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.