Search for tag: "aging"

Your arthritic joints ache, and there's a soft chair and a great book that's calling you. Tomorrow, you'll get a little exercise. Really?

After 50, it's use it or lose it. That refers to your brain, your bones, your joints, your muscles, and your heart. And after 50, the best perspective is move it or lose it.

Although many of the studies on aging and exercise use men as research subjects, more and more are including older women, and some specifically focus on women. Women are more likely to develop fragile bones from osteoporosis and creaky joints from osteoarthritis, and both are significantly improved with exercise. Women are more likely to be diagnosed with depression and anxiety, which may be like asking for directions. They are more likely to ask for help with these conditions than men, so are given the diagnosis more often.

The most common, crippling diseases of aging that lead to loss of life and quality of life include diabetes, hypertension, heart failure, and dementia. All can be modified for the better with exercise. Now, not all exercise does the same thing, and the same kind of exercise can be boring. Some exercises are off the table because of joint pain. Running is less likely to be comfortable with knee arthritis even though there's evidence that moving those joints makes them better. Some exercises are easy on your knees, but you have to get into a swimsuit, you know, hat black piece of Lycra that's hiding somewhere that you haven't put on for some years. The good news is that Lycra in old swimsuits seems to be infinitely stretchable, and at the pool, in the water aerobics class, it's just a giggle. You're under the water. Nobody can be looking at you, and you can look at everybody walking by. What fun.

For women in midlife, the following types of exercise are important. They don't need to be done every day and they don't take a long time, but some mix needs to be getting into your exercise salad.

Cardio. Ugg, I hate it when my heart beats fast. I spent a professional life as an OB-GYN working to stay calm and keep my heart rate down. But I know that getting my heart rate up is good for my brain and my heart.

Let's start with the brain. Randomized trials have found that short bouts of high-intensity exercise, 5 to 10 minutes, increases your capacity to do cognitively challenging tasks that require what's called executive function, to hold one thing in your brain that helps you solve the next step. That's really important in living. Being cardiovascularly fit, being able to do and doing cardio decreases your risk of developing dementia. It also improves insulin function, which decreases your risk of diabetes. There are lots of videos about short, high-intensity workouts, HIIT, high-intensity interval training. You don't want to run in public? How about stairs? Six minutes of going upstairs as fast as you can. Can only do it for a minute? Can only do it for 30 seconds? Work up to it. You don't have any stairs? Get a little step, 6 to 10 inches. Up one foot, then down. Up on the other foot, then down as fast as you can for a few minutes. It's okay to hold on to a chair if you're worried about your balance. Swimming, biking, rowing, running, hiking uphill, or any exercise that get your heart rate up is the right thing. Make your heart work a little is good for your heart.

Strength training. Now, post-menopausal women can put on muscle, and muscle improves insulin function. Being strong means that you can get out of a chair. Being strong means that you can rebalance yourself if you get tippy. Weight-bearing exercise in mice builds new memory neurons. Now, remember, mice like to run. They don't like to lift weights. So maybe it was the stressful new thing that was making them build new memory neurons. This probably works for women too. Or it works to improve cognitive function because new exercises, novel physical activities build more brain connections. You can do this at home. There are videos of six-minute workouts. Developed by The New York Times is a good one, that works all your muscle groups and there are bunch of them available.

Stretching and flexibility. Of course, yoga is the poster child for stretching and flexibility, but yoga was developed in a country where people have been squatting since birth, and they're more flexible. Still there are a lot of videos about stretching and keeping a range of motion in your neck, your shoulders, your hips, your knees, and your feet.

Balance. Tai Chi is the poster child for senior citizens doing balance, but there are balance exercises that you can do at home while you're brushing your teeth or waiting for the water to boil while you're making coffee. And you can Goggle "balance exercise for seniors" on your YouTube. You aren't senior? Okay, you can check out balance for deniers. There's any age. I'm a fan of Bob and Brad, the most famous physiotherapists on the internet, in their opinion, and they have lots of balance exercises.

How much? The American Heart Association recommends 150 minutes a week of moderate exercise, a brisk walk, or 75 minutes a week of vigorous exercise. And that's only about 10 and a half minutes a day if you're doing it vigorously or a combination of both. Recommendations for midlife women for resistance training, read weights, are 20 minutes 2 to 3 times a week. The 20 minutes could be several sessions of the 6-minute workout. Put the phone down. Put the book down. Walk away from the computer. Ten minutes, three times a day, upstairs, some weights, some balance. Mix it up. Pushing and pulling and lifting in the garden counts as resistance training.

Ten minutes, only 10 minutes, your heart, your brain, your joints, your mood, your sleep will all get better. Then do it again. And thanks for joining us on The Scope.

Interviewer: The real danger is fainting and falling when a person gets older. And how a faint and fall clinic can help your loved ones stay safe, that's next on The Scope.

Announcer: Health tips, medical news, research and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: There is a common misperception that falls are just accidental, but the reality is most falls aren't accidental and every fall or near-fall that does not result in an injury should be thought of as a crisis just barely missed. I know this sounds like a very strong statement. We're going to find out more about this now from Natalie Sanders. She is from the University of Utah Health Care Faint and Fall Clinic. It's a specialized clinic that helps track down the reasons why somebody you know and love fell and help prevent that.

First of all, falls are real serious when it comes to elderly people. We've all heard the stories, right, how the fall is kind of the incident that . . . from there it just doesn't get better.

Natalie: Yeah. Absolutely. Yeah.

Interviewer: Yeah.

Natalie: I mean falls are really just a marker of decline in older adults. So exactly like you said in your intro, Scot, when you have somebody who falls, it really needs to be thought of as a crisis.

Interviewer: Yeah.

Natalie: A dodged bullet.

Interviewer: It's a symptom just like, I don't know, maybe this is overstating, like a heart attack as a symptom.

Natalie: Yeah. Yeah. Absolutely, yeah. And it's . . .

Interviewer: And it's a sign that sums very, very wrong.

Natalie: Yeah. Yeah. The thing that's kind of fun about taking care of patients that fall is that it's due to lots of different factors. So with a heart attack, for example, you might have chest pain. With a fall, you have all of these different things kind of coming together and causing you to fall. So medications can be involved, problems with gait and balance can be involved, lightheadedness, problems with your blood pressure, not being able to see, all of these things can lead to a fall.

Interviewer: And when somebody falls, then, it could be more than just the injury. It could mean your independence is gone.

Natalie: Oh, yeah. Absolutely. You mentioned independence, that's one of the things that people really worry about as they get older. And then also, people that are taken care of their aging parents, or their grandparents, they worry about, "Gosh, if mom falls and she breaks her hip, then all of a sudden I'm going to have to start taking care of her and that means that I'm going to have time away from work and whatnot." And we know that falls are the number one reason why people are admitted to nursing homes in this country.

Interviewer: Wow, really?

Natalie: Yeah. Yeah.

Interviewer: Number one?

Natalie: And nobody wants to be in a nursing home.

Interviewer: No. And I've also heard something like adults that fall and break a hip, very few of them really get back to normal after that.

Natalie: Absolutely. Yeah. So less than a quarter of patients or adults who fall and break a hip, an older adult who falls and breaks a hip, will get back to their baseline function. So what that means is that if you were living independently, on your own, doing everything on your own and then you fall and break a hip, if you are over the age of 65, then you are fairly unlikely to get back to living independently like that.

Interviewer: Yeah. So when a fall happens, if nothing really comes of it, consider a bullet dodged, but go find out what caused it so more falls don't happen. And that's where a faint and fall clinic can help.

Natalie: Right. Right.

Interviewer: I mean, this isn't something, apparently, that I can just figure out on my own. Like I can't just say, "Grandma, we need to take care of these loose rugs because that's why you fell."

Natalie: Yeah. Yeah. No, exactly and that's how I explain it to my patients is that, yes, the loose rugs are one part of it, but really it's lots of different things that need to be addressed and that's challenging. And I think that it's very hard in this day and age for a primary care physician to be able to hit all of those different things that need to be addressed and so that's where a faint and fall clinic comes in.

We have the luxury in our clinic of having hour-long appointments for our new patients. And so, that really gives us the time to go through the history and to say, "Okay. Tell me exactly what happened with each of your falls. And then, all right, let's figure out the risk factors that you have that put you at risk for this. So was it medications, was it your home, that you were recovering from surgery and you were still really weak, was it the fact that you were depressed and you just haven't been able to get out as much? Do you have memory impairment that's playing a role there?" All of those things have to be addressed. And you can imagine that in a 15-minute visit, generally, most general practitioners can't hit all of those. So that's the value of going to a comprehensive clinic.

Interviewer: Yes. Not only the time to be able to analyze what's causing it, because there are multiple things that could, but then also to have an expert that can interpret that information in a way that then can help. So what does a typical appointment look like if somebody were to come in?

Natalie: Right. So, in all of our patients who fall, there are a couple of standard things that we do. So, obviously, this seems like a no-brainer, but we always see them walk and we actually get a gait speed on them because we know that even just how fast somebody can walk at their sort of typical pace can be predictive for falls. So if they are much slower . . .

Interviewer: Yeah. That's not a no-brainer. I never would have guessed that.

Natalie: Yeah.

Interviewer: So you take a look at them walking, you can tell a lot of things from that?

Natalie: Yeah. You can tell a lot of things. So, we look at their gait, we look at their balance, we check their eyes, we check their blood pressures when you are lying and then also standing, because that's frequently a time when patients will fall. We also do a cardiac evaluation. And the reason behind that is because it will sometimes surprise people that heart problems can actually be a contributor for falls. And that's actually why the faint and fall clinic is located within the Cardiovascular Center at the University.

Interviewer: Okay.

Natalie: So the other really important thing that we do is take a very critical look at all medications that the patients are taking, including over the counter ones.

Interviewer: All right. So you take a look at what some of the possible causes might be. Do you also take a look at could it just be a physical decline and you need to do some exercises? Is that something you take a look at as well?

Natalie: Yes. Absolutely. And that's kind of where the frailty part of the evaluation comes in. Frailty is just a very broad term for physical decline.

Interviewer: Yeah. I don't know if I'm going to be able to convince my dad to come into the frailty clinic, though.

Natalie: Right. Right. Yeah. No, we might want to avoid that term.

Interviewer: But it just means that your physical ability is declining a little bit and you might have to figure out to do some exercises to avoid falling?

Natalie: Yes. Yes. Exercises and address other risk factors as well.

Interviewer: Got you. So you would go through this process with a patient and then what would you do at that point, after you've identified some things?

Natalie: Yeah. So we typically give all of our patients handouts in terms of some things that they can do. We have very specific handouts on specific exercises that they can do to help prevent falls and changes to their environment that they can make. We communicate our recommendations with their primary care provider, set up any further testing that needs to be done. For example, if there needs to be cardiac testing done or any kind of testing for neurology, then we can set that up and expedite those referrals.

Interviewer: So I feel like after this conversation, going to a clinic like this when you are older is just about as important as other common check-ups that you might have.

Natalie: Right.

Interviewer: Yeah, I mean I feel like falls can be very dangerous. They can really take away a lot from a lot somebody's life so to be able to prevent those happening is huge. What about somebody who's never fallen before? Would they benefit from coming in?

Natalie: Yes. I think that they would and the reason why is actually because a lot of patients that come in they have not fallen before, but they come in because they are scared of falling. And we know that being fearful of falling is actually a risk factor for falling.

Interviewer: Oh, really?

Natalie: Yeah.

Interviewer: Okay.

Natalie: So you are fearful of falling and so then, therefore, you restrict your activity, you don't get up, but then, of course, everybody has to get up and walk at some point, get out of bed at some point. And so then they do get up and then they fall and then that feeds into that vicious cycle of fear.

Interviewer: Or, worse yet, they don't get up. They limit the amount of times that they get up, and all of sudden, you have muscular atrophy.

Natalie: Right, exactly.

Interviewer: And loss of function just from not functioning.

Natalie: Yeah. Exactly.

Interviewer: Is there anything that I should cover here, or anything that you would like to get on top of the mountain and say as we wrap this up?

Natalie: So I think that my main message is that falls are not a normal part of aging. They are a crisis averted. So if you have somebody in your family or someone that you're taking care of and they are falling or they are telling you that they're scared of falling or their balance is off and you're worried about them falling, they need to be evaluated because falls are a marker of things not going well.

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Interviewer: How to help and what to watch for when you accompany an older adult to a medical appointment - that's next on The Scope.

Announcer: Health tips, medical news, research, and more, for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: Dr. Mark Supiano is a Geriatrician and the Executive Director for the University of Utah Center on Aging. Dr. Supiano, I've read that when people go to the doctor, it's common that you don't really comprehend and retain a lot that's talked about, and it can be even more difficult for the elderly. That's why it's a good idea for anybody to really take somebody with them to the doctor to pay attention, especially in the case of the elderly. But what do I do when I'm there? Can you help give me some guidance? I'm in the room, what next?

Dr. Supiano: You're correct, Scott, that the communication between doctors and patients has long been a concern, not just in older people but across all ages. And given sensory loss and potentially cognitive challenges in older people, their ability to retain information from what the doctor's telling them may not be that good.

Now, I don't want to put the blame on the patient, in fact more often it's the case the blame should be on us physicians or health care providers who are not doing a good job in attending to the needs of our patients. So, being sensitive to those communication needs, and also being sensitive to health literacy, and making sure that patients can comprehend the medical terms and language that we're using, is a skill that is not fully developed in all physicians. Geriatricians are trained to be adept in those communication skills and be attentive to health literacy, so those are some of the things that we need to focus on.

One resource I can highly recommend is the public education arm of The American Geriatric Society, this is known as The Health in Aging Foundation. They have a great website, with a number of resources for patients and their family members and caregivers to point to, to get this kind of information. In that regard, the types of things that would be helpful to better prepare an individual for going to that doctor's appointment is, first of all, making sure that there's good communication of medical information. And if this is the first time you're seeing this healthcare provider, being certain that your medical records, your health history, is communicated and available for that healthcare provider to review.

Interviewer: Yeah, so it happens before you even show up, really, you should sit down with that person and perhaps make sure we have a complete medical history.

Dr. Supiano: Well, these days it's not a sit down. It's often a questionnaire, or increasingly we're going to web-based questionnaires to address that information, but making sure that there's that transfer of information. You don't want to expose yourself to unnecessary duplicated tests, not just the costs associated with that but putting yourself at risk for having more tests done, and so forth. So, the more information you can equip the provider with, the better.

Secondly, making your own list, what are your concerns? Going in with your agenda for that appointment, making sure that the healthcare provider knows what your agenda is, and can address those concerns as appropriate.

Interviewer: And that's even a bit of a paradigm change, a lot of times, for a lot of older adults, from the standpoint that my understanding is doctors used to direct the care, and now we're starting to switch towards more patient interaction.

Dr. Supiano: Exactly, so the catchword now is "patient-centered care."

Interviewer: Yeah, okay.

Dr. Supiano: It's not so much what the doctor is interested in, but rather what your concerns are and what your main priorities are for that visit.

Interviewer: And knowing that before you go in, it's just a huge paradigm shift, I think, but a good one to be aware of.

Dr. Supiano: So being prepared for that is key, and if you wish to engage your family members to help in generating that list, find out if they have concerns, might be another good way to help in that preparation.

Another key feature is, because so many problems are associated with medications in older people, either too many medications or medication interactions, it's important that you accurately communicate to your doctor exactly what medications you're taking. That should be all your prescribed medications as well as over-the-counter medications, supplements, anything that you are using.

And ideally, bring those medications in with you, it's called "the brown bag," you fill up a shopping bag of your medications. The other term for this, since there are very few procedures in geriatric medicine, this is called a "medicine chest biopsy." So you put the needle in the medicine chest and take a biopsy of all the medications that are in that person's medicine chest. But it's really critical that your health care provider know all of the medications that you're taking, and that those are carefully reviewed, and also that you tell your doctor how you're taking those medications, because it's not only what you're taking but are you taking the medications on time, on schedule, not taking duplicate medications, not missing doses, etc.

Interviewer: As somebody in the room during the procedure, if I'm in there with a parent or grandparent, what's my role? Is it just to listen? Is it to ask questions? Is it to take over the visit, I mean what am I supposed to do?

Dr. Supiano: Good question, and probably not the latter, but again it needs to be a patient-centric focus. So talking with your parent or family member and getting their lead, what role they would want you to have. I think, at a minimum, what anyone can do with the permission of the patient is to be another set of ears and eyes, and taking notes, and prompting questions when appropriate to make sure that, again, that information is adequately communicated.

Interviewer: So, it sounds like doing a little work beforehand, coming up with what [are] your concerns, what you would like to talk about, also perhaps going to the Health in Aging Foundation website and take a look at some of the resources there to get you more prepared for that trip to the doctor, having somebody with you that can maybe help be another set of eyes or ears, or come up with questions that you might not think of. Is there one more tip that you might have to making that visit as productive as possible?

Dr. Supiano: The last point is to make sure that there's good communication that follows the visit. So it is a requirement, you should set an expectation that you don't leave the visit without written instructions for what the physician or healthcare provider is asking you to do, whether that's a change in your medications, a change in lifestyle, additional tests that need to be done, what additional follow up needs to be done. Make sure that that is clearly explained to you, and that it's available in writing, so that you have that to refer to. And then, using that in terms of follow up information, that there's good after-visit communication, you want to get the results back from your tests, and being able to get feedback from your healthcare provider about the interpretation of those test results and what the next steps or additional follow up might be, based on the outcome of those results.

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Announcer: Health tips, medical news, research and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: The current medical guidelines for systolic blood pressure are between 140 to 150 but new research indicates that reducing that to 120 can drastically reduce the chance of heart disease and death for adults 75 or older even if they are considered frail elderly. Dr. Mark Supiano is a geriatrician and the executive director of the University of Utah Center on Aging. This study, is this a new revelation that lower could be better with systolic blood pressure especially for elderly adults?

Dr. Supiano: Yes, Scott. This is exciting new information that came out of the systolic blood pressure intervention trial otherwise known as SPRINT. The trial ended late in 2015, earlier than anticipated because of these very dramatic benefits.

Interviewer: When it initially ended early, a lot of people speculated that that meant bad news but it actually meant quite the opposite.

Dr. Supiano: Yes and particularly for the 28% of the SPRINT subjects who are over the age of 75 there were some concerns, myself and other geriatricians, that the very intensive systolic blood pressure target of 120 might not be safe for older people. When we first got news of the trial ending early I first thought that it was possible that older people had more side effects or more injurious falls or other complications of the very low blood pressure and that was why the data safety monitoring board might have ended the study early. In fact, the results were just the opposite.

Interviewer: Like a revelation almost it seems like.

Dr. Supiano: It really was a surprise to be honest. Not so much as a surprise that the benefit but the surprise that the benefit was of this magnitude and that this occurred this early on on the trial.

Interviewer: So the current guidelines are between 140-150. This study points out that 120 can drastically reduce the chance of heart disease and death. How drastic are we talking?

Dr. Supiano: I'll focus on the population 75 and older as I said, this is 28% of the SPRINT cohort and in that group there was a 33% reduction in the cardiovascular outcomes. This is primarily a myocardial infarction or heart attack or congestive heart failure and stroke and then in addition overall reduction of 32% in mortality.

Interviewer: That's pretty substantial.

Dr. Supiano: It is. To be honest there are very few treatments I can recommend for people over the age 75 that can have this dramatic impact on those outcomes.

Interviewer: So if you're going to do one thing, according to the study so far, it would be try to get that blood pressure down to 120. Now, does that mean taking medication? Does that mean lifestyle changes?

Dr. Supiano: All of the above. On average, the people in the intensive group who are managed to a blood pressure of 120 or taking one additional anti-hyperintensive medication relative to people on the standard arm.

Interviewer: Of course your eyes looking at the risk benefits and something like this. So the benefits are tremendous. Are there risks?

Dr. Supiano: Absolutely. The good news was, and again focusing on those 75 and older population, our major concern would have been there were higher rates of injurious falls or what's called orthostatic blood pressure - a reduction of blood pressure when the people first stand up and get light headed or dizzy. First, there was no increase in serious adverse events between the intensive and the standard arm. Second, and again very reassuring, there was no high rate injurious falls in the intensive group, nor were there serious rates in the intensive group. The intensive group did have higher rates of low blood pressure, of electrolyte abnormalities, largely low sodium levels which was to be expected because of the medications that were used and some other adverse events. But when we weigh though over the benefit of preventing heart attack, stroke, heart failure and death, most believe that those benefits outweigh those risks.

Interviewer: That number of 120, can you go lower than that and get more benefits or is there a point where no?

Dr. Supiano: That would be another study. And it's important to point out the one on average for 75 and older group achieve of systolic blood pressure of just under 122. That meant that half the people had a systolic blood pressure above 122. So 120 maybe recommended as a target blood pressure. That doesn't mean everyone is going to get there. Nor does it mean that the benefit won't accrue if you don't get exactly to that target. I think the take home message is, it seems to be that the lower, the better.

Interviewer: So is this something that if somebody does fall under this group or somebody has a grandparent or parent that's in this group that you would recommend that they go to their doctor and say, "I would like to try for a blood pressure of 120"? Because this isn't the guideline yet.

Dr. Supiano: So important point, the guidelines are being written down or likely incorporate this new information but those guidelines won't be out until later this summer. Even with that guideline, like everything we do in medicine and particularly in geriatric medicine we have to be patient-centric. So we need to weigh someone's benefits and risk of their elevated blood pressure and incorporate that those at greater risk are likely to have greater benefit. So it needs to be an informed decision with patient who discussed the pros and cons and determine their level of interest in trying to achieve this lower target and recognize those benefits.

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Interviewer: Aging on a microscopic scale, up next on The Scope.

Announcer: Examining the latest research and telling you about the latest breakthroughs. The Science and Research Show is on The Scope.

Interviewer: I'm talking with Dr. Adam Hughes, Assistant Professor of Biochemistry at the University of Utah. Dr. Hughes, when I think of aging, I think about getting wrinkles, going gray, slowing down, but you think of aging on a different scale. How do you think about aging?

Dr. Hughes: We think about aging, I'd say, more at an organismal level or even more specifically than that, the cell biology level. Sort of looking at not how aging affects the whole organism, but how it affects specific structures within our cells within different tissues.

Interviewer: A lot of your research focuses on one component of the cell, an organelle called the mitochondria. First of all, can you orient us to the mitochondria? What does it do?

Dr. Hughes: Sure. Mitochondria, they're known as the powerhouse of the cell. Historically, they're drawn as kidney-bean-shaped structures you see in all the textbooks, but mitochondria do a lot of different things in metabolism. They're a double-membraned structure that produces lipids, they're involved in oxidative phosphorylation, they basically make energy for cells and also participate in a large number of metabolic reactions.

Interviewer: Studying the mitochondria is actually a whole field in and of itself. What's some of the evidence that mitochondria is involved in aging?

Dr. Hughes: Mitochondria has drawn a lot of attention, not only for its role in changes in mitochondrial function affecting how long an organism lives but it's also become very clear that as mitochondria become faulty with age, which happens for a number of different reasons in a number of contexts, this is also been linked to driving the development of a large number of age-associated disorders as well.

Interviewer: And as it turns out, there's quite an elaborate system for getting rid of or repairing mitochondria that does not function well. You've just published some research about this in the journal "eLife."

Dr. Hughes: I haven't explained much of what we've been doing. We've been using yeast as a model system to understand the aging process. So it's pretty cool that the single-celled eukaryote, the simplest one, and a lot of labs have been using it for a very long time to understand lifespan regulation type processes. And so our lab actually uses this organism in it does, in fact, age. A yeast cell, we measure aging by the number of times a cell can divide before it dies. Now, it happens about 30 times before a cell dies. And so in these old cells, it started several years ago when I was a postdoc at the hutch in Dan Gotchling's lab, we found it in old cells there was damaged or dysfunctional mitochondria.

So we decided to use this system to try to see what we can learn about how cells handle this, how they respond, what can they do. And we went into it, at the time, wondering if we could model pathways that were already known in mammals, one of the most prominent being the autophagy-dependent or self-eating pathways that had already been fairly well characterized. And so when we went into this, we set out to see in an old cell, do we see pieces of mitochondria? And we're visualizing all this on the microscope, being ripped off and degraded after they're damaged/

And we saw that there was, in fact, this going on in old yeast cells and so we initially thought it was similar to what had been observed already. And that's how we got into it. We didn't go into it looking for new pathways, but eventually it sort of, as we got more into the details of what this is going on, we realized they totally new type of quality control that we discovered that was different than anything else that had been described before.

Interviewer: So what is it? What did you find and how is it different from what was there, what you knew before?

Dr. Hughes: In general, in this field, it was always thought as a mitochondria became damaged that these systems aren't very smart for a lack of a better word, that they would go to the damaged mitochondria and just degrade the entire thing. Which seems a bit wasteful and so when we came into this we thought the same thing and we were using a protein on the mitochondria. We are monitoring it by microscopy and we could see that it was being eaten. But what we did that went beyond these original studies and other systems was there are about 1000 different proteins in the mitochondria. And we just started looking at other ones too. So most of the studies in mammalian cells had only looked at one or two and made conclusions.

And so we went on and looked at all mitochondrial proteins to see how they were all being degraded. What we discovered, based on this, and this is the big crux of this study, is that the pathway we've uncovered now is the concept and idea that mitochondria actually, under these situations when they're damaged, don't just get totally degraded as a whole. They can actually be broken down piece by piece. And what I mean by that is certain proteins can be basically selectively sorted out and removed from the mitochondria and degraded and the rest of it can be left intact.

Interviewer: Do you have any ideas yet of whether this pathway relates to aging or how it relates to aging?

Dr. Hughes: We got into it looking at aging, but we think it's actually going to have many applications in other systems, especially sort of metabolic-related disorders. We've been working from the standpoint of seeing the structure and it forms, it's sort of very descriptive. It forms, it gets released, it gets degraded and certain proteins go into it and certain ones don't. But understanding what the importance of it is and why it happens has been a much more difficult question. And we are starting to get at that.

We didn't get into a lot of it in this currently published paper, but some of our certain experiments are directed in the range of one thing that we did include here. And one big clue to us is the identity of the proteins that are actually degraded by the system. So again, the mitochondria has about 1000 proteins in yeast and when we looked at the proteins that are degraded by the system that we discovered, it's only about 10% of those proteins. And it turns out it's very selective for one particular group, which is a group of proteins called the mitochondrial nutrient carrier protein.

So the role of this group of proteins, there are about 30 of them, in the in the mitochondria, they basically facilitate the transport of all nutrients into and out of the mitochondria. So we're working from the fact that these are the main targets of this pathway and we think that giving us a big clue as to what might be its role. And so clearly, they're metabolite transporters. They're very heavily involved in all aspects of metabolism. And so we're testing the idea now, a hypothesis that this pathway may be very important for actually protecting mitochondria in times of changes in cellular metabolic state.

Interviewer: It's also kind of amazing to me that, especially in something as simple as a yeast, that there are still entire processes that we're still discovering.

Dr. Hughes: Yeah, I think that's definitely a really cool point. Sometimes, yeast in this day and age will get a bad rap. You hear all kinds of things that yeast research is done and things that we used to only be able to do in yeast, now we can do them in humans and other organisms. But what's sort of the big arena right now, I'd say, in the yeast field is cell biology. And it's been very limiting for a long time, the ability to look at all different proteins and all different things within the cell.

And what's really cool in the yeast field is that many, many years ago now, probably 10 years ago, a lab developed a collection of all yeast proteins tagged with a fluorescent protein, GFP. So it's about 6000 proteins in yeast. And so we have strains that contain every single one of them. And so there are a number of labs across the country, including ours, that are essentially using this collection to look at how the entire protium changes not in terms of levels, but in terms of localizations in cells.

And people are discovering a lot of new things that no one had ever noticed simply because we have the tools to do it now. And this is what's really nice in yeast. And we still don't have the ability to do this in mammalian systems yet. So I think the future will get there and we'll be able to start looking at these. But there's a lot of new, I'd say, cellular structures, cellular compartments that form under very particular conditions that people just hadn't seen before.

Announcer: Interesting, informative, all in the name of better health. This is The Scope Health Sciences Radio.

Dr. Miller: Could you have a pelvic fracture? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: Hi, I'm Dr. Tom Miller and I'm here with Dr. David Rothberg. He's an orthopedic surgeon and specializes in trauma care. David, how would one know if they had a pelvic fracture? Now I know that these are fractures that don't just occur spontaneously. Generally, people will have some type of trauma. Tell us a little bit about how that happens. How does one suffer a traumatic pelvic fracture?

Dr. Rothberg: There really are two separate patient populations that will have a pelvic fracture. One is the patient with a devastating life-threatening injury. These are not ones where you're questioning. These are patients that come in as a Level 1 trauma activation, but really a lot of these come in in an older patient population who have had a ground-level fall. They've tripped on the carpet, or over a dog, or something like this, and they can have pain anywhere from there groin, their abdomen, or low back, and that's when the work-up starts.

Dr. Miller: Is it sometimes confused with a hip fracture?

Dr. Rothberg: Commonly. The type of pain that you have with those two fractures is extremely similar, and we typically will figure out which one it is by taking x-rays.

Dr. Rothberg: Now a pelvic fracture, I guess depending on the type of patient, generally those are surgically repaired. They're fixed and treated, and then there's a recovery period. What about a pelvic fracture? How do you treat those? It seems like it would be kind of hard to cast a pelvic fracture.

Dr. Rothberg: Yeah, that's true.

Dr. Miller: It's like a rib. You can't cast ribs.

Dr. Rothberg: We don't cast pelvic fractures. What we're trying to figure out when we're working up some of the pelvic fractures is is the pelvis stable or unstable? And what that means is how much motion is in the pelvis when someone would walk.

Dr. Miller: And how do you determine that?

Dr. Rothberg: It's based on physical exam, the x-rays, and oftentimes a CT scan really looking at the pattern of the fracture, or how the bones are broken, and trying to determine the best course.

Dr. Miller: So in a pelvic fracture, would you operate on them from time to time?

Dr. Rothberg: Yeah, it's a very common operation for us. We do them almost daily, if not weekly. It really depends on the age and patient health status and mobility, and a lot to do with what they've broken.

Dr. Miller: Is the recovery time similar to a repaired hip fracture, or is it longer? Is there a difference in the type of recovery?

Dr. Rothberg: It's pretty much in the same ball park depending on the pattern of fracture they had. The surgery is a little easier to recover from. The surgery is not as invasive, but the ability to get back walking is about the same. It's tough in the early period, but we do expect that most people will get back to their daily life.

Dr. Miller: So the real key is if someone falls at home, especially an older person, and they have persistent pain they ought to be checked out and receive some type of radiologic study in order to determine at least initially if there's a fracture.

Dr. Rothberg: That's exactly right.

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Interviewer: Going to learn more about a brand new book called Autism Spectrum Disorder in Mid and Later Life. That's next on The Scope.

Announcer: Health tips, medical news, research and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: Scott Wright is a researcher at University of Utah and also the editor of the book Autism Spectrum Disorder in Mid and Later Life. Tell me about this book. Why did you decide the world needed this book?

Scott: I do think the world needs this book. My interest into autism issues with the aging intersect, the gerontological connection, came about when I was involved in a research project where I saw grandparents, grandparents as being very involved in the care of children, young adults on the autism spectrum, and realized that okay, here you go. Here's the grandparents yet again showing the kind of support and that safety net to help out their grandchildren. But think about this, their grandchild that has special needs and the grandparents were there providing that care. Well, from there, I realized that grandparent issues are also aging parent issues. Are there aging parents that are still supporting their adult child with disabilities, in this case perhaps with autism spectrum disorder, autism conditions? And yes, there are. In my discovery of the literature and the research, aging parents very much have this very, in a way, very concerned futuristic look about what is going to happen to their son or daughter who's an adult in their 30s, 40s, and 50s. What's going to happen to them when the aging parents, when they die? And then from there I came to appreciate that the amount of research, literature looking at this topic, it simply wasn't there. There was just this huge gap in looking at autism issues and aging, which literally stopped at adolescence and then picked up again a little bit in the geriatric years but nothing in between.

Interviewer: So kind of like a dumbbell. There's a lot young, a lot old, but mid to later life, nothing.

Scott: That's a great image to think about, very much like this barbell effect where you have a lot of interest, activity, services, programs, just general thinking that autism is a childhood issue and then it just goes away. Or that we're not paying attention to it once individuals transition, the transition years to adulthood. What happens then? Because autism is a life-long condition. What happens after adolescence? This is what this book does.

Interviewer: Is this book accessible for the lay public? I'm noticing a lot of references and I don't even know what these are called, oh, they're called references. At the end of the chapter it looks like an academic kind of book.

Scott: The original intent of this book was to create a publication of the latest evidence-based research. And indeed it has, I would say a good part of the book is academic and written for other professionals. But really this book is for a variety of different audiences - grandparents, aging parents, adults on the autism spectrum that are aging themselves. So this book has this great feel of being accessible to so many different groups and I think it's been accomplished. That goal has been accomplished with the final outcome.

Interviewer: It sounds like, so when you first brought up what interested you in it, I guess I just automatically assumed that parents with, somebody with a child that has autism are probably just going to be essentially parents their whole life. And that's what you're seeing is actually going on, but maybe that's not the best way.

Scott: That is a great question because for many parents, their son or daughter will reach adulthood and the programs and services that were there in the K-12 years, which are federally mandated, suddenly it appears that once their son or daughter reaches adulthood there is such a lack and a huge gap in services and programs. Parents become, in effect, the support system. When we look at individuals with autism, role models like Temple Grandin, she has some very interesting advice. And what she would say is a key issue during the transition years to adulthood, work. Work. Employment is such a big factor for a hallmark indicator of adulthood. But it would be my guess that the listening audience may not even know this statistic: 90% of individuals on the autism spectrum, they have the highest unemployment rate of any disability group. We're talking about 85-95% of this population with autism are unemployed. This is unacceptable in our society. Why is this happening? Work is a hallmark for adulthood and yet unemployment is a huge challenge. We need to address this.

Interviewer: So what were some of the things that you found out in the process of editing this book? And I will say that you did tell me that there were a lot of contributors to it. International contributors, not only people with MDs and PhDs but people on the spectrum as well. So what did you learn? What are some of the things that can be done in mid and later life that isn't being done?

Scott: What to glean from this book, with you're right, international authors, individuals, adults on the spectrum who are contributing the chapters, I think the two big themes that emerge out of the book that are important issues actually relate to the general population, to you or me and to everybody. That is when you think about to love and to work are two key factors to well-being and quality of life. For individuals on the autism spectrum, to work, which we would think of as almost like an automatic factor of being involved in our society, is a huge challenge for all sorts of different reasons. And then to love would be the issue of establishing relationships. More importantly, social networks and I think of this term social capital in terms of to love and having connections and social support. And then work to have a productive contribution to society and in return the rewards of that, this is what needs to be worked on, addressed for autism issues into adulthood and then into later life.

Interviewer: And what are they answers? Are they within the covers of this?

Scott: I think that the authors, yes. The authors that have been collected here, brought together in this book, they've done a great job with indicating what the answers are. I'm proud to say that, again, the researchers that are involved in this are talking about the data that they have collected but more importantly are the contributors who are adults on the autism spectrum, they have shared their story. And their story says we have learned a lot, we'd like to share it with everybody else, the right steps to live a fulfilling life.

Interviewer: And it sounds like it might offer some new perspective and new thoughts, too. Just even the perspective of, boy, a job is really important. Inclusion is really important but yet also is autonomy. That's important as well.

Scott: It is, so think about . . .

Interviewer: And these are all relatively new concepts to the thinking of the condition, is that correct?

Scott: It would be because, again, think about how we view autism, it used to be primarily a childhood/adolescent context. Now the context is when you're an adult on the autism spectrum the issue of community inclusion is huge. How can I sustain an independent living circumstance? Which to maybe many other people that's going to be an automatic transition, for individuals on the spectrum it's fraught with a variety of different challenges. So community inclusion is big. And then the employment issue, again, I can't think of one issue that would help so much in the lives of individuals on the autism spectrum and their families and our communities and our society would be meaningful work, and the opportunity to engage in and interact with meaningful work is one of the key issues in the landscape of autism today.

Interviewer: So it sounds like it's really kind of perhaps a guide into some uncharted waters.

Scott: I think that's really the best way to describe that. This book is pioneering, I think, in opening up new understanding of autism and aging issues.

Interviewer: What would you hope if a parent or a grandparent that had somebody with autism in their life purchased it? What would hope that they would be able to do after they have read it?

Scott: I think the key here is to realize that services, programs are becoming available in our society and in our communities are rapidly increasing. That's the good news. And that for the individuals who would read this book is that they should not, please, feel like that they're all alone, isolated in this particular context. That there is an increasing amount of services and programs in our communities. The key is to build the bridge between the individuals who need it and the individuals who can provide it. That's going to be the key factor.

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Interviewer: Five tips for family caregivers of advanced cancer patients. That's next on The Scope.

Announcer: Medical news and research from University Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: You find yourself in a situation where you have to provide care for a family member who has advanced cancer. It can be a very, very difficult time. And today we've got Dr. Lee Ellington. She's a clinical psychologist. She has five tips to help maybe make that process better not only for yourself but, more importantly, for the cancer patient as well. What is your first piece of advice for somebody that has found themselves in the situation?

Dr. Ellington: Number one is to communicate openly with the patient or other family members about the remaining days. It may be uncomfortable, but it's an important conversation to have.

Interviewer: And why is that conversation important? What does that do? What does that accomplish?

Dr. Ellington: It helps people prioritize what's important in their life, things that may have gone unsaid that they might have regrets about later. It helps open up some understanding and I think, in general, just talking about how we want to live in our final days needs to be an open conversation.

Interviewer: How about number two?

Dr. Ellington: If you have a patient with advanced cancer, then I think it would be important to learn about hospice before you need it. So explore hospice and what hospice offers and how not only will it help the patient that they're caring for but they may have many resources for the family. So hospice is a team approach. There's a chaplain, a social worker, a physician, nurse, hospice aids and other resources, and the unit of care is for the family.

Interviewer: So it's not so much necessarily always for the patient, but it's also for those that are caring for the patient in the family?

Dr. Ellington: They will encourage about the caregiver to take care of themselves, but sometimes the caregiver will say, "No, no, no. I can't do that now." But to be at their best, to really take care of the patient and themselves, they need to do both.

Interviewer: All right. So it's a good idea to have an idea what hospice can do, what kind of resources will offer you. What's number three?

Dr. Ellington: Consider yourself a hospice team member. So hospice is a team care approach and the family caregiver and the patient are part of that team. Caregivers have valuable information about the family, about the home life. They know a lot about the cancer and the disease and values and preferences and they should empower themselves to voice that and see themselves as a team member.

The fourth thing is to take care of themselves, self-care. So maintain their health the best that they can. Be sure they get the rest that they need and the resources to provide rested if that's necessary. So kind of pace themselves.

Interviewer: So don't abandon all the other things in your life. You still need to keep maybe exercise routines or give yourself some breaks away from caring for that patient. Again, I would imagine a lot of people are like, "No, I can't do that. That's selfish of me."

Dr. Ellington: Absolutely. That's the most common statement, I think. The other would be to seek support, whether from the hospice team, from families, from friends. People don't know what to do. They want to provide support to you, to both the patient and to the family and to take people up on that and ask for it, meals, a friend to talk to, a break. So seeking that support.

Interviewer: Yeah. And so often in that situation, you'll find people will say, "You know, if there's anything I can do," and then how often does that conversation just end right there? You're recommending that that family member should say, "You know what? It would really help if you could cook a potluck dinner for us tomorrow night or whatever."

Dr. Ellington: Absolutely.

Interviewer: Is there a big bottom-line takeaway when it comes to you're the caregiver, how can you care for yourself for the benefit of not only yourself and your loved one as well?

Dr. Ellington: Death does not just one person's experience. It's everyone's experience. There's loss, there are goodbyes. And so I think the takeaway is that to come together and decide how the family or the support ties want this to occur, want it to happen and be clear about that. So that means maybe taking a break so that they can be present for important conversations or can be present to provide the care they need. Or it may be taking a break to reflect on, "What just happened here?"

Interviewer: Do you find that that uncertainty of the person that is giving care not exactly knowing what the person that they're caring for wants can cause a lot of undue stress and that's why these conversations are important?

Dr. Ellington: Yes. People are afraid to talk about it and, certainly, the patient drives the course of the conversation. If they're not comfortable about talking about the final days and you've gently tried to make that occur, then you need to talk about with someone the final days and what you want and how you can make that happen for yourself and for the patient, but definitely, these conversations are difficult in our current culture.

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Interviewer: You like your primary care physician just fine, but now you're told you need a geriatrician. Why? We're going to examine that with Dr. Supinao, next on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: You've just been told that you need a geriatrician but you like your primary care physician just fine. Why do you need a new doctor?

Dr. Mark Supinao is the Executive Director of the University of Utah Center on Aging. Why? Why do I need to change?

Mark: A couple of points first, geriatrics is a team sport and in our patient-centered medical home that we've just launched here as part of University Health System, the other members of that team are equipped to provide services and resources to patients who have functional needs to maintain their independents. In addition to me or my colleagues as geriatricians, that team includes geriatric nurse practitioners, a pharmacist, a Pharm.D prepared geriatric pharmacist, a geriatric social worker and a case manager to help navigate the needs that our patients have.

More that age, it is a change in function or cognition, the accumulation of multiple chronic conditions, so it's not just your age 65 but your now age 65 and heart disease and diabetes and depression and osteoporosis, and a number of other issues that may prompt you to be on a number of medications, and the challenge is who is coordinating all of that individual's care, particularly if their function and other needs are becoming apparent, and that's really where geriatrics comes into play.

Interviewer: Couldn't somebody much younger have those same issues, and why wouldn't they need geriatrician, then?

Mark: Good point, and so it works both directions. It's not, as I said, not just driven by age. There are many younger people with those multiple chronic conditions who, if they have functional and/or cognitive declines, would likewise benefit from this geriatric approach.

Interviewer: Okay, understood. Are there different health care needs for somebody who's older that has these conditions, though? Different considerations?

Mark: Yes. The real bang for the buck, frankly, is above the age of 85. That's where the geriatric's expertise is most likely to make an impact in terms of improving someone's health and function, because of the deficits that are often evident in that population. For example, perhaps as many half of people over the age of 85 have some evidence of cognitive impairment. If that becomes limiting in terms of their function, if they're having difficulty managing their ability to live independently, that's the time where a geriatric assessment to evaluate what the causes and consequences of that cognitive decline might be, and that's where a geriatric evaluation would come to play.

Interviewer: Yeah. So don't think about it as, "Oh, my gosh, I've got to go to a geriatrician. I'm getting older." Think about it as, "How can I maintain my independence and my health and my quality of life as long as possible?"

Mark: Exactly. So the skills that our team can provide is to perform that assessment, identify not just what the medical problem are but what the functional issues are, where someone might have limitations in their activities of daily living, their ability to live independently, where they may have limitations in managing their own medications, using the telephone, maintaining their finances, using transportation, shopping, preparing meals. If there are problems in those areas that's something that we are trained to evaluate and to try to remedy to the extent that we can, identify reversible conditions have a positive influence on someone's function.

Interviewer: So it sound like perhaps it's a new way of thinking, because it used to be as soon as the function would start to decline then perhaps maybe as you get older you would have to go to assisted living home or nursing home. Now it's go to a geriatrician and let's see how we can continue to keep you independent as long as possible, maybe even beyond what somebody might normally go to nursing home.

Mark: That certainly is a goal, and while that goal cannot always be achieved, our team is equipped to help patients and their family members, their caregivers, navigate that landscape to identify the living environment that would be most appropriate for their functional needs.

Interviewer: And something else I understand a geriatrician can do is really align the care given with the patient's wishes, almost like personalized medicine, which is an old concept for geriatricians but kind of a new concept for the rest of medicine.

Mark: It's critically important as people develop frailty and become more vulnerable to complications of their multiple chronic conditions that we identify what's really important to them and their care, and it may not be simply getting their numbers under control or managing their given disease, but it's a focus on function.

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Interviewer: How good nutrition can give you independence and functionality as you get older. We'll examine that next on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: As you get older, your nutrition needs change if you want to maintain your independence and functionality. We're talking to Susan Shirer. She's a registered dietitian nutritionist and we're going to talk about if you're a baby boomer, as you get older, how the things you eat can actually make a big difference in your functionality and independence as you age. So how important is nutrition when it comes to functionality and independence as a Boomer?

Susan: Boomers need to really focus in on their nutrition. This is the time when they can impact their aging process and their future independence so it might be the difference between living in your home and having to move to higher level of care later on. So the impact right now is super important.

Interviewer: And from what I understand, the genes can help you so far, but a lot of what determines whether or not you're going to be independent as you get older really is your lifestyle. I mean, that's a big deal.

Susan: Exactly. Lifestyle has more of an impact on your aging process than your genetics. Now, of course, centenarians, that's a different picture. But for the bulk, the masses of older people, it is that lifestyle factor that has to be addressed.

Interviewer: Yeah, it's the choices we make when it comes to food and nutrition. How are your needs different when it comes to nutrition as you age?

Susan: One of the major issues that really ties to functionality in is related to muscle mass, which is related to your protein requirements. As you get older, the turnover of muscle is greater and, therefore, you need more protein.

Interviewer: Really?

Susan: And so I always joke with my older patients and say, "Gosh, did you know you need the same amount of protein as . . ." I come up with some basketball person like Karl Malone or something. But it's really true. You almost double the amount of protein you need after age . . . and this is a little fuzzy, but we'll say 50 than you did when you were younger. So, again, it has to do with that increased turnover. And also it's just hard to maintain the muscle.

Interviewer: What other nutrition needs change as you get older? How does it affect your body?

Susan: So we'll stick with the muscle and we're going it to connect to the bones. They work together and you lose minerals, you lose calcium as you get older, in particular for women but men also. And one of the key factors in maintaining bone health is vitamin D. We think of vitamin D as the sunshine vitamin, but as you get older you can no longer or very minimally synthesize vitamin D from the sun and you become more diet dependent. So we've got to think about what food sources we have to access the vitamin D. There's fatty fish, there are eggs . . .

Interviewer: Great sources of protein as well.

Susan: Yes, exactly. So, again, hand in hand, and there are actually some mushrooms now that are being produced that they have been able to increase their vitamin D content. So there are some foods but not a lot. And milk is fortified with vitamin D only in the US. Yogurt is, although, when it comes to regulations, FDA, USDA, milk is the only food that has to be fortified. The other foods are optional.

So then you have to think about, "Okay. I'm getting x amount for my food. How much more do I need? How am I going to get that?" And for a lot of folks, that's going to be through a supplement. What is a supplement? A supplement is something that supplements your diet and so it's a combination of the two. And that can make a huge impact on maintaining your bone health.

Interviewer: As we get older, of course, we know that falls become a lot more likely and if you're stronger and you got stronger bones, it's less likely, I'd imagine . . .

Susan: Right.

Interviewer: . . . that you would fall. Is that correct?

Susan: Right.

Interviewer: Is that the thinking?

Susan: Right. Because muscle and bone work together and if one is weak then your fall risk is higher. There's research to show that vitamin D is associated with fall risk. And so that is definitely the case. And if you don't have muscle, then you're at high risk for falling too. A fall is extremely important. It's a symptom of something going on, something wrong. And so falls are right at the top of this for us in gerontology. We're always watching, and hearing and asking, "Have you fallen lately?" Because it's an indicator that something's amiss. It could be, again, not enough muscle strength, vitamin D deficiency or a combination of the two.

So there's one other nutrient that I think we should focus in on and that's vitamin B12. As we get older, we have less ability to digest and absorb vitamin B12. It's a type of anemia. It's not what some people talk about pernicious anemia. It's not that. It's called protein-bound B12 deficiency. And why are we worried about B12? Well, B12, as I mentioned, is involved with blood cells and anemia, but it's also involved with cognition. And we want to stay as sharp as long as we possibly can, mentally. So we need to be aware of this. Folks over age 50, the percent of folks that are potentially deficient in B12, it ranges a bit from 15 to 30% of the population. That's a large number and so we need to be watching that.

Now, just because you turn 50 doesn't mean that at 51 you're going to be B12 deficient. You can store B12 and if you had a healthy diet most of your life then you have B12 stored for maybe five, seven years. So it'll take a while. But it's something that you would want to have checked when you go in for your annual physicals and the like and see where you're at and check it because, again, you want the energy and you want the mental acuity.

Interviewer: So we talked about protein, vitamin B12 and vitamin D. For somebody now that is saying to themselves, "All right. I'm ready to start changing my diet so I can be healthier and I can live a more independent life," how much more of these nutrients do they need? So protein, for example, I think you said double.

Susan: Almost, in grams of protein. As a younger adult, you need 0.8 grams of protein per kilogram body weight. When you're older, there are recommendations that start at .2 grams per kilogram body weight, that is of protein, or up to .5, so that's where we're almost doubled. So you have to look at the protein content of your diet.

Now, most Americans eat a fair amount of protein. But, as you get older, protein just doesn't have that . . . you're just not that interested anymore and it's not that tasty. It's expensive, hard to cook. I mean, there's a multitude of factors. And so then it becomes a problem. So you do have to put a little more effort into that. If I might say we think about muscle meat as the protein source of choice, but milk, eggs, beans, they're excellent sources and they can fit in beautifully, and little prep.

Interviewer: And then what about vitamin D?

Susan: Vitamin D, you're going to get probably, at best, about 400 IUs of vitamin D a day. The recommendation, the Dietary Reference Intake for an older adult, it's around 800 IUs a day. So you do have to take a supplement in most cases.

Interviewer: So as you get older, just know that you're going to have to do a vitamin D supplement.

Susan: Yeah, you are. You are. Very much so.

Interviewer: And then B12, same thing? You're going to have to take a supplement?

Susan: You probably are. The amount . . . you can hear different recommendations, but 500 micrograms to 1000 to replace and then maintenance would just be like a part of a multivitamin type thing. But toxicity with B12 is a minimal risk, but you still want to know. In my mind, you want to have a blood test done to see where you stand.

Interviewer: Some very useful information and I didn't realize as the body changes as we get older that the nutritional needs would change so much. Any final thoughts? Anything that you wish I would have asked or anything you feel compelled to say?

Susan: I just think that we need to appreciate the foods that we have, we need to eat fresh, you don't need to take a lot of supplements, although we did mention two. All of this will make a huge difference in how you age. You will be able to maintain, again, your independence and enjoy life. Eat fresh, eat healthy and enjoy.

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Dr. Jones: Caregiving, it's been called compassion in action. Sixty million Americans function as full or part-time caregivers for family members or people in their community. November is National Caregiver Month, and we honor those who, through love, loyalty, duty, or a combination of all three, give their heart, mind, and body to care for others. But how do caregivers care for themselves? This is Dr. Kirtly Jones from the Department of Obstetrics and Gynecology at University of Utah Health Care. And today we're talking about the health of caregivers on The Scope.

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Dr. Jones: The economic value of informal and family caregiving in the U.S. is more than $300 billion a year, but there is also a cost to the caregivers. They've been called the invisible patient, in that their present in the doctor's office with the person for whom they care, but their responsibilities have a physical and mental cost. The risk factors associated with health problems and caregivers include, being a woman, the number hours of care provided, financial stress, cognitive impairment of the patient, a caregiver who lives with the patient, and a lack of choice in assuming the caregiver role. Today in the studio we're talking to a caregiver who is balancing her role as primary caregiver with her own health successfully, I might add. And I would like to welcome Kathleen to The Scope radio to talk about caregivers taking care of themselves. Welcome, Kathleen.

Kathleen: Thank you. I'm delighted to be here.

Dr. Jones: So help us understand a little bit about how long you've been the primary caregiver for a loved one in your home.

Kathleen: My husband was diagnosed with Alzheimer's about year after he retired. It's been nine years now that we've been dealing with this.

Dr. Jones: Did you plan for the long haul? Did you take it day-to-day, or a little bit of both? Did you think it was going to be this long?

Kathleen: No, I didn't think it was going to be this long. The prognosis, when you get it, is 3 to 20 years, and I looked in stunned shock at the doctor when he said that and he said, "But it won't be that long." I think probably because my husband was still considered early onset, because of his age. He was 63 at the time, but, no, I had figured really that he would probably be gone by now.

Dr. Jones: Some way, you've managed to stay alive cognitively intact, physically healthy. I mean, these are the things I'm assuming, but what have you learned over these years about taking care of yourself?

Kathleen: It's very, very important. There have been times when I thought I was doing fine and then suddenly realized that I really wasn't. What I do for myself is go hiking when I get a chance to. I belong to the book club, and I read voraciously. I read myself to sleep at night, partly because if I don't read before I go to bed my brain just starts thinking about all sorts of things. In this way, I can put myself in another world before I go to sleep. I indulge in chocolate as often as possible. I do volunteer work, and I'm lucky because I can still leave my husband home alone and I can take off and do volunteer work. I go to lunch with friends. At this point I can no longer take him to the theater or movies, so I go by myself.

Dr. Jones: In terms of his physical activities, can he dress and feed himself or is this something that you need to do for him?

Kathleen: He can still dress himself. If I don't put his clothes out for him, he will just put the same things on over and over again.

Dr. Jones: That sounds like me. That sounds like a great fashion idea.

Kathleen: But, yes, he can still dress himself, wash himself. Sometimes he needs a little encouragement, and he still eats by himself.

Dr. Jones: So you've been writing about your experiences. Is that helpful?

Kathleen: It has been extremely helpful. There's something about putting your thoughts in print that's very different from talking with someone casually, and you sort through your feelings and your emotions much more if you put it in print than you do when you're just speaking to someone. It's been extremely helpful for that. My goals with the blog were two-fold. Number one, to help me vent, but, number two, to help other people realize that we're all going through the same set of emotions at various times, and it's been very helpful.

Dr. Jones: I've certainly heard about writing as an exercise for people with PTSD and depression, but this is the first time I have actually thought of writing as a therapeutic choice for people who are locked in or choose to lock themselves into a caregiver role.

Kathleen: It's been extremely helpful. I noticed a change within the first few months in my feelings just because I had put them down and posted the blog. It was a very different feeling, so it's been extremely helpful.

Dr. Jones: Well, you mentioned talking to others. Can you expand on that little bit?

Kathleen: Yes. As I let friends know that my husband had Alzheimer's, I found other people out there who did. I mean, almost everybody knows someone, either in their direct family or a close friend, who has this disease or has some form of dementia. In my volunteer work I found several people who do, and we would start talking to each other. As we spoke together, we realized that we're going through some of the same things, different times maybe. This is a weird disease because everybody's a little bit different, but emotional horror is the same for all of us, and it helps.

Dr. Jones: You used the words "emotional horror." That's a strong word. I can see the use for writing. That's not something that you can just tell your children or tell someone casually, but that's a powerful sense that you might actually be able to write down or you can say in a small group of other caregivers.

Kathleen: Yes, and I do belong to a support group also for dementia.

Dr. Jones: What about respite care? Right now you can go for a walk and so keeping yourself physically fit and being able to go outside is really important. Sunshine on your face is critical, but what about respite care, if you need to go away longer than just a couple of hours?

Kathleen: There are facilities in the community where you can take whoever you're caring for, whether it's a spouse, a parent, whatever. You can leave them for a few hours or all day. Some people have insurance that will cover total expenses for that. The general cost, I think, is about $50 a day for those who don't have insurance that covers it. Its $50, that's a lot of money, but it beats a psychiatrist or the hospital bills if you succumb to caregiver-itis.

Dr. Jones: Right. What kind of ideas would you share? What do you think would help others?

Kathleen: The first thing is that I absolutely cannot dwell on this disease all the time. I would go completely bonkers if I did. You're in limbo for between 3 and 20 years, so you just cannot focus on the disease itself. So I locked that into a back corner of my mind and shut the door and go on with doing things I enjoy doing, which we've already discussed, chocolate being one of the most wonderful ones, chocolate, hiking, and getting together with friends.
The second, is guilt. So many people in my support group have said, "Well, I don't feel like I should take off by myself and go do something that's just for me because then I'm leaving my husband there by himself and I feel guilty about that." I lost the guilt bug a long, long time ago. You absolutely have to get out there and do things that are just for you that make you feel good, that you enjoy or you're not going to survive to take care of him. That's what you should feel guilty about.
I left my husband in respite care for a week recently and started to feel a little bit guilty as I was driving away, in spite of what I've just said. I turned on NPR and Diane Rehm was on, and she had someone from the Alzheimer's Association on who, as I turned it on, was saying Alzheimer's caregivers are six times more likely than the general public to develop Alzheimer's themselves because of the stress. I thought, "Okay, Kathleen, pat yourself on the back. You need this. You have to get out and go," and I did.

Dr. Jones: Well, you've really wrapped it up very nicely in a sense that, exercise, keeping yourself cognitively active, volunteering in another non-caregiving way, and chocolate. Great. So we are all caregivers to some degree or another, and, as I've been told, you cannot pull water from an empty well, so caregivers need to care for themselves. You mentioned that at this point you can leave your husband at home.

Kathleen: Yes.

Dr. Jones: The time may come when you can't do that.

Kathleen: Right.

Dr. Jones: Do you have plans for that, or are you just going to wait till that happens?

Kathleen: I'm peripherally aware of what's out there to use. The first thing that I will do when that happens is to take him to one of the places where you can leave them for a day for a few hours or all day so that I can escape and just do whatever I want to for that day. The second thing, which I'm already pursuing somewhat, I mentioned leaving him in respite care for a week, that, I think, is going to be a very good alternative to full-time care because it will allow me to escape completely for a week without the horrendous expense of full-time care. That would be my number two option. My two criteria for leaving him in full-time care would be if he gets violent or if he gets to the point where he needs physical help that I'm unable to give, if I have to lift him or something like that, that would be impossible. So those two things are my criteria.

Dr. Jones: Well, when I mentioned that Americans provide over $300 billion of care, if they had to have that care in a facility or have someone else hired to provide that care, that's what it would end up having cost. Full-time nursing home care for people who are at the end of their cognitive life is enormously expensive.

Kathleen: It is. At this point, it's the best-paying job I've ever had, and I don't see the cash but at least it's not going out.

Dr. Jones: That's a great way to put it.

Kathleen: Full-time care is anywhere from $6,000 to $8,000 a month. Medications would be extra.

Dr. Jones: Right, so it is very expensive.

Kathleen: It's very, very expensive.

Dr. Jones: Right. I tell people, from my own experience, once you add medications and doctor's visits it ends up being almost $100,000 a year.

Kathleen: Oh, yes.

Dr. Jones: $8,000 a month times 12 is 96.

Kathleen: Yeah.

Dr. Jones: So that's something that most people don't have insurance for.

Kathleen: Right.

Dr. Jones: Did you and your husband ever talk about long-term care insurance?

Kathleen: Long-term care insurance hadn't been around very long before he was diagnosed, and once he's diagnosed you can't get it.

Dr. Jones: Right.

Kathleen: So we talked about it briefly and then decided no. We had been in good health. Our parents had been in good health. We never anticipated this.

Dr. Jones: Well, that's a conversation that most of us don't want to have, but the realities are, with people living as long as we do, which is a blessing in so many ways, the fact that we may live beyond our cognitive capacities means that one out of three of us are going to spend time in some kind of health care facility.

Kathleen: Yes.

Dr. Jones: This is for younger people who can get long-term health insurance when it's still affordable.

Kathleen: Right.

Dr. Jones: But we never think it's going to be us.

Kathleen: Oh, you don't. Before you retire you never consider something like that.

Dr. Jones: Right. Well, as an aging nation, this is something we're going to have to pay attention to. As a member of the agers, I'm a Boomer, I want to live a long and productive life and I don't want to be a burden, but it's something that we as a nation are going to have to think about how we take care of our caretakers.

Kathleen: Yes.

Dr. Jones: What do you think is the most challenging thing in your role as a caregiver?

Kathleen: At this point in his development with the disease he's in stage six, out of the seven stages. I think the biggest challenge for me is that I get so terribly lonely. He has lost the ability to converse. He says three or four phrases over and over again, and I have to try to interpret those in context and sometimes that's impossible. He understands virtually nothing that I say, so I have no one to talk to and share with when we're at home together.

Dr. Jones: That's heartbreaking.

Kathleen: It is. It's very difficult. We've been married for 49 years, and I've lost the companion that I anticipated having. Now, that being said, I'm not going to do the pity party. I have friends and I have children that I talk to regularly and visit with regularly.

Dr. Jones: But the nights are long.

Kathleen: It's really hard.

Dr. Jones: Is it a challenge to care for someone for whom you now have to take care of?

Kathleen: Sometimes it really is. I know people who have said they just delighted in taking care of their spouse and were glad to do everything they could for them. I haven't been able to find the enjoyment in it. It gets very difficult. You're in limbo. You have no idea how long you're going to be doing this, and there are times when I just get frustrated and I resent being in this position.

Dr. Jones: And the person you are caring for is not the person that you fell in love with, that you raised your children with, that you had a career with, that you retired with.

Kathleen: No. My husband vanished many years ago, so I am taking care of a large two-year-old.

Dr. Jones: The National Family Caregiver support program, which is part of the National Administration on Aging, has a website that can direct you to ideas and local support. However, for all listeners, this Thanksgiving is the time to especially thank those who are providing compassion in action as caregivers. Thank you for joining us.

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Dr. Miller: Why you should make your health care wishes known, and why everyone should have an advanced directive. We're going to talk about that next on The Scope Radio. This is Tom Miller.

Announcer: Medical news and research from University of Utah Physicians and Specialists you can use for a happier and healthier life. You're listening to The Scope.

Dr. Miller: I'm here with Dr. Nate Wanner. He's an associate professor of medicine and internist, and a hospitalist, and the Medical Director of the Palliative Care Service. Nate, what is an advanced directive and why should everyone have one?

Dr. Wanner: An advanced directive is usually a written set of instructions that basically communicates to people what kinds of care a person would want in the event that they became unable to make those decisions for themselves in the future.

Dr. Miller: So you're sort of trying to look ahead to an unpredictable future when you know how you want to be treated.

Dr. Wanner: That's right. And we all know that we're going to die sometime, and a large percentage of people who are very ill lose the ability to make decisions well for themselves. And so this is more than a theoretical concern.

Dr. Miller: But you have a long history taking care of hospital patients, how many of the patients that come in are aware of advanced directives when they hit the door? I mean, how many do you think really understand that, and fill them out?

Dr. Wanner: Less than half of patients have advanced directives. And even those who have them are a fairly small percentage who really understand what they mean very well. And a lot of times people make an incorrect assumption that their advanced directive will answer any questions that the doctors have about their care. In reality, a lot of advanced directives are not very helpful in addressing certain specific medical situations.

Dr. Miller: What are the most common things that a patient would direct a physician to do or not to do in an advanced directive?

Dr. Wanner: One common scenario would be if a patient had a terminal illness, and was not able to have any treatments that could prolong life significantly, whether they would want certain treatments that are more burdensome to be done.

Dr. Miller: These are events where the patient codes, as we say in medical terminology, where they stop breathing and the heart stops beating, do they want to be revived, or resuscitated.

Dr. Wanner: That could be one example. Another example would be if a person were in a coma that was expected to last forever, would they want a feeding tube and artificial hydration and nutrition to keep them alive even if they were unable to communicate or move or function in any independent way.

Dr. Miller: I know that they offer advanced directives to be filled out when they enter our hospital, but how would a patient most reliably get started in filling one out? Do you have suggestions on that for the audience?

Dr. Wanner: What I would recommend is using the advanced health care directive that the State of Utah has created. It's a very helpful form that isn't terribly hard to understand.

Dr. Miller: Would they be able to just Google that and find it?

Dr. Wanner: They can, yes. If you just Google Utah advanced care planning or advanced health care directive you can fairly easily find it.

Dr. Miller: And do they give tips at that website about how to fill it out, or what sort of pertinent things one might want to put down to complete an advanced directive?

Dr. Wanner: There are some tips for that, and we could certainly provide a link to that.

Dr. Miller: Where should a patient once they fill out this form, should they keep it on their person, or do they keep it at home in their safe? Do they take it to the hospital? What's the best way for them to have this to show to their physicians?

Dr. Wanner: We recommend that they keep a copy for themselves somewhere where they can find it when they need to. Probably it's a good idea to give a copy to a family member as well, specifically the person that you would want to be your decision maker if you become unable to make decisions. It's also a good idea to give a copy to your primary care doctor. And those would be the most important steps. But I think it's also worth mentioning that people often think that because they've given one bit of information to one doctor that all doctors have access to that. And unfortunately that's just not the case often. And so having a copy handy if you're in the hospital is a good idea to be able to show the doctors there who may not have access to all your information from your primary care doctor.

Dr. Miller: I think that's a really good point, because a lot of times medical records are not immediately transferable between facilities from one ED to another hospital for instance. And if the patient keeps a copy at home they could easily have a family member bring that in and show it to the health care team, which is a good idea.
Now if you fill that advanced directive out, does that also stay on a website with the state so that they could look it up that way or not?

Dr. Wanner: I don't think there is anything like that right now, but that is being worked on. I don't believe that's in place yet, but I think there is hope that it will be soon.

Dr. Miller: Eventually with cloud technology all of our records will be available to physicians wherever we get treatment within the United States, I think, but we're still a few years away from that, I understand. Any other thoughts about advanced directives and the way that more people could be involved in filling out advanced directives?

Dr. Wanner: Well, I think this is a discussion that people should encourage their family members to have and loved ones. It's something that allows people's wishes to be honored, and it also takes a major burden off of the loved ones who would otherwise have the task of making those decisions.

Dr. Miller: Does the advanced directive also allow the patient to designate someone, a power of attorney, to make those decisions in a particular situation where they are not able to make the decisions?

Dr. Wanner: It does, and that's one of the things that I like about the State of Utah form. It offers an opportunity to say certain things about actual wishes of what kinds of care you would want to receive. And then it also provides an opportunity to assign someone who would be your decision maker if you became unable to. And one misconception with that is some people have is that by designating such a person, a health care power of attorney is the official name for that, that they are somehow giving up control. And that's not the case. Any advanced directive only goes into effect once the person themselves is unable to communicate their wishes clearly. It doesn't give anyone the opportunity to make decisions for you unless you become unable to make your decisions.

Dr. Miller: Some patients might be under the impression that they need a professional to help them fill it out, and I don't think that's the case. They don't need to hire an attorney to fill out an advanced directive or to send a power of attorney to another family member, right?

Dr. Wanner: You're exactly right. And so if you use the state form in particular, it's a legally binding form that's been approved by the State of Utah, and all it requires is a witness who has to have some independence from you to sign and say that they witnessed it. It does not require any need for a lawyer, and it's kind of a funny thing that in America we go to a lawyer for health care planning, I think. It's kind of like going to me and asking for legal advice.

Dr. Miller: So it sounds like the bottom line is to think about how you would want to be treated if you were unable to make your own medical decisions. Go to the website and again, what would they Google if they were going to fill out an advanced directive from the State of Utah?

Dr. Wanner: The official title of it is Utah Advanced Health Care Directive, and if you type that in you shouldn't have any trouble finding it. And it's a four-page form that has one section that allows you to assign someone to be your decision maker if you become unable to. And then it has a second section for expressing certain wishes regarding your health care. And then it talks a little bit about how to change or revoke that in the future if you want to. And then it has a place for signatures to make it legal. So it's a very simple form.

Dr. Miller: So fill it out, and then keep a copy at home, and then maybe give one to your primary care physician, and then each time when you have to go into the hospital bring it in with you so you can have that on file in the hospital where you're being treated. And you would also say that you don't have to be older; that's not a requirement. You could be any age, and probably should have an advanced directive if you're receiving medical care. Would that be your advice?

Dr. Wanner: Yes, and it's certainly a much more important issue for people who are older and have very serious medical problems. But even young healthy people can have unexpected tragic things happen, and if you look at some of the cases that have been in the media and in the legal system that have prompted laws addressing this type of issue, in general they've been young, healthy people who have had terrible things happen to them, and then their family has been put through the wringer trying to figure out what to do.

Dr. Miller: Trying to figure out what they wanted. Because, it does service to your family and your loved ones as well to fill out an advanced directive and keep that on file.

Dr. Wanner: Definitely.

Dr. Miller: Thank you very much, Nate, I appreciate it.

Dr. Wanner: All right, and thanks for having me.

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