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.
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:
- Gabapentinoids (anticonvulsants also used to treat neuropathic pain)
- Proton pump inhibitors (PPIs)
- 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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Staying Sane In A Hyper-Connected World
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Staying Sane In A Hyper-Connected World
There’s a war over there, a genocide in progress somewhere else, and another disease is ravaging the population of somewhere most Americans would struggle to point out on the map. Not only that, but that one politician is at it again, and sweeping wildfires are not doing climate change any favors.
To borrow an expression from Gen-Z…
“Oof”.
A Very Modern Mental Health Menace
For thousands of years, we have had wars and genocides and plagues and corrupt politicians and assorted major disasters. Dire circumstances are not new to us as a species. So what is new?
As some reactionary said during the dot-com boom, “the Internet doesn’t make people stupid; it just makes their stupidity more accessible”.
The same is true now of The Horrors™.
The Internet doesn’t, by and large, make the world worse. But what it does do is make the bad things much, much more accessible.
Understanding and empathy are not bad things, but watch out…
- When soldiers came home from the First World War, those who hadn’t been there had no conception of the horrors that had been endured. That made it harder for the survivors to get support. That was bad.
- Nowadays, while mass media covering horrors certainly doesn’t convey the half of it, even the half it does convey can be overwhelming. This is also bad.
The insidious part is: while people are subjectively reporting good physical/mental health, the reports of the symptoms of poor physical/mental health from the same population do not agree:
Stress in America 2023: A nation grappling with psychological impacts of collective trauma
Should we just not watch the news?
In principle that’s an option, but it’s difficult to avoid, unless you truly live under a rock, and also do not frequent any social media at all. And besides, isn’t it our duty as citizens of this world to stay informed? How else can we make informed choices?
Staying informed, mindfully
There are steps that can be taken to keep ourselves informed, while protecting our mental health:
- Choose your sources wisely. Primary sources (e.g. tweets and videos from people who are there) will usually be most authentic, but also most traumatizing. Dispassionate broadsheets may gloss over or misrepresent things more (something that can be countered a bit by reading an opposing view from a publication you hate on principle), but will offer more of an emotional buffer.
- Boundary your consumption of the news. Set a timer and avoid doomscrolling. Your phone (or other device) may help with this if you set a screentime limit per app where you consume that kind of media.
- Take (again, boundaried) time to reflect. If you don’t, your brain will keep grinding at it “like a fork in the garbage disposal”. Talking about your feelings on the topic with a trusted person is great; journaling is also a top-tier more private option.
- If you feel helpless, help. Taking even small actions to help in the face of suffering somewhere else (e.g. donating to relief funds, engaging in advocacy / hounding your government about it), can help alleviate feelings of anguish and helplessness. And of course, as a bonus, it actually helps in the real world too.
- When you relax, relax fully. Even critical care doctors need downtime, nobody can be “always on” without burning out. So whatever distracts and relaxes you completely, make sure to make time for that too.
Want to know more?
That’s all we have room for today, but you might like to check out:
- Distressing images and videos can take a toll on our mental health. How can we stay informed without being traumatised?
- PTSD expert on how to protect yourself and your kids from overexposure to war images from the Mideast
You also might like our previous main features:
- C-PTSD, And What To Do When Life Genuinely Sucks
- A Surprisingly Powerful Tool: Eye Movement Desensitization & Reprocessing
Take care!
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The Meds That Impair Decision-Making
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Impairment to cognitive function is often comorbid with Parkinson’s disease. That is to say: it’s not a symptom of Parkinson’s, but it often occurs in the same people. This may seem natural: after all, both are strongly associated with aging.
However, recent (last month, at time of writing) research has brought to light a very specific way in which medication for Parkinson’s may impair the ability to make sound decisions.
Obviously, this is a big deal, because it can affect healthcare decisions, financial decisions, and more—greatly impacting quality of life.
See also: Age-related differences in financial decision-making and social influence
(in which older people were found more likely to be influenced by the impulsive financial preferences of others than their younger counterparts, when other factors are controlled for)
As for how this pans out when it comes to Parkinson’s meds…
Pramipexole (PPX)
This drug can, due to an overlap in molecular shape, mimic dopamine in the brains of people who don’t have enough—such as those with Parkinson’s disease. This (as you might expect) helps alleviate Parkinson’s symptoms.
However, researchers found that mice treated with PPX and given a touch-screen based gambling game picked the high-risk, high reward option much more often. In the hopes of winning strawberry milkshake (the reward), they got themselves subjected to a lot of blindingly-bright flashing lights (the risk, to which untreated mice were much more averse, as this is very stressful for a mouse).
You may be wondering: did the mice have Parkinson’s?
The answer: kind of; they had been subjected to injections with 6-hydroxydopamine, which damages dopamine-producing neurons similarly to Parkinson’s.
This result was somewhat surprising, because one would expect that a mouse whose depleted dopamine was being mimicked by a stand-in (thus, doing much of the job of dopamine) would be less swayed by the allure of gambling (a high-dopamine activity), since gambling is typically most attractive to those who are desperate to find a crumb of dopamine somewhere.
They did find out why this happened, by the way, the PPX hyperactivated the external globus pallidus (also called GPe, and notwithstanding the name, this is located deep inside the brain). Chemically inhibiting this area of the brain reduced the risk-taking activity of the mice.
This has important implications for Parkinson’s patients, because:
- on an individual level, it means this is a side effect of PPX to be aware of
- on a research-and-development level, it means drugs need to be developed that specifically target the GPe, to avoid/mitigate this side effect.
You can read the study in full here:
Don’t want to get Parkinson’s in the first place?
While nothing is a magic bullet, there are things that can greatly increase or decrease Parkinson’s risk. Here’s a big one, as found recently (last week, at the time of writing):
Air Pollution and Parkinson’s Disease in a Population-Based Study
Also: knowing about its onset sooner rather than later is scary, but beneficial. So, with that in mind…
Recognize The Early Symptoms Of Parkinson’s Disease
Finally, because Parkinson’s disease is theorized to be caused by a dysfunction of alpha-synuclein clearance (much like the dysfunction of beta-amyloid clearance, in the case of Alzheimer’s disease), this means that having a healthy glymphatic system (glial cells doing the same clean-up job as the lymphatic system, but in the brain) is critical:
How To Clean Your Brain (Glymphatic Health Primer)
Take care!
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Thai Green Curry With Crispy Tofu Balls
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Diversity is key here, with a wide range of mostly plants, offering an even wider range of phytochemical benefits:
You will need
- 7 oz firm tofu
- 1 oz cashew nuts (don’t soak them)
- 1 tbsp nutritional yeast
- 1 tsp turmeric
- 4 scallions, sliced
- 7 oz mangetout
- 7 oz fermented red cabbage (i.e., from a jar)
- 1 cup coconut milk
- Juice of ½ lime
- 2 tsp light soy sauce
- 1 handful fresh cilantro, or if you have the “cilantro tastes like soap” gene, then parsley
- 1 handful fresh basil
- 1 green chili, chopped (multiply per heat preference)
- 1″ piece fresh ginger, roughly chopped
- ¼ bulb garlic, crushed
- 1 tsp red chili flakes
- 1 tsp black pepper, coarse ground
- ½ tsp MSG or 1 tsp low-sodium salt
- Avocado oil for frying
- Recommended, to serve: lime wedges
- Recommended, to serve: your carbohydrate of choice, such as soba noodles or perhaps our Tasty Versatile Rice.
Method
(we suggest you read everything at least once before doing anything)
1) Heat the oven to 350℉ / 180℃, and bake the cashews on a baking tray for about 8 minutes until lightly toasted. Remove from the oven and allow to cool a little.
2) Combine the nuts, tofu, nutritional yeast, turmeric, and scallions in a food processor, and process until the ingredients begin to clump together. Shape into about 20 small balls.
3) Heat some oil in a skillet and fry the tofu balls, jiggling frequently to get all sides; it should take about 5 minutes to see them lightly browned. Set aside.
4) Combine the coconut milk, lime juice, soy sauce, cilantro/parsley, basil, scallions, green chili, ginger, garlic, and MSG/salt in a high-speed blender, and blend until a smooth liquid.
5) Transfer the liquid to a saucepan, and bring to the boil. Reduce the heat, add the mangetout, and simmer for about 5 minutes to reduce slightly. Stir in the red chili flakes and black pepper.
6) Serve with your preferred carbohydrate, adding the fermented red cabbage and the crispy tofu balls you set aside, along with any garnish you might like to add.
Enjoy!
Want to learn more?
For those interested in some of the science of what we have going on today:
- Capsaicin For Weight Loss And Against Inflammation
- Ginger Does A Lot More Than You Think
- Why Curcumin (Turmeric) Is Worth Its Weight In Gold
- The Many Health Benefits Of Garlic
- Black Pepper’s Impressive Anti-Cancer Arsenal (And More)
- Making Friends With Your Gut (You Can Thank Us Later)
- What’s Your Plant Diversity Score? ← a score of 8.25 for this dish, not counting whatever carbs you might add. Remember, herbs/spices* count for ¼ of a point each!
*but not MSG or salt, as while they may in culinary terms get lumped in with spices, they are of course not plants. Nor is nutritional yeast (nor any other yeast, for that matter). However, mushrooms (not seen in this recipe, though to be honest they would be a respectable addition) would get included for a whole point per mushroom type, since while they are not technically plants but fungi, the nutritional profile is plantlike.
Take care!
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Just Be Well – by Dr. Thomas Sult
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Firstly, what this is not: a “think yourself well” book. It’s not about just deciding to be well.
Rather, it’s about ensuring the foundations of wellness, from which the rest of good health can spring, and notably, an absence of chronic illness. In essence: enjoying chronic good health.
The prescription here is functional medicine, which stands on the shoulders of lifestyle medicine. This latter is thus briefly covered and the basics presented, but most of the book is about identifying the root causes of disease and eliminating them one by one, by taking into account the functions of the body’s processes, both in terms of pathogenesis (and thus, seeking to undermine that) and in terms of correct functioning (i.e., good health).
While the main focus of the book is on health rather than disease, he does cover a number of very common chronic illnesses, and how even in those cases where they cannot yet be outright cured, there’s a lot more that can be done for them than “take two of these and call your insurance company in the morning”, when the goal is less about management of symptoms (though that is also covered) and more about undercutting causes, and ensuring that even if one thing goes wrong, it doesn’t bring the entire rest of the system down with it (something that often happens without functional medicine).
The style is clear, simple, and written for the layperson without unduly dumbing things down.
Bottom line: if you would like glowingly good health regardless of any potential setbacks, this book can help your body do what it needs to for you.
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Waist Size Worries: Age-Appropriate Solutions
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It’s Q&A Day at 10almonds!
Have a question or a request? You can always hit “reply” to any of our emails, or use the feedback widget at the bottom!
In cases where we’ve already covered something, we might link to what we wrote before, but will always be happy to revisit any of our topics again in the future too—there’s always more to say!
As ever: if the question/request can be answered briefly, we’ll do it here in our Q&A Thursday edition. If not, we’ll make a main feature of it shortly afterwards!
So, no question/request too big or small
❝My BMI is fine, but my waist is too big. What do I do about that? I am 5′ 5″ tall and 128 pounds and 72 years old.❞
It’s hard to say without knowing about your lifestyle (and hormones, for that matter)! But, extra weight around the middle in particular is often correlated with high levels of cortisol, so you might find this of benefit:
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Demystifying Cholesterol
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All About Cholesterol
When it comes to cholesterol, the most common lay understanding (especially under a certain age) is “it’s bad”.
A more informed view (and more common after a certain age) is “LDL cholesterol is bad; HDL cholesterol is good”.
A more nuanced view is “LDL cholesterol is established as significantly associated with (and almost certainly a causal factor of) atherosclerotic cardiovascular disease and related mortality in men; in women it is less strongly associated and may or may not be a causal factor”
You can read more about that here:
Statins: His & Hers? ← we highly recommend reading this, especially if you are a woman and/or considering/taking statins. To be clear, we’re not saying “don’t take statins!”, because they might be the right medical choice for you and we’re not your doctors. But we are saying: here’s something to at least know about and consider.
Beyond HDL & LDL
There is also VLDL cholesterol, which as you might have guessed, stands for “very low-density lipoprotein”. It has a high, unhealthy triglyceride content, and it increases atherosclerotic plaque. In other words, it hardens your arteries more quickly.
The term “hardening the arteries” is an insufficient descriptor of what’s happening though, because while yes it is hardening the arteries, it’s also narrowing them. Because minerals and detritus passing through in the blood (the latter sounds bad, but there is supposed to be detritus passing through in the blood; it’s got to get out of the body somehow, and it’s off to get filtered and excreted) get stuck in the cholesterol (which itself is a waxy substance, by the way) and before you know it, those minerals and other things have become a solid part of the interior of your artery wall, like a little plastering team came and slapped plaster on the inside of the walls, then when it hardened, slapped more plaster on, and so on. Macrophages (normally the body’s best interior clean-up team) can’t eat things much bigger than themselves, so that means they can’t tackle the build-up of plaque.
Impact on the heart
Narrower less flexible arteries means very poor circulation, which means that organs can start having problems, which obviously includes your heart itself as it is not only having to do a harder job to keep the blood circulating through the narrower blood vessels, but also, it is not immune to also being starved of oxygen and nutrients along with the rest of the body when the circulation isn’t good enough. It’s a catch 22.
What if LDL is low and someone is getting heart disease anyway?
That’s often a case of apolipoprotein B, and unlike lipoprotein A, which is bound to LDL so usually* isn’t a problem if LDL is in “safe” ranges, Apo-B can more often cause problems even when LDL is low. Neither of these are tested for in most standard cholesterol tests by the way, so you might have to ask for them.
*Some people, around 1 in 20 people, have hereditary extra risk factors for this.
What to do about it?
Well, get those lipids tests! Including asking for the LpA and Apo-B tests, especially if you have a history of heart disease in your family, or otherwise know you have a genetic risk factor.
With or without extra genetic risks, it’s good to get lipids tests done annually from 40 onwards (earlier, if you have extra risk factors).
See also: Understanding your cholesterol numbers
Wondering whether you have an increased genetic risk or not?
Genetic Testing: Health Benefits & Methods ← we think this is worth doing; it’s a “one-off test tells many useful things”. Usually done from a saliva sample, but some companies arrange a blood draw instead. Cost is usually quite affordable; do shop around, though.
Additionally, talk to your pharmacist to check whether any of your meds have contraindications or interactions you should be aware of in this regard. Pharmacists usually know contraindications/interactions stuff better than doctors, and/but unlike doctors, they don’t have social pressure on them to know everything, which means that if they’re not sure, instead of just guessing and reassuring you in a confident voice, they’ll actually check.
Lastly, shocking nobody, all the usual lifestyle medicine advice applies here, especially get plenty of moderate exercise and eat a good diet, preferably mostly if not entirely plant-based, and go easy on the saturated fat.
Note: while a vegan diet contains zero dietary cholesterol (because plants don’t make it), vegans can still get unhealthy blood lipid levels, because we are animals and—like most animals—our body is perfectly capable of making its own cholesterol (indeed, we do need some cholesterol to function), and it can make its own in the wrong balance, if for example we go too heavy on certain kinds of (yes, even some plant-based) saturated fat.
Read more: Can Saturated Fats Be Healthy? ← see for example how palm oil and coconut oil are both plant-based, and both high in saturated fat, but palm oil’s is heart-unhealthy on balance, while coconut oil’s is heart-healthy on balance (in moderation).
Want to know more about your personal risk?
Try the American College of Cardiology’s ASCVD risk estimator (it’s free)
Take care!
Don’t Forget…
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