Puffy feet

Several years ago whilst on a summer trip, I looked down with alarm and noticed the tops of my feet squeezing between my sandal straps. That, to me, is one of the surest signs of advancing age--sit for a long while in a car or on an airplane, especially in the summer heat, and poof! your feet puff up. The perfect storm of venous insufficiency: aging veins dilated in an overheated car unable to transport blood efficiently from toes to heart.

Now I'm once again amongst puffy feet, this time not my own. Two of my family members (FMs #1 and #2) are struggling to stuff their feet into shoes for two different reasons:

FM #1: Venous insufficiency plus too much sitting. The road back to the heart from the furthest reaches of your body (that would be your toes) is a long and passive one. While the arteries that carry oxygenated blood from your heart to your body have elastic walls that snap smartly with each beat of the heart, propelling blood along the route, the veins have no such resiliency.

Instead, the veins rely on valves that open with each pulse beat, then close as the heart relaxes, thus preventing the backwash of blood south to the floor with gravity (see picture above of healthy and varicose veins and their valves). If your veins dilate as in varicose veins (and you can have such veins deep in your leg even if you don't see ugly varicosities on the surface), the valves are too far apart to prevent the backflow of blood.

As a result, blood oozes through capillary walls, feet and lower legs swell, and the dilated capillaries and blood pigments released cause an irritating itchy rash (stasis dermatitis). These skin changes over time cause dark pigmentation in the lower legs, and the skin is more easily injured and less easily healed.

Since venous return from the legs is entirely passive, the squeezing action of the leg muscles is an important extra push to keep the blood moving upwards. Prolonged sitting because you're stuck in the middle seat of row 25 in coach, or perhaps because you're so old and your knees so bad that you're disinclined to get up, takes the muscular pump out of the equation. Add gravity sucking blood southwards and there go the feet into puffiness.

FM #2: Right-sided congestive heart failure plus too much sitting. The right side of the heart is responsible for boosting deoxygenated blood returning from the body into the lungs where it can pick up a new load of oxygen. When the lungs are diseased, say from emphysema, the lung tissue is far less efficient at delivering oxygen across the barrier to the blood. The blood vessels constrict in some misguided effort to bypass the damaged part of the lung (but, unfortunately, the whole darn lung is damaged), and the pressure rises in the narrowed arteries.

As a result, the right heart is now working much harder to push blood into these constricted arteries, and it starts to enlarge and fail. With each beat of the heart, less blood is emptied into the arteries heading for the lungs, and blood starts to back up in the body, particularly in the legs and in the liver. Add inactivity due to lung disease to the equation, and the legs and feet puff up.

Whether the lower extremities swell from inactivity, venous insufficiency, or heart failure, the blood is slowed and sludging in the veins of the leg. If Mr. or Ms. Bigfoot has a clotting problem--inherited, secondary to use of oral hormones such as birth control pills or HRT, as a result of cancer, or due to injury or recent surgery--this sludgy blood can clot. Clotted veins in the legs further aggravate the swelling, and if a glump of clot breaks free and travels up the veins and into the lungs, it can cause a pulmonary embolus which further accentuates right heart failure or, if big enough, stops heart function suddenly...and fatally.

Takes one to know one

My mother was a psychology professor at the University of Denver. She used to teach a class on late adulthood to the PsyD graduate students there. Noting yesterday that old age is rough, she added these wise words:

If you're young enough to teach that class, you can't really understand what it's like to be old. But if you're old enough to know better, you're too weak to teach.

Keeping aging skin intact

Age seizes my skin and turns my hair from black to white: My knees no longer bear me and I am unable to dance again like a fawn.
--Sappho

Fawn, schmawn, I'm just working here at getting the snow shoveled and hoofing it up and down 19th Avenue on a regular basis. But this post is not about the dancing abilities of an aging hippie, but rather this business of age-seized skin.

The passing years have definitely grabbed Ms. McM in a dermal sort of way. In her mid-60's, her 'photo-aged' or sun-damaged skin had thinned to the point that it ripped like old cloth when subjected to trauma such as banging against the bedframe and other household objects. Her forearms and shins are crisscrossed with fine white line where tears have turned to scars.

Skin that tears easily is common in older women, though generally in those more aged yet than Ms. McM. Thinned out skin is also responsible for the unsightly purplish blotches that appear on the forearms of older women. Loss of collagen between layers of skin allows the epidermis or top layer to shear over the dermis below when the arm is rubbed or bumped. As a result, tiny blood vessels rupture and bleed between the layers, at times in a rather dramatic and extensive manner.

Blotches are ugly, rips are devastating. Ms. McM was pleased, however, to show me her well-healed, blotch-free arms and legs during yesterday's visit. Her dermatologist had recommended the regular application of Retin-A cream (generic tretinoin cream) to the areas. Studies have shown that photo-aged skin produces significantly less collagen than protected skin (and scientists have the buttocks biopsies to prove it!). Further biopsies from philanthropic old gals prove that Retin-A restores collagen formation in their wrinkled, sunstruck forearms.* Newer studies suggest that tazarotene cream is even better--but more expensive!

Retin-A is pricey as well, even though it is available generically. Ms. McM noted one month's supply set her back over $100, but she bought additional tubes in Mexico for 6 bucks each.
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*Griffiths, C, et al. NEJM. Volume 329:530-535.

Small vessel disease

Large vessels check out with drama--devastating strokes where one side is paralyzed, a big heart attack, an aortic aneurysm, a gangrenous foot. Small vessel disease is insidious, and, once established, also devastating in a progressive sort of way.

Some years ago, my sixty-something year old patient with difficult-to-control hypertension was noted to have 'hypertensive retinopathy.' In other words, when her retina was visualized through dilated pupils by her opthamologist, the small vessels visible therein were noted to be thickened and narrowed (an appearance likened to copper wire), the arterioles smashed the little veins when their paths crossed (AV nicking), and 'cotton wool spots' denoted areas of inadequate blood flow.

The small blood vessels of the retina, which are the only small vessels that can be directly visualized during a physical exam, are quite similar to those of the brain. If you've got retinopathy, indicating that the blood supply to the back of the eye has been adversely affected by elevated blood pressure, your risk of similar troubles in the little blood vessels that supply the white matter of your brain is raised as well. In persons with similar risk factors for stroke such as hypertension, cigarette smoking, and elevated cholesterol, those with retinopathy are at 2-4 times greater risk for stroke than those without.

Dang if this patient did not go on to have an ischemic stroke* about five years after her retinopathy was found. An MRI done at the time of her stroke revealed extensive white matter disease. These little 'bright spots' noted on MRI deep within the brain are not bright spots for the brain at all, but rather represent areas with inadequate blood akin to the cotton wool spots seen in retinopathy. Cotton wool in the eyes and bright spots in the brain are dim prognostic signs for one's future health--in the Atherosclerosis Risk in Communities study, the five-year relative risk of stroke among subjects with both findings was 18 times greater than in participants with neither one.

The risk factors underlying such small vessel disease are aging, smoking, hypertension, diabetes and elevated cholesterol. This lady aged, she smoked, and her blood pressure was hard to control (multiple medications made her dizzy and prone to falling).

Yesterday, I got lab work back on another patient. Her estimated glomerular filtration rate or EGFR*** had fallen compared with the value from a year ago. She had an MRI done a year ago for an unrelated problem and was noted to have white matter disease. She's just my age (not so aged!), a non-smoker, her blood pressure is perfect on meds, and her cholesterol and blood sugar are fine. A newly published study in the journal Stroke** correlates decreasing kidney function with cerebral small vessel disease, supporting a link between vascular disease in the kidney with the same in the brain. She's off to a neurologist to see if she's a candidate for preventive blood thinners.
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*An ischemic stroke is caused by an interruption of blood flow whereas a hemorrhagic stroke is caused by a ruptured blood vessel in the brain.
**Ikram, MA, et al. Stroke. 2008; 39:55-61.
***For an explanation of EGFR, see EGFR.

Now calcium?

Gotta stay light on the feet these days when it comes to advice. Hormones? Depends. Zetia? Fuhgeddaboutit. Calcium? Maybe not... especially for the elderly.

New Zealand investigators asked 1,471 old ladies (average age 74) to take calcium citrate, 1000 mg/day, or not, and then checked out who suddenly pitched over dead (as in cardiac arrest), had a heart attack (MI), or suffered a stroke in the five years following. Their primary intention, actually, was to prove once again that calcium supplementation improves bone density, but they also theorized that it might improve cardiovascular health as well.

Wrong. In the final analysis, the old gals on calcium had double the risk of MI, 1.4 times the risk of stroke, but no increased risk of sudden death. When all these endpoints were combined, the cardiovascular risk from the recommended dose of calcium each day was increased 1 and 1/2 times over the unsupplemented group. Looked at another way, doctors would need to treat 50 old ladies with calcium to prevent one symptomatic fracture over 5 years, 44 to cause one MI, 56 to cause one stroke, and 29 to cause one cardiovascular event.

What are they saying about this one?

Dr Erin D Michos, Johns Hopkins University: This is a thought-provoking study, although not definitive, but further work should be done.

Judy O'Sullivan, British Heart Foundation: Anyone who has been advised by their doctor to take calcium supplements to protect their bones should not stop doing so in light of this study alone without medical advice.

Dr. Ian Reid, senior author on paper: What we think is happening is that the higher calcium intake—and particularly the bolus of calcium that supplementation provides—is somehow accelerating the laying down of calcium in the artery walls of the heart...The way I interpret this is that if you have preexisting heart disease—which probably most of our participants did, although they probably weren't aware of it—then the extra calcium appears to be bad. But if, on the other hand, you are 54 and you have nice clean arteries to your heart, then probably calcium is not going to cause you any major problems. That's my take on it. But I don't know if it can be proven.

What am I going to do? Just like most of my patients, I find calcium tablets big and gross. Sometimes I take them, sometimes I don't. I plan to keep up that strategy and advise my patients of the above information. If I was even older than I am, I think I'd leave my calcium tablets on the shelf and face up to yogurt, vitamin D, and exercise.

Take heart in your a.m. coffee

Imagine my delight that I was drinking coffee even as I read this study. Swedish investigators sorted the data from the Swedish Mammography Cohort. Almost 33,000 Swedish women, ages 40-74, supplied them with details on their daily coffee habits.

Those who drank 5 or more cups in a week were 32% less likely to pitch over with heart attacks during the 5 years studied compared with the undercoffeed. So take another mug shot!

These northern scientists went on beyond coffee while studying what keeps women in Sweden alive. They identified a low-risk diet* and 3 low-risk lifestyle behaviors**. The combination of the diet with all lifestyle habits equaled a 92% decreased risk of heart attack compared with those smoking ladies who waisted their weight and moved not at all.
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*same old dietary song: "high intake of vegetables, fruit, whole grains, fish, and legumes, in combination with moderate alcohol consumption."
**you've heard these before: "nonsmoking, waist-hip ratio less than the 75th percentile (hourglass vs. beach ball), and being physically active (at least 40 minutes of daily walking or bicycling and 1 hour of weekly exercise)."

Prehypertension is pretrouble indeed

If I get tired of time spent counseling folks on prehypertension, prediabetes, and prerenal failure, I just need to review the research to remember that these conditions are definitely pretrouble. Shoot, I just need to look back through the years of chart notes in some of my patients' records to see how their health unfolded out of pre-this, that, and the other into the real, unhealthy deal.

The ladies of the Women's Health Initiative, who contributed valuable data to much more than just the hormone therapy controversy, proved that blood pressures between 120/80 to 139/89 (the definition of prehypertension) roughly double the trouble. Investigators found that 39% of participants fell into this blood pressure category. Over a decade of follow-up, their risk for cardiovascular disease fell midway between the risk for those women with normal blood pressure and the group with pressures of 140/90 and above. The ten-year incidence was 3.32% for normotensives, 7.11% for prehypertensives, and 14.16 for hypertensives.

So that's what happened to 120/80 as 'normal.' It's yesterday's news; we've lowered target blood pressure to less than or equal to 115/75. Cardiovascular risk rises in a smooth progression for values greater than that.

Jaw problems with oral meds for osteoporosis

Pictures of osteonecrotic jaws are the sorts of displays that separate those destined for medical careers from those who would pass (or rather pass out). For that reason, I am not including a picture with this post, but, believe me, you do not want this to happen to your jaw.

In the past 5 years, a correlation has been noted between dead bone in the jaw causing separation and loss of teeth and the use of IV bisphosphonates (we will call this bisphosphonate-associated osteonecrosis of the jaw: BON). These drugs in their oral form, including Boniva, Fosamax, and Actonel, are used to prevent or treat osteoporosis. The IV forms--particularly Zometa and Aredia--are used in cancer treatment to slow tumor spread to bone, reduce bone pain from metastases, and decrease the high calcium levels that can result from bony involvement. They are very useful in this regard, and the risk of BON, while low, is not spontaneous but almost always associated with dental procedures such as extractions.

Oral bisphosphonates are increasingly favored as non-hormonal solutions to post-menopausal bone loss, but the possibility that their use could lead to an icky jaw situation of the BON-ish variety has left me somewhat reluctant to embrace their use. I was greatly relieved, therefore, to come across a report from the January edition of the Journal of the American Dental Association. This review of claims data for over 700,000 cases of osteonecrosis of the jaw confirmed that IV bisphosphonates indeed increase the risk of dead jaw bone by a factor of four or more. The good news, however, is that oral bisphosphonates such as Fosamax and Actonel were actually noted to decrease the risk of osteonecrosis in patients with osteoporosis by 1/3.

To review, osteonecrosis is dead bone. You don't want that in your jaw. Osteoporosis is thin bone. You don't want that anywhere. If you take oral medications such as Fosamax, Actonel, or Boniva to avoid thin bone, you do NOT increase your risk of dead bone lifting your teeth out of your mouth.

Nonfocal TNAs

Well this explains a lot. I've been wondering what causes my Mom's wildly fluctuating mental status, sometimes calling me first thing in the morning to request that I bring her the latest Newsweek, other days not even knowing my name.

Nonfocal TNAs or transient neurological attacks, that's what. As opposed to focal TNAs which are also known as TIAs (I stands for ischemic as in tissue without oxygen) which cause focal deficits such as weakness on one side or difficulty speaking, nonfocal TNAs leave a patient with non-localizing problems such as confusion or transient global amnesia (see older post below). Persons with mixed TNAs, some focal, some not, have a non-amusing array of days spent lacking now the use of a hand, another day the use of a leg, now and then disoriented or dizzy, or another perhaps with expressive aphasia (inability to find and use the right words). Mom's been there, done it all.

News from Rotterdam* suggests that my Mom, with her mixed TNAs, has the worst trouble of all. Shoot, I didn't need any fancy European data to know that, but it's always reassuring in a sad sort of way to understand what's what. Researchers there followed 6,000 some oldish sorts--55 and above--over ten years to see who transiently struggled with neurological troubles and who ended up with a stroke, a heart attack, or demented. Those with the focal variety had twice the risk of stroke but no greater risk for heart attack or dementia compared with the aging control group with no TNAs at all. Those with nonfocal TNAs had 1.5 times the risk of stroke and dementia, but the mixed-up mixed group had over twice the risk of heart attack, stroke, vascular death, AND 3.45 times the incidence of dementia.
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*Bos, MJ, et al. JAMA. 2007 Dec 26;298(24):2877-85.

RESPeRATE

Well, now how unlikely is that? Hook yourself up now and again to a gizmo that monitors AND moderates your breathing rate, then drop your BP up to 36 points! I would've rated this gadget as weird, but after witnessing its effects this week in the office, I'm tentatively branding it wonderful.

Ms. L is seventy-something, and too active with her worldwide travels to let hypertension get her down. She's on three different meds in two different pills: a beta-blocker and a two-fer-one combo called Lotrel which combines an ACE inhibitor with a calcium channel blocker. She arranged her Wednesday appointment to discuss her elevated pressures--158/96--despite all those drugs.

Prior to her visit, she hauled out her RESPeRATE machine, just for grins, and breathed to the tones. She bought this machine a couple of years ago, but like all health habits that take a little time, it got shelved due to busyness. The manufacturer claims that slowing your respiratory rate to 10 or less breaths per minute allows small blood vessels to dilate. Same amount of blood through now larger vascular space equals lower pressure. Ms. L stuck her arm up on the desk to get her BP checked--a moment that often causes white coat hypertension in the doctor's office--and poof there's our proof! 122/78! I checked both arms, just in case, and she was symmetrically normotensive.

These little hummers set you back $290 at Amazon.com. Hypertension sets you up for heart attacks, stroke, and dementia. RESPeRATE, $290. Peace of mind? Priceless. I don't have hypertension, but I think I want one.

Prostate cancer treatment

Tough choices to make when prostate owners are diagnosed with cancer of the gland. Pesky thing is prone to cancer--in autopsy studies of older men who no longer need their prostates nor much of anything else, nearly 1/3 demonstrate microscopic cancer of the prostate. Because of this high incidence of latent, asymptomatic cancer, urologists comment that more men die with it than of it.

As a result, one possible treatment choice for prostate cancer is to do nothing at all. One of my sixty-something year old patients went this route 4 years ago and continues to do well. Brachytherapy is another option; radioactive 'seeds' are implanted into the gland, and over time the prostate shrivels up and scars down. Several of my patients have chosen this route, and they too are doing well. The most radical route to a prostate cancer cure is the piecemeal removal of the whole darned thing which is inconveniently located beneath the bladder encased in important nerves in charge of urinary continence and other important male functions.

Only one of my patients opted for this choice. Now, a year later, he is also doing well, continent, potent, and cancer-free. He did his Internet homework, discovering a premier uro-oncologist at the University of Colorado Health Sciences Center. Dr. Shandra Wilson is not only superbly trained, per Mr. M, she's as nice as she can be. As I reread his consultation report from his initial evaluation at the UCHSC Urology Clinic, I was as impressed by the report from the dietician on the case as I was my Dr. Wilson's credentials. Epidemiological studies suggest that a diet high in animal fat contributes to prostate cancer, and this energetic dietician managed to enumerate all of Mr. M's favorite sources, including Popeye's, Red Lobster, and White Fence Farms.

Planting a radioactive field in the pelvis, hacking the gland out piecemeal with efficient little robotic arms, doing nothing at all, difficult choices for men and the people who love them. If you're in Denver and worrying about your own prostate or that of someone near and dear to you, consider a consultation with Dr. Wilson and company--they are most thorough and caring.

Independence in oldsters

When my Mom asked me if all the old ladies in the nursing home dining hall had committed some sort of crime, she was struggling with the delusion that she and they had landed in some sort of correctional facility. My first thought was that their only 'crime' was to have outlived their independence. Women live longer than men, AND they also live longer with disability.

A study from the journal Hypertension holds particular interest, then, for us aging ladies. Boston doctors studied a group of persons in their late 60s and beyond, looking for a correlation between hypertension--particularly 'uncontrolled hypertension' defined as 140/90 and above--and the inability to be independent in activities of daily living.

They found that the presence of hypertension, controlled or un-, increased the likelihood of disability by a factor of 1.3. If the blood pressure was uncontrolled-- and their definition of uncontrolled is met by many of the elderly I see in the office--the risk rose even higher.

If you're interested in the threshold you'd cross to be defined as dependent in your daily routine, check-out Katz' Activities of Daily Living Scale.