On the Increase

A study presented at the 2024 Annual Meeting of the American Academy of Orthopedic Surgeons in February pointed to a significant rise in sports-related injuries over the two-decade follow-up period, with the injury rate increasing from 55,684 in 2012 to 93,221 in 2021. The data also suggested that cycling increased in popularity between 2012 and 2021. Another recent study (BMC Geriatrics, May 27) looked at data collected from 1,109 older adults who sustained a fracture and visited a trauma center between June 2020 and July 2023. Among the participants, 144 had suffered a fracture while engaged in sports. The analysis showed that the average age of people who suffered a sports-related fracture was 74. “Sports-related fractures were most likely to happen outdoors, with men particularly susceptible,” Dr. Bloom says. “This fits with previous studies indicating that older men are more likely to participate in sports compared with older women.”

Specific Sports More Risky

In the BMC Geriatrics study, the sports most likely to be associated with fractures were outdoor walking intended as exercise (as opposed to more leisurely walking to get from one place to another), cycling, and mountain hiking, all of

which were linked with lower-extremity fractures. Having an underlying disease, such as diabetes, high blood pressure, or a heart condition, did not increase the risk of injuries. “Suffering a stroke lowered the risk,” Dr. Bloom observes. “The lower risk may reflect the fact that stroke often is followed by a decrease in muscle strength. This may limit a person’s ability to participate in sports.”

Many Benefits

Dr. Bloom says it is wonderful that more older people are getting involved in sports, since there is much trial evidence underlining the benefits of vigorous physical activity. It boosts cardiovascular health, slows age-related loss of muscle mass and bone density, can reduce your risk of falls by improving your balance, eases stress, helps you sleep better, and limits weight gain. Research also has linked high levels of physical activity with better brain function in older age. “Another great thing about sports is that many of them are sociable activities: You can walk, cycle, and play pickleball or other racket sports with friends,” Dr. Bloom adds. “It’s vital to maintain those social connections as you get older, since studies have suggested that social interaction may confer protection against cognitive impairment.”

But these data also highlight the risks associated with sports—and Dr. Bloom cautions that they also likely underestimate injury rates. “Many people who sustain sprains, strains, and lacerations while playing sports often seek medical care from their primary-care doctor or a local walk-in clinic instead of attending emergency departments and trauma centers,” she says. The data also suggest that older adults are participating in a wider variety of sports and/or participating in sports that are more likely to result in injury, especially if they require a level of strength, agility and balance that you don’t have. “It would be interesting to see data that includes an assessment of the participants’ degree of mobility and individual skill level along with other factors that may contribute to injury, such as weather conditions and whether someone was wearing suitable shoes and protective clothing,” Dr. Bloom says.

Pace Yourself

Staying safe while engaged in sports starts with managing your expectations when it comes to how much you can still do. The heart and lungs work less efficiently in older age, so less oxygen is transferred to the blood. Appetite decreases, meaning that most older adults eat less than they should. As a result of these changes, endurance, muscle mass and strength decline as you age. Your balance also may be affected by age, particularly if you have vision or hearing issues or take certain medications (including some blood pressure drugs). These factors don’t mean that you cannot or should not continue to enjoy the sports you’ve always loved, but you may have to slow down slightly to conserve your energy and avoid fatigue. One thing you might want to try is alternating between vigorous sports, such as pickleball or tennis one day and more leisurely options, such as golf, the next.

Starting from Sedentary

If you’ve been leading a sedentary life and/or have chronic underlying health issues, it’s particularly important to objectively assess your fitness level before taking up a sport. “If you need help doing this, ask your doctor to refer you to a physical therapist who can work out a safe sports regimen for you,” Dr. Bloom says. “You also might want to consult a personal trainer who works with older adults—your local gym or senior center may be able to recommend one.” Be patient—instead of launching yourself into your chosen sport, you may need to gradually build up your strength and cardiovascular fitness levels, perhaps by starting a walking program and pushing yourself farther and faster over time.

If you want to try a new sport, find out about it. “You’ll need background information about whether it’s important to wear special types of footwear, a helmet, and/or safety goggles, about the level of endurance and/or agility the sport requires, whether it’s a sport that involves rapid acceleration and deceleration and relies on you having good balance,” Dr. Bloom says. “Even if you’re very fit and want to challenge yourself, you don’t want to risk injuries that might have been highly preventable with a bit of preparation.” See What You Can Do for other strategies that will help you stay safe while playing sports.

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This isn’t the first study to point to links between stroke and dementia—in fact, up to 60 percent of stroke survivors develop some degree of post-stroke cognitive impairment, according to the ASA. Laura K. Stein, MD, MPH, associate professor of neurology at Mount Sinai, says the link underlines the importance of monitoring stroke survivors for cognitive decline and educating people about strategies that may confer protection against stroke and dementia.

First-Year Risk Greatest

For the study, a Canadian research team matched 180,940 people who had suffered a recent ischemic stroke (caused by a blood clot) or an intracerebral hemorrhage (caused by bleeding within the brain) with two control groups, one including people from the general population who had not had a heart attack or stroke, and the other including people who had suffered a heart attack but not a stroke. The researchers evaluated the rate of new cases of dementia starting at 90 days after a stroke, over an average follow-up of 5.5 years. In addition, they analyzed the risk of developing dementia in the first year after a stroke and over time, up to 20 years.

The analysis showed that the risk of dementia was greatest in the first year after a stroke, with a nearly threefold

increased risk. The risk halved by the five-year mark but remained elevated 20 years later. Dementia occurred in nearly 19 percent of stroke survivors over an average follow-up of 5.5 years. After accounting for dementia risk factors such as high blood pressure, diabetes, and high cholesterol, the risk of dementia was 80 percent greater in stroke survivors compared with people who had not experienced a heart attack or stroke. A similar increase in risk was seen in stroke survivors compared with people who had experienced a heart attack. The risk of dementia in people who had suffered an intracerebral hemorrhage (bleeding in the brain) was nearly one-and-a-half times greater than those in the general population.

Small-Vessel Disease Implicated

While there still is much we don’t undertand about the connection between stroke and dementia, Dr. Stein says we are learning more about the association between vascular health and brain health. “Researchers have recently identified the importance of the ‘neurovasculome’—a fancy term for the brain’s blood vessels, cells, and lymphatic system—to overall brain health and optimal cognition,” she says. “We know there is an association between dementia and damage to the small blood vessels of the brain, and there is evidence that cognitive outcomes may be better in people whose blood pressure is more aggressively treated.” She adds that damage from a stroke can damage brain structures and the connections between them, as well as the neurovasculome, and notes that this damage is especially likely in a brain with pre-existing susceptibility due to small-vessel disease and lower reserve (essentially the brain’s capacity to withstand harm). “In people with these vulnerabilities, a smaller stroke may have a greater impact than a larger stroke would in someone with greater baseline brain reserve,” she explains.

Post-Stroke Cognitive Screening Is Vital

While people with mild post-stroke cognitive impairment may recover fully, an improvement in cognitive impairment without a return to pre-stroke levels is more likely. Persistent impairment may be too mild to warrant a diagnosis of dementia, but still can affect your independence and quality of life after a stroke. This means it is important for stroke survivors to be evaluated for cognitive decline—indeed, a 2023 American Heart Association scientific statement recommends post-stroke cognitive screenings. If you are a stroke survivor and have not been screened for cognitive impairment, Dr. Stein recommends you discuss screening with your doctor. “Screening is especially important if someone is not meeting expected post-stroke milestones and may identify potentially reversible contributors to cognitive impairment,” she says. Possible contributing factors include depression, abnormal electrolytes (minerals that affect numerous body functions), thyroid disorders, low levels of vitamin B₁₂, and medication side effects. “Even if a reversible cause of cognitive impairment following stroke is not identified, a thorough cognitive evaluation can help an individual understand their cognitive strengths and weaknesses, identify areas for lifestyle modification and targeted cognitive therapy, and plan for the future,” Dr. Stein adds.

Safeguard Yourself Against Stroke

There is evidence to support that more severe and recurrent strokes are more strongly associated with post-stroke dementia. “This means that one of the most important things we can all do for our brain health is to identify and aggressively treat risk factors for stroke,” Dr. Stein emphasizes. These include high blood pressure, high cholesterol levels, the abnormal heart rhythm atrial fibrillation, diabetes, obesity, and smoking. Research suggests that having three or more cardiovascular risk factors may increase the risk of post-stroke dementia in older adults and has indicated that diabetes and atrial fibrillation may be particularly influential. See this month’s From the Editor for strategies to manage these risk factors.

Also be aware of symptoms that may indicate a stroke, including sudden problems with your balance and/or coordination, blurred vision or loss of vision, drooping on one side of the face, numbness/weakness in one arm, and slurred or incoherent speech. “Time is brain, and you should immediately call 911 if you think you or someone you know could be experiencing a stroke,” Dr. Stein concludes.

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The Centers for Disease Control and Prevention (CDC) recommend that all Americans over the age of six months get an updated COVID-19 vaccine when these become available this fall. By now, nearly all Americans have had a COVID infection, gotten a COVID vaccine, or both, but the updated vaccines offer a timely boost as immunity wanes and the virus continues to mutate. While mutations are thought to help COVID variants evade immune defenses and spread faster, there is no evidence they cause more severe illness. Even so, people ages 65 and older remain at great risk of COVID-related complications—they account for two-thirds of COVID hospitalizations and 82 percent of in-hospital deaths, according to the CDC. Only about 40 percent of Americans in that age group were immunized with the COVID vaccines that were offered last fall. You can visit the CDC’s dedicated COVID vaccine website for more information (http://tiny.cc/CDCCovid).

Plant-Based Meats May Reduce Cardiovascular Disease Risk

Plant-based meat alternatives often are marketed as being low in harmful saturated fat compared with “real” meat—however, up to now it hasn’t been clear if the products reduce the risk of cardiovascular disease. A recent review from researchers at the University of British Columbia, in Vancouver, suggests that they do even though they are classified as ultra-processed foods. The review (Canadian Journal of Cardiology, June 25) looked at studies published from 1970 to 2023, and found that cardiovascular risk factors like total cholesterol, LDL (“bad”) cholesterol, and body weight all improved when people substituted plant-based meat alternatives for real meat in their diets. Compared with real meat, plant-based meat products tend to be higher in sodium, which contributes to high blood pressure. However, the review did not find that the meat substitutes raised blood pressure.

Ultra-Processed Food Harms

A recent study underlines the mortality risks associated with diets that are high in ultra-processed foods. The National Cancer Institute study looked at data from more than 540,000 people who provided information about their eating habits and health in the mid-1990s, when they were ages 50 to 71. Over half of the participants have since died. The researchers analyzed overall rates of death among those who were in the 90th percentile for consumption of ultra-processed foods at the start of the study versus those in the 10th percentile. Processed foods were defined according to a standard classification system, and included deli meats, snacks, ready meals, fast foods, and soft drinks. People who ate the greatest amounts of ultra-processed foods over the median 23-year follow-up were 10 percent more likely to die early than those who ate the least. The study was presented at the annual meeting of the American Society for Nutrition in June.

Stroke Mortality Worse for Black People

Overall rates of long-term survival following stroke are getting better—but not for Black people, according to a new University of Cincinnati study (Neurology, July 15). Researchers identified 8,428 cases of ischemic stroke (the type caused by a blood clot) and 1,501 cases of intracerebral hemorrhage (a less common and more severe type of stroke caused by bleeding in the brain). Among participants with ischemic stroke, five-year survival decreased from 53 percent in 1993-94 to 48 percent in 2015. There were no changes in five-year survival following an intracerebral hemorrhage. While the overall numbers improved, Black study participants were found to be 20 percent more likely to die within five years after an ischemic stroke than white people. Long-term social, economic and environmental inequities likely contribute to the disparity. See this month’s From the Editor for stroke-prevention advice.

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Dry Mouth

Dry mouth is not a normal part of aging, but it is a common concern for many older adults. Saliva is an unsung hero of digestion—it coats food particles with enzymes that initiate the breakdown of carbohydrates into smaller food molecules and moistens and softens food so that it is easier to swallow. Chewing stimulates saliva secretion from the salivary glands in the mouth, but your production of saliva can decrease in older age due to medications, including some drugs that treat high blood pressure and urinary incontinence; certain diseases, such as diabetes, Parkinson’s disease, and the autoimmune condition Sjogren’s syndrome (you are at greater risk for this if you have rheumatoid arthritis); and having had treatments for cancer, including radiation therapy. Environmental conditions, like dry heat, also can cause dry mouth.

Dry mouth is uncomfortable, and not having enough saliva to moisten food can make it more difficult to swallow. Dry mouth also increases the risk of tooth decay and other oral infections because another one of saliva’s primary jobs is to kill bacteria. For this reason, it is important to see your doctor or dentist to determine what might be causing dry mouth. Self-help measures include sucking on sugar-free lozenges or chewing sugarless gum to stimulate saliva production—you also may want to try Salivart, an “artificial saliva,” that is available over the counter at pharmacies. Avoid mouthwashes that contain alcohol, as these can worsen dryness.

Coughing While Eating

Coughing during a meal is a sign that you’re having to clear your throat while you eat or drink. You’re doing this to avoid aspirating food or fluids into your lungs.

Eating and breathing share space in the back of the throat, or pharynx (see image, right). Food enters the esophagus (the muscular tube that leads to the stomach) through the pharynx while air is diverted into the trachea (windpipe) and lungs. The epiglottis—a small flap of cartilage attached to the larynx—plays a key role in this process of diversion by staying open during breathing and closing during swallowing. You need intact neuromuscular reflexes for the epiglottis to function correctly, but with aging, some of these reflexes become less effective. They also may be impacted by esophageal dysphagia (difficulty swallowing food due to inflammation or narrowing of the esophagus), stroke, dementia, and Parkinson’s disease. The result is that it becomes easier for food and drinks to “go down the wrong pipe.” The coughing and sputtering that accompanies this is uncomfortable and embarrassing if it occurs when you are eating out. But aspiration also can cause inflammation of the lungs (pneumonitis), pneumonia, and choking, so it is important to get evaluated by an ear, nose and throat specialist if you think you may be aspirating food. Interventions that may help include exercises, dietary modifications, or adopting different eating positions.

Difficulty Taking Medication

Pill esophagitis, which is when a drug gets stuck in the esophagus, occurs more often in older adults and can cause inflammation, injury, and pain. You may be able to prevent it by taking medications with plenty of water, while sitting up—also avoid lying down for about 30 minutes afterward. If you’re still having trouble it may be possible to split pills in half, but check with your doctor or pharmacist, since some tablets should not be split. If you get the go-ahead, use a proper pill-splitter (you can purchase them at most pharmacies). If your medication comes

in capsule form only, or tablets cannot be safely split, ask your doctor or pharmacist if a liquid version of the drug is available. If none of these approaches help, you may need to see a specialist who can check that your esophagus is functioning correctly.

Can’t Go, Won’t Go

The frequency of bowel movements considered normal ranges from three times a day to three times a week. In general, bowel transit time—the time it takes for food to move through the digestive tract—is about three days. But if you have chronic constipation, transit time can increase to four to nine days, and, if you are bedridden, up to two weeks. This increase in transit time is common in older adults due to a decline in peristalsis (involuntary muscle contractions that propel food through the intestines). If peristalsis is sluggish, stool moves too slowly through the colon. Slow passage means that more water is absorbed from food, and this results in hard, dry stools that contribue to constipation.

If you frequently suffer from constipation, eating more fiber and drinking plenty of fluids will help your colon make bulkier stools that are easier to pass. Also get plenty of exercise, since this can help food move through the gastrointestinal tract. Whenever you have the urge to move your bowels, go to the bathroom. Ignoring the urge allows stool to remain in the colon for longer and this means that more water will be absorbed from it, resulting in hard stools that are more difficult to expel. Also try to have a bowel movement after you’ve eaten a meal. After you eat, your stomach stretches, triggering what is known as the gastrocolic reflex. This reflex increases the movement of ingested food toward the rectum, increasing rectal pressure and stimulating a bowel movement.

If these measures don’t bring relief, ask your doctor if an undiagnosed health condition (for example, untreated thyroid disease—see last month’s issue for more on thyroid disease) might be contributing to your constipation. He or she also will be able to check if you take any medications that raise the risk of constipation (opioids are known to worsen constipation, and laxatives should always be prescribed when opioids are prescribed). Your doctor may suggest using a laxative and can advise on which option will suit you best.

Burning Fluid at the Back of the Throat

If you get this often, you likely have gastroesophageal reflux disease (GERD), a condition in which stomach acid refluxes (flows backward) from the stomach into the esophagus. The lower esophageal sphincter (LES), a muscular valve that separates the esophagus from the stomach, should prevent reflux, but if it has decreased resting pressure, it may not close properly between meals. LES pressure naturally decreases with age and may be affected by excess weight and a range of medications often taken by older adults, including some blood pressure drugs, statins, antidepressants, and bisphosphonates (used to treat osteoporosis).

GERD typically causes heartburn (a burning sensation in the chest), but older adults may not experience this because the older esophagus is less able to feel pain. Instead, they taste stomach acid at the back of their throat. Other GERD symptoms often reported by older adults include difficulty keeping food down after meals, a dry cough at night, a persistent sore throat, and a repeated need to clear their throat when they get up in the morning.

GERD is associated with potentially serious complications, so if you think you may have the condition, tell your doctor. He or she may prescribe drugs to ease the symptoms and should review your regular medications to ensure they aren’t contributing to the problem. Self-help strategies include eating smaller, more frequent meals instead of fewer large ones, avoiding foods that may trigger symptoms (such as fatty and spicy foods, citrus fruits, garlic, chocolate, and peppermint), limiting your alcohol intake, and not eating in the two to three hours prior to bedtime. Minimize pressure on your stomach by wearing loose-fitting clothing and avoiding tightly belted outfits. If you are overweight, losing weight may help, since excess belly fat places pressure on the stomach.

Gas and Stool Leakage

The tone and strength of the internal anal sphincter (a ring of muscle that prevents stools from leaking through the anus) decline in older age. The pelvic floor (a group of muscles that support the bowel and bladder) also may weaken, particularly in women who have experienced pregnancy and childbirth. These factors make flatulence and stool leakage more likely.

You may be able to reduce your production of gas by cutting back on certain gas-producing foods, such as onions, broccoli, cabbage, and beans. As to stool leakage, the more completely you empty your bowels the less there will be to leak, so be sure to take sufficient time on the toilet. Raising your feet eight to 12 inches (rest them on a pile of books or a box) while going to the bathroom may help you empty more completely.

Kegel exercises, which can help prevent urinary incontinence, also may help with stool leakage, since they strengthen the pelvic floor muscles. Your pelvic floor muscles are the same ones you may have been using to keep you from passing gas. To exercise them, slowly pull them up (imagine they are an elevator stopping on every floor of an apartment block), hold for three seconds, and then release them equally slowly. Work up to a set of 10 contractions and repeat each batch of 10 three times a day. Also reduce your intake of caffeine, lactose, and artificial sweeteners, as these can loosen stools. If these strategies don’t work, mention the problem to your doctor (try not to be embarrassed— we really have heard it all before!).

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Troubling Shortfall

The research, led by a team from the University of Michigan Health Frankel Cardiovascular Center, tracked nearly 150,000 people who were seen at hospitals for serious heart conditions (including heart attack and heart failure) between late 2015 and early 2020. The analysis (Journal of the Academy of Nutrition and Dietetics, July) showed that clinicians documented providing dietary counseling in just 23 percent of cases within 90 days of hospitalization. Women, adults ages 65 and older, and people with chronic kidney disease were least likely to receive counseling.

Getting Help

Nutrition counseling is included in cardiac rehabilitation programs, and also can be obtained via a separate kind of care called medical nutrition therapy. “Cardiac rehabilitation programs counsel participants on diet, exercise and behavior modifications, with the aim of improving health outcomes in people with cardiovascular disease,” Dr. Darrow says. “These programs have been shown to boost physical function and reduce the risk of hospitalization and death for older adults with heart failure.” Medicare Part B covers cardiac rehabilitation for enrollees who have had a heart attack in the previous 12 months and those who have stable angina (chest pain caused by blocked heart arteries) or chronic heart failure. People who have undergone cerain heart procedures also are covered—the Medicare website has details (www.cms.gov). “Medical nutrition therapy involves working with a registered dietitian to build an eating plan tailored to your individual health needs,” Dr. Darrow says. The therapy is covered by Medicare Part B for certain individuals (check at the Medicare website). You need a doctor’s referral to utilize the program.

Eating to Support Heart Health

Dr. Darrow provides nutrition guidance to his patients just in case they are not able to attend a cardiac rehabilitation program or get medical nutrition therapy. He recommends people who have cardiovascular disease or have suffered a heart-related event follow an eating plan that is low in sodium and fat, such as the Mediterranean diet (see our chart) or DASH (Dietary Approaches to Stop Hypertension) diet. “Both diets are high in fruits, vegetables, whole grains and healthy fats, and limit the saturated fats that can contribute to elevated blood pressure and cholesterol,” he says. “They also permit enough of what you enjoy that it doesn’t feel like you are depriving yourself at every meal.”

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Hyper vs. Hypo

The thyroid is a small butterfly-shaped gland situated in the neck, just below the larynx. Its function is to absorb iodine, an element that occurs mainly in salt, bread, and fish, and convert it into triiodothyronine (T3) and thyroxine (T4). These hormones control your metabolism, influencing everything from the speed at which you digest fats and carbohydrates, to the rate at which your heart beats.

Another hormone—thyroid stimulating hormone (TSH)— also plays an important role in thyroid function. TSH stimulates the thyroid to produce T3 and T4. As such, measuring the level of TSH in the blood can flag underlying thyroid issues. High TSH levels may indicate that the thyroid is not producing enough thyroid hormone (hypothyroidism, which also is known as underactive thyroid), while low TSH levels may mean that your thyroid is producing too much thyroid hormone (hyperthyroidism, or overactive thyroid).

Hypothyroidism

This is the most common thyroid disorder and occurs when T4 levels are too low. Low T4 levels cause body processes to slow down— as such, symptoms typically include fatigue, weight gain, sluggish bowel movements, and increased sensitivity to cold. However, in older adults, these symptoms are less common—instead, an underactive thyroid may cause depression, loss of appetite, weight loss, and joint pain. Since these symptoms are associated with other diseases that are common in older age, recognizing hypothyroidism is challenging. Dr. Arakawa adds that it also is possible to develop subclinical hypothyroidism, in which TSH levels are only slightly elevated while levels of T3 and T4 are normal. “People who have subclinical hypothyroidism may report nonspecific symptoms, such as an altered mood and cognitive impairment, while many don’t have any symptoms,” she says.

HYPOTHYROIDISM RISK FACTORS

You are at increased risk for underactive thyroid if you have a family history of thyroid disease, have been treated for an overactive thyroid, and/or have had extensive surgery or radiotherapy to your neck. Some medications also raise the risk— for example, the cancer drugs sunitinib (Sutent®) and imatinib (Gleevec®) can cause or worsen an underactive thyroid, as can amiodarone (Corderone®, Pacerone®), which is used to treat heart arrhythmias.

It also is possible for underactive thyroid disease to arise from an autoimmune condition called Hashimoto’s thyroiditis, which impedes the thyroid gland from secreting hormones. Hashimoto’s usually causes a goiter, which is a swelling in the neck arising from enlargement of the thyroid gland.

TREATING HYPOTHYROIDISM

Dr. Arakawa emphasizes that treatment has not been shown to have a significant impact on symptoms in older adults with subclinical hypothyroidism. Although subclinical hypothyroidism is associated with an increased risk for progression to overt hypothyroidism and adverse cardiovascular events, the policy is to monitor people with subclinical disease and initiate treatment only if overt hypothyroidism occurs.

Treatment for overt hypothyroidism is a synthetic version of thyroid hormone called levothyroxine (Synthroid®, Levoxyl®). The drug is one of the most prescribed medications in the United States, but overusing it is known to increase the risk of osteoporosis. Recent research suggests that levothyroxine overuse also may increase the risk of cognitive issues in older adults. The 2023 study (JAMA Internal Medicine, Oct. 23) included 65,931 older adults and focused on thyrotoxicosis (excess T3 and /or T4 levels in the body). The new study suggests that thyrotoxicosis caused by medication raises the risk of cognitive decline. Dr. Arakawa says the data are a useful reminder for doctors to be cautious when prescribing thyroid hormone to older adults. “It’s important to regularly monitor people who are taking levothyroxine and decrease the dose if needed,” she notes.

Hyperthyroidism

This occurs when the thyroid releases too much T3 and T4, and it causes the body to “speed up.” Younger people may experience symptoms like an increased appetite, palpitations (the sense your heart is “skipping” beats), a tremor in the hands and arms, more frequent bowel movements, excessive perspiration, anxiety, and insomnia. But—as with hypothyroidism—overactive thyroid symptoms may be different in older adults, who “tend to present more nonspecifically, with fatigue, weight loss, and mood changes,” according to Dr. Arakawa. “Cardiovascular manifestations of hyperthyroidism also tend to predominate, particularly the abnormal heart rhythm atrial fibrillation,” she adds.

HYPERTHYROIDISM RISK FACTORS

In older adults, hyperthyroidism usually is related to abnormal growths that form in the thyroid gland. Called thyroid nodules, these can produce more T3 and T4, which is what makes the thyroid overactive. An overactive thyroid also can be caused by an autoimmune condition (Grave’s disease). Studies have linked Grave’s disease to an increased risk of cognitive decline. In other cases, drugs may trigger thyroid overactivity— for example, amiodarone, which can trigger both overactive and underactive thyroid disease.

TREATING HYPERTHYROIDISM

Untreated hyperthyroidism is known to increase the risk of developing osteoporosis, a condition that raises the risk of fractures. “Hyperthyroidism also can impact the pumping and rhythm functions of the heart, which may lead to conditions such as heart failure and atrial fibrillation,” Dr. Arakawa says. “These risks are augmented in people ages 65 and older, so treatment is recommended to correct hyperthyroidism.”

Treatment options include anti-thyroid medications, such as methimazole (Tapazole ®), which blocks the production of thyroid hormones. Alternatively, radioactive iodine can destroy the overactive thyroid cells, rapidly shrinking an enlarged thyroid gland. This can leave the thyroid unable to produce any hormone, and it’s likely you’ll eventually become hypothyroid and require treatment for that.

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Sam Gandy, MD, PhD, professor of neurology at Mount Sinai and associate director of the Mount Sinai Alzheimer’s Disease Research Center, says that donanemab has some advantages when compared with lecanemab— however, he recommends older adults be realistic about the new drug’s possible benefits and carefully consider its possible harms.

A-beta Reduction

The FDA approved donanemab based on trial data from 1,736 older adults showing that the drug reduced A-beta plaques in the brain. While some A-beta accumulation is normal in older age, the protein is believed to contribute to AD by disrupting communication between brain cells and eventually destroying brain cells. “However,many older adults maintain normal cognition despite A-beta accumulation, so there is some debate as to just how much of a role it plays in cognitive impairment,” Dr. Gandy notes. In the trial, donanemab treatment was stopped as soon as the participants’ brain scans showed that A-beta had been cleared from the brain. Scientists involved in the trial have estimated that it would take about four years for A-beta to build up again to a level where it might impair cognition.

The trial data also suggested that donanemab slowed cognitive and functional decline compared with a placebo (inert substance). “Participants with lower levels of another abnormal brain protein—tau—saw more benefit from donanemab,” says Dr. Gandy. “Research suggests that tau also contributes to AD, with higher tau levels meaning more cognitive decline. The donanemab data support the theory that successful treatment depends on starting AD medications as early as possible in the course of the disease, before tau accumulates.”

Some Advantages

Dr. Gandy says that donanemab has some advantages over the currently available version of lecanemab. “Donanemab is given monthly, while lecanemab is given every two weeks,” he explains. “Both drugs are delivered via intravenous infusion, which means attending an infusion center—but while lecanemab must be given indefinitely, with donanemab there is the possibility of pausing the drug after 18 months, since, by that time in the trial, the amyloid scans of all the participants were negative. Since we don’t yet know the long-term side effects of these new drugs, the idea of pausing treatment makes donanemab especially attractive.”

Lecanemab Update

There is a new development with regard to lecanemab. A subcutaneous (injected) version of the drug is under review by the FDA. “Subcutaneous lecanemab would be more practical for people without easy access to infusion centers,” Dr. Gandy says. “Plus, trials suggest that the subcutaneous version is more effective than the intravenous version at clearing A-beta plaques.”

Benefits vs. Harms

As with lecanemab, donanemab is associated with swelling and bleeding in the brain, so anyone taking the drug would need regular brain scans to monitor for these harms. Does the risk of side effects outweigh the potential benefits? “In the trial, cognitive decline slowed by about four to seven months in people taking the drug,” Dr. Gandy says. “This likely would be acceptable to the family members of a person living with AD, but in reality, it is a very modest improvement that may not be noticeable on a day-to-day basis.” He adds that it is impossible to know how MCI might progress without treatment. “There is a risk that a person with nonprogressive MCI could take one of these new drugs and suffer potentially serious side effects,” he says. “Another caveat is that the trial participants were mostly white, so we don’t know how well other ethnicities would respond to donanemab.”

Overall, Dr. Gandy thinks that donanemab likely won’t prove to be a magic bullet. However, he is optimistic about what the drug might mean for the future. “It may bring us one step closer to developing safer treatments with greater impact for people living with AD,” he concludes.

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If you want to stay well as you age, turn off the TV and get off the couch. That’s the message from researchers at Harvard’s T.H. Chan School of Public Health who found that replacing even one hour of TV with physical activity could benefit a person’s health. For a study published in JAMA Network Open, June 11, the Harvard team looked at 20 years of data from 45,176 people free of major chronic diseases (including cancer, diabetes, heart attack, heart failure, and stroke). Healthy aging was defined as survival to at least age 70 with no major chronic diseases and no impairment in subjective memory (defined as a person’s own perception of their memory), physical function, or mental health. Among the participants, 3,873 achieved healthy aging. The analysis showed that each increase of one hour per day spent engaged in light-intensity physical activity (such as household chores) increased the odds of healthy aging by 8 percent.

Walking Relieves Back Pain

A new study from Macquarie University, in Sydney, suggests that regular walking is an effective way to manage chronic back pain. The study (The Lancet, June 19) included 701 adults, mean age 54, all of whom had recently recovered from an episode of low back pain. The participants were randomly allocated to a walking program or to a no-intervention control group. Participants in the walking program were advised to build up to 30 minutes of walking, five times a week over a six-month period. After three months, most were walking three to five days a week for an average of 130 minutes. Compared with the control group, the intervention group had fewer occurrences of activity-limiting back pain during the one- to -three-year followup period and a longer average period before they had a recurrence of back pain (a median of 208 days compared to 112 days in the control group). Walking is a good low-impact muscle-strengthening exercise for people with musculoskeletal pain; moreover, it can be good for easing the stress and depression that can accompany chronic discomfort.

Traumatic Brain Injury Risk

The number of older adults diagnosed with traumatic brain injury (TBI) is alarmingly high, according to a recent study from researchers at the University of California-San Francisco. TBIs range from mild concussion to more serious head injuries that subject brain tissue to severe damage and increase the risk of dementia, Parkinson’s disease, seizures, and depression. The study (JAMA Network Open, May 31) followed 9,239 Medicare enrollees, average age 75. Over an 18-year follow-up, 1,148 participants sustained a TBI. Contrary to studies looking at younger people, TBI was more likely among people who were healthier. It is possible this may be because these individuals are more likely to engage in physical activity. Keep in mind that the data reflect cases of TBI in which people were diagnosed and received care. Other research has suggested that many older adults do not seek a medical evaluation after a TBI. If you fall, let your doctor know, even if you think you haven’t hurt yourself.

Shingles Vaccine Uptake

New data (Journal of the American Medical Association, May 23), shows that uptake of the shingles vaccine (Shingrix®) among older Americans has increased, likely because of government action to eliminate cost sharing for vaccines covered by Medicare Part D. The policy was part of the Inflation Reduction Act and took effect in January 2023. To determine the impact of the new policy, a team from the University of California’s Mann School of Pharmacy and Pharmaceutical Sciences looked at monthly data on shingles vaccines administered between January 2022 and December 2023. The analysis showed that uptake of the shingles vaccine increased by 46 percent after the policy was implemented. The vaccine is recommended for people ages 50 and older and significantly reduces the risk of shingles and postherpetic neuralgia (chronic nerve pain that can persist for years).

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Not a Normal Part of Aging

Depression is not a natural part of the aging process, but several factors make us susceptible to the condition as we grow older. Other chronic illnesses that are common in later life may factor in, including Alzheimer’s disease, Parkinson’s disease, heart disease, stroke, cancer, and arthritis. Natural age-related conditions, including hearing impairment, also have been shown to contribute to the risk of depression in older age. “Many of these conditions can interfere with your mental and physical function, and not being able to think as fast or do as much as you used to may impact your emotional well-being,” Dr. Neugroschl says. The medications used to treat other chronic conditions also can play a role in depression, since some drugs affect motivation and mood. The inevitable losses we confront as we get older, as spouses, family, and friends die, also may factor in.

Combined Treatment Approach Best

Treatment for depression can be very successful, but it isn’t easy. A combination of psychotherapy and medication has been shown to be most effective. A recent review (TheBMJ, Feb. 14) also points to exercise as a powerful tool to fight depression. Researchers at Australia’s University of Queensland looked at 218 studies that included more than 14,000 people and found that walking, jogging, yoga and strength training were extremely beneficial.

PSYCHOTHERAPY

One of the most effective psychotherapy approaches for easing depression is cognitive behavioral therapy (CBT), which also is known as “talk therapy.” CBT can teach you to recognize and modify the negative thoughts that may contribute to depression. “Often, these thoughts are wildly exaggerated,” Dr. Neugroschl says. “For example, you ate something unhealthy and now are sure you’ll have a heart attack and never see your grandchildren grow up. CBT helps you replace these thoughts with more realistic ones: Everyone eats unhealthy food from time to time; it isn’t the end of the world.”

MEDICATIONS

Medication options include antidepressant drugs, such as sertraline (Zoloft®), escitalopram (Lexapro ®), and citalopram (Celexa®). These drugs don’t start working immediately—it may take four to six weeks for your mood to lift. “Once they start working, don’t stop taking them because you feel better, since it is possible your symptoms could return,” Dr. Neugroschl advises. “You also could experience withdrawal symptoms if you abruptly stop taking your medication.” Another recent study (The Lancet Psychiatry, June 5) found that about 15 percent of people who stop taking antidepressants report withdrawal symptoms including headaches, nausea, an irritable mood, and poor sleep. Side effects you may experience while taking antidepressants include nausea, headache, diarrhea and restlessness. However, many people experience no side effects from the drugs, or find that the side effects stop after a week or so.

Second-Line Strategies

If depression doesn’t respond to psychotherapy and medication, your doctor may recommend electroconvulsive therapy (ECT). “This uses controlled electric shocks to trigger seizures in the brain,” Dr. Neugroschl explains. “A general anesthetic is used, so the procedure is painless. ECT is safe and effective, though it is unclear how it works.” Side effects associated with ECT include nausea, fatigue, headaches, and temporary memory loss. Some people who undergo ECT experience permanent loss of memory for events that occurred just prior to the treatment.

Another option is transcranial magnetic stimulation (TMS). This noninvasive treatment can be administered in a doctor’s office and uses an electromagnetic coil placed on the forehead to send pulses to a part of the brain that helps regulate mood. “Research suggests that TMS works by helping to regulate connectivity within key regions of the brain,” Dr. Neugroschl says. Side effects associated with TMS include headaches and muscle twitching at the treatment site.

Seek Help

Unfortunately, depression in older adults frequently goes undiagnosed and untreated. “Research also has suggested that many older adults are less likely to ask for help to manage depression, either because they consider the condition to be normal in older age or because they believe they should be able to handle it themselves,” says Dr. Neugroschl. “Older people also may recall a time when there was a stigma associated with mental health issues and may not want to admit that they are struggling.” Try to overcome these obstacles to treatment if you can. Instead, see depression as a chronic medical illness in the same way that high blood pressure and diabetes are, and seek treatment.

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Comparing Diets

For the study (The Lancet Gastroenterology & Hepatology, June), researchers at Sweden’s University of Gothenburg set out to compare how well two different dietary approaches worked compared with IBS medications among 294 people with moderate to severe IBS symptoms.

The study participants were randomized to one of three groups. The first group followed a traditional diet (in which carbohydrates comprised 50 percent of their daily calorie intake, fat comprised 33 percent, and protein comprised 17 percent), combined with a low intake of FODMAPs. “The latter stands for fermentable oligosaccharides, disaccharides, monosaccharides and polyols,” says Dr. Shah. “All are sugars that often are fermented by bacteria in the digestive tract instead of being fully digested and absorbed by the body.” The second group followed a low carbohydrate/high fat/high protein diet (10 percent carbohydrates, 67 percent fat, 23 percent protein). The third group took IBS medications.

After a treatment period of four weeks, 76 percent of participants in the traditional diet/low-FODMAP group reported reduced IBS symptoms versus 71 percent of the group following a lowcarb/ high fat/high protein diet, and 58 percent of the medication group. At a sixmonth follow-up, when participants in the dietary groups had partially returned to their previous eating habits, a large proportion still had clinically significant symptom relief (68 percent in the traditional diet/low FODMAP group, and 60 percent in the low-carbohydrate/high protein/high fat group).

While most people with IBS do respond to dietary changes, some don’t. “It would be interesting to see further longer-term research that investigates whether certain factors can predict which people with IBS are more—and less—likely to benefit from dietary adjustments, so that clinicians can recommend treatments that are more tailored to the individual,” says Dr. Shah.

Focus on FODMAPs

The American College of Gastroenterology (ACG) clinical guidelines for IBS management recommend following a low-FODMAP diet. However, Dr. Shah notes that it involves avoiding many fruits and vegetables, wheat, most dairy, legumes, and some nuts. “There isn’t much good-quality data on the possible health harms of restricting these nutrients on a long-term basis,” he says. “That’s why the ACG emphasizes the importance of properly following all three phases of the diet. I also would urge that people who want to try the diet consult a dietitian.”

The first stage involves substituting high-FODMAP foods with low- FODMAP alternatives (see our chart), and the second stage involves gradually reintroducing foods containing specific FODMAPs into your diet while monitoring your symptoms. For the third stage, you personalize the diet to avoid the specific foods that trigger symptoms. “Studies suggest that it takes from two to six weeks to figure out if your symptoms are triggered by FODMAPs, after which you should be able to return to eating a much broader diet,” Dr. Shah says.

Low Carb/High Fat/High Protein Diet Also Helpful

If you are unable to significantly restrict your FODMAP intake, the new study suggests that the low-carb/high fat/high protein diet also was effective at relieving IBS symptoms. “Previous studies have suggested that a high fat intake may worsen IBS symptoms, but in the study, the high fat intake may have been balanced by the lower carbohydrate intake,” Dr. Shah says. “Again, further research would be useful to investigate these findings—but it is important to note that people following this dietary pattern experienced small increases in their cholesterol levels.”

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