11 posts categorized "The TGB Geriatrician"

THE TGB GERIATRICIAN: Aches and Pains

The TGB Geriatrician is Dr. Bill Thomas (bio), a world-renowned geriatrician, author, blogger (ChangingAging) and creator of the Eden Alternative.

Most recently, he has partnered with the Picker Institute, a leading foundation for health care reform that places a person's needs, interests and desires at the center of their care. Dr. Thomas and Picker operate an advocacy program called RealCareNow to promote patient-centered care – of which this series on Time Goes By is a part.


A couple of weeks ago here at TGB, we had a lively conversation about the common aches and pains that seem to accompanying getting older for most of us. I decided it would be a good discussion to have with Bill Thomas.

Special Note: Next Tuesday, 25 January, Dr. Bill Thomas will host a live internet discussion with another geriatrician, dementia expert Dr. Al Power, to talk about the ethics surrounding early diagnosis of Alzheimer's disease. You can join the live discussion at 11:30AM eastern U.S. time next Tuesday here.


SOCIAL SECURITY UPDATE
Yesterday, I asked you to write President Obama to urge him to refuse to cut Social Security. If you haven't done that, please do. Our messages are read.

Now Nancy Leitz, who is a long time contributor to The Elder Storytelling Place, has forwarded a link to moveon.org which is hosting a petition to President Obama to oppose cuts to Social Security. You can sign it here. It doesn't hurt to do both – write and sign the petition.


At The Elder Storytelling Place today, Linda Carmi: Together Our Journey



THE TGB GERIATRICIAN: Balance and Avoiding Falls

The TGB Geriatrician is Dr. Bill Thomas (bio), a world-renowned geriatrician, author, blogger (ChangingAging) and creator of the Eden Alternative.

Most recently, he has partnered with the Picker Institute, a leading foundation for health care reform that places a person's needs, interests and desires at the center of their care. Dr. Thomas and Picker operate an advocacy program called RealCareNow to promote patient-centered care – of which this series on Time Goes By is a part.


After our last conversation with Bill about Elder Energy Budgets, several of you left questions about difficulties with balance and how we can help avoid falling. So today's video tackles just that.

We haven't yet sorted out how to get transcripts made, so for people who have hearing deficits, here are Bill's bullet points:

  • Number 1: You do not lose your ability to balance just because you age.

  • Balance is a set of skills and abilities. Tai chi provides some of the best balance work Bill knows of.

  • Yoga is wonderful way to increase balance skills.

  • Get a prescription from your physician for physical therapy to do balance training.

  • Some health care providers have developed a sort of balance boot camp that can give you common-sense tricks to help maintain balance and avoid falling.

  • Wii is a fantastic, safe way to increase balance skills and also provides measurements to show you how you're doing.

[Is there an elder health issue you'd like Dr. Thomas to discuss? Leave your suggestions in the comments below and they may turn up in a future video. Remember, Dr. Thomas cannot advise on specific personal health problems.]


At The Elder Storytelling Place today, Rita Kenefic: What More Could One Ask?



THE TGB GERIATRICIAN: Elder Energy Budget

The TGB Geriatrician is Dr. Bill Thomas (bio), a world-renowned geriatrician, author, blogger (ChangingAging) and creator of the Eden Alternative.

Most recently, he has partnered with the Picker Institute, a leading foundation for health care reform that places a person's needs, interests and desires at the center of their care. Dr. Thomas and Picker operate an advocacy program called RealCareNow to promote patient-centered care – of which this series on Time Goes By is a part.


category_bug_geriatrician.gif In the past here, we have discussed how our energy and stamina have waned as we've gotten older. In this week's episode of The TGB Geriatrician, Dr. Bill Thomas and I talk about what he calls elders' “energy budget.”

[EDITORIAL NOTE: We are working on creating transcripts for these videos for readers who are hearing impaired and expect to include them soon.]

Children and elders have a number of things in common and when Dr. Thomas mentioned kindergarteners' nap time, that clicked with me. I do take afternoon naps now and then when I feel particularly tired, but I wake feeling drugged and sluggish so I save them for when I have evening plans to not fall asleep in the soup.

I know that I don't have heart problems and what was most useful to me was the idea of budgeting my energy better throughout the day, not rushing through my to-do list as fast as possible. I've been trying this in the ten days since Dr. Thomas and I recorded this video – even on Thanksgiving Day – and it's helping.

On days when weather allows, instead of soon after sunrise, I've been postponing my walk to mid or late morning after I've gotten a few things done. I'm experimenting with any shopping or errands out of the house to later in the afternoon. So far, the new pacing seems to have helped to keep me from collapsing before I want my day to be done.

I think part of the change is psychological; when I know ahead of time that I have somewhere to be at 3PM, I don't allow my energy to flag until I am home again. And, I'm giving myself a reading break for an hour at lunch time before returning to working on a blog post, vacuuming, cleaning the bathrooms or whatever else was on my list for the day.

Dr. Thomas's phrase, energy budget – which I'd never heard before – says it succinctly and has helped me to think about organizing my time in a new way.

[Is there an elder health issue you'd like Dr. Thomas to discuss? Leave your suggestions in the comments below and they may turn up in a future video. Remember, Dr. Thomas cannot advise on specific personal health problem.]


At The Elder Storytelling Place today, Steve Kemp: LONG LOST NEWS: President Denies Codpiece



The Return of the TGB Geriatrician

category_bug_geriatrician.gif Newcomers to this blog may not know that back in 2008, one of our contributors was Dr. Bill Thomas, a world renowned geriatrician who is also an author, blogger, creator of the Eden Alternative and it is one of his books, What Are Old People For? that has informed this blog from its beginning.

BillThomas2010 Most recently, Dr. Thomas has partnered with the Picker Institute, a leading foundation for health care reform that places a person's needs, interests and desires at the center of their care. Together, Picker and Dr. Thomas have created an advocacy program called RealCareNow that uses blogs, videos and other social media to promote patient-centered care.

And now, Time Goes By will be part of that reform movement. Beginning today and regularly thereafter, Dr. Thomas and I will chat via video about elder health.

One day last week, we recorded the first episode. I've coached a zillion people about how to relax on camera but as you will see, I'm not very good at it myself. So please forgive my awkwardness – I'll get better.

I'm looking forward to the future of this collaboration. Edited versions will be posted here and at YouTube. Soon, there will be live episodes that will incorporate a chat function so that you can send your comments and questions during the show.

Another way that we would like you to participate is to send in your elder health and medical questions for Dr. Thomas. You can do that today, in the comments below and we will select some for future shows. The only caveat – I'm sure you are aware of this – is that Dr. Thomas cannot answer questions specific to your personal health issues.

I'm so pleased and proud that Dr. Thomas as rejoined Time Goes By. As Bogart once said, I think this is the start of a beautiful – and healthy – friendship between Dr. Thomas and TGB readers.


At The Elder Storytelling Place today, B.J. Allen: Waiting Room



Dialing For Doctors

category_bug_geriatrician.gif [EDITORIAL NOTE: The TGB Geriatrician is a bi-weekly column written by Dr. Bill Thomas (bio) for Time Goes By to give us the information we need to help us navigate the health issues of aging. Dr. Thomas also writes his own blog at Changing Aging.]

USA Today goes in depth with a front pager on the issue of physician economics and the future of the aging baby boom. The story is a follow up on this earlier report:

"Millions of baby boomers are about to enter a health care system for seniors that not only isn't ready for them, but may even discourage them from getting quality care.

"’We face an impending crisis as the growing number of older patients, who are living longer with more complex health needs, increasingly outpaces the number of health care providers with the knowledge and skills to care for them capably,’ said John W. Rowe, professor of health policy and management at Columbia University.

“Rowe headed an Institute of Medicine committee that released a report Monday on the health care outlook for the 78 million baby boomers about to begin turning 65."

USA Today, 14 April 2008

Here is the latest news:

"Medical students are shying away from careers in general internal medicine, which could exacerbate the U.S. doctor shortage expected by the time the youngest Baby Boomers head into their senior years, researchers report today.

“Only 2% of 1,177 respondents to a survey of students at 11 U.S. medical schools said they planned to pursue careers in general internal medicine, according to the new study…

“According to one estimate, the USA will have 200,000 fewer doctors overall than it needs by 2020, according to the new report. Meanwhile, the number of older Americans is expected to nearly double between 2005 and 2030.

“’Many medical students are turned off by the thought of caring for chronically ill patients and the amount of paperwork general internists must deal with,’ says lead author Karen Hauer, a general internist on the faculty of the University of California-San Francisco.

"’They rated the intellectual aspects of the field highly, and they rated continuity of care appealing,’ Hauer says. ‘When you put the whole package together, it's too hard.’"

“On top of the workload, a "research letter" in the same issue of JAMA as Hauer's study ranked internal medicine as one of the lowest-paid medical specialties…

“Radiologists topped Ebell's list, with a starting salary of $350,000, not to mention, Hauer notes, more regular hours than general internists.

“Their amount of debt [following medical school] didn't seem to influence their choice of specialty in her survey, Hauer says.

“Rather students focused more on quality of life factors such as income and work hours, which did steer them away from general internal medicine."

USA Today, 9 September 2008

The problem with a health care system that is driven exclusively by the economic interests of the participants is that what the market rewards (that is, large numbers of radiologists) and what people need (large numbers of general internists) do not match up.

I raise this issue because it is a sub-species of the more general question, "Is health care a market good (like cars and candy canes) or is it a right?"

We as a society share the conventional wisdom that people do not have a "right" to cars and candy canes. If we want to have these things we have to pay for them. Health care is, somehow, different. Who would say that a child with pneumonia should be left to suffer because his/her parents cannot afford treatment. There is a law that requires hospitals to treat any person who comes to the emergency room, regardless of their ability to pay.

This reminds me of a bit of cynical medical humor I learned in medical school: Doctors who we thought were overly concerned with a patient's ability to pay were said to demand a "wallet biopsy" before they would be willing to accept the patient."

The profit motive has contributed to progress in medicine and the healing arts. I would not want to go back to a time when medicine was a small-time cottage industry of not very well educated physicians making use of a narrow range of not very effective treatment. It is also true that the market does a terrible job of matching resources to need.

So the wealthiest nation in the world is now facing the greatest age boom and will almost certainly live through it without the doctors we need.

EDITORIAL NOTE: You can subscribe to The TGB Geriatrician column by email by clicking here. Subscribe to the daily Time Goes By blog by email or RSS in the upper right corner of this page.

[At The Elder Storytelling Place today, Tom Speaks recalls his trucking days in Hard Working '50s.]



Exhorbitant Drug Price Increases

category_bug_geriatrician.gif [EDITORIAL NOTE: The TGB Geriatrician is a bi-weekly column written by Dr. Bill Thomas (bio) for Time Goes By to give us the information we need to help us navigate the health issues of aging. Dr. Thomas also writes his own blog at Changing Aging.]

“Drug companies are quietly pushing through price hikes of 100 percent or even more than 1,000 percent for a very small but growing number of prescription drugs, helping to drive up costs for insurers, patients and government programs.

“The number of brand-name drugs with increases of 100 percent or more could double this year from four years ago, researchers from the University of Minnesota say. Many of the drugs are older products that treat fairly rare, but often serious or even life-threatening, conditions.

“Among the examples: Questcor Pharmaceuticals last August raised the wholesale price on Acthar, which treats spasms in babies, from about $1,650 a vial to more than $23,000. Ovation raised the cost of Cosmegen, which treats a type of tumor, from $16.79 to $593.75 in January 2006.

“The average wholesale price of 26 brand-name drugs jumped 100 percent or more in a single cost adjustment last year, up from 15 in 2004, the university study found. In the first half of this year, 17 drugs made the list.”

USA Today, 8 August 2008

It is not a "free market" when producers can arbitrarily push through price increases at will for products people need to survive, and nothing can be done to stop them. Where is the pressure to lower prices?

By some bizarre logic, we are expected to accept the "workings of capitalism" when companies raise prices by 100 percent, and we are supposed to object to our government acting to bring prices down by increasing competition.

EDITORIAL NOTE: You can subscribe to The TGB Geriatrician column by email by clicking here. Subscribe to the daily Time Goes By blog by email or RSS in the upper right corner of this page.

[At The Elder Storytelling Place today, Susan Fisher tells us how she learned the kid-friendly explanation for thunder The Angels are Bowling.]



Generic Drugs Redux: Reader Beware

category_bug_geriatrician.gif [EDITORIAL NOTE: The TGB Geriatrician is a bi-weekly column written by Dr. Bill Thomas (bio) for Time Goes By to give us the information we need to help us navigate the health issues of aging. Dr. Thomas also writes his own blog at Changing Aging.]

When I was young, I was a very poor student. I failed sixth grade, but the teacher passed me anyway saying, “I’m not letting you get away with it!” One reason she passed me is that she knew me as a voracious reader. I still am.

One of the most important things I have learned from all that reading is that not all books are created equal. Not all authors are equally credible. Not everything that is written down can be trusted. That might seem cynical, but it really isn’t. A good reader asks questions:

Who is this author?
What are the author’s qualifications?
What are the author’s biases?
What are the author’s strengths?
What are the author’s weaknesses?

So it is with this background that I noticed a TGB comment in response to my last column here about Generic Drugs. It included the following:

“But these other filler items can vary considerably. I think people would be well-advised to be aware of such possibilities if they think they're experiencing a different response from their generic. A quick search turned up this link which is not alarmist, but adds some specifics about brand names vs generics.”

This is a solid, well-written comment and it includes a link to source information.

Yummy!

Of course I followed the link, and found this:

“Some people are allergic to some excipients. In addition, a person's body may have become accustomed to the entire mix of active an inactive ingredients in one manufacturer's drug, and changing the mixture - even if there is no allergy to a new ingredient - may cause a change in response to the medication.”

This statement is almost entirely false. First, excipients are the inactive ingredients in medications and they are selected on the basis of their lack of allergenicity. Here is a partial list (a more complete list here):

  • Cellulose: ethylcellulose, methylcellulose, hydroxymethylcellulose, hydroxypropyl, microcrystalline – obtained from fibrous plant material (woody pulp or chemical cotton)
  • Dextrans: partially hydrolyzed corn or potato starch
  • Dextrose: powdered corn starch
  • Iron oxide: used as a coloring agent
  • Sucrose: sugar, also known as refined sugar, beet sugar or cane sugar
  • Maltodextrins: a starch hydrolysate that is obtained from corn in the United States but can also be extracted from wheat, potato or rice.

The point is that we encounter “excipients” all the time and in amounts far greater than those used in pills. If a person truly has an allergy to an excipient, the problems would extend far beyond medications.

The second part of the statement,

“...a person's body may have become accustomed to the entire mix of active an inactive ingredients in one manufacturer's drug, and changing the mixture - even if there is no allergy to a new ingredient - may cause a change in response to the medication,”

is false. False.

False.

The FDA says:

“A generic drug is a copy that is the same as a brand-name drug in dosage, safety, strength, how it is taken, quality, performance and intended use. The FDA requires that all drugs be safe and effective. Since generics use the same active ingredients and are shown to work the same way in the body, they have the same risks and benefits as their brand-name counterparts.”

So, on the one hand I have the undocumented assertions of Marcia Purse and on the other hand, I have the explicit policy of the FDA. Let’s compare.

Here is Marcia Purse's job according to her profile posted at LinkedIn:

Office Manager, Airgun Designs USA (Privately Held; 1-10 employees; Sporting Goods industry) May 2001 — Present (7 years 3 months)

Airgun Designs USA makes paintball guns and accessories, but I've never played paintball, and at the only tournament I attended, which was Shatnerball 3, I was working so much at the registration booth that I never saw any of the game.

Although my title is Office Manager, since July of 2007 I have worked remotely at this job, handling accounting, sales, customer service and human resources. We just haven't come up with a better title!

Seriously, when it comes to the question of generics and brand name drugs, I give more weight to the FDA than I give to the office manager at Airgun Designs USA

Again, let us weigh the qualifications:

  • The FDA v. the Office Manager of Airgun Designs USA
  • Office manager of Airgun Designs USA v. the FDA

Okay, in this matter, I am going to give greater weight to the views of the FDA.

Some might think that I am being disrespectful of Ms. Purse, but I am not. I’ve read some of her writing about mental illness and I think she has valuable things to say. Also, she comes across as a really nice person. I am unwilling, however, to accept her unsupported assertions about brand name and generic medications. She is not a credible authority on this subject.

Two final points:

Crabby Old Lady sent me a note that said:

“I laughed when I first read your Generics column - the part about ‘I know you're out there thinking generics are inferior’. Since then I've been shocked at how many responded by telling you that you're wrong. I'm not unaware that some people are misinformed about generics, but still - the number who disagreed with you really surprises me.”

Big Pharma spends millions of dollars actively undermining the reputation of generic medications. That money has an impact on public opinions and attitudes. No surprise there.

Last, I encourage TGB readers to be critical. Ask questions. Probe. Ask for links. Reserve judgment until you can properly evaluate the source of the information you read on the internet.

EDITORIAL NOTE: You can subscribe to The TGB Geriatrician column by email by clicking here. Subscribe to the daily Time Goes By blog by email or RSS in the upper right corner of this page.

[At The Elder Storytelling Place today, Norm Jenson tells a kid's tale of having Gone Fishing.]



Generic Drugs

category_bug_geriatrician.gif [EDITORIAL NOTE: The TGB Geriatrician is a bi-weekly column written by Dr. Bill Thomas (bio) for Time Goes By to give us the information we need to help us navigate the health issues of aging. Dr. Thomas also writes his own blog at Changing Aging.]

I know you are out there. I know that there are still some people who see generic medications as being somehow inferior to brand name drugs. This is a big issue, worth billions of dollars to major corporations, but I do have a funny story to tell you about generics.

A few years back, the anti-anxiety medicine Xanax™ lost its patent protection and became available as a generic called Alprazolam. A patient of mine who was, I'll admit, a very anxious person, called me at home on a Saturday after seeing me in the office on a Friday. "Hey Doc," he said, "this new medicine you put me on doesn't work!"

I asked a few questions and slowly came to understand that when he had refilled his prescription, the pharmacist had supplied him with the just-released, lower-cost generic version of the drug.

I explained this to him and he continued to insist that something was wrong. He'd taken the new pills as prescribed and they "didn't work at all. Nothing." I learned early on in my medical career that it is never a good idea to argue with patients, so I told him I would talk to the pharmacist and then call him back.

I was living in a small town then and was friends with the pharmacist (I'll call him John since that is his name.) John confirmed that he had supplied our patient with the generic version of Xanax. Then came the kicker. "You know Pfizer* makes the brand name (called Xanax) and the generic (called Alprazolam) on the same production line in the same factory." In fact, the only difference was the shape and color of the pill.

I called my patient back and explained all this - that it was the same medicine made in the same place by the same people with the same machines. It just looked different and cost less. He didn't care. He wanted the Xanax that he knew and nothing else. What could I say? I called John back and made the switch.

So what was going on here?

  1. Pill colors and shapes are designed by marketing teams, not doctors. Color and shape are related to sales. That's why Viagra is a blue football and not a pink softball. Drug companies spend billions trying to persuade Americans that color and shape matter. Remember the "purple pill?"
  2. The chemical compound inside brand name drugs and their generic equivalents are exactly the same. It's like the salt in salt shakers, you can pay big money for engraved silver salt shakers or you can save money and buy simple glass salt shakers. But, in the end, the salt inside the shaker is exactly the same - it is sodium chloride.
  3. Drug companies have the right to force generic drug makers to make their pills a different color and shape. They rely upon the confusion sown by this difference to support sales of the brand name drug. As you can see in the case of my Xanax loving patient, it works.

  4. Generics are manufactured according to the same rigorous standards that govern the manufacture of brand name drugs. They are Cadillac drugs for sale at Chevrolet prices.
  5. The big, brand name drug makers have started to make what are called "reverse payments" to generic drug makers. Because of the huge profits that they make on the brand name drugs, they are able to pay generic drug makers to NOT MAKE GENERICS. Keeping competition from an equally good product that can be sold for less is good for the drug makers' profit-and-loss statements and bad for the health and healthcare of Americans.

Clear? Not as clear as you might think. Very soon after this post goes up someone is going to write a comment that reads something like: "Generics don't work on me. My doctor says that I have to have the brand name versions." Here is what I love about blogging at TGB, I get to tell you the story behind the story.

First, your doctor doesn't think that "generics don't work on you." She knows that your body reacts to generics the same way that it reacts to brand name drugs because, inside the body, brand name drugs and generics are the same thing.

Fillers and colorings are often blamed when patients say generics don't work, but generics use the same fillers as the brand names and the amount of food coloring in a pill is incredibly tiny. Problems with fillers and colorings are theoretically possible but the fact is, they are tremendously rare. Brand name drugs and generics are equivalent inside the body.

Second, your doctor has the same policy I do. She has explained that generics are just as good and that the only real difference is the price. You were not convinced and she is not going to waste time arguing with you. End of story.

Third, you should choose generics whenever you can. Why? I think that it is a matter of intergenerational fairness. Every dollar spent on brand name drugs that are no longer under patent and thus have a generic equivalent, is a dollar fewer for childhood immunizations, prenatal care, school health clinics and all the rest.

We all share an obligation to be thrifty with the health care resources we use. We are a rich nation, possibly the richest nation in history, but we are not so rich that we can afford to spend money foolishly on expensive pills simply because we are accustomed to a certain shape and color.

I look forward to reading this comment thread.

* The drug was developed by Upjohn before it merged with Pfizer.

[At The Elder Storytelling Place today, Herchel Newman attempts to exorcise the evil demons of modern life in Utter Frustration. ADDITIONAL NOTE: Today is the last day to vote in the Excellence in Storytelling Award. Polling closes at midnight eastern U.S. time. Links to nominated stories are here.]

EDITORIAL NOTE: You can subscribe to The TGB Geriatrician column by email by clicking here. Subscribe to the daily Time Goes By blog by email or RSS in the upper right corner of this page.


Quarterstaff Revolution

category_bug_geriatrician.gif [EDITORIAL NOTE: The TGB Geriatrician is a semi-monthly column written by Dr. Bill Thomas (bio) for Time Goes By to give us the information we need to help us navigate the health issues of aging. Dr. Thomas also writes his own blog at Changing Aging.]

In 1992, The New York Times took a look at the research AARP was doing on walking canes:

”Many people who use canes injure themselves because they don't do the necessary research before buying one. That is an early conclusion of a continuing study on canes sponsored by the American Association of Retired Persons.

“According to Dr. Margaret Wylde, vice president of the Institute for Technology Development in Oxford, Miss., which is conducting the study, the conclusion is based on a review of recent medical and rehabilitation literature and on more than 1,000 letters solicited from A.A.R.P. members who are regular cane users.

“Some of the most serious damage, Dr. Wylde said, can result from the cane's grip. Carpal tunnel syndrome, a painful ailment, can result from any repetitive motion like typing or using a cane.”

There are two reasons people use walking canes.

  1. To improve balance by providing a third contact point with the ground
  2. To redistribute weight away from an injured or arthritic lower limb

As a physician, I have never really liked walking canes. Here is one patient's experience:

”I noticed several problems within the first five minutes. My triceps were quickly fatigued as they worked to hold my weight up.

“As a result, my scapula elevated to relieve the triceps, putting strain on my rotator cuff. This "shrugging" effect could be somewhat offset by lowering the height of the handle below my waist, which served to extend the arm and reduce the amount of elevation in the shoulder.

“The handle of the cane was designed in such a way that the grip increased in broadness from the neck of the handle to the end, providing a wider, flatter surface where the palm would rest.

“Unfortunately, the result was not a more comfortable feel, but rather a terrible dorsiflexion combined with ulnar deviation in the wrist and a bruised hamate bone where the weight was concentrated. I felt tweaks of pain all day long in my wrist and shoulder which continued into the night, long after I had ended my experiment.

“Aside from design problems, there were several functional problems as well. For instance, each step was accompanied by a jarring vibration which was transferred up the entire length of the arm every time the rubber cane tip struck the concrete. The swing of the cane often had to be initiated by a flick of the wrist, resulting in a constant repetitive oscillation between ulnar and radial deviations.

“Furthermore, adjusting the cane to the correct height was difficult due to a simultaneous push of a button and pull of the shaft requiring relatively dexterous fingers; arthritic hands would be pitifully ineffective.”

PREDICTION! Elders of today and tomorrow are going to give up on the cane, abandoning it in favor of the quarterstaff.

Gandalfgrey5

"Gandalf the Grey carried about with him a spike brown staff which served partly as an agency of his power, as can be seen when he faced the Balrog in Moria. Besides functioning as a useful walking stick, it was also thought to symbolize what he was and his position in the Istari."

There are three reasons I think elders can and will retire the old-time walking cane and embrace the quarterstaff:

  1. The cane places the greatest strain on the smallest muscles and joints (the wrist and forearm). Repetitive use can easily lead to wrist and forearm injury.
  2. The quarterstaff transfers the weight into the shoulder girdle itself. The shoulder joint and its surrounding muscles are much better prepared to handle the load than are the wrist and forearm.
  3. Imagine a scene: an older woman using a bent-top walking cane crosses a building lobby, trying to reach the elevator before the doors roll closed. Now imagine the same scene with the older woman striding across the lobby with the aid of a seven-foot, oak quarterstaff. People hold the door open not because of chivalry, not out of a desire to help little old ladies, but rather because she just looks so damned cool.

Elders are obligated to give younger people clues about how deep and mysterious elderhood can be.

I would like any elders or elders-to-be who read this post to go out and get hold of a walking staff (it does not matter if you NEED one). Go out in public with it and follow your normal routine and have somebody take a picture of you using it. Send the photo to Ronni.

I'll close my appeal with a quote from one of America's greatest walkers...

"Although the vast majority of walkers never even think of using a walking staff, I unhesitatingly include it among the foundations of the house that travels on my back. I still take my staff along almost as automatically as I take my pack. It is a third leg to me - and much more besides.

“On smooth surfaces, the staff helps maintain an easy rhythm to my walking and gives me something to lean on when I stop to stand and stare. Over rough going of any kind, from tussocky grass to pockety rock, and also in a high wind, it converts me when I am heavily laded from an insecure biped to a confident triped…

“It may well be, too, that the staff also gives me a false but subconsciously comforting feeling that I am not after all completely defenseless against attack by such enemies as snakes, bears and men."

- Colin Fletcher, The Complete Walker III, 1984 (page 78)

[AFTERWORD from Ronni: For about the last six or seven years of her life, until she died in 1978, Margaret Mead and I lived across the street from one another in Greenwich Village. I didn't get to spend as much time with her as I would have liked, but we sometimes walked several blocks together on our errands around the neighborhood.

She always used a quarterstaff, although I didn't know it was called that. She looked magnificent and powerful striding down the block, especially in the colder months when she wore a full-length cape. I've known since then that when the time came, I would use a staff and not a cane. Now, with Dr. Thomas's permission for us to do so even if we don't require one yet and the Colin Fletcher quote, I may start sooner.]

[At The Elder Storytelling Place today, Ronni Prior explains why she left the Country Life.]

EDITORIAL NOTE: You can subscribe to The TGB Geriatrician column by email by clicking here. Subscribe to the daily Time Goes By blog by email or RSS in the upper right corner of this page.


Aging in the Land of Nod

category_bug_geriatrician.gif [EDITORIAL NOTE: The TGB Geriatrician is a semi-monthly column written by Dr. Bill Thomas for Time Goes By to give us the information we need to help us navigate the health issues of aging. Dr. Thomas also writes his own blog at Changing Aging.]

The comments about age-related changes in sleep patterns posted in response to Pinnacle of Adaptation, my last column here, reminded me of a patient I wrote about early in my practice.

”She slept an average of 16 hours a day, mostly in blocks of three to four hours at a time. It was clear that she was not distinguishing between night and day and that caused all kinds of problems for her caregivers. I saw the patient regularly and the good news is that, over the next three months, she started sleeping ten hours a day, almost all of them at night! Still, she was prone to napping in the middle of the day. I told the family not to worry; napping is normal at her age.”

Her mother and father were relieved by the changes, having a newborn baby in the house can be tough! It turns out that how we sleep changes as we age. Toddlers do not sleep in the same way a newborn does, nor does the 80-year-old experience sleep the same way a 30-year-old does.

So what do we need to know about age-related changes in sleep patterns? Not surprisingly, older people are more likely to develop sleep-related, medical disorders than younger people. Here are a few of the more common disorders along with their definitions:

  • Nocturnal Leg Cramps: This involves sudden, painful cramping of one or both calf muscles during sleep. The cramp can last for as many as 10 minutes, and the resulting pain from the cramp can last for much longer.
  • REM Sleep Behavior Disorder (RBD): The person is in REM (dreaming) sleep and acts out violent dreams through body movements and sounds. This disorder generally occurs in older men, but can occur in others as well.
  • Sleep Bruxism: Also known as teeth grinding during sleep, sleep bruxism is when a person involuntarily grinds or clenches their teeth while sleeping. This can lead to teeth wear and jaw discomfort. The method for treating teeth grinding is usually a mouth guard that is worn during sleep.
  • Sleep Talking: This usually occurs during a sleep/wake transition of the sleep cycle. The person can utter sounds or even entire sentences. The sleeper generally does not remember doing this in the morning.

  • Sleep Apnea: Changes in upper airway muscle tone during sleep make breathing difficult. The person experiences shortness of breath, wakes up, breathes and falls back asleep. The pattern can recur hundreds of times a night.

Most of these "parasomnias" have effective treatments you can discuss with your doctor.

Much more common are sleep-related problems that are caused by medications and medical conditions. It's always a good idea to tell your doctor about how you are sleeping even if she doesn't ask and even if you are sleeping well. Few physicians pay enough attention to sleep-related issues and patients are wise to raise the issue.

Sometimes small changes in medical treatment can make a big difference in how I sleep. I remember being a doctor-in-training and prescribing a "water pill" to a patient of mine. It was the right drug and the right dose, but the trouble was that I told her to take it in the evening. She was up half the night running to the bathroom because her doctor (me) didn't know what he was doing.

There are normal, age-related changes in sleep and sleep patterns. The most important thing is to understand what is normal and what is not normal. Here is a short list of normal changes:

  • Sleep efficiency is the ratio of the total time we spend in bed (not counting amorous adventures) and the total time we spend sleeping. Sleep efficiency generally decreases with age.

  • Daytime napping increases with age. It's normal. Enjoy it. Get used to it. Take pride in it. In medical school we used to joke that medical training also teaches students the value of a good nap. I still enjoy a mid-day nap when the opportunity arises.

  • Phase Advance is the fancy medical term for the experience of going to bed earlier in the evening and waking up earlier in the morning. The sleep phase advances as we age. Many older people fall asleep early in the evening, yet awaken much earlier than desired in the morning and cannot fall back to sleep easily.

Changes in sleep can be merely annoying or they can represent a symptom of a more serious medical situation (heart failure, depression, etc.) Sometimes not even your doctor can be sure which is the case. The general rule I follow is that when changes in sleep patterns are merely annoying, they are usually normal. When the changes cause real distress or are combined with other non-sleep related symptoms, it's time to make an appointment with your doctor.

Yawn. I think I'll take a nap.

EDITORIAL NOTE: You can subscribe to The TGB Geriatrician column by email by clicking here. Subscribe to the daily Time Goes By blog by email or RSS in the upper right corner of this page.

[At The Elder Storytelling Place today, Brent Green's story, Saving Us, is most appropriate for the 64th anniversary of D-Day today.]



Pinnacle of Adaptation

category_bug_geriatrician.gif [EDITORIAL NOTE: I am proud today to launch a new category at Time Goes By, The TGB Geriatrician. It's been a long time in planning and I'm proud that Dr. Bill Thomas has agreed to take on the duties of writing this column which will appear in the first and third weeks of each month.

Dr. Thomas is a world-renowned geriatrician and advocate for the dignity of elders. Long-time readers of TGB will be familiar with him from the many times I've quoted from his book What Are Old People For? You can find out more about Dr. Thomas here, and he also keeps his own daily blog, Changing Aging. I know you will welcome him to the TGB fold.]

I am excited about guest blogging here with Ronni Bennett. TGB is a terrific blog and if I can add something of value to this community, I will be happy.

I am a physician and my background is in Family Medicine and Geriatrics.

My approach to medical issues tends to focus more on the big questions of emphasis and interpretation and less on specific remedies. (Although I do get into that from time to time.) In medical school we used to joke that certain professors seemed to have favorite molecules that they studied exhaustively. That's never really been my thing.

What do I mean by big ideas? Well, how about this: I believe that older people are the healthiest people on the planet.

Huh?

Aren't old people sick most of the time? What about all of the billions of dollars we spend on Medicare? What about the statistics that show older people using the most health care resources per capita of any age group?

Those objections are valid, but they miss the deeper reality. In order to become an older person one must first have a healthy childhood, then it is on to decades of healthy adulthood. When the second half of life arrives, a person can already boast of a long span of very good health. The people who are really unhealthy, sadly, do not make it to old age.

Furthermore, statistics show that almost half of all Medicare expenditures are made in the last six months of life. Before the last six months, older people do pretty darn well.

It is true that the second half of life includes experiences related to loss, but it is also true that elderhood is not limited to these things. As we age, we encounter an unexpected and highly significant rise in the power of adaptation. The emergence of adaptability is perhaps the most important and least acknowledged of the virtues of aging.

The young grow accustomed to running faster and jumping higher with each passing year and the middle decades are marked by a struggle against the workings of gravity and time. Fortunately, elderhood provides us with new and supremely useful perspectives on flexibility and the reality of change over time.

An older person wakes up to a new body with new requirements and limitations not once, but many times. This reality batters our relationship to the status quo. Mental, physical and spiritual changes require elders to develop and deploy a string of enterprising strategies and subtle adaptations.

While it is true that muscles weaken in late life, it is also true that older people are less likely to report symptoms of depression than younger people. Hair may turn white, get thin and fall out but, when surveyed, older people often report an enhanced sense of wellbeing. We grow shorter rather than taller, our toenails turn yellow and our arches fall and still, many older people report that their health is good or even very good.

These seeming paradoxes are actually the fruits of adaptation which grow in tandem with and are nourished by the decline in physiological function.

A young man, transported magically into the body of his 80-year-old self would struggle to complete even the most basic tasks. Sitting, standing, dressing and walking would be difficult for him because the thoughtless ease of youth had left him ill-prepared for life in elderhood.

We need old age because it allows the body to instruct the mind in patience and forbearance while the mind tutors the body in creativity and flexibility.

Our culture discounts the fruits of aging. For example, we value (without even realizing that we are doing so) the long springy stride and narrow tandem gait of youth. The young trumpet their virtuosity, wearing preposterous shoes and paying no mind to the terrain underfoot. Actors and politicians have long understood how we unconsciously judge others by their stride. They lengthen and narrow their stride when they are in public and, in doing so, give the appearance of youth.

Trackers can easily determine a person's age by examining their footprints. Compared with the fluid stride of youth, the marks made by an older person can seem tentative and ungainly. This appearance is deceiving. The reality is that when elders walk, they execute a highly evolved, richly detailed strategy that maintains upright ambulation even into the last decades of life.

Old people alter their gait in specific ways that account for very real changes in strength, endurance, coordination, sensation and reaction time. The "shuffling gait" keeps the feet close to the ground and maximizes input from position sensors. The stance is widened to improve balance. The number of steps taken per minute is decreased to accommodate changes in endurance and to allow for increased reaction time.

Keeping a human body upright and moving is a spectacular feat of coordination and reaction under any circumstances. Doing so in the ninth decade of life magnifies rather than diminishes the beauty of this achievement.

When the world's best golfers come together to play a tournament, the course is lengthened and the rough deepened so that their skill might be tested fully. Olympic divers challenge themselves with the most difficult dives, not the easiest. The Tour-de-France includes the most taxing climbs on its route, including some that are rated as "beyond category" in difficulty.

When you see an old woman walking, you are witnessing a similarly exciting, high-level performance. This is a tightly choreographed ballet, the product of decades of refinement. Watch and marvel. Miracles are all around you, once you know where to look.

[NOTE: You are welcome to suggest topics for future columns of The TGB Geriatrician by leaving a note in the Comments section below or sending an email via the Contact link in the upper left corner of this page.]

[At The Elder Storytelling Place today, an announcement.]