Chan KM In The Media
Interviews done by local and international media.
My Alvernia #18
What’s Up Doc
Empowering a Healthier Silver Generation
As Singapore’s population ages, it is all the more vital that we adopt preventive healthcare measures for our elderly. Geriatric specialist Dr Chan Kin Ming tells us more.
No doubt about it, our pioneers have slogged hard to build Singapore into what she is today. Prime Minister Lee Hsien Loong’s announcement of a $8billion Pioneer Generation Fund, which offers those born before 1949 subsidies for outpatient care, Medisave top-ups and life-long subsidies for MediShield Life, is definitely a step in the right direction to help them cope with healthcare costs. However, prevention is always better than cure. Our pioneers’ quality of life can be much better if preventive healthcare measures are adopted to help them manage the challenges they face as they age.
There are three life stage challenges as a person grows old, highlighted geriatric specialist Dr Chan Kin Ming of Chan KM Geriatric & Medical Clinic Pte Ltd. The first are the ‘young old’ who are in their 60s, with some still working while others are retiring or just retired. “Retirement is a stressful event as it brings about changes that the older person may not be prepared for or unaware of. There is loss of social role and esteem as they now become a ‘dependent’. Having nowhere to go and nothing to do require psychological and emotional adjustment, unless they are prepared for it. As they ‘take it easy’ daily, this could lead to a decline in physical and mental functioning,” warned Dr Chan, adding that it may also result in changes and friction within the family relationship. They are also at the age when they start to have concerns about their health.
The second group are those in their 70s when frailty commonly sets in. A decline in their general health status further leads to decreased ability in their activities in daily living and mobility and causes further social isolation. They also start experiencing ‘loss’ – loss of spouse and friends of similar age, and loss of their own abilities, leading to low self-esteem and loneliness. “They start contemplating issues of being a burden to their family and issues of death.”
The third group are those aged 80 and older who need more assistance including personal effects like bathing and toileting and face increased risk of falls. Their ‘social’ and ‘physical space’ shrinks further as many become home bound, sometimes room bound, chair bound or bedbound. “Their social isolation becomes even more acute as even more of their peers and friends passed on. The issue of death becomes closer and they need to reconcile with that,” said Dr Chan.
How can preventive healthcare help our pioneers in their twilight years? Dr Chan shared his pearls of wisdom.
What is preventive healthcare?
There are 3 aspects of preventive healthcare. Primary prevention is the prevention of disease or injury before it occurs. For example, smoking is a cause of many chronic lung conditions like bronchitis, emphysema and even lung cancer. By preventing people from taking up smoking and by getting existing smokers to stop smoking, we could prevent the onset of these chronic lung conditions. In the elderly, it could also mean vaccinations against influenza or the prevention of falls by providing an appropriate physical environment like adequate lighting, having less steps or highlighting them, non-slip floors and having proper furniture, so that they could walk about safely and not fall.
Secondary prevention aims to stop or reverse a problem before it becomes symptomatic, through early detection. For example, identifying visual deterioration through eye screening to pick up early glaucoma or macular degeneration. These conditions may have no symptoms at the early stages but if allowed to progress, can cause blindness later. Other examples include the use of Bone Mineral Density to screen for early osteoporosis and to treat the condition when it is detected.
Tertiary prevention focuses on reducing disability and restoring functionality to people already affected by disease or injury. For example, a person with arthritis of the knees may need treatment of the pain with drugs or even surgery, followed by a course of physical rehabilitation to restore function.
What are some common health problems that our elderly face which will benefit from preventive healthcare?
Some common health problems include hypertension, diabetes, cancers (especially colon cancer), osteoporosis, atrial fibrillation, bladder and bowel problems like urine incontinence and constipation, falls, dementia, frailty and visual and hearing impairment. In elderly care, we often mention the ‘Giants of Geriatrics’ being:
- Iatrogenic causes as a result of inappropriate use of drugs, polypharmacy and drug interactions
- Incontinence of urine and stools
- Immobility, often caused by multiple causes like arthritis, heart and lung disease, stroke, visual impairment, fractures
- Instability and falls due to stroke, Parkinson’s disease, arthritis, unstable gait and balance
- Impaired cognition – depression, dementia and delirium.
Elderly people usually grow old with medical conditions that they had when they were younger. These often become chronic and complications arise from them. In addition, they develop new problems common in the elderly. For example, if a person has diabetes at 50 years old, by the time he becomes 70, he’ll have a 20-year history and would have developed some or all of the complications associated with diabetes, such as eye problems causing visual impairment, skin problems like ulcers, peripheral vascular disease, kidney disease and neuropathy (damage to the nerves). The vascular damage from diabetes will increase his risk of heart disease, stroke and even limb amputations. Neuropathy increases his risk of falls, injuries and fractures, especially so because diabetics are at risk of developing osteoporosis, the risk of diarrhoea, constipation, weakness of bladder muscle and urinary incontinence. Hence, from one initial condition, it can lead to so many possible complications causing instability, immobility, impaired cognition and incontinence. Therefore, each contributing factor of his morbidity needs to be managed carefully.
In a general population of community dwelling who are older than 60 years old in Singapore, 51% have poor vision, 46% rheumatism, 36% heart disease, 22% diabetes mellitus, 20% urine incontinence, 16% falls and 9.3% poor memory 9.3%.
What type of preventive healthcare do you recommend?
The elderly tend to have many health problems. It is difficult for them or their families/caregivers to know which problem or complaint is a result of age (and therefore they have to live with it) and which is disease (and therefore can be treated). Hence, regular health screening and check-ups are important, bearing in mind that many elderly are stoic and tend to play down their complaints, show an ageism attitude (“I fall down because I am old, or I am breathless because I am old”) or just do not like to see doctors or get admitted to hospitals.
The health screening for the older person is different from those for younger adults because there is an emphasis on their function – physical and mental functions, medication that they are taking, including all the health supplements bought over-the-counter as they also contribute to polypharmacy and interactions with the medicine that the person is taking.
How have your patients benefitted from preventive healthcare?
Many patients have benefitted from successful preventive healthcare, including an 80-year-old man. He refused to see any doctor because he declared himself “very well and very strong”. However, his family noted that he was limping and fell frequently, something he attributed to old age. To ‘trick’ him into coming to my consultation room, his family told him that a daughter was unwell and needed to see me. I had to ‘role play’ with the family, initially asking the daughter some general questions and later directing the questions to him when he got familiar with me. I even did a general physical examination and advised him to go for a general blood screen since he was already here. It showed he has early onset of Parkinson’s disease which caused him to be unsteady and fell frequently, and recurrent gouty arthritis, causing him to limp with pain. When he was treated, his strength, balance and gait improves. The gouty arthritis subsided and and he no longer limps and do not have any more pain in his knees. In the words of his children: “He walks faster than us now” and has started travelling again.
Should our elderly be put on a national health programme, just like what we have for babies?
It would be ideal if there is such a comprehensive programme for the elderly above the age of 60 years old. This programme should have a general medical screening for hypertension, diabetes, lipids, vision, hearing tests, oral health, gait, balance, muscle strength and falls risk, continence, mood and cognitive functional screen, nutritional screen, bone mineral density and screening for colon and breast cancer.
What to screen for and what vaccines to recommend depend on the patient’s history and findings of the clinical examination. But in general, annual influenza vaccination, pneumococcal vaccination and zoster vaccination are recommended for adults 60 years and older by the US Centre for Disease Control and Prevention.
The government recently announced a slew of measures under the Pioneer Generation Package during the Budget 2014, which aims to help our elderly with health-care costs. What do you think of these measures?
The announcement of this package is certainly a big relief and welcome for our pioneer generation and is targeted to benefit everyone in that generation, especially the poor. However, it is not useful if no one knows about it or knows how to access it. Similarly, existing facilities and manpower should be able to cope with the possible influx of patients utilising the facilities. I’m sure these are some teething problems that may arise but they should sort themselves out pretty soon.
Preventive healthcare is always difficult because the person is subjected to a change of lifestyle and the need to take drugs on a long term basis. They may be very enthusiastic initially, but after a while, they may lose the stamina to continue, especially when they may not even have the disease in the first place. This difficulty is multiplied many fold in the elderly, especially when they start thinking, “How many more years do I have left?” and “I’m already so old.” Therefore, it is a difficult balance to ‘enforce’ the strict lifestyle that is sometimes needed in preventive healthcare, versus the patient’s pragmatic view of his own life and lifestyle.
Thus, preventive steps have to be individualised to the person. But on a national level, to help the elderly achieve and maintain good health, there should be on-going education on conditions that are common for the elderly, perhaps with free admissions to such talks and done in a language or dialect that they can understand. There should be opportunities for health screening and healthy lifestyle – spaces for exercise, formation of exercise or activities groups, each elderly having a health tracking booklet, just like the health booklet that accompanies each baby born in Singapore. This will keep track of their vaccinations, annual health checks, illnesses etc.
Dr Chan Kin Ming is based at Mount Alvernia Medical Centre Block A, #02-24, Tel: 6255 5567.
My Alvernia #9 2011
The Big Interview
For the elderly, there is often no direct correlation between symptoms and the medical condition. My Alvernia speaks to Dr Chan Kin Ming, Senior Consultant, Geriatrician, about his area of specialty which aims to treat patients above 65 years old.
“Which nursing home are you working at?” This is the question that Dr Chan Kin Ming gets asked the most often whenever he tells people that he is a geriatrician and it always draws a chuckle out of the affable physician. In response, his tongue-in-cheek reply would be, “My job is to prevent the elderly from getting into a nursing home!”
It is a common misconception that geriatricians look after patients in nursing homes or those who are terminally ill and about to pass on. But this is far from the truth.
‘Paediatrician’ for the elderly
So what exactly do geriatricians do?
“In a nutshell, we are the general specialist for the elderly – the same way children see a paediatrician when they are not feeling well,” explained Dr Chan who has had 22 years of experience in his speciality.
It is the atypical presentation of symptoms in elderly patients that makes geriatric medicine particularly challenging. For example, falls can be because of a urinary tract infection and even classically textbook representation of a dementia case can turn out to be cancer
One common type of patients Dr Chan sees are dementia patients who do not even know why they are in his clinic. And his trick for handling such patients is to ‘go with them’ and instead, look to their family members for cues and verification.
“I usually have to do two sets of interviews and I’ll be given two different answers for each question!” he said. However with new developments in this field, doctors can now use the PET Scan machine to scan the metabolic activity of the brain to determine if the patient exhibit signs of Alzheimer diseases.
Emphasising that this is an area of specialisation that adopts a holistic approach instead of focusing on any single organs, the 52-year-old physician explained that this is because the elderly’s health is largely influenced by the living environment.
“It’s not only about treating their ailments but extending the care to ensure that their environment is conducive; making house visits and suggesting home modifications for safety; and teaching caregivers to make sure they are equipped with adequate knowledge to take care of the elderly at home in an appropriate manner.”
Taking things apart
Ask Dr Chan what he would be if he was not a doctor and his eyes would light up mischievously. “A detective or a destroyer!” Laughing, he shared that he loved tearing his toys apart when he was young.
Although he is not wielding the scalpel or ‘taking things apart’ physically now, he is doing so figuratively on a daily basis – deciphering patients’ words beyond what he hears.
“Most of the older generation are more stoic and they might not want to reveal personal problems. They are also very vague when questioned. Hence, it is important to be their friend and a non-threatening conversationalist without them feeling intruded or offended. One way is to take cues from their responses and connect with them in a way that they can identify with.”
Although this is a job fraught with challenges and uncertainty, Dr Chan relishes it because it gives him a great sense of satisfaction to be able to make a difference to the quality of life of his patients, especially during their golden years.
The silver lining
The experienced physician had his first contact with elderly patients back in 1985 as a volunteer community doctor at one of the housing estates. Two years after he graduated, he was approached to be part of the community outreach programme organised by the Community Clubs, to help poor, elderly patients who cannot afford to go to the hospital for treatments.
In the absence of equipment and sophisticated machineries during such house visits which he did twice per week for eight years, Dr Chan was convinced that he needed to be good at his craft in order to help patients like them.
“It fired up my desire to further my studies and increased my passion to want to help the older patients because they are so appreciative of every simple effort.”
Always young
Although some people might be averse to the thought of handling old people because they are known to be stubborn and grumpy, Dr Chan feels otherwise.
“It feels good being around them because I’m reminded of how young I am everyday!” he joked, explaining that 90 per cent of his patients are above 80 years old. “Sometimes even my patients’ grandchildren come to me, so I am literally serving three generations.”
However, he admits that it is a fine line between developing close relationships with his patients and their family, and drawing the line when it comes to medical professionalism. “All information given to us is confidential and I refrain from giving personal opinions especially where family matters are concerned. It’s all in and no ‘out’.”
His approachable nature and high level of professionalism is definitely something that has kept this physician in the good books of his clients as he gets invited to 100-year old birthday celebrations and grandchildren’s weddings. “It’s a wonderful feeling being treated like a family member and feeling that you have indeed made a difference in the last leg of the race.”
Age with Grace
Dr Chan shares some tips on how seniors can stay healthy and age with dignity.
- Do everything in moderation. Enjoy all you want but never in excess.
- Focus on quality of life and not longevity. Don’t think about living longer but make an effort to live better.
- Get out and about. Don’t be lazy and try to exercise even if it means doing arm raises while seated on your rocking chair.
- Have a social life! Who said this is reserved for the young? Make the best of your time by picking up a new hobby or making more friends.
Dr Chan Kin Ming is based at Chan KM Geriatric & Medical Clinic, #02-24, Blk A, Mount Alvernia Medical Centre, Tel: (+65) 6255 5567.
Medical Tribune November 2010
According to a recent survey, a large proportion of seemingly healthy elderly Singaporeans were found to be at moderate-to-high risk of malnutrition. Efforts should be made to ensure that the elderly facing such risk benefit from nutrition intervention strategies, which may include the recommendation of oral nutritional supplements (ONSs) such as Ensure® TwoCal (Abbott Nutrition).
Findings from a study commissioned by global healthcare company Abbott Nutrition which investigated the eating habits and nutritional status of a representative sample of 421 elderly Singaporeans (aged 50 and above), revealed that approximately 30 percent of respondents are at moderate-to-high risk of malnutrition. In absolute numbers, this means that some 295,574 elderly individuals in Singapore are at nutritional risk, which if left unaddressed, could result in significant morbidity and mortality.
“Next year we will have higher absolute numbers because of the aging population and so we are really dealing with a tsunami of sorts in terms of nutritional risk,” said Dr. Chan Kin Ming, a founding member and former vice president of the Society for Geriatric Medicine in Singapore, who presented the data during a recent continuing medical education (CME) event sponsored by Abbott Nutrition.
The study’s key message to physicians is that out of 10 elderly who walk into the clinic three are at risk of malnutrition and if these individuals persist in poor dietary habits they may eventually succumb to complications related to frailty, said Chan who is also a consultant for geriatric and internal medicine at the Gleneagles Medical Centre in Singapore.
Malnutrition is a state in which deficiency or excess of energy, protein and micronutrients causes adverse effects on tissue, body form and function, and adverse clinical outcomes.
“In other words the obese patient is also malnourished,” said Dr. Krishnan Sriram, chairman of the Division of Surgical and Critical Care and chief of the Section of Surgical Nutrition in the Department of Surgery at Stroger Hospital of Cook County in Chicago, Illinois, US, who spoke during the event.
He elaborated that adults are considered to be at nutritional risk if they have a potential for developing malnutrition, an involuntary loss or gain of above or equal to 10 percent of their usual body weight within a span of 6 months, experience a loss above or equal to 5 percent of the usual body weight in 1 month, have a weight of 20 percent over or under the ideal body weight, have a chronic disease or have increased metabolic requirements.
“The survey you did should spearhead the government in dealing with this [nutritional risk] as a serious problem,” said Sriram.
Abbott’s survey showed that only 1 percent of the survey respondents were adhering to the dietary recommendations by the Singapore Health Promotion Board (HPB). The HPB recommends 5-7 servings of rice and other carbohydrates per day but almost all the elderly surveyed only consumed 3.5 servings a day for this food group. A similar pattern of eating below the recommended HPB portion was seen for other food groups such as meat, dairy products, fruits and vegetables.
Good nutrition would enhance the elderly’s functional independence and attenuate their risk of disability, Chan said. An elderly individual who has protein-calorie malnutrition would experience muscle-wasting and because the elderly are also prone to falls and fractures those risks become compounded by muscle weakness, he explained.
Older adults have poorer diets because of a variety of factors including, dysgeusia and dysosmia, the intake of multiple medications which may further impair taste, and poor dental health which makes chewing food difficult.
An editorial comment, co-authored by Professor Francesco Landi, from the Department of Geriatrics and Gerontology at the School of Medicine in the Catholic University of the Sacred Heart in Rome, Italy and colleagues stated that these factors may even lead to secondary anorexia. [J Am Med Dir Assoc 2010;11(3):153-6]
“In this paper it is very clearly seen that the aging process, biological modification, functional impairment and chronic diseases result in anorexia which lead to frailty and subsequently cachexia, sarcopenia, poor quality of life and all-round increased mortality and poor outcomes,” Sriram said.
The GP’s role in nutrition screening and intervention
He also added that nutrition screening should become part of every outpatient and inpatient practice, and physicians should include in patients’ medical records a summary of the dietician’s review of the patients’ nutritional status.
Elderly patients should be screened to determine if they are at nutritional risk or malnourished. Those who fall in these two categories can be channeled to a more detailed examination of metabolic, nutrition, and functional variables.
Physicians can use the Subjective Global Assessment (SGA) tool, which assesses nutritional status based on features of the patient’s history and physical examination, to conduct nutritional assessment. This test can be accompanied by lab tests to measure serum albumin or pre-albumin levels, Sriram said.
Nutritional intervention and the role of ONSs
Once the patient’s nutritional risk is identified the appropriate nutritional intervention should be instituted.
The goal of nutrition intervention is to provide patients sufficient amounts of energy, protein and micronutrients, maintain or improve their function, activity and capacity for rehabilitation and therefore their quality of life. Nutritional intervention can come in the form of diet alteration, recommendation of vitamins and mineral supplements, ONSs, enteral nutrition and parenteral nutrition.
Giving patients ONSs is an important intervention strategy that contributes to optimal nutrition in a patient. Optimal nutrition essentially refers to a complete and balanced nutrition consisting of the essential vitamins and minerals and macro and micronutrients required to sustain and promote health. Such nutrition should have the appropriate caloric density for individual needs, adequate fiber for gastrointestinal health and nutrients to support bone health and immune function.
“Although the food scientist may say that in a jar of rice there is [a certain quantity of] zinc, or selenium, or carbohydrates, it doesn’t mean that the same [quantities] are bio-available to the patient. But the supplements on the other hand are designed such that they are present in the bioavailable form,” said Sriram.
Research shows that ONSs lead to a significant increase in energy and nutrient intake and reduce the number of complications in geriatric patients who have undergone orthopedic surgical procedures. [Clin Nutr 2006 Apr;25(2):330-60] It also shows that compared to routine care, care given together with ONSs was associated with a significantly lower incidence of pressure ulcer development in patients at high risk of developing them. [Ageing Res Rev 2005;4:422-450]
Conclusion
Malnutrition is a prevalent disease that significantly impacts morbidity, mortality and quality of life. The elderly should be screened for their nutritional status and be given the appropriate intervention. ONSs can augment the dietary recommendations for these patients and provide them with significant health benefits and may also prevent them from falling prey to the complications of frailty which can become physically, psychologically and financially draining.
Detik Health
Minum Suplemen Tiap Hari Agar Panjang Umur? Ini Kata Dokter
Singapura, Meski sudah menjalani gaya hidup sehat, konsumsi suplemen dan vitamin tetap dilakukan oleh sebagian orang. Padahal menurut pakar, konsumsi suplemen dan vitamin tak menjamin seseorang akan lebih sehat dan bugar.
Dr Chan Kin Ming, pakar kesehatan geriatri dari Gleneagles Hospital mengatakan konsumsi suplemen dan vitamin boleh saja dilakukan. Namun secara pribadi, ia sangat jarang meresepkan suplemen dan vitamin hanya agar pasien merasa lebih sehat dan bugar.
“Suplemen dan vitamin sebaiknya jangan dikonsumsi berlebihan. Boleh saja jika ingin konsumsi suplemen dan vitamin, tapi ketika tubuh dalam kondisi kekurangan vitamin atau mineral tersebut,” tutur Dr Chan, dalam Annual Scientific Meeting Gleneagles Hospital Singapore di Sheraton Tower, Singapura, Senin (27/4/2015).
Dijelaskan Dr Chan, suplemen dikonsumsi untuk menambah jumlah vitamin dan mineral di dalam tubuh. Namun suplemen bukanlah sumber utama vitamin dan mineral.
Sumber utama vitamin dan mineral adalah makanan serta minuman yang dikonsumsi. Jika tubuh sudah mempunyai cukup vitamin dan mineral, makan suplemen yang dikonsumsi tidak akan berguna, dan hanya akan dikeluarkan tubuh melalui keringat dan urine.
”Kalau kandungan vitamin dan mineral sudah cukup dalam tubuh, tidak akan berpengaruh. Hanya akan dikeluarkan melalui keringat dan urin kita,” tambahnya lagi.
Lalu bagaimana dengan lansia yang mengonsumsi suplemen protein? Bukankah seiring bertambahnya umur maka otot akan mengecil dan melemah, sehingga perlu lebih banyak asupan protein?
Menurut Dr Chan, anggapan tersebut tak sepenuhnya salah. Memang benar pada lansia, protein menjadi salah satu asupan penting untuk mencegah otot melemah dan mengecil. Namun bukan berarti lansia harus mengonsumsi suplemen protein seperti atlet binaraga.
“Saya kira suplemen protein hanya digunakan atlet binaraga, atau yang ingin membentuk otot. Untuk lansia perbanyak saja makan daging merah, dengan memerhatikan penyakit yang diidapnya, seperti jantung atau diabetes. Selama baik dan tidak berlebihan, tidak ada pantangan makan bagi lansia,” pungkasnya.
Shin Min 1 September 2010
News Page 9
Survey shows 300.000 elderly at risk of malnutrition
The Straits Times, Mind Your Body
Chest Infections in the Elderly Questions from Mind Your Body
- What do chest infections refer to, and which is the most common among the elderly?
Chest infection is a general term to indicate an infection affecting the airways right down to the lungs. In the airways, they are more accurately called acute bronchitis, whereas if it affects the lung tissues itself, it is referred to as a pneumonia. The most common among the elderly is pneumonia. However, in Western countries where smoking is very prevalent, acute bronchitis is more common.
- How are they treated in general?
Such patients usually have a wet cough, phlegm, fever and breathlessness. In acute bronchitis, they may also have a wheeze sometimes audible near by. Because of the condition, they eat poorly and are usually dehydrated. Hence, treatment would have to address these issues: namely 1. mucolytic agents to loosen the phlegm, making it easier to clear 2. may be assisted by chest physiotherapy and even suction of the phlegm if person can’t produce a strong cough to clear by themselves; 3. inhalation of a bronchodilator via a nebulizer to dilate the airways and reduce the wheezing; 4. antibiotics to treat the underlying infection, which in the elderly, is more commonly bacteria rather than viral; 5. for comfort of person, control of fever with paracetamol and perhaps, nasal oxygen if person is breathless; 6. adequate hydration, if necessary, via an intravenous infusion, and 7. adequate bed rest.
- How common are chest infections in the elderly and in the general population at large? For example, one in how many people are likely to get a chest infection some time in their lives, etc??
Chest infection is the most common infection in the elderly, followed by urine tract infection and skin infections. Patients aged 65 years and above account for more than 50% of all pneumonia cases, and annual hospitalization rates for pneumonia range from 12 per 1000 among community dwelling adults aged 75 and older to 32 per 1000 among nursing home residents.
- How will chest infections affect the elderly versus a young person? Any differences?
Chest infection mortality is 3 to 5 times more in an elderly compared to a younger person. The infecting organism also differs between the elderly and the young (e.g. elderly – more common to have gram-negative bacilli). Infecting organism also differs depending on residence of the elderly – own home or community dwelling elderly, or nursing home or other long term care facility; or hospitalized elderly.
- Can it warrant a hospitalisation if it happens in the elderly? How many percent of elderly who get chest infections get hospitalised for it? How many percent die from it? (Estimates will do)
Yes, because of the high mortality associated with pneumonia, they are usually hospitalized for treatment unless the infection is mild. For those hospitalized, mortality rate is between 10 and 25%. In fact, pneumonia is such a recognized cause of death among older people that it has been called ‘old man’s friend’ – a bad friend indeed.
- Is it easy to miss? What can chest infections to mistaken for?
The earlier (Q 2) paints a textbook description of what a person with chest infection usually present, but the elderly patient is not the typical textbook description. This makes it easy to miss. Many of them, especially smokers (past and present) may already have a chronic cough, due to chronic bronchitis. Sometimes, it is difficult to differentiate when the acute infection takes place in the setting of someone with chronic cough. 2. infections in the elderly make take place without fever; 3. sometimes, instead of fever, they may develop low body temperature (hypothermia); 4. weak cough because of weak muscles (chest and throat); 5. they may already have breathlessness from another underlying condition like heart failure.
In some instances, infection of the chest may present without any chest symptoms. Instead, the first sign may be acute confusion of the mind, urinary incontinence or falls. It is only after a few days that there are some symptoms and signs that point towards chest infection. So, chest infections may be mistaken for confusion or ‘dementia’, urine infection (because of urine incontinence) or limb weakness, poor balance or even stroke (because of falls).
- Hence, what are the key giveaway signs that someone is highly likely to have a chest infection, and not another kind of ailment?
Unfortunately, there is no key giveaway signs to indicate chest infection. The most common sign is increased heart rate, which is rather non-specific and may be attributed to anxiety or heart problem.
- How can we prevent our elderly from getting an infection?
To prevent chest infection in the elderly: 1. regular vaccination against the common influenza virus and pneumococcus (a common bacteria associated with pneumonia); 2. adequate exercises 3. for those who cannot walk or who are weak, ensure that they sit regularly and not lie in bed 4. ensure safe swallowing as the most common cause of pneumonia is aspiration pneumonia – i.e. swallowing into the wrong passage – via the trachea and into the lungs. This is particularly common in stroke patients and those with Parkinson’s disease. 5. healthy lifestyle and good nutrition (increases their body resistance against the infective agent. 6. for those with diabetes, to achieve adequate control of blood glucose.
The Straits Times, Mind Your Body
Geriatric medicine is all about identifying illnesses early, treating them appropriately and improving or maintaining their function so that their quality of life also improves. This concept appeals to me. Although at that time, not many doctors would want to specialize in this field, I submitted my traineeship application under geriatric medicine.
The human body is fascinating because every part of it is so well created and put together. As a result, we are able to do what we need to do. The other amazing thing is that it is intelligent as it is dynamic – it gets better and better with repetition of actions, it could strengthen itself in preparation to perform a task, and it could repair itself when damaged. There is also a lot of resilience to take the stress of daily wear and tear. It even has an army of soldiers in the form of white blood cells to protect against the bad guys – bacteria and viruses.
If I were to give an analogy for what I do, I’d liken myself to be a detective. A detective, when informed of a mystery, will set out to find the root of the problem or mystery and solve it. I usually get referrals for ‘difficult cases’ from doctors who are stuck with a problem that the elderly person is suffering from. With no known diagnosis, treatment is difficult. Such cases are especially challenging because like a detective, I have to unravel the root of it all, and then to plan step by step how to deal with it. I get a kick out of doing this and unexplainable joy when the mystery is finally solved and the patient gets better.
I have come across all types of cases. In the course of my practice, I have seen many with dementia presenting with some of the weirdest behavior (family said she love to chew on telephone wires), a tiny old lady with the strength of a bull (needing 3 persons just to hold on to her when she gets aggressive), someone who only eat 1 french fry a day (one as in one strand, not one packet), people who turn day into night and vice versa or having a 72 hour sleep-wake cycle.
A typical day for me would be getting up early to send my children to school. This is the most stressful part of my day. My children are extremely fond of sleeping and almost impossible to wake them up. After dropping them off by 7am, I have to rush off to do my ward round. My ward rounds may start from East Shore Hospital, coming down to Mt Elizabeth, then Mt Alvernia and finally ending in Gleneagles Hospital. Fortunately, this is not very common as I try to group my patients within 1 or 2 hospitals. I have to complete my ward rounds before my clinic starts at 9am.
After the morning clinic, I would like to enjoy a nice lunch, but sometimes that is not possible because there is a housecall to do. Rush to have lunch, then back for afternoon clinic. Late afternoon is again housecall times, then followed by a second ward round to look at my hospitalized patients. If I am lucky, that is the end of the day, which by then would be about 7pm. More often than not, the day would continue with a meeting which will bring me all the way up to 8 or 9pm. By that time, I would be physically and mentally exhausted. Nonetheless, it would be a satisfying day for me if I could complete all I had set to do.
I love patients who are understanding. When doctors run a clinic, we may need to prioritise which patient to see first. Obviously, the more frail or more sickly ones should be seen first and not just based on first come first served basis. Then there is also the emergency that sometimes happen to patients in the ward that we have to attend to first. These understanding patients and their caregivers who allow us to do our job rationally actually make us feel apologetic towards them and they actually get more attention and better services from us to make up for their inconvenience.
Patients who get my goat are those who called up last minute for a clinic appointment and insisted to be seen the same day. To accommodate such cases, sometimes I had to reschedule a housecall appointment or push back a meeting. And guess what, they don’t turn up. When called, they either don’t answer their phones or have their handphone switched off.
One little known fact about ageing is no two elderly are the same. In fact, it has been said that there are more similarities between two 12 year olds than between two 80 year olds. So, even if they have the same diagnosis, they would present in a very dissimilar manner.
Things that put a smile on my face are comments that showed concern for me. I had patients who personally called up my nurse to find out how I was feeling as I was having a running nose a few days ago when I saw them. Then there are some who reminded me to get adequate rest when they know of my hectic schedule for the day. Still, some will insist on giving me something (like fruits or cakes) whenever they see me. It may be a bit awkward for me to accept them or not, but it still put a smile on my face because it is the thought that counts.
It breaks my heart when patients don’t do well in spite of trying your very best. In those situations, I need to keep reminding myself that I am not God, and that not all elderly conditions or sickness will response to treatment. Doctors do grieve with the family although we do not show it. We have to ‘suppress’ our emotions in order to make rational decisions for our patients.
I wouldn’t trade places for the world because this is where I feel my calling is. I just love what I do and it has become not just a job, but a personal challenge to get the frail and sick elderly well again.
My best tip is to do everything in moderation. If you love to eat, then eat in moderation. Exercise in moderation and accept growing old gracefully, warts and all. There is no need to hide the lines or bags (eye bags) because the lines represent one part of you and the experiences you go through. The sooner we accept ourselves as we look, the better and more contended we become.
The Straits Times, Mind Your Body
Nutrition for Elderly Women
- As women age, what are the common health concerns that crop up? Do men also face similar concerns – how similar or different?
General increased risk of elderly who would have nutrition problem:
Living alone, House bound
No regular cooked meals,
Lower social class
Low mental score, Depression
Chronic lung conditions, History of stomach surgery
Poor Dentition
Difficulty in swallowing
Smoking and Alcoholism
Those on multiple medications
Mental health: more depression and anxiety disorders in women, more Alzheimer’s disease in women even when corrected for age. However, men suffers higher suicide rate and alcohol related disorders than women.
Higher obesity in women than men as they age.
Heart disease – younger age groups, men more susceptible than women, but with age, the difference gets less.
Loss of estrogen protective effect also meant more osteoporosis in women than men.
Arthritis more common in women (53%) than men (47%).
Women more likely to fall than men – because women sways more when they walk, increasing the imbalance. So they are 50% more likely to fall compared to men. Together with increased prevalence of osteoporosis, higher risk of fractures and fracture related morbidity.
Urinary incontinence more prevalent in women than men – because of child bearing, loss of estrogen and shorter urethra. 20% of women above age of 70 yrs living in community has urinary incontinence. Also for the same reasons, they are also more prone to urine tract infection and dehydration (the elderly think that by cutting down on fluid intake, they may reduce incontinence).
Overall effect of above – elderly women more likely to be disabled and disabled for longer period of their life than men – 3 years for women vs 1.5 years compared to men, and 2-3x more likely to be hospitalized than men, and more likely to be living in nursing home.
- How can nutrition help women to prevent, or help elderly women to reduce such problems?
Proper nutrition can prevent obesity as well as reducing heart related diseases, which is usually caused by high lipids, high blood pressure and diabetes.
Proper nutrition with adequate vitamins and minerals are good for brain and body resistance to fight infections.
Adequate calcium intake protective against osteoporosis.
Cranberry as a juice or fruit also helps to prevent urinary infections.
General need to increase protein intake as most elderly tend to have protein calorie malnutrition. This is partly due to lack of dentition, eating fags (that protein are not well digested or that they don’t need so much protein as they grow older).
- What then are the key nutrients that elderly women need in their diets? Can you give an estimate of how much to take daily (e.g. 1000mg calcium per day?) Can you also briefly describe the functions of these nutrients in the body to illustrate their importance to health?
Calcium – 1000 to 1500mg per day – bone pain, osteoporosis, bone fractures, muscles weakness
Vitamin A – 700 to 900ug RAE per day – night vision, dermatitis
Vitamin C – 75ug per day – loss of energy, bruising, gingivitis, bleeding gums, body resistance
Vitamin D – 400 IU (10ug) per day – prevent osteoporosis, bone pain, muscle weakness
Protein – about 1g/kg body weight per day – body resistance, muscle bulk and strength, leg swelling.
Fluid intake – about 30mls per kg body weight. So for an average person weighing 60mg, requirement is about 1800mls of water. This is provided there is no restriction of water intake because of disease like heart failure or kidney failure.
- Can you give some examples of the foods that contain the above nutrients?
| Food group | Deficiency syndromes | RDA* | Sources |
| Proteins | Kwashiorkor | 1 g/kg body weight depending on general health | Meat, fish, eggs, milk, peas, beans, nuts, soya bean products, milk products |
| Carbohydrates | Marasmus | 50 to 55% of total calories depending on general health | Rice, wheat, cakes, tapioca, potatoes, noodles, chappatis, kway teow, bee hoon |
| Fats | Deficiency in vitamins A,D,E,K | 20 to 35 % of total calories depending on general health | Fat meat, fish oils, butter, milk cream, oils from nuts, margarine |
| Calcium | Osteomalacia, osteoporosis | 1200 to 1500 mg** | Milk, soya bean products, tinned fish, green vegetables |
| Phosphorus | Osteomalacia | 800 mg | Milk, protein-rich foods |
| Iodine | Hypothyroidism | 150 µg | Fish, sea food, watercress, most drinking water |
| Iron | Anaemia | 10 mg | Liver, egg yolk, dried fruit, red meat |
| Sodium | Dehydration | Depends on general health | Salt, meat, vegetables, smoked meat |
| Potassium | Myopathy, arrhythmia | Depends on general health | Fruits |
| Zinc | Anorexia, dysgeusia, poor skin healing, acrodermatitis enteropathica | 15 mg | Oysters, shellfish |
| Magnesium | Irritability, tremors, carpopedal spasm, confusion | 300 mg in females, 350 mg in males | Whole grains, dried peas, beans, nuts, cocoa, seafood |
| Folate | Megaloblastic anaemia | 180 µg | Green vegetables |
| Vitamin A | Night blindness, xerophthalmia, keratomalacia | 800 µg, May be too high for the elderly as disposal is decreased. | Animal fats, milk, egg, green vegetables, carrot, bananas |
| Vitamin B complex | Beriberi, pellagra, angular stomatitis, raw tongue | B1= 1mg, B2= 1.2 mg,
B3= 13 mg, B5= 4 to 7 mg, B6= 1.6 mg |
Egg yolk, peas, yeast, liver, green vegetables |
| Vitamin B12 | Megaloblastic anaemia, dementia, subacute combined degeneration of cord | 2 µg | Meat |
| Vitamin C | Scurvy | 60 mg | Fresh fruits and vegetables |
| Vitamin E | Ataxia | 8 mg | Most food |
| Vitamin D | Osteomalacia | 5 µg or 100 IU | Cod liver or halibut oil, sunlight |
| Vitamin K | Bleeding diathesis | 65 µg | Spinach, cauliflower, cabbage, cereals, yeast, carrots, intestinal bacteria |
- On the other hand, what should elderly women be eating less of (or cutting out from their diets completely)?
Everything should be done in moderation. Even fats, which is generally seen as not good, must be included as part of the diet as fats is a rich source of important Vitamins like A, D, E and K.
- As the elderly may have teeth and other digestion problems, they may be unable to take some of the nutritious foods like crunchy vegetables, etc. What is your advice, or do you have any tips for them to overcome this problem?
Certainly important to grow old with a good set of dentition. If not possible, should have a set of well fitting dentures to help with chewing.
Meat etc can be prepared as finely minced to aid chewing and swallowing. Leafy vegetables can be washed whole first, then teared/break rather than cut to retain all the nutrition inside the leaf. Otherwise, they can be cooked whole first, then cut into smaller pieces and consume with all the ‘juice’ that comes with the vegetables. Avoid over cooking to soften the food as the over cooking will destroy all the nutrients that comes with it.
- In addition to diet, what else should elderly women do (or not do) in order to attain an all-round good health?
Early detection of illness – regular health checks, esp for problems mentioned in Point 1. Early detection mean early treatment to restore health of person.
Exercise – mentally and physically
Good social support – friends, active socially
Can continue to pursue what they had been doing all along. If they had been living a sedentary lifestyle and wish to start exercising, should have a medical check first to ensure fitness, advise on what exercises to avoid and start slow. E.g. if decide to take up tennis – need to check if there is any spinal problem, knee, shoulder and wrist problems and whether the heart and lungs can take the stress.
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Singapore Media
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My Alvernia #18
What’s Up Doc
Empowering a Healthier Silver Generation
As Singapore’s population ages, it is all the more vital that we adopt preventive healthcare measures for our elderly. Geriatric specialist Dr Chan Kin Ming tells us more.
No doubt about it, our pioneers have slogged hard to build Singapore into what she is today. Prime Minister Lee Hsien Loong’s announcement of a $8billion Pioneer Generation Fund, which offers those born before 1949 subsidies for outpatient care, Medisave top-ups and life-long subsidies for MediShield Life, is definitely a step in the right direction to help them cope with healthcare costs. However, prevention is always better than cure. Our pioneers’ quality of life can be much better if preventive healthcare measures are adopted to help them manage the challenges they face as they age.
There are three life stage challenges as a person grows old, highlighted geriatric specialist Dr Chan Kin Ming of Chan KM Geriatric & Medical Clinic Pte Ltd. The first are the ‘young old’ who are in their 60s, with some still working while others are retiring or just retired. “Retirement is a stressful event as it brings about changes that the older person may not be prepared for or unaware of. There is loss of social role and esteem as they now become a ‘dependent’. Having nowhere to go and nothing to do require psychological and emotional adjustment, unless they are prepared for it. As they ‘take it easy’ daily, this could lead to a decline in physical and mental functioning,” warned Dr Chan, adding that it may also result in changes and friction within the family relationship. They are also at the age when they start to have concerns about their health.
The second group are those in their 70s when frailty commonly sets in. A decline in their general health status further leads to decreased ability in their activities in daily living and mobility and causes further social isolation. They also start experiencing ‘loss’ – loss of spouse and friends of similar age, and loss of their own abilities, leading to low self-esteem and loneliness. “They start contemplating issues of being a burden to their family and issues of death.”
The third group are those aged 80 and older who need more assistance including personal effects like bathing and toileting and face increased risk of falls. Their ‘social’ and ‘physical space’ shrinks further as many become home bound, sometimes room bound, chair bound or bedbound. “Their social isolation becomes even more acute as even more of their peers and friends passed on. The issue of death becomes closer and they need to reconcile with that,” said Dr Chan.
How can preventive healthcare help our pioneers in their twilight years? Dr Chan shared his pearls of wisdom.
What is preventive healthcare?
There are 3 aspects of preventive healthcare. Primary prevention is the prevention of disease or injury before it occurs. For example, smoking is a cause of many chronic lung conditions like bronchitis, emphysema and even lung cancer. By preventing people from taking up smoking and by getting existing smokers to stop smoking, we could prevent the onset of these chronic lung conditions. In the elderly, it could also mean vaccinations against influenza or the prevention of falls by providing an appropriate physical environment like adequate lighting, having less steps or highlighting them, non-slip floors and having proper furniture, so that they could walk about safely and not fall.
Secondary prevention aims to stop or reverse a problem before it becomes symptomatic, through early detection. For example, identifying visual deterioration through eye screening to pick up early glaucoma or macular degeneration. These conditions may have no symptoms at the early stages but if allowed to progress, can cause blindness later. Other examples include the use of Bone Mineral Density to screen for early osteoporosis and to treat the condition when it is detected.
Tertiary prevention focuses on reducing disability and restoring functionality to people already affected by disease or injury. For example, a person with arthritis of the knees may need treatment of the pain with drugs or even surgery, followed by a course of physical rehabilitation to restore function.
What are some common health problems that our elderly face which will benefit from preventive healthcare?
Some common health problems include hypertension, diabetes, cancers (especially colon cancer), osteoporosis, atrial fibrillation, bladder and bowel problems like urine incontinence and constipation, falls, dementia, frailty and visual and hearing impairment. In elderly care, we often mention the ‘Giants of Geriatrics’ being:
- Iatrogenic causes as a result of inappropriate use of drugs, polypharmacy and drug interactions
- Incontinence of urine and stools
- Immobility, often caused by multiple causes like arthritis, heart and lung disease, stroke, visual impairment, fractures
- Instability and falls due to stroke, Parkinson’s disease, arthritis, unstable gait and balance
- Impaired cognition – depression, dementia and delirium.
Elderly people usually grow old with medical conditions that they had when they were younger. These often become chronic and complications arise from them. In addition, they develop new problems common in the elderly. For example, if a person has diabetes at 50 years old, by the time he becomes 70, he’ll have a 20-year history and would have developed some or all of the complications associated with diabetes, such as eye problems causing visual impairment, skin problems like ulcers, peripheral vascular disease, kidney disease and neuropathy (damage to the nerves). The vascular damage from diabetes will increase his risk of heart disease, stroke and even limb amputations. Neuropathy increases his risk of falls, injuries and fractures, especially so because diabetics are at risk of developing osteoporosis, the risk of diarrhoea, constipation, weakness of bladder muscle and urinary incontinence. Hence, from one initial condition, it can lead to so many possible complications causing instability, immobility, impaired cognition and incontinence. Therefore, each contributing factor of his morbidity needs to be managed carefully.
In a general population of community dwelling who are older than 60 years old in Singapore, 51% have poor vision, 46% rheumatism, 36% heart disease, 22% diabetes mellitus, 20% urine incontinence, 16% falls and 9.3% poor memory 9.3%.
What type of preventive healthcare do you recommend?
The elderly tend to have many health problems. It is difficult for them or their families/caregivers to know which problem or complaint is a result of age (and therefore they have to live with it) and which is disease (and therefore can be treated). Hence, regular health screening and check-ups are important, bearing in mind that many elderly are stoic and tend to play down their complaints, show an ageism attitude (“I fall down because I am old, or I am breathless because I am old”) or just do not like to see doctors or get admitted to hospitals.
The health screening for the older person is different from those for younger adults because there is an emphasis on their function – physical and mental functions, medication that they are taking, including all the health supplements bought over-the-counter as they also contribute to polypharmacy and interactions with the medicine that the person is taking.
How have your patients benefitted from preventive healthcare?
Many patients have benefitted from successful preventive healthcare, including an 80-year-old man. He refused to see any doctor because he declared himself “very well and very strong”. However, his family noted that he was limping and fell frequently, something he attributed to old age. To ‘trick’ him into coming to my consultation room, his family told him that a daughter was unwell and needed to see me. I had to ‘role play’ with the family, initially asking the daughter some general questions and later directing the questions to him when he got familiar with me. I even did a general physical examination and advised him to go for a general blood screen since he was already here. It showed he has early onset of Parkinson’s disease which caused him to be unsteady and fell frequently, and recurrent gouty arthritis, causing him to limp with pain. When he was treated, his strength, balance and gait improves. The gouty arthritis subsided and and he no longer limps and do not have any more pain in his knees. In the words of his children: “He walks faster than us now” and has started travelling again.
Should our elderly be put on a national health programme, just like what we have for babies?
It would be ideal if there is such a comprehensive programme for the elderly above the age of 60 years old. This programme should have a general medical screening for hypertension, diabetes, lipids, vision, hearing tests, oral health, gait, balance, muscle strength and falls risk, continence, mood and cognitive functional screen, nutritional screen, bone mineral density and screening for colon and breast cancer.
What to screen for and what vaccines to recommend depend on the patient’s history and findings of the clinical examination. But in general, annual influenza vaccination, pneumococcal vaccination and zoster vaccination are recommended for adults 60 years and older by the US Centre for Disease Control and Prevention.
The government recently announced a slew of measures under the Pioneer Generation Package during the Budget 2014, which aims to help our elderly with health-care costs. What do you think of these measures?
The announcement of this package is certainly a big relief and welcome for our pioneer generation and is targeted to benefit everyone in that generation, especially the poor. However, it is not useful if no one knows about it or knows how to access it. Similarly, existing facilities and manpower should be able to cope with the possible influx of patients utilising the facilities. I’m sure these are some teething problems that may arise but they should sort themselves out pretty soon.
Preventive healthcare is always difficult because the person is subjected to a change of lifestyle and the need to take drugs on a long term basis. They may be very enthusiastic initially, but after a while, they may lose the stamina to continue, especially when they may not even have the disease in the first place. This difficulty is multiplied many fold in the elderly, especially when they start thinking, “How many more years do I have left?” and “I’m already so old.” Therefore, it is a difficult balance to ‘enforce’ the strict lifestyle that is sometimes needed in preventive healthcare, versus the patient’s pragmatic view of his own life and lifestyle.
Thus, preventive steps have to be individualised to the person. But on a national level, to help the elderly achieve and maintain good health, there should be on-going education on conditions that are common for the elderly, perhaps with free admissions to such talks and done in a language or dialect that they can understand. There should be opportunities for health screening and healthy lifestyle – spaces for exercise, formation of exercise or activities groups, each elderly having a health tracking booklet, just like the health booklet that accompanies each baby born in Singapore. This will keep track of their vaccinations, annual health checks, illnesses etc.
Dr Chan Kin Ming is based at Mount Alvernia Medical Centre Block A, #02-24, Tel: 6255 5567.
CloseMy Alvernia #9 2011
The Big Interview
For the elderly, there is often no direct correlation between symptoms and the medical condition. My Alvernia speaks to Dr Chan Kin Ming, Senior Consultant, Geriatrician, about his area of specialty which aims to treat patients above 65 years old.
“Which nursing home are you working at?” This is the question that Dr Chan Kin Ming gets asked the most often whenever he tells people that he is a geriatrician and it always draws a chuckle out of the affable physician. In response, his tongue-in-cheek reply would be, “My job is to prevent the elderly from getting into a nursing home!”
It is a common misconception that geriatricians look after patients in nursing homes or those who are terminally ill and about to pass on. But this is far from the truth.
‘Paediatrician’ for the elderly
So what exactly do geriatricians do?
“In a nutshell, we are the general specialist for the elderly – the same way children see a paediatrician when they are not feeling well,” explained Dr Chan who has had 22 years of experience in his speciality.
It is the atypical presentation of symptoms in elderly patients that makes geriatric medicine particularly challenging. For example, falls can be because of a urinary tract infection and even classically textbook representation of a dementia case can turn out to be cancer
One common type of patients Dr Chan sees are dementia patients who do not even know why they are in his clinic. And his trick for handling such patients is to ‘go with them’ and instead, look to their family members for cues and verification.
“I usually have to do two sets of interviews and I’ll be given two different answers for each question!” he said. However with new developments in this field, doctors can now use the PET Scan machine to scan the metabolic activity of the brain to determine if the patient exhibit signs of Alzheimer diseases.
Emphasising that this is an area of specialisation that adopts a holistic approach instead of focusing on any single organs, the 52-year-old physician explained that this is because the elderly’s health is largely influenced by the living environment.
“It’s not only about treating their ailments but extending the care to ensure that their environment is conducive; making house visits and suggesting home modifications for safety; and teaching caregivers to make sure they are equipped with adequate knowledge to take care of the elderly at home in an appropriate manner.”
Taking things apart
Ask Dr Chan what he would be if he was not a doctor and his eyes would light up mischievously. “A detective or a destroyer!” Laughing, he shared that he loved tearing his toys apart when he was young.
Although he is not wielding the scalpel or ‘taking things apart’ physically now, he is doing so figuratively on a daily basis – deciphering patients’ words beyond what he hears.
“Most of the older generation are more stoic and they might not want to reveal personal problems. They are also very vague when questioned. Hence, it is important to be their friend and a non-threatening conversationalist without them feeling intruded or offended. One way is to take cues from their responses and connect with them in a way that they can identify with.”
Although this is a job fraught with challenges and uncertainty, Dr Chan relishes it because it gives him a great sense of satisfaction to be able to make a difference to the quality of life of his patients, especially during their golden years.
The silver lining
The experienced physician had his first contact with elderly patients back in 1985 as a volunteer community doctor at one of the housing estates. Two years after he graduated, he was approached to be part of the community outreach programme organised by the Community Clubs, to help poor, elderly patients who cannot afford to go to the hospital for treatments.
In the absence of equipment and sophisticated machineries during such house visits which he did twice per week for eight years, Dr Chan was convinced that he needed to be good at his craft in order to help patients like them.
“It fired up my desire to further my studies and increased my passion to want to help the older patients because they are so appreciative of every simple effort.”
Always young
Although some people might be averse to the thought of handling old people because they are known to be stubborn and grumpy, Dr Chan feels otherwise.
“It feels good being around them because I’m reminded of how young I am everyday!” he joked, explaining that 90 per cent of his patients are above 80 years old. “Sometimes even my patients’ grandchildren come to me, so I am literally serving three generations.”
However, he admits that it is a fine line between developing close relationships with his patients and their family, and drawing the line when it comes to medical professionalism. “All information given to us is confidential and I refrain from giving personal opinions especially where family matters are concerned. It’s all in and no ‘out’.”
His approachable nature and high level of professionalism is definitely something that has kept this physician in the good books of his clients as he gets invited to 100-year old birthday celebrations and grandchildren’s weddings. “It’s a wonderful feeling being treated like a family member and feeling that you have indeed made a difference in the last leg of the race.”
Age with Grace
Dr Chan shares some tips on how seniors can stay healthy and age with dignity.
- Do everything in moderation. Enjoy all you want but never in excess.
- Focus on quality of life and not longevity. Don’t think about living longer but make an effort to live better.
- Get out and about. Don’t be lazy and try to exercise even if it means doing arm raises while seated on your rocking chair.
- Have a social life! Who said this is reserved for the young? Make the best of your time by picking up a new hobby or making more friends.
Dr Chan Kin Ming is based at Chan KM Geriatric & Medical Clinic, #02-24, Blk A, Mount Alvernia Medical Centre, Tel: (+65) 6255 5567.
CloseMedical Tribune November 2010
Recognize and treat nutritional risk, experts sayAccording to a recent survey, a large proportion of seemingly healthy elderly Singaporeans were found to be at moderate-to-high risk of malnutrition. Efforts should be made to ensure that the elderly facing such risk benefit from nutrition intervention strategies, which may include the recommendation of oral nutritional supplements (ONSs) such as Ensure® TwoCal (Abbott Nutrition).
Findings from a study commissioned by global healthcare company Abbott Nutrition which investigated the eating habits and nutritional status of a representative sample of 421 elderly Singaporeans (aged 50 and above), revealed that approximately 30 percent of respondents are at moderate-to-high risk of malnutrition. In absolute numbers, this means that some 295,574 elderly individuals in Singapore are at nutritional risk, which if left unaddressed, could result in significant morbidity and mortality.
“Next year we will have higher absolute numbers because of the aging population and so we are really dealing with a tsunami of sorts in terms of nutritional risk,” said Dr. Chan Kin Ming, a founding member and former vice president of the Society for Geriatric Medicine in Singapore, who presented the data during a recent continuing medical education (CME) event sponsored by Abbott Nutrition.
The study’s key message to physicians is that out of 10 elderly who walk into the clinic three are at risk of malnutrition and if these individuals persist in poor dietary habits they may eventually succumb to complications related to frailty, said Chan who is also a consultant for geriatric and internal medicine at the Gleneagles Medical Centre in Singapore.
Malnutrition is a state in which deficiency or excess of energy, protein and micronutrients causes adverse effects on tissue, body form and function, and adverse clinical outcomes.
“In other words the obese patient is also malnourished,” said Dr. Krishnan Sriram, chairman of the Division of Surgical and Critical Care and chief of the Section of Surgical Nutrition in the Department of Surgery at Stroger Hospital of Cook County in Chicago, Illinois, US, who spoke during the event.
He elaborated that adults are considered to be at nutritional risk if they have a potential for developing malnutrition, an involuntary loss or gain of above or equal to 10 percent of their usual body weight within a span of 6 months, experience a loss above or equal to 5 percent of the usual body weight in 1 month, have a weight of 20 percent over or under the ideal body weight, have a chronic disease or have increased metabolic requirements.
“The survey you did should spearhead the government in dealing with this [nutritional risk] as a serious problem,” said Sriram.
Abbott’s survey showed that only 1 percent of the survey respondents were adhering to the dietary recommendations by the Singapore Health Promotion Board (HPB). The HPB recommends 5-7 servings of rice and other carbohydrates per day but almost all the elderly surveyed only consumed 3.5 servings a day for this food group. A similar pattern of eating below the recommended HPB portion was seen for other food groups such as meat, dairy products, fruits and vegetables.
Good nutrition would enhance the elderly’s functional independence and attenuate their risk of disability, Chan said. An elderly individual who has protein-calorie malnutrition would experience muscle-wasting and because the elderly are also prone to falls and fractures those risks become compounded by muscle weakness, he explained.
Older adults have poorer diets because of a variety of factors including, dysgeusia and dysosmia, the intake of multiple medications which may further impair taste, and poor dental health which makes chewing food difficult.
An editorial comment, co-authored by Professor Francesco Landi, from the Department of Geriatrics and Gerontology at the School of Medicine in the Catholic University of the Sacred Heart in Rome, Italy and colleagues stated that these factors may even lead to secondary anorexia. [J Am Med Dir Assoc 2010;11(3):153-6]
“In this paper it is very clearly seen that the aging process, biological modification, functional impairment and chronic diseases result in anorexia which lead to frailty and subsequently cachexia, sarcopenia, poor quality of life and all-round increased mortality and poor outcomes,” Sriram said.
The GP’s role in nutrition screening and intervention
He also added that nutrition screening should become part of every outpatient and inpatient practice, and physicians should include in patients’ medical records a summary of the dietician’s review of the patients’ nutritional status.
Elderly patients should be screened to determine if they are at nutritional risk or malnourished. Those who fall in these two categories can be channeled to a more detailed examination of metabolic, nutrition, and functional variables.
Physicians can use the Subjective Global Assessment (SGA) tool, which assesses nutritional status based on features of the patient’s history and physical examination, to conduct nutritional assessment. This test can be accompanied by lab tests to measure serum albumin or pre-albumin levels, Sriram said.
Nutritional intervention and the role of ONSs
Once the patient’s nutritional risk is identified the appropriate nutritional intervention should be instituted.
The goal of nutrition intervention is to provide patients sufficient amounts of energy, protein and micronutrients, maintain or improve their function, activity and capacity for rehabilitation and therefore their quality of life. Nutritional intervention can come in the form of diet alteration, recommendation of vitamins and mineral supplements, ONSs, enteral nutrition and parenteral nutrition.
Giving patients ONSs is an important intervention strategy that contributes to optimal nutrition in a patient. Optimal nutrition essentially refers to a complete and balanced nutrition consisting of the essential vitamins and minerals and macro and micronutrients required to sustain and promote health. Such nutrition should have the appropriate caloric density for individual needs, adequate fiber for gastrointestinal health and nutrients to support bone health and immune function.
“Although the food scientist may say that in a jar of rice there is [a certain quantity of] zinc, or selenium, or carbohydrates, it doesn’t mean that the same [quantities] are bio-available to the patient. But the supplements on the other hand are designed such that they are present in the bioavailable form,” said Sriram.
Research shows that ONSs lead to a significant increase in energy and nutrient intake and reduce the number of complications in geriatric patients who have undergone orthopedic surgical procedures. [Clin Nutr 2006 Apr;25(2):330-60] It also shows that compared to routine care, care given together with ONSs was associated with a significantly lower incidence of pressure ulcer development in patients at high risk of developing them. [Ageing Res Rev 2005;4:422-450]
Conclusion
Malnutrition is a prevalent disease that significantly impacts morbidity, mortality and quality of life. The elderly should be screened for their nutritional status and be given the appropriate intervention. ONSs can augment the dietary recommendations for these patients and provide them with significant health benefits and may also prevent them from falling prey to the complications of frailty which can become physically, psychologically and financially draining.
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Indonesian Media
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Detik Health
Minum Suplemen Tiap Hari Agar Panjang Umur? Ini Kata DokterSingapura, Meski sudah menjalani gaya hidup sehat, konsumsi suplemen dan vitamin tetap dilakukan oleh sebagian orang. Padahal menurut pakar, konsumsi suplemen dan vitamin tak menjamin seseorang akan lebih sehat dan bugar.
Dr Chan Kin Ming, pakar kesehatan geriatri dari Gleneagles Hospital mengatakan konsumsi suplemen dan vitamin boleh saja dilakukan. Namun secara pribadi, ia sangat jarang meresepkan suplemen dan vitamin hanya agar pasien merasa lebih sehat dan bugar.
“Suplemen dan vitamin sebaiknya jangan dikonsumsi berlebihan. Boleh saja jika ingin konsumsi suplemen dan vitamin, tapi ketika tubuh dalam kondisi kekurangan vitamin atau mineral tersebut,” tutur Dr Chan, dalam Annual Scientific Meeting Gleneagles Hospital Singapore di Sheraton Tower, Singapura, Senin (27/4/2015).
Dijelaskan Dr Chan, suplemen dikonsumsi untuk menambah jumlah vitamin dan mineral di dalam tubuh. Namun suplemen bukanlah sumber utama vitamin dan mineral.
Sumber utama vitamin dan mineral adalah makanan serta minuman yang dikonsumsi. Jika tubuh sudah mempunyai cukup vitamin dan mineral, makan suplemen yang dikonsumsi tidak akan berguna, dan hanya akan dikeluarkan tubuh melalui keringat dan urine.
”Kalau kandungan vitamin dan mineral sudah cukup dalam tubuh, tidak akan berpengaruh. Hanya akan dikeluarkan melalui keringat dan urin kita,” tambahnya lagi.
Lalu bagaimana dengan lansia yang mengonsumsi suplemen protein? Bukankah seiring bertambahnya umur maka otot akan mengecil dan melemah, sehingga perlu lebih banyak asupan protein?
Menurut Dr Chan, anggapan tersebut tak sepenuhnya salah. Memang benar pada lansia, protein menjadi salah satu asupan penting untuk mencegah otot melemah dan mengecil. Namun bukan berarti lansia harus mengonsumsi suplemen protein seperti atlet binaraga.
“Saya kira suplemen protein hanya digunakan atlet binaraga, atau yang ingin membentuk otot. Untuk lansia perbanyak saja makan daging merah, dengan memerhatikan penyakit yang diidapnya, seperti jantung atau diabetes. Selama baik dan tidak berlebihan, tidak ada pantangan makan bagi lansia,” pungkasnya.
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Chinese Language Media
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Shin Min 1 September 2010
News Page 9
Survey shows 300.000 elderly at risk of malnutrition
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The Straits Times - Mind Your Body
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The Straits Times, Mind Your Body
Chest Infections in the Elderly Questions from Mind Your Body
- What do chest infections refer to, and which is the most common among the elderly?
Chest infection is a general term to indicate an infection affecting the airways right down to the lungs. In the airways, they are more accurately called acute bronchitis, whereas if it affects the lung tissues itself, it is referred to as a pneumonia. The most common among the elderly is pneumonia. However, in Western countries where smoking is very prevalent, acute bronchitis is more common.
- How are they treated in general?
Such patients usually have a wet cough, phlegm, fever and breathlessness. In acute bronchitis, they may also have a wheeze sometimes audible near by. Because of the condition, they eat poorly and are usually dehydrated. Hence, treatment would have to address these issues: namely 1. mucolytic agents to loosen the phlegm, making it easier to clear 2. may be assisted by chest physiotherapy and even suction of the phlegm if person can’t produce a strong cough to clear by themselves; 3. inhalation of a bronchodilator via a nebulizer to dilate the airways and reduce the wheezing; 4. antibiotics to treat the underlying infection, which in the elderly, is more commonly bacteria rather than viral; 5. for comfort of person, control of fever with paracetamol and perhaps, nasal oxygen if person is breathless; 6. adequate hydration, if necessary, via an intravenous infusion, and 7. adequate bed rest.
- How common are chest infections in the elderly and in the general population at large? For example, one in how many people are likely to get a chest infection some time in their lives, etc??
Chest infection is the most common infection in the elderly, followed by urine tract infection and skin infections. Patients aged 65 years and above account for more than 50% of all pneumonia cases, and annual hospitalization rates for pneumonia range from 12 per 1000 among community dwelling adults aged 75 and older to 32 per 1000 among nursing home residents.
- How will chest infections affect the elderly versus a young person? Any differences?
Chest infection mortality is 3 to 5 times more in an elderly compared to a younger person. The infecting organism also differs between the elderly and the young (e.g. elderly – more common to have gram-negative bacilli). Infecting organism also differs depending on residence of the elderly – own home or community dwelling elderly, or nursing home or other long term care facility; or hospitalized elderly.
- Can it warrant a hospitalisation if it happens in the elderly? How many percent of elderly who get chest infections get hospitalised for it? How many percent die from it? (Estimates will do)
Yes, because of the high mortality associated with pneumonia, they are usually hospitalized for treatment unless the infection is mild. For those hospitalized, mortality rate is between 10 and 25%. In fact, pneumonia is such a recognized cause of death among older people that it has been called ‘old man’s friend’ – a bad friend indeed.
- Is it easy to miss? What can chest infections to mistaken for?
The earlier (Q 2) paints a textbook description of what a person with chest infection usually present, but the elderly patient is not the typical textbook description. This makes it easy to miss. Many of them, especially smokers (past and present) may already have a chronic cough, due to chronic bronchitis. Sometimes, it is difficult to differentiate when the acute infection takes place in the setting of someone with chronic cough. 2. infections in the elderly make take place without fever; 3. sometimes, instead of fever, they may develop low body temperature (hypothermia); 4. weak cough because of weak muscles (chest and throat); 5. they may already have breathlessness from another underlying condition like heart failure.
In some instances, infection of the chest may present without any chest symptoms. Instead, the first sign may be acute confusion of the mind, urinary incontinence or falls. It is only after a few days that there are some symptoms and signs that point towards chest infection. So, chest infections may be mistaken for confusion or ‘dementia’, urine infection (because of urine incontinence) or limb weakness, poor balance or even stroke (because of falls).
- Hence, what are the key giveaway signs that someone is highly likely to have a chest infection, and not another kind of ailment?
Unfortunately, there is no key giveaway signs to indicate chest infection. The most common sign is increased heart rate, which is rather non-specific and may be attributed to anxiety or heart problem.
- How can we prevent our elderly from getting an infection?
To prevent chest infection in the elderly: 1. regular vaccination against the common influenza virus and pneumococcus (a common bacteria associated with pneumonia); 2. adequate exercises 3. for those who cannot walk or who are weak, ensure that they sit regularly and not lie in bed 4. ensure safe swallowing as the most common cause of pneumonia is aspiration pneumonia – i.e. swallowing into the wrong passage – via the trachea and into the lungs. This is particularly common in stroke patients and those with Parkinson’s disease. 5. healthy lifestyle and good nutrition (increases their body resistance against the infective agent. 6. for those with diabetes, to achieve adequate control of blood glucose.
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I decided to specialise in geriatrics because of a previous volunteer work among the elderly. I was a medical officer way back in 1985 when I started volunteering at Boon Teck Constituency with Dr Ho Tat Kin, the MP then. I started a free medical service at the Community Centre which included home visits to the home bound poor elderly. That was my first exposure to treating the elderly. I could see the difference in their lives when they got better. As most of them are poor and being able to move on their own, fend for themselves, eat on their own, toilet and groom themselves goes a long way in making their lives better.Geriatric medicine is all about identifying illnesses early, treating them appropriately and improving or maintaining their function so that their quality of life also improves. This concept appeals to me. Although at that time, not many doctors would want to specialize in this field, I submitted my traineeship application under geriatric medicine.
The human body is fascinating because every part of it is so well created and put together. As a result, we are able to do what we need to do. The other amazing thing is that it is intelligent as it is dynamic – it gets better and better with repetition of actions, it could strengthen itself in preparation to perform a task, and it could repair itself when damaged. There is also a lot of resilience to take the stress of daily wear and tear. It even has an army of soldiers in the form of white blood cells to protect against the bad guys – bacteria and viruses.
If I were to give an analogy for what I do, I’d liken myself to be a detective. A detective, when informed of a mystery, will set out to find the root of the problem or mystery and solve it. I usually get referrals for ‘difficult cases’ from doctors who are stuck with a problem that the elderly person is suffering from. With no known diagnosis, treatment is difficult. Such cases are especially challenging because like a detective, I have to unravel the root of it all, and then to plan step by step how to deal with it. I get a kick out of doing this and unexplainable joy when the mystery is finally solved and the patient gets better.
I have come across all types of cases. In the course of my practice, I have seen many with dementia presenting with some of the weirdest behavior (family said she love to chew on telephone wires), a tiny old lady with the strength of a bull (needing 3 persons just to hold on to her when she gets aggressive), someone who only eat 1 french fry a day (one as in one strand, not one packet), people who turn day into night and vice versa or having a 72 hour sleep-wake cycle.
A typical day for me would be getting up early to send my children to school. This is the most stressful part of my day. My children are extremely fond of sleeping and almost impossible to wake them up. After dropping them off by 7am, I have to rush off to do my ward round. My ward rounds may start from East Shore Hospital, coming down to Mt Elizabeth, then Mt Alvernia and finally ending in Gleneagles Hospital. Fortunately, this is not very common as I try to group my patients within 1 or 2 hospitals. I have to complete my ward rounds before my clinic starts at 9am.
After the morning clinic, I would like to enjoy a nice lunch, but sometimes that is not possible because there is a housecall to do. Rush to have lunch, then back for afternoon clinic. Late afternoon is again housecall times, then followed by a second ward round to look at my hospitalized patients. If I am lucky, that is the end of the day, which by then would be about 7pm. More often than not, the day would continue with a meeting which will bring me all the way up to 8 or 9pm. By that time, I would be physically and mentally exhausted. Nonetheless, it would be a satisfying day for me if I could complete all I had set to do.
I love patients who are understanding. When doctors run a clinic, we may need to prioritise which patient to see first. Obviously, the more frail or more sickly ones should be seen first and not just based on first come first served basis. Then there is also the emergency that sometimes happen to patients in the ward that we have to attend to first. These understanding patients and their caregivers who allow us to do our job rationally actually make us feel apologetic towards them and they actually get more attention and better services from us to make up for their inconvenience.
Patients who get my goat are those who called up last minute for a clinic appointment and insisted to be seen the same day. To accommodate such cases, sometimes I had to reschedule a housecall appointment or push back a meeting. And guess what, they don’t turn up. When called, they either don’t answer their phones or have their handphone switched off.
One little known fact about ageing is no two elderly are the same. In fact, it has been said that there are more similarities between two 12 year olds than between two 80 year olds. So, even if they have the same diagnosis, they would present in a very dissimilar manner.
Things that put a smile on my face are comments that showed concern for me. I had patients who personally called up my nurse to find out how I was feeling as I was having a running nose a few days ago when I saw them. Then there are some who reminded me to get adequate rest when they know of my hectic schedule for the day. Still, some will insist on giving me something (like fruits or cakes) whenever they see me. It may be a bit awkward for me to accept them or not, but it still put a smile on my face because it is the thought that counts.
It breaks my heart when patients don’t do well in spite of trying your very best. In those situations, I need to keep reminding myself that I am not God, and that not all elderly conditions or sickness will response to treatment. Doctors do grieve with the family although we do not show it. We have to ‘suppress’ our emotions in order to make rational decisions for our patients.
I wouldn’t trade places for the world because this is where I feel my calling is. I just love what I do and it has become not just a job, but a personal challenge to get the frail and sick elderly well again.
My best tip is to do everything in moderation. If you love to eat, then eat in moderation. Exercise in moderation and accept growing old gracefully, warts and all. There is no need to hide the lines or bags (eye bags) because the lines represent one part of you and the experiences you go through. The sooner we accept ourselves as we look, the better and more contended we become.
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Nutrition for Elderly Women
- As women age, what are the common health concerns that crop up? Do men also face similar concerns – how similar or different?
General increased risk of elderly who would have nutrition problem:
Living alone, House bound
No regular cooked meals,
Lower social class
Low mental score, Depression
Chronic lung conditions, History of stomach surgery
Poor Dentition
Difficulty in swallowing
Smoking and Alcoholism
Those on multiple medications
Mental health: more depression and anxiety disorders in women, more Alzheimer’s disease in women even when corrected for age. However, men suffers higher suicide rate and alcohol related disorders than women.
Higher obesity in women than men as they age.
Heart disease – younger age groups, men more susceptible than women, but with age, the difference gets less.
Loss of estrogen protective effect also meant more osteoporosis in women than men.
Arthritis more common in women (53%) than men (47%).
Women more likely to fall than men – because women sways more when they walk, increasing the imbalance. So they are 50% more likely to fall compared to men. Together with increased prevalence of osteoporosis, higher risk of fractures and fracture related morbidity.
Urinary incontinence more prevalent in women than men – because of child bearing, loss of estrogen and shorter urethra. 20% of women above age of 70 yrs living in community has urinary incontinence. Also for the same reasons, they are also more prone to urine tract infection and dehydration (the elderly think that by cutting down on fluid intake, they may reduce incontinence).
Overall effect of above – elderly women more likely to be disabled and disabled for longer period of their life than men – 3 years for women vs 1.5 years compared to men, and 2-3x more likely to be hospitalized than men, and more likely to be living in nursing home.
- How can nutrition help women to prevent, or help elderly women to reduce such problems?
Proper nutrition can prevent obesity as well as reducing heart related diseases, which is usually caused by high lipids, high blood pressure and diabetes.
Proper nutrition with adequate vitamins and minerals are good for brain and body resistance to fight infections.
Adequate calcium intake protective against osteoporosis.
Cranberry as a juice or fruit also helps to prevent urinary infections.
General need to increase protein intake as most elderly tend to have protein calorie malnutrition. This is partly due to lack of dentition, eating fags (that protein are not well digested or that they don’t need so much protein as they grow older).
- What then are the key nutrients that elderly women need in their diets? Can you give an estimate of how much to take daily (e.g. 1000mg calcium per day?) Can you also briefly describe the functions of these nutrients in the body to illustrate their importance to health?
Calcium – 1000 to 1500mg per day – bone pain, osteoporosis, bone fractures, muscles weakness
Vitamin A – 700 to 900ug RAE per day – night vision, dermatitis
Vitamin C – 75ug per day – loss of energy, bruising, gingivitis, bleeding gums, body resistance
Vitamin D – 400 IU (10ug) per day – prevent osteoporosis, bone pain, muscle weakness
Protein – about 1g/kg body weight per day – body resistance, muscle bulk and strength, leg swelling.
Fluid intake – about 30mls per kg body weight. So for an average person weighing 60mg, requirement is about 1800mls of water. This is provided there is no restriction of water intake because of disease like heart failure or kidney failure.
- Can you give some examples of the foods that contain the above nutrients?
Food group Deficiency syndromes RDA* Sources Proteins Kwashiorkor 1 g/kg body weight depending on general health Meat, fish, eggs, milk, peas, beans, nuts, soya bean products, milk products Carbohydrates Marasmus 50 to 55% of total calories depending on general health Rice, wheat, cakes, tapioca, potatoes, noodles, chappatis, kway teow, bee hoon Fats Deficiency in vitamins A,D,E,K 20 to 35 % of total calories depending on general health Fat meat, fish oils, butter, milk cream, oils from nuts, margarine Calcium Osteomalacia, osteoporosis 1200 to 1500 mg** Milk, soya bean products, tinned fish, green vegetables Phosphorus Osteomalacia 800 mg Milk, protein-rich foods Iodine Hypothyroidism 150 µg Fish, sea food, watercress, most drinking water Iron Anaemia 10 mg Liver, egg yolk, dried fruit, red meat Sodium Dehydration Depends on general health Salt, meat, vegetables, smoked meat Potassium Myopathy, arrhythmia Depends on general health Fruits Zinc Anorexia, dysgeusia, poor skin healing, acrodermatitis enteropathica 15 mg Oysters, shellfish Magnesium Irritability, tremors, carpopedal spasm, confusion 300 mg in females, 350 mg in males Whole grains, dried peas, beans, nuts, cocoa, seafood Folate Megaloblastic anaemia 180 µg Green vegetables Vitamin A Night blindness, xerophthalmia, keratomalacia 800 µg, May be too high for the elderly as disposal is decreased. Animal fats, milk, egg, green vegetables, carrot, bananas Vitamin B complex Beriberi, pellagra, angular stomatitis, raw tongue B1= 1mg, B2= 1.2 mg, B3= 13 mg, B5= 4 to 7 mg, B6= 1.6 mg
Egg yolk, peas, yeast, liver, green vegetables Vitamin B12 Megaloblastic anaemia, dementia, subacute combined degeneration of cord 2 µg Meat Vitamin C Scurvy 60 mg Fresh fruits and vegetables Vitamin E Ataxia 8 mg Most food Vitamin D Osteomalacia 5 µg or 100 IU Cod liver or halibut oil, sunlight Vitamin K Bleeding diathesis 65 µg Spinach, cauliflower, cabbage, cereals, yeast, carrots, intestinal bacteria - On the other hand, what should elderly women be eating less of (or cutting out from their diets completely)?
Everything should be done in moderation. Even fats, which is generally seen as not good, must be included as part of the diet as fats is a rich source of important Vitamins like A, D, E and K.
- As the elderly may have teeth and other digestion problems, they may be unable to take some of the nutritious foods like crunchy vegetables, etc. What is your advice, or do you have any tips for them to overcome this problem?
Certainly important to grow old with a good set of dentition. If not possible, should have a set of well fitting dentures to help with chewing.
Meat etc can be prepared as finely minced to aid chewing and swallowing. Leafy vegetables can be washed whole first, then teared/break rather than cut to retain all the nutrition inside the leaf. Otherwise, they can be cooked whole first, then cut into smaller pieces and consume with all the ‘juice’ that comes with the vegetables. Avoid over cooking to soften the food as the over cooking will destroy all the nutrients that comes with it.
- In addition to diet, what else should elderly women do (or not do) in order to attain an all-round good health?
Early detection of illness – regular health checks, esp for problems mentioned in Point 1. Early detection mean early treatment to restore health of person.
Exercise – mentally and physically
Good social support – friends, active socially
Can continue to pursue what they had been doing all along. If they had been living a sedentary lifestyle and wish to start exercising, should have a medical check first to ensure fitness, advise on what exercises to avoid and start slow. E.g. if decide to take up tennis – need to check if there is any spinal problem, knee, shoulder and wrist problems and whether the heart and lungs can take the stress.
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