Will A Multivitamin a Day Keep Dementia Away?

Laura Baker, PhD, and associates of Wake Forest University reported in the journal Alzheimer’s & Dementia that taking a Centrum multivitamin daily seemed to improve cognitive function in senior citizens. The COSMOS-Mind study included 2262 participants with a mean age of 73 years. Sixty percent were women, almost 90% were Caucasian and none had a history of heart attack or stroke. The study looked at the effects of chocolate in the form of cocoa extract or a multivitamin on memory and cognitive function. The patients were followed for three years.

Daily multivitamin supplementation led to improvement in both memory and executive function. The effect was most pronounced in participants with cardiovascular disease. The researchers’ predictive formulas or “modeling” suggested that three years of multivitamin supplementation might slow cognitive aging by 60% or 1.8 years. In previous studies performed on older male physicians, this type of supplement did not reveal any cognitive benefits. In the Women’s Health Initiative this type of benefit did show some protection against certain malignant diseases, but no evaluation of cognitive function was performed.

The Alzheimer’s Association was encouraged by the findings but called for further randomized studies before they felt comfortable recommending a daily multivitamin. As a practicing physician, I see no downside to taking a Centrum multivitamin as long as patients read the label and make sure they are not taking any other fat-soluble vitamins (A, E, D, K) which can accumulate and, in large doses, cause toxicity.

I ask my patients to bring their vitamins and supplements to the office to read the labels or show me a photo of the labels if they feel uncomfortable performing this review themselves.

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The Flu Shot Lowers Stroke Risk. It’s Time to Schedule Yours.

Fall is just around the corner and its time to start scheduling your flu shot. This season we have the high dose quadrivalent vaccine for people 65 years of age or older and the Quadrivalent for those younger than 65 years of age. The vaccine takes about two weeks to provide full immunity and will reduce your chance of catching the illness.  Most importantly, it will prevent serious illness requiring hospitalization and or death. Last year influenza caused almost 45,000 deaths in the USA.

The vaccine is being given in our office. My patients should call 561.368.0191 to schedule the flu shot. You can take this vaccine at the same time as the new Omicron specific booster and near that vaccine which is being given at local pharmacies including CVS and Walgreens.

The journal Neurology published a peer reviewed article that examined whether getting a flu shot provided any additional protection beyond preventing the flu  The study, led by Francisco Jose de Abajo, MD, MPH, PhD of the University of Alcala in Madrid Spain, showed that the flu vaccine reduced the risk of stroke by 12% in those who had risk factors for cerebrovascular or cardiovascular disease. The study noted the protection began within two weeks of receiving the vaccine for both patients with cerebrovascular risk factors regardless of age.

Another study published several weeks ago noted that the risk of dementia was diminished in those patients receiving the flu shot as well.

Flu season is here. Please call the office and schedule your vaccine.

Bisphosphonates, Prolia & Forteo in Osteoporosis Treatment

When I started practicing clinical medicine in South Florida there were few if any treatments for osteoporosis. We saw the devastating effects of this condition in lean post-menopausal women in their seventies and eighties – especially those who had multiple pregnancies and smoked. In men we were more likely to see it in male smokers taking corticosteroids for an inflammatory disease.

Spontaneous collapse of their vertebrae leading to nerve compressions, brutal unrelenting pain and at times neuromuscular injuries preventing walking were common. If we measured height, we saw a decrease in height over time before these catastrophic spinal injuries occurred. We also saw a plethora of spontaneous hip fractures which occurred causing a fall with trauma. In most cases, both presentations resulted in major and extensive surgery and rehabilitation before a patient resumed their life. The only medications we had at the time for women were estrogen and progesterone which carried their own list of potential adverse effects.

The introduction of oral bisphosphonates changed that. Medications like Fosamax, Actonel, Boniva slowed down the process and, with weight bearing exercise, smoking cessation, appropriate nutrition, and luck, reversed it. These medications in pill form were tough to take and still are. They are large, poorly absorbable and require you to take them on an empty stomach while upright. Most instructions call for drinking eight ounces of water with the pill followed by another eight ounces of water after the pill then staying upright for 30-60 minutes. These pills are extremely corrosive if they get caught in your esophagus because you didn’t swallow them with water. They can upset the gastric lining of your stomach as well.

Bone Densitometry tests allowed physicians to detect and then follow serially over years the thickness of your bones. I believe due to the size of the pills and the gastrointestinal problems they can cause convincing patients to try these medications has always been a difficult prospect. Fortunately, much of the responsibility falls on the gynecologists who look for osteoporosis and osteopenia as part of their evaluation of perimenopausal women routinely.

For those individuals unable to tolerate these oral medications, or unwilling to try, rheumatologists have injectables to help the bones. Prolia (denosumab) an injectable given every six months, and Forteo, (teriparatide) a daily injectable, were developed. They too can produce side effects including back and bone pain and a host of others. The good news is they work.

In a recent study of 50,862 women published in the journal Therapeutic Advances in Musculoskeletal Diseases researchers from the University of Verona, Italy led by Giovanni Adami, found that the oral medications can reduce the risk of fracture by 30% while monthly Prolia did so by 60% and daily Forteo by 90%. The significant difference was the fact that the oral agents required one year of use before the risk of a spontaneous fracture occurred while the injectables achieved success much sooner. While rheumatologists and gynecologists surmised this was occurring, this study provides solid evidence to back up their hunches.

Take Your BP Medications Anytime You Choose To!

Two years ago, a large study called HYGIA concluded that taking your blood pressure medications at night resulted in fewer heart attacks and strokes and less death from those issues. The accompanying editorials and comments suggested that most heart attacks and strokes occurred in the early morning and the nighttime dosage helped prevent that.

As a clinician seeing patients during the COVID-19 Pandemic, I do not remember much objection to that study. As a result of it, I switched the time of my own BP meds from the morning to bedtime.

There was concern at the time that if you took your BP meds in the evening and awoke to void you might be more susceptible to falls. At about the same time, research appeared that showed that most combinations of BP medications lowered your BP but a second-generation calcium blocker, and ARB/ACEI, reduced mortality as well. I started prescribing amlodipine and losartan at bedtime and took it myself.

Many hypertension and cardiology researchers disagreed with the results, methods, and conclusions of this study. So they undertook the TIME study. 21,000 patients with high blood pressure who were assigned to take their medications in the morning or evening. The average patient age was 65 with a fair representation of diabetics, cigarette smokers (4%) and cardiovascular disease. They were followed for a median of 5.2 years with some for 9 years.

The results showed that it did not make a difference if your blood pressure was controlled, and you took the medication in the morning or the evening. There were no more cardiovascular events or cerebrovascular events in morning medication takers compared to evening medication takers. The results were contradictory to the HYGIA study.

I take two blood pressure medications. I will now take one pill in the morning and one pill at bedtime. I am sure this issue will be studied again. Until that is done, and the results are in, my advice is just remember to take your blood pressure medications every day as prescribed by your physician.

Our Pug Gigi – True Love, True Grit

We euthanized our rescue Pug Gigi last week. She joined our family five years ago, probably coming from a puppy mill. She was abandoned and left to die in an empty building where she stood at the window and barked until someone finally noticed.

Gigi was fostered by South Florida Pug Rescue and medically treated and rehabilitated. No one knows how old she was. After losing our original Pug to old age, we decided to bring some love to an animal that needed it and to provide our sweet older mixed breed dog Chloe with a friend.

On her first visit in our home, she walked over to a straw basket filled with dog toys and pulled out a squeaky toy and had great fun tossing it around and chasing it. The representative of Pug Rescue said she never had a toy and this was her first. We allowed her to take it with her back to her foster home after the first introductory visit.

The process of adopting a dog is quite lengthy and difficult. There is a home inspection. You fill out an application and need two citizens and a vet to vouch for you. In Gigi’s case, they were concerned about her kidney function. Being a physician, and reviewing their lab data, I was not the least bit concerned, nor were my consulting kidney specialists who reviewed the data with me.

We fought to adopt Gigi and won. Pug Rescue said she was gruff and not very affectionate. It took about 48 hours of play, food, long walks and petting for this formerly abused dog to trot up to my wife and I and I and cuddle and lick our hands. She returned our love, caring and attention in multiples.

We hired a professional trainer to help us teach her obedience and after a few weeks we noticed she stopped jumping onto and off of the furniture, which she was not supposed to be on in the first place. Several weeks later a neighbor noticed she was walking awkwardly having difficulty placing her rear paw. A trip to our vet and a consult to a neurologist disclosed that she had the doggie equivalent of Lou Gehrig’s disease. Genetic testing through the American Kennel Club confirmed that she had both genes for a degenerative neurological myelopathy with a prognosis of 1-2 years. The disease produced no pain, just a gradual loss of muscle function starting in the legs and moving forward. Eventually the respiratory muscles stopped functioning.

My wife and I talked about the poor animal’s horrible luck and decided to make her time on this earth as good as possible. We constructed ramps to make access easier. We did daily physical therapy. Having a swimming pool, we set aside an hour for her to swim most days. When the weather turned cold, we put her in a doggie wetsuit with her name on it and went swimming despite the cold.

Gigi thrived but her muscles continued to get weaker. First, the back legs stopped working. The tail stopped wagging. I had to support her rear on walks and make sure her rear paws were high enough off ground to prevent them from knuckling under and scraping away the skin.

For almost three years we followed this daily schedule of long walks with two dogs and me supporting Gigi’s rear followed by a trip to the pool for more exercises. It reached a point where Gigi’s only real freedom occurred in the pool when I allowed her to swim where she wanted to when she wanted to.

Throughout this process she was pain free, with a great appetite and a love for being with the family. There were some hurdles. She had a stroke a year and a half ago during a hurricane. Her paralysis resolved with exercise. She had several of urine infections too.

When her front paws started to decline, and she started having difficulty swallowing without aspirating, I knew her days were numbered. Despite this we took her and our other sweet puppy on a three-week driving vacation to visit family up and down the east coast of America. Both dogs behaved well.

Upon our return home I tried to renew our pool exercises. Poor Gigi lost her ability to stay buoyant and lost the strength in her front legs to propel herself. Her gag reflex started to decline, and meals sometimes went down the wrong pipe causing coughing. I thickened her meals like we would for a senior citizen and hand fed her. Then, last week, her front legs gave out despite me holding them up. She cracked a nail on her front paw, dropped her chin to the ground and scraped it on the pavement. I took her home, stopped the bleeding, cleaned and dressed the wounds and consulted my wife about her deterioration. It was time to end her battle before she suffered.

We called our vet and took both dogs to his clinic and put Gigi to sleep. As the vet injected a tranquilizer into her she found the strength to lift her head and lick my face with several kisses.

In my profession, I deal with life and death daily. I counsel patients and families on end-of-life issues routinely. You stay a bit detached and objective and professional. When the loss is yours, the grief sits like a basketball in your throat and chest.

We were blessed to be able to provide a loving home for five years to a creature who knew no love or care before entering our home. Despite a genetic degenerative illness, we improvised ways to give this puppy a high quality of life for far longer than the experts predicted. Those facts don’t make the sadness and loss any easier to bear. We miss her and she will always be in our hearts.

NSAIDS and Heart Failure in Type II Diabetics

The European Society of Cardiology is receiving a presentation on the increased risk of heart failure occurring in Type II Diabetics over the age of 65 years with an elevated HgbA1C level. The mechanism of the heart failure is still under discussion and being researched and it is believed to be beyond the accepted increased retention of fluid that occurs when you take an oral NSAID. The risk of developing heart failure was increased by almost 50% in Type II Diabetics 65 years of age or older. It was clearly not seen in patients with a normal HgbA1C younger than 65 years of age.

The study was led by Anders Halt, MD, a cardiologist and epidemiologist, who accessed the Danish National Health Registry to obtain his raw data. In his study it was clear that older age and elevated HgbA1C were present in those patients developing heart failure and requiring treatment and/or hospitalization. In Denmark patients were using Diclofenac Sodium and Ibuprofen primarily with few using celexocab or naproxen products.

As we age, we develop joint inflammation and aches and pains that make us reach for an over-the-counter anti-inflammatory medication frequently. This study raises the question clearly “If you are a Type II diabetic over sixty-five years of age with poorly controlled sugars should you be looking elsewhere than NSAIDs for relief”. Diclofenac sodium is no longer in oral form in the USA, but ibuprofen certainly is. The study clearly outlines the need for exploration of the mechanism of the heart failure. I believe the reason heart failure occurs must be clarified but until that occurs older Type II diabetics should be wary of reaching for an NSAID for relief of aches and pains.

Pre-Workout Caffeine and Energy Drinks May Be Detrimental to Your Health

Medical Bag, an online medical journal, looked at the practice of consuming high quantities of caffeine containing energy drinks before exercising or entering a competition and its effects on your health and performance. They followed their review of the recommendations of the European Association of Preventive Cardiology and the World Health Organization positions against consuming these drinks prior to exercise.

It was noted that in addition to elevated levels of caffeine these drinks contain taurine and glucuronolactone which can have a negative effect as well.  The high doses of caffeine may alter your susceptibility to lethal cardiac arrythmias by prolonging your QTc interval on your EKG. They also adversely alter the function of your endothelial cells which line our blood vessels and prevent random clotting within these vessels. They cite a 2019 study by Shah et al which looked at 2 popular energy drinks consumed before vigorous exercise and compared to consumption of a placebo resulting in the energy drinks prolonging the QTc intervals. This may cause arrythmias in individuals with healthy hearts but is much more likely to cause them in individuals with non-diagnosed heart issues. The caffeine and additives also contribute routinely to elevation of your systolic and diastolic blood pressure with vigorous exercise.

The energy drinks have become popular in the USA based on small studies that hinted that caffeine enhances one’s performance. The small sample size and design of the studies did not warrant that conclusion.

Energy drinks are relatively unregulated in the United States and are treated as a food not a medication.  It is far safer to hydrate with water or an electrolyte rich sports drink than a highly caffeinated beverage prior to vigorous exercise or athletic competition.