MarcH-MaY 2013

a PUBLIcaTION FOr PrIMarY carE PHYSIcIaNS

MIca (P) 242/03/2012

EyE on thE EldErly

GREY MATTERS

An Interview with Associate Professor

Chin Jing Jih

AGEING AND

ARTHRITIS

UNdEr-NUTrITION IN THE ELdErLY

Scan the Qr code using your iPhone or smart phone

to view GP BUZZ on the TTSH website or visit

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EdiToR’S noTEconTEnTS

thE GP BUZZ Editorial tEam:Lee Wei Kit Jessie Tay

celine Ong

adViSory PanEl:associate Professor Thomas Lew

associate Professor chia Sing Jooassociate Professor chin Jing Jih

adjunt assistant Professor chong Yew Lamdr Tan Kok Leong

Joe Hau

GP BUZZ is a quarterly magazine by Tan Tock Seng Hospital, designed by

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in EVEry iSSUE

03 editor’s note

04 in the news

30 fitness

35 healthy recipe

in thiS iSSUE

06 Eye on the Elderly

09 Grey Matters

12 Ageing and Arthritis

15 Vitamin Supplementation for the Older Person

19 Managing the Sweet Spot

22 Under-Nutrition In The Elderly – Can It Be Prevented?

25 The Sound of Silence: Hearing Loss in the Elderly

29 Ageing in Singapore

MarcH - MaY 2013

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Sources: # The Oxford dictionary* Singapore department of Statistics

n twenty years, Singapore will have undergone an unprecedented profound age shift. One in five Singaporean residents will be a senior, with

the number of residents aged 65 and above multiplying three-fold from 300,000 to 900,000*.

The greying profile of our society will be a strong driver for healthcare demand, as the elderly are more likely to require more medical care. With the rise in age-related chronic diseases, the trend indicates that the expectation for quality care will also rise.

Your role as primary healthcare practitioners in delivering effective treatment and care to the silver-haired generation has never been more challenging and significant.

Keeping an eye on elderly issues, we kick-start this issue of GP BUZZ with the cover story on cataract and age-related macular degeneration, two common visual impairments which affect up to 80% of the elderly locally.

Read about the symptoms and latest treatment options for arthritis and the importance of vitamin supplementation for healthy ageing in the older person. The risks and management of under-nutrition are also discussed in-depth with a contribution from the TTSH Nutrition and Dietetics Department.

Further in this issue, explore targeted interventions and treatment methods for diabetes and hearing loss. Specific exercises to aid mobility have also been specially developed by the TTSH Physiotherapy Department.

We round up this elderly-focused issue with a Tofu Sushi treat specially crafted by TTSH Food and Beverage Department.

An ageing population is a demographic reality. Indeed, we all have collective responsibility in shaping the future of aged care. Let’s forge ahead together to ensure that our seniors of today and tomorrow enjoy a high quality of life with innovative and accessible healthcare.

The GP BUZZ Editorial Team

I

Eu-ge-ria– A normal and happy old age#

(noun)

03

control that also allows them to control the reading light and ceiling fan over their beds.

To reduce patient fall risk and injury, the new wards now feature en-suite toilets for a shorter bed-to-toilet distance, additional hand-grab bars within the toilet and vinyl padded flooring to reduce fall impact.

A brighter, soothing colour tone has also been carefully selected for a comfortable healing environment.

Similar elder-friendly enhancements will also be made to other wards in phases.

in ThE nEwSin ThE nEwS

PHarMacY cONSULTaTIONS PrOvIdE SaFEr aNd MOrE INTEGraTEd carE FOr PaTIENTS

Pharmacist-run clinics, where patients’ medication is reviewed, monitored and explained is

becoming a regular feature in the public hospital landscape. With nine pharmacist-run clinics or outpatient services, Tan Tock Seng Hospital (TTSH) takes the lead with the most of such services in Singapore.

In a 10 to 15-minute session, the pharmacist goes through the patient’s list of medication, explaining what each drug is for, when it should be taken and in what dosage. These sessions help familiarise the patients with the drugs they are taking and the recommended dosage for each drug. The pharmacist also keeps an eye out for any adverse drug reactions and can take prompt action for side effects.

At TTSH PEARL non-subsidised clinics, first-visit patients undergo a review of their current medications even prior to the doctor’s consultation. This innovative process helps doctors in their prescriptions in accordance with the pharmacist’s review.

pharmacy consultation at ttsh pearl non-subsidised clinic 2B.

Besides educating patients on drug usage and the side effects, pharmacists can also make changes to the dosage. Some pharmacists also have prescribing rights, subject to approval by the medical board of the hospital and within approved protocol.

Sessions with the pharmacist are useful not only for patients. Caregivers of elderly patients may also benefit patients under the care of multiple specialists. A pharmacist working in partnership with the patient and his caregivers can minimise the danger of potentially harmful drug interactions.

nEw wardS rEady For thE EldErly

at Tan Tock Seng Hospital (TTSH), newly-renovated class B2 wards have been enhanced with more elderly-oriented features to meet the

rising demands of a rapidly ageing population. Each ward cubicle of five beds now has its own nurse station, giving assigned nurses a direct line of sight to their patients. The new configuration means nurses can see their patients better and respond to patients faster, sometimes without the need for bell calls.

The nurse call bell system at TTSH has also been improved. Patients now have an all-in-one remote

1. a brighter, more conducive healing environment.2. decentralised nursing workstation.

3. additional hand-grab bars within toilet.

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31

CmE Schedule March - May 2013

cMe points

date

tiMe

VenUe

reGistration details

2 CME points*

27 April

2.00pm - 4.00pm

Theatrette, Tan Tock Seng Hospital, Level 1

Ms Cynthia LeeDID: 6357 2373Email: cynthia_lee@ttsh.com.sg

dEalinG with GaStrointEStinal diSEaSES

* subject to the approval of singapore Medical council.

for an updated listing of cMe and event schedule, please visit

http://www.ttsh.com.sg/gp/. information is correct at the time of publishing.

04 05

CataraCt

What is Cataract?Cataract is a clouding of the natural (clear) lens in the eye. The prevalence of cataract increases with age, affecting up to 80% of the elderly. Both eyes are usually affected, although sometimes asymmetrically.

What are the Risk Factors?Risk factors for cataract include age, diabetes mellitus, smoking, ultraviolet radiation exposure, steroid medications (eyedrops, topical and systemic), and prior ocular injury.

What are the Symptoms of Cataract?A person with cataract may experience blurred vision, reduced colour saturation, reduced contrast, monocular double vision, increased glare and haloes at night. Poor night vision and the need for frequent changes to spectacles prescription are also common symptoms.

How can I Prevent Cataract?Patients should be advised to avoid or cease smoking, use sunglasses or a wide-brimmed hat when outdoors and to maintain a healthy diet. There are no medications to reverse cataracts once they have formed.

How is Cataract Detected?A reduced or absent red reflex can be detected with a direct ophthalmoscope. In late stages, the

lens becomes completely white and opaque, appearing as a white opacity in the pupil (Figure 1). A cataract does not cause an absolute or relative afferent defect.

What are the Treatment Options?Surgical removal is the only effective treatment, and should be considered when the cataract reduces visual function to a level that interferes with everyday activities. Cataract surgery is an outpatient procedure that is performed under local anaesthesia, and usually takes less than half an hour to complete.

Standard cataract surgery is performed by phacoemulsification (ultrasonic emulsification of cataract) through sutureless corneal incisions, replacing the cataract with an artificial lens implant.

A wide variety of lens implants (monofocal, aspheric, multifocal, accommodative and toric) are available, enabling patients to achieve various degrees of spectacle independence. The selection of lens implants is also tailored to each patient’s specific visual needs.

aGE-rElatEd maCUlar dEGEnEration

What is Age-related Macular Degeneration (AMD)?Age-related Macular Degeneration (AMD) is a leading cause of blindness in many developed countries. AMD affects a person’s central vision and is classified into dry and wet AMD.

1. figure 1 - late-stage cataract.2. figure 2 - wet aMd with haemorrhage.

figure 3 - amsler Grid eye test

1

2

normal Vision

abnormal Vision

EyE on thE

EldErlyVisual impairment in the elderly is associated with reduced mobility and physical performance, as well as an increase in hip fractures, depression, morbidity and mortality. Find out

more about Cataract and Age-related Macular Degeneration, two common causes of visual impairment in the elderly.

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SPoTLiGhT

GREY MATTERSAn Interview with

Associate Professor Chin Jing Jih

In your own words, how will the future landscape of geriatric care be like? The senior patients of the future will be better educated, more resourceful and probably more motivated. At the same time, they will want to participate more actively in their own care, and express their opinions more explicitly. They will likely place even more emphasis on quality of life and the healing experience. They will also be more familiar with the use of technology in everyday life, and have higher expectations of what tertiary and primary geriatric care

can offer them. As healthcare providers, we will have to constantly adapt and adjust in order to meet these new challenges. We will have to equip ourselves with skills in areas such as IT, medical ethics and health law, end-of-life communication, in order to connect well and be able to meet the medical and psychosocial needs of the seniors.

What was your motivation in setting up the Institute of Geriatrics and Active Ageing (IGA)?The need for an Institute of Geriatrics and Active Ageing (IGA)

was premised on our belief that, with a rapidly ageing population, we are unlikely to cope with the many medical and psychosocial needs of the elderly by merely doing more of the same. Current and future strategies to meet the complex and multi-faceted needs of the elderly will require increased efficiency and cost-effectiveness in our treatmentand our care delivery models. To achieve constant improvement and renewal, we will need research and innovation to find us the improved solution, and education and training to rapidly transform the new knowledge into daily practice.

With an intuitive interest in scientific enquiry and a desire to be engaged in an interactive and meaningful profession, a medical career was a natural choice for Associate Professor Chin Jing Jih. Currently a specialist in Geriatric Medicine and Senior Consultant in the Department of Continuing and Community

Care at Tan Tock Seng Hospital (TTSH), Associate Professor Chin is Chairman of the hospital’s Division of Integrative and Community Care, tasked primarily to develop an integrated framework of primary, tertiary and long-term geriatric care systems. He is also the incumbent President of the Singapore Medical Association.

In September 2012, the Institute of Geriatrics and Active Ageing (IGA) was launched. Spearheaded by Associate Professor Chin and housed in TTSH, the new centre seeks to embark on geriatrics research and innovation, and to attract, train and retain healthcare workers in elderly care. The institute will also work with three medical schools – Yong Loo Lin School of Medicine, Duke-NUS Graduate Medical School and the upcoming Lee Kong Chian School of Medicine – to beef up geriatric care training, develop initiatives to improve patient care as well as coordinate and fund research efforts.

We speak to Associate Professor Chin to learn more about the IGA and geriatric care initiatives at TTSH.

Dry (atrophic) AMD is more common, visually less debilitating and progresses more slowly.

Wet (exudative) AMD is characterised by the development of abnormal choroidal blood vessels (choroidal neovascularisation) with resultant visual loss from retinal oedema, bleeding and scarring. Wet AMD occurs in only 10% of patients with AMD, but is responsible for up to 90% of severe vision loss related to the disease.

What are the Risk Factors?These include ageing, smoking, a family history of AMD and genetic predisposition. Females and Caucasians are also at a higher risk.

What are the Symptoms of AMD? AMD presents with an insidious and progressive blurring of central vision. Patients usually maintain fairly good vision unless extensive degeneration and atrophy set in, or if wet AMD develops. Wet AMD presents with a more severe decrease in central vision and distorted vision (metamorphopsia).

How can I Prevent AMD?Patients should be advised to avoid or cease smoking. Conducting regular self-checks with an Amsler Grid Eye Test (Figure 3) is helpful in picking up early symptoms. Those aged above 55 should undergo screening for AMD every 1 to 2 years, especially in the presence of risk factors.

Dr Foo Fong YeeDr Foo Fong Yee is a Consultant at the National Healthcare Group Eye Institute at Tan Tock Seng Hospital, and Clinical Senior Lecturer at the Yong Loo Lin School of Medicine. She is a Fellow of the Royal College of Surgeons of Edinburgh, and the Academy of Medicine Singapore. Her subspecialty interest is in paediatric ophthalmology and strabismus.

References:1 Report on the Ageing Population 2006. Committee on

Ageing Issues. Department of Statistics Singapore. http://app.msf.gov.sg/Portals/0/Summary/research/CAI_report.pdf.

2 Key indicators on the elderly. July 2012. Department of Statistics Singapore. http://www.singstat.gov.sg/stats/themes/perople/elderly.pdf.

3 Ng DHL, Sangtam T, Au Eong KG. Ann Acad Med Singapore. Oct 2007; The emerging challenge of age-related eye disease in Singapore. 36(10): S9-13.

4 Hyman L. Eye 1987; Epidemiology of eye disease in the elderly. 1(2):330-41.

5 Quillen DA. Am Fam Physician Common causes of vision loss in elderly patients. 1999;60(1):99-108.

6 Foster PJ, Oen FT, Machin D, Ng TP, Devereux JG, Johnson GJ, Khaw PT, Seah SK. Arch Ophthalmol. The prevalence of glaucoma in Chinese rsidents of Singapore: a cross-sectional population survey of the Tanjong Pagar district. 2000 Aug;118(8):1105-11.

7 National Registry of Diseases Office (NRDO) Singapore. Information paper on diabetes in Singapore. Nov 2011.

How is AMD Detected?For Dry AMD, small, yellow subretinal deposits called Drusen are seen in the macular area. There may also be retinal pigmentation or depigmentation in the macular area, without leakage of fluid or blood.

Signs of Wet AMD include haemorrhages, exudates and oedema in the macular area, with macular scarring setting in if left untreated (Figure 2). Macular examination with direct ophthalmoscopy may be difficult due to small pupils from senile miosis or cataract.

What are the Treatment Options?For Dry AMD, there is no curative treatment and no active treatment indicated. The use of high-dose antioxidants (Vitamins A, C and E) and zinc supplementation has been shown to reduce the risk of progression in specific categories of Dry AMD. However, a high-dose of vitamin A should be avoided in smokers as it is associated with an increased risk of lung cancer.

Wet AMD is diagnosed and classified by special angiographic imaging with fluorescein and indocyanine green dyes. Depending on the location and lesion type, Wet AMD can be treated in various ways. These include laser, photodynamic therapy, peri-ocular steroids and intra-vitreal injection of anti-vascular endothelial growth factors (anti-VEGF) such as ranibizumab (Lucentis), pegatanib (Macugen) and bevacizumab (Avastin).

ConclusionThe ageing population of Singapore will increase considerably in the years to come, resulting in a corresponding increase in the prevalence of age-related eye conditions. Awareness of these conditions will better position the health practitioner to care for the elderly patient.

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All these efforts can only be productive and sustainable when supported by a well-planned, suitably resourced and coordinated platform that facilitates research and education. It is our conviction that the IGA will provide this much needed catalytic framework.

Why is TTSH an ideal location to house this Institute?Historically, TTSH is the birthplace of Geriatric Medicine in Singapore, and operates today one of the largest geriatrics services locally. The geographical area served by the hospital also happens to be demographically one of the oldest in the country. This provides a good match between available expertise and needs of the communities surrounding the hospital.

Furthermore, TTSH was one of the first acute hospitals to extend its geriatric services into the community in collaboration with Voluntary Welfare Organisations (VWOs) with aligned vision and goals.

What are some of the projects lined up for the IGA?In one of our key research projects, we are looking into factors that contribute to medical, psychological or social frailty among patients suffering from mild cognitive impairment (MCI) and mild-to-moderate dementia. By identifying these vulnerabilities, useful management strategies can be formulated to retard functional decline and enhance the ability of caregivers and patients to cope with the illness.

Many of our hospitalised elderly are also vulnerable to acute confusion whether or not they have clinically overt dementia. As such, we have established a Specialised Delirium Management Unit to better manage and study care innovations to improve the functional status of these patients.

What are some meaningful ways that our General Practitioner (GP) Partners can share in IGA’s goal of better serving the needs of Singapore’s ageing population?A collaborative relationship can be nurtured with our GP Partners by identifying and referring appropriate patients who can participate in the activities of the Institute, either as research subjects in clinical research, or providing valuable

A collaborative relationship can be nurtured with our GP Partners by identifying and referring appropriate patients who can participate in the activities of the Institute, either as research subjects in clinical research, or providing valuable feedback in patient-experience research that will impact designs, policies and care delivery models.

feedback in patient-experience research that will impact designs, policies and care delivery models.

We encourage our GP Partners to participate in piloting of shared care models with our clinical teams, and collaborate in education and training programmes such as CME activities. What are some of the initiatives that TTSH has embarked on for our geriatric patients?We are in the process of constructing a new outpatient geriatric clinic that is specially designed to provide a safer, more

comfortable and homely environment for older persons seeking consultation. In this new multi-disciplinary clinic, we aim to create an environment that optimises the function and confidence of patients while mitigating effects from ageing-related functional impairment.

Over the past year, the Department of Geriatric Medicine have re-structured the inpatient care teams to introduce new multi-disciplinary programmes for better elderly management and more targeted care.

On a personal note, why did you choose to specialise in geriatric care?I have always found Geriatric Medicine a complex and fascinating, yet practical medical discipline. It combines some of the most challenging aspects of medical and social care, dealing with issues such as illness experience, family dynamics, and the ethical, legal, financial and psychological aspects of care. I have also always enjoyed talking to seniors since my childhood, listening to their interesting stories and biographical accounts.

Geriatric evaluation, Management and sub-acute care (GeMs)

Patients are identified and channelled systematically to receive timely treatment and rehabilitation from a dedicated multi-disciplinary geriatrician-led team in an environment optimised for frail hospitalised older persons.

acute care of the elderly (ace) Targeted at patients with acute medical complaints with an emphasis on minimising functional decline and early discharge planning. An innovative addition to this model is the provision of a unique Geriatric Nurse Coordinator (GNC) in the ACE wards. The GNCs serve as a key channel for communications of medical issues, discharge preparation and follow-up medical care between the ward team, patient and caregivers. This has resulted in a more efficient discharge process, reduced communication errors and more satisfying patient experience.

Geriatric comprehensive assessment and rehabilitation for the elderly (Gericare)

An assessment team, anchored by a Geriatrician and a Geriatrics Nurse Clinician, is tasked to evaluate and identify specific rehabilitation needs and geriatrics care issues in medical patients, thereby allowing for better planning for their subsequent care.

Geriatric Monitoring Unit Specialising in the care of the elderly patient with delirium, this care unit aims at using non-pharmacological methods and bright light therapy to manage difficult behaviours of the confused elderly with minimal resort to physical restraint.

TTSH Geriatric Inpatient Care Units

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AGEING AND ARTHRITISArthritis is a painful disease that can affect any age, but usually occurs late in life. Understand more about the symptoms and effective treatment options for better outcomes and quality of life.

WHAT IS ARTHRITIS?

Arthritis is the result of wear and tear of the joint cartilage. The common cause is normal wear and tear with ageing. Arthritis can also be accelerated in the following situations:

1. Intra-articular injuries sustained in road traffic accidents, sports and injuries.

2. Inflammatory Diseases. For example, Rheumatoid Arthritis, Systemic lupus erythematosus (SLE) and other Autoimmune Diseases.

3. Joint Infections.4. Excessive joint loading from overuse in sports, heavy

manual work and obesity.

The most commonly affected weight joint for arthritis is the knee followed by the hip. The shoulder and elbow are affected in trauma and throwing sports as well as in inflammatory diseases.

SYMPTOMS OF ARTHRITIS

1. PainInitially, pain occurs at the end of the day and after prolonged walking and weight bearing. As the arthritis and wear of the articular cartilage progresses, the pain becomes more intense and occurs with shorter periods of weight bearing.

2. StiffnessEarly morning stiffness is a common presentation and patients find difficulty getting out of bed or out of a chair, squatting and climbing stairs after prolonged sitting due to loss of cartilage and joint lubrication.

3. DeformityThe commonest deformity in arthritis of the knees is bowed legs (genu varum) deformity. In rheumatoid arthritis, the deformity is usually a knock-knee (genu valgum) deformity, or a wind-swept deformity where one knee is in varus and the other knee in valgus deformity.

DIAGNOSIS

A careful examination of a patient’s medical history to elucidate the type of arthritis is important prior to giving treatment. Inflammatory arthritis can be distinguished from primary osteoarthritis with a history of fever, rashes, multiple symmetrical joints involvement and systemic symptoms. History of accidents and sports injuries accounts for arthritis in the younger patients. Excessive wear and tear is seen in patients who are extremely overweight or who participate in extreme sports.

A physical examination will reveal the degree of deformity, loss of motion and leg-length discrepancy. Assessment of neurovascular status of the limb is essential in pre-operative planning. X-rays of the joint in question with long-leg films are also needed.

In early cases of arthritis where there is severe pain but little radiographic evidence of arthritis, MRI imaging will be helpful to diagnose early osteonecrosis as well as to evaluate for degenerative meniscal tears which can occur with minimal trauma in the elderly.

TREATMENT OPTIONS 1. Joint Replacement SurgeryJoint replacement surgery has been very successful in treating severe arthritis of the hip, knee, shoulder, elbow and ankle joints. The survivorship of modern hip and knee replacements is 90% over 15 to 20 years. New methods to improve the longevity of the knee replacement surgery include computer-aided navigation surgery and use of patient-specific jigs during surgery to improve the leg alignment. Robotic surgery has also been

The most commonly affected weight joint for arthritis is the knee followed by the hip. The shoulder and elbow are affected in trauma and throwing sports as well as in inflammatory diseases.

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potent analgesic and anti-inflammatory effects but have side-effects on the heart, kidney and stomach. Glucosamine with or without Chondrotin has been prescribed with varying results.

5. Intra-articular ViscosupplementationHyaluronic acid injection is useful in early to moderate arthritis and can give pain relief for up to a year in 70% of patients. It acts as a joint lubricant and nutrition for the cartilage.

6. Weight-loss and Lifestyle Changes The role of weight-loss and lifestyle changes to treat arthritis have not often been emphasised in the consultation room. A person with arthritis should be advised to lose weight, avoid running on the roads or participating in cross-country runs and change to low-impact exercises such as cycling, swimming and walking. An elliptical cross trainer can also be used in the gym as opposed to running on the treadmill. Avoid using the stairs and squatting. Elevators and escalators should be used where possible.

In conclusion, advances and improvement in the treatment of osteoarthritis has enabled the arthritic patient to lead a healthy and active lifestyle.

fEATuRE fEATuRE

Dr Lai Choon HinDr Lai Choon Hin is a Senior Consultant in the Orthopaedic Sugery Department of Tan Tock Seng Hospital. Dr Lai was awarded the prestigious Public Service Commission Merit Scholarship to study Medicine in National University of Singapore and graduated in the top of class in 1979. He was awarded the Health Manpower Development Plan fellowship to the Mayo Clinic, USA to train in adult reconstruction and joint replacement surgery, tumor surgery, biomechanics and bone physiology from 1988 to 1989. His current interests include all forms of reconstruction surgery for the hip, knee, elbow and surgery, and treatment of sports injuries especially in the middle age and older sportsmen.

vITaMIN SUPPLEMENTaTION FOr THE OLdEr PErSONThere has been an increase in the number of nutritional supplements available in the market. It is also not uncommon for older patients to request for a prescription to improve their ‘well-being’ during a doctor consultation. Learn more about the vitamins that are important to the older person.

introduced to improve the precision and accuracy of the bone cuts in both hip and knee replacement surgeries.

Newer materials like trabecular metal for improved bone ingrowth of prosthetic components have been developed. These are used together with highly cross-linked polyethylene and ceramic bearings to prolong the longevity of the implanted joints.

2. Arthroscopic SurgeryArthroscopic surgery has been extensively employed for treatment of early and moderate arthritis to remove degenerate meniscal tears and loose bodies. In younger patients with small chondral lesion of less than 3cm2 in size, chondroplasty with microfracture and cartilage implantation has produced good clinical results with pain relief and reconstitution of the cartilage. Arthroscopic ligament reconstruction and meniscal repair restore the normal biokinetics of the injured knee to prevent the development and progress of arthritis.

In the hip, arthroscopic surgery repairs labral tears and remove bone deformities of the femoral neck which caused hip impingement leading to arthritis.

3. OsteotomiesOsteotomies have a role in early hip and knee arthritis where there is significant hip dysplasia or knee deformity. For a patient with varus deformity of the knee, the tibia can be osteotomised to correct the alignment of the leg. As in joint replacement surgery, this can be rendered more accurately with computer-aided navigation.

Acetabular dysplasia can be corrected with periacetabular osteotomy to correct the uncovering of the femoral head with or without femoral osteotomy. Open acetabular labral repairs and treatment of the cam or pincer causes of hip impingement can successfully prevent the development and progression of arthritis in patients experiencing hip impingement.

4. MedicationParacetamol is the safest analgesia for arthritis with the least side-effects. NSAIDs and Cox2 inhibitors have more

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Nutritional status is important and has been found to influence

immunity and the pathogenesis of atherosclerosis. Benefits of vitamins also include improving cognitive and physical function, preventing falls and osteoporosis as well as improving mood and preventing depression.

It is without doubt the elderly patient is more susceptible to inadequate intake of nutrition. This is due to the changes that occur as one ages. The older adult tends to eat less and chooses less energy-loaded foods. Physiological changes related to ageing like slower gastric emptying, altered hormonal responses, decreased basal metabolic rate and altered taste and smell all contribute to decreased energy intake. This puts the older adult at an increased risk for inadequate nutrition. Moreover, other factors like chronic diseases, impaired digestion and absorption from the gastrointestinal tract and nutrient-drug interactions can further compromise their nutritional status.

Older adults have been found to have an inadequate intake of specific vitamins like vitamin A, B6, B12, D and folate. The intake of carotenoids and vitamin C also declines with age.

types of Vitamins

vitamin aOne common benefit of Vitamin A is its effect on eyesight. It can help prevent night blindness because vitamin A is needed for the rods within the retina to function properly. These retina rods enable us to see at night. It also prevents cataracts due to its antioxidant effects in the removal of free radicals that preclude clouding of the lens. Vitamin A is also useful in preserving eyesight by delaying the onset of age-related macular degeneration.

vitamin B (including folate)Evidence suggests that increased homocysteine, which is an amino acid in the blood, is a major risk factor for cardiovascular disease. The postulated effect is via its promotion of atherosclerosis by damage of the inner lining of the arteries and the promotion of the formation of blood clots.

Homocysteine levels in the blood are strongly influenced by diet and genetic factors. Vitamin B and folate have been found to help in the break down of homocysteine in the body.

There are currently no randomised controlled trials to prove the effects of these vitamins on cardiovascular risk, but it is recommended by the American Heart Association that high-risk patients ought to have adequate folic acid and Vitamins B6 and B12 in their diet.

The other effects of this group of vitamins include its ability to improve cognitive function and memory and information processing.

vitamin cThe most significant effect of Vitamin C is in maintaining immunity to prevent simple infections like the common cold. It also prevents skin ageing and has been used commonly in patients with sacral sores.

vitamin dStudies have found that blood levels containing above 30ug/L of Vitamin D can delay bone loss and prevent osteoporosis thus reducing falls as well as fractures.

This is due to its action on the absorption and metabolism of calcium and phosphorous as well as their effects on the muscular receptors, decreasing body sway and improving proximal muscle strength.

Vitamin D has also been found to be an immune system regulator, reducing the risk of developing multiple sclerosis as well as rheumatoid arthritis. High levels of vitamin D have also been found to decrease the risk of colorectal and breast cancers.

There has also been interest in the relationship between vitamin D and frailty. If the replacement of vitamin D can help in the transition between the different frailty states, it may be prudent for the doctor to actively check and supplement the patient accordingly especially since the older Singapore adult has less propensity to consume sufficient dairy or fish products, or spend adequate time under the sun to have it being produced by the skin.

Physiological changes related to ageing like slower gastric emptying, altered hormonal responses, decreased basal metabolic rate and altered taste and smell all contribute to decreased energy intake. This puts the older adult at an increased risk for inadequate nutrition.

vitamin EVitamin E contains strong antioxidants that modulate cardiovascular, respiratory as well as cerebrovascular health.

There are six other major dietary carotenoids (alpha- carotene, beta-carotene, beta-cryptoxanthin, lutein, zeaxanthin and lycopene) which form an important component of the antioxidant defense system in human beings. They are a good indicator of intake of fruits and vegetables. Low levels of these are associated with poor grip, hip and knee muscle strength.

dangers of Excessive SupplementationWe must also be aware of the hazards of excessive supplementation.

A meta-analysis of Vitamin E showed that supplementation in large amounts is associated with increased mortality. Other harmful effects of excessive supplementation include diarrhoea, renal impairment, increased risk of fractures and neurotoxicity. However, the doses of supplementation required to bring about side effects need to be very high. Other considerations include the potential for drug interactions, for example Vitamin E and warfarin.

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vITaMIN ESSENTIaLSVitamin prevention

(with evidence)prevention(without evidence)

effects of excessive intake

A • Dry Eyes• Retinitis Pigmentosa

• Respiratory Infections• Gastrointestinal Cancers• Arthritis

• Constipation• Headache• Hair Loss

B • Pyridoxine Deficiency• Pernicious Anaemia

• Stroke Recurrence• Osteoporosis

• Neurotoxicity

C • Common Cold • Dementia• Cancers• Pressure Ulcers

• Diarrhoea• Constipation

D • Osteomalacia• Falls• Osteoporosis

• Cancers• Fractures• Muscle Strength

• Kidney Failure

E • Age-related Macular Degeneration

• Cognitive Health• Cardiovascular Health

• Scarring• Stroke

• Prostate Cancer• Death

manaGinG thE SwEEt SPotElderly patients with diabetes have unique medical concerns and require diabetes management goals to be tailored specifically to their needs. Doctors and other healthcare workers should be familiar with the challenges in caring for these elderly patients to ensure efficacious and safe treatment.

EldErly diaBEtES PatiEnt landSCaPE in SinGaPorEMost developed world countries use the chronological age of 65 years as a definition of ‘elderly’ or older person. It is known that the risk of having diabetes mellitus increases with age. According to the National Health Survey 2010, the prevalence of diabetes among those aged 60 to 69 years is 29.1% compared to the population average of 11.3%. In addition, the overall prevalence of diabetes in Singapore will increase due to the ageing of our population.

Type 2 diabetes remains a leading cause of premature deaths and ill-health in Singapore. This is because poorly-controlled diabetes increases the risk of cardiovascular disorders, blindness, end-stage renal failure, lower limb amputations and hospitalisations. It is also associated with increased risk of cancer, psychiatric illness such as depression, cognitive decline, chronic liver disease, accelerated arthritis and other disabling conditions. However, with effective management of diabetes, these complications can be prevented.

References:1 Vitamin status in elderly people in relation to the use of nutritional supplements. The Journal of Nutrition, Health and Aging 2012 16 (3): 206- 212.

2 The effect of undernutrition in the development of frailty in older persons. Journal of Gerontology: Medical Sciences 2006 Vol 61a (6): 585- 588.

3 Low serum micronutrient concentrations predict frailty among older women living in the community. Journal of Gerontology: Medical Sciences 2006 Vol 61a (6): 594- 599.

4 The effect of multi-vitamin supplementation on mood and stress in healthy older men. Human Psychopharmocology Clin Exp 2011; 26: 560-567.

5 Association of low vitamin D levels with the frailty syndrome in men and women. Journal of Gerontology: Medical Sciences 2009 Vol 64a (1): 69-75.

6 Mayo Clinic health information: http://www.mayoclinic.com/health.

Dr Joanne KuaDr Joanne Kua is an Associate Consultant with the Department of Geriatric Medicine in Tan Tock Seng Hospital. Her specialty interests are in falls and healthy active ageing.

ConclusionIdeally, older adults should obtain these essential vitamins from their diet. It is also imperative to note that vitamin supplementation is not a substitute for healthy lifestyle, but only when the older adults are unable to have their nutrition through normal oral diet that supplementation may be beneficial.

There are many supplements in the market for the older adult. It is important to know the dosages of the respective vitamins in the preparation and also who will benefit from them so that these vitamins can be of help to the older adult.

18 19

fEATuREfEATuRE

inCrEaSEd riSkThe elderly are at high-risk for the development of type 2 diabetes due to the combined effects of increasing insulin resistance and impaired pancreatic islet function with ageing. Age-related insulin resistance appears to be primarily associated with increase in body fat, decrease in muscle mass and physical inactivity, which may partially explain the observed effectiveness of the intensive lifestyle intervention in older participants in studies of diabetes prevention.

ChallEnGES oF CarE Patients with diabetes are a heterogeneous group with varying health status and different co-morbidities. This presents unique challenges in determining generalised therapeutic aims and choice of pharmaceutical treatment for elderly diabetes patients.

Furthermore, despite the higher prevalence of diabetes amongst the elderly, older patients have often been excluded from randomised controlled trials of treatment and measure of outcomes. Therefore, there is less evidence from trials to determine standard intervention strategies best suited for this large elderly group with diabetes. Patient-centred approach is therefore the most appropriate management strategy for elderly patients, taking into consideration the presence of the following factors:

1. Duration and complexity of diabetes2. Possible visual, hearing impairment and cognitive

dysfunction 3. Co-morbidities such as renal impairment4. Established vascular complications such as ischaemic

heart disease and stroke5. Risk for hypoglycaemia and its complications. For

example: falls and fractures, precipitating ischemic cardiac events

6. Risk of adverse events from polypharmacy7. Social support and economic resources 8. Life expectancy

It follows that standard HbA1c targets of 6.5% to 7.0% might be considered in healthy patients (with shorter disease duration, longer life expectancy and no significant cardiovascular disease) if this can be achieved through simple interventions without significant hypoglycaemia or other adverse effects of treatment. However, a less ambitious HbA1c of 7.5% to

8.0% may be acceptable in the frail elderly, transitioning upward as age, co-morbidities and the risk for hypoglycaemia increases, while the ability for self-care and social supports declines. Hyperglycaemia which causes acute symptoms and risks of complications such as acute metabolic derangement should be avoided in all patients.

intErVEntionS and trEatmEnt

TARGETED MEDICATIONDoctors should consider the selection of medications with a strong benefit-to-risk ratio which are efficacious and safe for the elderly. Long-acting anti-hyperglycaemic agents which increase the risk of hypoglycaemia such as glibenclamide should be avoided. The dose of other medications may need to be reduced in the elderly as renal function decreases with age.

Less complex treatment regimes containing anti-hyperglycaemic medications with lower risk for hypoglycaemia may be preferred in the elderly. The presence of hypoglycaemia should be assessed at every doctor’s visit through a comprehensive review of symptoms and home capillary blood glucose monitoring records.

Intervention to decrease long-term cardiovascular complications may include lipid lowering, blood pressure control and anti-platelet treatments. The benefits and risks of using these medications in the elderly are best discussed with the individual’s physician.

TEAM-BASED DISEASE MANAGEMENTThe unique needs of elderly patients with complex diabetes are best met and managed within a multi-disciplinary diabetes team approach.

Due to visual, functional or cognitive dysfunction, elderly diabetes can have issues with diabetes self-management and monitoring of glycaemic control. Diabetes nurse clinicians are able to spend time with patients and their caregivers to reinforce important information. Through strategies such as provision of handouts and sequenced visits, crucial information such as the recognition and rescue from severe hypoglycaemia can be imparted. Special techniques to cope with insulin administration and blood glucose

monitoring for the visually impaired are also handled by the nurse clinicians.

Elderly patients with diabetes often require a lower caloric intake and meeting micronutrient requirements while eating less can be a challenge. These nutrition issues can be handled by dieticians, who can in turn involve the caregivers who prepare the patients’ meals.

Clinical pharmacists assist in the review of medications to ensure that the age-specific aspects of medication use are considered especially in the elderly with polypharmacy. Unwanted side effects as a result of reduced renal elimination or combination use of certain medications should be avoided.

Importantly, as part of lifestyle intervention, the healthy and able-bodied elderly are encouraged to keep physically active.

References:1. National Health Survey 2010, Singapore.

2. Amati F, Dubé JJ, Coen PM, Stefanovic- Racic M, Toledo FG, Goodpaster BH. Physical inactivity and obesity underlie the insulin resistance of aging. Diabetes Care 2009;32:1547–1549.

3. Knowler WC, Barrett-Connor E, Fowler SE, et al.; Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393–403.

4. Reers C, Erbel S, Esposito I, et al. Impaired islet turnover in human donor pancreata with aging. Eur J Endocrinol 2009;160:185–191.

5. Ismail-Beigi F, Moghissi E, Tiktin M, Hirsch IB, Inzucchi SE, Genuth S. Individualizing glycemic targets in type 2 diabetes mellitus: implications of recent clinical trials. Ann Intern Med 2011;154: 554–559.

6. M. Sue Kirkman, et al. Diabetes in Older Adults. Diabetes Care Publish Ahead of Print, published online: care.diabetesjournals.org. October 25, 2012.

7. Silvio E. Inzucchi, et al. Management of Hyperglycemia in Type2 Diabetes: A Patient-Centered Approach Diabetes Care Publish Ahead of Print, published online: care.diabetesjournals.org. April 19, 2012.

Dr Daniel ChewDr Daniel Chew is the Head and Consultant of the Endocrinology Department at Tan Tock Seng Hospital. He graduated from the National University of Singapore in 1998 and did his fellowship at the Oxford Centre of Diabetes, Endocrinology & Metabolism in 2008. He has an interest in diabetes mellitus, especially in the prevention of hypoglycemia which is associated with cardiac mortality. Dr Chew is highly involved in initiatives which strive to improve diabetes management and medication safety concerning insulin and oral hypoglycaemic agents.

The unique needs of elderly patients with complex diabetes are best met and managed within a multi-disciplinary diabetes team approach.

20 21

fEATuREfEATuRE

UNdEr-NUTrITION IN THE ELdErLY

– caN IT BE PrEvENTEd?

The elderly is highly susceptible to under-nutrition due to the various changes associated with ageing. as there are adverse health consequences from under-nutrition, it should be prevented through early detection with routine nutritional risk screening. appropriate

nutrition interventions can be initiated to prevent and manage under-nutrition in the elderly.

With an ageing population, we need to be increasingly aware of the associated

health and social concerns, one of which being the higher risk of under-nutrition in the elderly. Should under-nutrition be an inevitable consequence of ageing or can it be prevented?

Why Should We Be concerned? Under-nutrition is more prevalent amongst the elderly and those in institutionalised care, with a prevalence of up to 70% reported in developed countries. The potential health consequences of under-nutrition in the elderly include increased risks of deaths, infections, falls, prolonged and frequent hospitalisations, loss of independence and decreased quality of life. Despite these adverse health outcomes, under-nutrition often remains under-diagnosed and under-recognised.

Is It a Problem In Singapore?In Singapore, the reported prevalence of under-nutrition is at an alarming rate of 30% to 52%, from the community to acute hospitals to long-term care settings. Local studies have similarly shown that the under-nourished elderly had increased risk of deaths and prolonged hospital stay. These findings are a cause for concern and there is a need to create more awareness about this problem.

What can We do To Prevent It?1) Know and Manage Risk Factors It is important to first appreciate the risk factors for poor nutrition in the elderly, who tend to be more susceptible. Table 1 lists some of the risks factors. Early interventions and strategies can be initiated to address these risk factors through a multi-disciplinary approach, especially when they are identified early in the community.

2) Implement Nutrition Screening Nutrition screening is an easy and effective approach for early detection of under-nutrition throughout the care continuum. It is recommended to use a validated nutrition screening tool to systematically detect under-nutrition. This is then followed up with appropriate action plans to address the identified nutritional

concerns. A more comprehensive nutrition assessment by a dietitian can be considered for those identified as at risk.

Unintentional weight loss is a key warning sign for under-nutrition. Weight loss of more than 5% to 10% within six months is considered clinically significant in the elderly. It is recommended that the elderly monitor their weight regularly, at least at monthly intervals, either independently or at every visit to the doctor.

Individuals who are at risk should monitor their weight weekly. Any recent changes in weight and food intake should also be highlighted for further evaluation by a doctor, to detect any potential underlying medical condition and should be followed-on with a nutritional assessment by a dietitian.

physiological psychological and social

• Early satiety • Reduced ability to prepare food

• Reduced taste sensitivity • Limited access to nutritious food

• Reduced smell perception • Loneliness

• Reduced chewing and swallowing ability

• Depression

• Poor dentition or ill-fitting dentures • Financial constraints

• Reduced ability to digest food • Poor nutrition knowledge

• Medication side effects

• Polypharmacy

table 1 - Common risk Factors for Elderly Under-nutrition

22 23

fEATuREfEATuRE

3) Maintain Optimal Nutrition Intake Maintaining optimal nutritional health is essential in preventing the onset of under-nutrition in the high-risk elderly. It is more difficult to reverse under-nutrition than to prevent it. A good nutrition reserves in the elderly can prevent or delay the onset of under-nutrition during periods of increased demands such as acute illnesses. Emphasis on both the quality and quantity of food intake is crucial to maintain a healthy nutrition reserves in the elderly. As overall intake may be insufficient for the elderly, a good diet quality is essential to ensure adequate nutrients intake. Consuming a variety of food from the different food groups is fundamental to ensure nutritional adequacy in the elderly.

4) Medical Nutrition TherapyMedical nutrition therapy prescribed by a dietitian should constitute as one of the important treatment approaches for at risk or under-nourished elderly. This should be implemented concurrently with the management of other medical conditions.

The nutritional advice provided should be customised to individuals depending on their unique requirements upon consultation with a dietitian. For those who are at risk of under-nutrition, some common nutrition interventions listed in Table 2 can be considered. Regular follow-up is necessary to ensure the compliance. Close monitoring of the individuals’ intake and weight during reviews will allow adjustment of the nutrition therapy.

• Encourage smaller and more frequent meals and snacks.

• Include food rich in energy and protein such as fish, meat, milk, nuts, legumes, cheese or yoghurt, in each meal or snack.

• Liberalise any prior dietary restrictions when appropriate.

• Fortify foods to increase protein and energy intake. Examples include adding sesame oil, egg or tofu to porridge, spreading peanut butter or cream cheese to plain biscuits or bread.

• Provide food in texture compatible with chewing and swallowing ability.

• Include nourishing beverages and fluids between meals such as milk, malted or cereal drinks.

• Use high energy and protein nutritional supplements such as nutritionally complete supplement drinks.

table 2 - Common nutrition interventions For Elderly at risk of Under-nutrition References:

1. Dietitians Association of Australia. Evidence-based practice guidelines for the nutritional management of malnutrition in adult patients across the continuum of care. Nutrition & Dietetics 2009; 66(3 Suppl):S1–4.

2. Flanagan D, Fisher T, Murray M, et al. Managing undernutrition in the elderly–prevention is better than cure. Australian Family Physician 2012; 41(9): 695-699.

3. Yap KB, Niti M, Ng TP. Nutrition Screening among Community-Dwelling Older Adults in Singapore. Singapore Med J 2007; 48(10):911-6.

4. Lim YP, Lim WS, Tan TL, and Daniels L. Prevalence, risk factors and outcomes of malnutrition in hospitalized older adults (Abstract). Annals of the Academy of Medicine Singapore 2008; 37(Supp):11,S1.

5. Chan M, Lim YP, Ernest A, and Tan TL. Nutritional assessment in an Asian nursing home and its association with mortality. The Journal of Nutrition, Health & Aging 2010; 14:1, 23-28.

Dr Lim Yen PengDr Lim Yen Peng is the Head and Principal Dietitian of the Nutrition and Dietetics Department at Tan Tock Seng Hospital. Dr Lim received her Bachelor of Science (Honours) in Nutrition and Dietetics from King’s College London (UK), and Masters in Health Science (Gerontology) from University of Sydney. Dr Lim’s specialisation is in nutrition in the elderly and she completed her PhD on elderly malnutrition.

conclusionAlthough a common problem in the elderly, under-nutrition is clearly preventable if close attention is paid to the risk factors and early warning signs. This should also be coupled with strategies to promote optimal nutrition intake.

Hearing impairment comes in a spectrum, from the very mild to complete deafness. Prevalence of hearing impairment increases with age. Left untreated, hearing impairment can lead to disability and handicap.

There are various causes of hearing impairment, with presbyacusis (age-related hearing loss) and excessive noise exposure being the commonest

ones. Other contributory factors include genetic conditions like otosclerosis, Meneire’s and recurrent ear infections.

In Singapore, half of 80-year-olds will have experienced significant hearing loss. As most hearing impairment develops slowly, many patients and their families choose to ignore or deny the problem. The perceived cost and stigma of wearing hearing aids add to the problem. Seeking late treatment is also common.

Beyond a certain point, hearing impairment can reduce normal human activity and function within society.

the soUnd of silence: hearinG LOSS in the elderly

24 25

fEATuREfEATuRE

Get checKed

If one suspects a hearing impairment, this can easily be checked by arranging a hearing test. This test is provided by ENT (Ear, Nose and Throat) and Audiology departments in hospitals and also private providers in the community. Community screening programs would be another option.

A joint ENT and audiology hospital review is highly advantageous in providing a holistic approach to the management of hearing impairment, especially where there are co-existing ear problems.

A historical medical examination will be performed followed by a hearing test. Patients will be counselled appropriately should a significant hearing impairment be diagnosed. Following this, a session to trial the use of hearing aids would usually be recommended. Family members will also be educated on how communication can be enhanced, such as maintaining good eye contact during a conversation.

preVention and treatMent options

Lifestyle and Well-beingWhilst hearing loss is not entirely preventable, we can delay its onset by looking after our ears. There is a need to be mindful of excessive loud noise exposure.

Excessive loud noise is not entirely avoidable if one works in shipbuilding and certain manufacturing industries, but turning down the volume of portable music devices will help. Ear infections also need to be managed promptly.

Acoustic Hearing AidsConventional acoustic hearing aids come in many shapes, sizes and designs. Hearing aids that sit completely in the ear canals are available for those who are conscious of their appearance.

Surgical ImplantsA Bone Anchored Hearing Aid (BAHA) is useful for anyone who is unable to wear a conventional hearing aid due to recurrent infections or problems with the ear canal. The BAHA is also useful for someone who has lost all hearing in one ear only, with good hearing in the remaining ear.

Middle ear Implants can be considered for certain types of hearing loss. For someone who has completely lost all hearing in both ears, a Cochlear Implant would enable the patient to hear again. There are also implants that would allow the hearing portion of the brain to be directly stimulated, bypassing the ear and its nerve supply completely.

iMportance of early treatMent

Hearing NormalitySound deprivation, where the ears and brain of a hearing impaired person ‘forgets how to hear’ from lack of sound stimulation can occur. The longer this is left untreated, the harder it would be for the person to get used to ‘amplified’ hearing in the future.

In a person who can hear normally, he is able to distinguish useful sounds from background noise such as the humming of an air conditioner. The brain is able to ‘shut off’ the background noise and focus on the useful sounds like speech. A person with a prolonged period of deafness prior to amplification may not be able to do that effectively and will complain of the hearing aids picking up a lot of unwanted sounds.

Successful Hearing Aid UseAdditionally, many people will experience some cognitive decline as they age. Take the example of two individuals, X and Y, who are of the same age and experience the same rate of hearing and cognitive decline. Person X starts using a hearing aid from the moment significant hearing loss is experienced. Person Y, however, ignores hearing loss and only decides to

Dr Ho Eu ChinDr Ho Eu Chin is a Consultant at the Department of Otorhinolaryngology at Tan Tock Seng Hospital with a clinical and research interest in ear disease, hearing and balance problems. Dr Ho runs a variety of specialist clinics that address various aspects of ear conditions and these include the Combined Hearing Clinic, Multi-Disciplinary Balance Clinic and Joint Occupational Deafness Clinic. His research focus is on strategies to address the disability and handicap of hearing impairment.

start wearing a hearing aid twenty years later when hearing is almost gone. Assuming that Persons X and Y have the same hearing impairment with the same rate of hearing and cognitive decline, Person X is far likelier to be a successful hearing aid user, even at 20 years down the line.

Tinnitus TreatmentMany patients with hearing impairment also suffer from tinnitus. Hearing aid usage can significantly reduce the level of unwanted sound being heard.

conclUsionWhilst age-related hearing impairment is still largely unpreventable, the technology and expertise currently available means that we should be able to keep the majority of patients in the hearing world.

A joint ENT and audiology hospital review is highly advantageous in providing a holistic approach to the management of hearing impairment, especially where there are co-existing ear problems.

26 27

In April 2011, 73-year-old medical doctor Santoso Tanuseputra woke up at 3 o’clock in the morning and realised that he had lost all his hearing in his left ear. At the same time, he experienced severe vertigo which resulted in balance dysequilibrium. The day after the onset of his sudden hearing loss, Dr Santoso sought the opinion of a neurotologist who prescribed medication and started him on Hyperbaric Oxygen Therapy and Intra-tympanic steroid injections into his left ear.

With his condition not improving, Dr Santoso sought further opinions from an ENT surgeon and a neurologist and was diagnosed with either a vestibular-cochlear neuronitis or a vestibular-cochlear vascular infarct. On their advice, he underwent Rapid Magnetic Stimulation and Sonolysis.

Despite all these treatments, his left hearing loss did not recover and appeared to be complete and permanent. It was Emilia, Dr Santoso’s daughter, who decided to get another opinion and arranged an appointment with Dr Yeo Seng Beng, Head and Senior Consultant from the Department of Otorhinolaryngology at Tan Tock Seng Hospital (TTSH) in August 2011.

A MRI scan of Dr Santoso’s internal auditory meatus excluded lesions like a vestibular schwannoma. There was also no clinical evidence of any vestibular weakness. After careful assessment, the option of using a Bone Anchored Hearing Aid (BAHA) in Dr Santoso’s left ear was recommended by Dr Yeo. The BAHA implant will help route sound from his left side directly to the working right cochlear, via bone conduction. This device has also been proven to reduce the ‘head shadow’ effect that patients who have lost all hearing in one ear experience. In March 2012, Dr Santoso trialled the BAHA using a headband and subsequently underwent surgery by Dr Yeo in June 2012. The procedure went well and took less than 45 minutes. He recovered quickly and returned to TTSH two months later to fit the external sound processor.

Now, Dr Santoso is able to hear well in his left ear with the BAHA and is extremely delighted with the sound quality of the device that has enabled him to continue serving his own patients well. He has also been able to return to his favourite hobby of fishing, a common passion which he shares with Dr Yeo.

HEAR TODAY, GONE TOMORROW

a Patient’s Journey

fEATuRE

in

of 80-year-olds suffer from

hearing impairment

50%

tOp 3 leading causes Of deaths

in singapOre

Sources:

1. National Health Survellience Survey 2007.

2. Ministry of Health, Singapore,

www.moh.gov.sg.

30%30%cancercancer

16.4%heart disease

16% pneumonia

of elderly have

visual impairment

50-80%

ageing singapOre

percentage Of singapOreans Between the age Of 60-69 suffering frOm:

38.8%48%

13.8%19.8%

17.3%

high BlOOd chOlesterOl

high BlOOd pressure

pOOr mental health

arthritis

diaBetes

of Singaporeans in their 50’s are at risk of

OsteOpOrOsis

45%

28 29

maintaining good mobility is essential for an elderly to enjoy an active life, both physically and psychologically. Poor mobility can lead to falls, which can result in complications and diminish the quality of life.

importance of Good mobilityMaintaining good mobility allows the elderly to be independent and actively involved in day-to-day activities like cooking, showering and gardening. A mobile older person will also be able to enjoy a good social life by having the physiological freedom to travel from their house to other destinations, such as the market or to visit their friends and relatives.

risks of diminished mobilityPoor mobility can affect the elderly both physically and psychologically. Diminished mobility may be characterised as having lower limb muscle weakness, poor balance and a slower reaction time. This may lead to an increased risk of falls. A minor fall may cause minor contusions but a bad fall may cause severe injuries such as fractures.

Fractures commonly suffered by the elderly occur in the hip or spine. Being immobile will reduce the ability of the elderly to take part in

social events and interact with others. The fear of another fall may lead the elderly or their careers to limit their mobility which may lead to social isolation, increasing their vulnerability to loneliness and depression.

targeted ExercisesThe lower limb consists of large muscle groups such as the gluteus muscle (buttocks), quadriceps (thighs), calf muscles and hamstrings (back of thighs). These muscle groups are responsible to help us to stand up, sit down, walk around, negotiate stairs, stand, squat and in other movements.

Performing exercises that target these important muscle groups can increase muscle strength and flexibility, balance and good reaction time in the elderly.

Points to note Please consult your doctor or physiotherapist before starting on the exercises in the next few pages, if you have any back or joint problems, injuries or other health concerns.

Maintaining Mobility

fiTnESSfiTnESS

30 31

fiTnESSfiTnESS

3.

multi-directional SteppingPlace yourself in an upright standing position near to a wall but do not hold for support. Stand on your right or left leg, and point at targets with your other leg. Perform three sets of 10 steps.

muscle Strengthening and Balance Exercises

Calf StretchIn an upright standing position, face a wall. Stand two steps away from the wall.

Step forward with one leg and place both heels firmly on the floor. Place your hands against the wall. Keep your back leg straight and with your heels on the floor, lean toward the wall until you can feel a stretch on your calf. Hold for 10 seconds. Perform three sets of 10 repetitions.

1.

2.

Sit to StandSit upright on a stable chair at knee height. Ensure both feet are well-supported on the floor. Stand up with your trunk leaning slightly forward. In standing position, sit down slowly. Perform three sets of 10 repetitions.

1

2

21 2

1

3

4

34

32 33

hEALThY REciPE

4. tandem walking Place yourself in an upright standing position near to a wall but do not hold for support. Walk forward and backwards in a straight line by placing one leg in front of the other. Perform five sets of 10 metres.

Mr Kelvin Loh Mr Kelvin Loh is the Senior Physiotherapist in the Physiotherapy Department of Tan Tock Seng Hospital. He completed his Bachelor Degree at University of Malaysia in 2008. Mr Loh works closely with geriatric patients with mobility problems. He has a special interest in musculoskeletal and fall prevention in geriatrics.

fiTnESS

2

1Recipe was designed by the Hospitality & General Services.Nutritional information provided by the Nutrition & Dietetics Department of Tan Tock Seng Hospital.Photo Courtesy of Mr Henry Lim, Photographer, Tan Tock Seng Hospital.

nutritional informationCalories (kcal) 487Carbohydrate (g) 48Protein (g) 22Total fat (g) 12

Saturated fat (g) 1.6Cholesterol (mg) 0Dietary fibre (g) 4.7Sodium (mg) 451

methodsTofu Sushi1. Blend one egg without yolk with tofu. Season with salt and pepper and steam in a

deep pan for 15 minutes. Allow contents to cool and slice in half.

2. Stuff with vegetables, roll and steam for 10 minutes.

3. Garnish with carrot shavings and serve with the sauce, vegetables and brown rice for a complete meal.

Sushi Sauce1. Dilute corn starch in 20ml of water.

2. Mix the corn starch with light and dark soya sauce and 60 ml of water.

Vegetables1. Heat up the pan and lightly coat the pan with oil, then add in the vegetables and

sauté with salt, pepper and garlic.

Brown Rice1. Steam the brown rice with 300ml of water for 10 minutes.

ingredients [1 serving portion]

Tofu SushiTofu 150gmEgg Without Yolk 1Celery 2gmZucchini 2gmRed Bell Pepper 2gmCarrot 5 gmSalt 1 pinchWhite Pepper 1 pinch

Sushi SauceLight Soya Sauce ½ tspDark Soya Sauce 5 dropsCorn Starch ½ tspWater 80ml

Rice Brown Rice ¾ cup

VegetablesKailan 20gmBrown Beech Mushrooms 20gmCherry Tomato 15gmVegetable Oil ½ tspSalt 1 pinchWhite Pepper 1 pinchGarlic 1 pinch

tofu sushi with Brown rice

34 35

CliniC B1B– Orthopaedic Surgery

• Hand Procedure Suite

– Rheumatology, Allergy and Immunology

• Intravenous Infusion Day Facility

– Diagnostic Imaging Services• X-ray

CliniC 2B– Gastroenterology and Hepatology

Our sub-specialties include: • General Gastroenterology • Hepatology (Liver) Service • Inflammatory Bowel Disease • Gastrointestinal Endoscopy • Pancreato-Biliary Diseases • Upper Gastrointestinal Motility • Nutrition

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• Liver, Pancreas and Biliary Services • Vascular Service • Veins Service • Thoracic Service • Plastics, Reconstructive and Aesthetics Services

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– Diagnostic Imaging Services• X-ray

CliniC 4B

– Diabetes and Endocrine – General Medicine – Haematology – Infectious Disease – Pain Management – Psychological Medicine – Renal Medicine – Respiratory and Critical Care Medicine

Multi-DisCiplinary

speCialist Care

TTSH PEARL’s suite of clinics and services is guided

by the four pillars of care through Evidence Care, Destination Care, Team Care and Personalised

Care. We remain committed to delivering a higher level of patient

care as we value our patients most.

CliniC B1BOrthopaedic Surgery Tel: (65) 6889 4055 Email: ClinicB1B@ttsh.com.sg

Rheumatology, Allergy and Immunology Tel: (65) 6889 4027 Email: ClinicB1B@ttsh.com.sg

CliniC 2B Tel: (65) 1800-PEARL-00 Email: Clinic2B@ttsh.com.sg

(65) 1800-73275-00

CliniC 4B Tel: (65) 1800-PEARL-00 Email: Clinic4B@ttsh.com.sg (65) 1800-73275-00