INTEGRATED MEDICINE AND COMMON AILMENTS IN ELDERLY
H L Dhar*
*Director, Medical Research Centre of Bombay Hospital Trust, Mumbai 400 020.
All systems of medicine including modern medicine have their centres of excellence in the country, however, they work independent of one another. This has resulted in each system developing in a more or less compartmentalised way. Time has come to look at health care in a more integrated and holistic manner so as to give best possible treatment to the patient. However, there is no alternative to modern medicine in acute bacterial infection or surgically treatable conditions and medical emergencies although certain chronic illnesses e.g. osteoarthritis, anxiety/depression, certain skin diseases and even obesity can better be treated with alternative systems.
Ideally acute conditions should be treated by modern medicine followed by one of the alternative system according to the choice of the patient; conversely chronic diseases unless exaggerated may initially be treated with alternative system failing which drug therapy may be instituted.
Common and urgent health problems are cardiovascular disorders, gastrointestinal conditions and other conditions from which elderly subjects usually suffer but certain conditions are more common to elderly men similarly certain other conditions are more common to women. However, certain problems are of special importance to both elderly men and women and still other conditions which are common to both elderly men and women. All these conditions can be treated by integrated system of medicine depending on urgency, patient’s choice and feasibility.
Since the dawn of civilization mankind has evolved methods of relief from diseases. Every human community has responded to this challenge by developing a ‘medical system’ i.e. the pattern of social institutions and cultural traditions that evolves from deliberate behaviour to enhance health. Until the beginning of the 19th century, all medical practice was what we call now traditional. Although we know very little about the earliest periods, the congruences in the traditional medicine of China, India (Ayurveda) and Moslim Asia (Unani), in classical Greek medicine and modern humoral pathology certainly reflect ancient cultural exchanges.
The published accounts of the worlds’ medical systems have made possible the new discipline of “ethnomedicine” i.e. those beliefs and practices relating to disease which are the products of indegenous cultural development and are not explicitly derived from the conceptual framework of modern medicine.
There are four main organizational relationships between official and traditional health care service. (i) monopolistic because it gives to allopathic practitioners sole right to practice medicine (ii) tolerant where traditional and unofficial practitioners are free to work and be paid for services in all other fields provided they do not claim to be registered medical doctors (iii) parallel, where allopathic and other systems of health care are officially recognised and render services to patients through equal but separate systems (iv)integrated system in which modern and traditional medicine are merged to medical education and jointly practised within a unique health service.
Purpose of this article is to identify important and common health problems in elderly subjects and approach to treatment through integrated system. Present discussion will be limited to recognised systems of medicine i.e. modern medicine, ayurveda, unani, homoeopathy and nondrug therapy particularly naturopathy, yoga and meditation.
Many problems presenting in general practice are self limiting and minor. The four major conditions encountered by general practice - anxiety/depression, respiratory disorders, skin diseases and pain all respond in some degrees to several alternative approaches. At times practitioners come across patients who have nothing more to receive from allopathic medicine. They now resort to alternative medicine like acupuncture/acupressure, ayurveda, unani, homoeopathy, osteopathy, relaxation technique, meditation, yoga, magnetotherapy and other manipulative techniques and even urine therapy.
However, there are many occasions when allopathic drugs because of their toxic effects are not wanted and the patients wish to have non drug treatment. But such therapy should never be offered to patients having acute bacterial infection or surgically treatable conditions and medical emergencies where the use of allopathic approach has been proved to be definitely life saving., Short comings of allopathic medicine are mainly felt in chronic illness. One such example is osteoarthritis of various joints. Then there are other illnesses like chronic bronchitis, inoperable malignancies and even patient of obesity who have tried various therapies - all of whom can be offered an alternative medicine.
If a patient reports for any acute illness should be treated with modern medicine, when acute phase is over one of the alternative therapy should be offered but ultimate choice should lie with the patient. Finally when a patient recovers, one of the vedic approaches like yoga (yogic exercises may not suit elderly) and meditation particularly transcendental meditation has been reported to reduce occurrence of illness and hospital admission, general management like diet and exercise notwithstanding. All the systems including allopathy have their centres of excellence in the country. They however, work independent of one another. There are also different research councils set up ostensibly for giving special encouragement to each branch of medicine. This has resulted in each system developing in a more or less compartmentalised way resulting in a fragmented and hence narrow manner. There are no known centres where all systems of medicine are available for a patient to choose from. The time has come to look at health care in a more integrated and holistic manner so as to give the best possible treatment to the patient.
COMMON AND URGENT HEALTH PROBLEMS
Heart disease is of great significance in old age as large number of the elderly suffer from heart problems and one fourth of them die. Cardiovascular diseases remain the leading cause of death in United States. Yearly death rate from cardiovascular diseases in India was 9% in 1986 which rose to 11.1% in 1989. However, no such data is available for elderly subjects.
Traditional cardiovascular risk factors: hypertension, diabetes mellitus, dyslipidaemia, smoking and family history of premature atherosclerosis are predictive of subsequent myocardial infarction and stroke in women as well as men although relative impact of individual risk factors differ.
An elderly person may be quite comfortable at rest but chest pain can occur during an effort. This is anginal pain. Usually anginal pain is often less severe in the elderly than in middle aged patients.
This may be due to reduction in normal physical activity or an altered pain perception. Severe chest pain with sweating occurring suddenly in an individual suggests an acute heart attack. But in the elderly the clinical features may be extremely variable and atypical presentations are common. Variable presentations include silent attack and sudden death, breathlessness, vomiting, palpitation, change in behaviour, unexplained abdominal pain or stroke. The severity of heart attack increases with age and complications in old age are common.
If an elderly person feels discomfort in the chest or feels exhausted suddenly or has breathing difficulty he should consult a doctor without delay to find out if he is suffering from heart attack. Common factors involved in silent heart attack:
1. As one gets older nerves become weak and ineffective and the patient loses the sensation of pain. Silent chest pain is most common in diabetes due to diabetic neuropathy.
2. Forgetfulness is common in old age. Elderly persons may either forget or ignore the chest pain.
3. Elderly persons are subjected to various disorders and malfunctioning of parts of the body and therefore they would have learnt to bear and live with discomfort and may not take chest pain seriously.
Treatment of acute cardiovascular disorders should be modern medicine, one should immediately consult a doctor and go to hospital. Once acute phase is over modern medical treatment may continue or may be combined with alternative systems or even replaced by alternative therapy. General guide lines are as follows:
1. Investigations done to arrive at proper diagnosis.
2. Predisposing factors should be attended to i.e. hypertension, diabetes, smoking, obesity, high cholesterol etc. Lack of adequate physical activity and stress and strain should be looked into. Stress and strain may better be taken care of by meditation.
3. Excess weight can be reduced by regular exercise including yogasanas if possible and/or by simple walking along with diet (balanced control).
4. Avoidance of smoking is a must. Smoking leads to constriction of blood vessels, obstructs flow of blood to the heart and may precipitate heart attack.
5. If diagnosed causes should be treated whether medical or surgical.
Hypertension is not a disease but a major risk factor leading to many diseases affecting the heart, brain, kidney and peripheral vessels. It is not a simple physiological accompaniment of aging but mostly depends on many factors like smoking, lack of exercise, stress and strain, life style and other environmental factors. In the elderly blood pressure should be around 140 systolic and 90 diastolic but upto 160/95 may be considered borderline hypertension, should be controlled by exercise, balanced diet, but blood pressure above 170 systolic and 100 diastolic must be treated with drug in addition to diet and exercise.
Hypertensive patient may be symptom free and the problem may come to light only when the doctor examines the patient and checks his blood pressure. Elderly subjects should have periodic health checkup, irrespective of whether they have symptoms of BP or not. Symptoms may vary from person to person, common ones are giddiness, headache, chest pain, breathing difficulty, swelling of the legs, paralysis etc. Hypertension affects the brain, heart, blood vessels, kidneys and eyes.
Investigations are necessary to assess the end organ damage of a hypertensive patient and also to find out any co-existent diseases. Basic investigations to be done are blood urea, serum creatinine, serum electrolytes, blood sugar, lipid profile, urine analysis, ECG and X-ray chest. Other special investigations may be done whenever necessary.
Management of hypertension can be divided into nondrug therapy and drug therapy depending on the degree of hypertension. In mild to moderate hypertension nondrug therapy must be tried.
Non drug therapy
Weight reduction in over weight patients, salt restricted balanced diet, stopage of smoking (in smokers), daily exercise (walking etc) should be must in all patients followed by
i) Yogasanas if possible. Yogic exercises have been shown to benefit hypertension.
ii) Meditation - Transcendental meditation has been reported to cure hypertension.
If above measures fail
i) Tranquilizers/sedatives in tense and worried patients.
ii) Diuretics are clearly the drugs of first choice with addition of beta blockers if required. Calcium channel blockers are alternative., For severe hypertension and hypertensive crisis patient should be admitted to hospital for further treatment.
Once patient’s BP is under control nondrug therapy must be followed with or without drug therapy.
Another common ailment that older individual may suffer from is postural hypotension - (fall of BP with change of posture). Changing from lying to the sitting or standing position leads to pooling of approximately half a litre of blood in the lower extremities. If no compensation is made, it leads to drop in the circulation to the brain and may produce giddiness or a fainting attack especially while trying to get out of bed after prolonged rest.
Postural hypotension is common in elderly because the compensatory mechanisms become less effective. The main predisposing factors for postural hypotension are:
i) Drugs like diuretics, tranquilizers, beta blocker etc.
ii) Volume depletion due to severe diarrhoea and vomiting.
iii) Varicose veins which cause pooling of blood in the lower limbs.
iv) Diabetic autonomic neuropathy.
i) Practical advice regarding gradual changes in position, particularly on rising first thing in the morning may prove to be very helpful.
ii) Use of elastic stockings are of benefit to avoid the pooling of blood in the lower limbs.
iii) Where drugs are responsible - avoidance or lowering of dose.
iv) Yogic asanas if practicable may be helpful. v) Meditation 15-20 minutes morning and evening are helpful.
Patients should be told postural hypotension carries no risk of mortality but should be advised to maintain physical fitness, avoid smoking, drinking etc and cardiac problems treated.
Prevalence of heart failure increases with age and in most cases heart failure in old age is associated with a multiplicity of cardiac pathology. Heart failure occurs secondary to heart disease like hypertension, heart attack, valvular heart disease and severe anaemia. The patient may suffer from breathlessness or exertion and breathlessness occurs especially at night.
Rational approach to treatment
The right or left side of the heart may fail and symptoms may vary accordingly. Acute left heart failure is a medical emergency and bronchospasm should be relieved immediately. Right sided failure can be relieved by diuretics and other supportive measures including use of digitalis on hospitalization.
Heart failure is a syndrome and where possible the underlying cause or precipitating factors should be identified and managed. Once the heart failure is controlled the patient should be mobilized gradually being allowed to walk a few yards at first and then by increasing it until fully abulant within 10-14 days. Other measures including balanced diet, change of life style, exercise (walking) and regular practice of meditation may follow.
However, efficacy of angiotensin converting enzyme inhibitors in asymptomatic patients with moderate to severe left ventricular dysfunction has underscored the importance of detecting systolic left ventricular dysfunction in older persons.
As age advances lack of appetite, impairment of the sense of taste, indigestion, stomach pain, sluggishness of bowel habits are common in elderly. Reduced motor activity resulting in delayed entry of food into the stomach, reduced salivary secretion and impaired absorption of major nutrients including Vit B1 and B12 are other common features in the elderly.
Common complaint among elderly is dryness of mouth. This may be associated with mouth breathing or insufficient fluid intake (elders are advised to take more water). It may also be due to drug side effects and diseases like diabetes mellitus, kidney problem etc. Common gastrointestinal disorders are:
Ulcers in the mouth may be due to deficiency of iron, folic acid or vitamin B12, diseases of the stomach and intestine. Drug may also produce redness and ulceration in the mouth e.g. tetracycline, barbiturates, sulphonamides, iodides, phenacetin and salicylates. Malfitting dentures can also produce mouth ulcers (old people require dental attention very frequently).
i. Mouth wash with warm saline water
ii. Supplementation of vitamin B complex forte
The next common problem is dysphagia or difficulty in swallowing (reduced motor activity in elderly). This is a disorder of motility and may occur due to conditions such as oesophageal spasm, hiatus hernia, reflux oesophagitis, obstruction by cancer, certain diseases of the nervous system and drugs.
One common cause of dysphagia in elderly subjects is due to weakness of the nerves of the food pipe and creates a sensation of destruction as food passes through it which may lead to discomfort and even chest pain which may be mistaken for heart attack.
Diagnosis and treatment
Simple barium meal X-ray and/or endoscopy can help diagnose and can be treated with simple medicine like smooth muscle relaxants.
Reflux oesophagitis is a condition where acidfrom the stomach enters the oesophagus and causes ulcers.
Symptoms : Heart burn, feeling of obstruction in the food pipe, vomiting and excess salivation in the mouth.
Treatment : Antacids particularly use of H2 blockers are helpful. Those who suffer from such disorders should not sleep immediately after eating (even otherwise one should not go to sleep just after dinner, there should be a gap of minimum 10-15 minutes). The pillows should be thick (2 pillows of ordinary thickness).
Some time part of the stomach gets drawn into the chest through diaphragm common among women and obese people.
i. Should avoid bending forward mainly after a meal.
ii. Small and frequent intake of food avoiding spicy and fatty food.
iii. Should use tilting bed with head portion at a higher level.
iv. Symptomatic treatment. If above measures fail - surgery.
Males are more affected than females, common predisposing factors are, smoking and consumption of spicy foods.
Symptoms : Obstruction in swallowing, initially of solid food later on even liquid. Retching and vomiting and gradual loss of weight. Men are more susceptible than women.
Report to doctor without delay.
Diagnosis : Based on barium x-ray confirmed by endoscopy with biopsy and cytology.
Treatment : Surgery, radiation therapy, chemotherapy etc. along with practice of meditation for reducing tension, worry etc. contributing to peace of mind. Meditation also alters pain perception.
Inspite of reduced gastric secretion in elderly peptic ulcer (ulcer of stomach and/or duodenum) is not uncommon which can be precipitated by drugs (aspirin, steroids), smoking and consumption of alcohol, stress and strain and infection with H. pylori (bacteria).
Symptoms : Pain abdomen and chest with or without radiation, altered by diet, anaemia, loss of appetite and weight may be associated with depression. Gastric ulcer without pain may occur in elderly taking nonsteroidal antiinflammatory drugs. Duodenal ulcer is more common and mostly benign and usually associated with pain relieved by eating.
Diagnosis : Barium meal X-ray and endoscopy.
Management : Change of life style (diet control) - no smoking or drinking. Treatment has become easy with the introduction of H2 blockers and complications like bleeding, perforation rarely occur.
The incidence of gall stones increases with advancing age. Gall stones are often symptomless, especially in the elderly. If they migrate into or through the bile duct, they may remain silent or produce severe abdominal pain. Partial obstruction of bile duct may produce obstructive jaundice. Cancer of the gall bladder may develop after some years. The diagnosis can be easily confirmed by ultrasonogram. Treatment is surgical.
Constipation is the most troublesome disorder affecting old people. Elderly people are always obsessed with the regular or irregular movement of bowels and at least 50% of them take laxative without doctor’s prescription.
i. Lack of adequate fibres in the food consumed.
ii. Inadequate intake of water for fear of passing urine frequently.
iii. Drugs : iron, pain killers, antacids, diuretics, antidepressants and sleeping pills.
iv. Lack of adequate movement due to arthritis.
i. Intake of fibres - fruits, vegetables etc.
ii. Intake of water
iii. Physical activity
iv. Yogic asanas sometime help. If above measures fail laxatives.
Diarrhoea is a common problem and a potential threat to debilitated frail elderly. Infective diarrhoea is the commonest; should be treated with appropriate antibacterial drugs.
Acute diarrhoea may result from dietary indiscretion, excessive use of purgative or secondary to drugs (e.g. magnesium trisilicate as antacid). Persistent diarrhoea may occur in kidney failure, thyroid disorders, diabetes, gastric and liver diseases and malabsorption syndrome. Intestinal tuberculosis and cancer bowel can also present as diarrhoea.
Intake of less bulky and non irritant food stuff (e.g. raw banana), natural astringents (substances that precipitate proteins) containing tannic acid (e.g. tea) may help.
If above measures fail i) Initially nonspecific antidiarrhoeal agents (kaolin, pectin etc).
ii.) Antimotility drugs, codiene, lomotil etc. In case of severe diarrhoea patient should be admitted in the hospital for saline infusion (iv fluid) to prevent dehydration.
Special problems of health in elderly
Specific problems of health in elderly male; (hypogonadism erectile dysfunction, prostate problem, gynaecomastia) and female (post menopausal hormone therapy, urinary incontinence, cancer lung and breast) should be looked into and treated accordingly. Problems of special concern to both male and female (osteoporosis, falls, nutrition and cognitive functions etc.) have been reviewed recently.
Geriatric assessment approach
Comprehensive geriatric assessment shows both men and women have a series of issues in common perhaps best represented by “Is” of geriatric syndromes.
Impaired vision and hearing
Intellectual impairment (delirium, dementia)
Iatrogenesis (especially polypharmacy)
Although a number of these conditions are even more important for women (e.g. urinary incontinence and impecunity), they remain important for both genders, are of particular concern for older men. Men are also more likely than women to suffer from alcoholism and baldness. Both genders can experience sexual dysfunction with age, but the problem of impotence is particularly pertinent for older men. Problems with prostatism and prostate cancer are unique for men and increase progressively with increasing age.
Impaired vision and hearing are common problems of elderly which should be referred to eye and hearing specialists. Yogic asanas and meditation might be complimentary.
Incontinence has been delt with in detail elsewhere, however, yoga asanas and meditation are beneficial.
Inanition (malnutrition) in the elderly subjects and the dietary requirements in Indian elderly has been reported recently. Instability (falls), its prevention and management has been under publication. Measurement of BP (sitting and standing) to detect orthostatic hypotension and meditation may help.
Immobility : Problem of immobility in the elderly as well as quantum of physical movement under different situation has been dealt with in detail.
Intellectual impairment (delirium, dementia): corrective measures have been discussed,18 however, meditation has been shown to be very much effective.
Isolation (depression) : One of the main causes of depression is loneliness which is a deadly enemy in old age, can be converted to solitude by practice of meditation and one never feels lonely.
Yogic asanas and meditation are the best remedy in this condition.
Insomnia : A common phenomenon in elderly can be better taken care of by regular practice of meditation.
Polypharmacy (use of more than one drug at a time) is the rule rather than exception in elderly. Consequences of multidrug therapy has been reported by us earlier.
Impecunity (poverty) is a social problem of national importance. However, one can take corrective measures right from middle age including saving and keeping the assets in own name till death.,
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