Month: July 2022

Breathing is under rated.  No, I really mean that.  Usually our breathing is such a passive thing and for much of our life.  It’s no wonder then that when someone is taught to meditate, so much emphasis is then put on breathing, perhaps to allow us to appreciate the wonder of life from this simple act.  Personally, meditating and focus on breathing always made me feel more short of breath, so I rather like to take it for granted.  So takes a look at what we need to know about our respiratory system, the system that helps us fulfill this simple wonder.

SHORTNESS OF BREATH

This is such a common feeling that can come over an elderly person.  And when it does, it can be from something really major or something small.  Let’s take a deeper dive into some common and important causes of shortness of breath:

1. Not enough blood – “anaemia”. If you lose blood, then eventually your body gets deplete of oxygen and you feel short of breath. This can happen either in a hurry when there is a blood vessel leaking somewhere in your body, for example, within your guts/ bowel or stomach.  Or, it can happen slowly where you have a chronic disease which is hampering your body making blood or you have some other disease which is causing you to lose blood slowly (for example bowel cancer).  Low iron, as a consequence of long term blood loss, inadequate intake from your diet or poor absorption can go on to itself slow blood production and cause a low blood level in your body.  A person who has anaemia looks pale and may have low blood pressure and a fast heart rate.
2. Chronic lung conditions. Many chronic lung conditions can contribute to shortness of breath.  These include asthma and chronic obstructive pulmonary disease or emphysema (from long term smoking).  These diseases may cause a person to often get wheezy as well as feel short of breath.  They may be associated with increased production of phlegm and coughing.  These conditions improve by treating both infections, usually with antibiotics and treatment to decrease inflammation and expand your airways.  This comes in the form of inhalers including salbutamol (Ventolin) and various steroids.  Sometimes, if you’re quite short of breath, it may be useful to take oral steroid (a tablet) called prednisolone.  This can be for a short period of time, anywhere between 3 days to 14 days, with a decreasing regimen.  The precise dosage can be recommended by a doctor.  However, it’s really handy to keep such things close at hand in your medicine cabinet, in case you need to improve your breathing during an infection, particularly if you get wheezy.  Prednisolone is essentially a very strong anti-inflammatory agent, helping your lungs to “calm down” somewhat during an infection.  At the same stage, prednisolone works by supressing your immune system and has other longer term side effects, so you don’t want to take it for too long, if you can avoid it.
3. Heart problems. If you have a heart attack, you may feel shortness of breath, usually all of a sudden.  This is particularly true for people with diabetes.  Apart from this, if you have long term heart issues, your heart may not pump the volume of blood it used to pump in the past.  Eventually your blood gets somewhat backed up and this back pressure leads to the collection of fluid in your lungs, as well as your legs.  This is called “heart failure”.  That extra fluid which is backed up in your lungs, caused by your weakened heart, makes you feel short of breath.  It could also cause wheeze.  You may notice your legs swelling. A tell tale sign of shortness of breath being caused by heart failure is that when you lay in bed, you feel more short of breath.  This may cause you to use more pillows at night, or even sit up, since being upright improves your shortness of breath.  A way to keep an eye on this is by monitoring your weight.  Provided your not eating more and exercising as you usually would, if your weight is rising, then chances are, that extra weight is fluid from heart failure.  You’ll perhaps see your legs swelling more as well.  If these things are happening, then it’s likely your shortness of breath is related to a weak heart.  In this case, the treatment is a diuretic, which is a medication which causes you to lose fluid.  The typical diuretic is called “frusemide”.  This drug causes your kidneys to retain less water.  Therefore, when you take frusemide, you will find yourself urinating more.
4. Pulmonary embolism. In a related chapter, we talked about deep vein thrombosis, and how that a blood clot which has formed anywhere within a vein in your body, can dislodge and travel to your lung, getting stuck there.  This blood clot, now located in your lung, is called a pulmonary embolism.  A pulmonary embolism causes an area of your lung to have no blood flowing through it.  That area of your lung can collapse and not function, leading to shortness of breath and sometimes the coughing up of blood.  It can also cause sharp chest pain when you breathe in.  Sometimes rather than one massive pulmonary clot, people do get smaller clots, over a slightly longer period of time, perhaps weeks, lodging in their lungs, and over time, this can cause increasing shortness of breath.  So always keep it in mind as a cause, particularly if you are relatively immobile and sit a lot.  You may notice your leg swelling, getting painful and red.  This could be the source of the clot which is going to your lungs.
5. Heart rate issues. We discuss in the section for the cardiovascular system how heart rate issues (heart beating too fast or too slow) can lead to shortness of breath.  This is very true since your heart rate is a major determinant of your blood pressure.  If your heart rate is too fast or slow, your blood pressure can drop and you can feel short of breath.
6. Mental origins to shortness of breath. This is a very common cause of shortness of breath.  Obviously other causes need to be considered, but a person who once gets short of breath from say asthma, or any other cause, rather remembers that experience, particularly if it happens repetitively.  And, all those of episodes of shortness of breath, can make them increasingly aware of their breathing.  Eventually, if you have lung conditions, you really do become very “aware” of your breathing and that constant awareness of something so fundamental as breathing itself, can start to drift into itself making your feel short of breath, worsening the situation.  This really is a form of health anxiety and it’s very understandable, particularly those with chronic lung conditions such as emphysema.  Often times, the mental stress and fear of having acute breathing issues, carries with them, and they are left in that anxious state about their breathing.  If you have chronic lung or heart conditions and have issues with your breathing along the way, you are very much at risk of this happening.  This shortness of breath, contributed to by your fear of that very same thing.  In this case, it may be worthwhile to slow your breathing, and maybe see a psychologist to get some other advice about how to control that part of things.

Even if you don’t have chronic lung or heart conditions, feeling short of breath can be associated with various mental states including depression and anxiety.  It’s really useful to consider your mind  state this way, and how it’s contribution to how you feel about your breathing.

TIPS:

1. Remember, acute shortness of breath, even in the absence of chest pain, could still be from a heart attack. This is especially true if you have diabetes.
2. If you get episodes of shortness of breath, and are well between, it could well be from your heart beating too fast or slow. During such an episode, sit down and if you have an automatic blood pressure cuff, wear it.  Although the accuracy may be reduced during such an event, it could show important information about your heart rate and blood pressure at the time.  Record this information and give it to your doctor the next time you see them.
3. Exercise is really important. Your lung function is a case of “move it or lose it”, so nearly all conditions benefit from some form of exercise.  The best exercise is usually just making sure you go for a walk every day if you can. Nothing fancy.
4. Inhalers/ puffers – such as salbutamol (Ventolin) can be helpful – if you use them properly. There are many devices these days which act as inhalers.  Make sure you really know how to use them.  Often people may be using an inhaler in an incorrect way, and this causes it to be ineffective.  Don’t let that be you.  Ask your doctor how to best use the device you’ve been prescribed, so that you get the maximum benefit out of it.
5. It is useful to check your weight periodically.  Don’t get obsessed by it, but certainly checking your weight maybe once a month will let you potentially keep a nice measure of your fluid status.  If you can’t explain why your weight is going up, then it may well be that you’re retaining fluid in your body, and a reason for that will need to be considered.  It could be your heart, although there are other causes including loss of kidney function.
6. Do your best to stay relaxed in your life. I’ve seen many patients get escalating anxiety as they get older.  This can be worsened if you have heart or lung conditions which cause you to have difficult breathing.  But your mental state, and trying to remain a calm person, really can help you a great deal feel less short of breath, or at least help you cope with your medical problems more.  There are various ways to stay more calm, both medication and non-medication based.  Be open minded about this.

COUGH

Once again, a very common symptom.  And once again, can be very annoying to the sufferer!  The common causes of a cough are:

Infections

Infections can be short term events, or longer term infections such as what is know as bronchiectasis.  Respiratory infections can also be classified essentially as bacterial or viral.  A viral infection causing a cough can have the symptoms of a sore throat and runny nose.  By contrast, a bacterial infection, may well just be a cough.  Both can cause fever.  And, remember, it’s not uncommon for a viral infection, to lead to a bacterial infection.  This is called a “secondary” infection.  Dry coughs can be either viral or bacterial.  It’s hard to know.  A few rules would be that if you have a very runny nose, you’ve likely got a virus, at least initially.  If your phlegm is getting more thick and colourful, then it could well be a bacterial infection.

In general, if you are getting more unwell with your cough, and not sure if it is viral or bacterial, then best to see your doctor and consider antibiotics.  Many elderly people go get pneumonia, which is a more significant infection within the lung itself.  This should be treated early, usually with antibiotics.  At this time, your lungs may also become inflamed and sensitive.  This will present as wheeze, and your doctor may prescribe a steroid – prednisolone to control some of that.  Provided you are not allergic to penicillin, your doctor may prescribe amoxicillin.  Alternatively doxycycline or roxithromycin may be used. These antibiotics are typically used for one week.  However, if you are feeling improved with the antibiotics, but not quite better, it may be appropriate to have another course.  Try to continue on with the second lot of antibiotics in this case, rather than allowing a gap between courses.

Influenza needs to be brought up here. When someone gets the “flu”, they could well have all the other symptoms of a virus – runny nose, sore throat, cough.  However, the defining difference the degree of body aches.  Influenza causes your whole body to ache.  You may have a high fever, alternating between chills and feeling very hot.  You’ll likely feel very tired.  It is really important to drink fluids, especially water, during this time.  Remember also that the flu can go on to lead to a bacterial chest infection.  So, if your phlegm starts to get thick, consider this.

TIPS:

1. Vaccinations – consider the influenza vaccination, whooping cough vaccination and the pneumococcal vaccination. These could help you.
2. Do some deep breathing. When you have respiratory infections, one way or another mucus and secretions may collect in your lung, usually the bases.  Even if you don’t have an infection, just sitting down in a chair too much can cause some parts of your lungs, typically the bases to collapse.  You should consider doing deep breathing to keep all these parts of your lungs well aerated.  This could become a suitable daily exercise, whereby you start and end your day perhaps by doing some deep breathing exercises, even when you’re well.  Better still, do this outside, getting some fresh air.  When you take deep breaths, it can cause you to become light headed.  This being the case, perhaps do them sitting down, provided you are upright enough allowing you to still open up the bottoms of your lungs.
3. Always consider providing a sample of your phlegm to the doctor if you’re not improving. In this case, your infection may be a resistant type, and that phlegm sample may prove vital to decide what antibiotic to use.  If your doctor hasn’t given you a jar for this purpose, you can simply take your own jar.  However, it’s a useful thing to keep a few of these pathology specimen jars at home since the same type of jar is often also used to collect urine.  This allows you to take samples to the doctor when you’re unwell.
4. Drink plenty of water. As long as you’re not on a fluid restriction for any reason, drinking fluids will stop you from getting dehydrated. This can happen when you’re sick and that dehydration can end up being as dangerous as the primary sickness itself.
5. Keep in mind whooping cough. If you have a dry cough which just doesn’t go away, it may be the whooping cough.  In adults, the whooping cough is known for causing a long standing cough, giving rise to the disease being referred to as the “100 day cough”.  Your doctor can test you for this.
6. If you think you have influenza, the “flu”, then get tested. Your doctor can test you for the flu with a sample of mucus from your nose.  The flu can be dangerous, and it’s good to know whether you’ve actually got it or not.

Chronic lung conditions

Asthma and chronic obstructive pulmonary disease and emphysema can all cause a chronic cough.  These coughs worsen with infection.  It’s really important to consider when you have an infection, and consider using antibiotics early, because you are more at risk of getting a more significant chest infection.  Also, you will likely need prednisolone as well, to manage the inflammation in your lungs.  This inflammation and constriction may present as wheeze.

Reflux

Sometimes people can just have a dry cough which lingers despite all sorts of cough medications.  If this is your case, then you could consider – is your cause actually from acid travelling up to your throat from your stomach.  This is possible.  When that acid gets high enough, it reaches a muscular ring called your cricopharyngeus.  This muscle is located roughly at the intersection of where your upper throat branches into your wind pipe (trachea) and gullet (oesophagus).  When acid hits this muscle it can go into spasm and cause you to feel tight in the throat, or at times cough.  To test this, you could trial a medication which decreases stomach acid.  These medications are called proton pump inhibitors, esomeprazole would be one such drug.  Taking this daily for one month would be a sufficient test.  If acid reflux is your cause of a cough, your symptoms should improve after this time.

Heart failure

Your heart is a pump used to pump blood around your body.  The heart pumps blood which is rich in oxygen out through your arteries.  Your body uses the oxygen in your blood.  That blood which is now deplete of oxygen flows to your veins from which it is sent back to your heart.  From your heart that venous blood is pumped to your lungs and from there, it returns to your heart to once again get pumped into your arteries.  However, for different reasons, including after having a heart attack, your heart can get weak and when it does its ability to contract and act as a pump diminishes.  In this case, blood which returns to your heart, struggles to be pumped out to your arteries.  The pressure builds backstream and the net result is that fluid collects in your lungs.  This fluid in your lungs can cause you to be short of breath, wheeze and indeed cough.  If this is your problem, you may well also notice that your legs are swelling with fluid.  In this case, your feet or legs will be swollen and when you pressure your finger into your shin for 10 seconds, you will notice that your finger leaves an indent, this is called “pitting oedema” and it is typical of fluid which is caused by your heart failing this way.

Of note, if your cause for a cough is heart failure, your problem will be worse when you lay down at bed.  In this relatively flat position, because of the redistribution of fluid around your body, your lungs collect with even more fluid and your tend to feel more short of breath and cough more.  You may find yourself increasing the number of pillows you need to sleep on, to prop yourself up at night, saving that feeling of shortness of breath and coughing when you lay more flat. Since the problem with heart failure is that your body ends up retaining too much fluid, the treatment for this is to limit your water intake (usually to a maximum of 1.5litres per day) and consider taking a medication which helps your body get rid of fluid.  This medication is called a diuretic and frusemide is the usual drug of choice for this purpose.

Medications

There are some medications which can cause you to cough. The most typical of these are a class of medication used to lower blood pressure called ace inhibitors.  Perindopril is one such medication.  These medications can cause you to get a dry cough at any time, even if you have been taking them for a while.  There are similar blood pressure medications which can also cause you to cough.  The main point is, consider what medications you are taking and whether they could be causing or at least contributing to your cough.

TIPS:

1. If you have a cough and think you have an infection, collect a sample of your phlegm in a jar and take it with you when you see your doctor. They will be able to then send it for testing.
2. Keep an eye on your weight. If you are putting on weight and yet you haven’t changed your diet, it could be that your body is retaining fluid and that some increased fluid is in your lungs contributing to your cough.  In this case, check your legs for any swelling.
3. If you are a smoker or have smoked in the past and have a chronic cough, you really should have a chest xray to be sure.
4. If you start coughing up blood, you really should talk to your doctor. There are different causes of coughing up blood including a pulmonary embolism, lung cancer or trauma at the level of your throat.  Worthwhile working out what’s going on with your doctor.

Problems with the skin tend to either be caused by infection or not. In this section, to keep things simple, we break things up like this.

Infections:

Shingles

This is the reactivation of the chickenpox virus.  To understand this, you could consider that when you contract some infections, like the chickenpox, often times your body never fully gets rid of that infection, rather it keeps it bay for the rest of your life.  In the case of the chickenpox, the virus gets contained, laying somewhat dormant in your nerves located close to your spine.  It is up to your immune system (bodily defence system) to keep it rather locked up there.  However, at times when your immune system may be under pressure or deplete, and basically at times of overall stress, the chickenpox virus may be let out of its cage.   When it does “reactivate” in this way, it travels along the path of a nerve, typically on one side of your body causing pain and producing a rash.  This is referred to as the “shingles”.  You could really get the shingles occur on any location in your body, however the main thing is that it will tend to present rather in a “band” on one side of your body, since it emerges and follows the path of the nerve where it was originally trapped and contained.

Tips:

1. Sometimes you will get pain and tingling of an area of your body long before the rash emerges.
2. The rash presents as red spots which go on to have small vesicles (blisters). These blisters then burst and scab over.
3. You are generally infectious so long as your blisters have not yet scabbed over. And, some groups of people, for example, pregnant women and infants can get badly affected by the herpes virus, so you should avoid these people in particular if you have the shingles.
4. The treatment of the shingles can include a course of antiviral tablets for about a week. That treatment is best started within 3 days of first getting the rash or symptoms. So – get on to it early.
5. Treatment for the shingles early with antivirals, especially during the first episode, can decrease the likelihood of getting “post herpetic neuralgia”. This condition is typified by episodes of intense pain in an area of your skin where you used to get the shingles.  You may not get the rash with it, rather just pain.  Post herpetic neuralgia can be very debilitating, so treating incidences of the shingles early with antivirals can be justified for this reason.
6. If you get the shingles on your face, it can affect the surface of your eye – your cornea. This is called “ophthalmic zoster”.  This can lead to scarring and damage of your eye. Sometimes, the presence of shingles on your nose and also extend into get close to structures related to your brain.  So in these cases, where shingles is on your face, you should especially see a doctor.

Cellulitis

This is an infection of your skin which goes deep enough to involve the fat layer located under the skin itself.  Cellulitis causes inflammation which is seen as an area of skin that is red, swollen, hot and tender.  Sometimes cellulitis can be associated with an open skin wound, insect bite or an areas which has been scratched because has been itchy.  However, where and why it all started may not be clear.  Instead, simply an area of skin can turn red and sore.  Preceding pain and tenderness, that area may well get itchy as an early symptom.

As mentioned, cellulitis can start on any place of your body, however it most readily occurs on legs.  Here it can cause a swollen leg, looking similar at times to a DVT.  It may be hard for you to differentiate the two, so you should get help.  In the case of cellulitis, your legs may leak fluid as the skin breaks open under the pressure and stretch.  In general, cellulitis can be severe enough to make you unwell in general. You may get a fever.

Tips:

1. Get on to it early. Cellulitis can start small, but spread quite rapidly.  So if you see a small area of skin which is suspicious, seek treatment early, before it becomes a big problem.  There are many elderly patients with cellulitis, particularly of the legs, which gets so bad that they end up needing intravenous antibiotics in hospital. However, if you do pick it up early, there’s a very good chance that you can get treated with antibiotics in tablet form at home, and get better quickly.
2. The antibiotics often chosen for cellulitis include cephalexin. Sometimes though, the bacteria can be resistant to standard antibiotics.  So if your legs are oozing or you have some sort of wound which your cellulitis is associated with, it’s a good idea to get a sample of that fluid (a “swab”) to have sent to pathology for testing.  This will help guide antibiotic treatment, should things not improve.  Your doctor can organise this for you.
3. Drink lots of water. As an infection possibly causing you to have a temperature, you will ten to get dehydrated.  Especially if you have cellulitis of the legs, you are at a high risk of getting a DVT, so please lower this risk by staying well hydrated.
4. Elevate your legs. Once again, if you have cellulitis on your legs, they’ll tend to get congested with fluid which could lead to the skin breaking and fluid draining.  This can all be reduced by elevating your legs causing them to drain more easily.  It’s good to keep your legs moving at least a little bit that way too, to reduce the risk of DVT along the way.
5. Monitor the progress of treatment. If you are prescribed antibiotics, it may be for one week or more.  However, you should start seeing some benefit at least by day two.  If after a few days, your cellulitis isn’t improving, you should think whether the diagnosis is correct, or whether you have a resistant form of the condition (likely due to a resistant bacteria).  Something will have to change if your legs are not getting better after a few days.
6. Signs of danger. If you legs are VERY tender, particularly despite antibiotics, and if the colour of your skin is getting darker, the infection may be going deeper than your fat, and starting to involve your deeper tissues.  This could (uncommonly) lead to a condition called necrotising fasciitis.  This is an emergency.  Similarly, if your leg isn’t improving then you may need an ultrasound to make sure you do not have a DVT.  Indeed, if you get any shortness of breath or chest pain which may indicate a PE, see you doctor.
7. Elderly people often may have heart conditions or other chronic diseases which lead to their legs being swollen and filled with fluid usually. In this case, cellulitis will need to be considered when there is a “change” to their usual condition.  For example, apart from the usual swelling and fluid, their legs may become red and hot and start leaking.  Or, they may get a temperature.  So, look and beware of any changes.

Fungal infections of the skin

Fungal infections tend to occur in warm, dark, moist places.  Common places include under the breasts, the groin and feet.  The skin here will get itchy and red, sometimes a little bit flaky or elevated.  The treatment of this is usually an antifungal cream with or without a steroid.  These creams are generally sold over the counter.  The constituents of the cream could be cotrimazole (antifungal) and hydrocortisone (steroid).  Commonly this combination goes under the trade name Hydrozole.

It’s important to consider that a fungal infection can get secondarily infected with a bacteria.  This usually happens from repetitive scratching which causes the skin to break more deeply allowing bacteria to enter.  In this case, you will notice that the skin is not only red, but gets distinctly weepy, more painful (rather than itchy) and can get golden or yellow pus.

Tips:

1. Not too much cream. When you apply antifungal cream, a common mistake is to apply it so thickly that it remains on the skin.  However, creams contain water, and by leaving the cream coated on the skin, you’re effectively making the area even more wet and all that moisture tends to cause the skin to breakdown, to macerate.  This is especially true between the toes.  You need to therefore avoid using too much cream, and really rub it into the skin, making sure it is dry and no coating remains after you’re done.
2. A long enough course. Sometimes people use an antifungal for a few days and stop.  Or a little bit here and there.  This should be avoided, because then the fungal infection won’t be eradicated, rather just dulled down, kept at bay, only to remerge promptly.  Use a fungal cream for a thorough course of treatment, which would be a minimum of two weeks.  It is classically said to use for one further week after the rash disappears.
3. Consider a swab. If your fungal infection isn’t going away, consider seeing your doctor so that a sample can be sent for testing.  This will involve just a cotton bud being rubbed on your skin, and that cotton bud (swab) sent to a pathology laboratory.  Occasionally, you can get a resistant fungal infection or bacteria could be the real cause.
4. Is it cellulitis? If it’s getting worse, you may have a bacterial secondary infection, and you should get a swab, as discussed above.
5. Is sweat or clothing the cause? If you keep getting fungal infection in particular areas, perhaps it’s due to that area getting too sweaty or having too tighter clothing on.  If sweat is contributing, you may have to place gauze or another simple material in position, to absorb that sweat.  Underwear may have to be looser so as not to cut into skin.

Nail fungus

This most commonly affects the toenails, but it can also affect the fingernails.  The nail will get discoloured and disfigured.  It could be darker or lighter in colour when compared to the other nails.  It could be thickened.  Fungal nails (called onychomycoses) are very stubborn to treat.  You can try using various antifungal nail paints and other topical remedies, but often times, they won’t work.  What is required is physically tending to the nail, cutting away any affected areas, and the use of antifungal tablets.  Antifungal tablets do have to be used for an extended period of time, anywhere between 12 to 24 weeks.

Tips:

1. Nail fungus may be a sign of the environment. This is especially true of the foot. If your foot has fungal infection of the skin and various other forms of skin dysfunction such as dermatitis, it’s more likely that you will get fungal nail infection. You should also consider how well you tend to keeping your nails well trimmed, so that they do not attract problems.  So the overall health of your foot, is important.  To this extent, whilst taking antifungal tablets for your nail, you may consider applying antifungal cream to the remainder of your whole foot.  Remember always to rub this in, so that your foot stays dry, as discussed in the section for fungal skin infections.
2. To send a nail sample or not to send a sample? When you go to see a doctor for fungal nail infection, they may suggest sending a sample of your nails (clipping) for testing.  If you choose to do this, you need a really good sample, because an inadequate one is liable to come back falsely negative.  In Australia, if you want to have your antifungal medication paid for by the Government, you will need to send a sample to the pathology laboratory for formal testing and diagnosis.  Your doctor will then have to make a phone call to get authority for the antifungal tablet medication script to be approved.  Yet, not infrequently, the pathology result will be negative when the nail clinically definitely looks to have fungal infection.  In this case, you may still wish to proceed with taking antifungal tablets.  The risk factors of this are the risk of a medication related adverse reaction.  One significant risk of antifungal medication is getting liver dysfunction and failure.  This risk is described as “rare”, meaning that there is a one in 1,000 – one in 10,000 chance of having liver failure.  For this reason, it may be a good idea that you do a blood test after about four weeks of treatment, checking your liver function test, and general parameters. Note that the cost of anti fungal medication is not so high (at the time of writing, about $22 for 42 tablets), so buying the tablets on a private script, despite a negative pathology sample, can most certainly be a viable option.
3. Preventing recurrences. As mentioned, fungal nail infections are stubborn to go.  If you do win the battle, to limit recurrence you may like to apply an antifungal cream to your foot, including your nails, routinely.  However, note that the antifungal of choice for nail infections is terbinafine, whilst the typical antifungal cream (clonea, canestan) for the skin contains the antifungal clotrimazole.  The cream form of terbinafine does exist and is often sold under the trade name Lamisil.  Perhaps consider using it for this purpose.

Wound infections

Wounds happen commonly in the elderly, particularly because of the tendency to fall.  An infected wound can be recognised when it gets red and pussy.  Antibiotic tablets may be needed.  Or, if it is small enough, an antibiotic cream may suffice.

It is important to clean the wound, daily.  This may be best done in the shower.  It’s preferable in this way, to clean a wound in general, rather than try to keep it “dry” under a dressing for long periods of time.  Usually that leads to wounds festering.  After washing your wound well in the shower, pat dry it, apply an antiseptic cream, and cover it.  In general, remember, a wet wound (infected) needs to have a dressing which basically keeps it dry.  I would suggest avoiding dressings which do not breathe and rather try to keep things waterproof, for extended periods of time.  This is because they tend to lead to the wound getting “wet” and boggy under them, particularly if they are left on too long.  Rather, use a dry dressing, wash the wound daily in the shower and start again, daily.

SUN DAMAGED SKIN

Sun damage shows itself usually as red and flaky skin.  Alternately, on elderly people of darker complexion, sun damage can appear as areas where there is increased pigmentation.  Sun damaged skin (solar keratotis), when it is confined to specific spots, can be treated by freezing it off (cryotherapy) with liquid nitrogen.  This has to be conducted by a doctor.  Either that or certain creams can be applied to the area.  This includes diclofenac gel or other chemotherapeutic creams (see below).  Since often sun damage occurs an large patches, and areas, for example the back of the hands, these creams can be really useful to treat such larger areas.  There is also some good evidence for using vitamin V3 (nicotinamide), taken orally, to help with decreasing the extent of sun damaged skin.  This research has been pioneered by Professor Diona Damian in Australia.  The recommended dose of Vitamin B3 is 500mg oral twice a day.  Although it is quite early in the use of this vitamin for sun damaged skin, early data looks very positive and certainly worthwhile investigating if you or someone you care for has significant sun damaged skin.

SKIN CANCER

Skin cancers occur very commonly in the elderly, especially in Australia.  Skin cancers are broadly speaking categorised as melanoma or non-melanoma.  We now discuss either type separately.

Melanoma

Melanomas are usually more dangerous since they more readily spread and can invade internal organs within the body.  Melanoma tend to be dark in colour, either being brown, blue or black.  It can be difficult for the average person to tell the difference between a melanoma and other brown/ black spots on skin that come with age.  In general though, if you have a spot which is new and changing, then you should have a doctor look at it.  The other type of skin change worthwhile considering could be a melanoma is a more large brown patch.  If such a patch has various shades of brown and even black, then it could be a melanoma. In this case, such larger patches may have actually grown very slowly, sometimes over many years.  These more slow growing forms of melanoma tend to occur on the face.  The main point to get through here is that if you’re worried that something could be a melanoma, it’s worthwhile asking your doctor to have a look.

Non Melanoma

These are skin cancers which are far more common than melanoma. They tend to occur on sun exposed areas including the hands, face, forearms, upper chest/ neck area and legs.  They are typically deep pink to red in colour.  Non melanoma skin cancers are either squamous cell carcinoma or basal cell carcinoma.  It would be hard for the average person to tell the difference, except to say that squamous cell carcinomas tend to be more dry and crusty.  Squamous cell carcinomas are generally more dangerous than basal cell carcinomas since they are more likely to become invasive and spread.  Basal cell carcinomas can also do this, but only rarely.

Skin cancer in the elderly – what to do?

As previously stated, skin cancer is very common in the elderly. And, it can sometimes require surgery.  However, even one person may have many skin cancers on their body, and having multiple surgeries may not be the best approach.  It really depends on the type of skin cancer.  If you are worried about a melanoma, then you need to see your doctor sooner rather than later and if you are found to have a melanoma, then having surgery to cut it out may well be the best option.  It usually is.  If however, you have a red spot or multiple spots on your body, which could be non melanoma skin cancer, certainly have your doctor look at them, but in this case, having surgery for all or any of them, may not be the best option.  Sometimes the elderly can become caught in a cycle of having multiple disfiguring operations, for such non melanoma skin cancers, when other treatments could have been considered.

Should I have a biopsy?

Whenever a spot on your body is considered to be a skin cancer, then sending a sample for testing may be a useful thing to do.  This sample is called a “biopsy”.  There are different types of biopsies which your doctor may want to do, but the point of the exercise remains the same, to send a sample, which hopefully represents the problem well enough so that it can be proven whether the skin change is a cancer or not.  With regard to melanoma, it’s generally advisable that a biopsy be sent.  With regard to a suspected non melanoma skin cancer, it may reasonable to treat the spot first, without a biopsy.  That’s appropriate in many cases.

Tips

1. Take a photo of a brown/ black lesion first. Before having a skin spot which may be a melanoma tampered with (biopsied), have a photo taken.  This may help doctors in the future understand the problem and work out what to do.
2. Biopsies do not spread disease. Sometimes, people worry that the process of taking a biopsy, can encourage or even start a skin cancer (or any cancer for that matter) spreading.  There is no evidence for this.  If your doctor recommends a biopsy, then don’t let this thought affect your decision.  The only one thing to mention here is that for melanoma, it is important that the biopsy performed captures a sample of the entire spot.  The reason for this is that it is not reliable to try and only biopsy the “worst” area of a brown/ black lesion to look for melanoma.  Some of the area remaining which is not biopsied may contain cancer.  There are some instances, where it is not possible to biopsy the whole thing, but it should always be strived for.  The same is also true for non-melanoma skin cancer, but it’s generally thought that taking part of a spot there is acceptable and indeed the repercussions of not sampling some parts are less dangerous than for melanoma.
3. Non melanoma skin cancer – often safe to use non surgical treatment first. Before jumping in to have your non melanoma skin cancer surgically removed, consider the option of cryotherapy, that is, to have it frozen off using liquid nitrogen.  This can simply be done at a GP surgery.  Often times, non melanoma skin cancer (SCC and BCC) respond well to this treatment and it is in general less invasive than surgical removal.  Also, it’s often found that after you do a biopsy for a skin cancer (removing a small sample surgically), the remainder of the cancer shrinks, and can even go away all together.  So for small, early, less invasive forms of skin cancer, It could be worthwhile to see whether this happens, before rushing in to do anything else.  Lastly, there are creams which can sometimes be of benefit, used well to treat an area of skin generally affected by sun damage.  These include Flurouracil cream for example. These can be very effective.  Ask your doctor about these options.

ECZEMA AND DERMATITIS

Elderly skin can readily become itchy, and when it does, it can be difficult to get things back to normal.  There are many reasons why elderly skin in particular can become itchy.  So perhaps the best place to start here is to look at those reasons and see what can be avoided.  These are some common causes of itchy skin in the elderly:

• This is especially true on your back but can include your whole torso.  If it’s summer, and you’re getting sweaty, do something to cool down.  As a simple tip, don’t wear too many jumpers and clothes when it’s warm.
• Some medications including blood pressure pills and diuretics can make your skin itchy.  Ask your doctor about the possible contribution of your medications to any skin conditions.
• If you sit too close to a heater for too long, the skin on your legs in particular can get very dry and subsequently start to itch.  Take it easy on the changes in temperature and especially that sitting close by a heater in the winter.  Preferentially wear more clothes, including thick socks, during winter.
• Varicose veins. Legs often times struggle with circulation problems.  In this case, the problem of gravity causing blood to pool in the veins of your legs, causing swelling and congestion of your legs and ultimately contributing to them becoming itchy.  The skin may then be red and warm.  Try not to sit in a chair, with your legs dangling for too long during the day.  If you have to sit, then elevate your legs.  Consider also wearing compression stockings to limit the amount of blood which can collect in your legs.
• Sometimes, your mental state can cause you to scratch and pick at your skin.  This could affect any part of your body.  The point is there though, that a tense person will tend to pick and scratch their skin more readily.  So, consider that, and whether techniques in relaxation may help you scratch less.
• Itchy skin can indicate an infection – fungal, bacterial or parasitic (in the case of scabies).  If you’re not sure about whether infection is the cause, please see your doctor.
• Dry skin. As we age, our skin tends to get drier.  Drier skin is generally more itchy.

These are some common causes of itchy skin.  The processes above can start as an episode, but the resultant damage to your skin can cause it to be itchy for a long time after, sometimes even, forever.  To avoid that outcome, you need to get on and treat any of the above causes when they happen, so your skin doesn’t change in any major or irreversible way.  During the way, a key factor is to avoid the temptation to scratch your skin.  We all know this.  But how to stop scratching?  Medically, a steroid based ointment or cream can help lessen the itch.  This will need to be applied once to twice a day to affected areas.  You will likely need a strong (potent) variety of this cream if it is to help.  This could for example be mometasone cream. There are many other steroids to choose from, and they do a similar job.  However, different people do react differently to various creams (any drug for that matter), so if one steroid cream doesn’t work, it may well be worthwhile trialling another.  Ideally though, try not to use a steroid cream long term, they do have their side effects.  Use it for a stint when necessary, perhaps two weeks as a maximum, then stop.

We mentioned dry skin.  Signs that your skin could be too dry include flaking and it easily being torn or bleeding.  These things can happen anyway to the skin with age, but they are worsened by dryness.  To help with this you need to make sure that you are always well hydrated, have a good balanced diet in general and apply moisturiser, perhaps twice a day.  There are many moisturises out there to choose from.  Once again, you may find one that you particularly find agrees with your skin.  It’s worth searching for this.  Sometimes the simpler the better, rather than the fancy expensive medicalised versions.  For example, Nivea cream is generally fine.  Otherwise, a good Vitamin E cream may help.  Try what works for you, but keep it simple.  Consider also changing the creams you use sometimes.  Your skin can develop an allergy to a cream if you use it for a very long time.  This tends to happen if the cream has more ingredients and is more complicated.  Some people are fine however using the same cream long term.  When you apply a moisturising cream, its better to rub it in, into the skin, rather than leaving it as an “oily film” on the skin surface.  After all, the idea is for the cream to penetrate your pores, and work there, rather than remaining as a barrier on the skin surface.  When creams are left on the skin surface, sometimes they can become as problematic, stopping the skin from breathing, than beneficial.  Rub in the cream, so your skin feels supple and bouncy, but not oily or wet to touch.

SKIN TEARS

Elderly skin can be very fragile.  This is generally part of the normal process of aging.  Keeping your skin well moisturised can help with this.  However, despite best attempts, at times, often related to falling or other trauma, the skin will tear.  When it does, it can lead to infection.  In treating a skin tear, we need to remember that each side of the tear can either live or die.  That’s to say, that the skin has been torn away from its usual blood supply, and so, even if we paste it back down where it was, that part of the skin may die because it doesn’t re-establish a blood supply.  So, in that way, let’s delve into what steps can help a skin tear heal:

1. Wash the area clean with chlorhexidine solution, then feel free to finish off with normal saline. Remember, more chemicals may help to clean, but too many harsh chemicals equally can hamper healing.
2. Please the edges of skin into their original place. You can at this stage apply “steristrips” which are pieces of tape especially designed for the skin, to hold apposing edges together.
3. On top of this, apply a vasoline impregnated gauze, and on top of this apply gauze and a crepe bandage.

You will have to keep this wound and dressing dry.  Some people use clear waterproof dressings.  However, if that waterproof dressing does start to allow water in, the wound will get macerated and start to fester, all increasing the likelihood of infection.

It’s important that you keep this area free from movement or other sheer stress.  The skin tear now under the dressing, needs to be kept still so that the flaps of skin can importantly re-establish their blood supply.  In this way, treatment of a skin tear is similar to the treatment of a skin graft.  Some pressure and immobilisation.

WHEN TO CHANGE THE DRESSING.

In keeping with the idea of keeping the wound still to start to regrow, we should avoid the urge of changing the dressing too often since every time we change the dressing, we interrupt the healing process.  Try to therefore keep the dressing on for one week.  A reason to change the dressing would be because there are signs of infection.  This is usually indicated by a dressing that has excessive fluid.  The pain of the wound itself could be increasing.  The person may get a fever or the wound get smelly.  If these things are happening, infection could be setting in.  In this case, the dressing needs to be changed, and should be changed daily or at least second daily depending the amount of ooze.  The wound needs to be kept dry.  If infection occurs, you may ultimately find that the original skin dies and peels off.  In this case, the area, now devoid of skin, will heal from the bottom up, purely as scar tissue.  This may take longer, but in general, will occur, unless the original wound was very deep.

ANTIBIOTICS OR NOT?

With any break to the skin, there is a chance of infection.  One important consideration is to consider when the last tetanus immunisation has been had.  If it’s more than 10 years ago, it is likely worthwhile to have a booster.  Antibiotics could be considered for skin tears which:

1. Are extensive and the risk of infection is therefore high
2. Receive delayed treatment (cleaned and dressed greater than 4 hours after the incident)
3. For patients who have conditions such as diabetes which impair their immune system.

TIPS:

1. Wear socks at home. Lots of elderly people get skin tears on their legs.  Wearing socks can offer protection for your legs and lessen the chance of the skin tearing should you knock them.
2. Is it useful to get a doctor to stitch the wound together? Generally, no because the skin is so fragile that it tends to tear and fray whilst trying to bring the edges together.  However, for deeper wounds, there may be more tissue to grasp and bring together, making stitching it together more viable.  If you’re not sure, see a doctor.  Perhaps if you are able, send the doctor a photograph.
3. Dressings – what to use? The main principle is that apart from steristrips, try to use a dressing that doesn’t get stuck to the wound.  For this reason, we do recommend using a vasoline impregnated gauze or similar material, with gauze on top of that.
4. If there is a large collection of blood under a skin tear (a “haematoma”) then it needs to be thought of whether it should be drained or not. Not draining it could increase the risk of infection, since bacteria thrive on eating blood.  You could consider draining it simply using a sterile needle.  After you drain it, you will need to have a dressing which places sufficient pressure on the area, so that it doesn’t recollect.
5. Should I continue my blood thinning (anticoagulant) medication? If you have a skin tear, generally the bleeding will settle and you can continue your anticoagulant medication such as aspirin and warfarin.  You should not stop such medications too readily or quickly since you may well be on them for a very good reason such as to avoid having a stroke.  Stopping them abruptly could lead to a much larger problem that way, than the bleeding from a skin tear.  However, this needs to be balanced with how large the wound is.  If it is a skin tear, and nothing deeper, then you should be able to continue taking your anticoagulant medication.

The cardiovascular system comprises all blood vessels.  These are basically made up of arteries – which pump blood that has oxygen to your body, and veins which return blood depleted of oxygen from your body.  The heart is a pump that sends the blood returned from your veins to your lungs, where it absorbs oxygen.  The blood from your lungs, rich in oxygen then goes back to your heart where it gets finally pumped out to the rest of your body via your arteries. This combined system of circulating blood around your body including the pump mechanism of your heart is described as the cardiovascular system.

Chest Pain

We begin this section by talking about chest pain. It can be a common symptom and can much anxiety for the sufferer or carer.

The heart has always got to be at least considered to be the potential cause of any chest pain or upper abdominal symptoms.  This is due to the potential life threatening nature of a heart attack (myocardial infarction).  However, many other causes of chest pain do exist.  Here are a few more common causes to consider:

• The joints between your sternum and the actual ribs can get sore.  Pain due to a joint this way is called arthritis.  Alternatively, ribs themselves can get inflamed.  This is called costochondritis.  Note that costochondritis can be brought on by a virus, so it may be the case that you recently had a “cold”.  It can particularly be sore when you breathe in.  The other reason people can get chest pain is from coughing too much and spraining a joint.  Muscles themselves can be torn from coughing too much.  In the process of coughing, you can even break a rib.  The nature of this pain will be such that when you cough, it hurts.

In general, musculoskeletal chest pain will reveal itself if a person gets the pain on movement.  Furthermore, when you touch the area the pain is occurring, it may be sore, or tender to touch.

• When acid from the stomach moves in the wrong direction and goes back up the gullet (oesophagus) a person can experience a quite severe chest pain that is typically sharp in nature. Relief could come from taking an antacid tablet or solution.
• Stomach acid. Even if acid doesn’t go in the wrong direction causing sharp chest pain, the presence of any stomach problem including increased acid, once again, or an ulcer, can sometimes cause chest pain. Again, taking an antacid tablet may help.
• Lung problems. Any problem with your lungs or the lining around your lungs, called the pleura, can cause chest pain. Usually, when the pain originates from the lung or lining, it especially hurts when you breath in.  This pain is then described as “pleuritic pain”.

How to recognise a heart attack in the elderly

Firstly, what is a heart attack?  This is the common description given to the situation where a blood vessel supplying the heart itself with blood to nourish the heart muscle (myocardium) gets blocked, usually by a clot, and the heart muscle no longer being nourished with blood, dies.  The technical name for a heart attack logically becomes acute (sudden) myocardial (heart muscle) infarction (death), often shorted to an “AMI”.

The fact is, when an elderly person is having a heart attack, they may or may not report having chest pain.  This is really important to remember, that they may not tell you they have chest pain.  The reason for this is because pain is actually a sensation reliant on our nervous system reporting things to us, accurately.  However, as we age, some of these mechanisms can diminish.  This is especially true of people with diabetes.  They may not have chest pain, rather, they may feel short of breath or just very tired.  There at times may be related sweating or clamminess.  This is a sign from your body, that something is wrong. What I mentioned at the start of this chapter is also worthwhile considering.  That is, when you have a heart problem, sometimes you may breathe too much and accidentally swallow air.  This can lead to burping or belching at the same time.

If you do get chest pain, it is typically on the left side of the chest, at the front.   However, it could be anywhere.  The pain may go into your back and travel down your arms or into your neck.  You may or may not have a racing heart.

The conclusion of this discussion about chest pain would be that if chest pain occurs, and despite our attempts at trying to decide on the origin of the pain, if the origin does not become clear pretty quickly, then you should call 000 and get an emergency ambulance, in case the pain is from a heart attack.  In this case, time does matter, and the faster any blockage can be fixed, the less damage to the body occurs.

A few tips:

1. Always keep aspirin at home. Aspirin thins the blood.  And, in the case of a heart attack, the thinner your blood, the less likely it is to get stuck and cause a blockage somewhere.  Therefore, aspirin, by thinning your blood, will help.  However, this should not be taken without the advice of a professional.  Usually, when you ring 000 and report chest pain, the call centre operator will ask you a few questions.  If it is thought that the person could be having a heart attack, they will ask you to give 300mg of aspirin (this is a usual tablet size).  Having this handy, will help.
2. Don’t let yourself get dehydrated. When you are sick, or during the summer or if you’re not very active, it’s very easy to get dehydrated because of not drinking enough water.  Once you get dehydrated, your blood literally gets thicker and as a consequence more sticky, making it far more likely to have a heart attack.  Therefore, make it a habit to drink plenty of water, always.  Of course, there are some situations where the amount of water you drink needs to be regulated, for example, if your body tends to accumulate water and you experience swelling of the legs or fluid in your lungs.  This could be from a weak heart or having kidney troubles.  If this is the case, then you need to balance things.  However, for everyone else, drinking plenty of water is a good way to help avoid a heart attack.
3. Take your medications. Heart attacks happen typically because of a blood clot within an artery forming and dislodging.  In other words, from damaged arteries.  There are different factors which contribute to arterial damage.  These include high blood pressure, high cholesterol, cigarette smoking and diabetes.  Often a person is meant to be on medications to control these “risk factors” for arterial disease.  It’s very important to take your medications.  This is especially true of blood pressure medications.
4. Stay active. Your heart is an amazing organ.  When you have blockages in an artery supplying the heart, which could have occurred slowly over time because of more gradual wall damage (as opposed to more suddenly with a clot), provided your active, new blood vessels and branches will grow to bypass that blockage.  This is called “collateral supply”.  Basically, what it represents is the fact that the heart is responding to your active lifestyle, over time, and your activity is stimulating the production of new blood vessels supplying your heart.  Amazing but true.  Obviously, the creation of all this “collateral” takes time.  However, if you can then stay active, your in effect conditioning your heart, so that if something did go wrong all of a sudden, your heart will hopefully be less damaged.  Stay active could be as simple as walking as much as you can.

Heart rate and rhythm disturbances

Your heart beat usually originates from one area in your heart, at the upper right section of it.  When functioning correctly, the heart rate (speed) should be between 60 – 100.  And the rhythm should be regular.  However, if the heart beat occurs from somewhere else, or if your body is experiencing some stress or lack of balance from any other reason, your rate could be less than 60 (described as being bradycardic) or greater than 100 (described as being tachycardic).

When your heart is beating normally, you usually don’t feel your heart beating.  However, when it beats abnormally, it may feel your heart beating.  This is what we call the sensation of having “palpitations”.  Of note, palpitations can tell you that there is a problem, but it may not tell you whether your heart is beating fast or slow, regularly or irregularly.  You can try to tap out the rhythm however, and get a sense of that.  Also, you may choose to feel the pulse on a wrist.  This can help with understanding whether the rhythm is regular or irregular, and also what the rate is.  If you can time how many heart beats there are in a 60 second period, this is helpful to then tell your doctor.  However, sometimes, the pulse at the wrist can be unreliable and a doctor will need to assess things further to decide what sort of rhythm problem is occurring, if any.

Some common issues with the elderly, and heart rhythms are:

Atrial fibrillation. 

As discussed earlier, the usual source of the heart beat is the right upper area.  This area is called the sinoatrial node.  The beat starts here and effectively spreads throughout the heart, starting from the top.  However, sometimes the top half of the heart (atria) can beat in an uncoordinated fashion, consequently causing the top half of the heart to quiver rather than actually contract and beat.  This is described as atrial fibrillation.  Thankfully, in this case, blood still flows to the bottom half of the heart (the ventricles) and subsequently gets pumped out and delivered to the rest of the body.  However, the output of the heart is said to be 25% less as a consequence of the atrial not contracting in a coordinated way.

Atrial fibrillation is a very common disease.  It can be caused by the accumulation of several longer term stresses on the heart (lack of blood, previous heart attacks, stretching of he heart over time), or factors relating to the make up of your blood (including your thyroid function) or more immediate reasons such as drinking too much alcohol.

A person with atrial fibrillation can feel dizzy, tired or short of breath.  If the heart is beating fast enough, causing stress, they may even have chest pain.  Or, they may not feel abnormal at all.  Atrial fibrillation increases the risk of stroke.  This is because when the top half of the heart (atria) quiver, they fail to really pump out all blood.  There are parts to the top heart of the heart, little nooks, where blood can then be prone to stagnate and subsequently form a clot.  That clot is then liable to dislodge, find its way into the arterial system, often into the brain where it blocks a vessel causing a stroke.  Therefore, in general, it is advisable to take a medication to thin your blood if you have atrial fibrillation.  This needs to be balanced with the risk of having a fall, in which case, if you are someone who falls over a lot, the risk of having a bleed from falling and being on a blood thinning medication may outweigh the benefit of taking the medication.  That’s a decision to discuss with your doctor.   You may also take medication to control how fast your heart beats, to avoid it going too fast.

Sometimes your heart may beat so fast or slow, despite medications, that you need a pacemaker.  A pacemaker is a mechanical device which sends an electrical impulse to your heart, dictating its rate and rhythm of beating.

In summary, heart rhythm disturbances are very important to understand and be aware of in the elderly.  They can be the origin of many symptoms including dizziness, tiredness and chest pain. And, most importantly, they can be the cause of person blacking out and falling.

A few tips:

1. Drink plenty of water. Once again, dehydration can affect your body and contribute to your heart rhythm becoming irregular.  It’s really important to stay well hydrated.  This is especially true of times when you are unwell.  For example, if you have diarrhoea, influenza, a urinary infection or skin infection.  All of these times in life put a stress on your heart, and that stress is increased by dehydration.
2. Report palpitations. Sometimes the heart rhythm and rate can drift between being normal and abnormal.  If you have experienced times when you thought, I could feel my heart beating, and it didn’t feel quite right, don’t ignore it.  Rather, let you GP know.  It can be investigated, and it’s really very important to know that you may be having an irregular heart rhythm and or heart rate, every now and then.  The risk of stroke is actually said to be greater when your heart drifts between being normal and abnormal this way.  Your doctor may advise you to wear a monitor which records your heart activity over 24 hours.  This is called a holter monitor.  This is a simple, pain free investigation and worthwhile doing if you can find the cause of your palpitation.
3. Look after your heart. In general, as aforementioned, stress on your heart will increase the chance of the rhythm becoming irregular.  Stress can come in the form of high blood pressure, smoking, a lack of exercise.  Care for your heart, and it is more likely to stay on track.  A special note here – alcohol.  If you drink too much alcohol, it’s more likely you’ll have a heart rhythm problem.  Drink in moderation and your heart will thank you.

Blocked arteries

Earlier, I mentioned that a heart attack is typically caused by a blood vessel which supplies blood to the heart, getting blocked.  Well, this same thing, could really happen to any blood vessel throughout your body.  And, like the heart with chest pain, the usual consequence is that we feel pain in area of the body which is lacking blood. This may be pain in your feet, particularly at night or pain in your abdomen after meals (when your bowels need more blood).  Remember a blockage to an artery can be longstanding or sudden and dramatic.  This will affect the way it presents.  But pain will likely be a feature.  A good way to consider whether a hand or foot has enough blood is to look at it’s colour and feel the temperature and note the fullness of any veins.  A warm, pink hand or foot, with bulging veins, likely has blood.  A cool, pale or blueish hand or foot, with flattened, spidery veins, is likely lacking in blood.

Varicose Veins

This is a problem usually encountered in the legs.  It is a very common problem of the elderly.  Veins usually only allow blood to travel in one direction.  This is because they have special one way valves.  However, over time, these valves can become faulty and allow blood to travel in either direction.  In the case of blood within the veins of your legs, it need to overcome gravity to be returned to the heart.  And that’s not easy.  So much so, that the force of gravity, can lead to the valves within your legs losing their one way functioning, allowing blood to pool within the veins, causing “varicose” veins.  It goes further because all the pressure of blood in the veins, causing an increasing pressure in the surrounding tissues, and the return of others fluids (via what is called the lymphatic system) is also compromised.  The leg is now swollen.  Added to this, iron from the stagnant blood, leaches out, discolouring the overlying skin.  The skin itself can get painful, itchy and red or purple.  This is called, venous eczema.  Sometimes, the stagnant venous blood and resultant pressure is so irritating to the skin, that an ulcer is formed.  This typically occurs on the inner aspect of the ankle.

In the case of varicose veins and such venous congestion, the problem gets worse as the day progresses.  This is because of the cumulative effect of gravity, since during the day, the legs are usually more upright.  The legs then improve overnight, whilst horizontal, the force of gravity now largely absent.  The problem can then be lessened during the day by elevating the legs.  If a person is sitting, then they should put their feet up on a foot stool, and recline the chair a bit, if this is able to be done.

A few tips:

1. Maintain some musculature within in your legs. Blood tends to collect in the legs in the case of varicose veins, as discussed.  However, leg muscles help literally push the blood back out of the legs, back up to the heart.  Therefore, maintaining and using your leg muscles, helps to keep blood moving, pumping it back out of your legs.  Some simple exercises could include calf raises.  However, the best way to maintain your leg muscles, is going for a walk.  Don’t sit down all day if you can avoid it.
2. Keep your legs elevated. If you do have to sit down for a long period during the day, try to keep your legs up on a foot stool.
3. Moisturise your skin. The congestion caused by the accumulation of blood can cause venous eczema, causing your legs to ache or feel itchy.  The skin can get dry along the way.  Moisturiser helps keep your skin strong and less itchy.  There are many products to choose from, but I think that simple vitamin E cream or Nivea is fine.  The main thing is to alternate products being used here and there.  If you keep using the same product forever, your skin may develop an allergy to it.  Of course, everyone’s different as well.  So what works for one person, may not work for another.  One point to note when discussing the use of any cream (which is water based) is not to allow it to be coated between your toes.  Sometimes, patients put creams between their toes, in such quantity that the water content itself, of the cream, causes the webspace of their toes to crack as it becomes macerated. Rub a cream (moisturiser in this case) in, so that it’s gone.
4. Compression stockings. If you do get swollen legs, you can use stockings to reduce the amount o
5. Be vigilant for leg cellulitis.

Deep Vein Thrombosis

This is a more serious medial condition.  It describes the situation when a deeper vein in your body (typically your lower limb) gets blocked.  If this happens, then that limb, usually the leg, starts to swell, get warm and tender.  The problem with having a DVT is that the clot inside your deep vein may flick off and travel in your veins to your heart, from where it gets pumped into your lungs, finally blocking a large blood vessel there.  The blood clot, now in your lung, is called a pulmonary embolus.  When that blood vessel in your lungs gets blocked, a portion of your lung itself may suffer and collapse, leaving you unable to breath.  If the clot is very large blocking off a sufficient part of your lung, it could kill you.

A DVT can be classified as “provoked” – meaning that there was a particular reason, why, at this time, a person had a DVT.  For example, after an operation.  Or, unprovoked, meaning that no such “special” circumstantial reason exists.  In this case, you may have an underlying medical condition which causes your blood to be sticky and therefore clot more easily.

A few tips:

1. The blood will block in your legs more easily if your legs aren’t moving, so keep those legs moving. This is true particularly of your ankle and calf muscle.  When your calf muscle contracts, it actually pumps the blood in the veins of your legs back up towards your heart.  Therefore, you should exercise your leg to encourage this to happen.  The best exercise is of course walking.
2. Elevate your legs. If you cannot walk either temporarily or permanently, consider elevating your legs. This will reduce the effect of gravity, which will tend to cause blood to collect and pool in your legs.
3. Compression stockings. These can help prevent blood from pooling in your legs. It is ideal that you put these on whilst you have been laying down, horizontal for a while, that is, before blood has had the chance to pool in your legs.  First thing in the morning, before you get up, may be suitable.  Otherwise, lay in bed for a few moments, before you put any compression stockings on.
4. Stay well hydrated. Dehydration is a reason for your blood to become more sticky.  Therefore, always try to stay well hydrated by drinking plenty of water or other fluids.  Tea or coffee is still better than nothing.  This is especially true if you have been ill, for example with an infection or diarrhoea.  Another very vulnerable time is after an operation, particularly one on your knee or hip.  After such a procedure, you may well find that your surgeon has prescribed for you a medication to keep your blood thin.  Still, you do your bit, by staying well hydrated.
5. Know the signs of a DVT. As described, a DVT can be a medical emergency, so you should get help if you experience:
   • A sudden swelling, tenderness, warmth and redness to your leg
   • Shortness of breath that you cannot explain. This may come on quickly, but in some instances, can come on more gradually over some weeks.
   • Coughing up blood. This generally is a worrying sign and you should see a doctor.
   • Chest pain. The type of chest pain experienced with a DVT may be sharp and particularly present when you breathe in.
   • Your heart racing. This can also be a sign of a pulmonary embolus.

Before I was ever a doctor, I was a paperboy.  And, I still remember meeting all those lovely elderly “customers” who stood at their letterbox, waiting for me.  Most of the time, I was on time, and the papers weren’t soaking wet, so all good.  And, when Christmas came, I still remember the little note I’d put in their letterboxes

“Christmas comes but once a year, and when it comes it brings good cheer.  And in midst of all your joy, please don’t forget your paperboy”

And you know what, many of them wouldn’t.  When Christmas came, they would leave a little envelope taped to their letterboxes with a tip, and sometimes a card.

I really got to know my paper rounds.  I should think I should have because I did a paper round from the age of 12 till 18.  6 days initially, then 7 days a week, on my bike with milk crate or two strapped to the front with octopus ropes.

I got to know a lot of elderly people, having a quick chat here and there as I went along.

For some elderly customers, we’d have special instructions to place the paper at the front door, or throw it onto the front porch… no broken windows from recollection.  So from a very young age, I got a gist that being an elderly person living at home, was a special experience.  This was bolstered one day when an elderly lady was standing outside of her house, waiting for me.  Nothing unusual about that, I’d often hand people their papers.  But when I got there, she asked me to come in and help pump her husband’s tyre on his wheelchair.  He had polio and was a paraplegic.   I stepped in, helped, and carried on my business.  But I remember it so vividly.  I got my first glimpse of how hard it could be to be elderly, living alone or with someone, in your own home.  Yet, looking at many photos and books, and treasured belongings, just how much it meant, to be able to do so, nonetheless.

When I became a doctor, I didn’t gravitate to serving the elderly immediately.  Instead, I had great ambitions of being a surgeon.  However, after training in that area, I realised that the field was just not for me. Perhaps I liked too much, talking to people while they were awake!

But I did like helping the elderly.  I liked going to nursing homes, I liked seeing them at the clinic, and I liked seeing them in their home.  I really liked seeing them in their homes.  I would find myself noticing all the intricacies of their furniture, photos, artwork and everything else that I never knew before.  So every time I would leave their home, I felt like knew them that little bit more, I felt like I understood them, that little bit more.

I remember once being asked to visit an elderly lady by her daughter, who lived with her.  I went.  I got to the house and was ushered in by her daughter.  We progressed to her bedroom.  There I found the patient, a frail, elderly lady laying in a bed, with a bell carefully positioned over the bed, hooked into place with a coat hanger.  In actual fact, her daughter really had tried her best to set up a version of “hospital in the home”.

I remember sitting down with another elderly patient on her couch, and whilst I was trying to listen to her chest and heart, she was only too eager to discuss the painting she had herself completed of her grand daughter.  I looked at the painting.  It was really good.  Wow, I thought.  I’ll never forget the smile of that patient.  Rosy cheeks always.  The face, in this case, of a contented artist.  It was sad news when I came to hear that she had to go to a nursing home.  I remember talking about how much she didn’t want that to happen.

Over the last 7 years, I have been on call basically all the time after hours, visiting patients.  Mainly at nursing homes, but sometimes in their homes.  And, from fulfilling that role, over the 7 years then, I have learnt a lot about caring for the elderly, more than any of my textbooks ever could have taught me.

I lament however, that despite my contributions as a general practitioner, that I never was able to really see enough patients at home, during the day.  Not as a regular doctor.  Some I do, but I could have seen more.  My own story has led me down the path of setting up a company, Atticus Health.  Through this, we have opened a chain of medical clinics, as well as leading an earnest group of doctors who attend nursing homes.  We have quickly become one of the largest providers of medical services to nursing homes in my home state of Victoria.

Despite all of this, I return to the fact that, when it comes to visiting patients at home, I wish I could have done more.  It’s very difficult to find a doctor who is willing to visit a patient regularly during the day.  There are many reasons for this, but essentially it amounts to being much more work and less pay, making it as a job, in the current situation, not a favourable one, when compared to seeing patients at a clinic.

Yet I find myself in a position now to help with some things. So I figured, it’s time to put that into action!  By writing this book, my express intention is empowerment. I hope that carers can become better informed as they go about their selfless work of helping and advocating for the elderly person/s they care for. Perhaps even other medical professionals would find reason and indeed something useful in reading this book.  And last, but not least, I hope that if you are an elderly person, trying to live at home, that this book may help you achieve that.  That this book, somehow, leads you to better health and peace.

Apart from writing this book, I still haven’t given up on the idea of getting more doctors conducting home visits and indeed becoming their regular home visiting doctor.  Because of the way the NHS operates, this is commonly the case in the United Kingdom.  As from experience, I think the need for home visiting general practitioners is real, and therefore I still believe this is a neglected topic.  So what can I do?  Well, I know how to lead and manage doctors, to support them.  So, I reckon I could help make the activity less “demanding” that way, by providing them with great support.  And, the outstanding thing then is – pay.  In the current system, you lose money from doing home visits.  That’s the plain fact.  So what I’m planning to do is support all of those doctors by essentially providing all our services, including access to required software, administration, compliance, reception, the whole thing – for free.  This project is called – Mobile GP.  You can look up details here – www.mobilegp.com.au

Between increasing empowerment and knowledge, and delivering more doctors to elderly patients’ homes, throughout the whole of Australia, I hope that things change.  That the level of medical care for housebound elderly people takes important, meaningful steps forward.

Caring for the elderly is arranged by considering health from a holistic perspective, what is said to be a “bio-psycho-social” model.  That’s a biological, psychological and social model.  Forgive me here, because I am a product of a medical degree, and we ideally considered the approach to any patient in these terms.  However, I’m sure that there would be other valid ways to do it.  Indeed I myself break from this organisation somewhat in the book, with a specific section on falls.  This is an important topic, I felt warranted a stand alone chapter.  Within the biological section, I consider problems in terms of systems – the respiratory system, cardiovascular system etc.  I hope this provides for a logical way to search between topics. Along the way, I offer many short stories, where I remember them, to aid to understanding and perhaps make any information and advice more practical.  This book isn’t exhaustive, it’s not meant to be.  Rather it covers really common problems, and hopefully gives you an approach to consider health from a pragmatic yet sufficiently professional standpoint still.  I hope that it’s simple enough to be an important tool.

Whilst here, I’d like to thank my family.  This is going to be a big section.  I hope you can understand why.  I truly am grateful in my life, and so to make this brief, would not be sufficiently representative of that.  And to be sure, as a couple of kids of mine have said, I’m talking about my “two” families.  I’m talking about my parents, and my own siblings.  And I’m talking my wife and my five kids.  Family life is never perfect, let’s be honest.  But somewhere there, in my life, there has been real magic of being part of these two families.

Mark, my dad was and is the most hardworking person I have ever come across.  And what’s more, he loved each of his jobs.  At the age of 70, I think he had three jobs still, at least two.  And, I know, he seemed to love each of them. He went to work with a smile, and absolutely loved serving the public.  He has passed away now, but I’ll remember him always. I’ll remember that he never forgot to massage each of his four children’s backs before they went to sleep.  Massages are addictive, and so were his renditions of Neil Diamond’s “Song Sung Blue”.

My mother, Sylvia, would be called “fiercely independent”.  I think that’s the description of someone still capable of slapping someone in the face if they had to!  No, in all seriousness, she’s the toughest, gutsiest person I’ve ever met.  Back in the day, I think she had to be.  But despite that, I think she was born tough.  From dodging her boarding school from making her a nun, to working full time, yet still getting four kids off to school – on time, what a legend. But perhaps most, I’ll remember my mum for somehow finding the time to, despite all, make me feel like a winner.  She’d be cooking, and I’d be sitting on the dining table, perhaps peel potatoes or garlic, or perhaps drawing a picture.  Yet somehow, in her company, she would genuinely take an interest in me, sufficiently so, that I grew up, as an adult, feeling like “I could do it”.  Believing that I had abilities.  Believing in myself.  As a busy dad now, I find it incredible that despite being so busy every day, she somehow took the time and effort to make me feel so special as a child still.  Mum, thank you.  But please… it must be time to stop getting on the ladder and painting the eaves!

That leads me to my siblings – Clare, Rolf and Bruce.  I must also mention here, that I had another brother, Clive, who died before I was born.  He was five at the time.  Clive, I hope you are resting in peace.  As a result of Clive’s passing, I grew up being the youngest of four children, and frankly, I think I was lucky.  The support I have received from my sister and two brothers has been so important and helpful to my life.

I work with my sister, she’s an executive in my company.  We work well together, and have done so for many years.  But her loyalty goes much further back.  Clare is a nurse and I still remember coming back from school, sometimes with a headache, and she would voluntarily get a warm face towel to sponge my face, particularly my forehead.  And she would enquire, “does that feel better”.  When the towel got too cool, she would put it under hot water again and place it on my face once again.  She’s a kind soul, and always been so, with me.

My brother Rolf is an inspiration.  He’s an engineer and cardiologist.  If you’ve heard about the “Heart of Australia”, that is, specialist medical care being delivered throughout rural and remote Queensland via specially designed massive trucks, then you would have heard about him.  It’s with his daringness to “think big” that I too dare to let my audacious dreams spur me to action.  Indeed, I took lead to study medicine, in the first instance, and never looked back since.  Rolf, thank you for the inspiration you’ve provided me in my life.

My brother Bruce.  If there was ever a person who truly loved spending time with people, Bruce is that guy.  And, I have a problem.  You see, he’s also a great cook.  As a consequence of that, I usually end up in a ‘food coma’ at his house, fast asleep on his couch, hopefully not drooling.  Although I do think there are a few unauthorised photographs that may have been taken along the way, showing me doing so.  I’m not sure, I was asleep at the time!  Thank you for forgiving me for being such a poor, and all at once, thank you yet for inviting me over so often.  It’s such a pleasure having people, family in this case, to see over the weekend.  I don’t know how isolated my life would be without the company of you and your family, but it would certainly be a less joyous one.  Bruce, you really have taught me what it means to live simply and be generous.  Thank you.

Now let’s get to my “actual” family (I think that’s what my daughter referred to it as).  To my kids, Tobias, Jonah, Livian, Gideon and Angelique.  For putting up with all my randomness including my willingness to drop you off at your schools in my pyjamas, thank you.  And, might I say, that I think I’ve learnt more from you, than I’ve taught you.  Most of all, thank you for being so understanding about me getting phone calls really any time of the day, any day.  This included whilst we were reading bed time stories, while we were having dinner, while we were doing anything.  I always had plans not to be on call, but that never quite worked out.  And you guys could have gotten very upset at me many a time, but you never did.  In fact, you usually run to bring me my phone.  It’s because of you that I’ve been able to be able to help others over the years, especially after hours.

Oh yes, and my wife, Nathalie.  We met in medical school (she’s an anaesthetist now) you see, so we should know each other pretty well by now.  But in actual fact, she still never ceases to amaze me.  And I have to reveal something perhaps that should be embarrassing, but nevertheless here goes.  I have what’s commonly known as a turkey pile.  That’s right, out the front of my cupboard, lays a pile of clothes.  If you choose to not buy or read this book because of this.  I understand and forgive you.  But let me tell you something, after years of telling me off, one day, Nathalie stopped telling me off.  I still don’t quite get it.  She just seemed to accept it.  And somehow, it reminded me of something I’d read in Charlie Brown comic “friends don’t try to change you”. Something like that.  I want to change my turkey pile, for you Nat, not for me.  Except, I’ve got no damn idea how to organise my clothes, that’s the truth!  Nathalie, you really have stuck by me through thick and thin.  And, as tough as it has made things many a time, you’ve let me loose to take risks and think big.  Yet never critised me, when things didn’t pay off.  That’s something special.  You’re an amazing mamma, friend and wife, grow more beautiful every day, and I love you.

So that’s it, that’s my whole family.  I have more people to thank also, my friends, my colleagues, my patients.  I am grateful for getting to know all of you in this life.

So with all of that being said, I hope you enjoy this book and get much out of it.  It’s my humble yet best attempt to record what I know about helping and caring for the elderly.  I hope that by reading it, you may be more empowered, and confident in combating medical dilemmas.  Most of all, I hope that this book, by improving medical care, helps more elderly people stay living for as long as possible in their homes. And not just so that they can tip the paperboy at Christmas, although, commit this to memory – “In the midst of all your joy, please don’t forget the paperboy”!

Happy reading ?

A note: since commencing writing this book, my mother has since sadly passed away.  May she rest in peace.