Benefits of Exercise on Blood Pressure and Prevention of Atrial Fibrillation

Senior Citizens, exercise v2Junxiu Liu, MD, of the University of South Carolina published an article in the September 15 , 2014 edition of the Journal of the American College of Cardiology showing that exercise and improving fitness levels prevented an age related expected rise in patient systolic blood pressure. His study followed 14,000 men for 35 years. Sedentary men started to see their systolic blood pressure rise at about age 46. Men who were fit delayed this rise in blood pressure until they were 54 years of age. The effect on the diastolic blood pressure was even more pronounced when looking at fitness levels. Men with low fitness ratings elevated their diastolic blood pressure to above 80 by age 42. Those men with a high fitness level did not see the rise in diastolic BP until they were beyond age 90. His research suggests that “highly fit men are likely to reach abnormal BP readings a decade later or more than sedentary men.

In an unrelated study published in the same issue, researchers in Texas found that regular aerobic exercise prevented the hearts left ventricle or main pumping chamber from developing stiffness. The stiff ness of the ventricle contributes too many common cardiovascular conditions effecting older patients. They found that low levels of casual lifelong exercise such as four (4) sessions of 30 minutes per week throughout adult hood was sufficient to keep the ventricle from stiffening.

Marco Perez, MD of Stanford University looked at exercise levels in women and the development of the heart arrhythmia atrial fibrillation. He found that sedentary women were much more likely to develop this pathologic arrhythmia than women who exercised regularly. Obesity and being overweight is a risk factor that increases your chances of atrial fibrillation. Regular exercise by obese women reduced this risk by about nine percent (9%).

The message is very clear that keeping moving and being active improves your blood pressure control and reduces your risk of developing many cardiovascular related problems. My advice is find some activity you enjoy doing and make sure you try it several times per week to gain the natural benefits the exercise provides.

Sarcopenia – A New Issue in Aging

Muscle MassSarcopenia is the medical term for low muscle mass. It affects at least 50 % of older adults, however most individuals are unfamiliar with the term. For years doctors themselves did not agree that there was such a problem and there was further disagreement on the definition of what constituted low muscle mass. S. Studenski, MD, Director of Longitudinal Studies Section at the National Institute on Aging says” Sarccopenia is not in anyone’s consciousness as a health problem, although we see it around us all the time. Perhaps we just take it for granted that when you get older you shrink. It doesn’t have to be a normal part of aging.” Physicians are now a bit more cognizant of recognizing the condition, treating it and possibly preventing it.”

In a series of articles published in the Journal of Gerontology of May 2014 Dr. Studenski defines the criteria for sarcopenia based on measurement of diminished hand grip strength and reduced muscle mass. The tests must be performed with specific equipment by professionals in order to meet the criteria for the diagnosis. Patients with sarcopenia have their youthful muscles replaced by ineffective fat even though their actual body weight may not change.

The consequences of low muscle mass can include issues with mobility, frailty, osteoporosis, falls, fractures, diminished activity, and weight gain and glucose metabolism abnormalities. Her studies inclusion criteria are based on observing 26,000 subjects and measuring grip strength and muscle mass in the arms and legs. Diet appears to play a major role in maintaining adequate muscles mass with normal Vitamin D intake of 600 IU per day in ages 51 – 70 and 800 IU in patients over 71 being necessary to retain muscle mass. You need an adequate intake of protein in the 40 – 70 gram range daily. When looking at choice of foods, acid producing foods and foods low in Vitamin B12 and Folic acid can be detrimental. Alkaline foods such as fruits, vegetables, tofu, almonds, herbs and spices are felt to be beneficial.

If your diet is adequate and appropriate then exercise, especially modest resistance training exercise, is very beneficial to maintain and rebuild muscle mass.

It appears that testing for hand grip strength and muscle mass will become a standard part of the geriatric evaluation in the future. The recommendations to preserve muscle mass are actually not new. Suggesting we eat a healthy diet rich in fruits, nuts and vegetables and high quality proteins while staying active is nothing new. What is new is the definition and categorization of another benchmark of healthy aging and suggestions on how to maintain it.

End of Life Issues and Family Disagreement

End of LifeI treat a fair number of elderly patients over many years who are now cognitively impaired and in the last stages of their life. Most of the times they live independently in their homes or apartments with the assistance of an aide while their children and closest relatives live elsewhere. End of life issues and discussions are an integral part of my practice in this group of patients. Having a living will and or a medical directive, appointing a health care surrogate for the future and discussing resuscitation status are complex but necessary discussions to have. I try to have these discussions with the patient and their life partner while they are still competent and cognitively intact. I try and review it with the designated health care surrogate if and when their mental status deteriorates. In most cases, when the clinical situation is appropriate for instituting palliative care or hospice care , and the patient when cognitively intact had indicated that this is the direction they wanted to go under these circumstances, these same families have tremendous difficulty in moving forward and following their loved ones plans. It is almost always the absentee children care takers of the Baby Boomer generation , who are now the health care surrogates, who will not institute their loved ones wishes and insist on continuing aggressive and acute care when expected changes in their loved ones health occur. There is always great discord within their families resulting in difficulty knowing who actually is calling the shots especially when all the children have a power of attorney document.

This situation is not unique to my practice. I am interviewed by potential new patients to join my practice all the time. Not a week goes by without a parade marching in of an elderly cognitively impaired patient, their aide, their child or children and sometimes a minimally impaired elderly life partner. The story is usually the same. Mom or Dad has been seeing “Dr. X” for so many years but he has them on too many medicines. They are lethargic. They do not want to socialize. In many cases the children have actually stopped medications based on their internet research, without discussing it with the doctor first. They are looking to change doctors. In most of these cases when I research the patient’s care and records, they have seen a board certified neurologist and geriatric psychiatrist and the diagnosis of cognitive impairment is accurate and appropriate. In most cases the trial of medications is appropriate as well and the care has been superb. In many cases the patient has an end of life terminal disease with a life expectancy less than a year whether it be a malignancy or not. The absentee children just are not able to accept that mom and dad are at the end of the life cycle and have asked for palliative and end of life care. I am sure that the children of some of my patients are seeking care elsewhere as well because they are not ready to accept an end of life diagnosis. This rarely if ever occurs with patients who live with their loved ones who provide hands on care on a daily basis. These hands on caregivers see the deterioration of their loved ones quality of life, understand what is occurring and how their loved one wished to be cared for in this situation.

We talk about death with dignity and living with a high quality of life. No physician or loved one wishes to accelerate the demise of a patient or family member. It is however; very difficult to honor the patient’s wishes when their absentee baby boomer children are not on the same page with their wishes and have not addressed the issues with mom and dad while they are competent and able to do so.

Why I Have “NO” Intention of Retiring in the Near Future

Not ReadyI was a bit surprised when an 85 year old potential patient asked me if I was planning on retiring soon. It is a fair question for someone considering joining a medical practice. They do not want to begin a relationship only to find out that the doctor is retiring in a short time.

I have no intention of retiring for at least the next 10 years. If I am fortunate enough to stay healthy, competent and caring, why would I give up something that I love doing? Practicing general internal medicine and having long standing relationships with my patients is a love and a passion – not a job. I am doing a fairly good job of it, feel confident that I can improve with time and more experience and, at this point, I am healthy enough to continue practicing as well as teaching future physicians.

Over the last 20 years, as medicine has changed dramatically, many of my colleagues who I started practicing with as new physicians in the late 1970’s have walked away from medicine with great disappointment and disgust. I am still having fun! When I converted my practice in 2003 from a traditional practice to a smaller concierge version, which allowed me to practice the way I was trained to practice, it reinvigorated my love for the profession.

I relish being in a position to show doctors in training the way it can be done and should be done to care for complex patients by giving them access to the doctor and time to express themselves while I listen. If you access the website of the American College of Medicine and the American Board of Internal Medicine and check out my data it says I am eligible for recertification in Internal Medicine through 2023. My goal is to continue to practice and remain eligible while practicing at a high level, being available and accessible and helping you to coordinate your care in a forever changing and more complex health care environment.

Patient Hand-Offs and Communication

document businesspeople 1I was finishing tying my shoes as I got dressed to take my lovely wife out to dinner for our 41st wedding anniversary. It was 7:30 p.m. after a hectic day at work and we had a wonderful dinner planned at a local restaurant.

The telephone rang with the caller ID identifying a call on my office work line. “Hello this is the Emergency Department, please hold on for Dr S.” Before I could get in a word edgewise I was put on hold. Five minutes later Dr S. got on the line. “Steve this is Pete. “Dr. Rheumatology” saw your mutual patient Mrs. T this afternoon and she was complaining of shortness of breath beginning three weeks ago. She complains of overwhelming fatigue. He sent her here for evaluation. Her exam is negative. At rest she doesn’t look short of breath. Her EKG doesn’t show any acute changes but I do not have an old one to compare it to. Her chest x ray is negative and her oxygen saturation on room air is 97 % (normal is greater than 90%). She has lupus and multiple autoimmune problems and is on many immune modulators. Maybe she has a constrictive cardiomyopathy or restrictive lung disease. I called Dr. Rheumatology and he said this isn’t his department to call the PCP (primary care physician) to admit the patient and you are the PCP. “I told the ER physician I had not seen the patient in over six months or heard from her but I would be right in to see her”.

I explained to my wife that duty calls and there was a sick patient in the ER. She was extremely understanding. On the drive to the ER I called the Rheumatologist to ask him his clinical impression because he had been seeing her every two weeks and had examined her just that afternoon. He returned my call and we discussed the clinical aspects of the situation and his thoughts. Then I told him that I thought he should have called me when he sent the patient to the ER if he expected me to assume care. If he did not call then he most certainly should have called me when the ED doctor called him to report on the findings and he said call the PCP. Hand-offs should be direct especially in an acute situation and especially if you sent the patient to the ER and do not intend to take ownership of the situation you sent the patient to the ER for.

He told me that in 30 years of practice no one had ever criticized him for this and he does it all the time. He told me he had been working long hours and did not have time to call referring physicians. I told him that was no excuse and if he was working that late maybe he needed to restrict his patient volume so he could communicate in a professional manner.

I arrived at the ER 20 minutes later and learned that the patient had been there for three and half hours already. She had been in the ER while I had been at the hospital earlier that afternoon checking on another patient. Had I known she was there I could have easily seen her, cared for her and still made my anniversary dinner.

A review of her old EKG and comparing it to the new one, plus taking a thorough history and exam, revealed the problem. She was having a heart attack. Her bouts of shortness of breath with activity with overwhelming fatigue were her equivalent of crushing chest pain.

Getting called to the hospital during “off” hours is part of a physician’s way of life. Having a colleague take your role and time for granted at the expense of the patient is disturbing and unprofessional.

All too often today physicians, both specialists and primary care, don’t take the time to communicate directly and clearly with their colleagues about patient care.  When this happens, clearly the patient is negatively impacted.

ACO’s and the Patient Centered Medical Home will not cure this. Only courtesy, respect and putting the patient first will change things.

New Test for Colon Cancer Screening Approved

Colon Cancer RibbonThe Cologuard test is the first DNA based screening test for colorectal cancer that has received approval for use from the FDA and preliminary approval by Medicare to cover the cost of the test. The test detects hemoglobin ( a component of red blood cells) and abnormal DNA in cells picked up by stool . A positive test indicates a need for colonoscopy to identify or eliminate colon cancer as a possibility. We currently screen patients with the fecal occult blood slide test and the more sophisticated fecal immunochemical test or FIT. The new Cologuard detected 92% of colon cancers and 42% of advanced adenomatous colon polyps as compared with 74% and 24 % for FIT. While the Cologuard test was accurate in picking up more colon cancers than the FIT it had slightly more false positive tests than the traditional Fecal Occult Blood Slide.

The Center for Medicare Services ( CMS) is proposing allowing coverage of the DNA test once every three years for beneficiaries who are 50 – 85 years old, asymptomatic and have average risk of colorectal cancer. The new test adds another non-invasive means of screening for colon cancer. We will need to see the cost of the test to the individual patient and accumulate more data on its accuracy in the near future before it becomes a mainstay of colon cancer screening.

At the same time that Cologuard was approved, researchers at the University of Michigan in Ann Arbor published in the online journal Cancer Prevention Research, information showing that evaluation of the pattern of bacteria in the colon of patients improved performance and detection of colon cancer by more than 50% as compared to the Fecal Occult Blood Test alone. Researchers using DNA sequencing and polymerase chain reaction methods were able to identify distinctly different patterns of bacteria in colon cancer and pre-cancerous polyps than in patients with no colon lesions.

It is clear that as researchers apply DNA technology to cancer screening their ability to detect abnormalities and avoid invasive colorectal screening will improve. At the moment recommendations for screening colonoscopy at age 50 remain but as science moves forward that too may soon change.

Flu Shots for the 2014- 2015 Season

Flu vaccineOur offices supply of influenza vaccine has been delivered to the office this week and we will begin immunizing patients on October 1, 2014. The Center for Disease Control in its Morbidity and Mortality Report of August 15, 2014 recommended that all adults be immunized against influenza this year beginning at a time that is appropriate to the appearance of influenza in your community. We generally do not see any significant influenza in South Florida before Thanksgiving with the season usually lasting through March. It takes ten days for the vaccine to take effect and your body to develop the immunity to resist the flu invasion. Immunity after vaccination begins to fade at 3 months and is markedly reduced or absent in most individuals 65 years or older at 6 months. Most pharmacies locally will begin their vaccine campaign in September. If you receive the vaccine then there is the chance that your immunity will be decreasing by December. For this reason we prefer to vaccinate you on October 15 or later. Please call the office for an appointment.

We will be administering the senior high potency vaccine which is the usual trivalent inactivated influenza vaccine at four times the dosage given to younger patients. Research has shown that the higher dose is needed to get senior citizens immune response to work well. Despite the higher dose, there are no more side effects reported than in the usual dosage administered to younger individuals.

For individuals younger than 65 years we will be administering the recommended quadravalent vaccine which is also an inactivated viral product. We will be charging $35 for the shot. Patients with egg allergies are encouraged to obtain the trivalent recombinant influenza vaccine (RIV3, known as FluBlok). It is available in limited supplies at the Health Department and at Passport Health.

Feel free to call the office if you have any questions at 561.368.0191

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