Falls in the elderly increase risk of injuries

IMA emphasizes on making the house risk free to avoid the risk of falling

New Delhi, 09 July 2017: According to statistics, about 14% to 53% fatal and nonfatal injuries in the elderly (above the age of 65) are due to falls, with the associated mortality standing at as high as 86%. India's elderly population is growing rapidly with the percentage expected to increase to about 10% by 2021. As per the IMA, the need of the hour is to create awareness among family members and caregivers alike on how they can ensure a safe and secure environment for the elderly and prevent falls.

Head injuries, shoulder and forearm fractures, spine fractures, and pelvic and hip fractures are some of the most common fall injuries in the elderly. The risk factors include muscle weakness; gait deficit; balance and postural deficit; visual and hearing deficit; arthritis; Vitamin D deficiency; uneven ground; slippery surfaces; stairs/railing; depression; and Dementia.

Speaking about this, Padma Shri Awardee Dr K K Aggarwal, National President Indian Medical Association (IMA) and President Heart Care Foundation of India (HCFI) and Dr RN Tandon – Honorary Secretary General IMA in a joint statement, said, "Falls are a common occurrence in the elderly but their associated complications can make matters worse. Many people believe that falls are a part and parcel of old age and cannot be prevented. However, this is not the case. It is the lack of knowledge that leads to a lack of preventive action, and thereby falls. Often, falls in the elderly happen at home itself. Elderly patients who have fallen need to get a thorough evaluation done. Doing so will help in determining and treating the underlying cause of the fall, which in turn will help them return to baseline function and reduce the risk of recurrent falls."

Elderly hospitalized due to falls stay in the hospital twice as long as those admitted due to some other reason. They also see a greater functional decline in activities of daily living (ADLs) as also subsequent institutionalization.

Adding further, Dr Aggarwal, said, "Falls are a sign of declining function and poor health in the elderly. It is important to question elderly patients with known risk factors for falling on a periodic basis. This is more so because many elders may not come out in the open about it, fearing institutionalization. They should also be examined for any physical injuries."

Some ways in which you can make the house safe for the elderly include the following.

·  Provide safety devices such as grab handles, high friction floors and footwear, as well as low power lighting at night in your home

·  Regular physical activity can increase muscle strength and improve balance. They will also help in improving co-ordination and help them perform functional tasks in a better manner.

·  Periodic monitoring and review of medications and ongoing medical problems

·  Ensure adequate intake of vitamin D as its deficiency is associated with increased risk of falling and bone fractures.

Number of patients needing dialysis in India shows an upward trend

Early detection key to treating this disorder, says IMA

New Delhi, 08 July 2017: According to statistics, in the past 15 years, the number of Indians suffering from chronic kidney ailments has doubled. It is alarming to note that there has also been a 10% to 15% increase in the number of patients undergoing dialysis in the country and this percentage includes children as well. As per the IMA, kidney disorders still do not receive as much focus in India and that is one reason for under-diagnosis of this condition.

Chronic kidney disease is a slow progressive loss of kidney function over a period of several years where the patient eventually has permanent kidney failure. It largely goes undiagnosed and people realize that they have chronic kidney failure only when the kidney function is down to 25%.

Speaking about this, Padma Shri Awardee Dr K K Aggarwal, National President Indian Medical Association (IMA) and President Heart Care Foundation of India (HCFI) and Dr RN Tandon – Honorary Secretary General IMA in a joint statement, said, "Chronic kidney failure is a slow and gradually progressive disease. The signs and symptoms become apparent only after the disorder reaches an advanced stage. However, once it reaches a later stage, the damage can't be reversed. In an advanced stage, dangerous levels of waste and fluid can rapidly build up in the body. Those at a risk of developing this disorder should get a kidney function test on a periodic basis as any signs detected at an early stage can help in preventing serious kidney damage. People with end-stage kidney disease cannot keep up with the waste and fluid elimination process on their own. They will thus need dialysis or a kidney transplant to survive."

There are various reasons for renal ailments including smoking, liquor intake, unhealthy eating habits, sedentary lifestyle, diabetes mellitus, and high blood pressure. It can also be the result of certain underlying medical conditions or at times medications.

Adding further, Dr Aggarwal, said, "Many people are unaware that diabetes and high blood pressure are the two most common causes of kidney disorders. Two simple tests can help in prevention of kidney disorders in a person: one to check the level of protein in urine and the other, a blood test for measuring serum creatinine. Both tests done once a year can help in detecting any abnormality and taking preventive care at the earliest."

The following tips by the IMA can help in reducing the risk of developing kidney disorders.

• Keep active: Activities like walking, running, and cycling can help in decreasing the chances of kidney disorders.
• Keep fasting sugar < 80 mg: Kidney damage from diabetes can be reduced or prevented if detected early.
• Keep lower BP < 80 mm Hg: High blood pressure is especially likely to cause kidney damage when associated with other factors like diabetes, high cholesterol and cardiovascular diseases.
• Keep your abdominal circumference < 80 cm: Eat healthy and keep your weight in check. This helps in preventing diabetes, heart disease and other conditions associated with chronic kidney disease.
• Reduce your salt intake: The recommended sodium intake is 5-6 grams of salt per day (around a teaspoon). Limit the amount of processed and restaurant food and do not add salt to food.
• Drink adequate fluids: Drink 1.5 to 2 litres (3 to 4 pints) of water per day. This will help the kidneys clear sodium, urea and toxins from the body.
• Do not advocate “aggressive fluid loading”, this can cause side effects. In addition, people who have already had a kidney stone are advised to drink 2 to 3 litres of water daily to lessen the risk of forming a new stone.
• Do not smoke: Smoking slows the flow of blood to the kidneys and increases the risk of kidney cancer by about 50%.
• Do not take over-the-counter pain killers: Common drugs such non-steroidal anti-inflammatory drugs like ibuprofen are known to cause kidney damage and disease if taken regularly.

Evidence-based vs eminence-based practice

Western “evidence” cannot take the place of Indian “eminence”

Medicine has undergone a generation change with the technology savvy younger doctors now coming to the forefront and taking over from the older doctors. These young doctors have the latest information at hand about the happenings (researches) in the field of medicine.

Evidence-based medicine has become the norm in clinical practice today.

In an editorial published in the BMJ in 1996, Dr David L Sackett and coauthors defined EBM as “conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research”.

Evidence-based practice (EBP) incorporates clinical expertise or skill with best available clinical evidence and patient expectations and values. It is a dynamic process, which is continually changing because new studies are being published everyday adding to the existing body of evidence.

Even the law requires evidence. Bolam test, which evaluates the standard of care and decide on the adequacy of information disclosed when deciding cases of medical negligence, is based on experience “… is not guilty of negligence if he has 'acted in accordance with a practice accepted as proper by a responsible body of medical man skilled in the particular act”. And, the adequacy of information disclosed to the patient for a valid consent, as per Bolam test, must be in accordance with the practice accepted at that time as considered proper by a responsible body of medical opinion.

Whereas, the case of Montgomery v Lanarkshire Health Board decided by the UK Supreme Court is based on evidence. Doctors in UK are now required to furnish information about all possible risks associated with a particular treatment, however rare, to the patient “…to ensure that the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments”.

Evidence-based medicine relies on scientific evidence derived from studies, which can be case reports, case series, case-control studies, RCTs, systemic review, meta-analysis, observational, retrospective. The methodology of each is different, the sample population is different. The population differs in terms of ethnic groups, geography, culture, phenotype, etc. Hence, data cannot be extrapolated from one population to another population not included in the study, especially of a different ethnic group.

For this reason, international guidelines are not suitable for India. The heterogeneity of population, different phenotype and cultural beliefs and practices need to be considered. For example, take the case of TB. Western data cannot be extrapolated to our population with TB. We have only recently started to come out with India-specific guidelines.

‘Eminence-based practice’ is based on clinical experience and wisdom of a person of eminence gathered over many years of clinical practice. Personal experience is also data, which is unpublished. Where Indian data is lacking, experience will count.

There will always be a place for “eminence-based” practice. Even if local evidence is available, but cannot be applied to the patient or the patient is a complicated case, clinical experience prevails over evidence.

So does, evidence-based practice trump eminence-based practice?

No. None can supersede the other. Both need to coexist with their individual benefits and limitations.

You need to be updated with the latest technologies and developments in medicine to give the best possible care to your patient, yet, the value of experience can never be discounted or disregarded. Eminence-based practice runs the risk of personal bias, which is omitted in evidence-based practice.

This scenario can be likened to the age-old debate of young (evidence) vs old (eminence), black hair (evidence) vs gray hair (eminence), experience (eminence) vs enthusiasm (evidence). There is no clear winner, no clear loser.

Maa Saraswati, the Goddess of Knowledge, wisdom and learning. She is shown holding a small Vedic book in one hand, a rosary in the second and a large Veena in the other two. The small Vedic book indicates that reading books is important but this alone is not sufficient to gain knowledge. The small rosary also denotes that one needs to read a subject repeatedly. The main tool, the large Veena represents practice or Abhyas or experience or “eminence”.

The practice of medicine is an art (eminence) based on science (evidence). Hence, the clinical expertise of the doctor and the best available evidence should be considered together for best patient outcomes. 

Dr KK Aggarwal

National President IMA & HCFI

IMA indicates five Ds that determine when to get a health checkup

Important to watch out for signs that the body gives and take steps to counter negative stress

New Delhi, 06 July 2017: According to studies, people go to the doctor only when they are experience a health problem or if they are looking for specific diagnosis or treatment. Many others get a health check up done as a follow-up to some chronic problem or disease. However, many are still unsure about how frequently they should get examined and under what circumstances.

As a general rule, the purpose of a periodic health examination is to ensure primary prevention, identify risk factors for chronic diseases, detect diseases with no apparent symptoms, promote self well being, and update clinical data since last checkup. Experts at the IMA feel that there are five Ds that can be used as determining factors for getting a health check up done: Decade, Death, Divorce, Diagnosis, and Decline.

Speaking on this, Padma Shri Awardee Dr K K Aggarwal, National President Indian Medical Association (IMA) and President Heart Care Foundation of India (HCFI) and Dr RN Tandon – Honorary Secretary General IMA in a joint statement, said, "The key to getting yourself checked is any kind of change, be it your social profile or mental status. The first determinant is when you enter a new decade of your life. Health needs and issues vary with age and therefore, one must get a checkup done according to age. The second and third are negative stress factors such as Death and Divorce. Divorce need not be just between a couple but also that from profession and friends. A death in the family, an underlying disease, or any other stressful event can precipitate symptoms in a person. Fourth is when you have a likelihood of or are diagnosed with some medical condition. Lastly, any decline in an existing health condition or any unusual and unexplained health issue or symptom which you may be observing for the first time in life warrants a checkup."

A health check up consists of updating your health statistics, physical examination, and diagnostic tests. The doctor also gives advice on the kind of dietary and lifestyle changes one needs to bring in with age and according to other determining factors.

Adding further, Dr Aggarwal, said, "People today are leading a life full of stress and worry. The human body responds to how one thinks, feels, and acts. When a person is stressed, anxious, or upset, the body reacts in a way which will indicate that something is not right. For example, one may experience a rise in blood pressure after a particularly stressful event such as the death of a loved one. While it is always better to get periodic health checkups done, it is also imperative that a person gets examined in case of any particular event that may cause the body to react differently."

Here are some lifestyle changes one can make to overcome stress.

• Take time out for relaxation In this age of smart phones and gadgets, it is a must that we take time away from them and relax the mind and body. Yoga and meditation are a good way to do this.
• Indulge in physical activity Get at least 30 minutes of exercise every day.
• Eat healthy A diet rich in fruits and vegetables can give you all the essential nutrients for the body to function well. Eat healthy and avoid junk food as far as possible.
• Get good sleep our mind and body can function well only if they are well rested. Get a good night's sleep and when possible get a power nap in the afternoons. 

Paradigm shift in blood donation

India has huge population of more than 1.3 billion, but is still short of blood by 20-25%. Blood donation is a requirement of the society. All donations should be voluntary.

Blood donation camps are often organized by hospitals and NGOs. But these are whole blood donation camps.

But, now no camp should be organized for ‘whole blood donation’. Instead components-only blood donation camps should be organised. One unit of blood collected can be used to help 3 to 4 patients, instead it is being wasted as whole blood depriving another patient in need. And, voluntary blood donation camps should be now called “blood component donation” camp and not just blood donation camp. So, if the blood being donated is collected in a single bag, do not give blood. Usually two component bags are used. 100 ml bags should be promoted for pediatric use.

People with rare blood groups should not donate in camps. They should instead donate only when needed.

Under the new National Blood Transfusion Council regulations, no blood is to be wasted. The surplus left over plasma is fractionated to manufacture products like albumin and intravenous immunoglobulins (IVIG). The blood that is donated in voluntary blood donation should be maximally utilized.

The tests done are for blood groups (A, B, O) and Rh factor and five transfusion-transmitted infections namely hepatitis B and C viruses, HIV 1 & 2, VDRL and malaria. Tests with the shortest window should be chosen as per affordability.

For safe blood transfusion, tests other than those prescribed by the government should also be available such as minor blood groups, nucleic acid amplification testing (NAT). NAT detects very low levels of viral RNA or DNA that may be present in donated blood and reduces the window period of detection of viruses like hepatitis C, hepatitis B, HIV, which may otherwise be undetected by 3^rd generation or even 4^th generation ELISA-based tests. The prevalence of hepatitis B, C and HIV is very high in India.

The doctor has a duty to inform the donor that facilities for these other tests are also available and the donor or the recipient should have the right to ask for extra tests. Till they a national policy is formulated in this regard, a doctor can help the donor or the recipient to decide. An informed consent must be taken from the donor or the recipient explaining the risks by not doing these tests, however small and rare they might be. These tests may add to the cost of the blood transfusion, but patient safety is foremost.

The donor’s blood should also be tested for lipids, liver enzymes (SGOT, SGPT), kidney function (creatinine); a complete hemogram can be done, so that the donor gets a comprehensive panel of tests done, when he/she volunteers to donate blood.

Rational blood transfusion is safe blood transfusion… Transfuse blood only when necessary. If only one unit is required, don’t transfuse blood; if two units are required, transfuse one. If hemoglobin is more than 7, give a trial of intravenous iron first. This is also a very important way by which the transfusion-transmitted infections can be reduced. 

Prevalence of thyroid disorders increasing in India

Women more likely to get affected, with increased risk of various side effects in pregnant women

New Delhi, 07 July 2017: According to a recent report, about 32% of Indians suffer from various kinds of thyroid disorders including thyroid nodules, hyperthyroidism, goiter, thyroiditis, and thyroid cancer. The most prevalent form of thyroid disorders across the country is sub-clinical hypothyroidism, which is a milder form of hypothyroidism and what is more alarming is that it is a silent disease. It is often diagnosed by chance. Subclinical hypothyroidism is defined as serum thyroid stimulating hormone (TSH) above the upper reference limit in combination with a normal free thyroxine (fT4).

Thyroid diseases are more prevalent in women and can cause many problems including weight gain and hormonal imbalance. The chances of men suffering from thyroid disease are comparatively lesser.

In the developed countries, the prevalence of thyroid disorders is about 4% to 5%.

Speaking about this, Padma Shri Awardee Dr K K Aggarwal, National President Indian Medical Association (IMA) and President Heart Care Foundation of India (HCFI) and Dr RN Tandon – Honorary Secretary General IMA in a joint statement, said, "Hypothyroidism can affect all organ systems. Genetics has a major role in determining thyroid hormones and TSH concentrations as well as susceptibility to autoimmune thyroid disease. Those with a family history are likely to be predisposed to thyroid abnormalities. Therefore, it is imperative for a person to be aware of their family’s medical history. If left untreated, hypothyroidism can cause elevated cholesterol levels, an increase in blood pressure, cardiovascular complications, decreased fertility, and depression. In pregnant women, this condition can increase the risk of premature birth, low birth weight, and miscarriage."

Adding further, Dr Aggarwal, said, "The need of the hour is to reach out and create awareness among people about the causes, symptoms, treatment, and importance of testing for thyroid problems. This is particularly significant for women as the incidence of acquiring this disease is more in them. Pregnant women or those planning to conceive should get themselves checked to ensure that their thyroid functions are normal."

Here are some tips for those living with thyroid disorders.

• Eat healthy Hypothyroidism is linked to weight gain. Thus, a person with this condition can find it difficult to lose weight. Consume a diet rich in fibre and low in fat to maintain a healthy weight.
• Exercise Although it may be difficult to get moving in those with a sluggish thyroid, it is a good idea to push yourself to do some physical activity.
• De-­stress Stress is known to exacerbate thyroid disorders. Do something to reduce those stress levels. It could be yoga, meditation, dance, or anything.

High cesarean section rates in the country

The rates of cesarean section deliveries are increasing in the country and there is a perception amongst the public that many of these are unnecessary cesarean sections.

According to a World Health Organization (WHO) report published in 2010, the cesarean section rate in India was 8.5%. The percentage of cesarean section deliveries in the country is 17.2% as per the National Family Health Survey (NFHS)-4 (2015-16) released earlier this year (Press Information Bureau, Ministry of Health and Family Welfare, March 28, 2017). This latest figure is apparently higher than the “ideal” rate between 10% and 15% as that recommended by the WHO in 1985.

The high cesarean rates in the country, as a number, cannot be viewed in isolation.

There are several reasons why a cesarean section delivery may be chosen over a vaginal birth.

There are the medical indications, the absolute and relative indications, because of which a doctor may recommend an elective caesarean section. At times, in conditions such as obstructed labor or other obstetrical emergencies, a caesarean section is done as an emergency procedure, where it is lifesaving for both the mother and the child.

Then there are the non-medical reasons.

The decision to perform a caesarean section is not solely in the hands of the doctor. Patient preferences or caesarean on maternal request also play a part.

Anxiety about vaginal birth, fear of vaginal birth (tocophobia), precious child are some factors which influence the choice of cesarean section by the expectant mother as a mode of delivery, in the absence of any medical or obstetrical contraindication to vaginal birth. Some women want to deliver on an auspicious date or even time. This is another reason why they opt for an elective cesarean.

Cesarean section rates are higher in tertiary institutes or superspecialty hospitals. Similar is the case with senior and experienced doctors, who may not do routine vaginal deliveries. If you take informed consent, then again the cesarean section rates may be higher.

All these non-medical factors contribute to the increase in cesarean section rates. And, while they are not the sole cause, they do need to be taken into account.

Then again it is important to evaluate the correlation between cesarean section rates and the infant mortality rate (IMR) and maternal mortality rate (MMR).

Data from NFHS-4 showed that private hospitals carried out 40.9% cesarean sections, while this rate in government hospitals was 11.9%. The two cannot be compared. It is important to assess the corresponding IMR and MMR.

Many women doctors may choose to have a cesarean section instead of vaginal birth, which also needs to be computed. Unless it can be proved that the cesarean rate in doctors and VIPs is low compared to the general population, it cannot be said that the cesarean rates are unnecessarily high. This is not so.

Cesarean section is a surgical procedure, with potential complications for both the mother and the child. An informed consent needs to be taken before proceeding with the procedure.

The decision of the United Kingdom (UK) Supreme Court in the case of Montgomery v Lanarkshire Health Board was a landmark judgement, which made the patient an active partner in decision making as far as his/her treatment is concerned. It ruled that the doctor has a duty “to ensure that the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments”. The doctor has to inform the patient of all possible risks, even though rare, and let the patient take a decision.

The patient should be informed that even elective CS is not risk-free and carries serious risks for mother and child.

An audit of deliveries cesarean sections, in the private as well as public health facilities, is needed to find out the reasons for the decision to perform each cesarean section before judging that economics and not medicine, influence a doctor’s decision to do a cesarean delivery.

Dr KK Aggarwal

National President IMA & HCFI