WEIGHT LOSS IN GERIATRIC

Weight loss improves many of the adverse health outcomes associated with obesity, including preventing or delaying the onset of diabetes, improving blood sugar control in those with diabetes, reducing low-density lipoprotein (bad cholesterol), raising high-density lipoprotein (good cholesterol), improving hypertension, improving symptoms of osteoarthritis, and providing an improved sense of well-being. Individuals must only lose a small percentage of their weight (B5–10%) to begin seeing these improved health outcomes. As many people know from their personal experiences, weight loss is difficult and lost weight is often regained for a variety of reasons. Returning to the original concept of energy balance, the formula for weight loss is predictable. To lose weight, energy expenditure must be greater than energy consumption.

The first recommendation therefore is lifestyle modification with a combination of increased exercise and decreased intake (diet modification). The amount of exercise needed to lose weight is variable. Current recommendations from the US Surgeon General is for adults to engage in an activity of moderate intensity (such as brisk walking) for 30 min daily or more strenuous activities (such as jogging) for 15–20 min daily. Additional exercise will increase energy expenditure and may result in further favorable health outcomes. Caloric restriction through dieting is also essential for losing weight. The ideal diet has not yet been established, but the principle of reducing caloric intake along with ease of long-term compliance remains the cornerstone of any diet. The American Dietetic Association currently changes their recommendation periodically in an effort to determine the most helpful, practical diet, based on current data. The problem with short-term dieting is that weight loss can rarely be maintained once the diet has ended. Exercise may help maintain some of the weight loss.

Some medications exist for weight loss. These medications are moderately effective, although they often have side effects that limit their widespread use. The history of diet medications has been plagued with adverse health outcomes, including valvular heart disease and heart arrhythmias. Many of these medications have focused on increasing the metabolic rate or suppressing appetite. One such medication that has been approved for use in the United States for weight loss is orlistat. This medication uses a novel mechanism to prevent the body from digesting a portion of the fat that has been ingested, thereby lowering the number of 280 Obesity calories absorbed. The undigested fat is excreted out of the body via bowel movements. This medication has minimal systemic side effects since there is little absorption; however, it results in uncomfortable changes in bowel movements such as oily discharge and increased frequency of bowel movements. Another medication available for weight reduction is sibutramine. The mechanism of action is inhibition of norepinephrine, dopamine, and serotonin reuptake, resulting in weight loss from appetite suppression, possibly combined with an increase in thermogenesis from stimulation of adipose tissue. Use of this medication combined with diet and exercise results in modest reduction (B7%) in weight at 1 year, although sustained weight loss at 2 years is less robust. Because of the high failure rates of lifestyle modification and medical therapies, surgical approaches for weight loss are becoming widely available. The most successful of these surgeries is the gastric bypass. It works by decreasing the size of the stomach, to achieve satiety earlier, as well as by bypassing part of the small intestine, which results in fewer calories being absorbed. This surgery is very effective in achieving weight loss and improving many of the obesity-related diseases. Complications include nutritional deficiencies, postoperative wound infections, leaks at the surgical sites, and postoperative mortality (B1.5%). Due to these risks, this therapy should be reserved for patients who are morbidly obese (BMI 440 or BMI 435), who have obesityrelated diseases, and who have failed behavioral modification therapies.

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GERIATRI PARADIGM

Geriatrics is the practice of care for frail older people. The epitome of geriatrics is treating multiple interactive problems that cross domains. In essence, geriatrics represents the intersection of chronic disease care and gerontology. Clinicians caring for older persons need to understand that diseases present differently in older persons, and their management is complicated by the presence of other factors. Older people take more medications, and hence are at greater risk of drug interactions. Older people may face problems in other sectors of their lives, such as their social roles, their economic status, their cognition, and their affect, which complicates treatment for specific health problems.

May be as hard to detect as a new peak among the Alps. The second relevant concept is based on the changes associated with aging. In general, age-related physiological changes are most evident in dynamic measures. Older people do not react to stress as well as their younger counterparts. Most of the manifestations of disease, what we call signs and symptoms, are usually not the effects of the disease per se, but the body’s reaction to the stress produced  by the disease. Little wonder, then, that older people would not show the classic symptoms of a disease, but instead some muted or general response. Whereas a younger person having a heart attack might complain about chest pain, an older person might present with confusion. This same symptom could be caused by pneumonia or a drug reaction. Thus, diagnosing disease in older people is often a much more difficult feat than with younger patients.

Diagnosis is hindered still further by communication problems created by problems with vision, hearing, or dementia. On top of these communication problems, older people often suffer from multiple diseases, making it harder to distinguish the onset or change of a given symptom. The basic technology of geriatrics is the comprehensive geriatric assessment (CGA). Experience has taught that exposing frail older persons to such an evaluation and then returning them to the same care environment did not sustain the effects. Gradually the concept of geriatric evaluation and management (GEM) evolved, which involved treating the patient for as long as needed to implement and sustain the necessary changes in the regimen. Few other approaches to care have been studied as thoroughly as CGA and GEM. Unfortunately, the results have provided a confusing and often contradictory story. Although meta-analyses imply that CGA is effective, the pattern is not consistent. Table 3 summarizes the results of several inpatient CGA/GEM randomized trials. Table 4 offers a comparable summary of outpatient studies. One of the largest and most recent studies was a multisite trial that involved both types of care. Although it was carefully targeted to patients who were deemed likely to benefit, it found scant effects. By contrast, a study that involved a simple home visit by a nurse practitioner to unselected older persons living at home yielded potent benefits, as did a preventive assessment by occupational therapists.

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HEALTH AND CARE SERVICES

Health care for older people involves managing chronic illness. In essence, geriatrics represents the intersection of chronic disease care and gerontology. Diseases present differently in older persons, and their treatment is complicated by the presence of impairments in other domains, such as affect, cognition, and economics. In the United States, older persons are the only group covered by a universal health care insurance system. Nonetheless, there remains substantial geographic variation in access to care. In general, older people still suffer from ageism; decisions about what care they should receive is influenced by beliefs about what is age appropriate.  The story of health care for older persons is inexorably linked to chronic disease. Indeed, chronic disease is the dominant factor in health care for all ages, but its predominance is especially high for older persons.If for no other reason than because such conditions accumulate with time, older people are disproportionately heavy users of health care, largely because they have a heavier illness burden. Figure 1 shows the distribution of chronic illness among elderly persons. In the United States, elderly persons are the only demographic group that has virtually universal health coverage, under Medicare. Addressing chronic care effectively implies drastically changing the current health system, which was developed to address primarily acute problems. The implied reformation addresses a wide range of aspects of care, including the definitions of concepts such as prevention, the role of patients, and even time. Prevention is best thought of in terms of avoiding major catastrophes. In effect, good chronic disease care will handle problems proactively to prevent emergency room visits and hospitalizations

 It is unrealistic to think about managing chronic disease without actively involving patients in their own care. They are the ones who must deal with the disease every day. The challenge lies in determining how to create a productive partnership between patients and their clinicians. Programs designed to give patients a greater sense of empowerment have been promising. Another approach encourages patients to record systematic observations on defined parameters that reflect the clinical course of their diseases and to notify their clinicians when the observed course deviates from what had been expected. Time too takes on a new meaning, beyond that implied by the term ‘chronic.’ In effect, chronic care means thinking in terms of investments. One provides active primary care with the expectation of recouping that effort in terms of subsequent care avoided. Focusing attention on high-risk periods, such as immediately after a hospital discharge, can pay dividends. Nurses working with patients in these situations can improve compliance with postdischarge regimens and prevent subsequent readmissions. Scheduling encounters need to be overhauled. Instead of seeing patients on a fixed time schedule based on a loose expectation of when another assessment is needed, visits should be triggered by patients’ actual courses. They need to be seen when their condition deviates from the predicted path; then they need to be seen quickly to treat the problem before it becomes serious.

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CANCER AND AGE

Cancer is the second leading cause of mortality after heart disease and the leading cause of death among women ages 40 to 79 and men ages 60 to 79. Within the 65þ age group, the population 85 years and older is projected to double from 4.3 million in 2005 million by 2030.

Life expectancy has increased. More people are treated successfully after a cancer diagnosis, resulting in a greater prevalence of the elderly living with or developing cancer. It is important for all professionals dealing with the elderly to understand what the disease is and how to deal with it. In the past, the elderly were denied treatment because they were considered ‘too old.’ We now know that in many instances the elderly do as well or better with cancer treatments than the young. This article reviews the causes and biology of cancer, possible ways of preventing it, clinical descriptions of some of the common cancers, how to screen for cancer, and new targeted treatment options. Cancer may be defined by the four characteristics that describe how cancer cells behave differently from normal cells:

1. Cancer usually begins from a single cell that proliferates to form a clone of malignant cells.

2. Cancer cells grow autonomously, are not regulated by the normal controls, and do not die appropriately via programmed cell death (apoptosis).

3. Cancer cells do not differentiate in a normal coordinated manner and do not look the same as the normal cells surrounding them.

4. Cancer cells develop the capacity for discontinuous growth and spread to other parts of the body (metastasis).

Cancer is also called malignant neoplasm. This implies that the growth is a new growth (neoplasm) that if unchecked will kill the host (malignant). Normal cells can express some of the preceding properties at certain appropriate times, such as in wound healing, embryogenesis, organ repair and regeneration, and revascularization, but the proliferation is coordinated, orderly, and self-limited. In cancer, however, these characteristics are excessive, disordered, and not self-limited, resulting in an inappropriate proliferation (tumor burden) and spread that is inappropriate to the host and that has morbid implications if not successfully treated.

Cancer traditionally was classified as being either a carcinoma or a sarcoma named for the presumed cell of origin: epithelial (carcinoma) or mesenchymal (sarcoma). Recent evidence has demonstrated that most if not all neoplasms arise from immature stem cells that then differentiate along normal cell lines, but mutate and acquire the properties of autonomous growth as described previously. We now realize that carcinomas of the lung, breast, and stomach do not arise from well-differentiated ‘normal’ cells in these organs but from stem cells that begin to differentiate in the direction of these tissues but then become autonomous and have impaired apoptosis. These cells lose their normal self-limiting capacity and acquire properties that allow them to enter the circulation and spread to other organs. These cancer cells are the ‘seed,’ and if other organ’s ‘soil’ supports their growth, metastases grow distant to the primary site.

So the golden age to growth the cancer is in geriatric or in old age so care your health today and keep healthy every day.

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