Dr. David R Buyer, MD, MBA, FACP

Category: Geriatric Health

  • Caregivers

    Caregivers are a vital part of maintaining health for others, regardless of age. Merriam-Webster defines a caregiver as a person who gives help and protection to someone who is sick. This definition can also be expanded to a person who gives help and protection to another person. Caregivers are not only providers, but they also are recipients of care. Their role puts them at risk for health conditions of their own.

    One study of primary family caregivers showed that 44% suffered from anxiety and depression, 15% pre-loss grief, and 10% from moderate to severe levels of demoralization. Caregivers often have poor sleep patterns as they “keep one eye open” at all times. Even caregivers who do not live with their charge do not sleep well as they are hypervigilant about the phone ringing with an issue.

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    “Caregivers are not only providers, but they also are recipients of care. Their role puts them at risk for health conditions of their own.”

    Caregiver access to the ill person’s medical information can be difficult as hospitals and offices may not grant information access to the caregiver. As the issue is more broadly recognized, this is beginning to change. If able, the sick person should have durable power of healthcare documents on file with the institutions or specifically sign a release to allow sharing of medical information.

  • Psychological Effects of Aging

    The effect of aging on emotional well-being is generally positive. Age brings acceptance which can be defined as the process of deliberately and non-judgmentally engaging negative emotions. Over time we have greater awareness and understanding. Acceptance does not depend upon mental capabilities or brain processing speed. Uncertainty, unpredictability and impermanence is better accepted with age. There is some evidence that today’s younger adults may not show increasing acceptance with age. 

    Another effect of age is decreasing anger. Sadness however is not reduced. One theory suggests that social connectedness is hindered by anger and anxiety, but helped by sadness. The difficulty with social connectedness as we age is fewer structured activities that promote connectedness.

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    “Life satisfaction is a comparison of life circumstances to one’s internal expectations. Satisfaction is affected by age and gender. Younger people tend to be unrealistic about the future, while older people are more realistic about the past and the future.”

    Evidence for the effects of age on anger, sadness and anxiety comes from a study measuring these emotions. A survey was given to people ages 21–73 before and after exposure to a stressful situation. Daily reports were also collected for two weeks. People were shown an emotionally-neutral short film prior to getting baseline measures, then they were given two minutes to prepare a speech stating their qualifications for a new job while being videotaped. The study results confirmed decreased anxiety and anger, but not sadness.

    Life satisfaction is a comparison of life circumstances to one’s internal expectations. Satisfaction is affected by age and gender. Younger people tend to be unrealistic about the future, while older people are more realistic about the past and the future. Men most highly rate satisfaction on partnership and financial position while women rate on partnership, relationship with children, sexuality, work situation, contribution to others’ welfare and financial situation.

    One survey of people ages 30–74 rated life satisfaction on health, financials, work, contribution to others’ welfare, relationship with children, partnership relations, and sexuality now, ten years ago and ten years from now. In all cohorts life was rated better now than in the past on all measures except for health and sex. People report health was worse than in the past and did not expect improvement, while sex was worse than in the past but expected to improve. The oldest cohorts were more satisfied with their partners than the youngest group.

  • Testosterone

    Happy, laughing Mature African American Male

    Advertisements for “low T” are everywhere now. The term is ubiquitous and even shows up in medical journals. Hypogonadism can be defined as symptoms of testosterone deficiency, along with levels two standard deviations below levels in young healthy men. Symptoms associated with hypogonadism may include decreased libido, loss of secondary sex characteristics, fatigue and depressed mood. Decreasing testosterone naturally occurs with age as 20% of men older than 60 and 50% of men older than 80 years have levels in hypogonadal range. Prevalence has been estimated at 5.6% between the ages of 30 and 79.

    Testosterone supplementation has become easier as transdermal applications are now available instead of injections. As a result of this delivery method and advertising about decreased sexual function, use of testosterone has dramatically increased. Prescriptions have increased 500% between 2000 and 2011 to 5.3 million prescriptions, and costs $1.6 billion. The number of patients being treated increased from 1.3 to 2.3 million during 2010–2013. Most prescriptions for testosterone (60%) are prescribed by primary care providers. Review of claims data in 250,000 men revealed that only 72% of men given testosterone prescriptions had a level checked prior to initiating therapy, 21% never had a level checked and 6% were checked after receiving a prescription for testosterone.

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    “Decreasing testosterone naturally occurs with age as 20% of men older than 60 and 50% of men older than 80 years have levels in hypogonadal range.

    As one would expect, testosterone affects body composition, strength and sexual function. One study examined testosterone and estradiol on these functional components. Testosterone production was blocked and then either replaced or given placebo. Another set of patients in the study also received medication to block testosterone conversion to estradiol, which normally happens in the body. The authors found that decreases in either testosterone or estradiol reduced sexual function. Testosterone deficiency accounted for decreased muscle mass, lean mass and strength, while estradiol deficiency accounted for an increase in body fat. The amount of testosterone needed to maintain muscle mass and strength varied greatly among individuals but was dose-related. Decreased muscle mass and strength are predictors of falls, fractures and ability to live independently. However, there is no evidence that testosterone supplementation reverses these risks. Cognition is also not improved with testosterone replacement.

    Increased risk of cardiovascular disease is caused by testosterone replacement. A retrospective Veterans Administration study evaluated testosterone use, heart attack, stroke and death. Veterans with low testosterone levels who had coronary angiograms between 2005–2011 were followed and stratified based on testosterone replacement. Of the 8,709 men who qualified for the study, 1,223 started on testosterone. Almost 20% of men who did not have testosterone replacement had an event, compared with 25.7% who did have testosterone.

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    “For a select group of men the benefits outweigh the risks, however, based on the number of prescriptions it is unlikely that the general population is educated about testosterone replacement.

    Other side effects of therapy can include acne, breast swelling or tenderness, increased red blood cell count, swelling of the feet or ankles, reduced testicular size and infertility. The effect of testosterone on prostate cancer is controversial.

    The decision to start testosterone replacement is personal. For a select group of men the benefits outweigh the risks, however, based on the number of prescriptions it is unlikely that the general population is educated about testosterone replacement. Prior to any treatment, it is imperative to prove that testosterone levels are low.

  • Physical and Cognitive Effects of Aging

    Senior Asian mother and her adult daughter facing each other in profile and smiling warmly

    Aging is typically associated with physical decline. This seems to be true for populations, but not for individuals. This is evidenced by a study that examined health changes in older adults over a 5 year span. The study measured:

    • Number of hospitalizations in the past year
    • Number of days in bed due to illness or injury (in past 14 days)
    • Cognition (mental status examinations)
    • Extremity strength (problems of lifting, reaching, and gripping)
    • Grip strength in dominant hand (measured)
    • Feeling about life as a whole
    • Satisfaction with purpose of life
    • Depression
    • Self-rated health
    • Digit symbol substitution test
    • Number of difficulties with activities of daily living
      (walking, transferring, eating, dressing, bathing, toileting)
    • Number of difficulties with independent activities of daily living (heavy or light housework, shopping, meal preparation, money
      management, or telephoning)

    The study showed that 10–22% of the individuals improved over time on these measures while 25–51% stayed the same and 28–53% worsened. Although these intervals are quite large, at worst a third of the individuals did not decline over time. Of the measures, gait speed, activities of daily living and independent activities of daily living declined the most. This was age but not gender related.

    Similarly, on cognitive measures there is decline that is age-related. Cognitive function is on a continuum from normal to full dementia with mild cognitive impairment as the middle ground and in varying degrees. Dementia is an overall term and can be divided into vascular and non-vascular causes. Vascular dementia is a decrease in blood flow in the fine arteries of the brain. Alzheimer’s is the largest category of non-vascular. Other examples of non-vascular dementia include dementia with Lewy bodies and Parkinson’s dementia. The largest category of vascular dementia comes from strokes.

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    “There are numerous studies evaluating ways to ward off dementia. Recommendations include physical activity, mental activity, social activity, vitamins and supplements. ”

    Only 5% of people over age 65 have full dementia. An additional 5% have less severe dementia. Subtle decreases in cognition can be found in two thirds of older adults. This does not necessarily impair independent living. Chronic illnesses such as high blood pressure, diabetes, emphysema, strokes and other illnesses can increase the risk of cognitive impairment. A quarter of patients with Parkinson’s disease get dementia. High blood pressure is a risk for vascular dementia and half of the people with vascular dementia have high blood pressure. Dementia incidence peaks in the ninth decade and half of people over 85 are affected by Alzheimer’s disease to
    some degree.

    Stated another way, of people younger than 85, 90% do not have dementia and over 85, 50% do not have dementia. Not all dementia is disabling and people can oftentimes still lead active lives with or without some adjustments in daily routines.

    There are numerous studies evaluating ways to ward off dementia. Recommendations include physical activity, mental activity, social activity, vitamins and supplements. Each has studies supporting and refuting the evidence. Regardless, physical, mental and social activities have other health benefits and should be incorporated into daily routines.

  • The 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults

    By the American Geriatrics Society 2015 Beers Criteria Update Expert Panel

    For more than 20 years, the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults has been the leading source of information about the safety of prescribing drugs for older people. To help prevent medication side effects and other drug-related problems in older adults, the American Geriatrics Society (AGS) has updated and expanded this important resource. The expanded AGS Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults identifies medications with risks that may be greater than their benefits for people 65 and older.

    Why Experts Developed the Beers Criteria

    As you get older, your body changes. These changes can increase the chances that you’ll have side effects when you take medications. Older people usually have more health problems and take more medications than younger people. Because of this, they are also more likely to experience dangerous drug-drug interactions. Every year, one in three adults 65 or older has one or more adverse (harmful) reactions to a medication or medications. This is why it’s important for researchers to identify and help reduce use of drugs that are associated with more risks than benefits in older people.

    Download the AGS Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults |