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Editorial by Dr Miguel Ramos
Philippine Journal of Internal Medicine 2011

Greetings! During the closing ceremony of the 41st Convention of PCP held last May 4, 2011 at SMX, some of us witnessed the birth of the Philippine College of Geriatric Medicine (PCGM). This was the result of the merger of two societies
namely the Philippine Society of Geriatric Medicine (PSGM), a component society of the PCP and the Philippine Society of Geriatrics and Gerontology (PSGG), an affiliate society of the PMA.

This coming together was long overdue but thanks to the brilliant mediation of PCP’s Dr. Oscar Cabahug it was finally realized.
In behalf of the officers of PCP I would like to WELCOME the board of Directors of PCGM led by its President Dr. Shelley de la Vega, VP
Dr. Innocencio Alejandro, Sec. Dr. Edwin Fortuno, Treasurer Dr. Teresita Castillo, Auditor Dr. Doris Camagay and Communications Officer Dr. Roy Cuizon.

With PCP’s support, we hope and pray that you deliver your vision and missions - that the PCGM can respond to the challenge of providing comprehensive quality health care to all elder Filipinos, which will include us in the near future.

Philippine Journal of Internal Medicine Editorial Allow me to take this opportunity to bid goodbye to PJIM as an editor for these past
10 years where I was fortunate enough to bear witness to some of the more relevant research outputs and publications of our time. First, I would like to thank past Chief Editors Drs. Esperanza
Cabral, Rafael Castillo and current Editor in Chief Dr. Linda Lim-Varona for giving me this opportunity and trusting me to do the job. I would also like to thank Ms. Connie Bayona , as she was instrumental in my joining the PJIM editorial board; and last but not the least, I would like to express my congratulations and gratitude to the contributing authors who have submitted their works for
publication to the journal. They are the real life of the journal, they who quietly, surely and sometimes unknowingly contribute to the much needed life sustaining push to maintain a culture of research in
our medical practice.

In the spirit of “publish or perish”, rest assured that I would pursue and continue to encourage the publication of relevant researches and outputs from our peers. Mabuhay

From Manila Bulletin

Ang tanda
The View from Rizal
By GOV. JUN A. YNARES, M.D.
July 24, 2011, 8:00am

MANILA, Philippines — I spotted the ever-present Lolo Sisong at a recent gathering of civic leaders in Antipolo, Rizal.

The event was one of several organized by outstanding nongovernmental organization (NGO) partners of the Rizal provincial government like the United Bayanihan Foundation. This one had to do with government and private sector putting their heads together. The aim: Help senior citizens remain productive and happy.

I know no senior citizen more intellectually productive than the inimitable Lolo Sisong, Rizal province’s self-appointed official sage. So, in that meeting where those who are superior in wisdom and years were the subject matter, the Lolo ng Lalawigan’s presence was a welcome one.

Since the word “matanda” (old) kept ringing throughout the event, I decided to signal Lolo Sisong to join my huddle with NGO leaders and ask him a question I had secretly asked myself for years.

The question: Why are those who are advanced in years called “matanda”?

“Why ask me, I am not old enough to answer the question,” Lolo Sisong said with his serious humor glowing in his face.

“It takes a young person to answer the question,” I answered, smiling, knowing he would bite the bait.

“Okay, then, I will answer the question,” Lolo Sisong said, pretending to capitulate.

“You see, Junjun, ‘matanda’ comes from the word ‘tanda’,” he began.

“So, therefore?” I egged him to make it quick.

“Well, ‘Tanda’ has three meanings,” he seemed naughtily dragging the conversation.

“Go ahead, what are they?” I asked, impatient.

“One, ‘tanda’ means ‘mark’,” he started the long process of sagely enumeration.

“Two, ‘tanda’ means ‘sign’,” Lolo Sisong continued.

“Three, ‘tanda’ means ‘recall’ or ‘remember’, or ‘reminisce’,” he ended.

“Care to explain?” I asked again, impatience growing.

“That’s where I’m going,” he answered, seemingly irked by my nagging.

“You see, a senior person has a lot of ‘tanda’ in his body and in his character – the marks of what he has gone through in life,” Lolo Sisong said. “His body and his personality shows the many marks of the happy and painful experiences that the senior person has gone through,” he added.

“Now, the quality of his body, his mind and his character as shaped by those experiences shows whether or not they made him into a better person… or a bitter one,” Lolo Sisong explained.

“So, when you see a senior person, you look at the ‘marks’ to determine what kind of person he is,” he essayed.

Impressed by the wisdom, I said, “Move on to number two – ‘tanda’ meaning ‘sign’.”

“Be patient, I am old, remember?” he answered, even more irked.

“Okay, ‘tanda’ also means ‘sign’,” he moved on. “Senior people are either ‘warning signs’ or signs similar to the beacon light of a lighthouse,” Lolo Sisong said, choosing his words carefully.

“When you find a bitter old person, he is a warning sign to you – don’t go where he went, such as his vices and his scheming ways,” he explained. “But when you find a ‘better’ senior person, ask him which path he chose and follow it – he is showing you a beacon light,” Lolo Sisong added.

I was silent, reflecting.

“May I go to point number three,” Lolo Sisong said, obviously trying to irk me reciprocally.

“Please go ahead,” I answered serious this time.

“Well, ‘tanda’ also refers to that big vault of memories of the many years we have gone through in life,” he began his final point.

“That is the gold mine of our advanced years – the definite advantage of being senior over being young,” Lolo Sisong moved on.

“We can open that vault anytime to retrieve the things that matter a lot to people – memories of love and joy, of friends and loved ones, of the many valuable experiences which prove to us that we did spend our years wisely,” he said, his aging eyes all of a sudden looking young.

“And if a senior person is generous, he lets young people into that vault and lets them frolic in the gold mine of precious memories,” he said, using his poetic abilities.

I was still silent, awed by the obvious advantage in wisdom that senior people have.

“That’s also what we mean by ‘growing old gracefully’, Junjun”, Lolo Sisong attempted to conclude.

“One ages well by being conscious of his role as ‘mark’, ‘sign’ and ‘treasure trove of memories,” he said.

“So, be careful about how experiences make their mark on you,” he continued.

“Be conscious about your role – are you a danger sign or a beacon light to the younger generation,” he moved closer to his closing.

“And consciously build the kind of memories that you bring into your vault,” he, at last, ended.

“Gotta go,” Lolo Sisong said, acting like a busy young person.

“Thanks much,” I said, trying to memorize his key points.

“By the way, those three things are also a technique on how one stays young despite advancing years,” Lolo Sisong post-scripted.

“Will remember that,” I answered.

“Only if your mind can stay young like mine,” Lolo Sisong said, underscoring that the last word is always his.

I kept my mouth shut, impressed by how he has, indeed, made great use of his years.

Feedback: provinceofrizal@yahoo.com

Authors: Silvina Levis, MD; Nancy Strickman-Stein, PhD; Parvin Ganjei-Azar, MD; Ping Xu, MPH; Daniel R. Doerge, PhD; Jeffrey Krischer, PhD

Journal: Arch Intern Med. 2011;171(15):1363-1369. doi:10.1001/archinternmed.2011.330

A 2- year randomized trial found no significant difference in bone loss or menopausal symptoms between women taking soy tablets or placebo.

Patients were women age 45-60 years, within 5 years of menopause and without osteoporosis.

Subjects were were randomly assigned, in equal proportions, to receive daily soy isoflavone tablets, 200 mg, or placebo.

Results
After 2 years, no significant differences were found between the participants receiving soy tablets (n = 122) and those receiving placebo (n = 126) regarding changes in bone mineral density in the spine (–2.0% and –2.3%, respectively), the total hip (–1.2% and –1.4%, respectively), or the femoral neck (–2.2% and –2.1%, respectively).

A significantly larger proportion of participants in the soy group experienced hot flashes and constipation compared with the control group. No significant differences were found between groups in other outcomes.

Authors’ Conclusions
In this population, the daily administration of tablets containing 200 mg of soy isoflavones for 2 years did not prevent bone loss or menopausal symptoms

Grannies get immunity

Link and Reference:
From the Medical Observer
Wednesday, June 15, 2011

The newly minted Expanded Senior Citizens’ Act of 2010 (Republic Act 9994) brings up an often overlooked aspect of elderly health care—geriatric vaccination. The law specifically provides for free influenza-virus and pneumococcal-disease shots among indigent senior citizens. It also singled out these vaccines for a 20-percent discount and value-added tax exemption when purchased by all senior citizens, regardless of their capacity to pay.

Pneumonia is fourth among the leading causes of death among Filipino elders, according to geriatric-health specialist Shelley De la Vega. In the United States, giving flu shots to senior citizens has been found to lower their chances of getting sick, being hospitalized and dying not only from influenza itself but also from heart attack and stroke during the flu season.

And yet, only about 1.4 percent of Filipino elders receive the pneumococcal vaccine while 3.4 percent get the flu vaccine, based on a national health survey done in 2001. “I hope that when we do another survey this year or next year, we will have better numbers, 50 percent, at least,” De La Vega said, during a recent forum on geriatric vaccination at the San Lazaro Hospital in Manila.

Most of the elderly who have been getting the vaccines so far are likely to belong to the more affluent Filipino communities where geriatric vaccines have been available for free since five years ago, said De La Vega.

In the absence of such freebies, she believes that even the relatively well-off seniors, not just the poorest of the poor as provided by law, need help in accessing the vaccines. “A lot of people cannot afford to pay out of pocket so we would like to find ways in which the government, through PhilHealth for example, can help alleviate the burden.”

Vaccines for other diseases like tetanus, herpes zoster, diphtheria, pertussis, and hepatitis are also on De la Vega’s wish list of vaccines that can be provided to Filipino senior citizens.

DoH needs help

It falls upon the Department of Health (DoH) to provide the free vaccination to indigent seniors under the law. And it is proving to be a challenge for the agency.

Dr. Lyndon Suy, DoH manager for emerging and reemerging infectious diseases, estimates that the agency would need around PhP1 billion to provide the free vaccines. This amount is based on statistics that the elderly comprises two to three percent of the country’s present population of roughly 90 million.

“This is not a small budget that you can just reallocate from other DoH programs without crippling them. We’re talking of a big chunk of money that needs a special provision from Congress,” he explained.

Suy admits that this issue of funding has led to a stand-off in the implementation from the DoH side. The agency still has to come up with its implementing rules and regulations (IRR) on the law as it searches for ways of sourcing the vaccine fund.

One possibility the agency is exploring is to get the local government units, especially the big-revenue cities and first-class municipalities, to buy the vaccines themselves for their indigent elderly constituents.

This is already happening in some Metro Manila cities. The Pasig city government has already vaccinated close to 8,000 of its senior citizens for both flu and pneumococcal disease since 2008. The city is prioritizing indigent and low-income individuals from its most highly populated and depressed areas. In Quezon City, many barangay senior citizens’ associations allocate part of the senior citizens’ fund given by the city government for flu vaccination.

For Suy, the importance of the LGU participation in the vaccine initiative cannot be stressed enough, from helping with the database of free vaccine recipients to assisting in the health-education activities that are meant to accompany each vaccination.

De la Vega agreed that the vaccination program has to be in the context of the elderly person’s total well-being. “You just don’t go there to give a shot in the arm. You educate them about other diseases and how to manage their lifestyle,” she said. “That way, you are also helping reinforce positive health-seeking behavior.”

Developed by:
American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents American Academy of Neurology American Geriatrics Society American Society for Preventive Cardiology American Society of Hypertension, American Society of Nephrology Association of Black Cardiologists European Society of Hypertension

Clinical Evaluation

Note: The reader should view the expert consensus document as the best attempt of the ACCF and document cosponsors to inform and guide clinical practice in areas where rigorous evidence may not yet be available or evidence to date is not widely applied to clinical practice.

Aside from a good and targeted history and physical examination, guidelines on laboratory testing were presented. The diagnosis is established with at least 3 blood pressure readings in at least 2 clinic visits.

Ambulatory BP monitoring (ABPM) is indicated when hypertension diagnosis or response to therapy is unclear from office visits, when syncope or hypotensive disorders are suspected, and for evaluation of vertigo and dizziness. The case for using out-of-office BP readings in the elderly, particularly home BP measurements, is strong due to potential hazards of excessive BP reduction in older people and better prognostic accuracy versus office BP.

The most important role for testing in an elderly patient
with hypertension is to assess for organ damage and modifiable
CVD risk factors, including tobacco smoking, hypercholesterolemia,
diabetes mellitus, and excessive alcohol intake.

Information on the following laboratory tests should be available:
1. Urinalysis to look for any evidence of renal damage,
especially albuminuria/microalbuminuria
2. Blood chemistry to assess electrolytes and renal function, especially potassium and creatinine with eGFR
3. Total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglycerides, preferably fasting levels
4. Fasting blood sugar and, if there are concerns about diabetes mellitus, hemoglobin A1c
5. ECG

Lifestyle Modification

Weight reduction, salt reduction, DASH diet, regular physical activity and moderation in alcohol consumption are recommended.

The general recommended BP goal in uncomplicated hypertension is 140/90 mm Hg. However, this target for elderly hypertensive patients is based on expert opinion rather than on data from randomized controlled trials (RCTs). It is unclear whether target SBP should be the same in patients 65 to 79 years of age as in patients 80 years of age.

Drug Treatment and other details may be viewed thru this link to the Journal of the American College of Cardiology Expert Consensus Document on Hypertension in the Elderly 2011

What are triglycerides?

Fat exists in the body as Triglycerides. It is a chemical that is found in blood plasma and, in association with cholesterol, form the plasma lipids.

Triglycerides come from fats eaten in foods or made in the body from other energy sources like carbohydrates. Calories ingested in a meal and not used immediately are converted to triglycerides and transported to fat cells to be stored.

How is an excess of triglycerides harmful?

Excess triglycerides in plasma is called hypertriglyceridemia. It’s linked to the occurrence of coronary artery disease and stroke in some people. Elevated triglycerides may be caused by untreated diabetes mellitus.

Like cholesterol, increases in triglyceride levels can be detected by a blood test. These measurements should be made after an overnight food and alcohol fast.

The National Cholesterol Education Program guidelines for triglycerides are:
Normal Less than 150 mg/dL
Borderline-high 150 to 199 mg/dL
High 200 to 499 mg/dL
Very high 500 mg/dL or higher

These are based on fasting plasma triglyceride levels.

AHA Recommendation — Dietary treatment goals

Changes in lifestyle habits are the main therapy for hypertriglyceridemia. These are the changes you need to make:

* If you’re overweight, cut down on calories to reach your ideal body weight. This includes all sources of calories, from fats, proteins, carbohydrates and alcohol.
* Reduce the saturated fat, trans fat and cholesterol content of your diet.
* Reduce your intake of alcohol considerably. Even small amounts of alcohol can lead to large changes in plasma triglyceride levels.
* Eat fruits, vegetables and nonfat or low-fat dairy products most often.
* Get at least 30 minutes of moderate-intensity physical activity on five or more days each week.
* People with high triglycerides may need to substitute monounsaturated and polyunsaturated fats —such as those found in canola oil, olive oil or liquid margarine — for saturated fats.

Eliminate dietary trans fatty acids, which increase triglycerides and atherogenic lipoproteins (ie, lipoprotein, LDL-C).

Substituting carbohydrates for fats may raise triglyceride levels and may decrease HDL (”good”) cholesterol in some people. Certain food products, such as bakery shortening and stick margarine, contain high trans fatty acid concentrations.

* Substitute fish high in omega-3 fatty acids instead of meats high in saturated fat like hamburger. Fatty fish like mackerel, lake trout, herring, sardines, albacore tuna and salmon are high in omega-3 fatty acids.

Overall, exercise is most effective in lowering triglycerides (eg, 20% to 30%) when baseline levels are elevated (ie, TG level of 150 mg/dL), activity is moderate to intensive, and total caloric intake is reduced.

Because other risk factors for coronary artery disease multiply the hazard from hyperlipidemia, control high blood pressure and avoid cigarette smoking. If drugs are used to treat hypertriglyceridemia, dietary management is still important. Patients should follow the specific plans laid out by their physicians and nutritionists.

Read More American Heart Association Healthy Tips

AHA Statement on Triglyceride and Cardiovascular Disease 2011

By ROXANA HEGEMAN, Associated Press Roxana Hegeman, Associated Press 11 April 2011

WICHITA, Kan. – In a courtroom in Wichita, the day begins much as it has for the past 49 years: Court is in session, U.S. District Judge Wesley Brown presiding. But what happens next is no longer routine; it’s a testament to one man’s sheer determination.

As lawyers and litigants wait in respectful silence, Brown, who is 103, carefully steers his power wheelchair behind the bench, his stooped frame almost disappearing behind its wooden bulk. He adjusts under his nose the plastic tubes from the oxygen tank lying next to the day’s case documents. Then his voice rings out loud and firm to his law clerk, “Call your case.”

“I do it to be a public service,” Brown said. “You got to have a reason to live. As long as you perform a public service, you have a reason to live.”

[caption id=”attachment_675″ align=”aligncenter” width=”160″ caption=”Judge Brown Kansas “][/caption]
Brown is the oldest working federal judge in the nation, one of four appointees by President Kennedy still on the bench. Federal judgeships are lifetime appointments, and no one has taken that term more seriously than Brown.

“As a federal judge, I was appointed for life or good behavior, whichever I lose first,” Brown quipped in an interview. How does he plan to leave the post? “Feet first,” he says.

In a profession where advanced age isn’t unusual — and, indeed, is valued as a source of judicial wisdom — Brown has left legal colleagues awestruck by his stamina and devotion to work. His service also epitomizes how the federal court system keeps working even as litigation steadily increases, new judgeships remain rare, and judicial openings go unfilled for months or years.

“Senior judges keep the federal court system afloat given the rising case loads,” said David Sellers, spokesman for the Administrative Office of the U.S. Courts. Of the 1,294 sitting federal judges, Brown is one of 516 on “senior status,” a form of semi-retirement that allows a judge to collect his salary but work at a reduced case level if he chooses. They handle almost a quarter of federal district trials.

And no one alive has logged more service than Brown, who took senior status in 1979 but still worked full time until recently. In March, he stopped taking new criminal cases and lightened his case load a bit. He still takes his full share of the new civil cases.

“I will quit this job when I think it is time,” Brown said. “And I hope I do so and leave the country in better shape because I have been a part of it.”

Full Story Link

The Alzheimer’s Association USA released the following Alzheimer’s Disease Facts and Figures 2011.
Go to the link to access the following information:

• Overall number of Americans with Alzheimer’s disease nationally and for each state
• Proportion of women and men with Alzheimer’s and other dementias
• Estimates of lifetime risk for developing Alzheimer’s disease
• Number of family caregivers, hours of care provided, economic value of unpaid care nationally and for each state, and the impact of caregiving on caregivers
• Use and costs of health care, long-term care and hospice care for people with Alzheimer’s disease and other dementias
• Number of deaths due to Alzheimer’s disease nationally and for each state, and death rates by age

Alzheimer’s is the sixth-leading cause of death in United States and the only cause of death among the top 10 in the United States that cannot be prevented, cured or even slowed. Based on mortality data from 2000-2008, death rates have declined for most major diseases while deaths from Alzheimer’s disease have risen 66 percent during the same period.

The conclusions in this report reflect currently available data on Alzheimer’s disease. They are the interpretations of the Alzheimer’s Association.

Details are available in the website Alzheimer’s Association

Former Hollywood child actor Mickey Rooney recently testified in a US Senate Committee investigation and admitted to being a victim of Elder Financial Abuse . In his statement he reports that he had been financially exploited and “stripped of the ability to make even the most basic decisions about my life.” His daily life, he said, became “unbearable.”

Elder Abuse refers to intentional or neglectful acts by a caregiver or “trusted” individual that lead to, or may lead to, harm of a vulnerable elder. Physical abuse; neglect; emotional or psychological abuse; verbal abuse and threats; financial abuse and exploitation; sexual abuse; and abandonment are considered forms of elder abuse. In many states, self‐neglect is also considered mistreatment.

Financial exploitation takes many forms. Warning signs include:

* Obtaining unauthorized access to an elder’s Social Security checks, pension payments, checking or savings account, credit card or ATM; identity theft
* Withholding portions of checks cashed for an elder
* Charging an elder excessive rent or unreasonable fees for basic care (e.g., transportation, food, or medicine)
* Scams (e.g., bogus sweepstakes, lotteries) that use deception, scare tactics, or exaggerated claims to get money from elders
* “Conning” by con artists who make their living preying on others and “befriend” elders
* Calls from telemarketers selling worthless, over priced, or nonexistent products
* Unfair or misleading home equity agreements that cause elders to lose their homes
* Unscrupulous home repair contractors
* Inappropriate financial products and services
* Fraudulent lifelong care offers in exchange for money or property
* Use an elder’s property or possessions without permission
* Forging an elder’s signature
* Coercing an elder to sign a deed, will, or power of attorney
* Pressuring an elder to give a “gift”
* Claiming to have found money and offering to split it with an elder if he or she first pays some amount as a sign of good faith
* Convincing an elder his or her child has been injured or is in jail and needs money

Steps to Protect Elders from Financial Abuse include:
1. Before donating to charity, check for its legitimacy in sites such as the Charity Navigator, or the Better Business Bureau
2. Donate only to well established organizations such as the Red Cross, HelpAge or Caritas
3. Encourage older persons to create a living will and keep financial records.
4. Contact Authorities and Be knowledgeable.
5. Screen prospective employees (helpers, caregivers) for criminal backgrounds, history of substance abuse and domestic violence, their feelings about caring for the elderly, reactions to abusive residents, work ethics, and their ability to manage anger and stress.

Links and Resources:
Elder Financial Protection Network
National Center on Elder Abuse USA
DSWD Senior Citizens Monitoring Board
UP-PGH Women’s Desk

Excerpts from the American Geriatrics and British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older Persons 2010

The complete guideline is published on the AGS website

SCREENING AND ASSESSMENT

1. All older individuals should be asked whether they have fallen (in the past year).
2. An older person who reports a fall should be asked about the frequency and circumstances of the fall(s).
3. Older individuals should be asked if they experience difficulties with walking or balance.
4. Older persons who present for medical attention because of a fall, report recurrent falls in the past year, or report difficulties in walking or balance (with or without activity curtailment) should have a multifactorial fall risk assessment.
5. Older persons presenting with a single fall should be evaluated for gait and balance.
6. Older persons who have fallen should have an assessment of gait and balance using one of the available evaluations.
7. Older persons who cannot perform or perform poorly on a standardized gait and balance test should be given a multifactorial fall risk assessment.
8. Older persons who have difficulty or demonstrate unsteadiness during the evaluation of gait and balance require a multifactorial fall risk assessment.
9. Older persons reporting only a single fall and reporting or demonstrating no difficulty or unsteadiness during the evaluation of gait and balance do not require a fall risk assessment.
10. The multifactorial fall risk assessment should be performed by a clinician (or clinicians) with appropriate skills and training.