Cancer in the Family

Posted By SHL Librarian

Presented by: Kerry Kingham, MS, CGC
Genetic Counselor, Cancer Genetics Clinic
Stanford Center for Clinical Informatics
September 30, 2009

Lecture Overview:

Although most cancers are not “inherited,” some families are particularly susceptible to cancer and may benefit from early detection or other risk reduction strategies.

  • The most common inherited cancers include breast, ovarian, and certain kinds of colorectal cancer.
  • A BRCA mutation is linked to a higher risk of developing breast cancer and ovarian cancer, and a higher risk for male breast cancer.
  • Genetic tests can help patients understand their risk of develop cancer and allow them to make educated decisions about screening and preventive measures

Hereditary cancer is the development of cancer due to an inherited gene mutation that has been passed from parent to child. People who have inherited a gene mutation have also inherited an increased risk to develop cancer that is higher than those in the general population.

Inherited cancers begin in the DNA, the body’s cellular blueprint. Each cell contains two sets of chromosomes—one from the father and one from the mother—that replicate each time a cell divides. Genes are segments of DNA carried on the chromosomes that determine specific characteristics. Though the body makes proteins to control mutations before cell division, when certain mutations are part of the original programming, they can lead to cancer.

Although most cancers are not “inherited,” some families are susceptible to cancer and may benefit from early detection or other risk reduction strategies. Specialists in the Stanford Cancer Genetics Clinic can help patients and their families understand the genetic contributions to cancer and develop personalized plans to manage their risk.

“As genetic counselors, we translate the information we find to help families make educated choices,” said Kerry Kingham, MS, CGC, a genetic counselor who explained the process at a presentation sponsored by the Stanford Hospital Health Library. “We provide short-term counseling, offering empathy as we help them to understand the impact of getting tested and their test results. And because we work closely with oncologists, we are able to explain various screening and prevention options.”

Most inherited genetic mutations that cause cancer are autosomal dominant, passed along in the dominant gene. “This means that the person has a 50 percent chance of having the mutated gene passed along—not that 50 percent of these people will get cancer,” said Kingham.

The most common inherited cancers include breast, ovarian, and certain kinds of colorectal cancer. Of the 12 percent of the population who develop breast cancer, the majority (70-80 percent) have sporadic cancer—the kind that develops from environmental factors or other causes. Only about 10 percent have the inherited form of breast cancer. In the 2 percent of the population who develop ovarian cancer, the ratio remains about the same, with about 10-15 percent carrying a genetic mutation.

Women with a BRCA1 gene mutation have a 65 percent chance of developing breast cancer, tend to have early-onset cancer, have a higher risk of developing a second primary breast cancer later on, and are at higher risk for ovarian cancer. The mutation affects about one person in 400 in the general population and about one in 40 in Ashkenazi Jews. A BRCA2 mutation is linked to a higher risk of developing breast cancer and ovarian cancer, and a higher risk for male breast cancer.

Though the BRCA test itself is expensive, Kingham said that insurance usually covers the costs if certain criteria are met. Tests are less expensive for people from the Ashkenazi Jewish population and even less for that group if previous tests have shown that the mutation is already in the family.

Tests are available for two types of inherited colon cancer: hereditary nonpolyposis colorectal cancer (HNPCC) and familial adenomatous polyposis (FAP). People with HNPCC must undergo early and regular screening since they have a much higher risk of developing the polyps that can lead to colon cancer. People with FAP develop thousands of polyps at a very young age and often need to have their colon removed.

Before being tested, counselors go over an extensive list of criteria, check medical records of relatives, and talk to families as a group to clarify details. They look for certain trends and characteristics, such as the first-degree relatives affected, early-age onset, bilateral tumors, or multiple primary cancers. If a woman tests positive for a mutation, counselors will recommend early screening and discuss options like a prophylactic mastectomy or removing the ovaries.

“We’re in the cancer prevention business,” said Kingham, who interviews several generations of a family whenever possible. “We try to provide a balance between prevention and screening, and we work together to get as accurate information as possible. Our goal is to provide clear options for medical or surgical interventions, and to make sure the patient understands the risk before making a medical decision.”

About the Cancer Genetics Clinic
The Stanford Cancer Genetics Clinic offers testing and counseling for people who are concerned about the risk of inherited cancer. The clinic’s specialists help patients and their families understand the genetic contributions to cancer and develop personalized plans to manage their risk. Services include individualized cancer risk assessments based on medical and family history, detailed discussions of options for genetic testing, and recommendations for preventive screening and treatments.

The clinic provides counseling for several types of inherited cancer, including colon, breast, and ovarian.

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Cancer Genetics Clinic

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Cancer Genetics (National Cancer Institute)

Genetic Testing for Breast and Ovarian Cancer Risk (National Cancer Institute)

Lifestyle and Safety Management

Posted By SHL Librarian

Presented by: Candace Mindigo, RN, BSN
Manager, Stanford Aging Adult Services
Stanford University Medical Center
October 28, 2009

Lecture Overview:

  • Diet and exercise are among the most important tools for maintaining health.
  • Keep blood pressure down by following a Mediterranean or DASH diet.
  • Keep your legal papers up to date and have copies located in one place so they are easy to find.
  • Modify your home to prevent falls-the No. 1 reason people come to the emergency room.
  • Stimulate your brain cells by taking on new mental challenges

With more and more adults living longer, it’s important to be aware of the many things you can do to make your later years healthful and stimulating, and keep you out of the hospital.

Heart disease, cancer, and stroke are responsible for 70 percent of all deaths. Certain steps can help lower the chances of developing these disorders.

Weight control. Many aspects of heart disease are preventable by developing healthy lifestyle habits, said Candace Mindigo, RN, manager of Stanford Aging Adult Services, at a presentation sponsored by Stanford Hospital Health Library. About one-half of deaths in the United States are attributable to preventable risk factors, particularly physical activity. Few Americans exercise enough, and 80 percent of men and 70 percent of women between the ages of 65 and 74 are overweight or obese.

Studies have shown that regular exercise can lower the risk of heart disease; delay onset of diabetes; improve blood pressure; reduce risk of falls and osteoporosis; and enhance cognitive function.

“To age well you need to maintain a healthy weight through diet and regular physical activity,” she said. “Even adding a small amount of exercise to your routine shows immense benefit. And as far as diet goes, less if better.”

Diet. Mindigo suggests following a Mediterranean or DASH (Dietary Approaches to Stop Hypertension) diet to keep blood pressure down. These diets are low in salt and emphasize generous amounts of fruits, vegetable, healthy fats, and whole grains. She suggested a diet that includes about 25-35 grams of fiber daily, three to four servings of fish a week, and only one or two servings of red meat a month. A good guideline, she suggested, is to compose your diet of 40-50 percent complex carbohydrates, 20-30 percent protein (chicken, salmon or white fish, eggs, tofu and soy products), and 30 percent monosaturated fat (olive oil, avocado, nuts).

Each person should know what his or her healthy weight and BMI (body mass index) should be, as well as cholesterol and glucose levels. It’s also important to keep up with annual screenings and booster shots, and to keep in touch with your primary care physician.

Because of increased longevity, more adults are living with multiple chronic conditions and are taking medications that can interact, affecting both physical and mental well-being.”Because the body’s metabolism changes as we age, it’s important to keep your physician up-to-date on your medications to avoid negative drug interactions,” Mindigo said. “Many people end up in the emergency room because they do not see a doctor on a regular basis.”

She also suggests finding ways to reduce stress, whether using guided imagery, meditation, or joining a support group. “The important thing is to take time during the day to do something you enjoy,” she said. “It helps to lower the heart rate.”

Paperwork. Be sure to bring all your legal papers up to date and have copies located in one place so they are easy to find. Older adults should complete an advance health care directive, living will, durable power of attorney for health, financial power of attorney, living trust, and conservatorship. Simplify finances by arranging for direct deposit and automatic bill payments, and minimize the number of accounts you maintain.

“People often don’t want to think about these things, but it is important to have them done,” Mindigo said. “You want to make your own decisions about your health, and it’s a gift to your children if you can be organized now, before anything goes wrong.

“Out-of-control paperwork, such as unopened mail, unusual purchases, disorganized paperwork, or late bills, is a warning sign for concern, she added.

Home safety. Falls are the No. 1 reason people come to the emergency room. Thirty percent of people over age 65 fall each year, which rises to 50 percent in people over age 80. Exercises that strengthen legs allow you to catch yourself in a fall, and Mindigo suggests taking calcium and Vitamin d daily to reduce the chance of osteoporosis.

Stanford established the Farewell to Falls program to assess potential trouble spots for seniors at risk for falling. The home-based program, free for Santa Clara and San Mateo county residents 65 and older, provides home visits to evaluate potential problems. Participants receive individualized suggestions and periodic follow-up phone calls from volunteers.

Because more than 60 percent of falls occur at home, Mindigo stressed the importance of making some simple modifications for safety:

  • Get rid of all throw rugs.
  • Remove clutter.
  • Use bright lights.
  • Use shoes with good support.
  • Keep items in easy reach.
  • Move electrical cords form walkways.
  • Install grab bars in the bathroom.
  • Have your vision checked regularly.

 Driving. “Giving up driving is a major step and needs to be grieved as a loss,” Mindigo said. “As your vision changes, you lose depth perception and have slower reaction time.  The time to back off is when driving makes you nervous. Or have a family member come with you and see if they’re comfortable with your driving skills.”

Cognition.  Exercising the mind is just as important for mental agility as physical activities are for a healthy body. While some occasional forgetfulness is normal, losing track of activities, forgetting how to accomplish common activities, repeating phrases, or having trouble handling money are not. “Keep your brain cells stimulated by taking on new challenges,” said Mindigo. “Maintain a balance of mental and physical activities, and stay socially active. Connecting with family and friends is good for you at every level.”

About the Speaker
Candace Mindigo, RN, BSN, is manager of Stanford Hospital’s Aging Adult Services, a program that provides specialized care and access to resources for older adults. The program’s extensive network offers consultations and assessments, assistance with appointments, physician referrals, advocacy, coordination of services, access to community resources, and educational workshops. Most of these services are free to community members.

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Your Heart on Exercise

Posted By SHL Librarian

Presented by: Euan Ashley, MD, PhD
Assistant Professor, Cardiovascular Medicine
Stanford University Medical Center
August 14, 2009

Lecture Overview:

  • heartscanHeart rate is controlled by the internal nervous systems:  adrenaline speeds up the heart, while the vagus nerve slows it down
  • Benefits of exercise are numerous, ranging from increased stamina to improved balance and cognition to lowered cholesterol, blood pressure, and risk of heart attack.
  • When exercising, try to keep your heart rate up for at least 30-40 minutes three to five times per week.
  • The differences in an athlete’s heart include slower resting rates, more muscle elasticity, a slightly enlarged chamber, and a slight increase in wall thickness.

The heart, the hardest-working muscle in the body, pumps out about 50 cc of blood at every heartbeat and has the ability to beat more than 3 billion times over a person’s lifetime. It’s the pump that pulses blood throughout the body, delivering oxygen and nutrients to tissue, removing waste, transporting immune-system cells, and regulating temperature.

“Think of the heart as a pump for your fuel supply,” said Euan Ashley, MD, PhD, an assistant professor of cardiovascular medicine and director of Stanford Hospital’s Hypertrophic Cardiomyopathy Center, at a peak Performance Lecture at the 2009 Senior Games. “It is the only organ to be in constant motion and, obviously to me, the most interesting organ in the body!”

A normal heartbeat is initiated by a small pulse of electric current-tiny rhythmic impulses that make the heart muscle contract-produced by cardiac pacemaker cells. Any cell in the heart can take on the pacemaker role, which is one reason the heart can continue to pump when damaged.

Exercise and the Heart
Your heart rate increases even before you actually start to exercise, as eons of evolution prepare your body for the stress and challenge of activity. Your heart responds to two interconnected aspects of the nervous system: The sympathetic system that releases adrenaline, the “fight or flight” hormone that speeds your heart rate and diverts blood from your internal organs, and the parasympathetic system, made up of the vagus nerve, which serves to slow the heart rate down. Withdrawal of the parasympathetic system, which takes care of “rest and digest” functions, is one of the first things to occur before exercise.

To receive the benefits of physical activity, it’s important to check the level at which your heart is working, said Dr. Ashley. For some people, a chest-style heart rate monitor is an excellent way to pace yourself and to acquire the greatest benefit from exercise.

Though many groups suggest you work out your ideal heart rate during exercise by starting with your maximal heart as calculated by 220 minus your age, Dr. Ashley said there is a wide variation in this figure. “Find your own maximal heart rate rather than following an equation,” he suggested. “The idea is to keep your heart rate at 50-60 of the difference between your resting rate and this maximal rate for 45 minutes or more. The more beats per minute, the greater the volume of blood being pumped.”

The Athlete’s Heart
At rest, the heart pumps about 50 ml of blood per stroke; in an untrained athlete, stroke volume can increase to 120 ml with exercise; stroke volume in endurance-trained athletes can reach as much as 200 ml or more. When you run, the heart rate increases. This combination of higher heart rate and higher stroke volume leads to a much greater cardiac output..

“The hallmark of an athlete’s heart is its elasticity. It can increase the volume per beat,” Dr. Ashley said. “It can change volume quite dramatically. It’s the key to performance.”

Dr. Ashley also emphasized the idea that in humans, heart rate is a predictor of longevity. However he mentioned that it is hard to compare species, citing the long-lived whale, whose heart beats about four times a minute, to a shrew, whose heart beats about 1,200 times a minute.

He also referred to the myth that athletes have bigger hearts. An athletes’ heart tends to be about 1 millimeter thicker than average-a very subtle difference. “Heart size does not change that much in an athlete, but extra beats are more common in athletes,” he said.

Benefits of Exercise
Dr. Ashley’s extensive list of the benefits of exercise ranged from cardiovascular improvements to neurological fitness. These include:

  • Increased longevity
  • Reduced risk of heart attack and stroke
  • Improved cholesterol levels
  • Lower blood pressure
  • Less stress
  • Improved mood
  • Better agility and balance
  • Enhanced cognitive function
  • Reduced back pain
  • Endurance
  • Retained bone density
  • Less risk for glaucoma, inflammation, and gallstones
  • Potential anticancer activity for colon, breast, and pancreatic cancers

The only paradox to exercise is a very slight increase in the risk of heart attacks or death from cardiac arrest during exercise. In young athletes, the most common underlying cause is known as hypertrophic cardiomyopathy. This rare genetic disease causes the heart muscle (myocardium) to become abnormally thick, making it harder for the heart to pump blood. Young athletes are now often screened for the disorder. For most people, exercise of moderate intensity for 30 to 40 minutes three or for times a week will provide almost-immediate heart benefits.

“There’s really no downside to exercise,” Dr. Ashley said. “The benefits start to kick in after just 10 minutes.”

About the Speaker
Euan Ashley, MD, PhD, is an assistant professor of cardiovascular medicine and director of the Stanford Hypertrophic Cardiomyopathy Center, a multidisciplinary program that coordinates care for people with heart muscle disease. He is also director of Stanford’s Cardiopulmonary Testing Laboratory. He has a particular interest in the care of athletes with cardiovascular disease and works closely with the Stanford Sports Medicine program. An exercise physiology graduate of the University of Glasgow, Dr. Ashley received his PhD in molecular cardiology from the University of Oxford and his MRCP in medicine from the Royal College of Physicians. He joined Stanford in 2003.

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2009 Summer National Senior Games

User’s Guide to the Shoulder

Posted By SHL Librarian

Presented by: Emilie Cheung, MD
Assistant Professor, Orthopaedic Surgery
Stanford University Medical Center
March 25, 2009

Lecture Overview:

  • shoulderThe anatomy of the shoulder is complex, flexible and elegant, but it can be damaged by trauma, overuse and the wear and tear of aging
  • Problems arise from a variety of causes, from sports to bursitis, tendonitis and bone spurs
  • Rotator cuff tears or inflammation are the most common sources of shoulder pain and problems
  • Nonsurgical treatments such as physical therapy should be the first option for treating tears and other shoulder damage
  • Minimally invasive arthroscopic surgery can be used to treat many shoulder conditions

Many shoulder injuries come on suddenly. You may be reaching for a kitchen spice, closing a curtain or changing a lightbulb. You may be practicing your moves for a chance on “Dancing with the Stars.” You may find that an activity you enjoy, such as swimming or tennis, suddenly causes pain.

About 14 million people saw a doctor for shoulder pain in 2003, and that number will increase as the population gets older, said Emilie Cheung, MD, an assistant professor of orthopaedic surgery specializing in shoulder and elbow surgery. She spoke at a Redwood City Library presentation sponsored by the Stanford Health Library.

Anatomy and Structure
Your shoulder joints move every time you move your arms. Because of this mobility, the shoulder is easily injured or overused. To explain the source of shoulder pain, Dr. Cheung first described the complicated anatomy of this easily injured joint. The shoulder is a ball-and-socket joint with three main bones: the upper arm bone (humerus), the clavicle and the scapula, all held together by muscle tendons and ligaments.

One of the most-used shoulder mechanisms is the rotator cuff, a group of muscles and tendons that holds the humerus in place. The rotator cuff helps to lift and rotate the arm and to stabilize the ball of the shoulder within the joint. Tendinopathy refers to inflammation or small tears in the shoulder’s tendons, affecting about 23 percent of people over age 60 with shoulder problems and 51 percent of people over age 80.

“Rotator cuff tendinopathy is the most common reason for shoulder pain and problems,” said Dr. Cheung. “It can be compared to old pair of jeans-after a while they start to wear down and you can see the material getting thin.”

Next to the rotator cuff is a bursa, a fluid-filled sac that lubricates and cushions pressure points between your bones and the tendons and muscles near your joints. Bursitis occurs when a bursa becomes inflamed, causing pain during movement. Shoulder pain can be also be caused by the basic anatomy of the bones-certain shapes are more prone to problems than others.

Sources of Problems
Rotator cuff problems arise from a variety of sources, such as surgery or a trauma like a fall, which can stretch tissue. Bone spurs and bursitis are an unfortunate but natural part of getting older. Poor posture over many years can cause the muscles to become imbalanced, which can lead to shoulder pain. Impingement, which is caused when the muscles rub against the shoulder blade, may arise from sports or certain professions.

Shoulder arthritis is another cause of shoulder pain. This is due to thinning of the cartilage as we grow older, or it may be related to trauma or fractures in the shoulder. If the arthritis is very severe, then total shoulder replacement surgery might be the best treatment option.

Some injuries affect the collagen in the tendons, which are aligned in healthy tissue and look like rope under a microscope. In damaged tendons, the collagen is twisted and convoluted.

Making Repairs
Treatment depends on the diagnosis and how it affects the person. An acute tear in the rotator cuff in an active young person should probably be repaired, said Dr. Cheung, while a partial or chronic tear may not require interventions. A tear may sometimes heal on its own or stabilize, or it could get worse over time. If the shoulder pain is due to arthritis, then total shoulder replacement surgery might be indicated.

“If you were in a mall and stopped 100 people over age 60, more than half of them would have a chronic tear with no pain or symptoms,” she said.

Dr. Cheung said the first methods of treating rotator cuff pain are nonsurgical. Physical therapy can help strengthen, stretch and stabilize the muscles, and NSAIDs, such as aspirin and ibuprofen can be used to reduce inflammation. Steroid injections may work for some people but show improvement after one year in only 50 percent of the people who use it, she said. Ultrasound therapy had questionable benefit, and acupuncture seems to help many people but its benefits have not yet been scientifically proven, she added.

If shoulder pain does not abate, it’s time to see an orthopaedic surgeon to discuss other options, she said. Highly sensitive imaging technologies, like MRI and 3-D CT scans may be used to refine the diagnosis.

When rotator cuff surgery is required, Dr. Cheung said that many repairs are now be done using arthroscopic surgery, a minimally invasive technique that requires only a small incision to smooth damaged cartilage, remove bone spurs and clean up loose cartilage. Open surgery is still used for large tears or for total shoulder replacement.

About the Speaker
Dr. Cheung is board certified by the American Board of Orthopedic Surgery. She specializes in reconstructive procedures of the shoulder, arm and elbow, and conducts research in clinical outcomes of total shoulder and elbow replacements, and complications from shoulder and elbow reconstruction procedures. Dr. Cheung received her MD from New York Medical College and did her residency in orthopaedic surgery at Drexel University in Philadelphia, Penn. She completed her fellowship in shoulder and elbow surgery at Mayo Clinic in Rochester, Minn. She joined Stanford in 2006.

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Neck Pain: The Latest in Evaluation and Surgery

Posted By SHL Librarian

Presented by: Ivan Cheng, MD
Assistant Professor of Orthopaedic Surgery
Stanford University Medical Center

Lecture Overview:

  • neckNeck pain is extremely common and most often stems from the wear and tear of normal aging
  • Most neck pain without serious pathology does not need to be treated surgically; physical therapy, exercise and rest are usually recommended first
  • Surgery for neck pain benefits only a small percentage of patients
  • While fusion has been the primary surgical option, today certain conditions can be treated with implants that preserve range of motion

Anatomically speaking, your head is something like a bowling ball perched on top of a stick. In that respect, it’s no wonder that neck pain is one of the most common ailments patients report to their doctor.

“As we age, the disc space tends to collapse,” said Ivan Cheng, MD, an orthopaedic surgeon who specializes in treating neck conditions. “It’s an arthritic process, and it happens to all of us.”

The neck is made up of seven cervical vertebrae. Like other joints, neck joints undergo wear and tear with age, which can cause pain and stiffness. As you age, the disks between the vertebrae start to collapse and can narrow the space surrounding the nerves. The discs in the neck also can herniate, causing it to protrude. Tissues and bony growths (spurs) also can press on the spinal nerves, causing pain, numbness or weakness in the hand, wrist, shoulder or arm. This condition is called cervical radiculopathy, which can occasionally mimic the symptoms caused by carpal tunnel syndrome or certain neurological disorders.

The first step is to identify the source of the trouble. X-rays can show if there are any degenerative disk problems, and many physicians use an MRI to image the discs, nerves, and spinal cord. An electromyography (EMG) may also be used to evaluate and record the electrical signals sent to the muscles.

Most neck pain can be alleviated by physical therapy and/or anti-inflammatory medication. Other options, like radiofrequency neurotomy, a less invasive procedure that disables a nerve from transmitting pain signals, and steroid injections, anti-inflammatory agents injected directly into the epidural space close to the affected nerve, have not shown consistent long-term results, Dr. Cheng said. He referred to a long-term study that tracked more than 200 people with neck pain over the course of 10 years: Fewer than one-third continued to report problems after receiving nonsurgical therapy.“

The majority of people do NOT need surgery,” said Dr. Cheng. “The best therapy is usually active exercise, which is critical and often overlooked.”

However, there are cases when surgical intervention is required, such as stabilizing the neck after a dislocation or fracture, tumors, or to control certain degenerative or inflammatory diseases.

Surgeons use an anterior approach to remove the faulty disc and replace it with bone, or a posterior approach that creates new space for the nerve root by inserting a plate to relieve the pressure. Patients have reported about an 85 percent improvement using these approaches.

While fusion has been the “gold standard” in neck surgery for years, Dr. Cheng said that some studies have shown an increased rate of problems adjacent to the fused bone, and more research is needed to determine if this is indeed the case. Today surgeons are looking more toward disc replacement, which tends to preserve natural movement and range of motion. To date, the FDA has approved the use of two artificial replacement discs.

“One thing to remember is that the improvement in neurologic symptoms is due to alleviating pressure on the nerve or spinal cord, and not the implant itself,” Dr. Cheng said. “But overall disc replacement implants have been very successful in terms of reducing pain and disability.”

Surgery is also called for in certain types of myelopathy, the gradual loss of nerve function often caused by the compression of the spinal cord that can result in reduced awareness of the extremities. A patient with this type of myelopathy does not always have pain but can experience poor coordination, loss of fine motor movement, and slow reflexes. Surgery is done to halt the progression of symptoms and possibly restore some function.

“Myelopathy does not resolve on its own,” said Dr. Cheng. “It’s prolonged and slowly progressive, and once it affects the gait, it’s often too late. You don’t want the problem to go long enough for significant neurologic problems to show.”

About the Speaker
Dr. Cheng received his MD from Harvard Medical School and completed his residency in orthopaedic surgery at University of California, Davis, and his spine surgery fellowship at Washington University in St. Louis. Board-certified in Orthopaedic Surgery, Dr. Cheng has received many awards for his work, including the Timothy Bray Trauma Award from UC Davis, the Saul Halpern Orthopaedic Teacher of the Year Award from Stanford, the International Society for the Study of the Lumbar Spine Prize in Clinical Research, and Outstanding Paper Awards from the North American Spine Society.

In addition to the latest techniques in spinal reconstruction, Dr. Cheng is also trained in minimally invasive surgery and in motion-preserving surgery.

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Avoiding the Elephant on Your Chest: How to Discuss Cardiac Risk With Your Doctor

Posted By SHL Librarian

Presented by: Euan Ashley, MD, PhD
Assistant Professor, Cardiovascular Medicine
Stanford University Medical Center

Watch the video

Lecture Overview:

  • Heart disease comes in many forms and variations; blood vessel plaque also has variations
  • The body’s immune system appears to play a role in the buildup of arterial plaque
  • No test yet exists to image the kind of vulnerable plaque buildup that might lead to a heart attack
  • Most of the risk factors for heart disease can be modified with changes to diet, exercise, stress reduction and other lifestyle behaviors

Patient A is in his 40s, overweight and sedentary, and thinks a fast-food burger with the works is a good dinner. Determined to get back into shape, he challenges a junior executive to a game of racquetball. Halfway through, he clutches his chest and is rushed to the hospital with a heart attack.

Patient B is 75, retired, eats well and walks a lot. Heading up a hill, however, she needs to stop for the pain in her chest to abate.

Patient C is fit, eats well, has low blood pressure and exercises regularly. Warming up for his routine one morning, he is rushed to the hospital with a heart attack and a stent is inserted into his blocked artery.

While most people understand the circumstances of the first two patients, the third is the one most people-and physicians-find the most confusing. How can you be perfectly healthy one day and have a heart attack the next? What, if anything, can you do to avert the same fate?

While certain measures can be taken to reduce heart disease risk, medicine is still working to understand the many factors that lead to heart attack and cannot yet perfectly predict who is most susceptible, according to Euan Ashley, MD, PhD, an assistant professor of cardiovascular medicine and director of Stanford Hospital’s Hypertrophic Cardiomyopathy Center.

“Ten years ago, we would refer to the heart and blood vessels as plumbing, and we cardiologists thought of ourselves as plumbers,” said Ashley, who gave a presentation sponsored by the Stanford Health Library on assessing heart attack risk. “The idea was that there were two stages of heart disease: angina, where there is not enough blood circulating to the heart, and heart attack, which is a complete blockage. This turned out to be too simplistic, because, among other reasons, it doesn’t help us explain why seemingly perfectly healthy people die of sudden heart attack.”

Simple plumbing does not fit the evidence, he continued. Angina, the chest pain that occurs when an area of your heart muscle doesn’t get enough blood, does not necessarily lead to heart attack, and many people who have heart attacks do not show symptoms of angina.

“The logic didn’t add up, so we needed a new paradigm,” he said.

Inflammation in the Arteries
Cholesterol is one key factor. Since the fat we eat doesn’t dissolve in the blood, the body must find ways to package and store it using lipoproteins of different sizes. When high levels of cholesterol occur in the bloodstream, excess low-density lipoprotein (LDL, or “bad”) cholesterol seeps into the inner wall of the artery, triggering an inflammatory response. White blood cells are attracted from the bloodstream and smooth muscle cells from the vessel wall migrate and start to form a fibrous cap.

As long as the cap doesn’t rupture, it remains a flow problem: an area of the heart needs more blood than the artery can deliver and chest pain develops, a condition known as stable angina.

With unstable angina, a thin-capped “vulnerable plaque” gets disrupted and the contents of the plaque are exposed to blood. These contents are among the most powerful clot-producing substances known. Many people who have heart attacks do not have thick buildups of plaque caused by high cholesterol but instead have vulnerable plaque that sometimes does not even block the blood flow through the artery.

“Inflammation is key, and cholesterol is part of the trigger,” said Ashley. “The plaque builds up, the fibrous cap ruptures and a clot blocks the artery, causing a heart attack. It’s not so much the size that matters-it’s the stability of the plaque. Often it’s the smaller lesions that open up.”

Reducing Risk
While there is still no way to predict exactly who will have a heart attack, there are still many ways to reduce its risk. Certain factors, like age, gender and genetic makeup, can’t be changed, but most risk factors can be modified for improved cardiovascular health.

Ashley referred to a large-scale, international study that showed that the key factors involved in 90 percent of all heart attacks could be controlled, leading to an 84 percent decrease in cardiovascular risk for study participants. These controllable lifestyle factors include cholesterol, blood pressure, stress, smoking, diet, obesity, alcohol use and exercise.

Ashley also explained the various medications available that work in different ways to reduce heart attack risk. These therapeutics include statins, which lower cholesterol and stabilize the plaques; aspirin or other agents which inhibit the ability of platelet cells to cause clotting; and diuretics, ACE inhibitors and calcium channel blockers, which cause the muscles in the blood vessels to relax and control high blood pressure.

Controllable Factors
As far as diet goes, Ashley said to use common sense and keep everything-including alcohol-in moderation.

“Every day you hear about a different fad diet,” he said. “But a guinea pig has the right idea. Your diet should be low in saturated fat, have lots of whole grains, be high in fiber with lots of fruits and vegetables, and rich in omega-3 fatty acids. Of all the supplements out there, fish oil absolutely does have benefits.”

He also emphasized the importance of reducing stress, and cited a 1998 study that found that heart attack rates in France dropped drastically the day of the World Cup soccer match, illustrating the effect of societal stress on heart health.

As for exercise, Ashley listed more than 25 benefits of a regular regimen, from reduced risk of stroke to increased bone density.

“The heart is a glorious organ- a remarkable muscle that beats more than 3 billion times over a lifetime,” said Ashley. “Overall the message is positive: 90 percent of the risk for heart attack can be explained. I’m a huge fan of lifestyle change, and exercise and diet are clearly part of that.”

At the end of his presentation, Ashley introduced a patient who described his sudden and unexpected heart attack two years ago.

About the Speaker
Euan Ashley, MD, PhD, is an assistant professor of cardiovascular medicine and director of the Stanford Hypertrophic Cardiomyopathy Center, a multidisciplinary program that coordinates care for people with heart muscle disease. He has a particular interest in the care of athletes with cardiovascular disease and works closely with the Stanford Sports Medicine program. He also oversees a research laboratory that is looking at the molecular and genetic causes of heart failure and the fundamental biology of the heart’s signaling pathways. A graduate of the University of Glasgow, Ashley received his DPhil in molecular cardiology from the University of Oxford and his MRCP in medicine from the Royal College of Physicians. He joined the Stanford faculty in 2003.

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The Humbling History of Multiple Sclerosis

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MRI snapshotPresented by: Jeffrey Dunn, MD
Associate Director, Stanford Multiple Sclerosis Center

Lecture Overview:

  • The symptoms of multiple sclerosis have been described since the 1300s, but it wasn’t until the early 20th century that a unified picture emerged
  • The biggest breakthroughs in understanding and treating MS have taken place when researchers and physicians work together
  • While excellent therapies currently exist, advanced imaging and technologies like proteomics are leading to the promise of more targeted and effective treatments

In the late 1300s outside Rotterdam, a young woman suddenly collapsed, suffering limb weakness, face pain and vision problems. Her symptoms were well documented as her health deteriorated, and she was later canonized as St. Lidwina, the patron saint of ice skating. She also appears to have been the first documented case of multiple sclerosis-a theory substantiated when her body was exhumed for study 650 years later.

Augustus d’Este, an illegitimate son of King George III, kept a detailed journal for more than 20 years that documented his health problems, even though, in 1822, no one yet knew what condition he had. He described his symptoms so clearly that later researchers were able to definitively diagnose him as having multiple sclerosis.

“Over the years, individual cases of MS have been reported in great detail,” said Jeffrey Dunn, MD, co-director of the Stanford Multiple Sclerosis Center, who discussed the past, present and future of MS at a presentation sponsored by The Health Library on May 15. “But it wasn’t until physicians and researchers started to compare notes and share experiences that a unified view of multiple sclerosis emerged.”

That first cohesive perspective of MS-one that connected the symptoms with anatomical changes-was introduced in 1869 by Jean-Martin Charcot, who is considered the father of modern neurology. He meticulously tracked the symptoms of one of the patients in the Paris hospital where he worked and taught. The autopsy of her brain revealed hard nodules, which he called sclerosis of plaques.

Additional reports throughout the 1800s described “strange cases” of this new disease, but it was considered rare, a perception that changed dramatically: By 1950, neurologists considered MS one of the most common neurological diseases in America.

“It’s important to look forward because the future of multiple sclerosis is one of hope,” said Dunn. “But we can understand the future better by looking at the past.”

MS appears to be more common among people of Northern European descent, although it is becoming more common in people with Latino backgrounds. While factors such as fat in the diet, industrial development, toxic exposure, vitamin D and viral exposure have all been attributed to inducing MS, its probable cause is most likely a combination of genetic and environmental factors, said Dunn

“No two cases are alike, which is one of the most challenging aspects of MS, but most cases present in a certain way,” he said. “Monthly MRIs show MS progression and plaques as white spots that show up and then disappear, like fireflies. Symptoms relapse in about 85 percent of cases, and the disease does tend to slow down over time. But MS is not only different in each patient; it changes over time even within an individual in many cases. Even more problematically, there are no biomarkers for the disease and no metrics for disability.”

Physicians learned to recognize MS because of improved technologies, such as magnetic resonance imaging (MRI), and because there were more neurologists with the skills to make the difficult diagnosis. Today there are six FDA-approved treatments for MS, and despite the challenges from new limitations on using placebos in clinical trials, Dunn said there are almost 70 new therapies in various stages of trials, many of which will be tested at Stanford.

Dunn explained the strategies and the trial-and-error studies behind several of the current therapies, some of which were originally designed as chemotherapies, treatments for other diseases and even carpet dye.

“The biggest advances in discovery take place when clinical care and research are combined together and allowed to interface,” said Dunn. “New technology like advanced microscopic techniques and proteomics, which maps proteins, gives us the chance to translate discoveries to humans and positions us to find specific therapies.”

About the Multiple Sclerosis Center at Stanford Hospital & Clinics

The Multiple Sclerosis Center provides comprehensive, specialty care, using state-of-the-art techniques to diagnose, evaluate, manage and treat adult patients with MS. Its team of neurologists offers particular expertise in diagnostic and treatment challenges, combining individualized care with promising clinical research opportunities. One of only two dedicated MS centers in the Bay Area, its physicians and staff offer a unique depth of knowledge for MS patients.

The Center provides:

  • comprehensive patient care
  • neurological tests and assessments
  • access to clinical trials
  • state-of-the-art technologies, including MRI and electrodiagnostics
  • a localized clinical immunology infusion service
  • information on new treatments and current research
  • recommendations for follow-up services

The Multiple Sclerosis Center is located on the third floor of the Boswell Building of Stanford Hospital & Clinics in the Neuroscience Clinic, Room A301.

Hours are 8:30 am-5 pm Monday-Friday.

Tel: 650-723-6469

About the Speaker
Dr. Dunn is the associate director of Stanford’s Multiple Sclerosis Center and an associate professor of neurology and neurological sciences. He is a board-certified neurologist specializing in the diagnosis, treatment and clinical research of multiple sclerosis and demyelinating disease.

With a focus on clinical care, he also conducts research on combination therapy and emerging immunotherapy and has worked as a principal investigator for clinical research studies sponsored by the NIH and other organizations. Dr. Dunn served as president and chief medical officer of the “MS Hub,” a novel regional care center at Evergreen Healthcare in Kirkland, Washington, before joining Stanford in early 2008.

Dr. Dunn earned his MD from Temple University and did his specialty training in neurology at the University of Washington.

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Updates on Dementia: Translating Research into Practice

Posted By SHL Librarian

At a Glance:

  • Alzheimer’s disease is not just one disorder with one specific set of symptoms
  • Studies show other disorders, such as frontotemporal dementia and mild cognitive impairment, show similar symptoms but affect different parts of the brain than Alzheimer’s
  • Research is leading to new understanding of cognitive decline, which in turn may identify new targets for therapy and possible prevention

Dementia is a brain disorder that seriously affects a person’s ability to carry out daily activities. The most common form of dementia among older people is Alzheimer’s disease, which initially involves the parts of the brain that control thought, memory and language. As more and more of the brain is affected, areas that control basic life functions, like swallowing and breathing, become irreversibly damaged.

Although scientists are learning more every day, they still do not know what causes Alzheimer’s, and there is no cure. New understanding, improved treatments and viable preventive strategies are becoming ever more crucial: Increasing numbers of people are joining the more than 5 million Americans already living with Alzheimer’s disease, and its prevalence is expected to double by 2020.

More than 400 physicians, nurses, social service workers, caregivers and community members attended the 10th annual Updates on Dementia: Translating Research into Practice, a conference held at Stanford in early June that featured experts in clinical research and elder care who covered topics that included sexuality, bathing and hygiene, ethnic and cultural sensitivity, and gay and lesbian issues. The event was moderated by Victor Henderson, MD, MS, a professor of Health Research and Policy and a member of the Stanford Center on Longevity.

Transition Phase
“It’s a burgeoning crisis, and if we don’t do anything about it the population curves indicate that tens of millions of people will have it over the next 20 to 30 years,” said Ronald Petersen, MD, PhD, director of the Mayo Clinic Alzheimer’s Disease Research Center, who spoke on Mild Cognitive Impairment: The Current Status. “If we are to have an impact on Alzheimer’s disease, we will need to prevent the whole process. This will require predictive testing before symptoms develop and interventions to slow its progression.”

Petersen’s presentation focused on mild cognitive impairment (MCI), a transitional period between normal function and the onset of Alzheimer’s. This condition does not fit the criteria for dementia because although patients show diminished memory and judgment, most abilities are preserved and normal activities are maintained. The challenge, he said, is that there are no specific tests, and the indices, such as verbal recall, fall into the expected profiles of aging.

Mild cognitive impairment falls into two patterns, he said. Approximately 10 percent of the people with amnesiac MCI, in which memory is affected, develop Alzheimer’s disease, while only 1 to 2 percent of the patients with non-amnesiac MCI-those with no memory impairment but with cognitive complaints-do not go on to acquire the disease.

“We have been tracking patterns of impairment over the years,” Petersen said. “We can measure the degree of shrinkage in the hippocampus. The volume of the brain shows a greater degree of atrophy in amnesiac MCI. By documenting serial progression using magnetic resonance imaging, we may be able to use and track disease-modifying therapies.”

Petersen also discussed the potential of using biomarkers, including proteins such as amyloids and apo-E, to study the patterns of impairment.

“Is MCI just early Alzheimer’s? Not always, and it’s still too soon to be sure of the connections,” he said. “Our future progress will depend on getting a diagnosis earlier so we can figure out ways to intervene or at least delay onset or prolong the transitional stage. There are lots of variabilities in the studies and, in the meantime, we must reassess the criteria.”

Molecular Connections
Research is showing that Alzheimer’s is just one disease related to cognitive decline, according to Bruce Miller, MD, director of the Memory and Aging Center at UCSF, who spoke on Frontotemporal Dementia and Other Non-AD Dementia.

Frontotemporal dementia (FTD) refers to a group of diseases that are commonly misdiagnosed as Alzheimer’s-an important distinction because these diseases are treated differently. Patients with FTD have different behaviors early on that appear to last longer.

The symptoms of FTD include apathy, indifference, repetitive mannerisms and addictive behavior, such as gambling and overeating. These behaviors affect a different part of the brain, making it relatively easy to separate FTD from Alzheimer’s. At the same time, FTD is a social disorder, and input from caregivers is important because its victims have poor self perception. People who are misdiagnosed can end up in the legal system, under psychiatric care or as social pariahs.

“It’s not so much how we label the disease as much as knowing what molecule is responsible,” he said. “These are not pure disorders. They have mixed pathologies, which means that people are starting to think of new ways to intervene. Lots of problems are neurochemical, so I think this is a very promising period.”

Many cognitive disorders relate closely to other disorders: For example, Parkinson’s puts people at high risk for dementia but not necessarily Alzheimer’s, and most Alzheimer’s patients eventually develop symptoms similar to Parkinson’s. And 65 percent of patients with REM (rapid eye movement) sleep behavior disorder, in which the motor system is not turned off during deep sleep, develop some kind of Parkinsonian disorder. These connections all point to potential points of intervention, Miller said.

“The circuitry in the brain is breaking down, but it is the part that affects social behavior and regulation rather than memory,” said Miller. “It’s a social disorder. There is no amyloid accumulation in the brain as you would see in Alzheimer’s disease. This is important because it requires different interventions and the need to monitor and evaluate therapies.”

Other speakers during the day-long conference discussed Love, Sex and Alzheimer’s; Caring for Someone with Dementia when you are Lesbian, Gay, Bisexual or Transsexual; and Bathing Without a Battle. Handouts offered lists of local and national resources, and descriptions of Alzheimer-related clinical trials.

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Stroke Awareness and Health Fair

Posted By SHL Librarian

Stroke Warning Signs:

  • Sudden numbness or weakness of the face, arm, or leg, especially on one side
  • Confusion, trouble speaking or understanding
  • Partial loss of vision in one or both eyes
  • Difficulty in walking, dizziness, loss of balance or coordination
  • Sudden, severe headaches

Tom Chivington was sorting some paperwork when he suddenly felt dizzy. A former college tennis coach, he considered himself in excellent health. He and his wife, Georgie, were both sports enthusiasts and avid travelers. Because he had seen a doctor about the same sensations just five days earlier, Chivington knew just what to do: He called 911.

“I had a stroke. The first time was a warning sign. When I felt the same symptoms the second time, I knew to call 911 and get to the hospital right away,” said Chivington, 70, who three years later shows no symptoms of his stroke. Chivington shared his experience at the annual Stroke Awareness and Health Fair in late May, a half-day community education program sponsored by the Stanford Stroke Center. The program included presentations from Stanford stroke specialists on prevention, treatment and rehabilitation.

The message was clear: Stroke can happen to anyone.

Timing is Everything
A stroke occurs when a blood vessel carrying oxygen to the brain suddenly bursts or becomes blocked, explained Anna Finley Caulfield, MD, a clinical assistant professor of neurology. Ischemic stroke, the more common of the two types of stroke, is caused by blockage of an artery in the brain. Hemorrhagic stroke occurs when a blood vessel breaks and leaks blood in or around the brain. Strokes can cause paralysis, language disturbances, coordination or balance difficulties, confusion or sensory loss.

But a rapid response can make all the difference, said JJ Baumann, RN, MS. The symptoms of a stroke manifest suddenly, so it’s crucial to act quickly. “You have about three hours to recognize what’s happening, get to a hospital, get a CT, and get drug treatment,” she said. “That’s a lot to happen in a short time. Most people just don’t get to the hospital fast enough, so it’s important to know the signs and call 911.”

Baumann said that only 50 percent of stroke patients call 911 and arrive at the hospital via ambulance. If patients call 911they are able to see a physician faster because the emergency department is prepared with experts who are trained to recognize the symptoms of stroke. She suggested that family members and coworkers learn to recognize the symptoms and remember the term FAST (face-arm-speech-time).

New Options
Every second the brain survives without blood flow, damage is done. The window of opportunity after a stroke is small-treatment is most effective within three hours of the onset of signs and symptoms. But that window is expanding.

“The reality is that not everyone can make it to the emergency room during that ‘golden window,’” said Greg Albers, MD, director of the Stroke Center and the Coyote Foundation professor of neurology.

Albers, an internationally recognized stroke expert, is studying the possibility of using clot-busting medications such as tissue plasminogen activator (tPA) up to six hours after the onset of certain kinds of stroke.

He also described promising breakthroughs in mechanical technologies, including a new clot retriever system called Penumbra, which was approved by the FDA in January 2008.  It uses a suction device that can remove a clot in less than 20 seconds. Another corkscrew-like device called the MERCI (mechanical embolus removal in cerebral ischemia) retrieval system, made up of a wire that is threaded up through an artery to the site of the blockage and retrieves the clot. Studies show that about 50 percent of patients benefit from this system up to eight hours after the onset of a stroke

“The technology is improving rapidly, and we have some new, positive options,” said Albers. “But we need to know what’s going on in the brain before we act so we can identify the patients who will have good outcomes after the three-hour window.”

Preventive Measures
While certain risk factors for stroke-age, gender, race, genetics-cannot be controlled, most people can take active measures to prevent its occurrence, said Neil Schwartz, MD, PhD, a clinical assistant professor of neurology. “There are modifiable factors that play an important part in stroke onset,” he said, “and there are multiple ways to control high blood pressure, cholesterol, smoking, inactivity and obesity.”

Schwartz described several studies that tracked the effects of drugs and behavior modification on preventing stroke. One study showed that stroke patients who used atorvastatin, a drug used to lower cholesterol, were 16 percent less likely to have another stroke; another demonstrated the direct effect of lowering high blood pressure on stroke occurrence. Other trials continue to track the benefits of preventive medication.

“It important that patients get involved in clinical trials to help us learn more about what works and what doesn’t” he said.

Recovery and Rehabilitation
Stroke is the No. 1 cause of disability in the U.S. Regaining and improving function after a stroke is of primary importance to restore independence and to enhance quality of life.

“Rehabilitation is about retraining the person. The patient needs to learn to utilize remaining function in a way that won’t develop into poor movement or behavior,” said Jeffrey Teraoka, MD, a clinical associate professor of orthopedic surgery, who discussed new interventions that range from drug therapy to virtual reality.

Patients often benefit from devices such as a supported gait harness, which helps patients focus on movement mechanics by holding their weight, somewhat like a baby jumper swing. He described animal studies using cognitive stimulants, like adrenaline enhance dopamine, that appear to enhance recovery. Today rehabilitation also includes virtual reality games, which are easy, accessible and safe, and provide positive reinforcement that can reduce the monotony of traditional therapy.

“Rehabilitation is designed to maximize function,” said Teraoka. “Be cautious what you invest in. Your treatment requires diligence, creativity and patience.”

For Tom Chivington, recovery was as much about outlook as action.

“I remember lying there and thinking, ‘Why me?’ and ‘Do I really want to live like this?’ Dr. Albers leaned down and said to me, ‘You know you can recover from this.’ I realized then the importance of attitude. That, and the support of friends.”

About the Stanford Stroke Center
The Stanford Stroke Center was one of the first centers of its kind in the United States and was one of the first to be designated a primary stroke center by The Joint Commission, a not-for-profit organization that accredits more than 15,000 health care organizations in the U.S. Stanford was the 15th hospital and the second academic hospital in the country to be stroke certified, an acknowledgment of its excellence in stroke care.

The Center incorporates a multidisciplinary approach to stroke care. It’s staffed 24 hours a day with neurologists, neurosurgeons, radiologists and rehabilitation experts, who use the latest technology when patients come in with signs or symptoms of stroke. In addition to utilizing cutting-edge technology for emergency stroke care, the Center is involved in studies to improve existing therapies and to develop new techniques for treating, diagnosing and preventing stroke.

Stroke Statistics

  • About 700,000 Americans suffer from a stroke each year-that’s someone every 45 seconds.
  • Twice as many women die from a stroke than from breast cancer
  • The incidence of stroke rises dramatically with age; the risk doubles for each decade after age 55.
  • About 5 percent of people over age 65 have had at least one stroke.
  • High blood pressure is a factor in 70 percent of all strokes.

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Farewell to Falls

Posted By SHL Librarian

Presented by: Ellen Corman, MRA
Injury Prevention Coordinator, Trauma Services
Stanford Hospital & Clinics

Lecture Overview:

  • Fifty percent of adults 80 and older fall each year
  • Most falls take place at home
  • Older adults who fall are two to three times more likely to fall again
  • Take proactive steps in your home to avoid falls by installing handrails, removing clutter and keeping floors clear
  • Exercise to maintain strength, balance and coordination
  • Have your physician check your medications

Nearly 1 million older Californians experience a fall each year. For people 65 years and older, falls are the most common source of injury resulting in a visit to the emergency room.

The odds of falling each year after age 65 are about one in three; after age 80 the chance of a fall is about 50-50. People are more likely to fall as they get older because of common, age-related physical changes and medical conditions, along with the medications prescribed to treat such conditions, weakness related to a sedentary lifestyle, and home and environmental obstacles. About 20 to 30 percent of the people who do fall face reduced mobility, and many people-even those who are not injured-develop a fear of doing it again.

“Older adults who have fallen are two to three times more likely to fall again within the next year,” said Ellen Corman, MRA, injury prevention coordinator for trauma services at Stanford Hospital & Clinics, who gave an hour-long presentation at the Redwood City Public Library on April 30. “The older you get-and the more risk factors involved-set up an even greater chance of falling.”

Corman asserts that falls do not take place because “I wasn’t watching,” or “I just tripped.” The reasons behind a fall can range from being tired and not lifting your feet properly to poor vision, distractions, slower reaction time and medications that cause dizziness or lightheadedness. Other factors can include physical weakness, cognitive impairment, depression, dehydration or a balance disorder.

But many falls can be prevented by making even small adjustments in three specific areas: your home environment, your medications and your exercise routines.

Taking Positive Steps
“When it comes to home safety, there are specific changes you can make to control your environment. Be proactive. There is usually a combination of factors so it’s important to take a multifaceted approach to making changes,” said Corman. “Most falls are preventable.”

Because more than 60 percent of falls occur at home, she stressed the importance of making some simple modifications to make it safe:

  • Get rid of your throw rugs. Hang them on the wall or give them to someone who will appreciate it.
  • Remove clutter-including papers, pet toys and the grandkids’ playthings.
  • Move electrical cords out of the way.
  • Wear thin-soled, non-skid shoes, sneakers or slippers, especially in homes with hardwood floors.
  • Use nightlights, and bring a nightlight with you when you travel.
  • Install grab bars in the bathroom. An occupational therapist can aid in making an accurate assessment of where to place the bars to suit your height and movements.

“My dream is that all homes have grab bars in the bathrooms, no matter what the person’s age,” Corman said.

Fitness is Key
Older adults generally score between 20 and 49 percent lower on strength tests-an impairment that makes them three times more likely to fall. While today’s older adults realize that exercise is important and tend to remain active in their later years, for too many people retirement means a sedentary lifestyle.

Corman mentioned one study of men and women aged 88 to 92 years involved in a simple exercise program: All participants showed improvement in strength and balance after only eight weeks.

“It’s never too late to start some kind of exercise,” she advised. “Keep moving, and try to mix it up.”

Corman recommended tai chi or a walking routine in a safe, flat location such as a mall or school track. She also emphasized the importance of including weight training to maintain strength.

Check Medications
The number, type and combination of medications can affect a person’s balance, perception and reaction time. Medications should be checked for side effects listed like lightheadedness or dizziness as these drugs could contribute to the potential for a fall. Check regularly for expiration dates, and be aware of possible complications from polypharmacy-the use of multiple medications that may interact.

Corman suggested that all medications be placed in a plastic bag and brought to a physician or pharmacist for review.

Support System
Stanford established the Farewell to Falls program in 2005 to assess potential trouble spots for seniors at risk for falling. The home-based program, free for Santa Clara and San Mateo county residents 65 and older, provides two home visits from an occupational therapist who evaluates the home for potential problems, performs a sensory-motor review and does a health risk interview. The therapist then offers individualized suggestions and a review of medications from a pharmacist. Participants also receive an exercise video to help improve strength and balance.

In addition to the home visits, participants receive periodic follow-up phone calls from volunteers to see how they’re doing. One year after the start of the program the occupational therapist returns to reassess the risk factors and to provide additional fall prevention tips.

“We’re hoping that seniors take advantage of this opportunity to participate in a program that can help them to maintain their independence,” said Corman, who added that more than 200 people take part in the program each year.

About the Speaker
Ellen Corman is the Injury Prevention Coordinator in the Trauma Service at Stanford Hospital & Clinics and has been involved in injury prevention activities for more than 20 years.

She is an occupational therapist and has a master’s degree in rehabilitation administration. Corman participated in the California state injury prevention strategic planning workgroup and is an active member of the California Stop Falls Network. She developed and manages the Stanford Hospital & Clinics Farewell to Falls program and co-chairs the San Mateo County Fall Prevention Task Force.

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