September Newsletter
In This Issue
Don't Fall For It
Blood Pressure Thinking
Get D or Die
A Better Model of Medical Care
Old-fashioned medicine with 21st Century convenience and technology
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I hope this newsletter finds you and your family well. It's a really exciting time to be in Milwaukee. Our Brewers are the talk of the nation with another incredible September run. Let's keep it going!
Falls are the leading cause of fatal and non-fatal injuries in older people leading to millions of ER visits, hospitalizations and morbidity from fractures and head injuries. Preventing falls and reducing our risk of losing our mobility should be a focus for healthy aging. What can we do now to improve our outcomes? The first article reviews the medical literature to give us some answers. Scroll to the bottom for a link to a 95-year old man who will teach you "how to fall". 

Dementia is one of the major concerns we all have with aging. We know that high blood pressure can lead to strokes (especially small ones) which can be a potential cause of dementia. This study looks at blood pressure over the long term and what levels seem to give us the lowest risk of dementia. Keeping our blood pressure under control should be a focus throughout life and monitored as we age. 

Vitamin D has always been somewhat controversial. Does it help? Does it hurt? The third study adds to our knowledge of possible ramifications of low vitamin D levels and what level we should shoot for. if you have diabetes you will definitely want to check this article out. 

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Don't Fall For It
Physical activity effectively helps older adults reduce risk of falling and improves mobility
Falls are the leading cause of fatal and non-fatal injuries in older Americans. One in four Americans over age 65 fall each year. One out of five falls cause a serious injury such as broken bones or a head injury. Each year over 3 million older people are treated in emergency departments for fall injuries and 800,000 people are hospitalized, most for head injury or hip fracture. Over 95% of hip fractures are caused by falling. The medical cost of falls is over $50 billion annually. So yes, this is a big problem which makes finding preventive solutions so important. This review, from the American College of Sports Medicine looked at the effects of physical activity on prevention of fall and how it affects physical function with aging. 
  • Purpose: To review and update the evidence of the relationship between physical activity, risk of fall-related injury, and physical function in community-dwelling older people that was presented in the 2018 Physical Activity Guidelines Advisory Committee Scientific Report (PAGAC Report).
  • Methods: Duplicate independent screenings of 1415 systematic reviews and meta-analyses published between 2006 and 2016 identified from PubMed®, Cochrane Library, and CINAHL databases yielded 111 articles used for the PAGAC Report. The PAGAC Aging Subcommittee members graded scientific evidence strength based upon a five-criteria rubric and assigned one of four grades: strong, moderate, limited, or not assignable. An updated search of 368 articles published between January 2017 and March 2018 yielded 35 additional pertinent articles.
  • Results: Strong evidence demonstrated that physical activity reduced the risk of fall-related injuries by 32% to 40%, including severe falls requiring medical care or hospitalization. Strong evidence also supported that physical activity improved physical function and reduced the risk of age-related loss of physical function in an inverse graded manner among the general aging population, and improved physical function in older people with frailty and with Parkinson's disease. Aerobic, muscle-strengthening, and/or multicomponent physical activity programs elicited the largest improvements in physical function in these same populations. Moderate evidence indicated that for older adults who sustained a hip fracture or stroke, extended exercise programs and mobility-oriented physical activity improved physical function.
  • Conclusions: Regular physical activity effectively helps older adults improve or delay the loss of physical function and mobility while reducing the risk of fall-related injuries. These important public health benefits underscore the importance of physical activity among older adults, especially those living with declining physical function and chronic health conditions.


There are several conditions that make one more likely to fall including lower body weakness, difficulties with walking and balance, certain medications, vision problems, foot pain, and home hazards such as stairs, clutter and throw rugs. The statistics regarding falls are certainly sobering. One-fourth of seniors who fracture a hip from a fall will die within 6 months of the injury. However, falling is not an inevitable result of aging. This review show strong evidence that physical activity reduces the risk of falling by up to 40%, and this includes the serious falls resulting in hospitalization. As I discuss with my patients, healthy aging and function are the goals. Physical activity also reduced the age-related reduction in physical function often seen. What does this mean for all of us? We should definitely incorporate physical activity into our lives. Since maintaining function as long as possible is the ultimate goal, the results can definitely be worth it!

Another preventive aspect is to learn to fall if we do lose our balance. This is a nice video demonstrating "how to fall".  

Blood Pressure Thinking
High and low blood pressure patterns linked to incidence of dementia
blood pressure

This study examined the relationship between blood pressure  (BP) and cognitive outcomes in 4761 adults who were followed over 24 years. BP was assessed over 5 visits and at visit 5 and a 6th visit detailed neurocognitive testing was performed. Eleven percent of the participants were diagnosed with dementia. The rate varied dramatically between those who had normal blood pressure in midlife and later life and those who developed high blood pressure or hypotension (low blood pressure) later in life.


  • Importance: The association between late-life blood pressure (BP) and cognition may depend on the presence and chronicity of past hypertension. Late-life declines in blood pressure following prolonged hypertension may be associated with poor cognitive outcomes.
  • Objective: To examine the association of midlife to late-life BP patterns with subsequent dementia, mild cognitive impairment, and cognitive decline.
  • Design, Setting, and Participants: The Atherosclerosis Risk in Communities prospective population-based cohort study enrolled 4761 participants during midlife (visit 1, 1987-1989) and followed-up over 6 visits through 2016-2017 (visit 6). BP was examined over 24 years at 5 in-person visits between visits 1 and 5 (2011-2013). During visits 5 and 6, participants underwent detailed neurocognitive evaluation. The setting was 4 US communities: Washington County, Maryland; Forsyth County, North Carolina; Jackson, Mississippi; and Minneapolis, Minnesota. Follow-up ended on December 31, 2017.
  • Exposures: Five groups based on longitudinal patterns of normotension, hypertension (>140/90 mm Hg), and hypotension (<90/60 mm Hg) at visits 1 to 5.
  • Main Outcomes and Measures: Primary outcome was dementia onset after visit 5, based on Ascertain Dementia-8 informant questionnaires, Six-Item Screener telephone assessments, hospital discharge and death certificate codes, and the visit 6 neurocognitive evaluation. Secondary outcome was mild cognitive impairment at visit 6, based on the neurocognitive evaluation.
  • Results: Among 4761 participants (2821 [59%] women; 979 [21%] black race; visit 5 mean [SD] age, 75 [5] years; visit 1 mean age range, 44-66 years; visit 5 mean age range, 66-90 years), there were 516 (11%) incident dementia cases between visits 5 and 6. The dementia incidence rate for participants with normotension in midlife (n = 833) and late life was 1.31 (95% CI, 1.00-1.72 per 100 person-years); for midlife normotension and late-life hypertension (n = 1559), 1.99 (95% CI, 1.69-2.32 per 100 person-years); for midlife and late-life hypertension (n = 1030), 2.83 (95% CI, 2.40-3.35 per 100 person-years); for midlife normotension and late-life hypotension (n = 927), 2.07 (95% CI, 1.68-2.54 per 100 person-years); and for midlife hypertension and late-life hypotension (n = 389), 4.26 (95% CI, 3.40-5.32 per 100 person-years). Participants in the midlife and late-life hypertension group (hazard ratio [HR], 1.49 [95% CI, 1.06-2.08]) and in the midlife hypertension and late-life hypotension group (HR, 1.62 [95% CI, 1.11-2.37]) had significantly increased risk of subsequent dementia compared with those who remained normotensive. Irrespective of late-life BP, sustained hypertension in midlife was associated with dementia risk (HR, 1.41 [95% CI, 1.17-1.71]). Compared with those who were normotensive in midlife and late life, only participants with midlife hypertension and late-life hypotension had higher risk of mild cognitive impairment (37 affected individuals (odds ratio, 1.65 [95% CI, 1.01-2.69]). There was no significant association of BP patterns with late-life cognitive change.
  • Conclusions and Relevance: In this community-based cohort with long-term follow-up, sustained hypertension in midlife to late life and a pattern of midlife hypertension and late-life hypotension, compared with midlife and late-life normal BP, were associated with increased risk for subsequent dementia.

We know that high blood pressure is linked to increased risk of strokes including "mini" strokes which worsen dementia. But in the absence of strokes, does high blood pressure worsen dementia? Can we alleviate this through good blood pressure control? This study looked at blood pressure levels over 24 years to examine the effects of blood pressure on dementia. People with normal blood pressure in their midlife years who remained normal had a dementia rate of 1.31/100 person-years. Those who were normal in midlife but became hypertensive had a risk of 1.99/100 person-years while people who were hypertensive in midlife and also later life had a risk of 2.83/100 person-years. So we can see that longstanding high blood pressure more than doubles risk of dementia. However, they also found that the group that was normal in midlife and hypotensive (low blood pressure) later in life had a 2.07/100 person-years risk and people who were hypertensive in midlife and then became hypotensive had a 4.26/100 person year risk of dementia. This is likely because hypotension later in life can result in inadequate perfusion of the brain and less blood flow to brain cells. It isn't clear why those who were hypertensive and then became hypotensive are at such dramatically increased risk. It may be that they are unable to autoregulate their blood pressure any longer and have resultant hypoperfusion. 


Bottom line: It appears quite important to control blood pressure from midlife years into later years to reduce risk of dementia, but to be aware of hypotension later in life. If your blood pressure is lower in younger years, this is not a concern. 

Get D or Die
Vitamin D deficiency is linked to increased mortality
vitamin D
This study examined data from over 78,000 patients over up to 20 years and found an association between vitamin D deficiency and increased mortality. This finding was especially pronounced in people with diabetes. Very low vitamin D levels (<10 nmol/L were associated with a 2-3 fold increased in the risk of death. Levels over 90 nmol/L were actually associated with a reduction in all-cause mortality of 30-40%. The largest effect was in those between the ages of 45-60 and no significant association was seen in those over age 75. The strongest associations were seen in causes of death other than cardiovascular disease and cancer. In diabetics, a 4.4 higher risk of death was seen in those with levels less than 50 nmol/L as compared to those higher than 50 nmol/L. 

  • Background and aims: Vitamin D deficiency, as reflected by low 25-hydroxyvitamin D blood levels (25D), is a prevalent correctable risk factor for death. The evidence ranges from numerous association studies and meta-analyses thereof, over Mendelian randomization studies, to randomized controlled trials (RCTs). However, most studies reported to date were performed in rather older populations and some of the largest association studies may have been confounded by increased vitamin D supplementation at old age. In addition, cause-specific mortalities and the impact of age on the 25D association with the risk of death have not been reported in detail, yet. 
  • Materials and methods: Data of all patients who had a 25D measurement at the Department of Laboratory Medicine, General Hospital of Vienna between 1991 and 2011 were retrieved and matched with the Austrian national register of deaths. First 3 years of mortality since 25D measurement were excluded in the analyses. Fine-Gray regression models adjusting for competing risks were used to estimate the survival time in dependence on 25D, adjusting for sex, age, year and month of blood draw. 25D was represented using a spline with 5 knots placed on the corresponding 1/6th quantiles. Using 50 nmol/L as the reference value, we estimated hazard-ratios of chosen serum vitamin D concentration levels (10 and 90 nmol/L). The significance level was set to 1% in order to adjust for multiple testing. 
  • Results: Data from 78,581 patients (mean age= 51.0 years, men 31.5%) were used for analyses. During 20 years (median=10.5) of follow-up, 11877 deaths were observed. Among these patients, 25D <10 nmol/L had 2-3 fold increased risk of death (<45 years old: HR=2.7, 95% CI:(2.1, 3.4); 45-<60 years old: HR=2.9, 95% CI:(2.6, 3.4); 60-<75 years old: HR=2.0, 95% CI:(1.8, 2.3), whereas 25D > 90 nmol/L has shown to be associated with up to 40% reduced all-cause mortality (<45 years old: HR=0.7, 95% CI:(0.6, 0.9); 45-<60 years old: HR=0.6, 95% CI:(0.5, 0.7); 60-<75 years old: HR=0.7, 95% CI:(0.7, 0.8). No associations were observed in the age group 75 years and older (10 nmol/L: HR=1.1, 95% CI:(1.0, 1.2); 90 nmol/L: HR=1.0, 95% CI:(0.9, 1.0)). In terms of cause-specific mortality, we found, surprisingly, only a relatively modest relationship for cancer and cardiovascular disease. The strongest association, accounting for most of the effect on overall mortality, was found for other causes of death with strongest effect sizes for diabetes HR=4.4, 95% CI:(3.1,6.3). 
  • Conclusion: Our survival data from a large cohort, covering all age groups, from a population with minimal vitamin D supplementation at old age, confirm a strong association of vitamin D deficiency (25D < 50 nmol/L) with increased mortality. This association is most pronounced in the younger and middleaged groups and for causes of deaths other than cancer and cardiovascular disease, especially diabetes. Some J-shaped curves were found, rather inconsistently, only for the 25D association with cancer and cardiovascular mortality in certain age groups. Our findings strengthen the rationale for wide spread vitamin D supplementation to prevent premature mortality, emphasize the need for it early in life and mitigate concerns about a possible negative effect at higher 25D levels up to 150 nmol/L.
There has always been controversy surrounding vitamin D. We know that it has a role in bone health. But does it have a role in other area? Other studies have pointed to increased mortality in people with low vitamin D levels, however the issue is always correlation versus causation. Many studies finding no difference focused on the elderly. This study, which was presented as an abstract at a scientific meeting and has not been published in a medical journal yet, found a possible cause for this. These researchers found that over age 75 there was no difference in mortality between the higher and lower vitamin D levels. This could explain many of the negative studies which have been published. Another interesting finding was no difference in cardiovascular and cancer outcomes. Other reviews have suggested a link but it wasn't found in this large study. 

It was interesting that there was such an increased risk for people with diabetes and low vitamin D levels. This should be a reason for diabetics to supplement with vitamin D. 

Many groups suggest that levels of 20-30 nmol/L are adequate. This study used 50 nmol/L as the cut off and had adverse findings below this level. Additionally, they did not find any adverse effects even for those with levels up to 150 nmol/L and in fact found better outcomes at levels of 90 nmol/L. Based on this, it seems reasonable to consider vitamin D supplementation especially in midlife for possible benefits on mortality later in life and to use a goal of a vitamin D level over 50 and likely closer to 90. 

Thank you for taking the time to read through this newsletter. I hope you have found this information useful as we work together to optimize your health. Feel free to pass this on to anyone you think would benefit from this information. 

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As always, if you have questions about anything in this newsletter or have topics you would like me to address, please feel free to contact me by email , phone, or just stop by! 

To Your Good Health,
Mark Niedfeldt, M.D.