Are You Taking PIMs?

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Getting Off The Overmedication Train

The older we get, the more likely we are to be on more medications. It’s easy to assume that this is because, much like the ailments they treat, we accumulate them over time. And superficially at least, that’s what happens.

And yet, almost half of people over 65 in Canada are taking “potentially inappropriate medications”, or PIMs—in other words, medications that are not needed and perhaps harmful. This categorization includes medications where the iatrogenic harms (side effects, risks) outweigh the benefits, and/or there’s a safer more effective medication available to do the job.

See: The cost of potentially inappropriate medications for older adults in Canada: A comparative cross-sectional study

You may be wondering: what does this mean for the US?

Well, we don’t have the figures for the US because we’re working from Canadian research today, but given the differences between the two country’s healthcare systems (mostly socialized in Canada and mostly private in the US), it seems a fair hypothesis that if it’s almost half in Canada, it’s probably more than half in the US. Socialized healthcare systems are generally quite thrifty and seek to spend less on healthcare, while private healthcare systems are generally keen to upsell to new products/services.

The three top categories of PIMs according to the above study:

  1. Gabapentinoids (anticonvulsants also used to treat neuropathic pain)
  2. Proton pump inhibitors (PPIs)
  3. Antipsychotics (especially, to people without psychosis)

…but those are just the top of the list; there are many many more.

The list continues: opioids, anticholinergics, sulfonlyurea, NSAIDs, benzodiazepines and related rugs, and cholinesterase inhibitors. That’s where the Canadian study cuts off (although it also includes “others” just before NSAIDs), but still, you guessed it, there are more (we’re willing to bet statins weigh heavily in the “others” section, for a start).

There are two likely main causes of overmedication:

The side effect train

This is where a patient has a condition and is prescribed drug A, which has some undesired side effects, so the patient is prescribed drug B to treat those. However, that drug also has some unwanted side effects of its own, so the patient is prescribed drug C to treat those. And so on.

For a real-life rundown of how this can play out, check out the case study in:

The Hidden Complexities of Statins and Cardiovascular Disease (CVD)

The convenience factor

No, not convenient for you. Convenient for others. Convenient for the doctor if it gets you out of their office (socialized healthcare) or because it was easy to sell (private healthcare). Convenient for the staff in a hospital or other care facility.

This latter is what happens when, for example, a patient is being too much trouble, so the staff give them promazine “to help them settle down”, notwithstanding that promazine is, besides being a sedative, also an antipsychotic whose common side effects include amenorrhea, arrhythmias, constipation, drowsiness and dizziness, dry mouth, impotence, tiredness, galactorrhoea, gynecomastia, hyperglycemia, insomnia, hypotension, seizures, tremor, vomiting and weight gain.

This kind of thing (and worse) happens more often towards the end of a patient’s life; indeed, sometimes precipitating that end, whether you want it or not:

Mortality, Palliative Care, & Euthanasia

How to avoid it

Good practice is to be “open-mindedly skeptical” about any medication. By this we mean, don’t reject it out of hand, but do ask questions about it.

Ask your prescriber not only what it’s for and what it’ll do, but also what the side effects and risks are, and an important question that many people don’t think to ask, and for which doctors thus don’t often have a well-prepared smooth-selling reply, “what will happen if I don’t take this?”

And look up unbiased neutral information about it, from reliable sources (Drugs.com and The BNF are good reference guides for this—and if it’s important to you, check both, in case of any disagreement, as they function under completely different regulatory bodies, the former being American and the latter being British. So if they both agree, it’s surely accurate, according to best current science).

Also: when you are on a medication, keep a journal of your symptoms, as well as a log of your vitals (heart rate, blood pressure, weight, sleep etc) so you know what the medication seems to be helping or harming, and be sure to have a regular meds review with your doctor to check everything’s still right for you. And don’t be afraid to seek a second opinion if you still have doubts.

Want to know more?

For a more in-depth exploration than we have room for here, check out this book that we reviewed not long back:

To Medicate or Not? That is the Question! – by Dr. Asha Bohannon

Take care!

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  • The BAT-pause!

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    When Cold Weather & The Menopause Battle It Out

    You may know that (moderate, safe) exposure to the cold allows our body to convert our white and yellow fat into the much healthier brown fat—also called brown adipose tissue, or “BAT” to its friends.

    If you didn’t already know that, then well, neither did scientists until about 15 years ago:

    The Changed Metabolic World with Human Brown Adipose Tissue: Therapeutic Visions

    You can read more about it here:

    Cool Temperature Alters Human Fat and Metabolism

    This is important, especially because the white fat that gets converted is the kind that makes up most visceral fat—the kind most associated with all-cause mortality:

    Visceral Belly Fat & How To Lose It ← this is not the same as your subcutaneous fat, the kind that sits directly under your skin and keeps you warm; this is the fat that goes between your organs and of which we should only have a small amount!

    The BAT-pause

    It’s been known (since before the above discovery) that BAT production slows considerably as we get older. Not too shocking—after all, many metabolic functions slow as we get older, so why should fat regulation be any different?

    But! Rodent studies found that this was tied less to age, but to ovarian function: rats who underwent ovariectomies suffered reduced BAT production, regardless of their age.

    Naturally, it’s been difficult to recreate such studies in humans, because it’s difficult to find a large sample of young adults willing to have their ovaries whipped out (or even suppressed chemically) to see how badly their metabolism suffers as a result.

    Nor can an observational study (for example, of people who incidentally have ovaries removed due to ovarian cancer) usefully be undertaken, because then the cancer itself and any additional cancer treatments would be confounding factors.

    Perimenopausal study to the rescue!

    A recent (published last month, at time of writing!) study looked at women around the age of menopause, but specifically in cohorts before and after, measuring BAT metabolism.

    By dividing the participants into groups based on age and menopausal status, and dividing the post-menopausal group into “takes HRT” and “no HRT” groups, and dividing the pre-menopausal group into “normal ovarian function” and “ovarian production of estrogen suppressed to mimic slightly early menopause” groups (there’s a drug for that), and then having groups exposed to warm and cold temperatures, and measuring BAT metabolism in all cases, they were able to find…

    It is about estrogen, not age!

    You can read more about the study here:

    “Good” fat metabolism changes tied to estrogen loss, not necessarily to aging, shows study

    …and the study itself, here:

    Brown adipose tissue metabolism in women is dependent on ovarian status

    What does this mean for men?

    This means nothing directly for (cis) men, sorry.

    But to satisfy your likely curiosity: yes, testosterone does at least moderately suppress BAT metabolism—based on rodent studies, anyway, because again it’s difficult to find enough human volunteers willing to have their testicles removed for science (without there being other confounding variables in play, anyway):

    Testosterone reduces metabolic brown fat activity in male mice

    So, that’s bad per se, but there isn’t much to be done about it, since the rest of your (addressing our male readers here) metabolism runs on testosterone, as do many of your bodily functions, and you would suffer many unwanted effects without it.

    However, as men do typically have notably less body fat in general than women (this is regulated by hormones), the effects of changes in BAT metabolism are rather less pronounced in men (per testosterone level changes) than in women (per estrogen level changes), because there’s less overall fat to convert.

    In summary…

    While menopausal HRT is not necessarily a silver bullet to all metabolic problems, its BAT-maintaining ability is certainly one more thing in its favor.

    See also:

    Dr. Jen Gunter | What You Should Have Been Told About The Menopause Beforehand

    Take care!

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  • Kale vs Watercress – Which is Healthier?

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    Our Verdict

    When comparing kale to watercress, we picked the kale.

    Why?

    It was very close! If ever we’ve been tempted to call something a tie, this has been the closest so far.

    Their macros are close; watercress has a tiny amount more protein and slightly lower carbs, but these numbers are tiny, so it’s not really a factor. Nevertheless, on macros alone we’d call this a slight nominal win for watercress.

    In terms of vitamins, they’re even. Watercress has higher vitamin E and choline (sometimes considered a vitamin), as well as being higher in some B vitamins. Kale has higher vitamins A and K, as well as being higher in some other B vitamins.

    In the category of minerals, watercress has higher calcium, magnesium, phosphorus, and potassium, while kale has higher copper, iron, manganese, and zinc. The margins are slightly wider for kale’s more plentiful minerals though, so we’ll call this section a marginal win for kale.

    When it comes to polyphenols, kale takes and maintains the lead here, with around 2x the quercetin and 27x the kaempferol. Watercress does have some lignans that kale doesn’t, but ultimately, kale’s strong flavonoid content keeps it in the lead.

    So of course: enjoy both if both are available! But if we must pick one, it’s kale.

    Want to learn more?

    You might like to read:

    Take care!

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  • Kate Middleton is having ‘preventive chemotherapy’ for cancer. What does this mean?

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    Catherine, Princess of Wales, is undergoing treatment for cancer. In a video thanking followers for their messages of support after her major abdominal surgery, the Princess of Wales explained, “tests after the operation found cancer had been present.”

    “My medical team therefore advised that I should undergo a course of preventative chemotherapy and I am now in the early stages of that treatment,” she said in the two-minute video.

    No further details have been released about the Princess of Wales’ treatment.

    But many have been asking what preventive chemotherapy is and how effective it can be. Here’s what we know about this type of treatment.

    It’s not the same as preventing cancer

    To prevent cancer developing, lifestyle changes such as diet, exercise and sun protection are recommended.

    Tamoxifen, a hormone therapy drug can be used to reduce the risk of cancer for some patients at high risk of breast cancer.

    Aspirin can also be used for those at high risk of bowel and other cancers.

    How can chemotherapy be used as preventive therapy?

    In terms of treating cancer, prevention refers to giving chemotherapy after the cancer has been removed, to prevent the cancer from returning.

    If a cancer is localised (limited to a certain part of the body) with no evidence on scans of it spreading to distant sites, local treatments such as surgery or radiotherapy can remove all of the cancer.

    If, however, cancer is first detected after it has spread to distant parts of the body at diagnosis, clinicians use treatments such as chemotherapy (anti-cancer drugs), hormones or immunotherapy, which circulate around the body .

    The other use for chemotherapy is to add it before or after surgery or radiotherapy, to prevent the primary cancer coming back. The surgery may have cured the cancer. However, in some cases, undetectable microscopic cells may have spread into the bloodstream to distant sites. This will result in the cancer returning, months or years later.

    With some cancers, treatment with chemotherapy, given before or after the local surgery or radiotherapy, can kill those cells and prevent the cancer coming back.

    If we can’t see these cells, how do we know that giving additional chemotherapy to prevent recurrence is effective? We’ve learnt this from clinical trials. Researchers have compared patients who had surgery only with those whose surgery was followed by additional (or often called adjuvant) chemotherapy. The additional therapy resulted in patients not relapsing and surviving longer.

    How effective is preventive therapy?

    The effectiveness of preventive therapy depends on the type of cancer and the type of chemotherapy.

    Let’s consider the common example of bowel cancer, which is at high risk of returning after surgery because of its size or spread to local lymph glands. The first chemotherapy tested improved survival by 15%. With more intense chemotherapy, the chance of surviving six years is approaching 80%.

    Preventive chemotherapy is usually given for three to six months.

    How does chemotherapy work?

    Many of the chemotherapy drugs stop cancer cells dividing by disrupting the DNA (genetic material) in the centre of the cells. To improve efficacy, drugs which work at different sites in the cell are given in combinations.

    Chemotherapy is not selective for cancer cells. It kills any dividing cells.

    But cancers consist of a higher proportion of dividing cells than the normal body cells. A greater proportion of the cancer is killed with each course of chemotherapy.

    Normal cells can recover between courses, which are usually given three to four weeks apart.

    What are the side effects?

    The side effects of chemotherapy are usually reversible and are seen in parts of the body where there is normally a high turnover of cells.

    The production of blood cells, for example, is temporarily disrupted. When your white blood cell count is low, there is an increased risk of infection.

    Cell death in the lining of the gut leads to mouth ulcers, nausea and vomiting and bowel disturbance.

    Certain drugs sometimes given during chemotherapy can attack other organs, such as causing numbness in the hands and feet.

    There are also generalised symptoms such as fatigue.

    Given that preventive chemotherapy given after surgery starts when there is no evidence of any cancer remaining after local surgery, patients can usually resume normal activities within weeks of completing the courses of chemotherapy.The Conversation

    Ian Olver, Adjunct Professsor, School of Psychology, Faculty of Health and Medical Sciences, University of Adelaide

    This article is republished from The Conversation under a Creative Commons license. Read the original article.

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    We hear a lot about the importance of mindfulness, yet how can Zen-like non-attachment to the material world go well with actually surviving (let alone thriving) in a Capitalist society?

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  • 4 ways to cut down on meat when dining out – and still make healthy choices

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    Many of us are looking for ways to eat a healthier and more sustainable diet. And one way to do this is by reducing the amount of meat we eat.

    That doesn’t mean you need to become a vegan or vegetarian. Our recent research shows even small changes to cut down on meat consumption could help improve health and wellbeing.

    But not all plant-based options are created equal and some are ultra-processed. Navigating what’s available when eating out – including options like tofu and fake meats – can be a challenge.

    So what are your best options at a cafe or restaurant? Here are some guiding principles to keep in mind when cutting down on meat.

    Mikhaylovskiy/Shutterstock

    Health benefits to cutting down

    Small amounts of lean meat can be part of a healthy, balanced diet. But the majority of Australians still eat more meat than recommended.

    Only a small percentage of Australians (10%) are vegetarian or vegan. But an increasing number opt for a flexitarian diet. Flexitarians eat a diet rich in fruits and vegetables, while still enjoying small amounts of meat, dairy, eggs and fish.

    Our recent research looked at whether the average Australian diet would improve if we swapped meat and dairy for plant-based alternatives, and the results were promising.

    The study found health benefits when people halved the amount of meat and dairy they ate and replaced them with healthy plant-based foods, like tofu or legumes. On average, their dietary fibre intake – which helps with feeling fuller for longer and digestive health – went up. Saturated fats – which increase our blood cholesterol levels, a risk factor for heart disease – went down.

    Including more fibre and less saturated fat helps reduce the risk of heart disease.

    Achieving these health benefits may be as simple as swapping ham for baked beans in a toastie for lunch, or substituting half of the mince in your bolognese for lentils at dinner.

    A hand holding a plate filled with vegetables and pita bread.
    Filling your plate with fibre-rich foods can help lower cholesterol. Wally Pruss/Shutterstock

    How it’s made matters

    For a long time we’ve known processed meats – such as ham, bacon and sausages – are bad for your health. Eating high amounts of these foods is associated with poor heart health and some forms of cancer.

    But the same can be true of many processed meat alternatives.

    Plant-based alternatives designed to mimic meat, such as sausages and burgers, have become readily available in supermarkets, cafes and restaurants. These products are ultra-processed and can be high in salt and saturated fat.

    Our study found when people replaced meat and dairy with ultra-processed meat alternatives – such as plant-based burgers or sausages – they ate more salt and less calcium, compared to eating meat or healthy plant-based options.

    So if you’re cutting down on meat for health reasons, it’s important to think about what you’re replacing it with. The Australian Dietary Guidelines recommend eggs, legumes/beans, tofu, nuts and seeds.

    Tofu can be a great option. But we recommend flavouring plain tofu with herbs and spices yourself, as pre-marinated products are often ultra-processed and can be high in salt.

    What about when dining out?

    When you’re making your own food, it’s easier to adapt recipes or reduce the amount of meat. But when faced with a menu, it can be difficult to work out what is the best option.

    Two people eat noodles from takeaway bowls.
    Eating a range of colours is one way to ensure variety. Mikhail Nilov/Pexels

    Here are our four ways to make healthy choices when you eat out:

    1. Fill half your plate with vegetables

    When cutting down on meat, aim for half your plate to be vegetables. Try to also eat a variety of colours, such as leafy green spinach, red capsicum and pumpkin.

    When you’re out, this might look like choosing a vegetable-based entree, a stir-fry or ordering a side salad to have with your meal.

    2. Avoid the deep fryer

    The Australian Dietary Guidelines recommend limiting deep fried foods to once a week or less. When dining out, choose plant-based options that are sautéed, grilled, baked, steamed, boiled or poached – instead of those that are crumbed or battered before deep frying.

    This could mean choosing vegetarian dumplings that are steamed not fried, or poached eggs at brunch instead of fried. Ordering a side of roast vegetables instead of hot chips is also a great option.

    3. Pick wholegrains

    Scan the menu for wholegrain options such as brown rice, wholemeal pizza or pasta, barley, quinoa or wholemeal burger buns. Not only are they good sources of protein, but they also provide more dietary fibre than refined grains, which help keep you fuller for longer.

    4. If you do pick meat – choose less processed kinds

    You may not always want, or be able, to make a vegetarian choice when eating out and with other people. If you do opt for meat, it’s better to steer clear of processed options like bacon or sausages.

    If sharing dishes with other people, you could try adding unprocessed plant-based options into the mix. For example, a curry with lentils or chickpeas, or a vegetable-based pizza instead of one with ham or salami. If that’s not an option, try choose meat that’s a lean cut, such as chicken breast, or options which are grilled rather than fried.

    Laura Marchese, PhD candidate at the Institute for Physical Activity and Nutrition, Deakin University and Katherine Livingstone, NHMRC Emerging Leadership Fellow and Senior Research Fellow at the Institute for Physical Activity and Nutrition, Deakin University

    This article is republished from The Conversation under a Creative Commons license. Read the original article.

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  • Shoulders Range – by Elia Bartolini

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    Shoulder flexibility and mobility can be a big deal, especially when it starts to decline—more so than other kinds of flexibility. Most seniors can get through the day without doing the splits against a wall, for example, but shoulder tightness can be more of a problem if you can’t easily get into or out of your clothes.

    If you think it couldn’t happen to you: the great Jane Fonda has a now-famous photoset of her looking glamorous in a dress at a red carpet event, and then looking frazzled making breakfast in the same dress in her kitchen the next morning, because, as she wrote, “I couldn’t get my dress unzipped so I slept in it”.

    Now, “to avoid ending up like Jane Fonda” is not a series of words that usually precedes advice, but in this case: this book delves into the science of one of the most quirky joints of the human body, and how to leverage this to maximize shoulder mobility, while maintaining adequate strength (because flexibility without strength is just asking for a dislocation) without doing anything that would actually bulk up our shoulders, because it’s just about progressing through passive, active, and tensed stretching, static, dynamic, and loaded stretching, as well as PNF stretching and antagonist stretching.

    If that seems like a lot of stretching, don’t worry; the author presents a series of workouts that will take us through these stretches in a very small amount of time each day.

    The style is instructional like a textbook, with clear diagrams where appropriate, and lots of callout boxes, bullet points, emboldening for key points, etc. It all makes for every easy learning.

    Bottom line: if you’d like to improve and maintain your shoulder mobility, this is an excellent book for that.

    Click here to check out Shoulders Range, and perfect your shoulders and upper body flexibility!

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