Acute vs. Chronic.

Under acute stress, you may feel a jolt of energy and notice your visual focus and thinking sharpen and your motivation increase. You are faster and stronger, and even your immune system is primed for action. When this moment of acute stress passes, your vital signs (and everything else) return to normal.

Chronic stress is different. If you’re under continuous stress for long stretches of time, such as from a high stress job, financial insecurity, living in fear of violence, or caring for a chronically ill loved one without adequate support, your body never gets the chance to return to baseline.

Health Impacts.

Long-term exposure to stress affects your whole body. It may increase your risk for health problems including high blood pressure, heart attack, stroke, type 2 diabetes, and mental health issues like depression, anxiety, and addiction. See “Possible Health Effects of Chronic Stress” for more information.

Day-to-day symptoms of chronic stress, such as trouble concentrating, crankiness, changes in appetite, fatigue, insomnia, and turning to mind-altering substances for relief, can interfere with productivity and relationships and add to the negative health impacts of chronic stress.

Managing Stress.

If you are feeling stressed a lot of the time, it’s important to identify the source and find healthy ways to reduce or relieve that stress (and avoid unhealthy ways, such as overeating, smoking, illicit drug use, or excessive alcohol consumption). If you can directly address the source of your stress (by discussing job responsibilities with management, for example), do so. If this is not possible, take steps to manage the stress in your life with the tips in the “Take Charge!” box. Your whole body will thank you!

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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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You may not be able to eradicate all of your individual stroke risk factors, but you likely can mitigate some of them enough to significantly reduce your chance of suffering a stroke. Along with any medications you may be prescribed to lower your blood pressure, cholesterol, and blood sugar, a healthy diet and plenty of exercise are cornerstones of stroke prevention. Eat plenty of fruits, vegetables, and whole grains, and substitute fish and poultry for red meat. Cut back on your salt intake, since too much salt raises blood pressure. Get at least 30 minutes of physical activity each day (you can break this up into smaller segments). If you’ve already had a stroke, eating more healthfully can help prevent another, and exercise can help you regain your cardiovascular fitness and cognitive function, as well as combat the depression that often follows stroke. Stroke rehabilitation programs focus closely on diet and exercise, so ask your doctor to refer you to one of these programs if he or she has not already done so.

Another crucial element of stroke protection is knowing the symptoms that can red-flag a stroke. The American Stroke Association recommends learning the “BE FAST” rubric:

• B for Balance. Do you have a sudden loss of balance or coordination? To check, walk in a straight line or touch your finger to your nose.

• E for Eyes. Are you noticing sudden vision changes, such as double vision, or loss of vision in one eye?

• F for Face drooping. Is there drooping or numbness on one side of your face? Is your smile uneven?

• A for Arm weakness. Look for weakness in one arm (raise both arms and see if one arm drifts downward).

• S for Speech difficulty. Is your speech slurred or otherwise hard to understand?

• T for Time to call 911. If you have any of the above symptoms, call 911.

Keep in mind that women may experience additional stroke symptoms, including confusion and disorientation, nausea and vomiting, and fatigue.

As our article emphasizes, time is brain. Recognizing possible stroke symptoms and seeking medical help immediately can make a huge difference to post-stroke function, since treatment with a clot-busting drug is most effective within 4.5 hours of symptom onset if your stroke is caused by a blood clot.

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According to the American Heart Association, women should have no more than six teaspoons of added sugar a day and men no more than nine teaspoons (which is equal to about 100 calories for women, or 150 calories for men). Many people are blowing past these numbers, and that is concerning. A 2023 review of 73 meta-analyses, published in The BMJ, found that a diet high in added sugar was linked to 45 poor health outcomes, including diabetes, cancer, gout, hypertension, cardiovascular disease, asthma, and depression. “In essence, added sugar contributes “empty energy” or calories without the benefits of key nutrients like fiber, protein, or vitamins,” says Debbie Petitpain, MBA, RDN, spokesperson for the Academy of Nutrition and Dietetics.

The good news is you can make a few simple changes to the way you eat to decrease (not eliminate!) your added sugar intake. Here’s how to cut back on the sweet stuff without feeling deprived.

Read the Fine Print. Now that the Nutrition Facts panel on packaged foods requires producers to list the grams of added sugar in their products, it is easier than ever to spot how much is being steathfully added to everything from granola to ketchup to jerky. Petitpain says this lets you compare the nutrition numbers on products so you can choose those with fewer grams of added sugar. Another good move is to look for labels such as “no added sugar” or “unsweetened” on items like almond milk and applesauce.

Natural Selection. To help quell a sweet tooth, try eating more foods that are naturally sweet. Sugars in vegetables, like beets or sweet potatoes, and fruit, such as apples don’t count as added sugars, and research is bereft of any data linking natural occurring sugars with health woes. “Naturally occurring sugars in vegetables, fruits, and dairy are part of a complex food matrix which alters how the body digests, breaks down, and uses these sugars, which changes the effects on the body,” notes Petitpain. “There also tends to be a lot less sugar, bite for bite, compared to foods with added sugars.” So buy plain versions of items like yogurt and oatmeal and sweeten them with naturally sweet foods such as berries.

Make the Cut. If you are keen on baking, keep in mind that many recipes including those for muffins and cakes call for more sugar than what is necessary. So, you can try reducing the amount of sweetener called for by about 25 percent. Petitpain suggests including sweet tasting items like mashed banana, dates, and applesauce in your baking in place of some of the added sugar.

Embrace Other Tastes. Sweet is one of the five main tastes, with others being salty, sour, bitter, and umami. To reboot your taste buds, gradually increase your intake of unsweetened sour (such as plain yogurt or tart cherries), bitter (like arugula and radicchio), and umami (such as parmesan and mushrooms) foods. As a payoff, you’ll net more nutrients.

Be Wary of Free. Be especially skeptical of products like peanut butter, frozen yogurt, and salad dressings advertised as “reduced-fat” or “fat-free,” “When fat is removed from a product, sugar is usually added as a replacement to improve mouthfeel and flavor” Petitpain says. A serving of fat-free, fruit-flavored yogurt typically has three times as much sugar as a serving of two percent plain yogurt.

Spice it Up. Research suggests amping up the flavor of your cuisine with spices may allow you to cut back on the amount of sugar added to foods while still preserving acceptable overall liking. So, go bigger on spices like cinnamon and nutmeg in items like baked goods, oatmeal, and hot chocolate.

Don’t Fall for Health Halos. Sugar now comes in many guises, some of which, such as honey and maple syrup, are marketed as being better-for-you “more natural” ways to get your sweet fix. But for the most part, they don’t live up to their hype. “While they may offer extremely minimal nutritional benefits over refined sugar, they should still be consumed in moderation,” says Petitpain. No matter how virtuous it might sound, “organic sugar” is still sugar.

Walk Away from Cravings. The next time you’re about to give into candy bar temptation, lace up your running shoes. Research shows the simple act of taking a 15-minute brisk walk is enough to tame cravings for sugary snack foods. “Exercise releases endorphins and can improve mood and reduce stress, which are common triggers for sugar cravings,” notes Petitpain.

Order Water. Soft drinks, even the smallest sized ones, sold at top-earning restaurant chains in the U.S., have greater amounts of added sugar than the suggested daily limit, according to a report from the Center for Science in the Public Interest. When dining out, look for unsweetened beverage options. Many chain restaurants now have added sugar numbers for their foods and drinks listed on their websites, making it easier to tailor your order so it’s less sweet.

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In this Q&A, Dana Hunnes, RD, MPH, PhD, Senior Dietitian Supervisor, UCLA Medical Center, provides insights on dietary choices that can help us potentially live longer and also live better.

What does the phrase “food is medicine” mean?

“This phrase means that what we eat has the ability to protect our health, as medicine can,” explains Hunnes. “When we use food to protect our health, we are eating in a way that lowers our risk for chronic conditions. Or if we already have chronic conditions, eating healthfully may help manage them or control them better. If we are fortunate, a heathy diet can possibly reverse them.”

For example, research published in the Journal of Clinical Endocrinology & Metabolism found that study participants who followed an intermittent fasting regimen achieved complete diabetes remission, defined as maintaining an HbA1c level of less than 6.5% for at least a year without diabetes medication.

Why is eating whole foods so beneficial?

“There are many nutrients in whole foods that work synergistically with each other that make the “whole” greater than the sum of its parts,” says Hunnes. “By that I mean, we reap so many more benefits from eating a whole raspberry with all of its fiber and seeds. We gain more antioxidants, anthocyanins, micronutrients, and other anti-inflammatory compounds than we can ever get from eating one isolated nutrient extracted from said raspberry. When we eat ultra-processed foods or isolated nutrients, we are not getting that synergy. We are only getting single nutrients that likely don’t have the same effects.”

A good example of this is taking fish oil supplements for heart health. Numerous studies have shown that fish oil supplementation makes little to no difference in reducing the risk for heart attacks and stroke. But eating fish high in omega-3 fats may reduce risk of heart disease.

Why the  buzz around adhering to a mostly plant-based diet?

“Whole plant foods are filling, lower in calories, nutrient dense, and are associated with lower risk for disease and disability. That doesn’t mean no risk. It just means reduced risk,” she explains. “Plants have naturally occurring compounds that protect them against disease and pests which are also healthful to humans. For example, there are bitter compounds in sulphorphane vegetables (e.g., broccoli, Brussels sprouts, cauliflower) that protect them against pests, but are extremely anti-inflammatory and healthful to humans. Fiber also helps clean out the toxins from our digestive tracts, which is good. We don’t want to keep too much waste in our digestive tracts for long periods of time.”

Though eating these veggies raw provides the most nutrients, not everyone enjoys them raw. Steaming for a minute or two, lightly sautéing or even blanching helps maintain nutrients. Definitely avoid boiling because that method destroys valuable nutrients.

Can foods replace medicines and even cure diseases?

“While I’ve heard of these so-called miracles, they are relatively few and far between,” says Hunnes. “Certain chronic conditions such as diabetes or heart disease can be relieved, reduced, and possibly even reversed (sort-of like cured) by an extremely healthy diet. Other diseases, such as certain types of cancer, far less so, though (again) not impossible. With that said, it’s much easier to decrease the risk of ever developing these diseases, which are food/diet associated, than it is to try to correct/treat them after you have them. Healthy diet is always to our benefit.”

What are some simple ways to incorporate heathy foods daily?

“For easy snacks, keep sliced jicama, carrots, bell peppers, or other favorite veggies with hummus or pureed beans in the fridge,” she suggests. “For sweet treats, make your own trail mix of dried fruits and nuts, or enjoy fresh fruit such as blueberries, raspberries, or other blackberries with walnuts or almonds.”

Another strategy Hunnes suggests is to have a variety of whole and minimally processed foods in your kitchen. Also, be sure to stock canned and frozen healthy foods to ensure that you always have nutrient-rich foods available, regardless of the season. Leave the ultra-processed foods at the store and make rich desserts something you go out for as a special treat. 

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The disease can take significant toll on emotional and social well-being. For example, people who have chronic OA pain may have to give up doing things they love, such as pickleball, gardening, or playing instruments. Difficulty participating in social and recreational activities can lead to feelings of isolation and loneliness. All this can spiral down into a sedentary life, raising risk for obesity, heart disease and diabetes. Chronic pain and physical limitations also can lead to feelings of frustration, sadness, anxiety, and depression. For these reasons and others, researchers at UCLA and elsewhere have been striving to find better treatments and cures for OA.

“There is the obvious challenge of optimizing the science of the treatment to make sure it is effective in all types of patients. But this process also requires obtaining funding in a fiercely competitive funding landscape, navigating the regulatory environment, and making the therapy available in the relatively near-term future,” explains Thomas Kremen, MD, an orthopedic surgeon, and clinician-scientist faculty member at UCLA’s David Geffen School of Medicine. “The commitment of significant funding greatly accelerates the pace of the research and allows for the implementation of therapies in my patients much faster than the traditional timeline for developing novel therapeutics.”

A MultiCenter Effort

UCLA Health is part of a multi-institution research team receiving the contract for up to $33 million from the federal Advanced Research Projects Agency for Health (ARPH-A) for the development of new treatments specifically focused on joint regeneration for OA. UCLA’s portion of the award will support the development of novel therapies, with the goal of completing an FDA phase 1 clinical trial within the next five years.

This multi-institution team, which also includes researchers from Duke University and Boston Children’s Hospital, is one of five selected to develop innovative forms of regenerative medicine–including affordable injectable and implantable therapies – that can regenerate joint tissue damaged by OA.

More Than Wear and Tear

The cause of OA has primarily been thought to be physical wear and tear, but it’s more complicated than that. “OA is multifactorial with contributions from our genetic backgrounds, environmental exposures, history of traumatic injuries, each patient’s individual activity level, medical comorbidities, and age,” explains Dr. Kremen. “While high-impact activities are generally thought to increase wear and tear in the joint, a lack of activity is also associated with joint degradation and progression of symptoms.”

Current recommendations to slow progression of OA include lifestyle behaviors such as not smoking, losing weight, and treating medical comorbidities such as diabetes. “As challenging as it is to lose weight, for each pound we lose that equates to 4 pounds of force removed from each knee joint, and patients really notice improved mobility and decreased joint pain when they do lose weight.”

While pain and stiffness also are symptoms of rheumatoid arthritis (RA), it is far less common than OA and a distinctly different disease process. RA affects about 1.3 million adults, women more than men, and tends to begin between the ages of 30 and 50.  Neither OA nor RA currently has a cure.

“With rheumatoid arthritis, an autoimmune disease in which the abnormal biology is more easily defined, there have been all sorts of advances in the last 20 years. With osteoarthritis, we haven’t made any progress,” says Dr. Kremen.

Joint replacement and surgeries for OA offer imperfect treatments. While there is no age limit for joint replacement per se, preexisting conditions may make the process and recovery more complicated for older adults. Joint injections work for some people, others not so much. And then there’s all the marketing hype surrounding regenerative stem cell treatments, of  which none are currently FDA-approved.

“We have much work to do to characterize the mechanisms by which these cells may influence the biology of healing,” says Dr. Kremen. “Like many things in life, if what a clinician is claiming about a cell-based therapy sounds too good to be true, then it probably is not true. If you are being offered a stem cell therapy or a birth product-based therapy (e.g. umbilical cord blood, placental tissue, or amniotic membrane derived products), this should only be done in the setting of a clinical trial.”

Insights Into Cartilage Regeneration

Tissue regeneration is a burgeoning field. Working alongside Dr. Kremen, the UCLA Department of Orthopaedic Surgery research team also includes Karen Lyons, PhD, professor, and vice-chair for research, and Weiguang Wang, PhD, an assistant research faculty member. All three of these investigators have developed innovative technologies that, when combined, lead to a novel multimodal treatment approach.

In the lab of Dr. Lyons, who is a developmental biologist, researchers have been studying the signaling pathways that cause cartilage to develop in utero during early development. Once Drs. Lyons, Wang and Kremen connected, the scientists wondered if they could target the same pathways to regenerate damaged cartilage and bone tissue in adult patients suffering from osteoarthritis.

“Many of the same pathways that were used during early development are redeployed when tissues try to repair themselves,” Dr. Lyons says.

While developmental biology studies offer important clues about which pathways might be best targeted to treat osteoarthritis, there are significant differences between newly formed joints and adult joints. Those include barriers like inflammatory pathways and a diminished pool of cells capable of regeneration and repair in adults.

To test how well these pathways might be employed to repair joint degeneration, the UCLA research team has used both genetic and pharmacologic approaches in mouse models to identify several drugs that have the potential to repair articular cartilage and its underlying bone.

In addition to using animal models, the researchers will be testing their strategies on a so-called “joint-on-a-chip” platform, which mimics the healthy or diseased features of joints inside of the body.

Moving Forward

Ultimately, the research team plans to develop three separate types of injectables that patients would receive once per year: one that targets joint tissues; another that targets adjacent bone; and a systemically administered drug that could treat cartilage tissues in patients who have OA in multiple joints.

At the end of five years, Dr. Kremen says, the researchers plan to have completed the testing of these treatments in phase I clinical trials, which will be conducted at UCLA.

“ARPA-H is really focused on commercialization and affordability,” Dr. Kremen says. “They have an ambitious timeline, because they, and we, want to get these therapies into people as soon as possible.”

“You gain immediate feedback from a knowledgeable physical therapy professional,” says Dr. Kremen.

Physical activity strengthens muscles and bones. If you have pain with one activity, Dr. Kreman suggests trying another activity that is known to be lower impact. For example, instead of running you try brisk walking, biking, or an elliptical machine. If those cause pain that is not tolerable, try something even lower impact like swimming or walking in the pool. 

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➥ Answering questions that weren’t asked.

➥ Watching TV with the closed captions on and the sound turned up.

➥ Difficulty talking on the phone.

➥ Avoiding social situations.

If any of these scenarios hit home with you, make an appointment with an audiologist. Audiologists typically hold a doctor of audiology (AuD) degree. They thoroughly assess your hearing, help you select the ideal hearing aids, customize the fit, and program the devices for your needs

Say Goodbye to the Stigma

A common concern is that hearing aids will make a person look old, but the reality is otherwise. “Having a tiny hearing aid behind your ear can be overlooked, whereas asking for repetition or not responding to a statement at all is more difficult to ignore,” says Gina Gracia, AuD, Clinical Manager, UCLA Audiology Clinic.

Some people may shy away from hearing aids because they lack the dexterity to deal with small batteries, or think they may be too complicated or too expensive. Rechargeable batteries solve the battery problem, and audiologists help you get the appropriate, affordable devices and provide instruction and follow-up appointments.

Over-the-counter hearing (OTC) aids may be a solution for some people, but they aren’t necessarily the right choice for everyone. “OTC hearing aids generally make all sounds louder, including background noise, which can interfere with understanding conversations,” explains Gracia. “Traditional hearing aids are programmed specifically to your type and degree of hearing loss, and are equipped with technology to amplify speech and reduce constant background noise.”

It’s also important to know that your brain needs time to adapt to hearing aids. The sooner hearing loss is diagnosed and treated, the better. But you should not expect hearing aids to restore hearing to normal. “Hearing aids give you a new definition of normal as long as a suitable selection is made, is programmed appropriately, and used consistently,” says Gracia.

Hearing aids have become smaller, some virtually invisible, and they have become quite sophisticated, too. For example, you can connect Bluetooth hearing aids directly to a cellphone, tablet, or computer so you can stream audio from these devices directly to your ears.

Although hearing aids are very helpful, unfortunately they are not covered by Medicare and can be quite costly. Some Medicare Advantage plans may offer partial coverage, depending on the plan. If too costly, less expensive alternatives, such as pocket talkers, amplifiers, or the OTC hearing aids, maybe viable options.

“Hearing aids can be as complicated or as simple as you want them to be,” points out Narine Oganyan, MHA, Director UCLA Speech Pathology & Audiology Clinic. “An audiologist will help you select a hearing aid that is appropriate for your hearing loss, taking into account lifestyle and personal preferences.”

Improve Your Social Life

Research suggests that using hearing aids to treat hearing loss may help slow the development of cognitive problems. In an NIH-funded study from Johns Hopkins University, nearly 1,000 adults ages 70 to 84 were enrolled to compare cognitive decline between those who received hearing aids and those who did not over a three-year period. Included were participants with significant hearing loss and substantial dementia risk factors. For them hearing aids reduced cognitive decline by nearly 50%.

Hearing better can reduce loneliness because it can facilitate clearer communication with family and friends, leading to stronger, more positive relationships. Improved hearing also can reduce the risk of depression and anxiety, and enhance personal safety and independence by helping you stay aware of surroundings and important sounds such as alarms, sirens, and traffic.

If you’re not hearing well, why not give hearing aids a chance for a few months to experience what you’ve been missing? You just might be pleasantly surprised. And if you suffer from tinnitus, in some cases, hearing aids can mask the irritating sounds. For some people that could be reason enough to try them.   

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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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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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