible pelvic floor disorders.

About enemas

Enemas are another form of “constipation treatment” available over-the-counter in the U.S.

The main thing to know is that the most commonly available form, saline enemas (Fleet is a common brand name), have been associated with serious electrolyte disturbances and even kidney damage. Because of this, the FDA issued a warning in 2014, urging caution when saline enemas are used in older adults.

Enemas certainly can be helpful as “rescue therapy,” to prevent a painful fecal impaction if an older person hasn’t had a bowel movement for a few days. But they should not be used every day.

Frequent use of enemas is really a sign that a person needs a better bowel maintenance regimen. This often means some form of regular laxative use, plus a plan to use a little extra oral laxative as needed, before things reach the point of requiring an enema.

If an enema appears necessary, experts recommend that older adults avoid saline enemas, and instead use a warm tap water enema, or a mineral oil enema.

My approach to constipation in my older patients

Generally, to help my older patients with garden-variety constipation, I start by recommending prunes and encouraging more fiber-rich foods. As noted above, a randomized trial found that 50 grams of prunes twice daily (about 12 prunes) was more effective in treating constipation than psyllium (brand name Metamucil).

Then we usually add a daily osmotic laxative, such as polyethylene glycol (Miralax). If needed, we might then add a stimulant agent, such as senna.

We do sometimes try a bulking agent, but I find that many frailer older adults tend to get stoppered up by the extra bulk. Again, if you use a supplement (such as Metamucil) to put extra fiber in the colon but can’t keep things moving along fast enough, that extra fiber might dry out and become very difficult to pass as a bowel movement.

It usually takes a little trial and error to figure out the right approach for each person, so it’s essential for an older person — or their family — to keep a log of the bowel movements and the laxatives that are taken. If a person has loose stools or too many bowel movements, in response to a given laxative regimen, we dial back the laxatives a bit.

It’s also important to have a plan for “rescue,” which means adding some extra “as-needed” laxative (usually either senna or a suppository), if a person hasn’t had a bowel movement for 2-3 days. The goal of rescue is to avoid the beginnings of fecal impaction.

Last but not least, we also try to make sure an older person is getting enough physical activity, and to establish a routine of having the person sit on the toilet after..

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Last year, I wrote an article on cerebral small vessel disease, a very common condition in which the small blood vessels of the brain develop signs of damage.

If you’re an older adult and you’ve had an MRI done of your brain, chances are pretty good that your scan showed signs of at least mild signs of this condition; one study of older adults aged 60-90 found that 95% of them showed signs of these changes.

These are basically like teensy strokes in the brain. Most are un-noticeable to people, but if you have enough of them, you can certainly develop symptoms, such as cognitive impairment, balance problems, or even vascular dementia.

To date, the cerebral small vessel disease article has generated over 100 comments and questions from readers. A common theme was this: “My MRI shows signs of this condition. What can I do?”

As I explain in the article and the comments, the first thing to do is to work closely with your doctors to understand what is the likely cause of the damage to the brain’s small blood vessels.

Now, when you do this, you may well find that your doctor just shrugs, or waves off the question.

That’s because in most people, cerebral small vessel disease is thought to be in large part a result of atherosclerosis (more on this term below) affecting the smaller arteries of the brain.  And atherosclerosis affects just about everyone as they age, because it’s related to many basic cardiovascular risk factors that become very common in late-life.

So in many cases, asking the doctor why you have signs of cerebral small vessel disease may be like asking why you might have high blood pressure, or arthritis. These are common conditions and they are usually due to medically mundane causes and risk factors, including sub-optimal “lifestyle” behaviors and the general “wear and tear” on the body that is associated with aging.

(However, in some people, damage to the small vessels in the brain may be related to one or more particular medical conditions. Younger people, in particular, seem more likely to have a particular condition or risk factor that may be causing most of the damage.)

Whether you are younger (i.e under age 60) or older, always start by asking your doctors what they think are the most likely causes for any cerebral small vessel disease, and what they recommend you do to slow the progression.

And for most people, the main advice will be this: evaluate and address your cardiovascular risk factors.

“Vascular,” as you probably already know, means “blood vessels.” And blood vessels are critical to the function of every part of the body, because blood vessels are what brings oxygen and nutrients to every cell in the body. They also carry away waste products and toxins. So, blood vessel health is key to brain health.

This article will help you better understand how to address blood vessel health. Specifically, I’ll cover:

  • Understanding cardiovascular risk factors
    • 3 key ways blood vessels become damaged
    • What is atherosclerosis
    • Why some chronic conditions are considered risk factors
  • The number one risk factor for future cardiovascular events
  • 12 key cardiovascular risk factors
  • How to manage cardiovascular risk factors for better brain health
    • 5 key approaches most older adults should implement

Note: Experts who study cerebral small vessel disease believe the story of what might be causing it is more complicated. That said, identifying and managing one’s cardiovascular risk factors is currently the mainstay of treatment and is likely to remain so. If you want to learn more about causes and contributors to cerebral small vessel disease, see here: Cardiovascular risk factors and small vessel disease of the brain: Blood pressure, white matter lesions, and functional decline in older persons.

Understanding Cardiovascular Risk Factors Known to Affect Brain Health

Lots of factors affect the health and function of your blood vessels. Before we dive into specific factors, let me share some practical ways to think about these risk factors.

3 key ways blood vessels become damaged

Generally, what is bad for blood vessels will fall into one of the following three categories:

  • A form of inflammation: “Inflammation” basically means that aspects of the body’s immune system are revved up. In the short-term, this helps fight infections, but in the longer-term, this actually creates a fair amount of wear and tear on cells in the body. Inflammation can also cause the blood vessels to build up plaque.
    • Inflammation is manifested in the body in many different ways. These include having higher levels of certain proteins, such as C-reactive protein, and/or by the increased presence of certain types of white blood cells.
    • Many health conditions, including obesity, are associated with chronic inflammation in the body. Aging is also associated with chronic inflammation, a phenomenon sometimes called “inflammaging.”
    • For more, see What is Inflammation?
  • A form of mechanical stress: This means physical forces — such as higher blood pressure — that create wear and tear on blood vessels.
  • A form of mechanical obstruction: This means build-up on blood vessel walls (sometimes called “plaques”) or blockages of blood vessels. A narrower blood vessel cannot transport oxygen, nutrients, or waste products as effectively as before. Plaques can also break off and then block a downstream part of the blood vessel; this can cause strokes or heart attacks.

Some risk factors will fall into more than one category.

What is atherosclerosis?

Atherosclerosis (and its related term, arteriosclerosis) means the process of artery walls becoming inflamed, thickened (by plaques), and then hardened. Calcium is often deposited into the blood vessel wall, which contributes to stiffening and “calcification.”  This process of accumulating damage happens over years and years, and is influenced by lifestyle factors, medical conditions, and other health factors.

In short, atherosclerosis is the most common way that blood vessels become slowly damaged and obstructed over time, and this process happens in large part due to chronic exposure to inflammation and mechanical stress.

Hardened arteries will contribute to higher blood pressure. Having a lot of atherosclerosis is also understandably a strong risk factor for developing problems related to blood vessels, such as heart attacks and strokes.

Damaged blood vessels also tend to become less resilient, and so they are also more prone to break or burst. Such breakages can be the underlying cause of ruptured aneurysms and certain forms of stroke.

Why some chronic health conditions are considered cardiovascular risk factors

Certain health conditions are considered cardiovascular risk factors, because research has shown that they are associated with a higher chance of having or developing cardiovascular disease. They can be categorized into two types:

  • Health conditions that cause inflammation or other stress on blood vessels:
    • Lots of diseases fall into this category, including diabetes and most auto-immune diseases.
    • Mental health conditions such as depression or anxiety may also qualify, as these are associated with increased stress levels in the body.
  • Health conditions that are often caused by damage to blood vessels.
    • This includes chronic kidney disease, which often — but not always — is related to blood vessel health, as well as peripheral artery disease.
The Number One Risk Factor for Future Cardiovascular Events

Probably the top risk factor having a cardiovascular event is having had one in the past.

This is called having “established cardiovascular disease,” or “clinical atherosclerotic cardiovascular disease.” It means a person has already experienced a health event or significant condition related to atherosclerosis. These include:

  • Heart attacks (“myocardial infarctions”), especially those related to a blockage in the coronary arteries, which supply blood to the heart
  • Strokes, which happen when blood flow to the brain is blocked
  • Peripheral artery disease, which happens when large arteries bringing blood to limbs (or sometimes organs) develop significant blockages

Since people with established cardiovascular disease have a higher risk of future cardiovascular events, clinicians are usually more proactive about treating their risk factors, to prevent future events. This is called “secondary prevention.” (“Primary prevention” means treating risk factors in people who have not yet had an event.)

The Rotterdam Study, among others, has found that a history of stroke or heart attack is associated with more signs of cerebral small vessel disease on MRI.

12 Key Cardiovascular Risk Factors that Affect Brain Health

Now that we’ve covered the broader categories of what affects blood vessel health, below is a list of the most common and important specific risk factors. If you’ve been worried about cerebral small vessel disease, these are probably the risk factors you’ll want to be discussing with your doctors.

This list is based in large part on the Uptodate.com chapter on established cardiovascular risk factors.

12 key cardiovascular risk factors

  1. High blood pressure
  2. High cholesterol, especially high low-density lipoprotein cholesterol (LDL-C) and high triglycerides
  3. Problems managing blood sugar, including diabetes, insulin resistance, and impaired glucose tolerance
  4. Chronic kidney disease (defined as an estimated glomerular filtration rate (eGFR) < 60 ml/minute)
  5. Obesity
  6. Cigarette smoking
  7. High levels of inflammation (as measured by C-reactive protein or other tests)
  8. Obstructive sleep apnea
  9. Psychological stressors (including depression, anger, anxiety, and stress)
  10. Insufficient exercise
  11. Dietary factors, including
    • Diets with a high glycemic index or load
    • Insufficient fruit and vegetable intake
    • Insufficient dietary fiber
    • Higher intake of red meat and high-fat dairy products
  12. Age and gender
Understanding the 12 cardiovascular risk factors in more detail

Now, you may be wondering: how are each of these risk factors defined? What blood pressure is high, or “too high”? What constitutes “insufficient exercise”?

This is where things get tricky. Basically, almost all of these risk factors can be thought of as a risk spectrum, with one side indicating increased cardiovascular risk and the other side associated with less risk. (Although for some factors, extremes on either side are associated with risk).

Where exactly to place a numerical cut-off, for the purpose of defining a disease — e.g. defining “hypertension” — tends to be hotly debated by experts. Similarly, there is often debate as to what constitutes an “optimal range,” or “optimal intake” (for diet and exercise factors), in terms of minimizing cardiovascular risk.

Within this article, it’s not possible to present each factor in depth.  Still, here’s a more detailed version of the list with some practical information for each, along with some relevant resources.

Then in the next section, I’ll cover five key approaches, which can address many cardiovascular risk factors simultaneously.

12 Cardiovascular (CV) Risk Factors (more detailed)

  1. Blood pressure:
    • Higher is generally riskier, lower generally corresponds to lower CV risk.
    • Treatment of high blood pressure has been associated with a reduction in CV risk.
    • For more information: New High Blood Pressure Guidelines Again
  2. Cholesterol (also known as “lipids”)
    • In general, higher levels of total cholesterol, LDL cholesterol, and/or triglycerides have been associated with higher CV risk.
    • Recent guidelines on lipid-lowering recommend basing treatment on a person’s 10-year risk of cardiovascular disease, rather than solely focusing on aiming to get cholesterol below a specific number.
    • The recent guidelines also recommend indefinite treatment with a statin drug for all people with proven clinical “atherosclerotic cardiovascular disease.”
    • Randomized trials find that treatment of elevated cholesterol (with statins) does reduce CV risk in many people.
    • Research also finds that cholesterol levels can be lowered through lifestyle modifications (e.g. changes to diet, weight, and physical activity).
  3. Blood glucose (blood sugar) and insulin levels
    • Higher levels of blood sugar — which usually indicates pre-diabetes or diabetes — are associated with higher CV risk.
    • Elevated blood sugar after meals has been associated with increased CV risk, and may be an important risk factor in of itself.
    • Controlling blood sugar in people with diabetes has been shown to reduce CV risk.
      • That said, studies find that reducing blood sugar too much via medication is also associated with increased cardiovascular risk (see here and here).
      • Research suggests that a hemoglobin A1C of 7-7.5% may be safer than using glucose-lowering medications to get the hemoglobin A1C below 7.
      • People with diabetes should avoid frequent hypoglycemia.
    • Insulin is a hormone that enables the body’s cell to absorb and use glucose. Higher insulin levels are associated with insulin resistance and pre-diabetes. For more information: Prediabetes & Insulin Resistance.
  4. Kidney function
    • Chronic kidney disease (usually defined as having an estimated glomerular filtration rate that is chronically less than 60mL/minute) has been associated with increased risk of CV disease.
    • A glomerular filtration rate of 90-120 mL/minute is normal, and a rate of 60-90 mL/minute is usually considered mild loss of kidney function.
    • For more on chronic kidney disease, including how to diagnose and manage it: What Is Chronic Kidney Disease?
    • For more on addressing CV risk factors: Cardiovascular Disease in CKD
  5. Obesity
    • A higher body-mass index (BMI) has generally been correlated with a higher risk CV disease, as in this study.
    • Obesity increases the likelihood of developing other conditions that increase CV risk, including high blood pressure, high cholesterol, insulin resistance, and diabetes.
    • Being overweight does seem to become less risky as one ages; learn more about the “obesity paradox” here and here. Some experts also believe that waist circumference is a more useful measurement than BMI in older people.
  6. Tobacco smoking (and other forms of inhaling toxins)
    • Smoking cigarettes is a well-established and strong risk factor for CV disease. The CDC estimates that smoking causes one in three deaths from cardiovascular disease.
    • Second-hand smoke exposure is also associated with CV risk.
    • Smoking is also known to particularly cause damage and inflammation to blood vessels.
    • Research finds that quitting at any age helps people live longer.
  7. Inflammation (as measured by C-reactive protein or other tests)
    • C-reactive protein C-reactive protein is synthesized by the liver and is considered a good marker of inflammation in the body.
    • Higher levels of C-reactive protein can be caused by a variety of specific health conditions. They may also reflect more generalized chronic inflammation in the body.
    • Research has found that C-reactive protein levels often correlate with the degree of existing atherosclerosis in a person’s blood vessels, and also with the risk of future CV events.
    • Statins have been shown to lower C-reactive protein levels, independent of their effect on LDL cholesterol levels. This may be part of the way that statins reduce the risk of CV events.
    • Using C-reactive protein to screen people without symptoms of CV disease is controversial, mainly because it’s unclear that this improves outcomes (compared to using the risk factors included in a “traditional” cardiovascular risk calculator.)
  8. Obstructive sleep apnea
  9. Psychological stressors
    • Research has linked psychological conditions, including depression, anxiety, and chronic stress, to CV risk.
    • A randomized study found that stress-management training was associated with improved markers of CV risk, in people with pre-existing heart disease. Another study found that depression treatment reduce the risk of a first CV event.
  10. Exercise and physical activity levels
    • Generally, greater amounts of exercise and regular physical activity correlate with decreased CV risk, as noted in this study.
    • A recently published analysis of data from the LIFE randomized trial found that in a previously sedentary group aged 70-89, increased physical activity (as measured by a wearable device) did correspond to a lower risk of experiencing cardiovascular events.
    • Guidelines generally recommend that people aim for 150 min/week of moderate aerobic physical activity, or 75 min/week of vigorous aerobic activity. However, research suggests that lesser amount of exercise also can provide benefit, so some exercise is always better than none. For a review of the effect of exercise on cardiovascular outcomes, see here.
  11. Dietary factors
    • Research generally suggests that higher intakes of dietary fiber, fruits, and vegetables are associated with a lower risk of CV disease. Newer research suggests that the benefits of these foods is at least in part due to their impact on the gut microbiota (the “good bacteria” in every person’s gut).
    • Research also suggests that a plant-based diet (one with no or minimal animal products, and minimal processed foods) can lead to significant reductions in CV risk.
    • Red meat consumption has been associated with a higher risk..
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 Q: My mother is 76 and has Alzheimer’s disease. She had a couple of unavoidable stays last year in the hospital (due to falls). This accelerated her decline due to delirium, which was treated as if she was just being an unruly and difficult patient. Once my sister and I understood what was going on due to this site’s information, we have been able to protect and support her.

Right now things are stable and quiet, so we are trying to plan ahead.

How should we go about planning for the years of decline my mother may experience before her actual last moments near death? It’s hard to imagine this possibility and I need help facing the (to me) not so obvious.

We have a will, power of attorney, and health care proxy in place.

A: Great question, and especially good that you’re taking advantage of a “quiet period” to address these issues.

It’s a little tricky to answer this question without knowing more about your mother’s current ability to participate in decision-making and in planning for her future care.

Since you say she’s declined after hospitalizations for falls and delirium, let me assume that she has moderate Alzheimer’s and can’t manage more than perhaps expressing some of what she likes and doesn’t like. (For more on the stages of Alzheimer’s and related dementias, see here.)

At this point, you’ve been through some health crises already, and you’ve seen her decline. You’ve also probably gotten a sense of just how many decisions have to be made on her behalf. Some are about her medical care and some are about other aspects of her life, like where she lives and how she spends her days.

Planning ahead is an excellent idea. Obviously, it’s simply not possible to anticipate and plan for every decision that will come up.

But let me offer you an approach that you can use both now as well as “in the heat of the moment” when specific issues arise. This is a framework to help you navigate all kinds of care decisions and future crises that you may encounter.

The following five steps will give you a foundation for anticipating, processing, and reacting to the complications and problems of later-stage Alzheimer’s, with less anxiety and more confidence. These steps are:

  1. Be aware of what kinds of declines and crises to expect, as your mother’s Alzheimer’s and other health conditions progress
  2. Think about what she would want, and what your family would want for her
  3. Consider and discuss goals of care with your health care providers
  4. Learn to use a benefits-and-burdens framework to navigate particular decisions
  5. Consider when and how you might dial back on “usual” medical care

Let me now explain each of these in a little more detail. By the end, you should be able to see how they will help you navigate your mother’s continued decline.

1. How to get a sense of what kinds of declines and crises to expect

You’ll be ahead of the curve, and better able to make informed and realistic decisions along the way if you have an understanding of three things:

  • The basics of how dementia progresses
  • What kinds of problems and crises might come up due to other chronic conditions your aging parent has
  • Typical problems and health crises often come up for people with dementia

Learning the basics of how dementia progresses.

If you haven’t already done so, you should become familiar with the broad trajectory of how people decline due to Alzheimer’s and related conditions.

I outline the stages here: How to Understand the Stages of Alzheimer’s & Related Dementias. You can also learn more about the progression of dementia by reading books, reading articles, or connecting with other dementia caregivers.

It’s especially important to pay some attention to what happens in the late-stage of dementia, and how people die from dementia. Honestly, most people find it sad and upsetting to learn about this, so many avoid it. You don’t have to think about this every day, but by having peeked ahead and focused on it at least once, you’ll be able to draw on that knowledge when important decisions have to be made.

A research study found that when people viewed videos of people with advanced dementia, they subsequently made different choices on their advance care planning documents.

I also highly recommend discussing this with your mother’s usual doctor. Just ask, “What kind of decline and problems should we expect, as my mother’s Alzheimer’s progresses?” This is a good way to let the doctor know you’re interested in being proactive and in planning.

Learning what to expect from other chronic conditions. 

Many people with dementia are also living with other chronic conditions. Some of these may be quite likely to cause health crises, or may even be likely to kill a person before the Alzheimer’s reaches its most advanced stage.

For instance, heart failure and chronic obstructive pulmonary disease are two common chronic conditions that often cause hospitalization. They can even cause breathing problems that might require the use of a ventilator (a breathing machine).

To learn what crises to expect from other chronic conditions, start by asking your mother’s usual doctors to help you understand the state of her other chronic conditions. Then you can ask something like, “Do you think this is likely to cause a hospitalization or health crisis in the coming year? What kinds of problems or declines should we anticipate?”

Other problems and crises that often come up for people with Alzheimer’s.

Most families realize that Alzheimer’s always features a progressive loss of abilities. But beyond that, it’s helpful to think through what types of crises and dilemmas this often sparks.

In short, you’ll want to be aware of situations that are likely to prompt difficult decisions about medical treatment or a care arrangement.

Below is a list of situations that come to my mind for mild and moderate Alzheimer’s.These are common events that tend to spark a significant change in health status or care arrangement.

For each of these, you can ask yourself, “Have we thought about how we’d manage when — or if — this comes up?”

  • Increased difficulty managing at home (especially for people who live alone or with an older spouse)
  • Increased need for supervision, assistance, and care
  • Injury due to falling or a safety problem in the home
  • Wandering
  • Financial mismanagement or abuse
  • Hospitalization (this is often associated with complications, a difficult rehab stay, and/or a significant step down in health status)
  • Delirium
  • Inability to continue with current care and living arrangement (this can be due to caregiver burnout, financial issues, safety issues, etc.)

Don’t worry too much if you haven’t yet thought through all these potential issues. You actually don’t want to get too deep into considering these, until you’ve gone through the other steps I’m going to describe. For now, the goal is to be aware of some of the issues you’re most likely to run into, and assess where you’re at in planning for them.

2. How to consider what your parent with Alzheimer’s would want

When faced with making decisions on behalf of someone with Alzheimer’s, who has lost the capacity to make the decision, you’ll want to ask yourself: “What would Mom (or Dad, or my partner) want?”

To answer that question, you’ll need to do the following:

  • Review any existing living wills, advance directives, POLST forms, or other documentation that’s been completed by your parent.
  • Consider your mother’s values and preferences regarding medical and life care, based on what you know of her. Use a specially designed conversation guide, if possible.
    • You might be able to invite her to express preferences to you, if she’s able to do so and if it doesn’t cause her too much distress.

Reviewing existing advance directives and other documentation

In an ideal world, every older adult would go through an “advance care planning” process and specify some preferences in writing, before becoming too disabled by Alzheimer’s disease.

For more on how older adults should address advance care planning, see 5 Tips to Help You With End-of-Life Planning.

By the way, you said you have a will but it wasn’t clear to me if this was a “living will,” which is a type of advance directive that provides some guidance regarding a person’s preferences for care before she dies. (A “last will and testament” type document spells out what a person wants after she dies.)

Considering your mother’s preferences and values

Even if you already have an advance directive or living will available, I recommend going through a questionnaire that will help you think about your mother’s preferences and values.

One free online questionnaire is here: Conversation Starter Kit for Families and Loved Ones of People with Alzheimer’s Disease or Other Forms of Dementia.

I especially like the questions on page 11, which are intended for the caregivers of a person no longer able to make decisions (i.e. beyond mild Alzheimer’s). They include questions such as:

  • Would she worry about not getting enough care? Or that she would get overly aggressive care?
  • Would she be okay with spending her last days in the hospital? Or would she really want to spend her last days at home?
  • Would she want us to take care of all her needs ourselves, or would she want us to get some help from professionals?
  • Would she prefer to be alone most of the time? Or would she prefer to be surrounded by loved ones?
  • If we had to list the three most important things she wanted us to know about her wishes for end-of-life care, what would they be?
  • What was she especially concerned about?
  • What was really, really important to her?
  • What kinds of treatment would she want (or not want)?

Another question that I think is useful for you to consider: At what point would she want us to back off from life-prolonging care? 

Now, you will probably find that it is hard to come up with exact answers to these questions. That’s ok! Just spending time mulling them over and talking with other family members will help you lay that foundation, I promise. You can also return to these kinds of questions when you’re in the midst of a situation involving decision-making.

Now, if your mother had previously completed an advance directive, you may be wondering if you need to bother going through these questions a second time.

I would say yes. In my experience, the information contained in most advance directives isn’t detailed enough to provide the foundation and guidance that dementia caregivers need.

Furthermore, a key part of the advance care planning process is to re-assess preferences and plans regularly, because people’s preferences often evolve as their health and life situation changes.

Given that a person with Alzheimer’s eventually loses the mental capacities needed to do this reassessment on her own, reviewing advance care plans becomes yet another thing that family caregivers and health-care proxies must take on.

As a surrogate, you won’t be able to change past documents. But you will need to provide guidance to your older parent’s doctors. Furthermore, in many states, certain forms specifying preferences for medical care, such as POLST (Physician Orders for Life-Sustaining Care), can be completed and revised by surrogate decision-makers. (Learn more POLST, which is also called MOLST or MOST in some states, here: POLST: Resources & Tips on Avoiding Pitfalls.)

In short, whether or not you have an advance directive available, part of your planning process should involve going through some questions designed to help you remember and crystalize your parent’s preferences and values.

3. How to consider and discuss “goals of care”

Understanding “goals of care”

“Goals of care” is a phrase that’s widely used by health professionals, but hasn’t yet caught on with the public. This is perhaps because many health experts seem to prefer to phrase more like “Talk about what matters most with your doctor.”

Myself, I explain “goals of care” to my patients and their families, because once they understand the idea, I find it becomes easier for us to revise the care plan, and also to navigate tricky situations.

So what are goals of care, and what does it mean to discuss them?

To begin with, it’s helpful to remember that medical care generally serves to help all people with three key goals:

  • To live longer. We do this by intervening when there is a life-threatening emergency, by operating or using life-support technologies or even by providing antibiotics and specialized medications. We also do this by managing chronic conditions, to prevent them from progressing or causing hospitalizations. And then we do this by using preventive strategies, to reduce a person’s risk of dying or experiencing a life-threatening event such as a heart attack or stroke.
  • To feel better. This means helping people address pain, shortness of breath, depression, anxiety, or any other issue that might cause distress.
  • To function better. This means helping people maintain or improve their ability to do things, so that they can keep participating as fully as possible in life. This includes helping people walk and stay mobile, as well as helping a person with dementia have the best brain function possible.

Ideally, medical care helps people with all three of these goals, because all three are usually quite important to people.

But in reality, medical care often involves making trade-offs. For instance, people often accept the side-effects of chemotherapy (which can include pain and disability), in order to have a chance to cure their cancer and live longer.

When people have Alzheimer’s disease, it becomes more and more common for the three goals to come into conflict with each other. For example, hospitalization might be the best way to minimize a person’s chance of dying during an illness, but it also often causes significant distress to a person with dementia. Furthermore, people with dementia have a high risk of developing delirium in the hospital, which can set their brain function back considerably.

In geriatrics, we routinely discuss goals of care with patients and families. We do this because as people get older, whether it’s due to Alzheimer’s or due to other health issues, it becomes impossible to prioritize all three goals equally.

And so, we invite our patients and families to tell us how important each of the three goals is to them, and which they would prioritize, if there were a conflict.

By understanding how important each goal is to a patient, or to a family, we’re then better able to tailor medical care, so that people get what they need the most from it.

How to sort out goals of care

You can certainly do some preliminary thinking on your own, when it comes to goals of care. But don’t try to figure it all out without involving your doctors.

Instead, it’s best to let the doctors know that you want to discuss goals of care for your mother. Even doctors who aren’t trained in geriatrics or palliative care will understand what you are referring to, and if they don’t feel comfortable guiding you through this conversation, they should be able to refer you to a clinician who can.

When you discuss goals of care with your medical team, here are a few more things to keep in mind:

  • It’s okay if you’re not initially sure which goals to prioritize. Sometimes it’s hard to decide, or it just takes a while for clarity to emerge.
  • It is normal for goals to change over time. Circumstances change. The health situation evolves. Or you may decide to adjust the goals of care after trying one approach to goals and realizing that it no longer feels like a good fit.
  • Feel free to bring up goals that don’t seem strictly “medical” or health-related. For instance, your family might realize that a key goal is to keep your mother living at home as long as possible, if you think that’s her preference or that’s what’s best for her quality of life. Your healthcare team should hear about this goal, as this will help them guide you through considering any trade-offs related to the goals of medical care.
4. How to use a benefits-and-burdens framework to navigate particular decisions

Along with understanding preferences and having broad goals of care, there’s an additional way you can hone in on a course of action in specific situations. Basically, it involves asking two key questions:

1.”Do the likely benefits of taking this path (which could be a starting or continuing a medication, proceeding with a hospitalization, or doing a procedure, etc.) outweigh the burdens and risks of doing this?”

2.“Would proceeding this way be in line with the person’s goals of care, and is this likely to help the person achieve their health goals?”

Geriatricians routinely rely on this helpful “benefits-versus-burdens” framework to help families navigate medical dilemmas, difficult decisions, or otherwise explore their options.

The main reason that we do this is that when it comes to many medical interventions, as an older person’s health declines, the likelihood of benefit goes down and the likelihood of harm goes up. So for instance, surgery and hospitalizations become riskier when people are frailer, or have dementia.

You can also use the benefits-and-burdens framework to work through non-medical dilemmas, such as whether to continue with a given caregiving situation versus make a change.

Start by identifying your available options for managing a situation, or even just taking a next step in addressing it.

Then, for each option, make a list of the “benefits” and the “burdens.” (You can also think of them as the “pros” and “cons.”)

Bear in mind that when it comes to figuring out the downsides of a certain course of action, you’ll want to consider two kinds of negatives. “Definite burdens” are the downsides that are pretty certain to happen. Whereas “risks” are bad things that may or may not happen in the future.

So for instance, if you move your mother with dementia into memory care, the usual “definite burdens” are that she’ll be distressed by the transition and that the care arrangement will cost more money. Whereas the “risks,” meaning the bad things that may or may not happen, are often that she might never get used to it, or that the facility might turn out to be lousy.

These are some of the tradeoffs you would be making, in exchange for certain likely benefits. If you’re moving your mother from a home caregiving situation to memory care, the benefit will be relief from many of the hands-on caregiving duties, which can be immensely helpful, especially if you’ve been providing care for a while and are starting to feel burned out. Moving to memory care can also mean more opportunities for social engagement and access to activities designed to engage people with dementia.

Going through the benefits and burdens doesn’t always yield a clear and easy answer. But almost everyone feels better having clarified what trade-offs they are making and why, when they decide to proceed — or not proceed — with a certain intervention, or a certain care plan.

5. Consider when and how you might dial back on “usual” medical care

By “usual” medical care, I mean the healthcare that’s commonly provided to older adults, regardless of whether or not they have dementia or are declining.

As you may have noticed, “usual” medical care tends to be quite oriented towards addressing the goal of helping people live as long as possible. This is done by intervening when people are acutely ill, and by using the emergency room, hospitalization, or even intensive care, in order to minimize the chance of a person dying. It also means providing chronic medical care and preventive care, again with a key goal being to minimize mortality risk.

This kind of care may sound good to you; it’s what most of us expect from our modern medical system. But in fact, it’s worth rethinking when it comes to an older person declining from dementia.

Why? Because when people are declining from dementia – or if they otherwise have limited life-expectancy – usual medical care becomes less likely to help them live longer, or better. It also becomes more likely to cause confusion, distress, and medical complications.

Furthermore, usual medical care can crowd out, or directly conflict, with approaches that help people with dementia maintain the best possible quality of life and function. When given the opportunity, most families of people with moderate and advanced dementia eventually decide to prioritize the goals of well being and function – helping a loved one be comfortable, out of pain, and able to enjoy companionship and the small pleasures of everyday life to the best of their ability – over the goal of extended lifespan whatever the cost.

For these reasons, it’s quite reasonable to consider when and how..

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And once again, high blood pressure is making headlines in the news: the American Heart Association and the American College of Cardiology (AHA/ACC) have just released new guidelines about hypertension.

Since this development is likely to cause confusion and concern for many, I’m writing this post to help you understand the debate and what this might mean for you and your family.

By the way, if you’ve read any of my other blood pressure articles on this site, let me reassure you: I am not changing my clinical practice or what I recommend to others, based on the new AHA/ACC guidelines.

The core principles of better blood pressure management for older adults remain the same:

  • Take care in how you and your doctors measure blood pressure (more on that here),
  • Start by aiming to get blood pressure less than 150/90 mm Hg, as recommended by these expert guidelines issued in 2017 and in 2014,
  • And then learn more about what are the likely benefits versus risks of aiming for more intensive BP control.

Perhaps the most important thing to understand is this: treatment of high blood pressure in older adults offers “diminishing returns” as we treat BP to get lower and lower.

Scientific evidence indicates that the greatest health benefit, when it comes to reducing the risk of strokes and heart attacks, is in getting systolic blood pressure from high (i.e. 160-180) down to moderate (140-150).

From there, the famous SPRINT study, published in 2015, did show a further reduction in cardiovascular risk, when participants were treated to a lower systolic BP, such as a target of 120.

However, this was in a carefully selected group of participants, it required taking three blood pressure medications on average, and the reduction in risk was small. As I note in my article explaining SPRINT Senior, in participants aged 75 or older, pushing to that lower goal was associated with an estimated 1-in-27 chance of avoiding a cardiovascular event. (The benefit was even smaller in adults aged 50-75.)

SPRINT did not include people who have certain common conditions, including diabetes, heart failure, past stroke, or dementia. Hence it’s not clear that the (small) benefits of intensive blood pressure control would apply to those older adults who would not have qualified for the SPRINT trial.

I will come back to the SPRINT study later in the article, since it undoubtedly influenced the recent AHA/ACC guidelines. But first, a little on why the new guidelines are notable.

Why the new blood pressure guidelines are notable

The most notable thing about these guidelines is that the AHA/ACC has decided to redefine hypertension.

Whereas hypertension has historically been defined as a blood pressure higher than 140/90 mm Hg, this expert group is now declaring that a blood pressure (BP) above 130/80 constitutes high blood pressure.

For more key points from the new guidelines, see the ACC News story here: New ACC/AHA High Blood Pressure Guidelines Lower Definition of Hypertension.

The AHA/ACC is also taking a notable position regarding the treatment of high blood pressure in older adults: they are not recommending a higher BP treatment goal for most older patients.

Instead, their guidelines say “Treatment of hypertension with a SBP treatment goal of less than 130 mm Hg is recommended for noninstitutionalized ambulatory community-dwelling adults (≥65 years of age) with an average SBP of 130 mm Hg or higher.”

(You can download a PDF of the full guidelines here: 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults.)

This is in stark contrast to the clinical practice guidelines issued in early 2017 by the American College of Physicians (ACP) and American Academy of Family Physicians (AAFP).

Titled “Pharmacologic Treatment of Hypertension in Adults Aged 60 Years or Older to Higher Versus Lower Blood Pressure Targets,” those guidelines suggest that “physicians initiate treatment in adults aged 60 years old and older with persistent systolic blood pressure at or above 150 millimeters of mercury (mm Hg) to achieve a target systolic blood pressure of less than 150 mm Hg to reduce the risk of mortality, stroke, and cardiac events.”

The ACP/AAFP guidelines also recommend that treatment to a lower BP goal be considered for certain older adults, based on their cardiovascular risk and also after discussing the likely benefits and harms with patients.

Why different expert groups are issuing different guidance on blood pressure in older adults

Now, when an expert group issues guidelines, it’s never a quick or casual thing. Guidelines are always the result of a lengthy, careful process of reviewing the scientific evidence before issuing recommendations. And the healthcare professionals who review the science and create guidelines are invariably academics who are highly trained in conducting and assessing scientific evidence.

Still, the experts writing the guidelines do have their favored ways of thinking about healthcare. They also have to exercise some judgment in deciding how the science should be turned into practical recommendations.

In this case, the AHA/ACC group (the cardiologists) and the ACP/AAFP group (the generalists) reviewed the same scientific evidence. But they came to different conclusions about what to recommend to practicing clinicians.

Why did this happen? In practical terms, it looks like the cardiologists heavily relied on SPRINT to guide their recommendations. Whereas the generalists noted that it’s a good trial but only one trial, and they made more nuanced recommendations about when to consider more intensive blood pressure management.

It’s also possible that the generalist expert group was more aware of some practical realities when formulating their guidelines. Namely, they may have been more aware that in real life, working to lower blood pressure down to the minimum can take up time and energy that might be better spent addressing other important health needs a person has.

Think about it: an older person only has so much time with the doctor at each visit. And most people don’t want to — or can’t — go back to the doctor frequently. Furthermore, most older people don’t just have high blood pressure; they also have other chronic conditions, other symptoms, and other questions that need attention.

In that real-world environment, is trying to get blood pressure down to the cardiologist’s idea of “optimal” — assuming the older adult is similar to the SPRINT participants — a good way to expend the time and effort of both the patient and the doctor, as they work to help an older adult achieve better health and wellbeing?

Or might it be better for the clinician and older adult to address fall prevention, or find a way to help the older person build and maintain strength, or perhaps address depression, or any other of the many issues that are often important to better health while aging?

In short, the current divergence in guidelines reflects different groups of experts choosing to frame the scientific evidence in different ways, and also perhaps prioritizing health issues in different ways. Cardiologists are understandably quite focused on minimizing cardiovascular risk. Whereas generalists may have a broader view on an older person’s health, and everything that goes into that.

For a good commentary on this, see “Don’t Let New Blood Pressure Guidelines Raise Yours.”

It is a little unfortunate, in that it’s probably going to cause some confusion for the public, and even within the medical field. But that’s where we are for now.

What you can do: inform yourself 

Given the debate and conflicting expert guidelines, what can you do?

Start by learning more about hypertension evaluation and management. Although the cardiology societies and generalist societies have made different recommendations in their guidelines, there are many important points about high blood pressure treatment that are not being contested. These include:

  • Correctly measuring blood pressure is very important. The ACC/AHA guidelines recommend careful measurement with good technique, using at least two measurements obtained on at least two occasions in order to determine average BP.
    • They also note that “Out-of-office BP measurements are recommended to confirm the diagnosis of hypertension and for titration of BP-lowering medication, in conjunction with telehealth counseling or clinical interventions.”
  • Consider a person’s underlying risk of cardiovascular disease when choosing a treatment goal. People at higher risk of stroke or heart attack are more likely to benefit from hypertension treatment.

I also urge you to learn a little more about the SPRINT trial. It’s especially useful to understand who was — and wasn’t — studied in SPRINT, and just how much benefit and harm the participants experienced.

I explain SPRINT in these two articles:

New Blood Pressure Study: What to Know About SPRINT-Senior & Other Research

What the New Blood Pressure Guidelines — & Research — Mean For Older Adults

Be proactive about high blood pressure management

Regardless of which guidelines you find most persuasive, what is most important is for you to be proactive in making sure that your high blood pressure management is correctly tailored to you. This means:

  • Making sure your blood pressure is correctly and reliably assessed. Ask questions if you are diagnosed or have your medication adjusted based on quick occasional office-based checks. Home blood pressure readings can be a huge help in getting BP reliably assessed.
  • Talking to your doctors about what your BP treatment goal should be, and why. Goals are best determined through a conversation between health professionals and patients. Your doctor should be able to discuss with you the pros and cons of aiming for a moderate goal (i.e. less than 150/90) versus a more intensive goal. Obviously, you will be able to ask better questions if you’re informed about the key studies on high blood pressure in older adults; I describe them in my article about SPRINT-Senior.
  • Getting help implementing lifestyle modifications that help lower blood pressure. Many non-drug approaches have been proven to help lower blood pressure, and they can often benefit your health in other ways.

I also recommend asking extra questions about blood pressure if you’ve had any concern about falls or near-falls. Although SPRINT did not find that intensive (compared to usual) blood pressure treatment resulted in increased falls, both groups did experience some falls and other research has linked blood pressure treatment to falls.

Per guidelines issued by the Center for Disease Control, an older adult who has been falling or seems to be at high risk should have blood pressure checked sitting and standing. You can learn more about medications that may affect falls through lower blood pressure here: 10 Types of Medications to Review if You’re Concerned About Falling.

You can also find more information on working with your doctor to address high blood pressure here: 6 Steps to Better High Blood Pressure Treatment for Older Adults.

And remember: you can learn everything you need to know about the SPRINT blood pressure trial in these articles:

New Blood Pressure Study: What to Know About SPRINT-Senior & Other Research

What the New Blood Pressure Guidelines — & Research — Mean For Older Adults

Do you have any questions or comments about managing high blood pressure in older adults? Post them below, I’d love to know what you think of this latest twist in the high blood pressure guidelines saga.

The post New High Blood Pressure Guidelines Again:
What the Cardiology Hypertension Guidelines Mean for Older Adults
appeared first on Better Health While Aging.

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It’s October, which means it’s that time of the year again: flu vaccination time!

Back when I worked in a primary care clinic, this is when we made a big push to offer the seasonal flu shot to all of our patients. (And we got ourselves immunized, as well.)

Not all of our patients agreed. Many older adults are skeptical of the need to get a yearly vaccination against influenza. They aren’t sure it will help. Or they think that the vaccination will actually give them a mild case of the flu. Or they just don’t like needles.

Or maybe they aren’t sure which type of seasonal flu shot to get: the regular one or one of the newer “stronger” versions, designed for older adults?

I’m never surprised when people bring up these questions. Vaccination for seasonal influenza can indeed be a confusing topic.

But it’s certainly important to consider. Depending on the year, the Centers for Disease Control (CDC) estimates that every year, influenza affects 9-60 million Americans, causes 140,000-710,100 hospitalizations, and results in 12,000-56,000 deaths. (Influenza is more severe in some years than others.) Most people get better without needing hospitalization, but some people get very sick. Older adults are especially likely to get dangerously ill from catching the flu.

So I agree with the CDC’s recommendation: everyone over the age of 6 months should get their seasonal flu shot.

In fact, I’m about to go get mine. As a healthy woman in her 40s, I’m not that concerned about getting dangerously ill from influenza. Instead, I get my annual flu shot because I want to minimize my chance of getting sick and perhaps exposing my older patients to influenza.

This month, you’ll probably be encouraged to get vaccinated too. So in this article, I’ll address some key things to know about influenza and the flu shot, along with some common questions and concerns. Here’s what I’ll cover:

  • The basics of influenza and vaccination against the flu
  • What to know about flu shots for older adults
  • What’s new and resources for the 2017-2018 flu season
  • Which influenza vaccination is probably best for most older adults
  • What to do if your older parent or relative is unwilling or unable to get vaccinated

The basics of influenza and vaccination against the flu

Q: What is influenza?

A: Influenza is a contagious respiratory viral illness, caused by influenza A or influenza B virus. It usually causes symptoms such as sore throat, stuffy nose, cough, fever, and body aches. In the Northern hemisphere, influenza is most common in the winter. Peak influenza activity usually occurs between December and February, but it can start as early as October and occur as late as May.

In “uncomplicated” influenza, the flu causes symptoms similar to — but usually worse than — a very bad cold, and then these get better over 5-7 days. Most people who catch the flu experience uncomplicated influenza, with some people experiencing more significant symptoms than others. In fact, some people (14%, in one study) will catch the flu and shed some flu virus, yet not report any symptoms!

However, influenza does sometimes cause more serious health problems, which we call “complications.” These are more likely to happen to people who are older, have other chronic conditions, or have a weakened immune system.

The most common complication of influenza is pneumonia, which means a serious infection of the lungs. Such pneumonias are sometimes purely viral. But it’s more common for them to be caused by bacteria, who are able to infect the lungs due to the body being weakened by influenza infection.

Many older adults also appear to experience worsenings of any chronic heart or lung conditions, when they experience influenza. These complications of influenza often cause hospitalization or even death.

To learn more about the basics of influenza, and for more on diagnosing and treating the flu, see:

Q: How does the flu shot help protect one from influenza, and how effective is it?

A: The flu vaccine works by stimulating the body to produce antibodies against whatever strains of influenza were included in that year’s vaccine.  After vaccination, it takes about two weeks for the body’s immune system to create its influenza antibodies.

Our bodies are able to fight off viral infections much more quickly, if we already have matching antibodies available when a virus tries to create illness in our bodies. If we don’t have matching antibodies available, then we’ll experience more illness, and it will take longer for our immune systems to control the infection.

The tricky thing about influenza is this: both influenza A and B have a tendency to be constantly changing into slightly different strains. This means that every year, scientists must study what influenza strains are present, and try to predict which ones we’ll be exposed to, during the coming winter. Influenza vaccines are then developed, to match those strains. (This is why the flu shot has to be given every year.)

Sometimes the scientific prediction works out well. In this case, we say that the vaccine was well matched to the influenza viruses circulating that winter, and influenza vaccination will have been more effective in preventing the flu.

But there are years in which the influenza strains that circulate the most in the winter are not the ones that scientists were expecting. These are the years in which the influenza vaccine is not well matched, and there tends to be more illnesses and hospitalizations.

The CDC estimates that when the vaccine is well-matched to the circulating influenza viruses, flu vaccination reduces the risk of flu illness by between 40% and 60%, for the overall population.

Several different flu vaccines are available every year. “Trivalent” flu vaccines have been available for the longest: these protect against two strains of influenza A and one strain of influenza B. “Quadrivalent” flu vaccines, available since 2012, protect against two types of influenza A and two strains of influenza B.

Vaccines also vary in terms of whether they are “standard-dose” versus “high-dose,” and one type includes an “adjuvant,” which is an additive designed to increase the immune system’s response to the vaccine. (More response is better, in that it means more protection from future infection.) I’ll discuss high-dose and adjuvant vaccines later in this article, in the section addressing flu shots for aging adults.

You can find a list of all available influenza vaccines in the Table listed below.

For more information:

Q: Can you get the flu from the flu shot? What are the risks and side effects of influenza vaccination?

A: No, you can’t get the flu from a flu shot. The currently recommended vaccines are made with either “inactivated” virus (which means the virus has been killed and can’t become alive again) or “recombinant” technology (which means they have cobbled together virus proteins). It is not possible for these vaccines to give you influenza.

There used to a “live attenuated” form of flu shot, available for people ages 2-49, which was given by nasal spray and was especially popular with children. (This did contain a weakened form of influenza virus.) However, the CDC advised against using this vaccine for the 2016-2017 flu season, and also for the 2017-2018 flu season.

The most common side-effect of the flu shot is arm soreness, and sometimes redness. People do sometimes report body aches, fever, or cough after the flu shot. But a randomized trial found that these are equally common in people who just had saline injected, so these symptoms are either due to getting sick from something else after your flu shot, or perhaps to even expecting to feel lousy after your flu shot.

Serious adverse effects related to the flu shot are very rare.

For more information:

Q: What are best ways to protect oneself from influenza and its complications?

A: To reduce your risk of getting sick from the flu, it’s best to combine two approaches:

  1. Minimize your exposure to people spreading influenza virus in the winter.
  2. Take steps to bolster your immune system, so that if you do get exposed to influenza virus, you’ll be less likely to get very sick.

Older adults should also make sure they are up-to-date on pneumococcal vaccination, which now requires two different vaccinations. (These are one-time, not yearly). Pneumococcal vaccination helps reduce the risk of certain types of bacterial pneumonia and other potential complications of influenza. A 2016 meta-analysis concluded that being vaccinated for both influenza and pneumococcus was associated with a lower risk of pneumonia and death. For more on pneumococcal vaccination, see: 26 Preventive Services for Older Adults (Vaccination section).

Minimizing your exposure to influenza virus

The main way people get exposed to influenza is when they breathe in air droplets containing influenza virus. These droplets are created when people infected with influenza virus talk, sneeze, or cough. The CDC estimates that a person infected with influenza virus may be contagious for one day prior to developing symptoms, and 5-7 days after getting sick.

Influenza virus can also survive on hard household surfaces for up to a day. The virus survives for much less time on soft surfaces, such as used tissues and bed linens.

Based on these facts, the best ways to minimize exposure to influenza are to:

  • Avoid exposure to people who may be infected with influenza.
  • Clean household surfaces, especially hard surfaces such as counters, and especially if someone living with you has been sick.
  • Wash your hands often, especially before touching your eyes, nose, or mouth.
  • Minimize your time near people who have not been vaccinated for influenza.
    • Your risk of influenza exposure is reduced if people around you — family members, co-workers, fellow residents of your living facility — are vaccinated for influenza.

Bolstering your immune system

Since we are social creatures and live in communities, we all have a good chance of being exposed to the influenza virus at some point. Whether we get sick from this exposure, and how sick we get, depends on how well our immune system can fight off the influenza virus.

Ways to bolster your immune system are:

  • Be vaccinated against seasonal influenza. If the vaccine is a good match with circulating viruses and you have a good antibody response, this is probably the best way to prepare your immune system to beat influenza.
  • Take good care of your health and body. This includes addressing healthy lifestyle basics such as not smoking, getting adequate sleep, avoiding chronic stress, and more. For a good review of what’s known about strengthening the immune system, see: How to boost your immune system (Harvard Health Review)
What to know about flu shots for older adults

Q: Is the flu vaccine effective for older adults?

A: You may have heard people say that the flu shot doesn’t work in older people. This is not entirely correct.

Now, it’s true that flu vaccine is usually less effective in older adults, because aging immune systems tend to not respond as vigorously to the vaccine. In other words, older adults tend to create fewer antibodies in response to vaccination. So if they are later exposed to flu virus, they have a higher chance of falling ill, compared to younger adults.

But “less effective” doesn’t mean “not at all effective.” For the 2015-2016 flu season, the CDC estimates that “vaccination prevented 23% of influenza-related hospitalizations,” for adults aged 65 and older.

For more on the effectiveness of influenza vaccination in older adults, see:

To provide more effective vaccination to aging immune systems, vaccine makers have developed “stronger” vaccines against the flu, which I explain in the next section.

Q: Are there flu shots specifically designed for older adults?

Yes, over the past several years, vaccine makers have developed vaccines that are designed to work better with an aging immune system. Most research studies to date show that these stimulate aging immune systems to produce more antibodies to influenza. There’s also some evidence that these vaccines reduce the risk of being hospitalized for influenza.

However, so far the CDC’s Advisory Committee on Immunization Practices (ACIP) has not particularly recommended these vaccines for older adults. Instead, the ACIP says that older adults should get any influenza vaccination approved for their age.

There are two influenza vaccines that are specifically approved for people aged 65 and older:

  • Fluzone High-Dose: This trivalent vaccine contains four times the amount of antigen, compared to Fluzone standard-dose. It is approved for adults age 65+.
    • Studies have found that the high-dose vaccine does improve antibody response. A study published in 2017 also found that use of the high-dose vaccine in nursing-homes was associated with a lower risk of hospitalization during flu season.
  • Fluad: This trivalent vaccine contains an “adjuvant,” which is an additive meant to stimulate a better immune response to the vaccine. It is a newer vaccine in the U.S., but had been licensed in Canada and several European countries prior to receiving approval here in 2015.
    • An Italian study found that this vaccine resulted in higher antibody titers, among older adults.
    • But no recent clinical trials of efficacy have been published. (Which means we don’t yet know whether people given this vaccine actually have a lower chance of being hospitalized during flu season.)

For more information on flu shots for older adults, see:

Q: Does Medicare cover the cost of influenza vaccination?

Yes, yearly influenza vaccination is 100% covered by Medicare, with no deductible or co-pay. So if you get your flu shot from a health provider that accepts Medicare payment, there should be no cost.

What’s new and resources for the 2017-2018 flu season

The CDC maintains a page dedicated to the current flu season. There is a section for the public and also a section for providers. This is a good place to get up-to-date information on influenza and influenza vaccination. You can find it here:

The CDC also provides information specific to older adults here:

Also important to know for the 2017-2018: the nasal flu vaccine (technically called “live attenuated” vaccine and branded as FluMist) has never been approved for adults age 50 and older. But in case you are wondering: it’s not recommended for anyone of any age to use, for the 2017-2018 flu season.

Which influenza vaccination is best for older adults?

Looking at the list of available flu shots can be overwhelming. In looking at this year’s CDC table of available influenza vaccines, I counted eleven options that are available for people aged 65 or older:

  • 4 standard-dose quadrivalent inactivated vaccines (Afluria Quadrivalent, Fluarix Quadrivalent, FluLaval Quadrivalent, Fluzone Quadrivalent)
  • 1 standard-dose quadrivalent inactivated vaccine manufactured with a newer “cell culture-based” technology (Flucelvax Quadrivalent)
  • 2 standard-dose trivalent inactivated vaccines (Afluria, Fluvirin)
  • 1 standard-dose trivalent adjuvanted inactivated vaccine (Fluad)
  • 1 high-dose trivalent inactivated vaccine (Fluzone High-Dose)
  • 1 quadrivalent recombinant vaccine (Flublok Quadrivalent)
  • 1 trivalent recombinant vaccine (Flublok)

Only Fluzone High-Dose and Fluad carry an age indication specific to 65 years or older.

However, the CDC does not recommend any influenza vaccine over another, for adults aged 65 or older.

So if you are an older adult, or if you’re trying to arrange a flu shot for an aging relative, which flu vaccine should you try to get?

My take is this: if you have a choice, go for one of the vaccines designed for older adults.

Why? Because we know that as people get older, their immune systems tend to respond less vigorously to immunization. And because research suggests that the high-dose flu shot generates higher antibody titers and has been associated with better influenza outcomes.

We do have more research and experience for Fluzone High-Dose than for Fluad, so unless you are enrolling in a clinical trial of Fluad, I would suggest going with the Fluzone High-Dose.

Now, both flu vaccines designed for older adults are trivalent and not quadrivalent. Quadrivalent vaccines do provide protection against an additional influenza B strain. However, experts say that older adults are less likely to be seriously ill from influenza B than from influenza A. Also, no published study has compared a quadrivalent vaccine against a high-dose trivalent vaccine. So for now, there does not seem to be a particular reason that an older adult should choose a quadrivalent vaccine over a high-dose trivalent vaccine.

You may have also heard that the New England Journal of Medicine published a study this past summer, about a newer influenza vaccine in older adults. That study, funded by the manufacturer of recombinant influenza vaccines, compared the effectiveness of a recombinant quadrivalent vaccine with a standard-dose quadrivalent inactivated vaccine, in adults aged 50 and older. Confirmed influenza cases were 2.2% in the  group receiving recombinant vaccine and 3.2% in the group receiving inactivated vaccine.  Hence the probability of influenza-like illness was 30% lower with the recombinant vaccine than with the inactivated vaccine. But again, this study did not compare the recombinant vaccine against a high-dose inactivated vaccine.

Bottom line:

  • What is most important is to get any type of flu vaccination that is approved for your age.
  • Research suggests that older adults are more likely to benefit from a high-dose influenza vaccination, such as Fluzone High-Dose.
  • If you are under age 65, you might get better protection from an influenza vaccine that is quadrivalent compared to trivalent. You also might get better protection from a vaccine that is recombinant rather than made from inactivated vaccine.
  • Flumist, the nasally administered vaccine, is not recommended for anyone of any age, for the 2017-2018 season. All influenza vaccinations..
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In this article, I’ll address a real mainstay of modern medicine: laboratory tests that require drawing blood.

This is sometimes referred to as “checking labs,” “doing bloodwork,” or even “checking blood.”

Most older adults have been through this. For instance, it’s pretty much impossible to be hospitalized without having bloodwork done, and it’s part of most emergency room care. Such testing is also often done as part of an annual exam, or “complete physical.”

Last but not least, blood testing is usually — although not always — very helpful when it comes to evaluating many common complaints that affect aging adults.

Fatigued and experiencing low energy? We should perhaps check for anemia and thyroid problems, among other things.

Confused and delirious? Bloodwork can help us check on an older person’s electrolytes (they can be thrown off by a medication side-effect, as well as by other causes). Blood tests can also provide us with information related to infection, kidney function, and much more.

Like much of medical care, blood testing is probably overused. But often, it’s an appropriate and an important part of evaluating an older person’s health care concerns. So as a geriatrician, I routinely order or recommend blood tests for older adults.

Historically, laboratory results were reviewed by the doctors and were only minimally discussed with patients and families. But today, it’s becoming more common for patients to ask questions about their results, and otherwise become more knowledgeable about this aspect of their health.

In fact, one of my top recommendations to older adults and family caregivers is to always request a copy of your laboratory results. (And then, keep it in your personal health record!)

This way, if you ever have questions about your health, or need to see a different doctor, you’ll be able to quickly access this useful information about yourself.

In this article, I’m going to list and briefly explain the blood tests that are most commonly used, for the primary medical care of older adults.

Specifically, I’ll cover four “panels” which are commonly ordered, and then I’ll list six more blood tests that I find especially useful.

In other words, we’re going to cover my top ten blood tests for the healthcare of aging adults.

I’ll finish with some practical tips for you to keep in mind, when it comes to blood tests.

4 common “panels” in laboratory blood testing

1. Complete Blood Count (CBC)

What it measures: A CBC is a collection of tests related to the cells in your blood.  It usually includes the following results:

  • White blood cell count (WBCs): the number of white blood cells per microliter of blood
  • Red blood cell count (RBCs): the number of red blood cells per microliter of blood
  • Hemoglobin (Hgb): how many grams of this oxygen-carrying protein per deciliter of blood
  • Hematocrit (Hct): the fraction of blood that is made up of red blood cells
  • Mean corpuscular volume (MCV): the average size of red blood cells
  • Platelet count (Plts): how many platelets (a smaller cell involved in clotting blood) per microliter of blood

The CBC can also be ordered “with differential.” This means that the white blood cells are classified into their subtypes. For more information on the CBC test, see Medline: CBC blood test. For details on the white blood cell count differential, and what the results might signify, see Medline: Blood differential test.

What the CBC is often used for:

  • Anemia may be diagnosed if the red blood cell count, hemoglobin, and hematocrit are lower than normal.
  • The white blood cell count usually goes up if a person is fighting an infection. Some medications, such as corticosteroids, can also cause an increase in the white blood cell count.
  • If several types of blood cells (i.e. red blood cells, white blood cells, and platelets) are low, this can be a sign of a problem with the bone marrow.
  • Occasionally an older person’s platelet count may be lower than normal (or even higher than normal). This usually requires further evaluation.

2. Basic metabolic panel (basic electrolyte panel)

What it measures: Although it’s possible to request a measurement of a single electrolyte, it’s far more common for electrolytes to be ordered as part of a panel of seven or eight measurements. This is often referred to as a “chem-7,”  and usually includes:

  • Sodium 
  • Potassium 
  • Chloride
  • Carbon dioxide (CO2) (sometimes referred to as “bicarbonate,” as this is the chemical form of carbon dioxide which is more common in the bloodstream)
  • Blood urea nitrogen (BUN)
  • Creatinine (often accompanied by an estimated “glomerular filtration rate,” or “eGFR”result)
  • Glucose

What the basic metabolic panel is often used for:

  • Medication side-effects can cause electrolytes such as sodium or potassium to be either too high or too low.
    • These electrolytes are often monitored when people take certain types of medications, such as certain blood pressure medications, or diuretics.
  • Carbon dioxide levels reflect the acidity of the blood.
    • This can be affected by kidney function and by lung function. Severe infection can also change acid levels in the blood.
  • Creatinine and BUN levels are most commonly used to monitor kidney function. Both of these measurements can go up if kidney function is temporarily impaired (e.g. by dehydration or a medication side-effect) or chronically impaired.
    • It is common for older adults to have at least mild decreases in kidney function.
    • Many medications must be dosed differently, if a person has decreased kidney function.
    • Laboratories now routinely use the patient’s age and creatinine level to calculate an “estimated glomerular filtration rate,” which represents the filtering power of the kidneys. This is considered a better measure of kidney function than simply relying on creatinine and BUN levels.
  • Glucose levels represent the amount of sugar in the blood.
    • If they are higher than normal, this could be due to undiagnosed diabetes or inadequately controlled diabetes.
    • If the glucose levels are on the low side, this is called hypoglycemia. It is often caused by diabetes medications, and may indicate a need to reduce the dosage of these drugs.

For more details on these tests, see Medline: Basic Metabolic Panel. From this page, you can find links to additional pages which explain each of the above electrolytes and metabolic components in detail, including common causes of the result being abnormally high or low.

3. Comprehensive metabolic panel 

What it measures: This panel includes the items above in the basic metabolic panel, and then usually includes an additional seven items. For this reason, it’s sometimes referred to as a “chem-14” panel. Beyond the seven tests included the basic panel (see above), the comprehensive panel also adds:

  • Calcium
  • Total protein
  • Albumin
  • Bilirubin (total)
  • Alkaline phosphatase
  • AST (aspartate aminotransferase)
  • ALT (alanine aminotransferase)

What the comprehensive metabolic panel is often used for:

  • Calcium levels are usually regulated by the kidneys and by certain hormones.
    • Blood calcium levels are not usually a good way to assess calcium intake or total calcium stores in the bones and body.
    • High or low blood calcium levels can cause symptoms, including cognitive dysfunction, and usually indicate an underlying health problem. They can also be caused by certain types of medication.
  • Albumin is one of the key proteins in the bloodstream. It is synthesized by the liver.
    • Low albumin levels may indicate a problem with the liver or a problem maintaining albumin in the bloodstream.
    • Malnutrition may cause low albumin levels.
  • AST and ALT are enzymes contained in liver cells.
    • An elevation in these enzymes often indicates a problem affecting the liver. This can be caused by medications or by a variety of other health conditions.
  • Bilirubin is produced by the liver, and usually drains down the bile ducts and into the small intestine. Some bilirubin is also related to the breakdown of red blood cells.
    • An increase in bilirubin can be caused by gallstones or another issue blocking the bile ducts.
  • Alkaline phosphatase is found throughout the body, but especially in bile ducts and also in bone.
    • Higher levels are often caused by either a blockage in the liver or by a problem affecting bone metabolism.

For more details on these tests, and the possible causes of abnormal results, see Medline: Comprehensive Metabolic Panel.

4. Lipid (cholesterol) panel

What it measures: These tests measure the different types of cholesterol and related fats in the bloodstream. The panel usually includes:

  • Total cholesterol
  • High-density lipoprotein (HDL) cholesterol, sometimes known as “good” cholesterol
  • Triglycerides
  • Low-density lipoprotein (LDL) cholesterol, sometimes known as “bad” cholesterol
    • LDL results are usually calculated, based on the other three results

People are often asked to fast before having their cholesterol checked. This is because triglycerides can increase after eating, and this can cause a falsely low LDL to be calculated. However, experts have recently concluded that in most cases, it’s not necessary for people to fast; it’s inconvenient and only makes a small difference in test results.

What the lipid panel is often used for:

6 more blood tests that I order often

Here are six other types of tests that I often order on my older patients:

1. Tests related to thyroid function

What these measure: These tests can be used to screen for thyroid disorders, or to help calibrate the dosage of thyroid replacement medications.  The most commonly used tests are:

In more complicated situations, other tests related to thyroid function may also be ordered.

What these tests are often used for:

  • Thyroid problems are common in older adults (especially older women), and are associated with symptoms such as fatigue and cognitive difficulties.
  • If an older person is having symptoms that could be related to a thyroid problem, the first step is to check the TSH level.
  • TSH usually reflects the body’s determination of whether the available thyroid hormone is sufficient or not.
    • If the thyroid gland is not making enough thyroid hormone, TSH should be higher than normal.
  • Free T4 is often used to confirm a thyroid hormone problem, if the TSH is abnormal.

For more information about thyroid problems in older adults, see HealthinAging.org: Thyroid Problems. You can also read a more in-depth scholarly article here: Approach to and Treatment of Thyroid Disorders in the Elderly.

2.  Tests related to vitamin B12 levels

What these measure: These measure the serum levels of vitamin B12 and provide information as to whether the level is adequate for the body’s needs.  The two tests involved are:

Depending on the situation, if an older adult is found to have low vitamin B12 levels, additional testing may be pursued, to determine the underlying cause of this vitamin deficiency.

What these tests are often used for:

  • Vitamin B12 deficiency is quite common in older adults, and can be related to common problems such as fatigue, memory problems, and walking difficulties.
  • Methylmalonic acid levels in the body are related to vitamin B12 levels, and can help confirm a vitamin B12 deficiency.
    • It is especially important to check this, if an older person has vitamin B12 levels that are on the low side of normal.
    • Low vitamin B12 levels are associated with higher-than-normal methylmalonic acid levels
  • For more information, see: How to Avoid Harm from Vitamin B12 Deficiency.

3. Glycated hemoglobin (Hemoglobin A1C)

What it measures: Glycated hemoglobin is formed in the body when blood glucose (blood sugar) attaches to the hemoglobin in red blood cells.  It is normal for glucose to do this, but if you have more glucose in the blood than normal, your percentage of glycated hemoglobin will be higher than normal. The higher one’s average blood sugar level, the greater percentage of glycated hemoglobin one will have. A result of 6.5% or above is suggestive of diabetes. For more information:

What this test is usually used for:

  • This test is most often ordered to monitor the blood sugar control of people with diabetes.
    • Whereas a blood glucose level (which can be checked by fingerstick or as part of a basic metabolic panel) reports the blood gluose level at a specific moment in time, a hemoglobin A1C reflects how high a person’s blood sugar has been, on average, over the prior three months.
  • A hemoglobin A1C test can also be used as part of an evaluation for possible diabetes or pre-diabetes.
  • Older adults should work with their doctors to determine what A1C goal is right for them. It is often appropriate to aim for a slightly higher goal in older adults than in younger adults. For more on this, see HealthinAging.org: Diabetes Care & Treatment.

4. Prothrombin time (PT) and International Normalized Ratio (INR)

What it measures: These two tests are used as a measure of how quickly a person’s blood clots. People taking the blood-thinner warfarin (brand name Coumadin) must have this regularly monitored. For more information:

What this test is usually used for:

  • The INR is calculated by the laboratory, based on the prothrombin time. In people taking warfarin, the usual goal is for the INR to be between 2.0 and 3.0.
    • The most common reason older adults take warfarin is to prevent strokes related to atrial fibrillation.
    • Warfarin may also be prescribed after a person has experienced a blood clot in the legs, lungs, or elsewhere.
  • The prothrombin time is also sometimes checked if there are concerns about unexplained bleeding, severe infection, or the ability of the liver to synthesize clotting factors.

5. Brain natriuretic peptide (BNP) test

What it measures: Despite the name, BNP levels are mainly checked because they relate to heart function (not brain function!). BNP levels go up when a person’s heart cannot pump blood as effectively as it should, a problem known as “heart failure.” For more information on this test:

A related, but less commonly used, test is the “N-terminal pro-B-type natriuretic peptide” (NT-proBNP) test.

What this test is used for:

  • Checking a BNP level is mainly used to evaluate for new or worsening heart failure. This is a common chronic condition among older adults, which can occasionally get worse.
  • The BNP test can be especially useful in evaluating a person who is complaining of shortness of breath.
    • Shortness of breath can be caused by several different problems, including pneumonia, chronic obstructive pulmonary disease, pulmonary edema, angina, and much more.
    • A low BNP level means that at that moment, the shortness of breath is unlikely to be due to heart failure.
  • Checking BNP levels over time is also sometimes used to monitor a person’s heart failure and response to treatment.
  • For more about heart failure, see MayoClinic.org: Heart failure tests and diagnosis and also HealthinAging.org: Heart failure.

6. Ferritin

What it measures: The body’s serum ferritin level is related to iron stores in the body. For more about this test:

Depending on the situation, if an older person’s iron levels need further evaluation, additional tests can be ordered.

What this test is used for:

  • Ferritin levels are most commonly used as part of an evaluation for anemia (low red blood cell count). A low ferritin level is suggestive of iron-deficiency, which is a common cause of anemia.
    • Studies estimate that only a third of anemias in older adults are due to deficiencies in iron or other essential elements.
    • It’s important to confirm iron deficiency by checking ferritin or other tests, before relying on iron to treat an older person’s anemia.
  • Ferritin levels are also influenced by inflammation, which tends to make ferritin levels rise.
  • If the ferritin levels are borderline, or if there are other reasons to be concerned about an older person’s ability to manage iron, additional blood tests related to iron may be ordered.
  • For more on evaluating and treating anemia in older adults, see Anemia in the Older Adult: 10 Common Causes & What to Ask.

Obviously, there are many more tests that can be ordered as part of the medical care of older adults. But the tests I cover above are, by far, the ones I order the most often.

Tips to help you benefit from your blood tests and results

Here are my top tips:

1. Be sure you understand why a given test is being ordered. Is it meant to help evaluate a symptom? Monitor a chronic condition? Assess whether a treatment is working?

You will understand your own health issues better, if you ask questions about the purpose of the blood tests your doctors are proposing.

In general, blood tests should only be ordered for a reason, such as to evaluate a concerning symptom, to monitor a chronic disease, or to check for certain types of medication side-effect.

Keep in mind that it’s only occasionally appropriate to order blood tests for “screening.” A screening test means a person doesn’t have any symptoms. Such screening blood tests are only recommended for a handful of conditions.

For more on preventive health care and screening tests that may be appropriate for older adults, see 26 Recommended Preventive Health Services for Older Adults.

2. Ask your doctor to review the results and explain what they mean for your health. Try to look at the report with your doctor. It’s especially important to ask about any result that is flagged as abnormal by the laboratory system.

For instance, I have found that many older adults are unaware of the fact that they have mild or moderate kidney dysfunction, even though this has been evident in prior laboratory tests. This happens when people do not review reports and ask enough questions.

Wondering why the doctor wouldn’t tell an older person that the kidney function is abnormal?

Well, if it’s been going on for a while, the doctor might think the older person already knows about this issue. Or perhaps the doctor mentioned it before, but the older person didn’t quite hear it. It’s also not uncommon for doctors to just not get around to mentioning a mild abnormality that is pretty common in older people, such as mild anemia or mild kidney dysfunction.

3. Ask your doctor to explain how your results compare with your prior results. Laboratory reports will always provide a “normal” reference range. But what’s usually more useful is to see how a given result compares to your previous results.

For instance, if an older person’s complete blood count (CBC) shows signs of anemia, it’s very important to look at prior CBC results. This helps us determine what the “trajectory” of the blood count is. A blood count that is drifting down — or worse yet, dropping fairly suddenly — is much..

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Have you ever wondered whether you — or your older relative — might be taking too many medications?

If so, know that you’re probably right to be concerned about this!

And, you’re not alone.

Over the years, I’ve had countless older adults express their worries and frustrations, related to their medications. These include:

  • The hassle of having so many pills to take
  • Worries about side-effects
  • Frustration with medication costs
  • Wondering whether a given medication is the “right” one for you, or for your condition
  • The sneaky feeling that some of those medications don’t seem to help much
  • The hassle of coordinating a long medication list among multiple doctors

If you’ve ever experienced any of the above — or if you (or your older relative) are taking more than five medications — then I want to make sure you are familiar with a term that is becoming more prominent in health care: deprescribing.

In this article, I’ll cover what every older adult and family caregiver should know about deprescribing:

  • What is deprescribing?
  • Why is deprescribing especially important for older adults?
  • How does deprescribing work?
  • What medications are most important for older adults to consider deprescribing?
  • How can older adults and family caregivers get doctors to address deprescribing?

This way, you’ll have a better shot at what everyone wants when it comes to medication:

  1. To only take medications that are more likely to help than to harm
  2. To be taking the minimum amount of medication necessary, to optimize health and well-being
What is deprescribing?

In literal terms, deprescribing means what it sounds like: it’s the opposite of prescribing.

So instead of adding a medication to someone’s care plan, healthcare providers remove — or reduce the dosage — of one or more medications.

The Canadian Deprescribing Network has an especially nice definition here:

Deprescribing means reducing or stopping medications that may not be beneficial or may be causing harm. The goal of deprescribing is to maintain or improve quality of life.

Of course, there’s a little more to deprescribing. The truth is that it requires a long-needed shift in mindset and approach to health care, for doctors and patients alike.

That’s because deprescribing comes down to doctors and patients regularly asking themselves:

  • Is this medication still needed?
  • Does the likely benefit of this medication outweigh any risks or harms that it might cause?
  • Could we manage without this drug, or could we make do with a lower dose of it?

You might think this would be the default in healthcare, but unfortunately, it isn’t. For many reasons — the influence of drug companies, the shortage of time during visits, etc. — it tends to be much easier for doctors to prescribe medication, than it is for them to deprescribe.

And once prescribed, medications tend to just…stay. And be refilled almost indefinitely.

The result of all this is that older adults are often on a lot of medications. But when we take a close look, many of these can and should be deprescribed.

Why is deprescribing especially important for older adults?

Deprescribing is especially important to address in older adults because:

  • People tend to be prescribed more medications as they get older. A 2015 study found that almost 40% of older Americans take five or more prescription medications.
  • Many older adults experience “inappropriate prescribing.” Studies have found that 20% to 79% of older participants were taking a potentially inappropriate medication. Despite recent efforts to educate doctors about safer medication prescribing in aging, it remains common for seniors to be prescribed medications on the “Beer’s List”, which is a regularly updated American Geriatrics Society list of  “Medications that Older Adults Should Avoid or Use with Caution.”
  • Many “potentially inappropriate medications” are bad for the brain, or increase the risk of fallsFalls and declines in mental abilities are two very common problems that most older adults want to avoid. Yet many of them don’t realize that they are often taking medications associated with increased risk for these problems.
  • Older adults are more vulnerable to side-effects and harm from their medications. The CDC estimates that every year 177,000 older adults visit the emergency room due to medication problems.
  • Most older people would like to be on fewer medications. Surveys generally find that older adults don’t like being on many medications.
  • It is often possible — and usually safer — to treat many health conditions with non-pharmacological methods, such as therapy and lifestyle changes.

Geriatricians have long known that many of the prescription drugs seniors take are not strictly necessary. Some are even causing harm to those who take them.

So really, deprescribing means doing what geriatricians are very proactive about doing: eliminating medications that aren’t needed, or are more likely to harm than to help.

Fortunately, since the concept of deprescribing is becoming more common in healthcare, it’s becoming easier for seniors and families to get help with this, even if they can’t see a geriatrician in person.

How does the process of deprescribing work?

Deprescribing requires doctors and other clinicians to follow these basic steps:

  • Create an accurate and up-to-date list of all the drugs a person is currently taking.
    • The best way to do this is to ask a person to bring in all the medications they are taking, and review the bottles.
    • Clinicians should avoid relying on the medication list they have in the chart or computer. These lists are often inaccurate or out-of-date, especially if the person has been seeing multiple doctors.
  • Review the reason each medication has been prescribed.
    • Doctors should consider whether this use of the medication is in line with best practice guidelines, or otherwise is likely to benefit the person, based on good clinical evidence.
    • Clinicians and patients together should consider whether the medication is providing symptom relief, or otherwise seems likely to be providing a meaningful benefit to the person.
    • It’s important to consider whether the likely benefit is a good fit for someone’s health situation and values. For instance, if the likely benefit is a 1-in-60 chance of avoiding a heart attack over the next 10 years, this may be more worthwhile to someone in their 60s than to someone in their 90s.
  • Consider whether any safer alternatives are available, for a given purpose.
    • It is often possible to treat a given health concern with non-drug alternatives, or with medications that are less risky for older adults.
  • Discontinue or reduce dosages of medication when possible.
    • Many medications will require a tapering process, in which the dose is lowered over time.
  • Make a plan to follow-up on the deprescribing plan.
    • It’s essential to follow-up after medication changes, to check on related symptoms or health conditions.

Deprescribing isn’t something that you can do for yourself or a family member; you should always work with a health professional before stopping or reducing any prescription medications.

However, you can certainly get a head-start on the process by doing a little research and preparation before discussing medications with your health providers. I explain how to do this here: How to Review Medications for Safety & Appropriateness.

Which medications are the most important to consider deprescribing in older adults?

Here are some of the medications that are especially important to assess for deprescribing:

  • Non-steroidal anti-inflammatory drugs (NSAIDs). These are painkillers in the same class as ibuprofen. They are easily available over-the-counter, but are also prescribed by doctors. They are usually used to treat arthritis or other conditions related to pain and inflammation.
  • Medications that lower blood sugar (for people with diabetes). Most people with diabetes take medication to keep their blood sugar from getting too high. It’s important to be careful that such medications don’t overtreat the person and cause too much low blood sugar.
    • Low blood sugar (known as hypoglycemia) can provoke a fall or otherwise leave a senior feeling weak and unwell. Frequent episodes of hypoglycemia have also been associated with developing dementia and with higher mortality.
    • Many experts, such as the authors of this 2016 review, recommend “moderate” blood sugar control for older adults, which means aiming for a middle ground in which blood sugar is kept not too high but also not too low.
  • Proton-pump inhibitors (PPIs). This is a class of anti-acid drugs; they have been widely prescribed to treat gastroesophageal reflux disease, which can cause pain in the stomach area. They are also used to reduce stomach acid to treat other health problems.
    • Research suggests that long-term use (e.g. more than 8 weeks) may be linked to an increased risk of problems such as bowel infection, hip fracture, malabsorption of key vitamins, and other problems.
    • Commonly used PPIs include omeprazole, esomeprazole, lansoprazole, and pantoprazole (US brand names Prilosec, Nexium, Prevacid, and Protonix, respectively).
    • For more on these, see You May Be At Risk: You are currently taking a proton-pump inhibitor (PPI)
  • Medications used in Alzheimer’s and other dementias to manage difficult behaviors. Antipsychotics and sedatives are often used in people with Alzheimer’s and other dementias, to try to control difficult behaviors. But these medications are often prescribed before safer alternatives have been tried, and families are not always aware of the risks.
  • Opioids and other medications prescribed for pain. Pain is common in older adults, so many are taking opioids or other prescription painkillers. Although prescription medication for pain is often needed and appropriate, it’s essential to regularly review the use of these medications.
    • Per a recent review, it is not yet clear if overdose and misuse are as big a problem among seniors as they are in the general population.

All of these medications are frequently prescribed to older adults. Most of them are commonly — although not always — reduced or discontinued by geriatricians and others who are particularly knowledgeable about medications in older adults.

If you or your older relative are taking any of these medications, remember that this is not necessarily inappropriate. In some situations, there’s no good alternative available to continuing with the medication. Sometimes after a careful review of the situation and alternative options, we do conclude that the likely benefits of continuing a “risky” medication do outweigh the risks.

What’s most important that seniors and their doctors regularly discuss any associated risks and available alternatives. This is how you can ensure that you are only taking medication that is truly needed, or otherwise is more likely to help than to harm.

How can older adults and family caregivers get doctors to address deprescribing?

The most important thing to do is to regularly ask your doctors to review your medications with you, and ask for help with deprescribing.

Fortunately, several excellent resources online can make deprescribing easier for you, and for your doctors. The Canadian Deprescribing Network, in particular, has some of my favorite resources. They include:

  • Tips on starting a deprescribing conversation. I especially like the suggested questions you can ask, which include:
    • Why am I taking this medication?
    • What are the potential benefits, and potential harmful effects?
    • Can it affect my memory?
    • Can it cause me to fall?
    • Can I stop one of my pills? Do I need to reduce the medication slowly?
    • Who do I follow-up with and when?
  • Deprescribing algorithms, and other useful resources for healthcare providers. These provide step-by-step guidance to doctors and other clinicians, which makes it much easier for them to work with you in reassessing the use of risky medications.

Remember, it will really help if you can regularly remind your doctors that your goal is to be on the minimum number of medications necessary.

To do this, you and your doctors will have to work together to regularly reassess every medication you are taking.

Again, healthcare providers are supposed to be regularly reassessing all your medications, but they are often too busy to do so unless you remind them.

So if you want to be proactive about maintaining health and well-being in aging, learn more about your medications. And then talk to your doctors about deprescribing!

Have you ever asked your doctor to deprescribe a certain medication, or for help reducing your medications overall? Please share your stories and questions in the comments below!

The post Deprescribing: How to Be on Fewer Medications appeared first on Better Health While Aging.

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Have you ever had questions about what might be going on with an older loved one’s health? But then you find that your older relative is unable — or unwilling — to let you in on the health details?

Such questions come up often for the family caregivers of older people. Common situations include:

  • An older parent who starts to act in ways that are strange or worrisome, such as becoming paranoid or delusional.
  • An older adult who seems to be physically or mentally declining, but seems reluctant to discuss the situation
  • A hospitalization or emergency room visit
  • A hospitalized older person becoming confused (this would be delirium) and becoming no longer able to explain to family what the doctors have said

In these situations, family caregivers often find themselves grappling with issues related to the HIPAA (Health Insurance Portability and Accountability Act) Privacy Rule.

Why all the grappling?

Well, although most people — and all clinicians — have heard of HIPAA, its rules and requirements are often misunderstood. So for instance, families may assume they can’t report a relative’s worrisome behavior to the doctor, because their relative hasn’t given them permission to do so.

Even worse:  doctors and other clinicians sometimes refuse to disclose any information to families, and will incorrectly claim that HIPAA doesn’t allow them to do so. This can create extra confusion and stress for families, or can even sometimes put an older person at risk for harm.

If you’ve been concerned about an older parent’s health, or are otherwise helping someone with their health concerns, then it can be very helpful to understand HIPAA better.

In fact, the American Bar Association includes “Know your rights of access to health information” among its Ten Legal Tips for Caregivers.

The detailed ins and outs of HIPAA can indeed be hard to fully understand. But, it’s not too hard to learn some practical basics, especially since the US Department of Health and Human Services (HHS) provides a Summary of the Privacy Rule here, and maintains a truly useful set of online FAQs about HIPAA here.

In this article, I’ll explain five useful key basics to help you understand HIPAA better, especially when it comes to getting information as a family caregiver.

I’ll also address five questions I’ve often heard family caregivers ask about HIPAA.

At the end, I’ll share some of my favorite online HIPAA resources, as well as some final tips to keep in mind.

5 Key Basics About HIPAA

1. What is HIPAA?

The Health Insurance Portability and Accountability Act (HIPAA) is a federal law passed in 1996. Among other things, HIPAA required the Department of Health and Human Services (HHS) to create a federal “Privacy Rule” for health providers and health plans, governing how these entities must protect the privacy of an individual’s medical information.

Usually, when people refer to HIPAA, they are actually referring to the HIPAA Privacy Rule created by HHS.

The HIPAA Privacy Rule basically says that “covered entities” must take certain steps to keep a person’s health information confidential and secure.

“Covered entities” means health providers, health insurers, and many other professionals whose daily work involves the handling of individuals’ medical information.

Private citizens and family caregivers are not “covered” by the Privacy Rule. This means that you do not have to maintain your — or your older parent’s — health information confidential in the same way that health providers do.

Exactly how “covered entities” should comply with the Privacy Rule can get pretty complicated to explain. What is most important for you to know is that this often — but not always — means taking steps to make sure that patients are in agreement, before their health information is shared with other people.

Overall, HIPAA is intended to balance a person’s right to privacy with the need for health providers to communicate with others, in order to properly care for a patient and act in the patient’s best interest.

To read about the rule in more technical detail, see here: Summary of the HIPAA Privacy Rule.

To read a good plain-English summary of your rights (as an individual) under HIPAA, see here: Your Rights Under HIPAA.

2. What information is protected by HIPAA?

HIPAA’s Privacy Rule protects all “individually identifiable health information” held or transmitted by a covered entity, no matter what form it is in. So HIPAA applies whether a person’s health information is held or disclosed electronically, orally, or in written form.

A person’s health information is often referred to as “protected health information.” This covers information that relates to:

  • a person’s past, present or future physical or mental health or conditions
  • any health care provided to a person (e.g. clinical notes or lab results related to a person’s medical care)
  • past, present, or future payments related to a person’s health care (e.g. billing records)

In other words, this is information created by, or stored by, healthcare providers and insurers.

HIPAA also covers demographic data and any information that can be used to identify a person, such as names and addresses.

If you are a family caregiver, remember that you are not a “covered entity.” Hence you aren’t responsible for protecting health information in the same way that your relative’s doctor is.

3. What to know about HIPAA’s rules on the disclosing of protected health information

You’ll be able to sort out health information disclosure issues more easily if you understand a few fundamentals about HIPAA’s rules on these issues.

According to the HHS Summary of the HIPAA Privacy Rule: “A covered entity may not use or disclose protected health information, except either:

(1) as the Privacy Rule permits or requires; or
(2) as the individual who is the subject of the information (or the individual’s personal representative) authorizes in writing.”

In other words, doctors are allowed to disclose health information if a person authorizes it in writing, or if the Privacy rule otherwise permits or requires such disclosure.

Now, let’s address the difference between being required and being permitted to disclose, because that is really at the heart of a lot of HIPAA confusion.

The difference is that when doctors are required to disclose, then they have to do it, whether or not they want to.

Whereas when they are permitted to disclose, they are allowed to do it, but they don’t have to. (Which means, they might refuse to do it, and they are legally allowed to do so, unless other federal, state, or local laws apply.)

You now probably will want to know: under what circumstances are health providers required or permitted to disclose health information?

Required disclosures of health information. Health providers must disclose protected health information in these two situations:

  • When individuals — or their personal representatives — request access to their protected health information. Individuals can also request an accounting of disclosures, which means the covered entity has to tell a person with whom the information was shared.
  • When the Department of Health and Human Services requests information, as part of a compliance audit or enforcement investigation.

In short: if you request it, your doctors must give you copies of your health information. This is known as the “Right of Access.” You can learn more about your rights to view or obtain copies of your health information here: Individuals’ Right under HIPAA to Access their Health Information.

And if you are the durable power of attorney for healthcare for your relative, and if you are currently authorized to act, you have the right to request and obtain your relative’s health information.

Permitted disclosures of health information. Under certain circumstances, health providers are allowed — but not required — to disclose information, without obtaining the patient’s written permission.

Now here’s where things start getting trickier, because the list of permitted circumstances is much longer and more complicated than the list of required disclosures.

If you want to learn about all the permitted disclosures and uses, you can do so by reading the HHS Summary of the Privacy Rule.

But I think it’s more useful to learn from the FAQs that HHS has published online, especially the ones created to guide doctors and other healthcare professionals. I will share some of the more useful ones in the next section, when I address FAQs based on the questions I’ve had people ask me.

For now, the main thing you should know is this: in many cases, health providers are allowed, but not required, to disclose health information to others, even if a patient doesn’t give written or verbal permission for this.

As you will see below, when we go through some FAQs, doctors are allowed to use their clinical judgment and disclose information when a patient lacks capacity to give consent, if the clinician decides that the disclosure is in the best interest of the patient.

4. What to know about HIPAA’s “minimum necessary” requirement

The HIPAA Privacy Rule describes a principle of “minimum necessary” use and disclosure:

“A covered entity must make reasonable efforts to use, disclose, and request only the minimum amount of protected health information needed to accomplish the intended purpose of the use, disclosure, or request.”

Basically, this means that when health providers disclose health information to someone other than the patient, they can’t just disclose anything and everything about their patient’s health. Instead, they should only share on a “need to know” basis, and focus on what’s relevant and necessary.

Note that the minimum necessary requirement does not apply to all disclosures. The Privacy Rule summary lists six situations as exempt, including “disclosure to or a request by a health care provider for treatment.”

In short, if your doctor refers you to another doctor, she can send your whole medical chart along. But, if a doctor is speaking to your family while you are sick in the hospital, the doctor is only allowed to disclose what is necessary and relevant to your current hospitalization and care needs.

5. What is a “HIPAA release”?

Many health providers and other covered entities will require a person to sign a written authorization, before they disclose protected health information. This is sometimes called a HIPAA release, a HIPAA waiver, or a release of information authorization.

Interestingly, the HIPAA Privacy rule itself does not require health providers to do this. Instead, per the Summary:

‘Obtaining “consent” (written permission from individuals to use and disclose their protected health information for treatment, payment, and health care operations) is optional under the Privacy Rule for all covered entities. The content of a consent form, and the process for obtaining consent, are at the discretion of the covered entity electing to seek consent.’

In other words, although it’s extremely common for health providers to ask patients to sign written authorizations before disclosing health information, such written consent is not actually required by HIPAA.

Instead, a requirement for written consent usually reflects a clinic’s policies, or perhaps the preference of an individual clinician. Understandably, clinicians want to avoid being accused of failing to protect a patient’s confidentiality.

5 Useful Caregiver FAQs about HIPAA and the Disclosure of Health Information

1. Is written permission always required, for a doctor to be able to talk to me about my older parent’s health?

Nope! As noted above, for permitted disclosures of health information, HIPAA does not require that a patient give written permission.

Instead, clinicians are allowed to use a patient’s verbal consent. HIPAA also says it’s ok for clinicians to give patients an opportunity to object and to proceed if they don’t object, or even to “reasonably infer, based on professional judgment, that the patient does not object.”

Personally, I have often spoken to a patient’s adult children on the phone, because the patient told me it was okay to do so. However, I usually document in my clinical note that the patient said it was fine to talk to his or her children.

Last but not least, if a patient is not present or if it’s “impracticable because of emergency circumstances or the patient’s incapacity for the covered entity to ask the patient about discussing her care or payment with a family member or other person,” HIPAA says that clinicians can disclose information if they determine that doing so is in the best interest of the patient.

Most state laws are similar to HIPAA, but in some states, requirements may be more stringent.

You can find more details through these FAQs:

If I do not object, can my health care provider share or discuss my health information with my family, friends, or others involved in my care or payment for my care?

If I am unconscious or not around, can my health care provider still share or discuss my health information with my family, friends, or others involved in my care or payment for my care?

Does the HIPAA Privacy Rule permit a doctor to discuss a patient’s health status, treatment, or payment arrangements with the patient’s family and friends?

Do I have to give my health care provider written permission to share or discuss my health information with my family members, friends, or others involved in my care or payment for my care?

If the patient is present and has the capacity to make health care decisions, when does HIPAA allow a health care provider to discuss the patient’s health information with the patient’s family, friends, or others involved in the patient’s care or payment for care?

2. Can doctors talk to me about my older parent’s health during an emergency?

Yes, HIPAA allows this type of disclosure. So doctors are permitted to update you about your parent’s health during an emergency.

Furthermore, HIPAA does not require providers to ask family caregivers for proof of identity, before disclosing information.

That said, just because doctors are permitted to disclose information to you doesn’t mean they have to do it. As this FAQ notes, “a health care provider is not required by HIPAA to share a patient’s information when the patient is not present or is incapacitated, and can choose to wait until the patient has an opportunity to agree to the disclosure.”

For more information:

Does the HIPAA Privacy Rule permit a doctor to discuss a patient’s health status, treatment, or payment arrangements with the patient’s family and friends?

If the patient is not present or is incapacitated, may a health care provider still share the patient’s health information with family, friends, or others involved in the patient’s care or payment for care?

If my family or friends call my health care provider to ask about my condition, will they have to give my provider proof of who they are?

3. My older parent doesn’t want his doctor to talk to me. What can I do?

This question tends to come up when a family has become concerned about an older person’s mental and/or physical decline. Some older adults will resist their family’s desire to communicate with the doctor. So what can be done?

First of all, as a family member, remember that you are not a “covered entity.” So whether or not a doctor is permitted to disclose information to you, HIPAA does not prevent you from contacting your parent’s doctor and relaying any concerns or information you have.

You can even ask questions; the doctor probably won’t answer them, but it’s good for your parent’s doctor to know what kind of questions your family has.

Otherwise, if your parent has specifically told his doctor to not talk to you, then there are a couple of angles you can consider:

  • Consider the possibility of incapacity. HIPAA does permit doctors to disclose information to family when a patient is incapacitated or otherwise unable to consent to the disclosure.
    • If you think your parent might be incapacitated by cognitive decline, delirium, or another medical problem, ask the doctor to consider this.
    • You can start by voicing concerns in a phone call, but it’s best to eventually put them in writing, because your letter will normally end up scanned into your parent’s medical chart. Be sure to include information on concerning behaviors of incidents that you have observed (such as any of these: 8 Behaviors to Take Note of if You Think Someone Might Have Alzheimer’s).
    • You can learn more about incapacity here: Incompetence & Losing Capacity: Answers to 7 FAQs
  • Has anyone been designated as durable power of attorney for healthcare? HIPAA allows a patient’s representative to request health information.
    • Check any durable power of attorney documentation to see under what circumstances the agent has authority to act. Most documents require the older person to be incapacitated, but some allow the agent to act right away.

Of course, even if you are legally permitted to seek information about your parent’s health, your parent is likely to be angry about your doing so. The decision to override an older person’s decision or preferences is a serious one, and should only be considered under special circumstances.

If you have good reason to believe your parent’s insight and judgment are impaired, then it may be ethically reasonable to override their preference for privacy and take actions that will help them achieve their health and safety goals. Just be sure to think through the benefits and risks of your available options carefully, before you proceed.

Of course, what is better is that older adults plan ahead and tell their children what they should do if their older parent ever seems to be ill or mentally impaired, and refuses assistance. But as most seniors don’t get around to doing this, family caregivers do sometimes have to consider some difficult trade-offs when it comes to privacy versus health, safety, or other goals.

Relevant HIPAA FAQs and other information:

If the patient is not present or is incapacitated, may a health care provider still share the patient’s health information with family, friends, or others involved in the patient’s care or payment for care?

Under HIPAA, when can a family member of an individual access the individual’s PHI from a health care provider or health plan?

Incompetence & Losing Capacity: Answers to 7 FAQs

4. Does a power of attorney for healthcare give me the right to access my parent’s health information?

HIPAA gives a patient’s  authorized “personal representative” the right to access information. A personal representative is defined as a person authorized, under State or other applicable law, to act on behalf of the individual in making health care related decisions.

So yes, if you are the durable power of attorney for healthcare, then you will have a right to access your parent’s health information, provided you are currently authorized to act.

A power of attorney document should specify under what conditions the agent can act. Some are “springing,” which means the agent can only act if the..

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Have you ever wondered whether it’s worth your while to encourage an older person to start exercising?

In 2014, the top-notch journal JAMA published the results of a fantastic research project: a study in which 1635 sedentary older adults (aged 70-89) were assigned to get either a structured exercise program, or a program of “successful aging” health education. The researchers called it the Lifestyle Interventions and Independence for Elders (LIFE) study. (You can read the full study here.)

During the LIFE study, the two groups were followed for a little over 2.5 years. And by the end of the study, guess which group of volunteers was more likely to still walk a quarter of a mile (without a walker)?

That’s right. When it came to avoiding “major mobility disability” — which the researchers defined as becoming unable to walk 400 meters or more — a structured exercise program was better than a program of healthy aging education.

Specifically, the researchers found that 30% of the exercisers experienced a period of major disability, compared to 35.5% of the seniors enrolled in the healthy aging education program.

This is a very encouraging finding! That said, it’s also a bit sobering to realize that even with exercise, almost 1 in 3 older adults experienced a period of limited mobility, of which half lasted 6 months or more.

In this post, I’ll share some more details on this study, because the results provide a wonderful wealth of information that can be helpful to older adults, family caregivers, and even geriatricians such as myself.

Want to know how often the exercisers experienced “adverse events”? (Hint: often!) Wondering just what the structured exercise program involved? (Hint: more than walking!)

Let’s dig into the details! At the end of this post, I’ll share my list of key take-home points for older adults and family caregivers.

Key features of the exercise in aging study

Who were the study volunteers? Whenever you read about a research study, it’s important to understand how the study volunteers compare to the older adults in *your* life. One of the many things I love about this study is that they purposefully enrolled older adults who were sedentary, and physically vulnerable. To identify vulnerable adults, the researchers looked for volunteers who could walk a quarter of a mile, but showed signs of physical weakness on a test known as the Short Physical Performance Battery (SPPB).

(The SPPB includes tests very similar to the Timed Up and Go, the 30 Second Chair Rise Test, and the 4 Stage Balance Test. These tests are often part of assessing an older person’s risk for falls; you can watch short videos demonstrating these tests here: Videos Illustrating Otago Exercises for Fall Prevention.)

Specific criteria for the study volunteers included:

  • Age 70-89 years
  • Sedentary at the start of the study, meaning  less than 20 min/wk of regular exercise in the past month
  • Evidence of high risk for mobility disability, based on a score of 9 or less (out of 12) on the Short Physical Performance Battery. Results on this test have previously been shown to predict future disability.
  • Able to walk 400 m in less than 15 minutes, without a walker or the help of another person.
  • No major cognitive impairment (i.e. no Alzheimer’s or other dementia)

Ultimately, of the 1635 older adults who completed the study, about two-thirds were women. I found the list of chronic medical conditions interesting: 70% had hypertension, about 25% had diabetes, and 15% had chronic obstructive pulmonary disease.

What was the exercise intervention? The older adults assigned to exercise received a very structured and organized program of physical activity. People were ramped up toward a goal of  150 minutes/wk of walking, along with additional activities to improve strength, balance, and flexibility. Here are some specifics:

  • In-person activity sessions at the study center twice a week, plus home-based activity 3-4x/week.
  • Daily walking at moderate intensity, goal of 30 minutes/day
  • Lower extremity strength training using ankle weights (2 sets of 10 repetitions), goal 10 minutes/day
  • Balance training and large muscle flexibility exercises, goal 10 minutes/day of activity

Of note, the study provided personalized assistance, and helped the older participants slowly work up to these goals. The study also included a protocol to safely restart the exercise program after a hospitalization or other interruption. (For more on the exercise protocol, see this journal article which describes it in detail.)

What was the health education intervention? Half of the study volunteers participated in a health education program focused on “successful aging,” rather than the exercise program. For the first 6 months, this involved weekly workshops on various topics related to health and aging, followed by monthly sessions thereafter.

Per the study report, these topics included ” how to effectively negotiate the health care system, how to travel safely, preventive services and screenings recommended at different ages, where to go for reliable health information, nutrition, etc.” The health education sessions also included 5-10 minutes of gentle exercises.

An informational brochure on physical activity was provided at the first successful aging session, but otherwise physical activity topics weren’t included in the workshops. However, the LIFE researchers noticed that many study volunteers in the health education group began exercising during the study.

Overall, the researchers noted that the physical activity group maintained an average of 218 min/week in walking and weight training activities, whereas the health education group maintained an average of 115 min/week.

What were the results? The main outcome of interest was whether study participants developed “major mobility disability,” which the researchers defined as being unable to walk 400 meters (a quarter of a mile) unassisted, within 15 minutes.  Here’s what the researchers observed over the 2.5 year follow-up period:

  • Major mobility disability happened to 30% of the exercisers, versus 35.5% of the healthy aging education group.
  • Persistent major mobility disability — meaning disability lasting at least 6 months — happened to 14.7% of the exercisers and 19.8% of the education group
  • “Serious adverse events” — usually a hospitalization — happened to 49.4% of the exercisers, and 45.7% of the health education group (a difference that was not statistically significant). The reasons for hospitalization were quite varied, and often seemed unrelated to the exercise study.
  • Among the exercisers, almost 60% had to go on medical leave at least once. Half of the medical leaves lasted longer than 49 days.
  • 5.1% of the exercisers died, compared to 5.9% in the health education group. (This difference was not statistically significant.)
Other findings based on the LIFE study

A good randomized trial, such as LIFE, will often result in several different published research papers. That’s because different projects will use the same original data set, but analyze and report on different outcomes of interest.

Since the publication of the main LIFE findings in 2014, several related studies have been published.

Unfortunately, the results were disappointing, in that the exercise intervention didn’t seem to help with many health outcomes of interest to older adults.

In particular, participants assigned to exercise didn’t seem to experience better cognitive outcomes, fewer cardiovascular events, fewer serious fall injuries, or less need for help with key life tasks.

Here are the details related to these studies:

Effect of a 24-Month Physical Activity Intervention vs Health Education on Cognitive Outcomes in Sedentary Older Adults: The LIFE Randomized Trial (2015)

  • Participants in the LIFE study completed a series of cognitive tests at the start of the study, and after 24 months.
  • Based on their cognitive tests and other factors, participants were also assigned one of three cognitive classifications at the beginning and end of the study: no cognitive impairment, mild cognitive impairment (MCI), or dementia.
  • Results:
    • 13.2% of the physical activity group developed MCI or dementia by 24 months compared with 12.1% of the health education group. This difference was not statistically significant.
    • The exercise intervention did not seem to result in better cognitive testing results.
  • Conclusion:
    • The exercise intervention provided in the LIFE trial did not seem to result in better cognition. Participants in the exercise intervention did not experience lower rates of MCI or dementia.

Cardiovascular Events in a Physical Activity Intervention Compared With a Successful Aging Intervention
The LIFE Study Randomized Trial (2016)

  • Participants in the LIFE study were followed for 2.6 years and the occurrence of cardiovascular events was tracked.
    • Tracked events included strokes, heart attacks, hospitalizations for heart failure, and death from cardiovascular disease.
  • Results:
    • New CVD events occurred in 14.8% of the physical activity participants and in 13.8 % of the health education participants. This difference was not statistically significant.
  • Conclusion:
    • The exercise intervention provided in the LIFE trial did not seem to reduce participants’ risk of cardiovascular disease.

Effect of structured physical activity on prevention of serious fall injuries in adults aged 70-89: randomized clinical trial (LIFE Study) (2016)

  • Researchers counted serious fall injuries among all participants in the LIFE trial.
    • Serious fall injuries were defined as a fall that resulted in a clinical, non-vertebral fracture or that led to a hospital admission for another serious injury.
  • Results:
    • Over the 2.6 year follow-up period, a serious fall injury was experienced by 9.2% of participants in the physical activity group and 10.3% in the health education group. This difference was not statistically significant.
  • Conclusion:
    • The exercise intervention provided in the LIFE trial did not reduce the risk of serious fall injuries.

Effect of Physical Activity on Self-Reported Disability in Older Adults: Results from the LIFE Study (2017)

  • Participants in the LIFE study were regularly interviewed as to any difficulties managing Basic Activities of Daily Living (BADLs) and Instrumental Activities of Daily Living (IADLs).
  • Results:
    • Over an average follow-up of 2.6 years, the overall occurrence of BADL dependency was essentially the same among the two groups: 15.2% of the physical activity participants and 15.1% of the health education participants.
    • The groups also had similar rates of BADL disability and IADL disability.
    • Dependency was defined as “receiving assistance” or “unable” to do ≥1 activities. Disability was defined as having “a lot of difficulty” or “unable” doing ≥1 activities.
  • Conclusion:
    • Although the LIFE exercise intervention did reduce major mobility disability among participants, it didn’t result in less difficulty managing life tasks.
Take-home points for older adults & family caregivers

The New York Times coverage of this study was titled “To Age Well, Walk.” It’s a good article and I agree with the media’s general conclusion, which is that a walking program is healthy and is doable, even in people who are older and start off with physical weaknesses.

That said, I think this study — and the related findings — highlights many additional issues that family caregivers should keep in mind:

  • Getting an older person to exercise requires consistency and a plan. This study didn’t test how a structured program compares to a far more common scenario, which is that either a doctor, or an adult child (or both), tell a sedentary older adult to walk more.

If you want your older loved one to get moving, I recommend you start by asking the doctor about any contraindications or concerns. Assuming the doctor gives an ok, you’ll then want to think hard about how to make it feasible and sustainable. For example, people of all ages tend to find it easier to exercise with another person, or a group, because it helps maintain motivation. And don’t forget that slowly ramping up the activity will be important for most sedentary adults.

You can certainly ask your loved one’s doctor for a recommendation on where to find an exercise program. But in my experience, most docs will not know where to send you, unless their own healthcare system has activity program for seniors. So you might have to sleuth around a bit to find something suitable.

Once you have a plan for exercise, try to find a way to track the daily exercise, via a pedometer or other device. (Those fancy new fitness trackers might come in handy for this purpose.) Most people like being able to see their progress, although they may not bother to track it unless the tracking is easy.

  • Physically vulnerable older adults are fairly likely to have a period of reduced mobility. I always tell people to hope for the best, but plan for the likely. Even with exercise, this study found that almost 1 in 3 seniors had a period of reduced walking ability. So I would recommend that all older adults and families consider what they’d do if this happened to them. Can the older person’s home be managed with a walker?
  • Hospitalizations are common. Almost half of the older adults in this study experienced at least one hospital stay, over 2.5 years. So if you are caring for someone similar to these study participants, it’s a good idea to have some planning in place, in case you have to help your older loved one through an emergency or a hospital stay. What does this type of planning look like? Well we could do a whole course on that topic, but at a minimum, I would say:
  • Exercise is not guaranteed to solve all your health worries. Getting a sedentary older person to start exercising more is a terrific idea, and I would certainly encourage people to pursue this. But it would be a mistake to assume that this, in of itself, is enough to reduce the risk of cognitive decline, or cardiovascular disease, or eventual declines of independence, or of any of the other things that we don’t want our older loved ones to experience.
    • Along with exercise, be sure to look into other proven ways to help older adults prevent or delay any health problems you may be concerned about. For instance, blood pressure treatment has been shown to reduce cardiovascular events in older adults with high blood pressure.
    • It’s also probably best to accept that despite the best efforts of seniors and family members, disability and difficulties will eventually happen to many older adults. So don’t just hope for the best and don’t forget to prepare for the possibility of future difficulties. No one likes to think about this, but families who plan ahead often experience a little less stress and difficulties. You can find my tips on planning ahead here: Addressing Medical, Legal, & Financial Advance Care Planning.

Now, if you’ve been interested in helping older adults get more exercise, I’d love to hear from you in the comments below.

What have you found works well, to help aging adults get regular exercise?

The post How Exercise Helps Aging Adults:
Key benefits (and disappointments) from a landmark study
appeared first on Better Health While Aging.

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