Oh! sleep it is a beloved thing..........

Babies can sleep through a thunderstorm, but older people will awaken at the sound of a pin dropping!
The average old person's circadian rhythm changes such that melatonin-induced sleep occurs earlier, say by 8 or 9 pm, and awakening occurs earlier by 4 or 5 am. The "early to bed and early to rise" phenomenon of the older person is well known. The structure of sleep is altered in older persons; non-REM sleep is shortened , and depth of  sleep during this period is decreased, so sleep is fragile. Frequent awakenings also occur because of the urge to pass urine. Distressing symptoms arising from any diseases such as heart and lung disease, or gastric reflux, or joint pains, can cause awakenings.
Medications taken by the older person also disrupt sleep, and it is worth sifting through the drug list and suggest changes. Not many people know that beta-blockers, deriphylline, statins, and steroids, and others, cause insomnia.
In women the menopause is a difficult time as the fluctuations of hormonal levels disrupt sleep.

Sleep problems range from difficulty in falling asleep, to easy awakening, to not feeling refreshed in the morning after disturbed sleep. The distress of the insomniac is impossible to ignore, but difficult to treat without prescribing sleeping pills.  As a result, doctors all over  the world drug their older patients with addictive drugs belonging to the class of benzodiazepines. There is no real estimate of what percentage of the older population in India is on the sleeping pill, but a reasonable guess (needs corroboration with hard data) is that it is upwards of one in every 5 older persons in the urban setting.

The problem with sleeping pills is that they silently take over the body and ..... the mind also perhaps, and make the person vulnerable to many  killers, and here is why;
a) addiction is almost 100%, with patients needing increasing doses (tolerance); the non-benzodiazeoine sedatives such as zolpidem, and zolpiclone are thought to be less addictive.
b) sleep pattern is destroyed, so one function of sleep, which is to "restore" the body, does not happen;
c) daytime drowsiness occurs because the drug's half-life increases in the elderly because it is stored and later released from the increased fat compartment;
d) postural reflexes are weakened, and falls occur more often;
e) acute agitation occurs when the drugs are inadvertantly stopped  when they get ill and are hospitalized, or forget the pills when travelling;
f) but perhaps one of the worst things is that cognitive functions of the brain decline.
In short, one creates a zombie, not immediately, but gradually, whenever one prescribes sedative hypnotics to older people. These drugs should be given for just 7 to 10 days to tide over stressful times, and then discontinued immediately.

 The panacea to insomnia is not a magical potion; but a bit of hard work in the consultation room giving tips on how to promote sleep helps a great deal. 

So here are some golden rules, or the "sleep-inducing charter".
a) Reduce coffee, tea and other caffiene-containing beverages to the barest minimum, and restrict them to early morning.
b) Milk, and bananas, and carbohydrate -containing foods are rich in serotonin, and provide the right stage for sleep when taken as a bedtime snack. Protein foods should be avoided.
c) Exercise promotes sleep, but should not be taken in the evening hours.
d) Sleep-inducing ritual must be practised religiously. The bed must be seen as a place for sleep alone, and of course intimacy! So reading, paperwork, TV watching from the bed are taboo. Lighting, temperature, tranquillity in the bedroom is important. If the person cannot sleep after 40 mins of lying down, he/she must stop counting sheep, and instead should leave the bed and engage in some restful activity such as listening to soft music, or reading. Normally stimulating activities such as sodoku, crosswords, watching TV etc may induce sleep in some people, but could be counter-productive in others.
e) The time of awakening should remain the same, even if  the person feels he/she has not slept enough and is entitled to a late morning.
Instilling these "sleep hygiene" points takes time during the consultation, but can be very effective by encouraging the person to take responsibility for themselves rather than relying on the doctor for a magic potion. Family members are excellant supporters and should be roped in.

A final word: dont be the one to create the zombie; but rather be the caring physician who not only motivates the patient to come off sedatives, but is willing to undertake the hard task of slow and gradual withdrawal.

Eating your way to happy old age

As a doctor caring for seniors I regularly talk to older people about a nutritious diet. A lot of stuff is written about how seniors should eat but unfortunately not much about the difficulties they have following such advice.

For example, drinking of milk. Milk is as good for ageing persons as it is for babies; 250 ml (1 glass) of milk  contains 300 mgs of calcium,, 8 gms protein, and only 4 to 5 gms of fats (low fat toned milk), in addition to Vit A, D, some B vitamins; it is low in iron, Vit C and E and B1. Since milk is expensive, most of the amount bought  by  a family is reserved for the children; those who are addicted to south indian coffee will drink about 50 to 75 ml in their coffee, but chai lovers only consume 5 to 10 ml. Most milk is taken in the form of curds, but at the most,  a half cup of the stuff contains just 75 to 100 ml. So an average "milk guzzling" adult consumes, voluntarily, only 150 ml of milk. Contrast this with the daily recommended calcium requirement of 1500 mgs; one has to consume at least 500 ml milk to get just half the daily requirement of calcium! So, addition of a tablet of calcium carbonate  yielding 1000 mgs of elemental calcium and Vit D for just 2 to 3 rupees is a cost-effective nutritional supplement. This is well worth it for everyone above 60 yrs, especially women. All this effort is essential to fight the ravages of ageing on bone health. It is surprising how many older people are unaware that milk is as good for them as it is for babies. What if one is lactose intolerant? An alternative is Soy milk which contains less calcium and carbohydrate but equivalent amount of fats and proteins.

Research shows that older people should consume less calories so that they do not become obese, which is not hard to contest,  as it is known that obesity contributes to many health problems. That apart, the digestion and metabolism of food, results in formation of oxygen free radicals, those nasty by-products that accelerate ageing. The trouble with a low calorie diet, however, is that nutrients like protein, vitamins, minerals all are sacrificed as well. Seniors need all the nutrients they can get their "mouths" on, so the trick is to eat what are called,  nutrient-dense foods. Foods that contain a lot of nutrients in smaller number of calories are known as nutrient-dense foods. Foods that do not come under this category are alcohol, sugar, other refined carbs, and fatty foods; they  provide "empty calories", meaning only calories, hardly any nutrients.
Examples of nutrient dense foods good for the elderly can be found at www.whfoods.org by the George Mateljan Foundation.

Elderly require a lot of protein to boost bone matrix, declining serum albumin, and slowing ageing in general. The USPHS recommends 0.85 gm/kg body weight of protein per day, but recently have upgraded it to 1 gm/kg/day. This utopian level is not  a big deal for meat eaters because just a small serving of any meat will fetch almost 20 gms of first class high biological value protein. There is hardly any vegetarian food that contains quite as much protein per serving both in quantity and quality, except for soya. Soya is only just getting to be popular and now we can get soya flour, plain or mixed with atta, as well as the nuggets. Unfortunately, soya is not a traditional  Indian food, so the Indian recipies for soya are few and far between. Soya has the added advantage of containing plant estrogens, so it could be a good thing for ageing women, but this hopeful thought needs scientific backing. Other vegetarian sources of protein are dhals, including chana (chick peas), rajma, and these are doubly good because of high fibre content. Vegetarians need to ensure that their protein comes from many sources, as vegetable protein from any one source is missing in some essential amino-acid.
Talking of vegetarians, there is the additional concern about adequacy of B12 levels, as this vitamin is present mainly in animal protein; small amounts are also present in milk and eggs, and there is a complex way in which the body conserves and reuses it's stores of Vitamin B12. Hence low levels and related diseases are more due to pathology in the ileum, or lack of intrinsic factor in the stomach, than due to low dietary intake per se. The  ageing brain is very vulnerable to low B12 levels, and a reversible form of dementia can occur. Neuropathy and blindness are also likely in deficient states.
Fresh fruits and vegetables are a must for everyone, young and old. Most middle class Indians do not put a great value on fruits because they are expensive and perishable. However, they are invaluable as mineral, vitamin and anti-oxidant and fibre sources. Salads and raw vegetables are not such popular items in the average Indian diet, but should be encouraged, because cooking inactivates so many vitamins.
Ayurveda has a lot to say about ageing and effects of lifestyle, body type and nutrition. I am going to undertake a search of what is known from the Ayurvedic veiwpoint and judge how those concepts are aligned to the allopathic concepts of nutrition.
Eating is also all about tasting and enjoying food. Elderly lose the sense of taste and smell. The "salt" perception declines and "sweet" perception is retained; hence the craving for sweet foods, and the desire to reach for the salt cellar! The answer lies in flavouring foods with herbs such as coriander, spices such as cinnamon, cardamom etc, or the use of enhancers such as monosodium glutamate; reducing the intake of medicines is another way to enhance taste, but may not be always practical. 

Perhaps we are just beginning the drive to find the right foods, and the right ways of enticing the elderly palate. Nutritionists, families, general practitioners, and the older persons themselves can all contribute to "eating one's way to healthful old age.......





 

The Oldie Goldie: Hello, physicians, elderly friends (well and not s...

The Oldie Goldie: Hello, physicians, elderly friends (well and not s...: Hello, physicians, elderly friends (well and not so well), young people who are interested in the welfare of our seniors, welcome to my firs...

Hello, physicians, elderly friends (well and not so well), young people who are interested in the welfare of our seniors, welcome to my first blog.

I would like to share with you some  ideas about ageing and the health of older people. In this blog I would like to share some general thoughts on illnesses affecting older people, and as we go along we can talk of common symptoms, and how they can be addressed.

Elderly people suffer from diseases just like young people do, but the effects of ageing have a profound impact on the presenting symptoms, course, and outcome of the illness. Age-related changes affect every organ, but some organs are so vital that their malfunction is noticed sooner than others. The dysfunction of the brain, cardiovascular system, musculo-skeletal system, and the urinary bladder, bring the most grief to ageing seniors. The dysfunction of the immune system, kidneys, metabolic functions  of the liver, respiratory tract, the increased prevalence of diabetes and hypertension, and the long term effects of smoking and obesity all add to the increased disease burden. 

An interesting point about ageing is that every individual ages differently, and at different "speeds", perhaps because of genetic programming, and certainly influenced by lifestyle adopted. This means that elderly people are a heterogenous lot physiologically speaking, hence a random "selection "of 70 year olds would look very much like a patchwork quilt, metaphorically speaking. You would have a crisp, athletic, full -of- beans Mr. X, along with a wheezy, hard-of-hearing Mr.Y, not to mention the bemused, frail, bent- double (read osteoporotic)  Mrs. Z; all the same chronological age, but functionally as different as chalk and cheese. This is one of the reasons why the elderly are often excluded from research studies, because one wants to study as homogenous a sample as possible! So, a researchers nightmare, are the elderly!

Elderly people are more likely to have multiple diseases. For example, a Mr. V who is  75 year old, has the following medical problems: diabetes, hypertension, osteo-arthritis knees, impaired hearing and, urinary incontinence. Each problem by itself causes distress, but when combined, the problems adversely impact on each other, causing exponential misery. For example, poorly controlled diabetes is well known to cause polyuria; an impaired bladder control ( detrusor instability) is part of normal ageing, but when confronted with large urine volume, it leads to incontinence. Further, the knee joint disease makes it difficult to reach the toilet in time. Mr. V, is isolated socially because he is ashamed by his incontinence, and also by his inability to hear.

To make Mr. V feel better, not only must the diabetes be improved, but also incontinence, and knee joint pain, as well as the hearing. It is not so important to "cure" all of them; for a start, small improvements in all the problems will have an additive and synergistic effect, and Mr. V's misery will become at least bearable.

In the example cited above, Mr. V is  taking many different medications, and it is well known that the longer the list of drugs, the higher the chance of adverse drug reactions. To add to this seemingly legitimate reason for large list of medications in the elderly,  the practitioner who has inadequate experience in old age medicine is likely to give a "pill for every ill". The elderly are not the only people who are victims of this last sin, in fact, many doctors and younger patients feel comfortable when the litany of "ills" is matched by a different "pill". While the younger person's metabolism is robust enough to combat the medication tsunami, the older person develops serious reactions and new symptoms created by drug effects.  Hence not only is prescribing parsimony a virtue, non-pharmacological therapy is ideal for the older population ( also applies to everyone).

So much for the biological model of disease affecting elderly. Now, what about the social and psychological dimensions of the ageing person? Every person is unique in terms of their gender,genetic personality type, and the  religious, social, economic , cultural, vocational milieu that they live in. As one progresses in age, one develops one's own world view, belief systems, and this has profound impact on one's ability to adjust to ageing and the new life events which occur at old age. Loss of vocation, income  and prestige when a person retires from a job, the physical and mental changes associated with the menopause, death of a spouse  or close relative, loss of social interaction and mobility, all require adjustments by the older person. The physician must see the unique  backdrop of the patient and tailor the advice and treatments accordingly.

Many of us in India are used to older people being ill, and in fact the elderly population worldwide do use a larger proportion of the health services when compared to younger people. Important to remember, however, that old age is not synonymous with disease. Many diseases such as diabetes, hypertension, and disease-producing factors such as smoking, alcohol intake and obesity, to name a few, usually start in young age, and when poorly treated, go on to cause much misery in old age. This apart, the concept of healthy ageing is a realistic one; it is entirely possible to live out one's "predetermined" lifespan in good health, and be ill for just a short time, or not at all, before dying. How does one achieve this? From antiquity man has searched for immortality, but has not found it. It is unrealistic and undesirable to search for that cosmic potion to prolong life; rather we must pursue the goal of achieving a healthful quality of life determined by the limitations of the normal ageing process, sans disease.

Health promotion is the key to healthy old age. Early detection and treatment of diseases such as diabetes,a nd hypertension, cancers, is important.

How can one promote healthy ageing as opposed to "unhealthy" ageing which accelerates the ageing process? Next blog............. ?