Chapter 9

This chapter does not seek to answer all your medical questions and is not written by doctors, but it will provide you with an overview of the main physical and mental problems which affect us all as we age and provide information on where to seek further help.

The important regular check-ups everyone should have

If your relative takes the time to undergo some basic routine health check-ups regularly, it is so much easier to spot problems in the early stages and get treatment sooner rather than later.

Eye tests

An eye test checks vision, but just as importantly, it can detect signs of a number of other conditions, such as diabetes, often before your relative has any symptoms. An optometrist examines your relative’s eyes for any evidence of abnormality, injury or disease and will ask them to read letters from a chart. They will also test eye pressure by directing a puff of air at the eye to calculate the pressure inside and check for glaucoma. After the test, the optician will tell your relative if they need any sight correction and if so, they will usually help them with that at the time. If there are any signs of further eye complications, the optician will refer them to their GP, or to an eye specialist. Over the age of 60, your relative is entitled to a free NHS sight test every two years and, if aged 70+, they may be entitled to a free test annually.

Hearing tests

Hearing tests are crucial, as many people suffer from deficient hearing as they age and this can lead not only to difficulties following conversations, but also to isolation and dementia. Following a conversation about any hearing difficulties, an audiologist will examine your relative’s ears with a light called an auriscope, which is a small torch with a magnifying glass, which allows them to see into the eardrum. They will check for any discharge coming from the ear and check the eardrum for bulging eardrum, which means there is infected fluid in the middle ear; for dull eardrum, which means there is uninfected fluid in the middle ear (this is known as glue ear); for retracted eardrum, which means the Eustachian tube is not working properly; for perforated eardrum, which means there is a hole in the eardrum, which may or may not be infected, or for foreign bodies which might be blocking the ear, including ear wax. The Eustachian tube is a narrow passage leading from the pharynx to the cavity of the middle ear, permitting the equalisation of pressure on each side of the eardrum.

The audiologist may then carry out simple tests using their voice to determine the extent of any hearing loss. These might include pure tone audiometry (PTA), where a machine (audiometer) produces sounds at different volumes and frequencies (pitches). Your relative listens through headphones and responds when they hear them by pressing a button. There is also a speech perception test, which tests the ability to hear words without using visual stimulus. Words are played through headphones, or spoken by the tester. Tympanometry tests can confirm whether there is any fluid behind the eardrum and if the Eustachian tube is working normally. A small plastic bung seals the ear and the machine changes the ear canal pressure. The whispered voice test involves the tester blocking one of the ears and testing your relative’s hearing by whispering words at varying volumes. Your relative will be asked to repeat the words as they hear them. The tuning fork test measures different aspects of hearing. The tester taps the tuning fork on their elbow or knee to make it vibrate and then places it in different areas around your relative’s head. It can determine if your relative has conductive hearing loss, caused by sounds passing freely into the inner ear, or sensory-neural hearing loss, where the inner ear is not working properly. The bone conduction test involves placing a vibrating probe against the mastoid bone behind the ear and measuring how well your relative hears sounds transmitted through the bone. It is a more sophisticated version of the tuning fork test and can check if hearing loss is emanating from the outer and middle ear, the inner ear, or both.

The type of hearing loss your relative has is important, because it determines what help or treatment is most suitable. The audiologist will then recommend hearing aids, or refer them to a specialist. Your relative should get their hearing checked annually and tests are usually free. However, if you need financial help with the cost of hearing aids, you must contact your local authority, or the NHS.

Dental checks

It is very important to have regular dental check-ups. Not only can teeth have decay, but gums can as well. Infection in the gums can lead to infection in the bloodstream, which can cause other, more serious problems, and if gums erode, it is much harder to fix than actual teeth. If any work is necessary, the dentist will explain the next steps. The dentist will also take a medical history, including the use of anti-psychotic drugs, anti-epileptics, antidepressants, beta-blockers, and diuretics, which can all cause a reduced saliva production. Poor saliva production makes it much harder for denture wearers and there is a higher risk of tooth decay and gum disease in people with dry mouth, due to the lack of cleansing effect from the saliva.

Older people are more vulnerable to tooth decay, sometimes because of a preference for sweeter foods, or taking less care with their oral hygiene and inability or reticence to access dental treatment. The dentist will check heavily filled teeth, or teeth under crowns and bridges. They may look sound, but the nerves in these teeth may die off and then the dead nerve tissue can become infected and toothache can follow. The dentist will also look for broken teeth, which can leave sharp ends and result in tongue ulceration.

Checking for gum disease is critical, as it causes bone loss, tooth loosening, or even tooth loss and requires treatment. Ninety per cent of gum diseases can be prevented by effective oral hygiene, so regular tooth brushing is essential and using an electric toothbrush is preferable. It also helps to floss regularly and to have check-ups with the hygienist. The dentist will also look for any lumps, white lines and patches. Your relative should get their teeth checked every six months. They may be eligible for free dental treatment, but you have to contact your local NHS dentist to discuss eligibility

Bowel cancer screening

Bowel cancer screening can detect potential problems, even when people have no symptoms. The testing kit, called a fecal occult blood test (FOBT), is posted to your relative and they then collect stool samples on a special card, which are sent to a laboratory for analysis. Bowel cancer is the third most common cancer in the UK. Eight out of 10 people who get cancer of the bowel are over the age of 60. Screening is offered every two years to all men and women aged between 60 and 70. The test looks for blood in the stool and if there is any, your relative will be asked to repeat the test. Their GP may then recommend a bowel examination (colonoscopy) to rule out cancer. About 2 per cent of people will have an abnormal result and will need follow-up tests.

Cervical screening

Cervical screening aims to detect cervical abnormalities. Cervical cancer is the 11th most common cancer in women. Early detection and treatment prevents up to 75 per cent of cancers developing. A doctor or nurse inserts an instrument known as a speculum to open the vagina and uses a spatula to sweep the cervix to take a sample. It is a slightly uncomfortable procedure. Women aged between 25 and 64 are eligible for a free cervical screening test every three to five years. Results should come back within six weeks. An abnormal result requires further investigation and treatment.

Prostate test

While there is no national screening programme for prostate cancer, it is worth getting a check done – which is just a simple blood test – through your relative’s GP, as it can prove a lifesaver. Symptoms may include needing to go to the toilet more often and difficulty passing urine, as well as blood in the urine or semen. Be aware that many men suffer from some of these symptoms from having an enlarged prostate gland, which is actually a benign condition. Making sure that it is benign rather than cancerous can provide peace of mind, as well as helping to prevent a serious condition from worsening. It is worth getting a regular prostate test over the age of 50 anyway, as early detection has a very high cure rate. It is a simple blood test and not invasive at all.

Cholesterol test

Cholesterol is a type of fat that is carried by the blood around the body. High levels of cholesterol can clog the arteries and increase your relative’s risk of a heart attack or stroke. High cholesterol does not cause any symptoms, so the only way to find out is to take the test. Cholesterol is measured with a simple blood test by the GP and should be checked annually. If your relative has high cholesterol, they can make some simple changes to their diet and exercise regime. Their doctor will help them and may refer them to a dietician. The GP may recommend statins in certain cases, which are a group of medicines that can help lower the level of low-density lipoprotein (LDL) cholesterol in the blood. This is often referred to as ‘bad cholesterol’. Statins reduce the production of it inside the liver. There can be side effects from taking statins, so ensure that you discuss these with the doctor.

Blood pressure tests

High blood pressure can weaken the heart and damage arteries, increasing the risk of heart disease, stroke and kidney disease. In the UK, about 50 per cent of people over 65 have high blood pressure, but many do not realise it. The GP will place a cuff around the upper arm and inflate it until it becomes tight. The test is quick and painless. A blood pressure reading below 130/80mmHg is normal. The first/top number refers to the amount of pressure in your arteries during the contraction of your heart muscle. This is called systolic pressure. The second/bottom number refers to your blood pressure when your heart muscle is between beats. This is called diastolic pressure. If results are abnormal, your relative will need to have their blood pressure checked regularly. If it is consistently high, they may need to make lifestyle changes, including eating more healthily and taking exercise, and possibly have to take medication. Get them to get it checked annually. It is free at their GP’s surgery.

Breast screening

Breast screening (known as a mammogram) detects breast cancer early. A third of breast cancers are now diagnosed through screening. Each breast is placed alternately on the X-ray machine and is compressed with a clear plate. It only lasts a few seconds, but it can be slightly uncomfortable. The result will be sent to your relative within a fortnight. If the result is abnormal, they will be asked to go for further tests, such as an ultrasound or needle test. Women are invited for a mammogram between their 50th and 53rd birthdays and then every three years until they reach the age of 70. After the age of 70, they can request a mammogram every three years.

Skin checks

Keeping an eye on moles can help your relative to spot the early signs of skin cancer. Most moles are harmless, but they can develop into skin cancer (known as malignant melanoma). Deaths from melanoma have tripled in the last 30 years for people over 65. Skin cancer is linked to sun exposure over a lifetime, so older people are more likely to develop the disease. If your relative notices a strange mole, ask their GP to look at it. If the GP is concerned, they will refer them to a specialist for further testing. Your relative should look out for a change in colour, size or shape of existing moles and check moles regularly themselves, or ask someone else to do so if they are on their back. They can take a photograph and then compare it with a more recent photograph to help see if anything has changed.

Overview of medical conditions affecting older people

Arthritis

The term arthritis literally means ‘joint inflammation’, but it is generally used to refer to more than 100 different conditions, which affect the joints and may also affect the muscles and other tissues. Osteoarthritis is the most common form of arthritis, which happens due to the breakdown of the tissue inside the joints. Rheumatoid arthritis is an autoimmune disease. This is when your immune system, which usually fights infection, attacks the cells that line your joints, making them swollen, stiff and painful. Despite the prevalence of the disease, the causes are not completely understood.

There is no cure for arthritis and many different factors may play a role. Incidences of osteoarthritis increase with age due to simple ‘wear and tear’ on the joints – the older you are, the more you have used your joints. However, it is not an inevitable part of getting older, because not everyone suffers from it. Increased body weight adds stress to lower body joints and is a well-established factor in the development of osteoarthritis. The knees carry the brunt of someone’s body weight and are particularly at risk.

Top tip: Keep your weight down. Did you know that every extra pound a person gains adds four pounds of pressure on the knees and six times the pressure on the hips? Gaining weight increases the likelihood of developing osteoarthritis and therefore the likelihood of needing hip and knee replacements, so it helps to keep any excess weight off.

Athletes and people whose jobs require repetitive motion (such as landscaping, typing or operating machinery) have a higher risk of developing osteoarthritis, due to injury and increased repetitive stress on certain joints. Soft tissue injuries can also lead to osteoarthritis, which can also appear in joints affected by previous bone fractures and surgeries.

Genetics play a role in the development and progression of osteoarthritis, particularly in the hands. Inherited bone abnormalities affect joint shape or stability, or defects that cause cartilage to form abnormally. It is also more common in joints that do not fit together smoothly, such as those of people who are bow-legged or double-jointed, but having these traits does not necessarily mean osteoarthritis will develop. Studies show that weakness of the muscles surrounding the knee is associated with osteoarthritis, especially in women, and makes the pain and stiffness worse after onset. Strengthening exercises for thigh muscles are important in reducing the risk.

One of the main symptoms of osteoarthritis is its effect on the cartilage of a person’s joints. Cartilage acts as a cushion or hinge in between the joints. When everything is working well, the cartilage protects the bones of the joint from rubbing together. In someone with osteoarthritis, the cartilage around the affected joints begins to wear away. This, in turn, causes the bones in the joint to begin to rub directly against one another, which can be incredibly painful. It is also common for this to result in small bone fragments breaking away, which can cause infection and disability. In the body, any joint can fall victim to the effects of osteoarthritis, but it is most often found in the hips and knees, which are weight-bearing. It can also be found in smaller joints, such as the hand. In most cases, only one joint in a pair will be affected by this disease; for example, in someone with knee osteoarthritis, if the right knee were infected, the left knee would typically not be affected. This is referred to as an asymmetrical arthritis. Sufferers will generally have pain, swelling or stiffness in one or more joints, or in the back or neck or after heavy activity, such as gardening or housework, after long walks, or when getting up in the morning.

Rheumatoid arthritis is classified as an autoimmune disorder, which means that it causes the body’s own immune system to attack itself. The immune system is used to fight infection, but in someone with rheumatoid arthritis, the body thinks that the joint is actually an infection. As a result, the cells in the body begin to attack and break down the joint, causing rheumatoid arthritis. The exact trigger of this autoimmune disorder is not known. Rheumatoid arthritis shares a number of similarities with osteoarthritis, but it is considered to be symmetrical arthritis, i.e. usually joints are affected uniformly. Sufferers experience stiffness, throbbing and aching pain, which is often worse in the mornings and while resting, rather than after activity. As the lining of the affected joint becomes inflamed, it can cause the joints to swell and become hot and tender to touch. The condition can also cause inflammation of the tear glands, salivary glands, the lining of your heart and lungs, and your blood vessels.

There is no cure for arthritis, but there are many ways to make life more comfortable and to keep mobile and independent:

• Try to keep weight down to avoid unnecessary wear on the joints

• Keep a good balance of adequate rest with sensible exercise (such as walking, cycling and swimming), but stop any exercise or activity that increases the pain

• Arthritis responds better to warm conditions, so a hot water bottle, warm bath, electric blanket or microwave-heated wrap can soothe the pain and stiffness

• Try to avoid getting too cold

• Physiotherapy and osteopathy can be helpful in improving muscle tone, reducing stiffness and maintaining mobility

• Shoe inserts (orthotics), good footwear and a walking stick can help painful knees, hips and feet

• Aspirin, ibuprofen and paracetamol can all be effective painkillers, but the doctor may prescribe special anti-arthritic medication if required, or may refer your relative to a pain specialist to consider cortisone injections

• There is a wide range of inexpensive equipment and tools that can help with cooking, cleaning and other household chores. These can be discussed with the doctor, physiotherapist, or occupational therapist.

Surgery can be considered to relieve severe pain for most joints. The new techniques and artificial joints are improving all the time. Replacement of a worn-out hip joint with an artificial hip made of a combination of metal, or plastic, is a very common operation and can be done as keyhole surgery in most cases. More than 90 per cent of these are successful. Modern knee replacements are also giving excellent results, and if your relative has crippling knee pain, this operation can bring great relief.

You can find more helpful information at Arthritis Care (www.arthritiscare.org.uk).

Bladder

The bladder and bowels are two important organs. They are at the end of the digestion process and work to filter out what the body does not need or want. Looking after these organs is essential, because in doing so, your relative can avoid urinary and fecal incontinence. The smallest of lifestyle changes and choices can have a positive, immediate impact on the bladder and bowel.

People who have issues with a weak bladder, or occasional urge incontinence, will often assume that, to control it, they need to control their fluid intake. Unfortunately, this can make incontinence worse, especially if your relative has an overactive bladder or urge incontinence. The bladder, when dehydrated, will become more irritated and the condition will appear worse. As counterintuitive as it sounds, encourage your relative to drink plenty of water, slowly increasing their intake to about two litres a day. Glugging a pint of cold water is not the best way to solve incontinence either. Most health professionals recommend spreading drinks throughout the day, but to try to have most fluid intake by 6 p.m. to help manage nocturnal toilet visits.

Caffeine and alcohol are stimulants on the bladder and can contribute to inflammation and further irritation. Both also have a diuretic effect on the body, so when your relative drinks these, they need the toilet more often. Carbonated drinks can also make them urinate more and caffeine is not just found in ordinary tea and coffee, so check food labels carefully. Many people find that by drastically reducing or cutting out caffeine altogether, their overactive bladder is much more manageable. Sadly for many, avoiding chocolate bars and hot chocolate drinks can also be helpful in controlling the symptoms of an irritated bladder.

Fruit juices are acidic and although we may think of them as healthy, they can be a major cause of an irritated bladder. Encourage your relative to keep fruits and juices to a minimum. Hot or highly spiced foods can also be a major cause of bladder irritation, because they stimulate the body, so ask your relative to consider cutting out, or decreasing their intake of spiced foods, including chilli peppers and salted fish and meats, as well as instant soups, noodles and some stock cubes and gravies. Some diet or low-fat products contain artificial sweeteners called aspartame and saccharin, two known bladder irritants, so sugar-free drinks or low-fat yogurt may also cause a few bladder issues.

You can find more information at Bladder & Bowel Community (www.bladderandbowel.org).

Bowel

Bowel cancer can affect any part of the colon, rectum or anus, which are the three main parts of the large bowel. It usually starts as slow-growing polyps or ulcers attached to the inside of the bowel wall. These can gradually start to change and become abnormal over time. Untreated, these polyps and ulcers can gradually increase in size, becoming cancerous. There are many common conditions that can affect the health of our bowels. Many symptoms are similar to those of bowel cancer, so it is important to get your relative checked out by their doctor. The doctor will examine them and take a careful history to make sure that whatever is causing the problem is investigated properly and treated promptly. Your relative should not be embarrassed, or put off, as it is so important to get any possible problems checked out.

Bowel cancer claims a life every half an hour and it affects men and women almost equally.

The good news is that bowel cancer can be successfully treated in over 90 per cent of cases, if it is diagnosed at an early stage, before it has had a chance to grow and spread. Regular bowel cancer screening has been shown to be very effective in detecting early changes in the bowel. Bowel cancer screening aims to detect signs of bowel cancer at an early stage before obvious symptoms occur. It is available to eligible people every two years and everyone eligible is urged to take it up when offered. Screening kits are sent through the post automatically, to the address registered with the GP. In England and Northern Ireland, screening is offered to people between the ages of 60 and 69, although in England, this is gradually being extended to include people aged between 70 and 74. In Scotland, people are currently offered screening from ages 50 to 74, and in Wales, they are offered screening from ages 60 to 74.

If your relative is over the eligible age for automatic screening, they can still request to be sent a screening kit by calling the bowel cancer screening helpline free on 0800 707 60 60. The existing screening programme is a simple FOBT (fecal occult blood test), which detects blood hidden in the small samples of poo. The test is completed at home over the course of a few days and then returned by post to a central laboratory for testing. It involves handling faeces, so although the test is simple, some people may be a bit squeamish. The test does not diagnose bowel cancer, but can find blood in the poo. A positive test will trigger an invitation to retake the test. If this is also positive, the patient will have further investigations (a colonoscopy, where a camera is inserted into the bowel) to find out what is causing the bleeding.

We all experience problems with our bottoms and bowels from time to time. Usually there is nothing to worry about. However, if your relative notices certain symptoms for more than three weeks, then they must see their GP. The early symptoms for bowel cancer can include blood in faeces, or loose stools for three weeks or more, although these are very similar to other, much less serious problems with the bowel. It is very important to be aware of what is normal, so they can recognise any unusual changes and act quickly to get them investigated. Chances are that it is nothing to worry about, but these symptoms could be signs of bowel cancer, so get your relative to tell their doctor. Finding bowel cancer early makes it more treatable and could save their life. Your relative must see their doctor if they have rectal bleeding without any obvious reason, especially if it is unusual and does not respond to prescribed treatment for more common problems, such as haemorrhoids. A persistent change in bowel habit, especially if they are going to the toilet more often, or experiencing unexplained looser stools, should also be checked. Symptoms may also include unexpected constipation and a feeling of fullness in the rectum for three or more weeks. Constant, unexplained pain anywhere in the abdomen, especially if it is severe, is also of concern. It may also be linked to going to the toilet, or it might come and go, like cramps or colic. Check out any unexpected lump in the stomach, especially if it is on the right-hand side, unexpected weight loss, perhaps due to lost appetite, or feeling bloated or sick or unexplained tiredness, which is a symptom of anaemia. Most people with these symptoms do not have bowel cancer, but the GP will want to examine your relative and may do further tests to rule it out. While the exact causes of bowel cancer are unknown, there are certain things that can be done to reduce the risk of developing it – for example, getting more exercise, eating a better diet or reducing alcohol intake, or stopping smoking.

Symptoms could be caused by other common conditions that can easily be treated and managed. Piles or haemorrhoids are soft swellings just inside the anus, often accompanied by other symptoms, such as pain and itching. They can cause bright red bleeding from the bottom and you might be able to feel them with a finger, especially after going to the toilet. Anal fissures, which are tears in the skin around the opening of the anus, are often caused by constipation. Irritable bowel syndrome (IBS) is a collection of symptoms, such as stomach cramps or pain, diarrhoea and/or constipation and a change in bowel habits caused by inflammation and infection in the lining of the bowel. People with IBS do not have higher risk of developing bowel cancer, or any other serious bowel condition. Crohn’s disease, diverticular disease and ulcerative colitis are other common inflammatory bowel diseases with symptoms that include abdominal pain, tiredness, weight loss, sores, bloating, bleeding and mucus. These diseases can also put you more at risk of developing bowel cancer and the GP should monitor this regularly.

You can find more information at Bowel Cancer UK (www.bowelcanceruk.org.uk).

Dental problems

Older people are more vulnerable to tooth decay, possibly due to a preference for sweeter foods, less care with their oral hygiene, weakening enamel and inability or reticence to access dental treatment. Tooth decay is largely preventable by reducing the quantity and frequency that sugar is consumed. If you eat five times a day and brush with fluoride toothpaste at least twice a day, it is hard to develop tooth decay. Remember, even fresh fruit eaten in excessive amounts causes tooth decay. Food grazing throughout the day is especially bad, as it means that there is sugar and acid against the teeth all day. Rinsing with water will help to dilute any sugar or acid (in the case of fruit) and then the application of fluoride toothpaste as a tooth ‘ointment’ can prevent further tooth decay.

Heavily filled teeth, or teeth under crowns and bridges, may look sound, but the nerves in these teeth may die off. Once this happens, the dead nerve tissue may become infected and toothache can follow. The ideal treatment would be root canal treatment, or possibly extraction. If it is not possible to get to a dentist, a combination of painkillers (ideally, ibuprofen) and antibiotics can be used if prescribed by a doctor. Antibiotics normally take a minimum of 24 hours to work, so it is important to control any pain with painkillers. Always read the instructions and try to take them regularly and especially before bed, when pain can be particularly severe.

Decayed teeth, worn teeth and old fillings do break, often leaving sharp ends that the tongue plays with. This can result in tongue ulceration, which can be very sore. Ideally, your relative should ask the dentist to smooth off the sharp piece as soon as possible or they might need a filling replacing or removing. Gingivitis (bleeding gums) is present in almost all mouths and is not especially significant, but should be checked out if it persists. Gum disease can cause bone loss, tooth loosening, or even tooth loss. A dental check-up is the opportunity to assess the level of gum disease. Ninety per cent of gum diseases can be prevented by effective oral hygiene, which should include cleaning in between the teeth with small brushes or dental floss. There is no evidence to suggest that mouth rinses make a significant difference, but an electric toothbrush can be more effective than a manual brush. Food impaction can cause sore gums. Small brushes or flossing will prevent this.

It is not uncommon to see a range of lumps, white lines and patches in the mouth. Ulcers are common, but, if they have not healed within two weeks and there is no obvious cause (sharp tooth or filling), the ulcer should be investigated by a dentist. Any lump or patch in the mouth should be investigated if it bleeds or changes in size, appearance or ulcerates. Mouth cancers account for over 2 per cent of all cancers and their incidence is increasing. Smokers are at increased risk and if the person has a history of smoking and heavy drinking, the risk of oral cancer increases by 16 times.

Old age itself can eventually lead to a reduction in saliva gland function, but anti-psychotic drugs, anti-epileptics, anti-depressants, beta-blockers, and diuretics can all cause a reduced saliva production. Poor saliva production makes it much harder for denture wearers and there is a higher risk of tooth decay and gum disease in people with dry mouth, due to the lack of cleansing effect from the saliva. Using sugar-free gum and regular sips of cold water can help and there are saliva substitute sprays available. Increased toothpaste use is important to prevent tooth decay. Diabetics are more vulnerable to gum infections. People with dementia must be individually assessed for dental problems. Most dental treatments are done without anaesthetic or with a local anaesthetic, but some conditions may require a general anaesthetic and this may only be available in a hospital.

Prevention is the easiest cure. Regular dental check-ups, liberal use of fluoride toothpastes and effective oral hygiene twice a day should be encouraged.

Dentures

Dentures are removable false teeth, which replace original teeth, if they have become sufficiently damaged. They are made from either metal or acrylic. While the aim is always to keep your own teeth, some people, even those who have looked after their teeth, may need dentures at some point as they age. Obviously, if your relative does lose teeth, it can affect their ability to eat, speak properly and may affect their self-confidence too. Dentures can also enable them to continue to eat well, speak properly and feel that they have the self-confidence to face the world. Depending on your relative’s dental problems, they may need either complete or partial dentures. Their dentist will advise on the best solution.

Dentures are made by the dentist, who will take an impression from your relative’s mouth. This is done by placing a tray with dental putty inside, which is pushed around the teeth and gums and takes an impression of the mouth and its specific shape. Those impressions are then sent to a dental technician to be custom-made. The dentist will match the shape and colour of the dentures as far as possible to your relative’s natural teeth. If some of their own natural teeth are still in good condition, they may only need partial dentures. These are usually a metal or plastic plate, to which a number of false teeth are attached. This plate is then either fastened by means of a metal clasp to your relative’s natural teeth, which can be removed, or alternatively, the dentist may place crowns over some of the natural teeth to anchor the partial denture.

There are several types of complete dentures. There are complete immediate dentures (also called full dentures), required if all your relative’s teeth need to be removed. Usually these dentures can be used immediately after the extraction of any remaining natural teeth, so that your relative does not have to manage without any teeth at all. Complete immediate dentures fit over the gums and jawbone. However, gums and bone may shrink, especially during the first six months after teeth extraction as part of the gums’ natural healing process. If this happens, your relative may have to have their dentures adjusted to ensure they still fit well. Complete conventional dentures are required if the gums need to heal before your relative can wear dentures. While they may have to manage without teeth for a few months, when they finally get dentures, they should fit well and not require further adjustment, as the gums will have already shrunk.

An implant is a good option if your relative has suffered too much bone loss for conventional dentures, or is unsuited to them. Between four to six implants are placed within each arch of the mouth, which contain special fittings, to which the dentures will attach. This requires the creation of a hole through the gum into the jawbone, where the dentist will insert an artificial titanium root. These titanium roots require between two to six months to fuse with the bone, after which time the dentures can be attached. Implants help to preserve the amount of remaining jawbone, which is crucial for supporting the dentures. Your relative might be advised to wear their new dentures all the time until they get used to them and after that, they will normally take them out when they go to bed, depending on the type of dentures they have. Implanted dentures are not removable. It is worth noting that dental implants help to preserve the amount of jawbone which forms the foundation to support the denture.

For NHS dental patients in England, dentures cost £256.50, coming under Band C of dental charges. Prices are subject to change, so do check on the NHS website. If you have dentures fitted privately, partial dentures will cost anything from £500 and complete dentures upwards of £2,500. The cost of implanted dentures depends very much on how much work your relative needs, but they can expect to pay anything from £3,000 upwards. Ask their dentist for a written quote before proceeding.

Your relative should clean their dentures just as they would clean their natural teeth – often and well. If they are removable dentures, it is best to brush them with toothpaste and/or soap and water to remove food and dental fixative before soaking them in denture cleaning solution. They should try not to drop them, as they can crack and break. If they take their dentures out at night, they should put them in water so they do not warp. If they have dental implants, they can clean them just as they would clean their natural teeth. Well cared-for dentures may last years, but they will need to be checked regularly. They may also need to be relined from time to time, which is a method of adjusting the internal part of the base of the dentures with an acrylic resin to correct their fit. If your relative’s dentures feel as if they are fitting badly, ask their dentist to check them immediately, as badly fitting dentures can give severe discomfort and may lead to mouth sores and infections. Eventually, their dentures will probably have to be made again due to changes in their mouth and gum shape over time. Some people who have been wearing full dentures over long periods can find it difficult to have well-fitted dentures made.

When someone starts to wear dentures, it can be a good idea to begin eating soft food, but once they have got used to them, they should be able to eat as they did before. While your relative is getting familiar with their dentures, they may want to use a fixative to help keep them in place. This may also be the case if the gums have shrunk. However, tight-fitting dentures should not require any adhesive to keep them in place.

Dental anxiety

Dental anxiety – a fear of dentists – is very common. It affects one in every six adults in the UK alone. If your relative is afraid of the dentist, then it is much better to find a sympathetic one. In particular, you want to find a dentist who will work with your relative to help them to become less anxious and one who is prepared to take treatments and check-ups slowly to give them as much time as possible to prepare mentally and put them at ease as much as possible. Many dentists will offer an initial meeting without any invasive procedures. This is a great way to get to know them and see if they will be a good fit for your relative. Before you choose a practice, read some reviews online to check how the dental practitioners are reviewed. In order to overcome dental anxiety, your relative needs to be able to share their problems with their dentist and others. Sharing dental anxiety with the dentist is essential, but sharing with friends and family is also a great way to get some additional support and help.

Top tip: Controlled breathing is a very useful technique which helps to relax the body and gives your relative something to focus on during dental treatment. Simply breathe in through the nose for an internal count of three, and then exhale for a count of three. Repeat this and focus the attention on maintaining a steady, rhythmic breathing pattern. This helps reduce stress and distracts the patient from their mouth.

Dental prevention is better than cure

If you want to make the dentist as pain-free and relaxed as possible for your relative, then they need to keep their oral hygiene levels very high. You want to make sure that they are brushing at least twice a day (preferably three times) and flossing regularly. This will help to destroy plaque and keep gums healthy, which are just as critical as the teeth. If you can encourage your relative to perfect their oral hygiene routine and spend time every day working on their teeth, they will be able to avoid 90 per cent of all the most common oral problems. In addition, it helps to cut down on sugary food and they could try chewing gum to reduce plaque and keep the mouth as healthy as possible.

Diabetes

Diabetes is a condition where the amount of glucose in the blood is too high, because the body cannot use it properly. This is because the pancreas does not produce any insulin – or not enough – to help glucose enter the body’s cells, or the insulin that is produced does not work properly (known as insulin resistance). Insulin is the hormone produced by the pancreas that allows glucose to enter the body’s cells, where it is used as vital fuel for energy, so we can work, play and generally live our lives. Glucose comes from digesting carbohydrate and is also produced by the liver. Carbohydrate comes from many different kinds of food and drink, including starchy foods, such as bread, potatoes and chapattis, fruit, some dairy products, sugar and other sweet foods. If your relative has diabetes, their body cannot make proper use of this glucose, so it builds up in the blood and is not able to be used as fuel.

There are two types of diabetes – type 1 and type 2.

Type 1 diabetes develops when the body’s immune system attacks and destroys the cells that produce insulin. As a result, the body is unable to produce insulin and this leads to increased blood glucose levels, which in turn can cause serious damage to all organ systems in the body. Nobody knows for certain why these insulin-producing cells have been destroyed, but the most likely cause is the body having an abnormal reaction to the cells. This may be triggered by a virus, or other infection. Type 1 diabetes can develop at any age, but usually appears either before the age of 40, or especially in childhood. Type 1 diabetes accounts for between 5 and 15 per cent of all people with diabetes and is treated by daily insulin injections, a healthy diet and regular physical activity.

Type 2 diabetes develops when the body does not produce enough insulin to maintain a normal blood glucose level, or when the body is unable to use the insulin that is being produced effectively. Type 2 diabetes usually appears in people over the age of 40, although it can appear earlier in Southern Asian and black people, who are at greater risk. It is also becoming increasingly more common in children, adolescents and young people of all ethnicities. It can also be caused by being overweight. Type 2 diabetes accounts for 85 to 95 per cent of all people with diabetes and is treated with a healthy diet and increased physical activity. In addition to this, medication and/or insulin are often required. Type 2 is reversible if the correct diet and exercise regimes are implemented and maintained.

Diabetes is a common condition that can have a significant impact on the health and wellbeing of older people. The medication that is required to control the condition may be more likely to cause side effects, because of changes in the circulation and kidneys as people get older. Becoming diabetic in later life can complicate existing health problems, such as arthritis, heart trouble and memory problems and may be catastrophic for a vulnerable older person.

It is not always easy for your relative to eat well when they have diabetes, but one of the most important rules is to eat regularly, so do not let them skip meals and remind them that breakfast is the most important meal of the day. So, after a night of fasting, make sure they start the day off with a healthy breakfast in order to get their metabolism firing. As far as possible, try to encourage your relative to space meals evenly throughout the day. If there is a possibility that they may miss a meal, such as going on a long journey, or having a day out, remind them to take a small meal with them as back-up, such as a salad or a sandwich.

They must also remain hydrated, ideally by drinking 8 to 10 glasses of fluid per day. Water is by far the best refreshment for diabetics, but milk, tea and coffee, and herbal teas work, as do citrus fruits, such as oranges, although citrus fruit may be too acidic for some older people. It is important for us all to carry a small bottle of water during warmer weather, but this is particularly important for diabetics. Sugary drinks should be avoided as much as possible, but do not necessarily have to be cut out altogether. Hot drinks should ideally be drunk without sugar, or with artificial sweeteners. Take advice from a dietician.

It is very easy to eat too much and many older people are of a generation that always makes sure they leave a clean plate no matter how much food is put on it. Portion size is a very important issue in supporting healthy eating for diabetics, as weight control is crucial.

The best ways to reduce over-eating include:

• Drinking plenty of water with meals to fill up and be less tempted to take second helpings

• Using smaller plates so it is difficult to put too much food on them

• Putting healthy vegetables on the plate first with a main meal to fill the plate up and leaving less room for the fattier stuff. It will fill you up more as well.

Fats are essential to a healthy diet and everybody needs them, but there are good and bad fats. Saturated fats are the ones which should be avoided by all of us, but especially by diabetics, and although many manufacturers have cut down on saturated fats in their foods, they are still found in many everyday foods, such as cakes, processed meats, butter and cheese, so check the ingredients when shopping for food. It is better to avoid ready-made meals and processed foods.

Carbohydrates are an important part of any diet. Healthier wholegrain starchy foods, fruits and vegetables, pulses and some dairy foods are all good sources of carbs. But all carbs affect blood glucose levels. As a diabetic, your relative will need to be particularly conscious of the amount they eat to control their blood sugar levels. If they need specific guidance on the type and amount of food they should be eating, speak to their GP or to a dietician.

Too much salt contributes to high blood pressure and this can cause complications for diabetics in particular, so should be avoided. As people age, their sense of taste diminishes and so they will often add more salt to their meals when cooking and at the table. Adults should not have more than one teaspoon (5g) of salt per day. Cooking from fresh ingredients will help keep salt levels low and reduce the risk of high blood pressure.

Top tip: Removing the salt cellar from the table can be a very simple way to help reduce salt intake, as is adding herbs and spices instead.

Encourage your relative to include fish in their diet as much as possible, as it is an excellent form of protein. It does not matter if it is fresh, frozen or canned – it is still good for you as long as there is no added salt. Fish fried in batter is best avoided, but if it is too tempting, your relative can always just pick out the fish inside and leave the batter. Oily fish, such as mackerel and salmon, is rich in Omega-3, protects the heart and helps with brain power, as well as being a good food for diabetics, so stocking up your relative’s larder with cans of oily fish is a good idea – they are easy to serve, soft to eat and very healthy.

Eating five portions of fruit or vegetables a day is really crucial for a good diet in order to get the range of vitamins, minerals and fibre needed. For any older person, sometimes the best way to eat their five a day can be by drinking it. There are many types of machines available which can liquidise fruit and vegetables into tasty drinks for an older person and these can even be made into batches and frozen. Just be careful about how much salt and sugar is contained in the fruits. Choosing seasonal produce will help to keep down costs too.

Some sugar can be eaten by diabetics, but really only in moderation. It is best to consider something sugary as an occasional indulgent treat. Artificial sweeteners should be used when sweetening food and drink whenever possible. It is also very tempting to buy foods labelled as ‘diabetic’, but they really do not offer any real benefit to diabetics and indeed may do harm, as they may still affect blood glucose levels. They are often expensive and contain as much fat and calories as ordinary versions. Once again, fresh unprocessed items are always going to be healthier.

More information is available at Diabetes UK (www.diabetes.org.uk).

Eye problems

There are several eye problems that become more common among people as they get older, although they can potentially affect anyone at any age.

The cornea and eyelids

The cornea is the clear, dome-shaped window at the front of the eye. It helps to focus light that enters the eye. Disease, infection, injury, and exposure to toxic agents can damage the cornea causing pain, redness, watery eyes, reduced vision, or a halo effect. Treatments include making adjustments to the glasses prescriptions, using medicated eye drops, or having surgery.

The eyelids protect the eye, distribute tears, and limit the amount of light entering the eye. Pain, itching, and tearing are common symptoms of eyelid problems. Other problems may include drooping eyelids, blinking spasms, or inflamed outer edges of the eyelids near the eyelashes. Eyelid problems can often be treated with medication or surgery.

Presbyopia/long-sightedness

Long-sightedness is the loss of the ability to see close objects or small print without glasses clearly. It is a normal process that happens slowly over a lifetime. Presbyopia is often corrected with reading glasses or bifocals. Your relative can try ready-made reading glasses, which can be bought from most pharmacies or supermarkets. Start with a low-level lens, such as a +0.5, or +1, and increase it gradually if needed, or your relative should visit an optometrist for an eye test and bespoke glasses. Be careful with bifocals when you or a relative first wear them, as it takes a while for the brain to get used to them and they can cause dizziness and even falls.

Everyone over the age of 40 should have a two-yearly eye examination, even if they do not need glasses, just to check the health of the eyes. Most people find they cannot read without reading glasses once they have read with them, as their vision is much clearer and there is less strain on the eyes.

Floaters

Floaters are tiny spots or specks that float across the field of vision. Most people notice them in well-lit rooms, or outdoors on a bright day. Floaters are often normal, but they can sometimes indicate a more serious eye problem, such as retinal detachment, especially if they are accompanied by light flashes. If your relative notices a sudden change in the type, number of spots or flashes they see, they should visit the GP as soon as possible, who will refer them to an ophthalmologist.

Dry eyes

Dry eyes happen when tear glands cannot make enough tears, or produce poor-quality tears. Tear quantity and quality reduces with age and many people, particularly women, get dry eyes. Symptoms are gritty, itchy, red and burning eyes and the eyes may even water as the body tries to flush away the irritation with ‘reflex’ floods of tears as there is not enough continuous ‘background tear’ production. You can try lubricant drops or gels from the pharmacist, or have them prescribed by the GP. If neither helps, your GP or optician may suggest that your relative tries a humidifier at home, or uses humidifying aerosols. The GP might also suggest preservative-free drops, or drops with hyaluronic acid. Tear duct plugs or surgery may be needed in more serious cases of dry eyes, but results can be variable.

Too many tears

Having too many tears can come from being sensitive to light, wind, or temperature changes. Protecting the eyes by shielding them or wearing sunglasses can sometimes solve the problem. Tearing may also mean that your relative may have a more serious problem, such as an eye infection, or a blocked tear duct. They should see their GP or optician in the first instance, who can refer them for treatment for both of these conditions. The cause may be excess tear production, poor-quality tears (see above), or blepharitis, which is inflammation of the eyelid margins. If eyelid margins are crusty, sticky or red, blepharitis is usually the culprit. It can be improved by keeping the lashes clean by bathing them with dilute baby shampoo, or blepharitis solution and cotton wool balls daily. There are also eye wipes available, which should be used twice daily. Heated eye bags can also be very effective. It is also worth trying Carbomer gel four times a day for a month to see if reflex tearing is the problem. If this does not work, then see your optometrist or GP. If the eyelid is lax, or the tear duct blocked, referral to an ophthalmic surgeon for further expert advice and treatment may be appropriate.

Top tip: I struggled with blepharitis for years, which caused many painful corneal ulcers. I now use a hot microwaveable eye bag for 10 minutes each evening and bathe my eyes morning and night with Optrex eyewash and Blephaclean eye wipes. I use Viscotears gel at night. It’s a boring routine, but my eyes have never been better!

Conjunctivitis

Conjunctivitis is a condition in which the tissue that lines the eyelids and covers the eyeball becomes inflamed. Sometimes called pink eye, it can cause redness, itching, burning, tearing, or a feeling of something in the eye. Conjunctivitis occurs in people of all ages and may be caused by infection, exposure to chemicals and irritants, or allergies. This can be treated by buying chloramphenicol drops over the counter at the chemist. Once opened, they should be kept in the fridge and discarded after one month. Be careful about sharing towels with someone with conjunctivitis, as it is highly infectious.

Cataracts

Cataracts are cloudy areas that cover part of, or the entire lens, inside the eye. From middle age onwards, the lens gradually becomes cloudy and this is cataract formation, but the speed of this formation and how much it affects vision varies. Cataracts often form slowly, without pain, redness, or tearing in the eye. Some stay small and do not alter eyesight. In a healthy eye, the lens is clear like a camera lens and light has no problem passing through it to the back of the eye to the retina, where images are processed. When a cataract is present, the light cannot get through the lens as easily and, as a result, vision can be impaired. Symptoms include glare in bright sunlight and headlights, and blurred vision, particularly in the distance when reading road signs and recognising people from a distance. If they become large or thick, cataracts can usually be removed by surgery. If your relative develops symptoms, they should see their GP. If they are diagnosed with cataracts, it is probably reasonable to go for surgery. Cataract surgery and replacement of the lens with an implant is high-tech, but very safe these days. It is usually done under local anaesthetic, so age is not a barrier. HM the Queen has just had hers corrected at the age of 92 and carried on with a royal wedding and the races straight afterwards! Patients of 100 years old are commonly treated and more than 95 per cent of them will have an improvement in their vision with no complications. However, if your relative feels that they can see well even if they have some cataract, there is usually no need to consider an operation until they find there is more of a problem with their sight. The operation is the same whether the cataract is mild or more severe, so your relative can wait until they feel they need it.

Glaucoma

Glaucoma develops when there is too much fluid pressure inside the eye. Glaucoma affects one in 50 people over the age of 40 and this incidence increases with age, so it is relatively common. It is a disease of the optic nerve that causes insidious painless damage to sight. The eye pressure is usually, but not always, elevated. Holes in the vision at the side occur, but these are only noticed when the disease is very advanced. There is no treatment that will cure loss of vision, so it needs to be prevented. As most people are unaware that they suffer from glaucoma, everyone over 40 years should see an optometrist every two years for an eye examination, even if you do not need glasses. The optometrist will check the eye pressure with a puff of air, do a visual field test and look at the optic nerve. If any of these tests are abnormal, your relative may be recalled for a repeat test, or referred to an eye clinic. Treatment is usually prescription eye drops, but occasionally laser or surgery. Glaucoma treatment is usually needed for life. Note: glaucoma runs in families, so if your relatives or grand-relatives suffered from it, you are at greater risk.

AMD

Top tip: Anyone noticing sudden loss of vision in one eye should never ignore it. Phone the optometrist immediately and ask to be seen that day. If your relative cannot see an optometrist, they should get an emergency appointment with the GP, or go to A&E. They will need to be examined and then it can be decided how urgently they need to be seen by a specialist. If loss of vision is gradual, make an appointment to see an optometrist, not the GP, as they have the best training and equipment to assess you.

The NHS has further information on eye care for the over-60s. Visit www.nhs.uk/live-well/healthy-body/eye-health-tips-for-older-people.

Falls

Falls are common in older people and the risk of falling increases with age. A third of those aged 65 years and over, rising to over 40 per cent of those aged 80 years and above, fall each year, compared with 8 per cent in middle age. A fall may be the result of a simple trip due to an environmental hazard, such as poor footwear, wet and slippery floors, loose rugs or poor lighting, but often it is caused by additional factors affecting the person themselves.

Physiological changes associated with normal older people reduce balance, increase reflex times and thus, increase the risk of falling. Specifically, we rely on our vision, sensation from the feet and legs, the inner ear and processing of all these inputs by our brain. Even in healthy old age, all of these systems show physiological decline, putting us more at risk. Additionally, without regular exercise or training, we lose muscle strength and blood pressure control on changing position (e.g. standing up) becomes less effective, which may cause unsteadiness and dizziness. Chronic problems, such as osteoarthritis, eye disease and inner ear problems are also often present and increase the risk of falling. Acute problems, such as infection, heart rhythm disturbances and drug problems, can also cause a fall or loss of consciousness. Thus, falls may be caused by a single factor, but much more commonly by a combination of environmental, physiological and pathological factors in older people. Neurological problems, such as dementia, can cause metabolic disturbance, as do certain drugs or drug withdrawal (including alcohol), environmental change, strokes, Parkinson’s disease, loss of sensation, particularly in feet and disc disease or spinal osteoarthritis. Falls can also be caused by vertigo.

Many drugs are capable of increasing the risk of falling, but only a careful medical history will help establish if this is likely. You should read patient leaflets carefully and ask the GP if any new drug or combinations of drugs may increase the risk of your relative falling.Drugs can cause falls due to lowering of blood pressure, particularly when standing, or by causing drowsiness and increasing reflex times. They can also slow the heart rate and cause low blood sugar. Visual defects, such as cataracts, macular degeneration and glaucoma, can also contribute to falls, as can arthritis and foot problems. Disuse of muscles leading to wasting and weakness can also cause falls. Homes should be checked for poor lighting, loose rugs and carpets and uneven steps. Footwear should have good grip and walking aids should be appropriate (see here for tips on ensuring good home safety).

Falls can have serious consequences, including head and soft tissue injuries, as well as fractures. A fear of further falls can limit an older person’s activities and unchecked, can lead to isolation, further physical decline, depression and even institutionalisation. A lengthy lie on the floor, if someone is unable to get up by themselves, can potentially lead to muscle breakdown and kidney damage, pressure sores, hypothermia and the effects of missed medication. Two-thirds of all falls in older people lead to hospitalisation, which brings its own complications.

If an older person falls, do not ignore it. Consider making an appointment with the GP, who will assess risk factors, give advice and may refer your relative to a falls service in hospital. If an underlying medical condition is found, a drug review may be necessary. A strength and balance programme through the physiotherapy service may be offered and a care assessment to optimise independence and safety at home (see here for details on the care assessment). Bone health should be assessed, so that osteoporosis can be detected and treated, resulting in a lower chance of fracturing a bone in a fall. This may require answering some questions, but in some cases may warrant a bone-density scan. Everyone, regardless of whether or not they have fallen, will benefit from regular exercise, as this will increase mobility and balance (see here for suggestions). You may want to consider a fall alarm for your relative.

The NHS has further information on falls at www.nhs.uk/conditions/falls.

Gout

Gout is the most common form of inflammatory arthritis and occurs when crystals of sodium urate form inside joints. Typically, it presents with sudden, severe pain in the joint, together with redness and swelling. Gout attacks can last between three and 10 days. Gout is a chronic progressive condition and can develop in any joint, but it seems commonly to affect the big toe joint. There is a separate condition known as pseudo gout, which is caused by crystals of calcium pyrophosphate forming in the joints. The cause of gout is an excessive build-up of a usually harmless chemical called uric acid (urate) in the blood. Urate is made in the body every day and results from the breakdown of chemicals called purines. It is usually filtered out by the kidneys and excreted in urine. When too much uric acid is produced, or not enough is excreted from the body, uric acid builds up and can cause tiny, gritty crystals of sodium urate to form in the joints and this leads to inflammation.

Top tip: An enduring myth about gout is that only older men can get it. Certainly, gout is most common in men aged 30 and over, but it can affect people of all ages. Gout actually affects 1 in 7 older men and 1 in 16 older women. This makes it the most common type of arthritis after osteoarthritis.

According to the charity Arthritis Care, gout affects 1 in 40 people in the UK and since 1997, there has been a 30 per cent increase in patients diagnosed with gout. Furthermore, this figure is increasing by almost 2 per cent every year. While more men than women get gout, the risk for women increases after the menopause as the body produces less oestrogen, which facilitates the excretion of uric acid. Risk factors for gout include high blood pressure, genetic predisposition (close relatives with gout), chronic kidney problems, a diet rich in purines (found in foods such as sardines and liver), sugar-sweetened soft drinks, fruit and fruit juices with high levels of fructose and drinking too much beer, wine or spirits.

It is important to get proper medical treatment for gout, as it can lead to long-term health problems, including joint damage, kidney stones, and cardiovascular disease. Most people take anti-inflammatory painkillers to cope with gout attacks. A key treatment for gout is known as urate-lowering therapy (ULT), which aims to lower uric acid levels sufficiently to prevent new crystals forming and helps to dissolve existing crystals. This is done with drugs, such as Allopurinol or Febuxostat. ULT can eventually lead to a permanent elimination of sodium urate crystals and a ‘cure’ for gout. However, patients normally have to continue the treatment daily to maintain the effects. Getting appropriate medical advice and treatment is essential, but there are also some simple diet and lifestyle changes which you can make to prevent gout attacks. Losing weight can help to lower uric acid levels in the blood and tends to improve general health. A calorie-controlled, sensible diet plan is recommended. Regular exercise reduces urate levels and will therefore decrease the risk of developing gout (for more details on exercise see here). It also makes people feel more energised and healthier. It is a good idea to drink less alcohol, especially beer, stout and port wines, as these are known to raise the level of uric acid in the blood.

Some foods contain very high levels of purine, which can raise uric acid levels. Foods to avoid include offal (liver and kidneys), game (rabbit, pheasant), oily fish (sardines, mackerel, anchovies), seafood (mussels, crab, shrimp), and foods high in yeast and meat extracts such as Marmite, Bovril, and commercial gravy. The best foods to eat include fruit, vegetables, starchy carbohydrates (potatoes, bread, pasta, and rice) and some milk and dairy. Soft drinks sweetened with sugar are known to increase significantly the levels of uric acid in the blood, so avoid drinking these. Consumption of fruit juices high in fructose should also be reduced. Staying hydrated is important and will help to reduce the amount of uric acid in the blood, so drink plenty of water, ideally up to two litres per day. There is evidence that vitamin C (500mg per day) can reduce the risk of developing gout. It is thought that vitamin C increases the amount of uric acid excreted in the urine.

Top tip: Get regular blood pressure checks. People with gout tend to have higher blood pressure, so it is a good idea to have regular checks at least once a year. Contact your GP’s surgery.

Arthritis Research has further information on gout at www.arthritiscare.org.uk.

Hearing loss

There are various types of hearing loss, which can affect each and every one of us at some point regardless of age. Hearing loss can stem from various sources including noise, traumas, medication and hereditary conditions. The most common case of hearing loss is age-related, however. Early signs of this type of hearing loss can appear from the age of 40, but it is far more evident in the over-60s. It is associated with the overall decline of the human body and the detrimental effects of the increased number of free radicals which damage cells, including those responsible for hearing.

Our inner ear contains tiny hair cells tasked with capturing vibrations in the air (what we refer to as ‘sound’). Once captured, these are sent to the brain by way of the hearing nerve. As the body matures, their number and quality diminishes, resulting in a growing difficulty to hear certain sounds. Hearing loss can also be noise-induced. Our contemporary lifestyle means that we are exposed to man-made sounds, some at a level which have a devastating effect on hearing ability. Exposure to harmful sounds over short or long durations can cause irreversible damage to the inner ear parts. Thankfully, unlike age-related hearing loss, using noise protection and distancing yourself from the source of the sound can help reduce the likelihood of noise-related hearing loss. Some people may also suffer temporary hearing loss due to infections, such as common flu. These are usually treatable using medication.

The severity of the symptoms of hearing loss may vary from one person to the next. They can include difficulty in hearing the people around you within noisy environments, where background noise may seem far too loud compared to the actual speech, and sound generally seems less clear.

Your relative may not be able to hear the telephone or doorbell ring when others can, other people may sound mumbled or slurred, and they may have an inability to hear high-pitched sounds such as ‘s’ and ‘th’. This could lead them to have to ask people to repeat themselves, or to have the television or radio turned up much higher than other family members. Hearing loss can also make older people feel tired after participating in a conversation held within background noise.

Unfortunately, age-related hearing loss is an irreversible condition. Inner ear hair cells cannot regrow or regenerate. Recommended treatment revolves around managing the condition. There are medical devices which can help overcome hearing impairment, but equally, those around a hard-of-hearing person can help by demonstrating their support. Family members, caregivers and partners can try to ensure that the cause of the hearing loss is understood to be an issue. When engaging in a conversion with someone who struggles to hear, attempt to position yourself facing the person so that they are able to read your lips. In addition, speaking clearly in a normal manner is essential as shouting can cause distortion of sound. Most importantly, be patient and do not allow yourself to become frustrated. It is just as frustrating for the person trying to hear and demonstrating empathy can be very constructive.

There are plenty of devices designed to help the hard-of-hearing to overcome hearing loss on a daily basis. The most common are digital hearing aids, which are small devices that fit inside or outside the ear and help amplify external sound. Other devices which fall under the category of assistive hearing devices include amplified phones, doorbells, loud alarm clocks and induction loops. Hearing aids and assistive hearing devices do not cure hearing loss, but they do make it possible to carry out many daily activities without relying on external help. Any hearing-loss management solution should follow a hearing test taken at a reputable hearing centre.

Top tip: Did you know that hearing aids take patience to use and manage? Often older people hear whistles and distortion and struggle to get the volume level right. Also, the batteries are very small and fiddly, which is not user-friendly for older, arthritic hands. So be patient.

There is an association between hearing impairment and dementia, but there is little evidence to suggest that a hearing impairment alone leads to a decline in brain function. One study found that 50 per cent of people with a mild hearing loss and dementia improved when hearing aids were fitted. They found that hearing aids did not improve their cognitive function, or reduce behavioural or psychiatric symptoms, but it did show that patients improved because they could hear better and engage with others more easily.

The NHS has more information on dealing with hearing loss at www.nhs.uk/conditions/hearing-loss.

The heart

Blood pressure

Controlling your relative’s blood pressure is important, as if the pressure is too high, it can make them vulnerable to heart attack and stroke. Blood pressure is represented by two numbers, which show the highest and lowest pressure the blood exerts during the heartbeat cycle.

Systolic pressure is the highest force the blood exerts against the arteries when the heart contracts and diastolic pressure is the lowest force the blood exerts while the heart is resting between contractions. Ideally, blood pressure should be 120/80 or less. If it is higher than this, but below 140/90, then it is still considered normal, but cardiovascular risk increases and you should try to lower it. Discuss diet and exercise options with your GP, as well as possible medical help. Blood pressure is considered too high if it runs consistently over 140/90. Low blood pressure is usually measured at 90/60 or less, but unless you often feel faint or dizzy, it is usually nothing to worry about. Some conditions, such as diabetes and Parkinson’s, can also lead to low blood pressure, as can certain medications your relative might be taking for other conditions.

High blood pressure puts people at risk of developing cardiovascular disease, as it puts the heart under strain and damages the interior linings of the arteries, which makes it easier for layers of fatty cholesterol to build up. If there is a short-term increase in blood pressure when stressed, this can cause blood clots, which can lead to a stroke or heart attack. It is therefore very important not only to have a healthy resting blood pressure, but also good blood pressure control during times of emotional and physical stress.

There are medicines available to help control blood pressure, but your relative can also make lifestyle changes which will help. Being overweight and having a large waist measurement and a high waist girth can increase blood pressure. Try to encourage your relative to reduce excess weight with exercise and by maintaining a healthy diet. Too much alcohol can also raise blood pressure, so make sure they are careful and do not binge drink. Exercise makes the heart work more efficiently and this helps regulate blood pressure. Just half an hour a day of activity will help, but check with your relative’s doctor before they start any exercise programme, if they have not done any for a while. If their blood pressure is consistently over 140/90, then they should consult their doctor for further advice.

Your relative should stop smoking, as it raises blood pressure with the very first drag, due to the effect of the nicotine. Smoking also damages the walls of the arteries, which makes your relative more susceptible to high blood pressure in the future. Salt can mean that they retain fluid in the blood, which can increase blood pressure. Many ready meals and other pre-prepared food contain a great deal of salt, so try not to add more.

Top tip: Bananas contain potassium, which is good for the heart, as well as providing a great energy boost.

Stress drives blood pressure up, so encourage your relative to manage it through exercise, sleep and relaxation techniques, such as mindfulness (see here for more details).

Managing cholesterol

Cholesterol is a fatty substance which is found in the blood. Mainly made in the body, it plays an essential role in how every cell in the body works. However, too much cholesterol in the blood can increase your relative’s risk of heart problems. Cholesterol is carried around the body by proteins. The combinations of cholesterol and proteins are called lipoproteins. There are two main types of lipoproteins: LDL (low-density lipoprotein), which is the harmful type of cholesterol and HDL (high-density lipoprotein), which is a protective type of cholesterol. Having too much harmful LDL cholesterol in the blood can increase the risk of cardiovascular disease. The risk is particularly high if your relative has a high level of LDL cholesterol and a low level of HDL cholesterol. Triglycerides are another type of fatty substance in the blood. They are found in foods such as dairy products, meat and cooking oils. They can also be produced in the body, either by the body’s fat stores, or in the liver. People who are very overweight, eat a lot of fatty and sugary foods, or drink too much alcohol are more likely to have a high triglyceride level and have a greater risk of developing cardiovascular disease than those with lower levels.

A common cause of high blood cholesterol levels is eating too much saturated fat. However, some people have high blood cholesterol even though they eat a healthy diet. For example, they may have inherited a condition called familial hyperlipidemia (FH). The cholesterol which is found in some foods, such as eggs, liver, kidneys and some types of seafood, e.g. prawns, does not usually make a great contribution to the level of cholesterol in your blood. It is much more important that you eat foods that are low in saturated fat, such as fruit, vegetables, wholegrains, poultry, fish and nuts.

My father suffered from high cholesterol due to familial hyperlipidemia. When on holiday in Florida, he took a cholesterol test in the pharmacy – it was a novelty at the time as such a test was not yet available over the counter in the UK – and the level was so high that the pharmacist told him to lie down in the store while they called an ambulance. My father knew the level was normal. He did not lie down and he refused to go to hospital, heading back to the beach instead.

To help reduce your relative’s cholesterol level, they need to cut down on saturated fats and instead, use unsaturated fats, such as olive, rapeseed, or sunflower oils and spreads. They should also reduce the total amount of fat they eat. Oily fish provides the richest source of a particular type of polyunsaturated fat known as Omega-3. Omega-3 from oily fish can help to lower blood triglyceride levels and prevent the blood from clotting and regulate the heart rhythm. Foods that are high in soluble fibre, such as oats, beans, pulses, lentils, nuts, fruit and vegetables, can help lower cholesterol. Regular physical activity can help increase HDL cholesterol (the ‘protective’ type of cholesterol). There is evidence to show that substances called plant sterols and stanols may help reduce cholesterol levels when 2g per day is regularly consumed. They can be found in margarines, spreads, soft cheeses and yogurts.

For most people, there is currently no limit on the number of eggs that they can eat in a week. However, because the recommendation has changed over the years, it is often a common source of confusion. In the past, a restriction on eggs was recommended, because it was thought that foods high in cholesterol (including liver, kidneys and shellfish, as well as eggs) could have an impact on cholesterol levels in the body. However, as research in this area has developed, so has our understanding of how foods that contain cholesterol affect our heart health. For most people, the amount of saturated fat they eat has much more of an impact on their cholesterol than eating foods which contain cholesterol, like eggs and shellfish. So, unless your relative has been advised otherwise by their doctor or dietician, if they like eggs, they can be included as part of a balanced and varied diet.

Whether they need to take cholesterol-lowering drugs or not depends not just on their total cholesterol HDL and LDL levels, but also on their overall risk of cardiovascular disease. Cholesterol-lowering medicines, such as statins, are prescribed for people who are at greatest overall risk of suffering from cardiovascular disease.

Angina

Angina is a pain or discomfort felt in the chest and usually caused by coronary heart disease. However, in some cases, the pain may affect some people only in the arm, neck, stomach or jaw. Angina often feels like a heaviness or tightness in the chest, but this may spread to the arms, neck, jaw, back, or stomach as well. Some people describe a feeling of severe tightness, while others say it is more of a dull ache. Symptoms of experiencing shortness of breath have been reported too. Angina is often brought on by physical activity, an emotional upset, cold weather, or after a meal. Symptoms usually subside after a few minutes. Unfortunately, you cannot reverse coronary heart disease, but your relative can help prevent angina and the condition from getting worse by keeping their heart healthy.

It is important to stop smoking, control high blood pressure, reduce your relative’s cholesterol level, be physically active, achieve and maintain a healthy weight, control blood glucose if your relative has diabetes, eat a healthy, balanced diet and only drink moderate amounts of alcohol. Their doctor may be able to diagnose whether they have angina from the symptoms that they describe. Alternatively, the GP may want to carry out a health check, or send them for some tests. There is medication available that can help control symptoms, whereas some people require angioplasty, or heart bypass surgery to clear the arteries. Many people with angina have a good quality of life and continue with their normal daily activities. Your relative’s doctor or nurse will be able to advise them on daily activities and any lifestyle changes they may need to make.

If your relative experiences chest pains, call 999 immediately.

Heart attack

Most heart attacks are caused by coronary heart disease, which is when coronary arteries narrow due to a gradual build-up of fatty material (atheroma) within the walls. If the atheroma becomes unstable, a piece may break off and lead to a blood clot forming. This clot can block the coronary artery, starving the heart of blood and oxygen and causing damage to the heart muscle. This is a heart attack. It is also called acute coronary syndrome, myocardial infarction, or coronary thrombosis. A heart attack is life-threatening. If you think your relative, or anyone else, is having a heart attack, you should phone 999 for an ambulance immediately.

Top tip: You are more likely to survive a heart attack if you phone 999 straight away and receive fast treatment. Don’t hesitate.

Cardiac arrest is totally different from a heart attack. A cardiac arrest happens when the heart stops pumping blood around the body. As a result, your relative will be unconscious and will not be breathing normally. Immediate cardiopulmonary resuscitation (CPR) and defibrillation is needed to have any chance of survival. One of the causes of cardiac arrest is a heart attack. Other causes include electrocution, or choking.

Top tip: If you witness a cardiac arrest, you can increase the person’s chances of survival by phoning 999 and giving immediate CPR. As a carer, it is worth considering taking a first aid course, which covers CPR and trains you in how to act in emergency medical situations. St John Ambulance, the British Red Cross and other organisations all run first aid training courses.

The symptoms of a heart attack vary from one person to another. They can range from a severe pain in the centre of the chest to having mild chest discomfort that makes your relative feel generally unwell. The pain or discomfort may feel like bad indigestion. This may spread to the arms, neck, jaw, back or stomach and can also cause chest pain. Your relative can feel light-headed or dizzy and short of breath. They may also feel nauseous or vomit. Phone 999 immediately if you think someone is having a heart attack. This means that you will get potentially life-saving treatment as soon as possible. Do not phone the GP if you think someone is having a heart attack, you must dial 999 for an ambulance.

Top tip: If your relative is not allergic to aspirin and has some next to them, or if there is someone with them who can fetch some for them easily, they can chew an aspirin to try to prevent further damage to the heart muscle and increase their chances of survival. The British Heart Foundation advises that if your relative does not have aspirin to hand, they should not get up and wander around the house looking for one as this may put unnecessary strain on the heart. They should call 999 and wait for assistance from an ambulance crew.

When the ambulance staff arrives, they will do an electrocardiogram (ECG). This should not delay transfer to the most suitable hospital. The crew will administer aspirin if it has not already been given, assess your relative’s symptoms and medical history, give pain relief if needed and oxygen if oxygen levels are too low. They will also examine your relative and monitor their heart rate and blood pressure. They may perform primary percutaneous coronary intervention (PPCI), which is emergency coronary angioplasty. This involves reopening the blocked coronary artery and placing one or more stents in it. It restores blood supply to the part of the heart that is starved of blood, which helps to save as much muscle as possible. A medicine is injected into the vein to dissolve the blood clot and restore the blood supply to the heart. If PPCI is not possible in the home, it will be given in the ambulance. In some types of heart attacks, people do not receive either of these two treatments, because they will not benefit from them.

Living a healthy lifestyle can help prevent your relative from having a heart attack. They should ask their doctor or nurse for a heart health check to assess their risk of having a heart attack in the next 10 years. If they have already had a heart attack, they can dramatically reduce the risk of having another one and of future heart problems by keeping their heart healthy and taking their medicines. A heart attack can be a frightening experience and it can take time to come to terms with what has happened. It is natural to be worried about recovery and the future. Many people make a full recovery and within a few months are able to return to their normal activities. Some may find that they are not able to do as much as they previously did, but attending a cardiac rehabilitation course will increase the chances of getting back to normal as quickly as possible. Ask your relative’s GP or consult www.cardiac-rehabilitation.net/cardiac-rehab.htm.

Heart failure

Having heart failure means that, for some reason, the heart is not pumping blood around the body as well as it used to. The most common reason is that the heart muscle has been damaged – for example, after a heart attack. It can be very frightening to hear that your relative has heart failure. For many people, heart failure can be a debilitating condition, where normal everyday tasks, such as having a shower or bath, doing the shopping, or simply playing with the children, takes enormous energy and leaves them breathless and exhausted. There are many reasons why your relative might be diagnosed with heart failure. It can be sudden, or it may happen slowly over months, even years. Some causes of heart failure are a heart attack, high blood pressure, problems with heart valves, cardiomyopathies (diseases of the heart muscle), drinking too much alcohol and congenital conditions (those that people are born with).

Not everyone experiences the same symptoms and everyone copes in different ways. Your relative might feel out of breath when they are physically active, or in some cases, even when they are at rest. They may also have swollen feet and ankles and feel very tired. Everyone is different, so it is important to speak to their GP about what is best for them. The reason for their condition will make a difference as to how their symptoms are controlled. You may need to have tests, which include blood tests, an electrocardiogram (ECG) and an echocardiogram.

While there is no cure for heart failure at the moment, the treatment to control symptoms has improved dramatically. With treatment and the right medicines, many people live full and active lives. Your relative’s doctor will prescribe drugs that will help control their blood pressure and help the pumping action of their heart. They will also give advice about making changes to their lifestyle, such as cutting down on salt, staying active and stopping smoking, which will help them to do all the things that they enjoy, improve their condition and try to live a normal life.

Heart valve disease

The heart is a muscle, which pumps blood to the lungs and around the rest of the body. There are four chambers to the heart, which are separated by valves to make sure that the blood flows in one direction through the heart. The two large blood vessels that leave the heart also have valves which ensure that the blood does not go back into the heart once it has been pumped out.

The main causes of heart valve disease are being born with an abnormal valve or valves (congenital heart disease), having had rheumatic fever, cardiomyopathy (a disease of the heart muscle), damage to the heart muscle from a heart attack, or a previous infection with endocarditis (an infection of the inner lining of the heart chambers and heart valves). A diseased or damaged valve can affect the flow of blood in two ways. If the valve does not open fully, it will obstruct the flow of blood. This is called valve stenosis, or narrowing. If the valve does not close properly, it will allow blood to leak backwards. This is called valve incompetence, regurgitation, or a leaky valve. Both will put extra strain on the heart and if your relative has stenosis, the valve can restrict the flow of blood, making their heart pump harder to force the blood past the narrowing. If your relative has valve incompetence, a leaking valve may mean that their heart has to do extra work to pump the required volume of blood through the heart.

Your relative may not experience any symptoms, but if they do, some of the common symptoms are being out of breath, swelling of the ankles and feet and being unusually tired. Their doctor may hear a murmur (an unusual sound) when they listen to their heart. A murmur does not always mean that there is a problem with the heart as people with normal hearts may also have murmurs. The GP may suggest that your relative has further tests to see how well the heart is working. The most common test is an echocardiogram, which uses sound waves to look at the structure of the heart. It is similar to an ultrasound scan used to look at babies before they are born. Your relative may not need any treatment at all, but their doctor may ask them to come back in a year’s time, or if symptoms get worse. Most valve problems, however, can be treated using medicines or by surgery. The treatment will depend on the cause of the problem and the effect that it is having on the heart.

You can find more information on heart-related illness and prevention at British Heart Foundation (www.bhf.org.uk).

Hip and knee replacements

Hips

A worn hip means that the bones rub together and cause considerable pain. A replacement involves removing this bone and replacing it with new pieces, made from either metal, plastic or ceramic. Hip replacements last between 10 and 20 years and should reduce or eliminate pain and increase mobility. A replacement also reduces dependency on painkillers and anti-inflammatory drugs.

Replacement hips can be either cemented, known as ‘fixed’, or un-cemented. Fixed hips tend to be given to older people, who hopefully will not need a second replacement in their lifetime. A second hip replacement is known as a ‘revision’. In un-cemented hips, metal surfaces can be treated with a substance and roughened to encourage the bone growth into the artificial joint and fix it in place. Metal and ceramic parts tend to be more hard-wearing and more common now as metal-on-metal implants tend to wear out faster and need future hip revisions. Hip revisions can be more complicated than the original hip replacements, as they require removal of the first hip replacement and some bone will be lost. It can take longer to recover from revisions. If you are under 65, hip resurfacing might be an option, which is where damaged bone is removed and the ball and socket are covered with metal caps. First hip operations are often now performed as keyhole surgery, but this is not possible for revisions.

Prior to having a hip operation, there are a few things to bear in mind. Smoking increases the risk of chest and wound infection and can slow recovery. Losing weight reduces the pressure on your relative’s hip and may help to speed up recovery. When visiting the specialist, it can be a good idea to make a list before you go with your relative, so that you do not forget to ask anything while you are in the appointment.

A hip replacement operation usually takes about an hour and a half to perform and can be done using an epidural as a spinal block, which means you are awake during the procedure, but can feel nothing below the waist. In this instance, your relative does not need to recover from a general anaesthetic. If they do have general anaesthetic, they will not be allowed to eat or drink for about six hours beforehand. The surgeon and anaesthetist will advise on the right procedure for them. Hip revision surgery can take longer. To avoid blood clots forming in the veins in the legs after surgery and causing deep vein thrombosis (DVT), your relative will probably be asked to wear compression stockings, which are normally supplied by the hospital. They might also be given drugs to prevent DVT. When they wake up, they may find a pillow between their legs to hold the hip joint still and prevent dislocation. They will be given painkillers.

Your relative will usually get physiotherapy treatment very soon after their operation and regularly afterwards for a while. They will be given exercises to restore movement and will be expected to stand within 24 hours of the operation and walk not long after that. It is very important to do the exercises the physiotherapist prescribes. Your relative is usually in hospital for three to five days and will be discharged when they can walk easily with crutches or a stick (see here for details on hospital discharge). They may have stitches which need to be removed, or they might have dissolvable stitches, which do not need removing. Your relative should be prescribed painkillers to take at home when they leave hospital and they will need to continue with their physiotherapy exercises. It is important not to cross the legs or twist the hip as it may strain the scar or even dislocate the new hip. They will need help at home getting in and out of bed and chairs and going to the toilet. Ideally someone should stay with your relative on their return until they are well enough to cope on their own, but hospitals are not always able to arrange this, so it is usually a family member.

Top tip: Using a heightened toilet seat extension can often be very helpful, so your relative does not have to squat as deeply as usual while recovering at home after a hip replacement. The hospital should provide this if you ask.

Your relative will not be able to drive for a while and how quickly they can return to driving will depend on which leg has been operated on and if they have a manual or an automatic car. Once recovered, they may need to avoid sports, which have a risk of being hit hard or even falling.

There may be complications with hip surgery. Infection can occur, but your relative will be given antibiotics after surgery to prevent this. Post-surgery, one leg may be slightly longer or shorter than the other, but this can be corrected with orthotics in their shoes. Dislocation and fractures can occur, but are rare.

My husband had a hip replacement. Originally, his leg had been an inch shorter than the other due to an accident in childhood. After the operation, when the nurses stood him up, he banged his leg hard on the floor because the surgeon had now made it an inch longer. It took him a while to get used to it and the change in leg length has created additional back problems for him.

The NHS has further information at www.nhs.uk/conditions/hip-replacement.

Knees

If your relative’s quality of life is severely restricted due to knee pain and immobility, they may wish to consider a knee replacement. The operation is rarely an emergency and is generally their choice. Typical symptoms which may mean they need knee replacement surgery include pain, which gradually gets worse over time, and having sudden acute attacks of pain. The pain is normally worse when weight-bearing and doing any normal activity. Swelling can be severe and prevent your relative from bending their knee. They should see their doctor to rule out any infection, especially if they have a fever. Knees can be stiff in the morning in particular, but may improve slightly during the day. This is particularly prevalent in people with rheumatoid arthritis. Being overweight makes knee pain worse. Carrying too much weight puts extra stress on the joints and can make symptoms of arthritis considerably worse.

There are two types of knee replacement: total and partial. Total knee replacement requires an incision over the knee and usually entails a hospital stay of a few days to a week. Recovery can take from one to three months, but the good news is that most patients are free of their arthritic symptoms once they have recovered. Partial knee replacement is less invasive, but is only suitable for about 10 per cent of all patients. This is suitable for someone who only has arthritis in one of the three knee compartments. Your relative’s GP will refer them to an orthopaedic surgeon, who will examine them, as well as looking at their medical history and taking X-rays, which will clearly show any arthritis. X-rays taken standing up are preferable as they show what happens to the knee when it is weight-bearing. More than 90 per cent of people who have total knee replacements have no pain after recovery, or substantially less pain. Replacements also relieve stiffness and enable them to live normal active lives.

Physiotherapy usually begins on the day of surgery, or on the day afterwards. Patients are encouraged to walk and to weight-bear as much as they can. They will also be given exercises to do regularly. Immediately after getting home, they may need help getting around, getting out of bed, or going to the toilet. Having grab rails in the bathroom and by the bed can be very helpful. Physiotherapy will normally continue after discharge from hospital and your relative can also do exercises at home. The aim is to get to at least a 90-degree knee bend within two weeks of surgery. After about a month, most people can move about well and will be back to normal after three months. After recovery, it is a good idea to walk, swim and do other exercises to keep fit, keep weight off and keep the knees supple. Running is usually not recommended with a total knee replacement.

My sister had both knees replaced at the same time and her recovery was long and difficult. She ended up being admitted back into hospital for quite a while. My mother had her knees replaced individually, one year apart, and her recovery was much faster, despite being 30 years older than my sister.

The NHS has further information at www.nhs.uk/conditions/knee-replacement.

Incontinence

Older people suffering with incontinence can often be too embarrassed to come forward and seek help for it. They do not find it an easy subject to discuss with relatives or medical staff. However, it is really important that if someone does have problems getting to the toilet on time that they should ask for help. It is not something they should have to cope with alone, or that cannot be resolved and it is important to recognise that these problems are common and nothing to be ashamed of.

When seeing healthcare staff about a bladder or bowel problem, your relative should be seen and examined by a nurse or doctor, who is trained to do an assessment and then they might be referred to a specialist, who is able to answer questions relating to incontinence problems, can provide a diagnosis and discuss all available treatments. Staff should always treat the patient with sensitivity. This can be a distressing time and your relative should be made to feel as comfortable as possible at all times. They may wish to take a chaperone, although some people prefer to go alone. Make sure that different treatment options are explained, as well as what they can do to help themselves. There are also patient groups they can join.

When visiting healthcare staff about bladder or bowel problems, the staff should ask about what the symptoms are and about other medical conditions which may be contributing to the bowel or bladder problem. Medication can be a cause. Your relative will possibly have tests for infection and may be asked to record the frequency of toilet visits. There may also be an internal examination to check for prolapse in women and prostate issues in men. Again, your relative may wish to take a chaperone, although some people prefer to go alone.

It may be helpful to reduce caffeine intake and to drink more fluids to aid constipation. There are incontinence pads on sale in all leading supermarkets and chemists, as well as on numerous websites. Many of these products come as pull-up pants, so they can be worn as underwear. Barrier cream, such as Sudocrem, is helpful to protect and soothe the skin. Try to encourage your relative to go to the bathroom regularly to avoid accidents and to plan ahead for trips and visits outside the home and take products with them. They can keep a bag packed with pads, cream, wipes, etc. ready to go. Stopping smoking is important, as this can make the bladder over-active. Pelvic floor muscle exercises are often very effective in treating urinary incontinence. These exercises, also known as Kegel exercises, are aimed at strengthening the bladder’s sphincter and therefore allowing it to seal off the bladder better. Sphincter muscles are part of a group called the pelvic floor muscles. Strengthening the pelvic floor reflects positively on the strength of the sphincter and greatly improves stress incontinence.

The NHS offers further information at www.nhs.uk/conditions/urinary-incontinence.

Managing medication

Medication often plays an important role in older people’s health and ensuring that the people you care for take it at the right time, in the right way and with the right frequency and dosage, is essential. Medication should be taken as directed by a doctor or pharmacist, or according to the instructions on the packet. This ensures your relative achieves the full benefit of the medication and lessens any possible side effects. Try to make sure that thay take their medication at the same time every day. Some medicines need to be taken at specific times, such as before, with, or after food. The management of certain medical conditions, such as Parkinson’s disease, can only be controlled with very precise, set dosage timings, so it may help to set reminders on a calendar, phone, or in a special app on your or their smartphone or tablet. Medication that is out of date should never be taken. In the event a dose is missed, do not take another or give a double dose to make up for the missed dose. Check the patient information leaflet in the medication packaging, which your relative should always keep until the medication is finished as there is usually a section which relates to missed doses, though it is recommended that you speak to a pharmacist to get the best advice. It is a good idea to keep the phone number of the pharmacy and doctor’s surgery in your phone or diary (see page 25 for a list of useful numbers to keep). When a new medication is prescribed, always ask your doctor for the appropriate course of action if a dose is missed. If doses are missed regularly, start to keep a medication diary of what your relative has taken and not taken (and why, if known) and discuss it with their GP as soon as possible.

It is very important to inform the doctor of all other medication that your relative might be taking in order to ascertain how all the drugs might interact together and to discuss possible side effects and things to watch out for. It is also a good idea to meet with the GP regularly to ensure all medication is still needed.

The doctor only ever prescribes a limited course of medication, so it is sensible to make a note in your relative’s or your diary, or set a reminder on your phone, to order a repeat prescription a week before it is due to run out. Check with the GP’s surgery to find out how many days the practice needs to process repeat prescription requests. Most GPs now offer a dedicated telephone line for repeat prescription ordering, or an online web service and some pharmacies offer a convenient repeat prescription service, where you let them know what medicines your relative needs and they will arrange the repeat prescription with the GP practice for you and in some cases, deliver the medication to your relative directly.

Medication can deteriorate and not work as intended if exposed to heat, light or moisture. It is best not to keep medicines in a damp or steamy place, such as a kitchen or bathroom, or on windowsills. Medication is best stored in a cool, dark place. However, always check the label for special storage instructions, such as ‘store in the fridge’ or ‘away from sunlight’. Try to keep all medication together in one place for ease of access unless there are specific instructions for storage. Medicines stored in the fridge are best placed in a separate container (e.g. a plastic box or resealable bag) and kept away from food and other consumables. If the person you care for does not live alone, make sure that medication for each person in the home is stored separately, so that they do not get mixed up. Always keep medication out of the reach of children. It is important to store medicines in their original containers and packaging, along with their instructions for use. Do not decant medication into other containers as they may get mixed up and taken accidentally.

Many people need help with medication from carers due to poor eyesight, or if they are registered blind. If the person you care for is unable to read the directions on their medication packaging, ask the pharmacist to provide them in large print and to talk through the instructions as well. If the person you care for is registered blind, it is important that new supplies of medication are checked for any brand changes, which may be in different sized outer packaging, or have different shaped tablets. Speak to the pharmacist, who may be able to ensure generic brands are always provided, so that the tablet shape remains familiar and consistent and this will help to prevent medication errors. There are some specialised apps available, which will connect blind people with sighted volunteers who can help with medication labelling – among other things – via video link. Labels can be provided in Braille for blind or partially sighted patients.

If you care for someone with swallowing difficulties, or someone who has to chew tablets before swallowing, speak to the pharmacist about suitable soluble and liquid alternatives. You can also use a pill crusher to halve and/or crush pills and tablets to make them easier to take. A dry mouth makes it harder to swallow, so it’s a good idea to moisten the mouth with water first. Place the tablet in the centre of the tongue and lengthways along the tongue if the pill is oval-shaped. Immediately, take a sip of water and wash the pill directly into the throat, throwing the head back.

Top tip: Try getting your relative to use a straw to drink the water as the suction may help them to swallow tablets.

There are options available for people who have dexterity difficulties when taking medication. A blister pack pen device is easy to hold and helps your relative to get into a medication blister pack more easily. A Haleraid, or other inhaler aids, are available for those who are arthritic, or have difficulty depressing an inhaler. If an eye drop bottle is too small to squeeze a drop from, there are dispensers designed for arthritic hands. A winged cap is a simple device that is placed onto the top of a medication bottle to help open it. If your relative has memory problems, having a medication record with pictures of the medication and an explanation of all the medicines to be taken, including when they should be taken, how many and what they are for, can help as a useful prompt. These can be on paper, or in electronic form. People who have difficulty remembering if they have taken tablets may benefit from a medication diary or tick chart. If ticked when tablets are taken, these charts can be a good way of reminding them that tablets have been taken, but they are obviously inappropriate if a patient is unaware of the day and time. Managing medication for someone who needs to take a variety of pills every day is a critical task as it is important to ensure the correct dosage and timing. Modern pill dispensers can be pre-loaded with a day’s, or a week’s worth of medication, and will automatically dispense the right medication at the right time by sending out an alert, or sounding an alarm, to show that the medication is ready to take. You can also buy standard pill boxes to pre-allocate medication by days of the week.For people with more pronounced memory issues, electronic medicines dispensers audibly and visibly remind them to take their medicines. These are locked within the device, so they can only take medicines at the times at which the alarm has been set.

Pharmacists are medicine experts and will be happy to help you with any medication queries you may have. In England & Wales, pharmacists provide a free medicines use review (MUR) service. This may benefit you and the people you care for by providing a review of all medicines to see if there are any overlaps or interactions, and they can provide extra information on what medicines are for and their side effects. Your local pharmacy can often provide a medication delivery service or collection of unwanted medicines and provide advice on compliance aids to assist with taking medicines. It will make it easier for your pharmacist to talk to you about the medicines of the person you care for if they know you are a carer and have written consent from the person for whom you care. You can also call NHS direct on 111.

Important: Do not throw away unwanted or expired medication with your normal rubbish, or wash it down the sink or toilet. Take any medicines that the person you care for no longer needs, or are out of date, back to your local pharmacy. Do not keep them ‘just in case’. After a medication is changed or discontinued, the remaining supplies should be returned to your pharmacy to be disposed of safely.

In the event a person dies, keep their medication for at least seven days in case the Coroner’s Office, Procurator Fiscal or Courts ask for them. Always dispose of medication which has reached its expiry date. Remember, some medication expires sooner once it has been opened, such as eye drops. Write the date your relative opened them on the packaging, so you can keep track of when they are due to expire.

Pain management

It is thought that much pain in the older population often goes under-reported due to stoicism. Older people tend to put up with severe discomfort and pain because they do not wish to be a nuisance. Unfortunately, not addressing pain can have negative long-term consequences, including reduced mobility and depression, and so managing pain in older people is critical.

The first step is to visit the GP to get a proper diagnosis and medical opinion. If your relative is otherwise healthy, then painkillers will normally be prescribed. Of course, some older people genuinely dislike taking painkillers and if this is the case, there are other approaches to managing and reducing pain. There are around 300 pain clinics in the UK, mostly located in hospitals staffed by multi-disciplinary teams, including occupational therapists, psychologists, doctors, and physiotherapists, who work together to help people with pain. The aim is to help them manage chronic pain and maintain a good quality of life.

Remaining physically active as you age is vital to staying healthy and maintaining independence. Regular exercise is known to improve general health, help maintain a healthy weight and to reduce the risk of falls, heart disease and stroke. It also helps to reduce and manage pain. Even if your relative has never been particularly sporty or interested in exercising, it is not too late to start. It is important for older people to keep moving and avoid spending too many hours sitting down. There are many ways to get physical exercise, such as walking, gardening, golf, bowls, tennis, swimming, dancing, Tai Chi and yoga (see here for ideas). Older people are recommended to do around two to three hours of moderate-intensity aerobic activity every week, with a target of achieving 30 minutes on at least five days a week. At least two days a week, activities should focus on strengthening muscles. One of the benefits of regular exercise is that it helps people to relax and proper relaxation can help to reduce stress caused by chronic pain. There are many relaxation techniques that older people can try, from breathing exercises to meditation. The important thing here is that regular practice should help to reduce pain. Their GP should be able to offer advice and there may be local classes they can attend. Exercise also helps with depression as it releases endorphins, which improve your mood.

Physiotherapy can help maintain physical function and enhance psychological and social wellbeing, so reducing pain. Importantly, physiotherapy includes specific exercises designed to improve or increase coordination, flexibility, endurance, balance, strength and general range of motion. This all helps to improve circulation, reduce pain and the risk of falls. Physiotherapy is available through the NHS (via a GP referral), through the voluntary sector, and privately (see also here). Acupuncture too can be very effective in managing pain in older people. It uses ultra-fine sterile needles inserted into specific parts of the body to rebalance energy, promote self-healing, and reduce pain. Acupuncture is sometimes available on the NHS, so it is worth checking with your relative’s GP (see here).

Sometimes, simply shifting one’s focus onto something else can help take one’s mind off moderate pain. Depending on what your relative is interested in, you can try suggesting activities, such as watching TV, going to the cinema, visiting a friend, listening to music, doing a crossword, or spending time enjoying a favourite hobby, such as singing, knitting or photography. Going out for the day can also provide stimulation and company that helps to distract from dwelling too much on aches and pains.

You can get more information from The British Pain Society at www.britishpainsociety.org/people-with-pain.

Parkinson’s disease

Parkinson’s is a progressive neurological condition. One person in every 500 has Parkinson’s. Most people who get Parkinson’s are aged 50 or over, but younger people can get it too. One in 20 is under the age of 40. People with Parkinson’s do not have enough of a chemical called dopamine, because some nerve cells in their brain have died. Without dopamine, people can find that their movements become slower, so it takes longer to do things. The loss of nerve cells in the brain cause the symptoms of Parkinson’s to appear. There is currently no cure for Parkinson’s and it is not yet known why people get the condition. Parkinson’s does not directly cause people to die, but symptoms do become worse over time.

The main symptoms of Parkinson’s are tremor, rigidity and slowness of movement. People with Parkinson’s can find that other issues, such as tiredness, pain, depression and constipation, have an impact on their day-to-day lives. Bladder problems may occur in Parkinson’s, as it affects the nerves that control emptying the bladder. This can lead to an overactive bladder and the need to pass urine more often and quickly. Some people with Parkinson’s may get constipation, which can make them feel unwell, lethargic and even nauseous, but it rarely leads to serious complications. Increasing the amount of water they drink and how much fibre they eat, following a balanced diet and taking regular exercise will stimulate the bowel to help prevent constipation. Some people with Parkinson’s may find they have problems when eating and saliva can build up in the mouth, which sometimes overflows. Practising keeping lips together, learning tips on tongue control and other similar exercises may help with any difficulties in swallowing and may also help to control drooling. In some cases, changing posture and sitting more upright can improve matters. You can find out more at www.parkinsons.org.uk.

Loss of balance and falling can be common in Parkinson’s. Falls are caused by many factors, such as the changes in posture that may happen as Parkinson’s progresses. Some people with Parkinson’s will experience freezing, stopping suddenly while walking and feeling as if their feet are glued to the ground. They may then be unable to move forward again for several seconds or even minutes. It is not known exactly what causes freezing, but it may happen when movements are interrupted, or when the movement is just starting. Freezing does not just affect walking. It can also occur during repetitive movements, like writing or brushing teeth. There may be problems with different kinds of communication, including speech, facial expressions and writing. Many people with Parkinson’s have some speech problems when they first develop the condition. These may make everyday activities, such as talking to friends or using the phone, difficult. The speech problems that some people with Parkinson’s have may be helped by speech and language therapy.

Eye problems, such as blurred or double vision, dry eyes or excessive watering, can be common for people with Parkinson’s. Some of these issues will be due to Parkinson’s, or the treatment they are receiving. If they experience any eye problems, they should see the GP, specialist or Parkinson’s nurse. Parkinson’s can also cause the sweat glands to overreact. This can lead to too much or too little sweat, or to extremely dry skin. Changes in medication can often reduce excess sweating and ensure that the body produces enough perspiration. Dry skin and scalp problems can be irritating, but are often manageable with creams and medicated shampoos. Having a balanced diet is an important part of looking after health. With Parkinson’s, the patient may need to take a little extra care, as some symptoms and side effects of treatment can limit or upset the appetite. Being underweight or overweight can have an impact on health generally.

There are many different types of pain related to this disease – for example, headaches or muscular and joint pain. Not everyone with Parkinson’s experiences the same symptoms. For some people, pain can be the main symptom of their condition, although not everyone will experience this problem. It is important that both people with Parkinson’s and their carers are aware of the problems pain may cause. To be able to treat pain in Parkinson’s, the GP, specialist or Parkinson’s nurse needs to find out what is causing the pain. In the early stages of Parkinson’s, many people complain of certain difficulties in thinking and memory that can interfere with day-to-day life. This can be experienced as a slowing down of thinking, much in the same way as they might experience slowing down of movement. While some people do complain of forgetfulness, memory problems are not usually a significant complaint in the early stages of Parkinson’s. It is more likely that other factors, such as stress, depression and poor general health, will have an impact on the ability to think, recall and process information efficiently. A diagnosis of Parkinson’s dementia is given if the symptoms of dementia appear after those of Parkinson’s. Symptoms of dementia can include slowness of thinking, poor recall, impaired concentration and talking less. Memory problems, such as forgetfulness and repetitive questioning, can also be experienced. However, some people can have dementia with hardly any memory problems. In general, people with Parkinson’s dementia find they have problems with judgement and problem solving. This means it is difficult for them to make complex decisions. Activities of daily living, such as dressing, hygiene, cooking and cleaning, may also become increasingly difficult. Extra help from carers may be necessary.

Some people with Parkinson’s have anxiety related to the on/off state of their motor symptoms. When off and less able to move well, they may develop significant anxiety symptoms and at times may even have panic attacks. If anxiety is related to movement problems, then talking to a doctor about altering anti-Parkinson’s medication can help. For anxiety symptoms which do not respond to changes in anti-Parkinson’s medication, a trial of either talk therapy, such as cognitive behavioural therapy (CBT), or medication, may be helpful. For those who experience mild anxiety every now and then, avoiding stimulants, such as caffeine, alcohol and cigarettes, can help. Some people can find relaxation tapes, yoga, massage, acupuncture and complementary therapies beneficial.

Hallucinations are rare, but some people with Parkinson’s may experience complex visual hallucinations. Typically, these involve seeing small animals, insects, or other people in the room. The length of the hallucination varies and is usually visual. Auditory hallucinations are rarer for those with Parkinson’s. Sometimes, when people with Parkinson’s hallucinate, they experience a feeling that an animal or object is present, just next to them, but they do not actually see it. Hallucinations are caused partly by Parkinson’s itself and partly by the medication that is prescribed to treat it. Dopamine and anticholinergic drugs are more likely to cause hallucinations. If your relative is experiencing hallucinations, it is important that they visit their doctor so that the cause can be identified and any appropriate treatment given. The symptoms can be controlled using a combination of drugs, therapies and, occasionally, surgery. As Parkinson’s progresses, an increased amount of care and support may be required, although many people maintain a good quality of life with limited care or treatment.

Parkinson’s UK has more information at www.parkinsons.org.uk.

Pneumonia

Pneumonia is usually the result of an infection, where germs multiply and cause lung infections. This is more likely to happen if your relative is already frail, or in poor health. This inflammation causes the alveoli (tiny air sacs in the lungs) to become full of fluid and as a result, the lungs struggle to work properly. In response, the brain sends white blood cells to the lungs to fight the infection, which helps kill the germs causing the infection, but also inhibits the passage of oxygen from the lungs into the bloodstream. Pneumonia is not the same as bronchitis, which is an inflammation or infection of the large airways, known as the bronchi. It is possible to get bronchitis and pneumonia at the same time, known as bronchopneumonia. Pneumonia can be caused by various bacteria, viruses or fungi. The most common bacteria are called Streptococcus Pneumonia. Pneumonia spreads via infection from person to person, as it is an airborne infection. It can develop from flu, particularly in older people, as flu lowers the immune system.

If your relative has pneumonia, they will have similar symptoms to flu or a chest infection, but symptoms often develop more quickly. These will include a high or very high temperature, shivering, sweating and coughing, which produces dark yellow or green phlegm, sometimes flecked with blood. They may also experience rapid breathing, which if too rapid, can be a sign of the severity of pneumonia, as well as disorientation and confusion and a sharp pain in the side of the chest, worse with deep breathing, which can mean that pleurisy has developed. Pleurisy is when the thin outer covering of the lung becomes infected and inflamed by pneumonia. If they are suffering any of these symptoms, seek medical help immediately.

People who are in hospital with other problems sometimes develop pneumonia while they are there. This does not mean that the hospital is unhygienic, simply that their resistance to the germs that can cause pneumonia has been weakened by their other medical problems. To avoid catching pneumonia, your relative should try to stop smoking. Smokers have an increased risk of developing pneumonia, as well as other chest infections. It is important to practice good hygiene to reduce the spread of germs, so encourage them to use a tissue and hand sanitisers when they cough or sneeze and to dispose of it immediately. They must wash their hands regularly too. It is a very good idea to get a flu jab, which is available from their GP, or from many pharmacists. The flu jab is free for anyone over the age of 65. You can also vaccinate older people against pneumonia. The pneumococcal polysaccharide vaccine (PPV) is available for people aged 65+ and anyone over the age of two, who fall into a high-risk category. It is usually only needed as a one-off vaccine.

The doctor will diagnose pneumonia based on the symptoms described above, or if necessary, using a chest X-ray. The main treatment for pneumonia is antibiotics. In addition, it is important to get plenty of rest and to drink ideally eight glasses of water per day. Painkillers will almost certainly be prescribed to alleviate headaches and other aching and pain. Some people with mild pneumonia manage at home with treatment from the GP while others need to go to hospital, where they will be given antibiotics and fluids intravenously by drip into a vein. Oxygen may also be provided. Seriously ill patients, who are struggling to breathe, may be put on a ventilator, which moves air in and out of the lungs if a person is unable to breathe normally.

If pneumonia is mild, your relative may be ill for a week or so and slowly get back to normal, followed by a steady return to normal activity. With severe pneumonia, requiring hospitalisation, it might take weeks or months for them to feel fully well again. Most people recover from pneumonia and return to good health, but between 5 and 14 per cent of people who are admitted to hospital with pneumonia sadly die, many of them older.

You can get further information from the NHS at www.nhs.uk/conditions/pneumonia.

Prostate

The prostate gland is a part of the male reproductive system. It is about the size of a walnut and sits below the bladder, surrounding the urethra, which is the tube that carries urine and semen from the bladder to the penis. Its main function is to produce seminal fluid. When many men reach the age of 40, their prostates begin to get bigger and can cause problems when urinating. This is usually a non-cancerous, treatable condition, known as benign prostatic hyperplasia (BPH). According to the NHS, prostate cancer is the most common cancer in men in the UK, with more than 40,000 new cases diagnosed every year, which is more than 110 men every day. Across the UK, around 250,000 men are currently living with prostate cancer. When cells in the prostate grow faster than normal in an uncontrolled way, this can result in a tumour. In the early stages, the tumour is hard to detect, as it cannot be seen, grows slowly, and often causes no symptoms for years.

It is important to note that the symptoms of growths in the prostate are very similar, whether they are cancerous or benign (BPH). Most prostate cancers (80 per cent) grow slowly and may not cause any symptoms or illness. Symptoms may only be noticed when the prostate is large enough to put pressure on the urethra and causes problems with urination. However, in 20 per cent of cases, the prostate cancer cells can grow more quickly and may spread to other parts of the body. Men are often very reluctant to get their prostate checked, usually out of embarrassment, but the test is usually just a blood test and it can save your life, so encourage your male relative to have it done.

Common symptoms for prostate problems (both BPH and cancer) may include increased need to urinate, often during the night, needing to rush to the toilet, difficulty in starting to urinate, straining while urinating, a weak flow of urine, or feeling the bladder has not fully emptied. Rarer symptoms may include pain when urinating and finding blood in the urine or semen. Symptoms that the cancer may have spread include bone and back pain, loss of appetite, pain in the testicles and unexplained weight loss.

If symptoms become worrying, a visit to the GP is needed. The doctor will probably do a blood test and rectal examination. The blood test is taken to check for levels of a protein called prostate specific antigen (PSA), which is made in the prostate. It is normal to find some PSA in a man’s bloodstream – this is called the PSA level. The PSA level reading generally increases as men get older. If the PSA level is slightly raised, the GP will usually request a second blood test is done one to three months later to check if the PSA level is rising or staying the same. A high PSA level is usually due to non-cancerous prostate enlargement (BPH), but very high PSA levels usually indicate that cancer is present and the GP will refer the patient to a specialist for an appointment within two weeks, in line with NHS guidelines. To check the prostate for any abnormal signs, including lumps, the GP will perform a digital rectal examination (DRE), which involves putting a gloved finger in the patient’s back passage, or rectum. The GP may then refer the patient to hospital for more diagnostic tests. These may include rectal ultrasound, needle biopsy and an MRI scan.

If prostate cancer is detected at an early stage, then treatment is not always immediately necessary for some men. In these cases, the patient will be carefully monitored. If treatment is recommended, it will usually include surgery to remove the prostate, followed by radiotherapy and hormone therapy. As the side effects of these treatments can include erectile dysfunction and urinary incontinence, many men often choose to delay treatment. Newer treatments such as high-intensity focused ultrasound (HIFU) and cryotherapy, which have reduced side effects, may be offered by some hospitals. If the cancer is diagnosed at a later stage, it may have already spread to other parts of the body (often the bones) and cannot be cured. Treatment in these cases focuses on prolonging life and relieving the symptoms.

Prostate cancer and its treatment may cause physical changes (including extreme tiredness, bowel and bladder problems, and erectile dysfunction) as well as emotional issues. Patients should allow time to convalesce and come to terms with their experiences.

You can find out more at Prostate Cancer UK (https://prostatecanceruk.org).

Shingles

Shingles is a nerve infection, which also affects the surrounding surface connected to the nerve. Shingles comes from the same virus as chickenpox (the herpes virus), but your relative can still get it, even if they have had chickenpox as a child, as the virus remains dormant in the central nervous system. The inactive virus may not cause problems for years, if ever. Your relative cannot get shingles if they have not had chickenpox. One third of the population develops shingles and the older you are, the more common it is. It is most common in people over the age of 50, with half of all cases occurring over the age of 60 years. Most people only get shingles once. Age, a lowered immune system, cancer and its related treatments, other medication and stress can all lead to shingles.

Shingles appear as blisters in one or more bands on one side of the body, usually around the waist, or on one side of the face. The blisters normally appear a few days after the pain and initial rash. Sometimes the blisters join together, so they resemble a large burn. New blisters can keep appearing for up to a week, but will gradually heal. There may be minor scarring. An episode could last between two to four weeks. The pain from shingles can be mild to severe and may include burning, shooting pain or itching. The pain can sometimes last for months after the blisters have healed. In addition, your relative may experience a temperature, headache, nausea, upset stomach, difficulty passing urine, joint pain, swollen glands and generally feel tired and unwell. It can also affect their sense of taste and give ear and eye problems. Most adults with the dormant virus will never experience an outbreak of shingles, unless an unknown trigger activates the virus.

It is normally easy for a doctor to diagnose shingles from looking at the skin and blood tests are not usually necessary. It is important to keep the rash dry and clean to avoid infection, to wear loose-fitting clothing, which will not irritate the skin, and to use non-adherent dressings if your relative needs to cover the rash. Adhesive dressing and antibiotic dressings will irritate the rash further. Calamine lotion can help to soothe and alleviate the itching. Antihistamines may be helpful to alleviate night-time itching. Painkillers can reduce the pain. Your doctor may prescribe antiviral medicine, such as Aciclovir, to help prevent the virus from spreading. It is thought that if someone has been vaccinated against chickenpox, they are less likely to develop shingles, although this is not always the case.

The NHS has more information at www.nhs.uk/conditions/shingles.

Skin

The skin forms a natural protective barrier that, as we age, becomes less effective. It is more prone to becoming dry and less robust when exposed to irritants, such as soaps, shower gels and biological washing powders. However, by following a few simple skin care strategies, it is possible to keep the skin healthy and to avoid many of the unpleasant symptoms that can accompany the older skin.

Healthy skin can be likened to a brick wall structure, where the skin cells are the bricks, which are held together by a complex mixture of fatty acids. When there are not enough of these fatty acids, the structure of the brick wall becomes unstable. Water is lost from the skin’s surface, leading to dry skin, and irritants can penetrate through the skin more easily.

There are two key ways of ensuring that the brick wall structure is kept strong. First, avoid substances which irritate the skin. These tend to break down the natural fatty acids and lead to itching and dryness. The skin may also become sore. Detergents and soaps are two of the main culprits. Normal perfumed soaps and bubble baths will cause skin dryness and are best avoided in the older person. Soap substitutes are now commonly available in chemists; broadly speaking, these are formulated in such a way as to moisturise the skin, rather than dry it. Aqueous cream has been a commonly used soap substitute; however, this has been shown to be irritating, so other non-perfumed white creams are better options. Aqueous cream should not be used as a leave-on emollient either. Other substances which will irritate the skin include washing-up liquid, cleaning products, laundry detergents and fabric conditioners. Protective gloves should always be worn when these substances are in use.

Always apply a moisturiser to the skin. There are dozens of products on the market, so it is important to find one that suits you. Greasy ointments can be helpful for very dry skin, but most people find them too sticky for everyday use. Creams are usually the best bet as they have a good ability to moisturise and are more cosmetically acceptable. Lotions are generally more watery and therefore, while easily absorbed, are less effective. The key is to find an unperfumed product and these tend to be the pharmaceutical grade emollients. Mostly, these are only available in pharmacies. Pump dispensers are cleaner and easier to use and most products are now available in this format. It is important that moisturisers are used regularly, and always after a bath or shower.

Top tip: When applying moisturiser to the skin, do so by gently stroking rather than vigorous rubbing. The moisturiser will sink into the skin of its own accord given a few minutes.

Itchy skin is a common complaint in older people. While itchy skin may be a symptom of a more serious underlying condition, more often than not, itching is the result of dryness, so avoiding irritants and using moisturisers is enough to keep itchy skin at bay. Itchy skin is always worse when an individual is not occupied or distracted. Feeling anxious seems to heighten itching, so a vicious cycle can occur, as itching causes anxiety and this worsens the itch. Keeping busy and having something else to focus on is another strategy, along with using moisturisers, for lessening the impact of itchy skin. If these simple measures are not helping, a visit to the GP is advised so that other causes of itching can be identified.

Looking after skin in cracks and crevices is particularly important. Between toes and under skin folds are vulnerable to fungal infections – the moist, warm, dark environment makes them ideal places for fungi to take hold. Careful cleansing and drying of these areas is vital. While a fungal infection is more of a nuisance than anything else, the fact that they cause breaks in the skin mean that other, more dangerous infections can take hold.

Top tip: Drying hard-to-reach areas can be difficult, so using a cool hair dryer may be helpful, or using gauze rather than a fat towel can ensure that small gaps, especially between toes, are easier to get to.

Bedsores

Bedsores result over time from pressure on skin in contact with another surface, such as a bed or wheelchair. They are very painful, difficult to treat and often lead to life-threatening infection in older people. The human body should be constantly moving, even while we are asleep. That is why we fidget in our chairs and toss and turn in bed. When we stop moving, circulation slows down. The tissue is then deprived of oxygen and nutrients and the skin can die in less than a day, or over several weeks. Older people are at much greater risk from bedsores. Skin is thinner and more vulnerable, and therefore tears more easily. Even moving an older person from the bed into a chair can cause a bedsore. Bedsores usually occur in the areas without much muscle or fat, especially on protruding bones, such as the bottom of the spine (coccyx), shoulder blades, hips, heels and elbows. They can also occur in people with arthritis, or who have limited movement. Diabetics and paraplegics also suffer. Bedsores initially begin with an itchy or sore patch of skin, which can feel warm and might feel spongy, or possibly hard. If caught at this stage, and the pressure on the area is relieved, the bedsore will normally not develop. However, if it is not caught early on, a bedsore will become blistered and sore. If it gets worse, it will eat through all the layers of skin to make a very deep wound, which means the tissue has been destroyed. At the worst stage, bedsores can destroy bone, tendons, muscles and joints and can be fatal.

To avoid bedsores, move your relative’s body at least every two hours in bed, or every 30 minutes in a wheelchair. Try special beds, pillows and mattresses (foam, air, gel or water are all good options), which can help. However, this repositioning can cause its own problems. Support underneath the legs with a foam pad or pillow from the middle of the calf to the ankle and keep knees and ankles from touching. Try not to lay older people on their hip bones. Check regularly for the first signs of sores and act quickly. The majority of people suffering from bedsores are in nursing homes. Ensure that the staff treat the bedsore as they should and are constantly checking for new ones.

Bedsores are hard to heal, but it helps to eat plenty of fruit and vegetables, or to take a vitamin C supplement to aid healing. Dark red, orange and green vegetables are especially rich in the needed nutrients and nutritional supplements of vitamin C and zinc can also be helpful. Clean open sores with saltwater when you change the dressing. This helps to remove dead, damaged or infected tissue. The right dressings can help speed the healing process and protect the wound. Keep surrounding skin dry and the wound moist. Transrelative, semi-permeable dressings retain moisture and encourage new skin to grow. Infected wounds can be treated with topical antibiotics. Surgery is a last resort option and it can be very difficult to recover afterwards.

Stroke

Each year, over 150,000 people in the UK have a stroke and it is the leading cause of severe adult disability. Stroke is a medical emergency, so the sooner you can get your relative to hospital, the better chance they will have of a good recovery. The important thing for families is to be able to recognise the signs of stroke and know what action to take.

Check for stroke with the FAST test:

• Facial drooping: A section of the face, usually only on one side, that is drooping and hard to move. This can be recognised by a crooked smile

• Arm weakness: The inability to raise one’s arm fully

• Speech difficulties: An inability or difficulty to understand or produce speech

• Time: If any of the symptoms above are showing, time is of the essence; call the emergency services, or go to the hospital independently.

Sometimes the symptoms of stroke may only stay for about an hour or so, and then seem to disappear. This may be a mini stroke, otherwise known as TIA (transient ischaemic attack). TIAs may be a warning sign that a major stroke is on the way, so still ring 999. It is important that you get to a TIA clinic, where the stroke risk can be assessed and managed. Forty per cent of all strokes could be avoided by the better management of high blood pressure (see here).

Those who have a stroke and are admitted to hospital will be admitted to a stroke ward. There will be a multidisciplinary team of people, including Stroke Association Life after Stroke staff, speech and language therapists, physiotherapists and occupational therapists, who will work with the stroke survivor to support them in their recovery. Stroke can cause a wide range of disabilities but it is worth remembering that more people than ever before are making a good recovery. In fact, more than a third of stroke survivors go on to make a full recovery.

For those who are left with a disability, the most obvious problems are the physical ones, perhaps loss of mobility in their leg or arm, but the emotional impact on the stroke survivor and also the family can be just as traumatic. The sheer suddenness of a stroke turns people’s lives upside down and families are left to make sense of what has happened and to create some kind of order and normality. Stroke can also affect people’s ability to speak and understand what is being said. They may find it difficult to make sense of the everyday things around them and it affects their ability to connect with others. The burden of a stroke often hits home after leaving hospital. Support from the stroke team for the stroke survivor who has returned home can last up to about a year, but it is often after this time that people suddenly find themselves on their own. It is really important that stroke survivors’ needs are regularly assessed. In doing so, health and social care professionals will be in a much better position to work with the stroke survivor and carer to establish what kind of treatment, care and support is needed. If this has not happened, speak to the key worker or ask your relative’s GP.

The Stroke Survivor’s declaration, which can be found online at www.stroke.org.uk (created for stroke survivors by stroke survivors and carers to give guidance on how to navigate the health, social care and welfare systems and what to do if the individual’s needs are not being met) sets out what level of treatment, support and care people who have had a stroke should be entitled to receive. Make sure your relative’s GP is aware of their changing health needs. Carers can ask to be tagged on the records as their relative’s carer, so if you need to speak to the GP, you can get a carer’s appointment. This can be a really helpful way of getting things moving on those occasions when they appear to be stuck.

The vast majority of strokes happen to people over the age of 65 and, consequently, they are likely to have some existing conditions, but new ones will constantly emerge. This can be the most challenging and complex of things to manage, as health services are set up to treat a range of conditions, rather than the whole person. You may find that you end up doing much of the coordination of services, as this can be the only way to move things on. It is often the seemingly small things that cause people to become trapped in their own homes. Ensure blood pressure is regularly checked to prevent a second stroke, that sight and hearing are regularly checked (stroke can affect vision and hearing), toenails are regularly clipped and teeth are OK. If a stroke sufferer seems to become confused, it is worth getting it checked out. Ill health can diminish people’s world significantly and if they are unable to get out of the house, it can lead to them feeling as though their lives are of little value and hence to depression.

You can get more information from the Stroke Association at www.stroke.org.uk.

Urinary tract infection (UTI)

Urinary tract infections (UTI) can be painful and may lead to serious health problems, such as acute or chronic kidney infection, which could permanently damage the kidneys and even lead to kidney failure. They are a leading cause of sepsis, a life-threatening infection of the bloodstream. UTIs occur when bacteria in the bladder or kidney multiplies in the urine. Older people are more vulnerable to UTIs for several reasons. They are more susceptible to all infections, due to the suppressed immune system that comes with age. With age, there is also a weakening of the muscles of the bladder, which leads to more urine being retained, so the bladder does not empty properly, and they may also suffer from incontinence. The typical symptoms include cloudy urine, bloody urine, strong-smelling urine, frequent or urgent need to urinate, pain or burning with urination, pressure in the lower pelvis, low fever and night sweats, shaking or chills. Older people with serious UTIs often do not have a fever, because their immune system does not combat infection as effectively. In fact, they often do not exhibit any of the common symptoms.

UTIs in older people are often mistaken as the early stages of dementia or Alzheimer’s because symptoms are similar. People can suffer confusion or a delirium-like state, agitation, hallucinations, poor motor skills, or dizziness and a propensity to fall.

Other conditions which make the older person more susceptible to UTIs are diabetes, use of a catheter, bowel incontinence, an enlarged prostate, immobility or surgery of any area around the bladder and kidney stones. People with incontinence are more at risk from UTIs because of the close contact of incontinence pads and underwear with their skin, which can reintroduce bacteria into the bladder. Some recommendations to help reduce this risk include changing pads and underwear frequently, encouraging front-to-back cleansing and keeping the genital area clean. If possible, set reminders using timers for those who are memory-impaired to try and use the bathroom instead of incontinence underwear. Other ways to reduce the occurrence of UTIs include drinking plenty of fluids (2–4 litres every day) – drink cranberry juice, or use cranberry tablets – but avoid these if there is a history of kidney stones. Avoid caffeine and alcohol because these irritate the bladder and also avoid douches and other feminine hygiene products as they can act as irritants.

Top tip: Encourage your relative to wear cotton rather than synthetic underwear and to change it at least once a day.

If you think your relative may have a urinary tract infection, make sure they see their doctor immediately. UTIs can make older people delirious and very ill in a very short space of time.

My mother suffers from regular UTIs, but on one occasion, it progressed very quickly and by the time I arrived at her house, there was blood everywhere. It looked like a murder scene. She was taken to A&E, delirious and in great pain, and spent a week in hospital recovering. The infection became that serious within a few hours.

More information is available at the NHS website www.nhs.uk/conditions/urinary-tract-infections-utis.

Mental health

Dementia and Alzheimer’s

Dementia is a very sad illness, which robs people of many of the pleasures of life. It is extremely common and will affect one in five of us who reach the age of 80. It is less common in those under 80, but some people may start with the illness in their 60s, or even earlier. It is very important to get a diagnosis and to learn to navigate your way through the various caring agencies, including the NHS, social services and the voluntary and private sectors. Dementia is probably the most difficult problem that families face when caring for an older person. Most dementia cases are caused by Alzheimer’s disease, but there are other causes, including vascular dementia, Lewy body dementia (associated with Parkinson’s disease) and fronto-temporal dementia. Many patients suffer from a mixture of Alzheimer’s and vascular pathology. Alzheimer’s disease causes 62 per cent of dementia cases in the UK.

The main area affected by Alzheimer’s disease is the grey matter covering the brain, known as the cerebral cortex. This area is responsible for processing thoughts and complex functions, like retrieving and storing memories, calculation, spelling, planning and organising. It is thought that clumps of protein, known as plaques and tangles, form inside the brain. The plaques build up in the spaces between nerve cells and tangles develop inside the brain cells. Together, they interrupt the communication mechanisms between nerve cells and disrupt the processes essential to the cells’ survival. Medical treatments are available to slow the onset of dementia symptoms caused by Alzheimer’s disease. Cholinesterase inhibitor medications have been shown to be beneficial. These drugs make the brain cells work a little harder, thus reducing symptoms.

Vascular dementia occurs when the brain’s blood supply is slowly restricted, causing brain cells to die. Alongside more common dementia symptoms, such as slower mental agility and memory loss, it can also cause muscle weakness and paralysis on one side of the body. The symptoms are similar to the symptoms of a stroke. Vascular dementia is caused by atherosclerosis, which is the narrowing and hardening of the blood vessels in the brain, which is usually a result of fatty deposits along the vessel walls. In smaller blood vessels, these fatty deposits build up, clogging the vessels and gradually depriving the brain of blood and therefore oxygen. This is known as small vessel disease. Atherosclerosis is more common in those with type 1 diabetes, high blood pressure and those who smoke. A history of stroke or small vessel disease can also increase the chances of a person developing vascular dementia.

A person with dementia with Lewy bodies will display the usual symptoms of poor memory, confusion and weaker cognitive ability, plus they may also experience alternating periods of alertness and drowsiness, fluctuating levels of confusion, visual hallucinations and less fluid physical movement. The symptoms may look similar to Parkinson’s disease as the two conditions are closely related. Lewy bodies are small, circular clumps of protein that develop inside brain cells. It is unclear why they develop, or how they damage the brain, but it is thought they have an effect on the neurotransmitters that send information from one brain cell to another. The same inhibitor medications used to treat Alzheimer’s disease have also shown to be beneficial in cases of dementia with Lewy bodies. By encouraging the unaffected brain cells to work harder, the medication can improve the dementia symptoms.

Fronto-temporal dementia affects the temporal lobe and frontal lobe. It typically has a greater effect on personality and behaviour. A person may seem cold and unfeeling as they have difficulty relating to the emotions of others. They may also lose their inhibitions, resulting in erratic behaviour. Language problems may occur, including loss of speech and difficulty finding the right words. This is one of the more common causes, after Alzheimer’s disease, of early onset dementia. It is estimated that, in 15–40 per cent of fronto-temporal dementia cases, the person has inherited a genetic mutation from their relative.

Pick’s disease is a rare type of age-related dementia that affects the frontal lobes of the brain and causes speech problems, behavioural difficulties and eventually death. It was first described by Czech neurologist and psychiatrist Arnold Pick in 1892. In some older medical texts, Pick’s disease is used interchangeably with ‘fronto-temporal dementia,’ but in modern medicine, Pick’s disease is understood to be one of three very specific causes of fronto-temporal dementia.

Parkinson’s disease is caused by progressive damage to the brain resulting in tremor, slow movements and body stiffness. A person with Parkinson’s disease may be diagnosed with one of two forms of dementia – Parkinson’s dementia, or dementia with Lewy bodies – depending on the timing of the onset of symptoms in relation to the physical symptoms caused by Parkinson’s disease (see here).

With dementia, the first thing you may notice in your relative is memory lapse, such as an inability to name objects or people, and perhaps the beginning of more difficulty with everyday tasks, like cooking and planning. There may be incidents, such as losing the car in the car park, or failing to get off the bus at the right stop. These issues are not always caused by dementia, however. Memory problems are sometimes associated with depression, which is easily treated, or they may be worsened, or even caused by physical problems. It is important to see your relative’s GP if you are worried.

Dementia is still a diagnosis that is made from your relative’s clinical history and talking to them and the people who know them best, but patients also perform tests to give some clarity. They may perform a set of blood tests, including thyroid function tests, and maybe an electrocardiogram (ECG) to check the heart, as well as some cognitive tests. These tests vary, but commonly, the Mini Mental State Examination is used – where the GP asks questions, such as what day it is and who the Prime Minister is – and other more detailed tests as well. Your relative may also be offered a CT scan, or even an MRI scan, if it is felt to be necessary. Dementia is a frightening diagnosis for the patient and for those caring for them, so you will need to learn about the illness and about the help that is available. The Alzheimer’s Society (www.alzheimer.org.uk) can be very helpful, but the GP may also refer your relative to the old age psychiatry service, which will also be able to give you helpful information.

You may find it extremely trying when someone you are caring for becomes very repetitive, or is always asking the same questions. They may have odd ideas, especially if they have lost something and feel that it has been stolen, or deliberately moved. They can become aggressive and argumentative. There is not much to be gained from arguing with people in this state and it is sometimes easier for you both to accept some of what they say and only correct them when it is really necessary. As the illness progresses, patients need increasing amounts of help, particularly with personal care, and they may become very upset and angry with those trying to help them. It is important always to remember that the person living with dementia is very sensitive to his or her environment and the way in which they are treated, so they should always be offered an explanation of what is happening and be treated with gentleness and consideration. This can sometimes try the patience of a saint and carers almost always need support. You can ask for a carer assessment from your local authority to help you, and possibly to provide respite care (see here).

Dementia is the main reason why people have to move into residential or nursing care. Although this is often a difficult decision to take, they may find the routine of institutional care reassuring and can benefit from having a larger space to wander around. Carers often feel very guilty, as eventually they cannot manage and have to let their loved one go into care, but sometimes it simply is not possible to carry on at home. The children of the person with dementia often live far away and have to try and organise the care from a distance, which is also difficult. These problems can put great pressures on families and may impact on many family relationships, so try to talk regularly and to share the load as much as you can with siblings, even if it is just helping with admin (see here for tips on caring from a distance).

If your relative is diagnosed with dementia, it is essential early on to grant a Lasting Power of Attorney to trusted family members or friends, so that they can make health and financial decisions on their behalf when they are no longer able to do so. Ensure your relative chooses someone they trust to look after their money and property and to make decisions about their health and wellbeing. Once a person no longer has mental capacity, Power of Attorney cannot be granted. It is also important to be sure that your relative makes a will while they are still able (see here).

If diagnosed with dementia, your relative should try to maintain a healthy blood flow to the vessels in the brain as much as possible, by keeping blood pressure within a normal range through a healthy diet and adequate levels of exercise. If they smoke or use alcohol to excess, this can make dementia symptoms worse. For some types of dementia, specifically Alzheimer’s disease and dementia with Lewy bodies, medication can be used to delay the onset of symptoms. Medication may also be useful in treating other conditions, such as vitamin B deficiency or depression, which could be making symptoms worse. Cognitive stimulation is a psychological therapy designed to help people with dementia cope with the symptoms they experience. The therapy is often completed in a group-based environment. The activities are designed to improve memory, problem-solving skills and language ability. Evidence suggests that regular engagement with cognitive stimulation therapy helps slow the deterioration caused by dementia. It is the only psychological treatment recommended by the National Institute for Health and Care Excellence (NICE). Behavioural therapy can also be helpful in the treatment of dementia. Working from the view that all behaviour is meaningful, the carer can seek to understand what drives the behaviour presented by a person with dementia, and then, with the guidance of a healthcare professional, devise a strategy to change it. For example, someone who wanders about restlessly in the early evening may not be receiving enough exercise during the day to be able to feel restful at night. One strategy to change this behaviour may be to introduce a daily walk in the afternoon.

Significant weight loss is common in people with dementia as it often affects a person’s ability to make decisions and the ability to follow simple instructions, making meal planning challenging. A simple list of tried-and-trusted meal and snack ideas, especially if presented as photos rather than just words, can help a person decide what they would like to eat. A carer may need to help prepare meals. If dementia is affecting a person’s ability to speak and swallow, they must seek medical advice. An inefficient swallowing mechanism can cause food particles to enter the airways, resulting in a chest infection.

It is important not to make multiple major changes to the home at once. However, there are a few minor adaptations that can be made to enable the person to live independently at home for as long as possible. Use a bright contrasting colour to make the important features of a room more visible – for example, the toilet seat, armchair – or bed linen. Keep important phone numbers on display next to the telephone (see here for a list). De-clutter the home space and reduce the amount of furniture to reduce the risk of trips and falls. Ensure all rooms are well lit. A daily newspaper delivery can help a person keep track of the day and date, combined with a calendar listing all upcoming appointments and events. Reflective surfaces can be frightening for someone with dementia if they can no longer recognise their own reflection, so you may wish to cover mirrors. Written labels or photographs posted on doors and cupboards can help them to navigate around the home.

More help is available from the Alzheimer’s Society (www.alzheimers.org.uk) and Dementia UK (www.dementiauk.org).

Anxiety

Anxiety issues in older people are often under-diagnosed, as older patients tend to place more emphasis on their physical problems. It used to be thought that, as we age, we become less anxious, but we now know that anxiety is just as common in old age as it is in younger age groups. Indeed, it is likely that many older people with an anxiety or panic disorder have endured the condition since they were much younger, often coping with it alone.

Anxiety is described as a feeling of unease, which can range from mild worry to severe fear. We all experience anxiety from time to time as a natural response to life events, such as exams, job interviews, public speaking, relationship problems, bereavement, moving house, etc. Severe anxiety can be caused by particular conditions, such as phobias, generalised anxiety disorder (GAD) – which is a chronic condition – post-traumatic stress disorder (PTSD), caused by distressing events, and obsessive compulsive disorder (OCD), where obsessive worries are calmed by compulsive rituals. For many older people, fear of falling can also result in severe anxiety.

Around 1 in 10 people experience occasional panic attacks, which are usually triggered by a stressful event rather than triggered by ongoing anxiety. Panic attacks are short-lived (5–20 minutes), but are unpleasant and frightening experiences, involving a rush of intense psychological and physical conditions. A person having a panic attack may experience overwhelming fear and anxiety, plus other symptoms, such as dizziness, shortness of breath, nausea, trembling, sweating, rapid heartbeat, chest pain and confusion. Although the symptoms are scary, panic attacks are not in themselves physically harmful. People with a panic disorder experience recurring feelings of anxiety, stress and panic on a regular basis, inducing more panic attacks, often for no reason. It affects roughly 2 in 100 people in the UK and is more common in women. The frequency of panic attacks can be from once or twice a month to several times a week, leading to ongoing feelings of worry in anticipation of the next attack. Panic disorder often begins in people aged between 20 and 35 and is thought to be rare in older age groups, although older people can and do experience panic attacks, usually due to life changes, such as the death of a spouse, health issues and depression. All people with panic disorder will get panic attacks on a recurring basis. Some people have attacks once or twice a month, while others have them several times a week. But simply having panic attacks does not necessarily mean your relative has a panic disorder.

Try not to let the fear of a panic attack control your relative and importantly, remind them that panic attacks always pass and that their fears are caused by anxiety so they should try to ride out the attack. Confronting their fears lets them discover that nothing bad is going to happen. If you are with them, you can provide reassurance. Breathing exercises and practicing mindfulness can also be very helpful in managing anxiety (see here for more details). However, it is very important to seek medical help if their panic attacks become more frequent.

If you are concerned about your relative’s anxiety, then the first port of call should be a chat with their GP to rule out any unknown physical cause of the anxiety. There are anti-anxiety medications which can help, but they may also suggest regular exercise, a referral for counselling, or contacting a support group. Caregivers are clearly an important source of support and can help by learning about the condition, providing reassurance and maintaining a normal routine. Fortunately, there are a number of organisations and charities who provide great support for those who suffer with panic attacks. Support groups are a way for them to share common experiences and provide tips on how to cope.

For further help and information, contact Anxiety UK at www.anxietyuk.org.uk, or No Panic at www.nopanic.org.uk. MIND also has helpful tips on anxiety. Visit www.mind.org.uk.

Depression

Many issues can cause depression as people age, such as retirement, the death of friends and loved ones, increased isolation, or medical problems. Left untreated, depression can impact on physical health, impair memory and concentration, and prevent people from enjoying life. The symptoms of depression can affect all aspects of life, including energy, appetite, sleep and interest in work, hobbies and relationships. Many depressed older people, or their relatives, fail to recognise the symptoms of depression and/or do not take the steps to get the help they need. There can be an assumption that older people have good reason to be down, or that depression is just part of getting older. Older people may be reluctant to talk about their feelings, or to ask for help, or they may simply be frightened of admitting to depression. It is so important to remember that depression is not a sign of weakness, or a character flaw. It can happen to anyone, at any age, no matter what your background, or your previous accomplishments in life.

As people grow older, they face significant life changes that can put them at risk of depression. Causes and risk factors that contribute to depression in older adults and the elderly include illness and disability, chronic or severe pain, cognitive decline and damage to body image due to surgery, or disease. Living alone and having a dwindling social circle, due to deaths or relocation, as well as decreased mobility, due to illness or loss of driving privileges, can also lead to depression. Sufferers may feel a lack of purposelessness, or loss of identity. Fear of death or dying, or anxiety over financial problems or health issues can cause depression, as can the death of friends, family members, pets or the loss of a spouse or partner.

As we age, we tend to experience more loss and this is painful. The loss can be felt in different ways, as a loss of independence, or of mobility, health, your long-time career, or someone you love. Grieving over these losses is normal and healthy, even if the feelings of sadness last for a long time. Losing all hope and joy, however, is not normal. Distinguishing between grief and clinical depression is not always easy, since they share many of the same symptoms. However, there are ways to tell the difference. Grief involves a wide variety of emotions and a mix of good and bad days. Even in the middle of the grieving process, there will be moments of pleasure or happiness, but with depression, the feelings of emptiness and despair are constant. Signs include feelings of guilt, suicidal thoughts, or a preoccupation with dying, feelings of hopelessness or worthlessness, slow speech and body movements, the inability to function at work or home and sometimes, seeing or hearing imaginary things.

Symptoms of depression can also occur as part of medical problems such as dementia, or as a side effect of prescription drugs. Medical conditions which can cause depression include Parkinson’s disease, stroke, heart disease, cancer, diabetes, thyroid disorders, vitamin B12 deficiency, dementia and Alzheimer’s disease, lupus and multiple sclerosis. Symptoms of depression can also be a side effect of many commonly prescribed drugs and especially a combination of many drugs taken together. Older adults are more sensitive because, as we age, our bodies become less efficient at metabolising and processing drugs. Medications that can cause or worsen depression include blood pressure medication, beta-blockers, sleeping pills, tranquillisers, medication for Parkinson’s disease, ulcer medication, heart drugs, steroids, high-cholesterol and painkillers and arthritis drugs. Alcohol can make symptoms of depression, irritability and anxiety worse and impairs brain function. Alcohol interacts in negative ways with numerous medications, including antidepressants, and affects quality of sleep.

Signs of depression include overriding sadness, constant fatigue, abandoning or losing interest in hobbies or other pastimes, a reluctance to be with friends, engage in activities or to leave the house, weight loss or loss of appetite, sleep disturbances, anxiety, increased use of alcohol or other drugs, suicidal thoughts or attempts, aggravated aches and pains, memory problems, lack of energy, slowed movement and speech and irritability. The more active people are, physically, mentally, and socially, the better they will feel. Physical activity has powerful mood-boosting effects. In fact, research suggests it may be just as effective as antidepressants in relieving depression. The best part is that the benefits come without side effects. Encourage walking, taking the stairs, or if mobility is more difficult, suggest seated exercises, such as leg and arm lifts and circles. Try to encourage older people to socialise with others, or talk on the phone. They must also try to get enough sleep and maintain a healthy diet. Encourage your relative to get out and about by volunteering, taking up a new hobby, or looking after a pet (see here).

Antidepressants should be used with care if prescribed by the GP. Older adults are more sensitive to drug side effects and vulnerable to interactions with other medicines they may be taking. Recent studies have also found that drugs, such as Prozac, can cause rapid bone density loss and therefore, a higher risk of fractures and falls. Because of these safety concerns, older adults on antidepressants should be carefully monitored. Your relative can also try herbal remedies, acupuncture and natural supplements, which can be effective in treating depression, and in most cases, are much safer for older adults than antidepressants (see here for details on acupuncture). Omega-3 fatty acids may boost the effectiveness of antidepressants, or work as a standalone treatment for depression. St John’s Wort can help with mild or moderate symptoms of depression, but should not be taken in conjunction with antidepressants. Folic acid can help relieve the symptoms of depression when combined with other treatments.

Therapy works well on depression, because it addresses the underlying causes of the depression, rather than just the symptoms. It can ease loneliness and the hopelessness of depression. Therapy helps people work through stressful life changes, heal losses, process difficult emotions, change negative thinking patterns and develop better coping skills. Support groups for depression, illness, or bereavement are a safe place to share experiences, advice, and encouragement. Cognitive behavioural therapy (CBT) is often used to treat depression and focuses very much on the symptoms, rather than the underlying causes of depression.

If an older person you care about is depressed, you can make a difference by offering emotional support. Listen with patience and compassion. Try not to criticise the feelings they express, but point out realities and offer hope. You can also help by making sure that you get an accurate diagnosis and appropriate treatment. Go with them to appointments and offer moral support. Take them out, as depression is less likely when minds remain active. Suggest activities to do together, such as walks, attending an art class, taking a trip to a museum or going to the cinema. Group outings, visits from friends and family members, or trips to the local senior or community centre can help combat isolation and loneliness. Be gently insistent if your plans are refused, because depressed people often feel better when they’re around others, even when they do not think they will.

Plan and prepare healthy meals. A poor diet can make depression worse, so make sure your loved one is eating well, with plenty of fruit, vegetables, whole grains and some protein at every meal. Make sure all medications are taken as instructed and watch for suicidal tendencies. If you are worried, see their GP.

MIND has helpful information on depression. Visit www.mind.org.uk.

Insomnia

Everyone has a bad night’s sleep occasionally, but for some, insomnia is a serious issue, which can have serious consequences. Insomnia is more common in older people and is often debilitating as it can go on for days, months or even years. If normal sleep patterns are disrupted, it can affect memory and cause depression, anxiety, irritability and many other problems.

Sleep requirements change with age. Babies sleep for about 16 hours out of every 24, adolescents need 9 hours and adults need between 7 and 9 hours each night. As we age, however, we often wake earlier and go to sleep earlier. Quality of sleep is as important as quantity. Older people tend to sleep less deeply and for less time. There are also two types of insomnia: the inability to get to sleep and inability to stay asleep. Insomnia can be caused by stress due to work, bereavement, divorce, moving house and many other issues which have an effect on overworking the mind, so that you cannot switch off. Poor sleep hygiene, such as the wrong temperature, uncomfortable bedding and too much light, can all affect your relative’s ability to get to sleep and to stay asleep. An irregular sleeping routine can affect their ability to fall asleep, as can stimulants, such as coffee, tea, chocolate and smoking. Alcohol initially promotes sleep, but later fragments it. As we age, the brain’s internal clock shifts to an earlier sleep cycle, so older people tend to fall asleep earlier, but wake earlier and night-time sleeping can also be affected if naps are taken during the day.

Medication can have significant effects on sleeping, particularly if your relative is taking multiple prescriptions. Pain and physical discomfort will also inhibit sleep. As we age, we need to go to the toilet more often during the night, which wakes us as well. And if your partner snores, it will definitely affect your sleep! Try to encourage your relative to get into a good routine with a regular time to sleep and wake up. Exercising during the day, preferably in the morning, will help, and it is best to avoid exercise for a few hours before bed. Make sure your relative’s bedroom is dark enough, that the bed and bedding is comfortable and that the room is not too hot or too cold. Try to encourage them to make time to take a warm bath or shower before bed to relax. They should avoid heavy meals, caffeine, smoking and alcohol for at least three hours before bed, and try not to sleep or nap during the day. Watching television in bed, or using phones or tablets, can prevent the mind from switching off, so limit their use before bed. They should also try to avoid sleeping pills and never take them without advice from their GP. Mindfulness can be very effective to calm the mind before bed (see here for details) and sometimes, counting sheep really can help!

Huntington’s disease (HD)

Huntington’s disease is an inherited condition, causing progressive brain damage. The disease is caused by a faulty gene, which creates a protein which damages and ultimately kills off brain cells. As the disease progresses, it leads to depression and psychiatric problems, uncontrolled movement, problems with eating and swallowing, behavioural changes, memory loss and poor cognition. Around 12 people out of every 100,000 in the UK have Huntington’s. The disease affects both men and women and it is possible to develop it at any age. Typically, most people who develop problems are diagnosed between 35 and 55 years old. The condition generally progresses for around 10–25 years.

Although symptoms of HD can vary, the progression of the disease is fairly predictable. Early symptoms, such as personality changes, mood swings and unusual behaviour, are often subtle and can be overlooked. Patients can often alternate between excitement and apathy, and between depression and excitement. A general lack of coordination becomes more apparent. Patients can be unsteady on their feet and develop jerky body movements. Loss of motor control can make eating and swallowing difficult. Behavioural changes become more pronounced and there is a gradual decline in communication and mental abilities. Some patients may develop dementia. Although a genetic test for HD has been available for those with a family history of the disease since the early 1990s, some people prefer not to know if they are carriers. However, finding out may give them more time to get appropriate treatment and come to terms with the disease.

Unfortunately, there is no cure as yet for Huntington’s, but research continues worldwide. In the meantime, some aspects of the disease can be managed successfully with medication, specialist therapies and keeping as active as possible. Medication may be prescribed to control involuntary movements, depression and mood swings. Speech therapy can help with communication and swallowing issues and physiotherapy can help maintain balance and mobility. Local authority social services can provide occupational therapy to help make daily living much easier with home adaptations and equipment (see here for more information on care assessments). As well as your relative’s GP and local social services, there are some organisations which offer specialist advice and support.

You can contact The Huntington’s Disease Association (HDA) on their website at www.hda.org.uk, or there is more information on the NHS website at www.nhs.uk/conditions/huntingtons-disease.