University Place Positive Aging Series Steve Barczi, "Your Optimal Health: Conversations to Have with Your Doctor" 8/13/2010  UP 472   cc >> Welcome to the Positive Aging Lecture Series which is brought to you by Supporting Active Independent Lives, SAIL, Oakwood Village, and also Continuing Studies at UW Madison. We're delighted to have you here and delighted to welcome our speaker, Dr. Steve Barczi. Dr. Barczi is an associate professor in the UW Division of Geriatrics, and associate director of education and evaluation at the Madison Veterans Administration Geriatric Research, Education, and Clinical Center. Additionally, he's director of the UW geriatric medicine and sleep medicine fellowship programs. He received his MD from the University of Illinois at Urbana-Champagne and completed residency training in internal medicine at the University of Minnesota. He obtained his fellowship training in geriatric medicine here at UW Madison and completed an additional research fellowship in sleep medicine also here. Dr. Barczi is nationally recognized as a medical educator and directs one of the premiere fellowship programs in the country. He has received several national and local awards of excellence as an educator and leads various clinical programs in geriatrics at both UW and Madison VA hospital. Dr. Barczi plays a major role at the UW, both to direct and advise the institution in establishing new directions in geriatric education and curriculum development. And I know that he is a popular speaker here and also a really busy man, so we're especially grateful that you could join us today. 

So now please join me in welcoming Dr. Steve Barczi. (applause) >> Good morning and thank you all for your patience with regards to the scheduling changes that occurred this morning. As was shared, I am a geriatric physician. I actually wear hats both as a primary care provider, as well as a specialist. And today I hope, oops. >> Sorry, no you're fine. Excuse me, we have to switch his microphone because it's not picking up. We have to change this one. Sorry. Thank you. 

 >> Okay. Hopefully now we're all wired and ready to go. My focus today in talking with all of you is to help to empower you all to realize that there are a number of things that you can do that will affect the trajectory of your life in the coming years. We, in the field of medicine, and I'm talking about the big field of medicine, have made amazing technological advances, as all of you are aware. There are approaches and treatments and sophisticated cardiac tests that are available now that were certainly not available 10 or 20 years ago. But when we look at the kinds of things that influence a person's quality of life, and if you want to use the term successful aging, it turns out that although those important cardiac interventions and some of these other things are valuable, more often than not it's smaller things, things that actually, the patients themselves, in conjunction with their primary doctor, do that make the difference. And so I hope today to go over with all of you what I call conversations that you might have with your primary care provider about the whole role of healthy aging. And there is a handout that is being circulated in the auditorium that covers these points, and hopefully within the next few minutes all of you will have that handout. And I'm working through the topics as are listed on the handout. When we look at those individuals who are remaining independent and accomplishing the kinds of activities that they want to accomplish in their 70s, 80s, 90s, 100s, some of it has to do with good general medical care. 

But some of it also has to do with what I would call good preventive geriatric care. And by that I mean that as with different age groups, in children we see certain kinds of conditions, we see things like ear aches and respiratory infections and things that are fairly specific to that age group. Equally, when we have individuals move into their 60s and beyond, there are health issues that are somewhat unique to that group. If we know up front what some of those health issues are and we can anticipate how some of those health issues could take away a person's independence or their quality of life, then we have a way of changing the person's health and improving or, if you will, making a person more successful in the aging process. A while back, meaning 40-50 years ago, we would have individuals, I'll use an example, Uncle Joe out in the farm field, working very hard, as he might always do, and then kind of suddenly without any apparent warning or indication dropping dead from a heart attack. Now 50 years ago we didn't have the level of understanding that we do now about that uncle Joe might have had terribly high blood pressure that wasn't recognized. Terribly high cholesterol. He might have had other blood vessel risk factors that were going on. And so it was kind of felt to be a mystery. We don't know why it happened. 

Well, these days if you went to see any health provider in a clinic system and that person said to you we have no idea why that person has heart disease or heart attack, you would look at them and wonder. Because we certainly do know that there are a number of common risk factors that predispose an individual towards accelerated heart disease, towards heart attack. Well, now I want to move forward to the present time, and although the heart is the easiest example as one that I think all of you can recognize, we now understand how to influence heart disease and how we might be able to reduce chances of heart attack. If we start looking the at other what I would call age associated health problems, things like osteoporosis with associated fractures, situations of cognitive change, that is a person having change in their memory and therefore influencing important aspects of their life. Looking at things like mood and depression or sleep, for example. Or urinary control or what I would call urinary continence or the opposite, when people lose urine, is incontinence. All of these conditions, which are more common as we get older have predictable risk factors and have things that we can do to potentially influence those conditions. And when I say we, I mean the health providers, myself and many of my colleagues who work as general practitioners, general internists, family medicine doctors, nurse practitioners, physician's assistants. But it's also equally important that you all as patients feel that you have a piece in the process. And the more engaged you are in your health, the better that combination of physician and patient will go and the better the outcomes will go regarding what I would call successful aging. 

So I'd like to now move from my introduction of saying why is it important that we talk about these things, it's because we now understand a lot more about these conditions, and we also understand that you all as patients can play a very important role in your healthcare. Now, the field of geriatrics is relatively young. By that I mean that in the 1950s it was very active in places like the United Kingdom and just beginning to the addressed in the United States. But really practically from the perspective of geriatric research and geriatric education it's probably been the last 25 years where we have really learned a lot about these conditions that I was alluding to. And because practitioners who work out in the community, some of them have graduated recently from medical school, some of them have graduated a few years back from medical school, but what we can say is there has been a very unpredictable amount of education provided to these clinicians on geriatric topics. And so many physicians, unless they actively sought out extra education in these areas, they may not be as comfortable talking about things like incontinence or depression or falls or osteoporosis than they would be about talking about things like high blood pressure, high cholesterol, diabetes in these examples. So that's where all of you come in because if you have a little bit of extra information about, hey, I might be at extra risk for osteoporosis or falls, or I might be at extra risk for problems with worsening mood or worsening memory, then you can kind of engage that physician or that nurse practitioner or whoever that provider is in a conversation and make sure that things are done. So now I think by this point in time you probably all have in front of you that handout. So you can see that I put down seven talking points on this handout, and I'd like to kind of walk my way through or work through each of these points. And if nothing else, give each of you just a little bit more insight into some of the things that you might want to talk about with your provider if you have not yet done so. 

The first point is this whole idea of bone health. Just the term bone health is a term that sometimes is not commonly used. We talk more about disease. We talk about osteoporosis. We talk about conditions where a person's spine curves. We've all had a family member or someone we knew who used to be five foot eight and then as their health changed and as their physique changed now they're five foot three. Well, that kind of height loss and that kind of curvature of the spine is the extreme. And we really don't want people to get the to point where their spine is curved that terribly. We don't want to allow things to go to the point where a person falls down and has an immediate hip fracture and then is left with all kinds of disability and rehabilitation that is necessary afterwards. So once again, just like talking about those blood vessel risk factors for heart disease, I'd like to entertain or engage all of you to thinking about bone health and how there are very clear risk factors for osteoporosis and for fractures. 

And as is stated in the handout here, it starts out with understanding who is at risk for osteoporosis, and we now know there are easily eight or nine distinct processes that can set a person up for having thinned bones. So certainly genetic predisposition and heredity plays some role, but we used to put a lot of weight on that as being the primary factor, and now we realize that actually that does play a role but it's nowhere close to the only explanation. We know that individuals who have smoked, tobacco itself is a bone toxin, and if you smoke, even if you smoked in the past, then you run some risk that your bones have been affected. Additionally, alcohol is another bone toxin and so for individuals who may have had periods of time in their life where they were drinking more steadily or heavily, that could also influence their bone status. We know that medications, and there's a long list of medicines that can cause thinning of the bones. And I couldn't possibly today in the time that I have cover that, but I can say that for example a person who has ever been on a medicine called Prednisone, which is a common medicine used for things like lung disease, certain kinds of arthritic conditions, and other conditions too, for people who've been off and on Prednisone, that's a special risk for osteoporosis. We know that inactivity, so for people who are not up and around and weight-bearing as often. And we've all had periods of time in our life where we had health setbacks, where we may have had to spend a lot more time sitting or on the couch. But persons who are chronically more sedentary are also at increased risk. We know that women post-menopause clearly, and that was the very first group we started spending a lot of time focusing on, but we now realize that men are maybe about a decade behind. 

So where we start worrying a lot about osteoporosis in women by their, say, 50s or 60s, oftentimes by mid-70s or early 80s men are right there too. And I just came from the veterans hospital, and I can tell you that I work with a lot of older veterans, men, who have significant bone problems. So acknowledging that these risks exists, have you had a conversation about your bones with your doctor or with your practitioner? If you haven't, it would be a good place to start. Just ask, I understand there are risk factors. Not only that, but there are actually on the computer now programs that exist that a doctor can take a little bit of information and punch it in, and then press the button and come up with an approximate risk for if you might have a problem with a debilitating fracture in the next five years. And so it's just like those heart disease risk calculators that sometimes the doctors work through, well there's one for bones. And it's called FRAX and it's actually listed on your handout. F-R-A-X. This oftentimes means some type of measurement of your bone health. Just like as I look around this room, I cannot see who has high blood pressure by just looking at you, I also could not, just by looking at you, say who does or doesn't have osteoporosis. 

But a bone mineral density test can be done, and we frequently encourage any woman who is post-menopausal to have it, and there's now increasing evidence to suggest that men, certainly at age 75 or 80 should also have at least one bone density test because if we don't measure, we have no way of knowing where a person's at. And then it comes to the other part which is what can you do. Besides understanding what's the status of your bones, another important factor is understanding what are the things you can do, even today, for making sure your bones are as healthy as they can be. And although there's a long list, I'm going to distill that into just a couple of key points. Number one, be as active as you can, and weight-bearing activity is very important. So although swimming is good for the heart and for a number of other things, swimming is an example of an exercise that does not produce weight-bearing forces through the bones. Whereas walking, and as an example of a weight-bearing exercise, does produce a standard force through the feet and the knees and spine and does contribute toward the bone constantly remodeling in a positive sort of way. So being active can be critical. Making certain one has adequate amounts of calcium and vitamin D in one's diet. Now calcium is in many different factors, and I'm not, today, going to give you a lecture on calcium, but you can find out without a lot of research what kinds of foods are high in calcium and how much calcium you need to take. 

And short of a mild constipating affect, calcium has very few risks, unless, I suppose, you were to take a pound of calcium tablets a day. But short of that, it's quite safe. Another factor, which leads into my second point, is the relationship between osteoporosis, falls, and fracture. Because falls are another area that, for a long time, physicians and other health practitioners didn't feel they had much control over. It was this general sense that gravity must have just gotten stronger. (laughter) Or it was just that darn chair that we tripped on. And we've all had those little stumbles. But more than that, there are a number of the established risk factors for falls also. Just like for osteoporosis. And increasingly, now, there are some wonderful community programs that are being developed for improving mobility and reducing falls. 

Because we know that one of the easiest ways to have a person go from being independent and living on their own or with a loved one to being dependent and possibly being in an assisted living or even in a nursing home facility is a really bad fall. And I guarantee most of you in this room have known someone who had a bad fall, and after that fall their health and their general quality of life was not the same. So instead of trying to mend Humpty Dumpty back together, the whole idea is keep him on the wall rather than falling off. And our hope is by informing health practitioners and informing you all as patients that there are things we can do. May be able to cut down on some of these severe falls. So what am I talking about with the issue of falls and fracture? Well, as I just mentioned, a person who has very severe osteoporosis is more prone toward an injurious fall. So obviously we want to make sure a person's bone health is being attended to. Beyond their bone health, we want to understand what is their muscle function like, what is their walking or gait pattern like? We know that individuals with certain types of gait changes or walking changes are at more risk for falling than the general population. We know that if individuals have what I call deconditioning, which just means that their muscle strengthening or their muscle strength goes down in important muscle groups like the upper legs here, we call the quadriceps, and the low back, that with that kind of muscle loss it can especially increase a person's chances. Sometimes just falling when they're getting out of a chair and getting going but more often if someone has, what I would call, a perturbation or they do stumble, what are their chances of recovering by catching themselves versus not and going down? And if you don't have appropriate muscle strength and some flexibility in the spine, then from the moment you stumble to the moment you go down, you're less likely to be able to catch yourself or recover or fall in a way that would be potentially less injurious. 

An important other risk factor for falls, aside from gait pattern and aside from bone health, is issues of vision, obviously if a person's vision is compromised then they are at more risk for those little subtle things that might happen when they're kind of climbing up a curb or uneven ground. And so again, if we can be aggressive about addressing vision. We also know that there are a number of commonly prescribed medications that can influence our blood pressure and can influence how quickly our blood pressure adjusts when we go from sitting to standing. Again, I suspect a number of you within this room are on some medicines that if you stand up really quick and you start moving quick you catch yourself because you get this transient very short kind of sense of imbalance or dizziness. And if you add several of those medicines on to that list then that imbalance can be even more severe. And that's where a thoughtful review of medications comes in. Because not all medicines are created equal with regards to falls and falls risk. There is, again, a very well-described list of medicines that we in the field of geriatrics, in the field of physical therapy, in the field of rehabilitation medicine and neurology, we know about this list, and these are medicines that are particularly are prone for increasing the chance for falling. And again, you should not, as a group, know necessarily what all those medicines are, but you can have a conversation with your health provider or with your pharmacist about this. And they can then help you to sort out are you on some of those higher risk medicines. 

Just for example, some of the anti-anxiety medicines, a group of medicines we call benzodiazepines which are helpful for kind of calming people down but also have a very prominent muscle relaxant property, and because of that if a person does stumble and lose their balance, they're much more prone to fall. And that's just one example. Another area that is evolving in understanding about falls is this relationship between vitamin D. Now I talked about bone health, and I think most of you in the room if I quizzed you would say yes vitamin D has some relationship with bones, but vitamin D also appears to have a relationship with falls, distinct. And we know that the receptors for vitamin D not only exist in bones but there's a number of them that exist in muscles. And so we're now starting to understand that people who have low vitamin D levels are also at increased risk for falling. So have you had your vitamin D level tested? And I bet some of you in the room will nod and say yes I have, but there maybe some of you in the room who have not. And if you've got a very, very low vitamin D level, then that may not only be a bad thing for your bones, but that may also be a bad thing for your risk for falling. So, again, in having this conversation, now as I've been trying to emphasize, there's some things that we as the health system can do, but there's also always your part. So where is your part here? Well, some of these, asking about have I had my vitamin D level checked? Am I on any of these medicines that might predispose me to falling? If I've got some changes in my walking pattern, have I had the appropriate assessment by a physical therapist or someone? And do I have to, and this is a big question, should I consider using a gait assistive device? Okay now, everybody in this room is thinking, or many of you are thinking, I don't want to be seen walking around using a cane or a walker of this variety or that variety because and there's a hundred reasons why. 

But if the difference between you staying independent in your home and you having a catastrophic fall is the use of one of these types of devices, then it may be worth that little bit of concern or aesthetic pride to be able to stay independent. Now again I'm not saying that every person who gets above a certain age should be using such and such a type of a gait assisted device, but if you thought the idea and you had clear-cut walking and gait problems then it would be valuable to at least begin a dialogue. As we keep moving along, the next point on here is this whole issue of memory health. And I actually give a whole lecture, and maybe some of you in the audience have actually heard me speak on the issue of memory health. Now notice I'm not specifically saying Alzheimer's disease because without getting into a lot of digression there's a lot of different things that can contribute toward memory change. And certainly sometimes it can be dementia. It could either be Alzheimer's dementia or one of a number of other forms of dementia. But we also know that there are other things that can contribute. And again, so part of the discussion is what is clinically important, because, and this I'm going to say with some degree of confidence, every one of us in the room here has at one point or another in our lives walked from one room for another room and then questioned what in the world am I doing in here? (laughter) And then what we all do is we of course back up and go back into the room so we can somehow jog our memory. And that begins in our 30s. 

So we can't say that that is a serious memory problem. But yet it is a way by which our memory is less efficient. And there are other examples of what I would call age associated memory changes, which are not specifically a red flag for dementia. And to be able to tease out what is worrisome and what is attributable to just inefficiencies of age is something that, again, none of you in this room should have to do but in concert with discussion with your provider. And if your primary provider isn't quite comfortable with a specialist, it could be a neuropsychologist, neurologist, a geriatrician, there are many practitioners out there who address memory complaints. Now, coming back to that example I gave before about measuring blood pressure or measuring bone density, if you never in your whole life have had one time even a simple form of memory test done and then all of the sudden you start to experience some difficulties and you come into your health provider's office, at that point in time there's no way that that person could know just, did some of these things start 10 years ago, did some of these things start one year ago or six months ago. So I do encourage and in my own clinical practice I try very hard to have my patients cooperate with some type of memory test, even with a basic screening test, just to have it down in the record before they start complaining, if they're going to complain of memory difficulties because then I have some point of reference, and I can say back three years ago we did this test and this is where you were. And I do it today and it looks like it's about the same, that's good news. Or I might say there are changes and maybe we need to do some more testing. Now there's this misperception that why do we care? Because if we've got, say, an Alzheimer's condition there isn't a cure right now, right? So why would you even want to know? Wouldn't that be worrisome or couldn't that produce more anxiety? And for many years the response was let's not test and if a person develops it then let's do what we can. 

But increasingly, and I work in a center that does a lot of Alzheimer's research, we're now recognizing that there are risk factors for dementia too. And there are things that we can do if a person is in the beginning stages of a memory illness to potentially take their trajectory of loss of memory and loss of function from what could be fairly precipitous to something that is more slower and drawn out, allowing them more time to do the things they want to do, be with the people they want to be, and make plans. So for those reasons we're now suggesting people should have some sense of what's going on with their memory, and should, if there are early changes, should have a chance to be put on certain types of medicines and have conversations with their family. So for all those reasons, it's important for us to think about this idea of memory health. Now, I won't go into a lot of detail with what are some of the risk factors, but let me, I will give you two or three examples and then move along. One example is for a long time it seemed to be a shrouded mystery about what was changing in the brain to contribute towards Alzheimer's and Alzheimer's like problems. We now are recognizing increasingly that some of the same kinds of blood vessel risk factors that are associated with heart disease and stroke also contribute to small blood vessel changes in the brain that seem to potentially have an unmasking effect on other underlying factors that could lead toward dementia. So we now, in our memory clinics at the university, are very aggressive about managing things like high blood pressure, out of control diabetes, out of control cholesterol, for the purposes of memory preservation. So I just wanted you to realize that I think to have a basic conversation with your provider about, you know I've never, ever had any testing down for my memory, should I have some baseline testing done? I know that there are risk factors, I know there are medicines, so that's the other point I didn't make, but our brain functions with an amazing myriad of chemicals that I think you've had other speakers actually talk about, how amazing the brain is. These neurochemicals, and it's not one but it tends to be a number of them, play a key role for our thinking and our remembering. 

And there are a number of medicines out there that actually will lower some of these important brain chemicals, thereby making a person more disoriented or, in extreme cases, outright confused. And it doesn't just mean you have to be age 60 or 75. I can take a 20-year-old and if I give them enough of a medicine like Atropine or certain other medicines, I don't care how young their brain is, I will make them goofy as can be. And so if you are starting to experience some early changes you think or others around you think with your memory, it would be important to talk with your provider and say, look closely at my medication list. So just the same way I was talking about the falls, am I on any medication that would affect my memory? And in fact, there are a whole class of medicines that have what we call anticholinergic property, and that's a big mouthful and I don't expect any of you to spell that back to me. But your pharmacist, if you is ask your pharmacist, am I on any anticholinergic medications, they will be able to tell you. And if you're on one or two or three or in some cases much more than three and you're having some early forgetfulness or inefficiencies in your memory, then it may be worth while to be adjusting those medications as a reversible intervention for memory change. Let me move along here then to talk a little bit about mood and sleep. Now, my geriatric practice is a mix of geriatric medicine and geriatric psychiatry. And so I'm very attentive to the issues of how mood can affect the person's quality of life. 

Not only the quality of their life but their engagement in living. Because if a person starts experiencing debilitating degrees of depression or anxiousness, then what's the first thing they do? They cut themselves out of some of the activities that used to be important in their life. They start to abridge or adjust some of the relationships they have with others. If they had been an active walker, which remember that walking is really good for your bones and for other things too, they may disengage and become much more inactive. So mood is important and we are all at risk for having temporary mood changes. Even more so as we move through life and as our health status changes and as life circumstances change, people around us, friends, spouses, others become sick, they pass away. In those situations, we can be at extra risk for lapsing into depression. Depression is much more common in individuals above 60 than just about any other age group for all those reasons I mentioned. And there's a phobia. There's a concern that exists out there across several generations that depression or anxiety is mental weakness. 

If I was strong enough, if I was spiritual enough, if I did things in the right way, I wouldn't feel this way so it must be some inherent weakness in me. But the reality is, just like I talked about those brain chemicals influencing our memory, we know that those same types of brain chemicals can sometimes in the setting of illness perturbate or change in a way where we become specially prone toward depression symptoms. So in that regard depression is a medical illness as much as it is a psychological or emotional factor. So if you are experiencing a sense of decreased enjoyment in life, a sense of increased sadness or worry day-to-day that may be influencing your life, if you're disengaging from important relationships, if others around you are concerned, then the last thing you want to do is resist the idea and not seek out attention. Because in doing so, you will continue to have this spiral of decreasing quality of life, potentially decreasing health status. So by having a conversation with your provider about your mood, if it becomes a concern, can be very important. And increasingly, we have a whole array of different medicines that can temporarily be used to influence those brain chemicals I was talking about, and in doing so, can take a person from being depressed to not being depressed. But if you never have the conversation, then your provider will never know, and you will probably not have the chance to be treated for that depressive problem or that anxiety problem. I think, I just want to confirm, I believe I started around 11:00 so I've got a few more minutes. I just want to make sure I don't have to spend one minute in the final kind of point. 

Another important area, and I could spend, I do spend whole hours giving lectures on sleep because, as it's been stated, I'm both a sleep specialist and a geriatric specialist. And I don't think anyone in the room here would argue with the point that sleep is important. If nothing else, it's a wonderful respite from the other events of the day. It provides restoration. It now, we increasingly realize, is playing a key role with memory. And there's all kinds of animal data and increasingly human data that tells us certain types of sleep help us to consolidate certain types of memory. And the biggest myth that I end up going around busting all the time in the community relates to this idea that, oh, I'm getting older so my sleep will naturally deteriorate. There are a lot of people out there who have that misperception. And I can counter that by saying as a sleep specialist I've done research and others have done research to show that there are individuals easily into their 80s and 90s and 100s who sleep very well. Now, there is more common sleep problems as we get older because sleep is so interrelated with other health problems and with medications. 

And we know that other health problems can contribute toward poor sleep. We know that medicines themselves can contribute toward poor sleep. We know that our internal clocks, which have been keeping time and knowing when we should go to bed and wake up through our whole life, can shift sometimes. Furthermore, there are some primary sleep disorders that we know are more common as we get older. So for example, sleep apnea, in the general population, sits somewhere between 5% to 10%. At age 45, that number is probably closer to 15%. By age 65 plus, that number could be approaching 20%. And in special populations like patients with heart failure and patients with stroke and other conditions, that number can be much higher than 20%. And so unless you have a conversation with your provider that I'm not sleeping that well, they won't know, and because there are other health issues that sometimes can take precedence, you may not have a conversation about your sleep. Now for the same reason I was talking about before about geriatrics and what the primary provider may or may not know about geriatrics, sleep medicine is also a relatively young field. 

And there are lots of physicians who graduate from medical school or nurse practitioners who graduated from nursing school who never had or had an hour total lecture time talking about sleep problems. But if they are not completely comfortable in attending to sleep complaints and approaching a sleep problem, there are a number of practitioners that are. Within this community, there are three or four distinct health systems that each have sleep programs or sleep clinics associated. With sleep specialists or psychiatrists or neurologists who have background in this area. And it doesn't pay to be living with terrible sleep patterns over years and years and years and never having it being attended to. I regularly react with patients in my geriatric sleep clinic who have lived with sleep problems for five or more years, terrible sleep problems, and then we got to the bottom of those issues and they wished they had done something about it sooner. So I'm just being a little bit of a cheerleader here and saying that if there are sleep issues, not only will they affect things like your memory and your general sense of well-being, they may also influence other health matters. Since we know for example, sleep apnea plays an particular role for increased risk for heart attack and stroke. So it's another one of those topics that may or may not come up in a general interaction but I think is important to consider discussing with your primary provider. So we're moving down the list here, we're coming towards the end. 

The next point is a point that's what I call the don't ask don't tell problem. (laughter) And it's important all of us in the room here can chuckle about this but urinary incontinence is a fairly common problem, as we age, for lots of reasons. And sadly there are many, many people that have their primary management of their urinary continence being going out and purchasing certain pads or certain types of adult containment or diaper type devices to address the issue. We know that just like I've been talking about with these other factors, there are common reasons why individuals can have change in urine control and urinary frequency and other kinds of differences in their urine pattern compared with the past. And it's important to recognize that it is a medical condition, and just like I've been saying, I'm sounding like a broken record and I apologize, but it's important for you all to recognize that if there is incontinence and if you have not have some discussion with your provider about that issue or if you've not had some assessment for the possible causes, then it would be very important to do so. Because incontinence has a whole litany of different things that can happen if is person does not have it attended to. So obviously it can be a source of embarrassment. And so people will inherently change their social patterns. If they start having more incontinence, one of the first things they're going to do is potentially restrict some of the places they're going to go. They may no longer go on long car trips. 

They may decide they no longer can visit their daughter in California by plane because they would be too fearful. So there's all kinds of social changes that can come about from this process. Furthermore, when we have a lot of urinary urgency, which means just a feeling like you've got to go and you've got to go now, then frequently individuals will have to respond quickly. And let's now put together that they've got a little bit of walking changes and they're on a couple medicines that maybe affect their blood pressure a little bit and all the sudden they have this terrible urge like they need to get to the bathroom now. And you know where I'm going with this? A fall can sometimes occur. And in fact, another risk factor for falls is urinary incontinence. So without getting into a big discussion about all the nuances of how we evaluate urinary incontinence, I do want to mention one or two things. Which is even in this institution here, Oakwood, there is a nurse practitioner who is specially trained in urogynecologic management in the women's clinic at the university and a number of other practitioners in the community are well-equipped and well-trained to address this issue if your primary provider is a little bit uneasy or uncomfortable about addressing the issue. Furthermore, there are a number of important behavioral approaches I want to emphasize. In geriatrics one of the things we really, really try to do, and this comes to the very final point here on our handout, is we don't try to add pills. 

If anything, we try to minimize or reduce the pills. So if we can discover behavioral approaches, and we know there are a number of effective behavioral approaches that can address the issue of incontinence, we want to focus on those areas first. Maybe add medications additionally, but frequently that shouldn't be the very first thing. If you mention I'm having urine leak, the very first response shouldn't be here's a prescription. We want to know why and we want to attend to some of the behavioral approaches that may play a risk. So now, in the final approximately five or 10 minutes, I just want to attend to two final points on this handout. So the sixth point here is one that, again, I could spend a lot of time talking about, and I feel passionately about this issue. This is the issue of what are your preferences for care now and if and when things get really bad. I'm not going to ask for a raising of hands, but I hope most of you in this auditorium have what would be called the healthcare power of attorney document or a living will. If you haven't taken the opportunity to have a conversation with your provider about that, then in some respects you're robbing yourself of the opportunity to be involved with the decision-making near the end of your life. 

If you've had a brother or a close friend who went through a tumultuous hospital stay that ended up with a long stay in the intensive care unit, and in the end the quality of their life or those final days or weeks was nowhere close to what they would have wanted, and you in your mind think I don't want that to happen to me, then the best way for you to be able to prevent that from happening is by stating your preferences. And I'll warn you all, just because you've got a healthcare power of attorney document, that doesn't always mean that you've told people what you want. That just means you've told people who should decide for you if you can't decide for yourself. So I not only encourage having the document completed, but I encourage having a conversation with the people that are on that document before you're so sick, saying, you know if it ever gets to be where I'm in such and such a situation, I do or I don't want this or I want intensive care but maybe only for two or three days and if I'm getting better I don't want them to keep pushing, pushing, pushing. You can say what you want. And so I really do strongly encourage that you have a conversation about those care preferences, not only with your provider, but also with at least one important person in your life, whether it be a friend or a family member so surprises don't happen. So, I'm to the end of my list, and you've been very patient with me. So the final point on the list comes back to something I alluded to before, which is in my role as a geriatric specialist, I don't have a lot of fancy procedures like my colleagues in cardiology who can put catheters in all different blood vessels or the gastroenterologist who can kind of take a look from either end. (laughter) But what I have in my tool box is what I call pharmacologic debridement. Now let me qualify because the term debridement is a term that is a medical term but what it means is taking away or removing. 

So one of the procedures that I can do is I can look at a person's medication list which has accumulated over many years and many different providers, and you might say so why is it that all the sudden yesterday I was taking two medicines and it seems like just today now I'm taking 12. Well, it's because doctors practice with evidence-based approach, and so if you have heart disease, they're going to want to do everything they can to treat that heart disease. If you've got diabetes, they're going to want to do all the things for diabetes. And you just go down that list, and pretty soon that list gets to be long. The other thing, and this is not saying anything negative about any of my colleagues, I'm as guilty of this as anyone else, but when a person walks in an office with a list of 10 medicines and they were never prescribed by me, then sometimes the provider is a little bit apprehensive about taking things away because they don't know why that was added and when it the added and what were the circumstances and why rock the boat. Well the point is when anyone gets on more than five medications, then their chances for drug-drug interaction start to climb. By the time a person is at eight medicines, it's almost 100% that a person is having at least one or two medicines interacting with another medicine or causing them side effects. Now you might say, oh, no that's not the case, I'm on eight medicines. Does anyone here have medication associated constipation, which is a side effect. Does anyone have dizziness? And we can go down the list. 

There's lots of effects that come from medicines that aren't quite what we want. So we should always, almost every time we're interacting with our health providers, have a conversation, is the list that I'm on now absolutely necessary because I'm different now than I was five years ago. And I may have some patients who have severe illness, severe heart disease, such severe heart disease that some of the preventive medicines that might quote help them in five years aren't really practical right now because their other health problems are probably going to shorten their life. And so in those cases we can start to pick and choose. Now, in other words, I'm just telling you all that just because you were put on such and such a medicine in the past, that does not mean that you should stay on that medicine, and your body does change. 20 years ago you might have been tolerating that medicine at that dose, but now that medicine at that dose may not be appropriate. So it's just important to be aware. So now in closing, what I'd like to do is to summarize that you all can play a pivotal role with regards to your general healthcare and what happens in the future. It's not lightning bolts out of the sky. It's not just dropping dead in the farm field like I was talking about before. 

We have ways by which we can anticipate certain common age associated complications. And what I want all of you to leave this room knowing is that you can have some of these conversations with your providers, and by doing so you may bring up an issue that your provider just didn't think about, he or she was too busy to think about but now they can. And then the two of you can work well together as a team. So at this point in time I'm going to stop, and I don't know if there's any time for any questions or if we need to go offline or how you want to work things. >> We'll first show our appreciation for you. (applause)