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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Starting an Exercise Program: How Your Doctor Can Help

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Presented by: Paul Wang, MD
Director, Stanford Cardiac Arrhythmia Service

Nawal Atwan, MD
Clinical Instructor, Internal Medicine
Stanford University Medical Center
October 21, 2010

Lecture Overview:

  • Many heart conditions often have no symptoms, so it is important to screen young athletes before they start a sport or activity.
  • Screening should include a health history and a complete physical, which may include an electrocardiogram.
  • People over 40 who have symptoms of chest pain or shortness of breath should have a stress test before starting a new sport.
  • Mix up your routine to include exercises for cardiovascular health, weight training for strengthening muscles, and stretches for flexibility and balance.
  • Start with a plan and steadily increase your goals to measure improvement.

Most people know the many benefits of exercise. Including workouts into your routine has shown to increase longevity, reduce the risk of heart attack and stroke, improve cholesterol levels, lower blood pressure, prevent diabetes, and make you feel better. It helps with weight loss, strengthens bones, and enhances cognitive function-all concerns that affect the quality of life as we age.

Screen for Heart Conditions The only paradox to exercise is a very slight increase in the risk of heart attacks or death from cardiac arrest. Sudden cardiac arrest-when the heart ceases to beat without any warning-is one of the largest heart health problems in the United States. The heart’s electrical system goes awry, making it unable to pump blood to the rest of the body.

The chance of successful resuscitation drops 10 percent every minute, said Paul Wang, MD, director of the Stanford Cardiac Arrhythmia Service and Cardiac Electrophysiology Laboratory, who spoke about cardiovascular evaluation and screening at a presentation sponsored by the Stanford Health Library.

There are more adults with congenital heart defects than ever before, due in large part from improved surgeries. According to the 36th Bethesda Conference, which establishes guidelines for people with cardiac disorders, most congenital heart disease patients have a reduced ability to exercise. Experts are still debating how much exercise is appropriate and whether teens with a heart condition should be allowed to participate in sports.

Many heart conditions often have no symptoms, so it is especially important to screen young athletes before they start to participate in a sport or activity. In athletes younger than age 40, the most common underlying cause of heart problems 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.

The condition tends to manifest in the late teens, and the risk remains an ongoing concern, said Dr. Wang.

“If you’ve had an arrhythmia once, or have a condition that could lead to arrhythmia, the likelihood is higher that you can suffer from cardiac arrest,” he said. “The recommendations are that you should be excluded from most competitive sports.”

There are other conditions that young people should be screened for before taking on a strenuous sport, including anomalous coronary artery, a rare condition that can be detected by an angiogram. These youths should also be restricted in their athletic activities, said Dr. Wang.

In older athletes, the most common cause of problems is coronary artery disease-the buildup of plaque inside the blood vessels. Other conditions of concern include myocarditis, an inflammation of the heart wall, and Marfan syndrome, a disease that weakens the walls of the aorta.

Dr. Wang recommends that all young people see their doctor for a complete physical that includes a health history. An electrocardiogram may be helpful in some cases, but experts are still discussing its benefits. Athletes over 40 who have possible symptoms of heart disease such as chest pain or shortness of breath, and sedentary people with risk factors for heart disease should have a stress test before starting a new regimen. These tests can provide clues to help your physician uncover underlying disease.

“Screening athletes is an important aspect of safety,” he said. “Then follow-up is essential.”

Before You Start to Exercise Nawal Atwan, MD, provided more detail about the benefits of exercise and how to start a healthy regimen. She recommended working out at least 30 minutes five times a week and mixing activities for cardiovascular health, strengthening muscles, and stretching.

She suggested that you start with a plan and steadily increase your goals to measure improvement. Use a pedometer for inspiration, and be realistic about what you can and can’t do. Start with lower goals and then build up the intensity and frequency, she said.

Dr. Atwan suggested a visit to the doctor before starting a new exercise or to assess risk. The physical should assess your blood pressure, heart rate, cholesterol, body mass index (BMI), percentage of body fat, gait, balance, and hand grip. Your doctor may recommend an electrocardiogram or a stress test to measure your heart capacity.

Talk to your physician if you have joint pain or how to prevent developing joint problems. If you have arthritis, you may benefit from a low-impact activity like swimming or water aerobics, which studies have shown can decrease pain, she said. All participants should be sure to stretch as a warm-up and cool-down, holding each position for at least 30 seconds.

“There are lots of excuses to not exercise: no time, no motivation, it’s boring, it hurts. But it’s a matter of getting out there and doing something,” Dr. Atwan said. “Exercise is the cheapest drug around-you can get the same benefits as some medications and without any side effects.”

About the Speakers
Paul Wang, MD, is a professor of medicine (cardiology) and director of the Stanford Cardiac Arrhythmia Service and Cardiac Electrophysiology Laboratory. He received his medical education at the College of Physicians & Surgeons at Columbia University in New York, did his internship at New York Presbyterian Medical Center, and did his fellowship at Brigham and Women’s Hospital at Harvard Medical School.

Nawal Atwan, MD, is a clinical instructor of medicine (internal medicine) who specializes in women’s health, athletic health, and chronic disease management. She received her MD from Harvard Medical School and did her residency at Stanford. She joined Stanford in 2009. She is Board Certified by the American Board of Internal Medicine.

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WebMD: Starting an Exercise Program

Cancer Awareness Series: New Successes in Colorectal Cancer Treatments and Outcomes

Posted By SHL Librarian

Presented by: George Fisher, MD, PhD
Associate Professor, Oncology

Uri Ladabaum, MD, MS
Associate Professor, Gastroenterology

Hanlee Ji, MD, PhD
Assistant Professor, Oncology

Samuel Strober, MD
Professor, Immunology and Rheumatology

March 24, 2011

Lecture Overview:

Colorectal cancer (CRC) is the third most common cancer in the United States and is the country’s second leading cause of cancer death (behind lung cancer)

“We are working to raise awareness of the disease and to celebrate the  successes we have had with colorectal cancer,” said George Fisher, MD, PhD, an associate professor of oncology, who spoke at a presentation sponsored by the Stanford Cancer Center and the Stanford Health Library. “Our strongest advocates are the people who have been touched by the disease who can help us engage others and build a community dedicated to the elimination of colorectal cancer.”

Colorectal cancer can develop from an atypical growth called a polyp. There are two types of polyps: hyperplastic, which have a very small chance of developing into cancer, and adenomatous, the source of nine out of 10 cases of CRC.

At least half the cases could be prevented with regular screening since early detection is crucial to successful treatment. Colorectal cancer’s mortality rate has declined steadily in recent years, aided by a public awareness of the importance of screening for prevention and early detection, as well as significant improvements in treatment.

“Advances are being made, but until we can create screening systems for all people at risk, we will continue to deal with advanced disease. We are improving our therapies and looking for a cure so that colorectal cancer is gone forever. The challenge can be met if we are able to put all the pieces together,” said Dr. Fisher. “That’s the advantage of an academic medical center like Stanford, where we can combine the multidisciplinary expertise of scientists in different specialties together with clinicians working directly patients.”

Patients benefit from teams made up of surgeons, radiologists, gastroenterologists, and radiation oncologists, he said, as well as experts in peripheral specialties like interventional radiology and genetics, who discuss treatment plans for each individual. “This approach is of enormous value because it allows us to provide care that is both seamless and cutting-edge,” he said. Research is integrated into patient care and includes investigations into cancer stem cells, vaccines, and cancer genomics.

Dr. Fisher also advocated for community involvement to support research in pivotal areas, including investigations to:

  • identify biomarkers to aid in early diagnosis and therapy follow-up
  • study the genes involved in colon cancer
  • refine prevention and therapeutic trials
  • educate individuals and families
  • encourage lifestyle changes to eliminate avoidable risk factors like smoking and obesity
  • promote early screening and develop strategies for early diagnosis
  • improve treatments through targeted therapies and genomics

Genetics and Screening
While we do not know the cause of colorectal cancer, it’s most likely related to genetic changes from external influences in our cellular DNA. Risk factors include age (most cases appear in people over age 50), a diet high in red or processed meat, lack of physical activity, obesity, smoking and alcohol use, and health conditions like diabetes.

“Why screen? To find and remove polyps before they can develop into cancer and to identify cancer at an early stage when treatments are most effective,” said Uri Ladabaum, MD, MS, a professor of gastroenterology, who spoke on Screening and the Role of Genetic Evaluation.

The lifetime risk for developing colorectal cancer is one in 18 for men, and one in 20 for women. In most cases, physicians cannot identify a specific risk. In fact, in about 75-85 percent of cases, there is no genetic cause for the disease. Only between 10 and 30 percent of cases are clustered within a family, pointing to a genetic, or hereditary, root.

“When there is a family history of colorectal cancer, the risk is higher based on the number the relatives and the age they had it,” he said. “The younger the age, the greater the risk. But even when older, a first-degree relative (a parent or sibling) can elevate the risk.”

For example, a person with no family history of CRC has a 5 percent chance of developing the disease. The chance is 10 percent for a person with one family member with CRC and three times higher with two family members. Risk is also elevated when a person has an inflammatory bowel disease such as Crohn’s or ulcerative colitis. Irritable bowel is not a risk factor, he said.

Lynch syndrome, or hereditary nonpolyposis colorectal cancer (HNPCC), is a rare inherited condition that increases the risk and early onset of colon cancer. If a parent has the gene mutation for Lynch, each child has a 50 percent greater chance of inheriting the defective gene and an 80 percent chance of developing cancer over their lifetime, said Dr. Ladabaum. However if the gene mutation is identified, colonoscopies can remove polyps before cancer develops and significantly decrease the risk.

Genetic testing for inherited conditions like Lynch syndrome can help identify who is at an elevated risk so screenings can be scheduled more frequently and at a younger age.

“The point of screening is to reduce risk—to find the precursors of cancer and remove them. It’s not just early detection, it’s also prevention,” he said. “We remove the adenomas before symptoms develop, when the condition is most treatable.”

Adults with average risk should start screening at age 50 and repeat the test every 10 years. A person with a relative who developed symptoms after age 60 should start screening at age 40 and return every 10 years; a person with a relative who developed symptoms under age 60 should be screened at age 40, or 10 years before the relative’s onset, and return every five years.

“We’ve progressed from one-size-fits-all screening protocols to the ability to tailor tests for individual risk,” said Dr. Ladabaum. “Intensive screening can dramatically reduce the incidence of CRC and its mortality rate.”

Analyzing Cancer Genomes
Deoxyribonucleic acid (DNA) is the chemical compound that encodes your genetic blueprint—the instructions your cells need to develop and function. A complete set of DNA is called the genome.

Throughout your life, DNA can make mistakes during cell replication. Most of these genetic glitches are harmless, but once in a while a mutation causes damage that pushes a cell to becoming cancerous. Through a process called sequencing, scientists have created vast databases of the genomic mutations found in several cancers, including CRC.

“Through a combination of technology, computational analysis, and DNA  sequencing, we know more about the genetic factors of colorectal cancer than any other cancer,” said Hanlee Ji, MD, an assistant professor of medicine (oncology), who discussed Personalized Colon Cancer Medicine through Analyzing Cancer Genomics.  “There’s a new era in personalized cancer treatment, based on the analysis of the genes in tumor cells.”

DNA sequencing allows scientists to identify mutations, cellular variations, and other genomic anomalies that contribute to cancer development. They can then home in on likely suspects, and these mutations can then be used to identify targets for therapy and to anticipate how a patient will respond.

Dr. Ji predicts that as technology continues to improve, genomic applications will be more fully integrated into a diagnostic setting. Assessing the genome will allow physicians to determine the risk of developing CRC, track the possibility of metastasis, and predict patient response. This process is accelerated at Stanford by the close proximity of scientists to clinicians who are working together in a back-and-forth dynamic called translational medicine.

“It used to take months to deal with the amount of data contained in a cell genome, and now it’s possible to isolate a tumor and potentially sequence an entire cancer genome in weeks,” he said. “There is no comparison as to what we could do and what we can do now. Next-generation gene sequencing will cause a major change in how we look at genomics. Diagnostic solutions will allow personalized medicine to become a reality.”

Vaccine Strategies
“The purpose of cancer vaccines is to elicit a more powerful immunity in the patient,” said Samuel Strober, MD, a professor of immunology and rheumatology. “However, tumor-specific antigens have been hard to find, and many immune agents now in use target healthy cells as well as the cancerous cells.”

Dr. Strober spoke about the challenge of developing ways to attack a tumor without affecting normal cells. One promising option may be the development of a cancer vaccine. Last year the U.S. Food and Drug Administration approved the first anti-cancer vaccine: a patient-specific dendritic-cell vaccine for use against advanced prostate cancer.

There are two fundamental concepts behind vaccines. One is prophylactic—to prevent the disease from occurring. The Human Papillomavirus vaccine (HPV) works by causing the body to make antibodies that recognize and fight the virus cells before they develop. HPV is a cause of cervical cancer and genital warts.

The other type of vaccine is therapeutic— stimulating the immune system response to home in on existing cancer cells.

Current cancer treatments—radiation and chemotherapy—are non-specific: They destroy healthy as well as malignant cells and can cause severe side-effects. Dr. Strober has been looking at ways to harness the immune system to develop precisely targeted therapies that home in on just the tumor cells.

His research involves using T-cells, a type of white blood cell that protects the body from infection by responding to antigens presented to T-cells by dendritic cells. Antigens stimulate the T-cells to produce proteins that can kill or slow the growth of a foreign invader or a tumor.

Dr. Strober’s laboratory has been developing ways to stimulate immunity to tumors in animal models of primary and metastatic tumors that involve three steps:

  • The primary tumor is treated with focused, high doses of radiation to kill the cancer cells. The few cells remaining are made more apparent to the immune system as foreign. The scientists take dendritic cells and insert them into the tumor to activate a T-cell response. The T-cells, which have now been trained to recognize tumor antigens, are collected and stored.
  • Animals are treated with additional irradiation and/or chemotherapy to kill metastatic tumor cells and to promote expansion of T-cells that will be injected.
  • The T-cells are injected into the blood. Because they have been conditioned to recognize the cancer antigen, they go straight to the tumor and destroy remaining tumor cells.

All three steps are required for the system to work, said Dr. Strober. Using all three steps resulted in a cure in eight of 11 animals, and when a second tumor was introduced, the immune system prevented its growth. “The animal was immunized,” he said, “and 80 percent survived more than six months.”

The process showed that advanced tumors can be treated with the three-step strategy, and Dr. Strober and his team are working with clinicians to develop protocols for human clinical trials. “We hope to have trials in place by the end of 2011,” he said.

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