A PUBLICATION FOR     PRIMARY CARE PHYSICIANS                                                           MICA (P) 242/03/20...
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TTSH GP BUZZ (March - May 2013)
TTSH GP BUZZ (March - May 2013)
TTSH GP BUZZ (March - May 2013)
TTSH GP BUZZ (March - May 2013)
TTSH GP BUZZ (March - May 2013)
TTSH GP BUZZ (March - May 2013)
TTSH GP BUZZ (March - May 2013)
TTSH GP BUZZ (March - May 2013)
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TTSH GP BUZZ (March - May 2013)

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TTSH GP BUZZ (March - May 2013)

  1. 1. A PUBLICATION FOR PRIMARY CARE PHYSICIANS MICA (P) 242/03/2012 MarcH-MAY 2013 GREY MATTERSEye An Interview with Associate Professor Chin Jing Jihon theElderly Under- Nutrition In The Elderly AGEING AND ARTHRITIS Scan the QR code using your iPhone or smart phone to view GP BUZZ on the TTSH website or visit http://www.ttsh.com.sg/gp/.
  2. 2. contents editor’s note 25 in every issue Eu-ge-ria – A normal and happy old age# (noun) 030 editor’s note 040 in the news The GP BUZZ editorial team: I Lee Wei Kit Jessie Tay 300 fitness n twenty years, Singapore will Read about the symptoms and latest Celine Ong 350 healthy recipe have undergone an treatment options for arthritis and ADVISORY PANEL: unprecedented profound age the importance of vitamin Associate Professor Thomas Lew shift. One in five Singaporean supplementation for healthy ageing Associate Professor Chia Sing Joo residents will be a senior, with in the older person. The risks and Associate Professor Chin Jing Jih the number of residents aged 65 and management of under-nutrition are 30Adjunt Assistant Professor Chong Yew Lam above multiplying three-fold from also discussed in-depth with a Dr Tan Kok Leong Joe Hau in this issue 300,000 to 900,000*. contribution from the TTSH Nutrition and Dietetics Department. GP Buzz is a quarterly magazine by 06 ye on the Elderly E The greying profile of our society Tan Tock Seng Hospital, designed by will be a strong driver for healthcare Further in this issue, explore 09 Grey Matters demand, as the elderly are more targeted interventions and treatment likely to require more medical care. methods for diabetes and hearingWe value your feedback on how we can enhance 12 Ageing and Arthritis With the rise in age-related chronic loss. Specific exercises to aid the content of GP Buzz. Please send in your diseases, the trend indicates that mobility have also been specially comments and queries to gp@ttsh.com.sg. 15 Vitamin Supplementation the expectation for quality care will developed by the TTSH Physiotherapy © All rights reserved. for the Older Person also rise. Department. No part of this publication may be reproduced or transmitted in any form by any means without prior consent from the publisher. 19 Managing the Sweet Spot Your role as primary healthcare We round up this elderly-focused practitioners in delivering effective issue with a Tofu Sushi treat specially 22 Under-Nutrition In The treatment and care to the silver- crafted by TTSH Food and Beverage Elderly – Can It Be haired generation has never been Department. Prevented? more challenging and significant. An ageing population is a 25 he Sound of Silence: T Keeping an eye on elderly issues, we demographic reality. Indeed, we all 06 22 Hearing Loss in the Elderly kick-start this issue of GP BUZZ with have collective responsibility in the cover story on cataract and shaping the future of aged care. Let’s age-related macular degeneration, forge ahead together to ensure that 29 geing in Singapore A two common visual impairments our seniors of today and tomorrow which affect up to 80% of the elderly enjoy a high quality of life with locally. innovative and accessible healthcare. The GP BUZZ Editorial Team Sources: # The Oxford Dictionary * Singapore Department of Statistics march - may 2013 03
  3. 3. in the news in the newsPharmacyConsultationsProvide Safer And 2More IntegratedCare For Patients 1 3 1. A brighter, more conducive healing environment. 2. Decentralised nursing workstation. New Wards Ready 3. Additional hand-grab bars within toilet. For The ElderlyP harmacist-run clinics, where A patients’ medication is reviewed, t Tan Tock Seng Hospital (TTSH), newly- control that also allows them to control the reading light monitored and explained is renovated class B2 wards have been enhanced and ceiling fan over their beds.becoming a regular feature in the public with more elderly-oriented features to meet thehospital landscape. With nine rising demands of a rapidly ageing population. To reduce patient fall risk and injury, the new wardspharmacist-run clinics or outpatient now feature en-suite toilets for a shorter bed-to-toiletservices, Tan Tock Seng Hospital (TTSH) Each ward cubicle of five beds now has its own nurse distance, additional hand-grab bars within the toilet andtakes the lead with the most of such station, giving assigned nurses a direct line of sight to vinyl padded flooring to reduce fall impact.services in Singapore. their patients. The new configuration means nurses can see their patients better and respond to patients faster, A brighter, soothing colour tone has also been carefullyIn a 10 to 15-minute session, the sometimes without the need for bell calls. selected for a comfortable healing environment.pharmacist goes through the patient’slist of medication, explaining what each Pharmacy consultation at TTSH PEARL non-subsidised Clinic 2B. The nurse call bell system at TTSH has also been Similar elder-friendly enhancements will also be madedrug is for, when it should be taken and improved. Patients now have an all-in-one remote to other wards in phases.in what dosage. Besides educating patients on drug usage and the sideThese sessions help familiarise the patients with the effects, pharmacists can also make changes to thedrugs they are taking and the recommended dosage for dosage. Some pharmacists also have prescribing rights,each drug. The pharmacist also keeps an eye out forany adverse drug reactions and can take prompt action subject to approval by the medical board of the hospital and within approved protocol. CME Schedule March - May 2013for side effects. Dealing with Gastrointestinal Diseases Sessions with the pharmacist are useful not only forAt TTSH PEARL non-subsidised clinics, first-visit patients patients. Caregivers of elderly patients may also benefit CME POINTS 2 CME points*undergo a review of their current medications even patients under the care of multiple specialists. A DATE 27 Aprilprior to the doctor’s consultation. This innovative pharmacist working in partnership with the patient and TIME 2.00pm - 4.00pmprocess helps doctors in their prescriptions in his caregivers can minimise the danger of potentiallyaccordance with the pharmacist’s review. VENUE Theatrette, Tan Tock Seng Hospital, Level 1 * Subject to the approval of Singapore harmful drug interactions. Medical Council. REGISTRATION Ms Cynthia Lee For an updated listing of CME and DETAILS event schedule, please visit DID: 6357 2373 http://www.ttsh.com.sg/gp/. Email: cynthia_lee@ttsh.com.sg Information is correct at the time of publishing.04 05
  4. 4. cover story cover story Cataract lens becomes completely white and opaque, appearing as a white opacity What is Cataract? in the pupil (Figure 1). A cataract Cataract is a clouding of the natural does not cause an absolute or (clear) lens in the eye. The relative afferent defect. prevalence of cataract increases with age, affecting up to 80% of the What are the Treatment Options? elderly. Both eyes are usually Surgical removal is the only effective 1 affected, although sometimes treatment, and should be considered asymmetrically. when the cataract reduces visual function to a level that interferes What are the Risk Factors? with everyday activities. Cataract Risk factors for cataract include age, surgery is an outpatient procedure diabetes mellitus, smoking, that is performed under local ultraviolet radiation exposure, anaesthesia, and usually takes less steroid medications (eyedrops, than half an hour to complete. 2 topical and systemic), and prior 1. Figure 1 - Late-stage Cataract. ocular injury. Standard cataract surgery is 2. Figure 2 - Wet AMD with haemorrhage. performed by phacoemulsification What are the Symptoms of (ultrasonic emulsification of Cataract? cataract) through sutureless corneal A person with cataract may incisions, replacing the cataract with experience blurred vision, reduced an artificial lens implant. colour saturation, reduced contrast, monocular double vision, increased A wide variety of lens implants glare and haloes at night. Poor night (monofocal, aspheric, multifocal, Eye vision and the need for frequent accommodative and toric) are changes to spectacles prescription available, enabling patients to are also common symptoms. achieve various degrees of spectacle independence. The selection of lens on the Normal Vision How can I Prevent Cataract? implants is also tailored to each Patients should be advised to avoid patient’s specific visual needs. or cease smoking, use sunglasses or a Elderly wide-brimmed hat when outdoors Age-related Macular and to maintain a healthy diet. There Degeneration are no medications to reverse cataracts once they have formed. What is Age-related Macular Degeneration (AMD)? Visual impairment in the elderly is associated with reduced How is Cataract Detected? Age-related Macular Degeneration mobility and physical performance, as well as an increase in A reduced or absent red reflex can (AMD) is a leading cause of blindness be detected with a direct in many developed countries. AMD hip fractures, depression, morbidity and mortality. Find out ophthalmoscope. In late stages, the affects a person’s central vision and Abnormal Vision more about Cataract and Age-related Macular Degeneration, is classified into dry and wet AMD. two common causes of visual impairment in the elderly. Figure 3 - Amsler Grid Eye Test06 07
  5. 5. cover story SPOTLiGHTDry (atrophic) AMD is more common,visually less debilitating andprogresses more slowly. How is AMD Detected? For Dry AMD, small, yellow subretinal deposits called Drusen are seen in Conclusion The ageing population of Singapore will increase considerably in the GREY MATTERS the macular area. There may also be years to come, resulting in a An Interview withWet (exudative) AMD is characterised retinal pigmentation or corresponding increase in theby the development of abnormal depigmentation in the macular area, prevalence of age-related eye Associate Professor Chin Jing Jihchoroidal blood vessels (choroidal without leakage of fluid or blood. conditions. Awareness of theseneovascularisation) with resultant conditions will better position thevisual loss from retinal oedema, Signs of Wet AMD include health practitioner to care for thebleeding and scarring. Wet AMD haemorrhages, exudates and oedema elderly patient. Woccurs in only 10% of patients with in the macular area, with macular ith an intuitive interest in scientific enquiry and a desire to be engaged in an interactive and meaningfulAMD, but is responsible for up to 90% scarring setting in if left untreated profession, a medical career was a natural choice for Associate Professor Chin Jing Jih. Currently aof severe vision loss related to the (Figure 2). Macular examination with specialist in Geriatric Medicine and Senior Consultant in the Department of Continuing and Communitydisease. direct ophthalmoscopy may be Care at Tan Tock Seng Hospital (TTSH), Associate Professor Chin is Chairman of the hospital’s Division of Integrative difficult due to small pupils from and Community Care, tasked primarily to develop an integrated framework of primary, tertiary and long-termWhat are the Risk Factors? senile miosis or cataract. geriatric care systems. He is also the incumbent President of the Singapore Medical Association.These include ageing, smoking, afamily history of AMD and genetic What are the Treatment Options? In September 2012, the Institute of Geriatrics and Active Ageing (IGA) was launched. Spearheaded by Associatepredisposition. Females and For Dry AMD, there is no curative Professor Chin and housed in TTSH, the new centre seeks to embark on geriatrics research and innovation, and toCaucasians are also at a higher risk. treatment and no active treatment attract, train and retain healthcare workers in elderly care. The institute will also work with three medical schools Dr Foo Fong Yee indicated. The use of high-dose Dr Foo Fong Yee is a Consultant at the – Yong Loo Lin School of Medicine, Duke-NUS Graduate Medical School and the upcoming Lee Kong Chian School ofWhat are the Symptoms of AMD? antioxidants (Vitamins A, C and E) National Healthcare Group Eye Institute at Medicine – to beef up geriatric care training, develop initiatives to improve patient care as well as coordinate and Tan Tock Seng Hospital, and Clinical SeniorAMD presents with an insidious and and zinc supplementation has been Lecturer at the Yong Loo Lin School of fund research efforts.progressive blurring of central vision. shown to reduce the risk of Medicine. She is a Fellow of the Royal CollegePatients usually maintain fairly good progression in specific categories of of Surgeons of Edinburgh, and the Academy of Medicine Singapore. Her subspecialty interest We speak to Associate Professor Chin to learn more about the IGA and geriatric care initiatives at TTSH.vision unless extensive degeneration Dry AMD. However, a high-dose of is in paediatric ophthalmology and strabismus.and atrophy set in, or if wet AMD vitamin A should be avoided indevelops. Wet AMD presents with a smokers as it is associated with an References:more severe decrease in central increased risk of lung cancer. 1 Report on the Ageing Population 2006. Committee onvision and distorted vision Ageing Issues. Department of Statistics Singapore. http://app.msf.gov.sg/Portals/0/Summary/research/ In your own words, how will the can offer them. As healthcare was premised on our belief that,(metamorphopsia). Wet AMD is diagnosed and classified CAI_report.pdf. future landscape of geriatric care providers, we will have to constantly with a rapidly ageing population, we by special angiographic imaging with 2 Key indicators on the elderly. July 2012. Department of be like? adapt and adjust in order to meet are unlikely to cope with the many Statistics Singapore. http://www.singstat.gov.sg/stats/How can I Prevent AMD? fluorescein and indocyanine green themes/perople/elderly.pdf. The senior patients of the future these new challenges. We will have medical and psychosocial needs ofPatients should be advised to avoid dyes. Depending on the location and will be better educated, more to equip ourselves with skills in the elderly by merely doing more of 3 Ng DHL, Sangtam T, Au Eong KG. Ann Acad Medor cease smoking. Conducting regular lesion type, Wet AMD can be treated Singapore. Oct 2007; The emerging challenge of resourceful and probably more areas such as IT, medical ethics and the same. Current and future age-related eye disease in Singapore. 36(10): S9-13.self-checks with an Amsler Grid Eye in various ways. These include laser, motivated. At the same time, they health law, end-of-life strategies to meet the complex and 4 Hyman L. Eye 1987; Epidemiology of eye disease in theTest (Figure 3) is helpful in picking up photodynamic therapy, peri-ocular elderly. 1(2):330-41. will want to participate more communication, in order to connect multi-faceted needs of the elderlyearly symptoms. Those aged above steroids and intra-vitreal injection of actively in their own care, and well and be able to meet the will require increased efficiency and 5 Quillen DA. Am Fam Physician Common causes of vision55 should undergo screening for AMD anti-vascular endothelial growth loss in elderly patients. 1999;60(1):99-108. express their opinions more medical and psychosocial needs of cost-effectiveness in our treatmentevery 1 to 2 years, especially in the factors (anti-VEGF) such as 6 Foster PJ, Oen FT, Machin D, Ng TP, Devereux JG, explicitly. They will likely place even the seniors. and our care delivery models. To Johnson GJ, Khaw PT, Seah SK. Arch Ophthalmol. Thepresence of risk factors. ranibizumab (Lucentis), pegatanib prevalence of glaucoma in Chinese rsidents of more emphasis on quality of life and achieve constant improvement and (Macugen) and bevacizumab Singapore: a cross-sectional population survey of the the healing experience. They will What was your motivation in renewal, we will need research and Tanjong Pagar district. 2000 Aug;118(8):1105-11. (Avastin). also be more familiar with the use setting up the Institute of innovation to find us the improved 7 National Registry of Diseases Office (NRDO) Singapore. Information paper on diabetes in Singapore. Nov 2011. of technology in everyday life, and Geriatrics and Active Ageing (IGA)? solution, and education and training have higher expectations of what The need for an Institute of to rapidly transform the new tertiary and primary geriatric care Geriatrics and Active Ageing (IGA) knowledge into daily practice.08 09
  6. 6. SPOTLIGHT SPOTLiGHT feedback in patient-experience comfortable and homely On a personal note, why did you research that will impact designs, environment for older persons choose to specialise in geriatric policies and care delivery models. seeking consultation. In this new care? A collaborative multi-disciplinary clinic, we aim to I have always found Geriatric relationship can be We encourage our GP Partners to create an environment that Medicine a complex and fascinating, nurtured with our GP participate in piloting of shared care optimises the function and yet practical medical discipline. It Partners by identifying models with our clinical teams, and confidence of patients while combines some of the most collaborate in education and mitigating effects from ageing- challenging aspects of medical and and referring appropriate training programmes such as CME related functional impairment. social care, dealing with issues such patients who can activities. as illness experience, family participate in the Over the past year, the Department dynamics, and the ethical, legal, activities of the Institute, What are some of the initiatives of Geriatric Medicine have re- financial and psychological aspects of that TTSH has embarked on for our structured the inpatient care teams care. I have also always enjoyed either as research geriatric patients? to introduce new multi-disciplinary talking to seniors since my childhood, subjects in clinical We are in the process of programmes for better elderly listening to their interesting stories research, or providing constructing a new outpatient management and more targeted and biographical accounts. valuable feedback in geriatric clinic that is specially care. designed to provide a safer, more patient-experience research that will impact designs, policies and care delivery models. TTSH GeriatricAll these efforts can only beproductive and sustainable when Furthermore, TTSH was one of the first acute hospitals to extend its Many of our hospitalised elderly are also vulnerable to acute confusion Inpatient Care Unitssupported by a well-planned, geriatric services into the whether or not they have clinicallysuitably resourced and coordinated community in collaboration with overt dementia. As such, we have Geriatric Evaluation, Patients are identified and channelled systematically to receive timely treatment andplatform that facilitates research Voluntary Welfare Organisations established a Specialised Delirium Management and Sub-acute rehabilitation from a dedicated multi-disciplinary geriatrician-led team in an environment Care (GEMS) optimised for frail hospitalised older persons.and education. It is our conviction (VWOs) with aligned vision and Management Unit to better managethat the IGA will provide this much goals. and study care innovations toneeded catalytic framework. improve the functional status of Acute Care of the Elderly (ACE) Targeted at patients with acute medical complaints with an emphasis on minimising What are some of the projects these patients. functional decline and early discharge planning. An innovative addition to this model is the provision of a unique Geriatric Nurse Coordinator (GNC) in the ACE wards. The GNCsWhy is TTSH an ideal location to lined up for the IGA? serve as a key channel for communications of medical issues, discharge preparation andhouse this Institute? In one of our key research projects, What are some meaningful ways follow-up medical care between the ward team, patient and caregivers. This has resultedHistorically, TTSH is the birthplace we are looking into factors that that our General Practitioner (GP) in a more efficient discharge process, reduced communication errors and more satisfyingof Geriatric Medicine in Singapore, contribute to medical, psychological Partners can share in IGA’s goal of patient experience.and operates today one of the or social frailty among patients better serving the needs oflargest geriatrics services locally. suffering from mild cognitive Singapore’s ageing population? Geriatric Comprehensive An assessment team, anchored by a Geriatrician and a Geriatrics Nurse Clinician, isThe geographical area served by the impairment (MCI) and mild-to- A collaborative relationship can be Assessment and Rehabilitation tasked to evaluate and identify specific rehabilitation needs and geriatrics care issues inhospital also happens to be moderate dementia. By identifying nurtured with our GP Partners by for the Elderly (GeriCARE) medical patients, thereby allowing for better planning for their subsequent care.demographically one of the oldest in these vulnerabilities, useful identifying and referring appropriatethe country. This provides a good management strategies can be patients who can participate in the Geriatric Monitoring Unit Specialising in the care of the elderly patient with delirium, this care unit aims at usingmatch between available expertise formulated to retard functional activities of the Institute, either as non-pharmacological methods and bright light therapy to manage difficult behaviours ofand needs of the communities decline and enhance the ability of research subjects in clinical the confused elderly with minimal resort to physical restraint.surrounding the hospital. caregivers and patients to cope with research, or providing valuable the illness.10 11
  7. 7. feature featureAGEING 3. Deformity The commonest deformity in arthritis of the knees is bowed legs (genu varum) deformity. In rheumatoidAND arthritis, the deformity is usually a knock-knee (genu valgum) deformity, or a wind-swept deformity where one knee is in varus and the other knee in valgus deformity.ARTHRITIS DIAGNOSIS A careful examination of a patient’s medical history to elucidate the type of arthritis is important prior to giving treatment. Inflammatory arthritis can be distinguishedArthritis is a painful disease that can from primary osteoarthritis with a history of fever,affect any age, but usually occurs late rashes, multiple symmetrical joints involvement andin life. Understand more about the systemic symptoms. History of accidents and sports injuries accounts for arthritis in the younger patients.symptoms and effective treatment Excessive wear and tear is seen in patients who areoptions for better outcomes and extremely overweight or who participate in extremequality of life. sports. A physical examination will reveal the degree of deformity, loss of motion and leg-length discrepancy. Assessment of neurovascular status of the limb is essential in pre-operative planning. X-rays of the joint in question with long-leg films are also needed.WHAT IS ARTHRITIS? In early cases of arthritis where there is severe pain butArthritis is the result of wear and tear of the joint little radiographic evidence of arthritis, MRI imaging willcartilage. The common cause is normal wear and tear be helpful to diagnose early osteonecrosis as well as towith ageing. Arthritis can also be accelerated in the evaluate for degenerative meniscal tears which canfollowing situations: occur with minimal trauma in the elderly. SYMPTOMS OF ARTHRITIS1. Intra-articular injuries sustained in road traffic accidents, sports and injuries. 1. Pain TREATMENT OPTIONS2. Inflammatory Diseases. For example, Rheumatoid Initially, pain occurs at the end of the day and after 1. Joint Replacement Surgery Arthritis, Systemic lupus erythematosus (SLE) and prolonged walking and weight bearing. As the arthritis The most commonly affected weight Joint replacement surgery has been very successful in other Autoimmune Diseases. and wear of the articular cartilage progresses, the pain joint for arthritis is the knee followed treating severe arthritis of the hip, knee, shoulder, elbow3. Joint Infections. becomes more intense and occurs with shorter periods of4. Excessive joint loading from overuse in sports, heavy weight bearing. by the hip. The shoulder and elbow and ankle joints. The survivorship of modern hip and manual work and obesity. are affected in trauma and throwing knee replacements is 90% over 15 to 20 years. 2. Stiffness sports as well as in inflammatoryThe most commonly affected weight joint for arthritis is Early morning stiffness is a common presentation and New methods to improve the longevity of the knee diseases. replacement surgery include computer-aided navigationthe knee followed by the hip. The shoulder and elbow patients find difficulty getting out of bed or out of aare affected in trauma and throwing sports as well as in chair, squatting and climbing stairs after prolonged surgery and use of patient-specific jigs during surgery toinflammatory diseases. sitting due to loss of cartilage and joint lubrication. improve the leg alignment. Robotic surgery has also been12 13
  8. 8. feature featureintroduced to improve the precision and accuracy of the potent analgesic and anti-inflammatory effects but havebone cuts in both hip and knee replacement surgeries. side-effects on the heart, kidney and stomach. Glucosamine with or without Chondrotin has beenNewer materials like trabecular metal for improved bone prescribed with varying results.ingrowth of prosthetic components have been developed.These are used together with highly cross-linked 5. Intra-articular Viscosupplementationpolyethylene and ceramic bearings to prolong the Hyaluronic acid injection is useful in early to moderatelongevity of the implanted joints. arthritis and can give pain relief for up to a year in 70% of patients. It acts as a joint lubricant and nutrition for2. Arthroscopic Surgery the cartilage.Arthroscopic surgery has been extensively employed fortreatment of early and moderate arthritis to remove 6. Weight-loss and Lifestyle Changesdegenerate meniscal tears and loose bodies. In younger The role of weight-loss and lifestyle changes to treatpatients with small chondral lesion of less than 3cm2 in arthritis have not often been emphasised in thesize, chondroplasty with microfracture and cartilage consultation room. A person with arthritis should beimplantation has produced good clinical results with pain advised to lose weight, avoid running on the roads orrelief and reconstitution of the cartilage. Arthroscopic participating in cross-country runs and change to low-ligament reconstruction and meniscal repair restore the impact exercises such as cycling, swimming and walking.normal biokinetics of the injured knee to prevent the An elliptical cross trainer can also be used in the gym asdevelopment and progress of arthritis. opposed to running on the treadmill. Avoid using the stairs and squatting. Elevators and escalators should beIn the hip, arthroscopic surgery repairs labral tears and used where possible.remove bone deformities of the femoral neck whichcaused hip impingement leading to arthritis. In conclusion, advances and improvement in the treatment of osteoarthritis has enabled the arthritic Vitamin3. OsteotomiesOsteotomies have a role in early hip and knee arthritis patient to lead a healthy and active lifestyle. Supplementation for the Olderwhere there is significant hip dysplasia or knee deformity.For a patient with varus deformity of the knee, the tibiacan be osteotomised to correct the alignment of the leg. PersonAs in joint replacement surgery, this can be renderedmore accurately with computer-aided navigation. Dr Lai Choon Hin Dr Lai Choon Hin is a Senior Consultant in the Orthopaedic Sugery Department of Tan Tock SengAcetabular dysplasia can be corrected with Hospital. Dr Lai was awarded the prestigiousperiacetabular osteotomy to correct the uncovering of Public Service Commission Merit Scholarship to There has been an increase in the number of nutritional study Medicine in National University of Singaporethe femoral head with or without femoral osteotomy. and graduated in the top of class in 1979. He was supplements available in the market. It is also notOpen acetabular labral repairs and treatment of the cam awarded the Health Manpower Development Plan uncommon for older patients to request for aor pincer causes of hip impingement can successfully fellowship to the Mayo Clinic, USA to train in adultprevent the development and progression of arthritis in reconstruction and joint replacement surgery, prescription to improve their ‘well-being’ during a tumor surgery, biomechanics and bone physiologypatients experiencing hip impingement. from 1988 to 1989. His current interests include doctor consultation. Learn more about the vitamins all forms of reconstruction surgery for the hip, knee, elbow and surgery, and treatment of sports that are important to the older person.4. Medication injuries especially in the middle age and olderParacetamol is the safest analgesia for arthritis with the sportsmen.least side-effects. NSAIDs and Cox2 inhibitors have more14 15
  9. 9. feature feature N Types of Vitamins utritional status is Vitamin B (including folate) Vitamin D Vitamin E important and has been Evidence suggests that increased Studies have found that blood Vitamin E contains strong found to influence Vitamin A homocysteine, which is an amino levels containing above 30ug/L of antioxidants that modulate immunity and the pathogenesis of One common benefit of Vitamin A acid in the blood, is a major risk Vitamin D can delay bone loss and cardiovascular, respiratory as well atherosclerosis. Benefits of is its effect on eyesight. It can factor for cardiovascular disease. prevent osteoporosis thus as cerebrovascular health. vitamins also include improving help prevent night blindness The postulated effect is via its reducing falls as well as fractures. cognitive and physical function, because vitamin A is needed for promotion of atherosclerosis by There are six other major dietary preventing falls and osteoporosis the rods within the retina to damage of the inner lining of the This is due to its action on the carotenoids (alpha- carotene, as well as improving mood and function properly. These retina arteries and the promotion of the absorption and metabolism of beta-carotene, beta- preventing depression. rods enable us to see at night. It formation of blood clots. calcium and phosphorous as well cryptoxanthin, lutein, zeaxanthin also prevents cataracts due to its as their effects on the muscular and lycopene) which form an It is without doubt the elderly antioxidant effects in the removal Homocysteine levels in the blood receptors, decreasing body sway important component of the patient is more susceptible to of free radicals that preclude are strongly influenced by diet and improving proximal muscle antioxidant defense system in inadequate intake of nutrition. clouding of the lens. Vitamin A is and genetic factors. Vitamin B and strength. human beings. They are a good This is due to the changes that also useful in preserving eyesight folate have been found to help in indicator of intake of fruits and occur as one ages. The older adult by delaying the onset of age- the break down of homocysteine Vitamin D has also been found to vegetables. Low levels of these tends to eat less and chooses less related macular degeneration. in the body. be an immune system regulator, are associated with poor grip, hip energy-loaded foods. Physiological reducing the risk of developing and knee muscle strength. changes related to ageing like There are currently no randomised multiple sclerosis as well as slower gastric emptying, altered controlled trials to prove the rheumatoid arthritis. High levels Dangers of Excessive hormonal responses, decreased effects of these vitamins on of vitamin D have also been found Supplementation basal metabolic rate and altered cardiovascular risk, but it is to decrease the risk of colorectal We must also be aware of the taste and smell all contribute to recommended by the American and breast cancers. hazards of excessive decreased energy intake. This Heart Association that high-risk supplementation. puts the older adult at an patients ought to have adequate There has also been interest in increased risk for inadequate Physiological changes folic acid and Vitamins B6 and B12 the relationship between vitamin A meta-analysis of Vitamin E nutrition. Moreover, other factors related to ageing like in their diet. D and frailty. If the replacement showed that supplementation in like chronic diseases, impaired of vitamin D can help in the large amounts is associated with slower gastric emptying, digestion and absorption from the The other effects of this group of transition between the different increased mortality. Other gastrointestinal tract and altered hormonal vitamins include its ability to frailty states, it may be prudent harmful effects of excessive nutrient-drug interactions can responses, decreased improve cognitive function and for the doctor to actively check supplementation include further compromise their basal metabolic rate memory and information and supplement the patient diarrhoea, renal impairment, nutritional status. processing. accordingly especially since the increased risk of fractures and and altered taste and older Singapore adult has less neurotoxicity. However, the doses Older adults have been found to smell all contribute to Vitamin C propensity to consume sufficient of supplementation required to have an inadequate intake of decreased energy intake. The most significant effect of dairy or fish products, or spend bring about side effects need to specific vitamins like vitamin A, This puts the older adult Vitamin C is in maintaining adequate time under the sun to be very high. Other considerations B6, B12, D and folate. The intake immunity to prevent simple have it being produced by the include the potential for drug at an increased risk for of carotenoids and vitamin C also infections like the common cold. skin. interactions, for example Vitamin declines with age. inadequate nutrition. It also prevents skin ageing and E and warfarin. has been used commonly in patients with sacral sores.16 17
  10. 10. feature feature Conclusion Managing Ideally, older adults should obtain these essential vitamins from the Sweet Spot their diet. It is also imperative to Dr Joanne Kua Dr Joanne Kua is an Associate Consultant with the note that vitamin Department of Geriatric Medicine in Tan Tock Seng supplementation is not a Hospital. Her specialty interests are in falls and substitute for healthy lifestyle, healthy active ageing. but only when the older adults are Elderly patients with diabetes have unable to have their nutrition through normal oral diet that unique medical concerns and require supplementation may be diabetes management goals to be beneficial. References: 1 Vitamin status in elderly people in relation to the use of nutritional supplements. tailored specifically to their needs. The Journal of Nutrition, Health and Aging 2012 16 (3): 206- 212. There are many supplements in 2 The effect of undernutrition in the development of frailty in older persons. Journal of Doctors and other healthcare the market for the older adult. It Gerontology: Medical Sciences 2006 Vol 61a (6): 585- 588. workers should be familiar with the is important to know the dosages 3 Low serum micronutrient concentrations predict frailty among older women living in the community. Journal of Gerontology: Medical Sciences 2006 Vol 61a (6): 594- 599. challenges in caring for these elderly of the respective vitamins in the preparation and also who will 4 The effect of multi-vitamin supplementation on mood and stress in healthy older men. Human Psychopharmocology Clin Exp 2011; 26: 560-567. patients to ensure efficacious and benefit from them so that these 5 Association of low vitamin D levels with the frailty syndrome in men and women. Journal of safe treatment. vitamins can be of help to the Gerontology: Medical Sciences 2009 Vol 64a (1): 69-75. older adult. 6 Mayo Clinic health information: http://www.mayoclinic.com/health. Elderly Diabetes Patient Vitamin Essentials Landscape In Singapore Vitamin Prevention Prevention Effects of Excessive Most developed world countries use the chronological (with evidence) (without evidence) Intake age of 65 years as a definition of ‘elderly’ or older A • Dry Eyes • Respiratory Infections • Constipation person. It is known that the risk of having diabetes • Retinitis Pigmentosa • Gastrointestinal Cancers • Headache mellitus increases with age. According to the National • Arthritis • Hair Loss Health Survey 2010, the prevalence of diabetes among B • Pyridoxine Deficiency • Stroke Recurrence • Neurotoxicity those aged 60 to 69 years is 29.1% compared to the • Pernicious Anaemia • Osteoporosis population average of 11.3%. In addition, the overall prevalence of diabetes in Singapore will increase due to C • Common Cold • Dementia • Diarrhoea the ageing of our population. • Cancers • Constipation • Pressure Ulcers Type 2 diabetes remains a leading cause of premature D • Osteomalacia • Cancers • Kidney Failure deaths and ill-health in Singapore. This is because • Falls • Fractures poorly-controlled diabetes increases the risk of • Osteoporosis • Muscle Strength cardiovascular disorders, blindness, end-stage renal E • Age-related Macular • Scarring • Prostate Cancer failure, lower limb amputations and hospitalisations. Degeneration • Stroke • Death It is also associated with increased risk of cancer, • Cognitive Health • Cardiovascular Health psychiatric illness such as depression, cognitive decline, chronic liver disease, accelerated arthritis and other disabling conditions. However, with effective management of diabetes, these complications can be prevented.18 19
  11. 11. feature feature Increased Risk 8.0% may be acceptable in the frail elderly, transitioning monitoring for the visually impaired are also handled by The elderly are at high-risk for the development of type upward as age, co-morbidities and the risk for the nurse clinicians. 2 diabetes due to the combined effects of increasing hypoglycaemia increases, while the ability for self-care insulin resistance and impaired pancreatic islet function and social supports declines. Hyperglycaemia which Elderly patients with diabetes often require a lower with ageing. Age-related insulin resistance appears to causes acute symptoms and risks of complications such caloric intake and meeting micronutrient requirements be primarily associated with increase in body fat, as acute metabolic derangement should be avoided in while eating less can be a challenge. These nutrition decrease in muscle mass and physical inactivity, which all patients. issues can be handled by dieticians, who can in turn may partially explain the observed effectiveness of the involve the caregivers who prepare the patients’ meals. intensive lifestyle intervention in older participants in Interventions and Treatment studies of diabetes prevention. Clinical pharmacists assist in the review of medications TARGETED MEDICATION to ensure that the age-specific aspects of medication Challenges of Care Doctors should consider the selection of medications use are considered especially in the elderly with Patients with diabetes are a heterogeneous group with with a strong benefit-to-risk ratio which are efficacious polypharmacy. Unwanted side effects as a result of varying health status and different co-morbidities. This and safe for the elderly. Long-acting anti- reduced renal elimination or combination use of certain presents unique challenges in determining generalised hyperglycaemic agents which increase the risk of medications should be avoided. therapeutic aims and choice of pharmaceutical hypoglycaemia such as glibenclamide should be avoided. treatment for elderly diabetes patients. The dose of other medications may need to be reduced Importantly, as part of lifestyle intervention, the in the elderly as renal function decreases with age. healthy and able-bodied elderly are encouraged to keep Furthermore, despite the higher prevalence of diabetes physically active. amongst the elderly, older patients have often been Less complex treatment regimes containing anti- excluded from randomised controlled trials of treatment hyperglycaemic medications with lower risk for and measure of outcomes. Therefore, there is less hypoglycaemia may be preferred in the elderly. The evidence from trials to determine standard intervention presence of hypoglycaemia should be assessed at every doctor’s visit through a comprehensive review of Dr Daniel Chew strategies best suited for this large elderly group with The unique needs of symptoms and home capillary blood glucose monitoring Dr Daniel Chew is the Head and Consultant diabetes. Patient-centred approach is therefore the of the Endocrinology Department at Tan Tock most appropriate management strategy for elderly elderly patients with records. Seng Hospital. He graduated from the National University of Singapore in 1998 and did his patients, taking into consideration the presence of the complex diabetes are fellowship at the Oxford Centre of Diabetes, Intervention to decrease long-term cardiovascular following factors: best met and managed Endocrinology & Metabolism in 2008. He has an complications may include lipid lowering, blood interest in diabetes mellitus, especially in the within a multi- pressure control and anti-platelet treatments. The prevention of hypoglycemia which is associated 1. Duration and complexity of diabetes with cardiac mortality. Dr Chew is highly involved 2. Possible visual, hearing impairment and cognitive disciplinary diabetes benefits and risks of using these medications in the in initiatives which strive to improve diabetes dysfunction team approach. elderly are best discussed with the individual’s management and medication safety concerning insulin and oral hypoglycaemic agents. 3. Co-morbidities such as renal impairment physician. 4. Established vascular complications such as ischaemic heart disease and stroke TEAM-BASED DISEASE MANAGEMENT References: 5. Risk for hypoglycaemia and its complications. For The unique needs of elderly patients with complex 1. National Health Survey 2010, Singapore. example: falls and fractures, precipitating ischemic diabetes are best met and managed within a multi- 2. Amati F, Dubé JJ, Coen PM, Stefanovic- Racic M, Toledo FG, Goodpaster BH. Physical cardiac events disciplinary diabetes team approach. inactivity and obesity underlie the insulin resistance of aging. Diabetes Care 2009;32:1547–1549. 6. Risk of adverse events from polypharmacy 3. Knowler WC, Barrett-Connor E, Fowler SE, et al.; Diabetes Prevention Program 7. Social support and economic resources Due to visual, functional or cognitive dysfunction, Research Group. Reduction in the incidence of type 2 diabetes with lifestyle 8. Life expectancy elderly diabetes can have issues with diabetes self- intervention or metformin. N Engl J Med 2002;346:393–403. management and monitoring of glycaemic control. 4. Reers C, Erbel S, Esposito I, et al. Impaired islet turnover in human donor pancreata with aging. Eur J Endocrinol 2009;160:185–191. It follows that standard HbA1c targets of 6.5% to 7.0% Diabetes nurse clinicians are able to spend time with 5. Ismail-Beigi F, Moghissi E, Tiktin M, Hirsch IB, Inzucchi SE, Genuth S. Individualizing might be considered in healthy patients (with shorter patients and their caregivers to reinforce important glycemic targets in type 2 diabetes mellitus: implications of recent clinical trials. Ann disease duration, longer life expectancy and no information. Through strategies such as provision of Intern Med 2011;154: 554–559. significant cardiovascular disease) if this can be handouts and sequenced visits, crucial information such 6. M. Sue Kirkman, et al. Diabetes in Older Adults. Diabetes Care Publish Ahead of Print, published online: care.diabetesjournals.org. October 25, 2012. achieved through simple interventions without as the recognition and rescue from severe significant hypoglycaemia or other adverse effects of hypoglycaemia can be imparted. Special techniques to 7. Silvio E. Inzucchi, et al. Management of Hyperglycemia in Type2 Diabetes: A Patient-Centered Approach Diabetes Care Publish Ahead of Print, published online: treatment. However, a less ambitious HbA1c of 7.5% to cope with insulin administration and blood glucose care.diabetesjournals.org. April 19, 2012.20 21

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