October 2016
Taking Action Against Aging
Mon - Sat : 6am - 8pm
Sunday 9am - 6pm
A team of community members can empower you to make healthy choices.
Fresh meat counter offering market-made sausage, brats, burgers and ready to cook dinner options. Bakery, deli and made to order burrito/salad bar. Gluten free options store wide.
CHIEF EXECUTIVE OFFICER DOUGLAS BENNETT VICE PRESIDENT OF FINANCE & OPERATIONS BOB GANLEY VICE PRESIDENT OF ADVERTISING DAVID HABRAT
970.563.4400
CREATIVE SERVICES PRODUCTION MANAGER SUZANNE DUKE DIRECTOR OF CREATIVE SERVICES TODD BARTZ
Fresh Rx - A Full Service Pharmacy Accepting New Mexico Medicaid along with all major insurance plans. Providing retail and compounding services. Fast service · Delivery · Mail-Out (at no charge)
EDITOR/WRITER HUNTER HARRELL
ADVERTISING DESIGN/PREPRESS JIM DODSON CHRISTIAN RIDINGS MICHELLE MARTIN JUSTIN MEEK NICK GONZALES
970.442.6400
ACCOUNT EXECUTIVES COLLEEN DONLEY HANK BLUM RYAN ROBISON SARA KNIGHT SHAWNA LONG EMILY ROOS TERESSA NELSON
Mon - Fri : 9am - 6pm Sat : 10am - 4pm Sunday : Closed 535 Goddard Ave · Ignacio, CO www.farmersfreshco.com
04 Accepting Aging 07 Medication Management 08 A Little R&R 10 Dealing Dental 11 Centering Focus 12 Choosing Care 13 Managing Cost 14 Diet and Exercise 15 Fine Foods 16 Physical Pain 18 Prime Time
DESIGNER CHRISTIAN RIDINGS
Hablamos Español
Taking Action Against Aging
19 Losing Sight 20 Hearing Health 21 Choosing an Oncologist 22 Side Effects 23 What Exactly is Cancer
The Durango Herald uses reasonable effort to include accurate and up-to-date information for its special magazine publications. However, all information comes from a variety of sources and may change at any time for any reason. To verify specific information, refer to the organization or business noted. To view the online version of this guide, visit: www.durangoherald.com
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Accepting aging By: Karla Sluis
… d l o g n i w o r g d n i ” m . t t i ’ n o t o d d I e “ s u t o n t s I am ju – Victor
Borge
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ging is a process that can be filled with joy and vitality, but it can also be harder to keep a positive attitude. Aches and pains may begin to emerge where there were none before, sometimes affecting you in ways you weren’t expecting. Older adults often face challenges in adjusting to retirement, changes in their health, redefining identity and managing loss. While mood shifts can occur at any age, the key to staying happy and healthy while growing older is to recognize the link between mind and body and the role healthcare can play to optimize your overall health and well-being. The whole-person care team approach can improve overall health as people grow older, which improves quality of life. Addressing only physical aches, pains and chronic conditions doesn’t always get at the whole health of a person. For example, older adults with physical health conditions such as heart disease have higher rates of depression than those without. Conversely, untreated depression in an older person with heart disease can negatively affect the management of the heart condition. It is important to note that depression is a clinical condition and not a normal part of growing older. Screenings can help identify the difference between typical challenges of aging versus depression, and help a patient engage with providers to find the right support. More than 6.5 million American older adults suffer from depression. Feeling better and enjoying what life has to offer can be accomplished with the support of healthcare that recognizes the mind-body connection for a happier, healthier life in your later years.
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Symptoms & signs of clinical depression: Hopeless or helpless outlook on life Loss of interest or withdrawal from things you used to enjoy Overwhelming fatigue and sleep-pattern disturbances Anxiety or irritability Appetite and weight changes Uncontrollable emotions Suicidal thoughts
a e l u d Sche
o t e m o c l e “W are” c i d e M isit
Stay Active & Improve Y our Health!
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“Welcome to Medicare” is an introductory, conversational visit for adults over age 65 that includes a review of medical and social history, counseling about preventive services and screenings. It also includes: height, weight and blood pressure measurements; a calculation of body mass index; vision test and a review of the potential risk for depression. Schedule “Welcome to Medicare” visits at Cortez Integrated Healthcare, (970) 565-7946; or La Plata Integrated Healthcare in Durango, (970) 335-2288. The clinics are run by the local nonprofit Axis Health System, and are currently accepting new patients. A sliding-fee scale is available for those who qualify. Karla Sluis is a representative for Axis Health System, which includes nine facilities in five counties of Southwest Colorado. Reach her at ksluis@ axishealthsystem.org.
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October 2016 | Four Corners Healthy Living | 5
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6 | Four Corners Healthy Living | October 2016
Medication management Are your medications under control?
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edication management is an important issue for seniors and their families. Failure to properly manage medications can threaten the lives of seniors, highlighting the emphasis families must place on ensuring seniors take their medications in strict adherence to their physicians’ instructions. Polypharmacy, or the taking of multiple medications for different conditions, can be a potential health hazard for the thousands of seniors who must manage health conditions with prescription drugs. Harmful drug interactions are a result of the confusion that can arise when seniors take multiple medications at the same time. The American Society of Health-System Pharmacists estimates that more than 34 percent of senior citizens are prescribed medications by more than one physician, and 72 percent use medications they were prescribed more than six months prior. Many people also have begun “pharmacy shopping” to save money. According to a study published in 2010 in American Nurse Today, 44 percent of men and 57 percent of women older than age 65 take five or more medications per week, with some taking as many as 10.
Medication confusion is one risk, but older adults also metabolize medications differently than young people. As a result, they may be more susceptible to overdose or other ill effects. Families looking to help seniors effectively manage their medications should consider the following tips. • Keep a running list of medications. Maintain a list of all medications being taken, noting both prescription and over-the-counter medications and any supplements and herbs. Provide a copy to any new doctors you visit and any new pharmacies you patronize. • Use pill sorters. Medication sorters can keep medications organized and eliminate some of the personal error in medication management. Organizers have daily slots and may also differentiate between nighttime and daytime medications. • Understand why each medication is being prescribed. Ask your pharmacist and doctor to explain why each medication is prescribed. This information should be printed on the prescription label. Some drugs designed for one symptom may actually be used to treat other issues as well. • Ask for help. Some seniors may benefit from friendly reminders from a loved one regarding when to take certain medications, especially if they need to take multiple doses throughout the day. Seniors with cognitive impairment may require the services of a visiting nurse or another caregiver. • Recognize that not all medications are right for seniors. The American Geriatrics Society maintains a list of medications that older adults should avoid or take with extreme caution. Some drugs pose a high risk of side effects or interactions, while others are less effective. Discuss alternatives with your physician if you are prescribed one of these medications. • Keep a medication diary. Record any side effects that occur and how the medications make you feel. Always bring up issues promptly with a doctor.
Proper medication management can help seniors avoid drug-related accidents or worse. October 2016 | Four Corners Healthy Living | 7
A little R&R Retaining & relaxing BY PAMELA HATTEN, RN
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ombining medical practices and a relaxing environment, a medical spa or med spa is a hybrid between the traditional day spa and a medical clinic. A med spa differs from a day spa as it must be overseen and run by medical personnel. Every med spa in the State of Colorado is affiliated with a medical doctor as medical director. In order to be an independent med spa, treatments are performed by a registered nurse. In some cases, an esthetician or paramedical esthetician may do laser treatments, however the esthetician must be constantly supervised by the medical doctor. Treatments used in a med spa are driven by results with an emphasis on comfort and a pleasing environment.
COMPREHENSIVE CARE FOR THE ENTIRE FAMILY
SOME PHYSICIANS ACCEPTING NEW MEDICARE PATIENTS BOARD CERTIFIED FAMILY PHYSICIANS Jude Harrison, MD Susan Weber, MD Brad Lyons, MD Jordan Loftis, MD Lauren Loftis, MD Mandy Morford, MD Robert Klein, MD Ryan Duvall, MD
• • • • • • • •
Walk-Ins Welcome • Low Cash Pay Prices Sports Physicals and Well Child Care Childhood and Adult Vaccinations Comprehensive Care for All Ages Women’s Healthcare - Breast & Pap Exams Birth Control, IUDs, DepoProvera, Nexplanon Treatment of Skin Growths and Rashes Occupational & Industrial Medicine Services
Call for an appointment at 259-3110
“Hablamos Espanol”
Website: lpfma.com
Your Appointment will ALWAYS be with a Board Certified Family Physician.
Open on SATURDAY for your convenience Walk-In Appointments for Acute Illness & Injury
HOURS: Mon.-Thurs. 8am—7pm Friday 8am-5pm Saturday 9am—5pm 316 Sawyer Drive in BODO PARK 8 | Four Corners Healthy Living | October 2016
Injectable services: KYBELLA Kybella is a new injectable (deoxycholic acid) that destroys fat cells under the chin (double chin). Once these fat cells are destroyed, they will not return. Reducing the double chin changes the appearance of the face to look younger and slimmer. BOTOX COSMETIC OR XEOMIN To target the underlying causes of frown lines and crow’s feet, among other dynamic lines, caused by repeated muscle contractions like squinting, frowning and smiling, a registered nurse or MD will inject these muscles to temporarily reduce muscle activity. This allows a visible smoothing of the area where lines grow increasingly deep and etch into the skin. DERMAL FILLERS Dermal fillers such as (Juvederm Ultra XC, Juvederm Ultra Plus XC, Voluma XC, Belotero and Radiesse) are made from Hyaluronic Acid or Calcium Hydroxyapatite. Dermal Fillers have various applications in the contouring and improving the balance of facial structure by an educated and experienced provider.
Laser treatments: INTENSE PULSED LIGHT (IPL) IPL (often called photo-rejuvenation) is used to even out skin tone by lightening pigmented lesions such as age spots, and sun damage, along with tiny blood vessels and Rosacea. SUBLATIVE TREATMENTS This is an effective treatment for wrinkles and acne scars that uses fractionated bi-polar radiofrequency, precisely directed to the skin in the form of a matrix. Healthy skin around the matrix dots accelerate the healing process, causing new collagen and healthy skin cells to be produced, providing a smoother and more elastic skin texture. SUBLIME TREATMENTS Combining bi-polar radiofrequency and light energies to precisely heat the dermal tissue, sublime treatments stimulate collagen production within the target treatment area. LASER HAIR REMOVAL This treatment is used to target and destroys hair follicles using bi-polar radiofrequency and diode laser light energies. Pamela Hatten, RN has been involved in nursing for 35 years, first attending nursing school in Florida before moving to Durango in 1994. She has worked in women’s health in Durango, first at Southwest Women’s Health Associates, where she was certified in DEXA bone densitometry. Later Pamela worked for Four Corners Obstetrics and Gynecology where she was first introduced to Laser technology and Injectables in 2003. In 2006 she joined Avabella Med Spa for six years, followed by Signature Med Spa for 3 years. Last January, after the closing of Signature Spa and Salon, Pamela established Pamela Hatten, RN Med Spa on 3600 Main Ave. Through the years Pamela took courses, attended conferences and other training opportunities through P.A.L.L.E.T.T.E., InjectAbility Institute, Epic, Syneron, among others, in Laser and Injectables. She achieved Master Expert level in neuromodulator injection (Botox and Xeomin) and Dermal Filler (Juvederm, Voluma, Radiesse & Belotero) injection techniques. Pamela is a member of ASPSN (American Society of Plastic Surgical Nurses), a local PEO Women’s Organization, Durango Chamber of Commerce and Local First.
Pamela Hatten, RN · Jessica Tambre, RN · Deb Gibson, Coordinator
Educated and Experienced in the Art of Aesthetic Injectable: · Botox Cosmetic · Xeomin Cosmetic · Voluma XC · Juvederm XC · Radiesse · Kybella · Dermal Fillers · Laser Treatments 3600 Main Ave Suite B · Durango
970-799-6999 www.pamelahattenrn.com 235977
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72 Suttle St., Suite C Durango, CO 81301 239388
October 2016 | Four Corners Healthy Living | 9
Dealing with dental needs BY NATHAN ROBISON
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entistry has made tremendous advances in recent years. In fact, according to researcher Gary Slade at the University of North Carolina, people keep their natural teeth much longer than in previous years. On the flip side of that trend, the general population is living much longer than previous generations—thus there continues to be a sizable population of individuals living without teeth in the U.S. The good news in all of this is there are options for people who are missing some, if not all, of their teeth. With the steady rise of the success and popularity of dental implants, a prosthodontist (dental specialist that makes prosthetics for the mouth) can fabricate dental prostheses that look and act very similar to natural teeth. There is hype surrounding a procedure known as the ‘all-on-four’ technique wherein a full arch of prosthetic teeth is fastened to four strategically placed dental implants. Because of the ability to treat patients with less than ideal amounts of jaw bone by adjusting the orientation of the implants, this method has gained popularity. With the arch of prosthetic teeth secured to the four implants, the teeth are held rigidly in place and do not rock or float on the gums as opposed to dentures retained with O-ring snaps. The ‘all-on-four’ technique is a wonderful prosthetic option, however there are significant disadvantages. The main set back is the patient cannot remove the prosthesis to clean and maintain its function. With that being said, the patient must take a considerable amount of time to meticulously clean around each implant post on the underside of the prosthesis often. In addition to tedious cleaning, the patient must see their dentist every three months to remove the prosthesis and professionally clean it. This process can be a difficult and costly endeavor, which unfortunately is rarely discussed in detail before the patient has the procedure. While the ‘all-on-four’ technique is certainly appropriate in some situations, other removable prosthetic options are very similar and equally rigid, yet have the advantage of being removed and cleansed. These other prostheses generally have a bar incorporated in them which locks the dentures into place. Some even incorporate the bar into the denture which prevents the need for a bulky bar attachment to implants in the mouth. So the next time you or a family member considers options for replacing teeth, remember there is more than one way to achieve the desired results. For more information, visit American College of Prosthodontist’s website or contact a local dentist or prosthodontist with experience in dealing with multiple types of implant supported dentures. Nathan Robison is a prosthodontist that practices locally in Durango. He received his certificate in prosthodontics from the University of Tennessee Health Science Center in Memphis, Tennessee and attended dental school at the University of Minnesota. Dr. Robison has specialized training in treating people who suffer from tooth loss as well as those with complex dental needs. For more information, see his website is twinbuttesdental.com.
Centering focus By: Hunter Harrell
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Local senior center aims to aid in aging
ime never stops, which means aging doesn’t either. As the years go by, an individual’s needs change greatly. Nutrition becomes increasingly important, as does exercise and social interaction. Thanks to the Older Americans Act created in 1965, the aging population across the country has access to social services to help maintain health and wellbeing. The Durango-La Plata County Senior Center is just one of those organizations dedicated to providing services that improve quality of life for older adults and offering activities to support their independence to help them age with dignity and purpose. “I think that is what we want for our families,” said Sheila Casey, Director of Senior Services at DurangoLa Plata County Senior Center. “We care about our loved ones and we know if they are in good care it would make a difference in both their lives and our lives as well.” Casey said she believes the Senior Center is a community focal point where people can go to socialize, eat a nutritious meal and receive information, recommendations and access to services that enhance their physical and mental wellness. “This place really focuses on helping seniors live independently in their own homes,” Casey said. One of the ways the center works toward helping seniors remain independent and live in their own homes is by cooking meals. The foundation of the Senior Center is its Nutrition Program, Casey said. Through this program, the center serves more than 45,000 wholesome meals to individuals in Durango, Bayfield and Ignacio as well as areas such as Allison and Arboles. About 60 percent of those prepared meals are delivered to senior’s homes by volunteers through the Meals-on-Wheels program. Each meal is created entirely from scratch and is analyzed by a registered dietician. Menus are available online or at the center and include the nutritional information. The Home Chore Program is another service available to help seniors live more independently. Through this program, six volunteers spend a total of 1200 hours each year making modifications to homes to increase safety. They also spend their time making minor repairs, cleaning homes, doing yard work and shoveling snow for older adults.
Transportation is another crucial factor in improving quality of life for seniors. As people age, their eyesight or other disabilities can limit mobility. The Senior Center provides reliable transportation to places like the Senior Center, doctor appointments, pharmacies, shopping and the post office via wheelchair accessible buses and minivans. By providing these services, individuals are able to retain their independence for longer amounts of time. However, there are additional needs among the 55 and over crowd, and they continue to grow.
“Every single day, we look at how we are going to be improving our programs,” Casey said.“Everything changes.” Other programs, such as the Aging and Disability Resources for Colorado Program (ADRC), provide expert support for families. The ADRC provides a coordinated access point to long term care and support options. Similar to the ADRC, Family Caregiver Support is another expert program that assists family caregivers by offering counseling, support groups and caregiver training. Additionally, the Durango-La Plata Senior Center holds an annual Caregiver Conference and Senior Resource Fair for the community members. Medicare Counseling and Income Tax Assistance is another popular program that aids seniors with tax
returns and questions about Medicare policies,fraud, abuse and prescription medications. While these services provide information and guidance, one of the most important contributions to the community is the Recreation Program. Classes and activities offered under the Recreation Program focus more on socialization and entertainment, but they have other purposes as well. “I think that all of our programs really enhance health and wellbeing,” Casey said. “You name it, we have it. I think that is what is so wonderful about this senior center. It really does offer a wide variety of programs and activities.” With coordinated senior exercise classes such as yoga, tai-chi, zumba, line dancing and the Watch Your Step Program for Strength and Balance, fitness is the focus. Other classes offer the opportunity to learn new skills, such as how to paint, craft and quilt. Card games, bingo, billiards and movie showings are other popular ways seniors spend their time at the center. Even educational opportunities, such as computer classes, abound. Casey said the center works to provide something for everyone. To see what needs the center can fulfill, employees work with senior groups, county commissioners, town officials and program participants, as well as those who have never participated. “We ask them, ‘What is it that you want that we don’t offer?,” she said. “The resource guide was one outcome of that.” The resource guide provides a basic list of services in the county available for a variety of needs, including home health needs, governmental services, housing and rental assistance and many more. By that token, the Senior Center really does have something for everyone, even if it is just a referral. So as people age, services offered by the Senior Center can aid individuals in maintaining their health and remaining active members of the community. “We live in a vibrant and health oriented community, which is wonderful to see trickling into older adults,” Casey said. “The baby boomers are not going to settle for the stereotypical aging. They are movers, shakers and social change makers. They are not going to identify with having anything but a vibrant life.”
October 2016 | Four Corners Healthy Living | 11
Choosing care
BY HUNTER HARRELL
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ealthy living is about making choices to keep oneself in ‘mint condition.’ However, aging sometimes leads to difficulties performing routine tasks without assistance. Though the time for this comes at no certain age, seniors will eventually have to make an important decision regarding their own long-term care. With a plethora of options, considering the level of care one needs is an important first step. To determine the level of care needed, evaluate both physical and medical needs. Is assistance needed for tasks like shopping, cleaning and cooking? Can moving and bathing be done independently? Is maintaining a home or yard increasingly difficult or expensive? Is transportation easily accessible? Determining these needs help guide one through comparing types of care. In addition to the physical and medical needs, evaluate social and emotional needs as well. Over time, family members may move away, while others move on. Likewise, friends may not be as close either. Opportunities to socialize are important for overall mental health and should be taken into consideration. After determining needs, look into the different options available. Though care facilities go by many names, here are seven categories they may fall under.
Home care Home care allows an individual to stay in a familiar place while also receiving the assistance needed to remain independent. If one has access to a close network of nearby family, friends and neighbors and transportation is accessible, this option could be best. In some cases, a homeowner might have the advantage of modifying the home to make it safer by adding things such as rails to the stairs or shower. Home care assistant services can range from weekly visits to 24-hour care based on individual needs. They often offer to assist with bathing, dressing, meal preparation, transportation, paying bills, making appointments and companionship.
Independent living communities Communities that cater to seniors who do not need assistance with daily routines are called Independent Living Communities. Usually, these places have the advantage of offering a range of activities for all interests both on and off-site, while removing the hassle of meal preparation, housekeeping and laundry for the individual. Some examples of independent living communities include retirement communities, senior apartments, 55+ communities and retirement homes.
Assisted living communities Assisted living comes in many forms. Some facilities are designed apartment-style, while others are rooms with a kitchenette. Most provide assistance with daily tasks, but do not provide medical care. Often, assisted living communities will provide transportation to access medical services instead. This option is for those who need more personal care services that are not available at home. Another sector of assisted living is memory or Alzheimer’s care. These facilities can be inside assisted living communities or entirely separate with special emphasis on supervised care. Some examples of other names for assisted living communities include personal care homes, adult congregate care and residential care facilities.
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Residential care homes Private homes adapted for community living are called residential care homes. Live-in assistants care for the residents by assisting with meals, medication management, housekeeping and laundry as well as transportation to doctor’s appointments. Unlike assisted living facilities, there is usually no emphasis on organized activities, but instead focuses on personal care. Some residential care homes have a group dynamic and family-like atmosphere. These homes are often referred to as group homes, adult foster care homes, adult family care homes or personal care homes.
Nursing homes For those who require 24-hour monitoring and medical assistance, nursing homes may be the best option. In addition to providing round-the-clock medical care, nursing homes provide daily assistance with bathing, eating, dressing, cooking and housekeeping as well. With licensed physicians and nurses, and access to in-house pharmacies and programs like physical and speech therapy, nursing homes are able to cater to an individual’s needs.
Adult day services With transportation often provided both to and from the facility, adult day programs provide additional support to caregivers who work outside the home or need a break. Typically, these programs offer services such as personal care, meals and therapeutic activities. Adult day care is primarily for adults with physical or mental disabilities as well as frail elders who may benefit from the company.
Respite care Respite care usually refers to a short-term type of care, whether in a senior community or in the home. This option is great for when a family caregiver needs to travel or needs a temporary break. In the same way, seniors can use respite care for a change of pace or to test out living in a senior community. Though some services overlap between the different types of care, the key to finding the right one involves careful consideration of the individual’s wants and needs. Some services may be costly, but there are a variety of ways to help manage cost after deciding which direction to take. The best option is the one that keeps one on the path to healthy living. For more information, check out www.helpguide.org/home-pages/seniorhousing.html. They have a variety of articles to assist seniors and their families in choosing care. Aplaceformom.com, a referral service to help seniors navigate housing options, has A Guide to Senior Housing available for download.
Managing the costs of assisted living
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s individuals age, various circumstances have to be reassessed. A current living situation may not be meeting the needs of a senior who may be having difficulty caring properly for himself or herself. Families often consider senior residences to provide welcoming and safe environments for their loved ones during the golden years of their lives. These facilities may range from independent living homes with minimal care offered to nursing homes that provide more intensive care when needed. Somewhere in the middle lies assisted living homes, which blend the independence of personal residences with other amenities, such as the housekeeping, medication reminders or meal services. Assisted living can be a viable option when a person can no longer live alone, but such facilities come with a price. According to a Market Survey of LongTerm Care Costs conducted by MetLife, the national average for assisted living base rates was $3,550 per month in 2012. In the 2015 Cost of Care Survey conducted by Genworth Financial, the assisted living, national-median monthly rate was now $3,600 — and it’s only expected to grow. Affording these homes and apartments can be challenging for those with fixed incomes, but there are some strategies that can help. The payment method that serves you best will depend on your unique circumstances, but there are options available. • Long-term care insurance: Longterm care insurance is specialized insurance that is paid into and may cover the cost of assisted living facilities and other medical care, depending on the policy. The American Association for
Long-Term Care Insurance says that only roughly 3 percent of Americans have this type of insurance, but it is something to consider during working years. • Personal savings: Some people have the means to pay for assisted living with their own savings and retirement nest eggs. However, it’s easy for savings to become depleted when facing a $40,000+ per year bill. • Life insurance: A financial advisor may advocate to pay for assisted living with a life insurance policy. Some companies enable you to cash out for “accelerated” or “living” benefits, which usually is a buy-back of the policy for 50 to 75 percent of the face value. Other third parties may purchase the policy for a settlement of a lump sum, again roughly 50 to 75 percent of the policy’s face value, according to Caring. com, an online source for support and information about the needs of aging people. • Location: Costs of assisted living facilities vary depending on location. It’s possible to get a lower monthly rate simply by choosing a facility in a different state. • Negotiation: Not all prices are set in stone. Speak with a manager at the facility and see if there is any price flexibility or move-in incentives. You also may be able to get a lower rate by negotiating certain a-la-carte costs against all-inclusive pricing. Perhaps you do not need laundry or shopping services, and family members can fill in the gaps, reducing your bill. • Veteran’s benefits: Many veterans are eligible for care benefits that can offset the cost of assisted living care. • Rooms: Opting for a smaller room or sharing a space can keep costs down as well. See if shared rooms are a possibility. Assisted living is a necessity for thousands of people. Explore the ways to finance this purchase.
Consider the different options available to help pay for assisted living services. 220673
October 2016 | Four Corners Healthy Living | 13
Diet & exercise
Needs change with age
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aintaining a healthy weight is important at any age. But avoiding being overweight or obese can be particularly crucial for seniors, considering many illnesses are tied to body weight. Maintaining a healthy immune system also can require eating a balanced, nutritionally sound diet. The Geriatric Research, Education, and Clinical Center at Durham Medical Center in Virginia says people need to change how they eat for every decade they reach. Caloric intake should be reduced because individuals are generally moving around less, have less muscle and their metabolic rates decline. People who find that they are having trouble losing weight in their 50s and older may be basing weight-loss goals on calorie recommendations for younger people. One challenging thing about eating less overall is supplementing with more nutrient-rich foods. Older bodies still require similar amounts of protein, vitamins and minerals as younger ones, but older men and women must balance that need with their need to consume less calories. Consuming more fruits, vegetables and lean protein sources, including beans, and choosing whole grains over refined starchy foods can be the key. Watch what you drink, as well. Soft drinks and other sugary beverages may be packed with calories you don’t need. Choose unsweetened beverages and opt for water as much as possible. Protect yourself against dehydration, which can be harder to detect as you get older. In addition to modifying food and beverage choices and reducing their calorie intake, seniors should continue to exercise. Healthy eating paired with moderate exercise remains one of the best combinations for healthy weight loss or weight maintenance. The goal is to consume fewer calories and expend more energy. While cardiovascular exercises can be a good way to get the heart pumping and stimulate your metabolic rate, as you age you should perform strength-training and weightbearing exercises as well. Muscle mass naturally diminishes with age, and according to the Mayo Clinic if you avoid strength exercises you can eventually lose muscle and increase the percentage of fat in your body. Strength training also helps you develop stronger bones, which can help prevent fractures. In addition, as you gain muscle, your body will begin to burn calories more efficiently, making your time in and out of the gym more productive. Apart from diet and exercise, aging adults may need to consult with their doctors about nutritional supplements. Your body may produce less stomach acid as you get older, making it more difficult to absorb vitamins from food, including vitamin B12 and vitamin D. Aging skin is less able to transform sunlight into the vitamin, which can affect the body’s ability to absorb calcium. Deficiencies in vitamins D and B12 and calcium can result in a number of health conditions. Routine blood work can help pinpoint whether you are deficient in key nutrients. The body’s nutritional and fitness needs change as a person ages. Those uncertain about the lifestyle changes they will need to make should speak with their physicians.
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THE TOP FIVE FOODS FOR THE OVER 50 CROWD
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en and women must alter their diets as they age. Portion sizes that young adults might have been able to get away must shrink when those same men and women enter their 30s. And as thirty-somethings head into their 40s, what’s on the plate requires more careful consideration than it might have a decade ago. The same goes for men and women over 50, who must take steps to reduce their risk for heart disease, stroke and diabetes. One of the easiest ways to do just that is to eat healthy foods. The following are five flavorful and healthy foods tailor-made for the over 50 crowd. 1. Apples: Apples definitely qualify as a superfood, helping reduce cholesterol by preventing plaque buildup in the blood vessels and, as a result cutting an individual’s risk of diabetes considerably. In fact, a recent study published in the British Medical Journal found that eating at least two servings of apples per week can reduce a person’s risk of type 2 diabetes by as much as 23 percent. Apples also make for a great source of fiber, potassium and vitamin C.
2. Blueberries: Blueberries help men and women maintain healthy blood sugar levels because they are high in soluble fiber, which lowers cholesterol while slowing the body’s uptake of glucose. And despite their relatively small size, blueberries contain more fiber, vitamins and minerals per ounce than any other fruit. 3. Broccoli: Though broccoli might not have been your best friend during childhood, you may want to cozy up to this powerful green vegetable now that you have cracked the half-century mark. Broccoli is loaded with vitamin C. A single 3.5 ounce serving of broccoli contains more than 150 percent of the recommended daily intake of vitamin C, which can shorten the duration of the common cold. In addition, a 2013 British study published in Medical News Today found that broccoli may help prevent osteoarthritis, a degeneration of joint cartilage and the underlying bone that is most common from middle age onward. A similar study from researchers at New York’s Roswell Park Cancer Institute published in the same publication six years earlier found that just three servings of broccoli per month can decrease bladder cancer risk by as much as 40 percent. 4. Fava beans: Fava beans are cholesterol-free and low in fat. Fava beans also may provide cardiovascular benefits and help men and women maintain healthy weights. Fava beans are considered “nutrient-dense,” a term used to describe lowcalorie foods that boast lots of nutrients, and are an excellent source of vitamin B1, which is important for nervous system function and energy metabolism. 5. Oatmeal: Another food that might never make youngsters’ lists of their favorite foods, oatmeal is nonetheless a healthy option at the breakfast table. Oatmeal is loaded with soluble fiber, which can reduce cholesterol levels and subsequently reduce a person’s risk of heart disease. Also low in calories, oatmeal can help men and women maintain a healthy weight. Those who find oatmeal a tad too bland for their tastes can double on their superfoods by adding some blueberries into the mix, making their breakfast more flavorful and healthy.
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Physical therapy helps relieve pain C hronic pain affects people all around the world, greatly impacting sufferers’ quality of life. According to the American Academy of Pain Medicine, recent reports have indicated more than 1.5 billion people worldwide experience chronic pain. Common complaints include lower back pain, headache, neck pain, or neurogenic pain, which is pain resulting from damage to peripheral nerves. Pain can impact people in many ways, as some people can tolerate discomfort better than others. Chronic pain may result in missed time at work, depression, anger, and an inability to live a full life. According to a recent Institute of Medicine Report: Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research, pain is a significant public health problem that costs society at least $560 to $635 billion annually. To cope with pain, many people rely on over-the-counter and prescription medications. This reliance on drugs has helped to fuel pain medication addictions that can lead to other drug abuse. The National Institute on Drug Abuse says research now suggests that abuse of opioid pain medications may actually open the door to heroin use. Some individuals report switching to heroin because it is cheaper and easier to obtain than prescription opioids. A safer and sometimes more effective method of pain relief than opioids, physical therapy can help a person get back on track and feel much better in the process. The American Physical Therapy Association says while surgery and prescription drugs can be the best course of treatment for certain diagnoses, there is increasing evidence that conservative treatments like physical therapy can be equally effective and cheaper treatment plans for many conditions. Physical therapy can be as effective as surgery for meniscal tears and knee osteoarthritis, rotator cuff tears and spinal stenosis, among other conditions.
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Treatment plans
W
hen a patient is prescribed physical therapy, a therapist will develop a treatment plan that addresses the specific needs of the patient. This is essentially a collaboration between patient and physical therapist. Therapists are experts in improving mobility and motion and have studied extensively to that end. Because weakness or stiffness may be contributing to pain, therapists try to address the source of the pain and relieve the pain itself. Physical therapy may include exercises that stretch the body and improve flexibility. Strengthening exercises will help work on core muscles as well as other parts of the body to prevent injury down the road. Therapy may target specific areas of pain. Because of their expertise, therapists may be able to assess posture, gait and other attributes that may be contributing to injury and make suggestions to reduce recurrence. In addition to the therapies mentioned, a combination of massage and other work may be included in a physical therapy plan. This may include TENS and ultrasound. According to WebMD, Transcutaneous Electrical Nerve Stimulation, or TENS, uses a device to send a low-voltage electric current to the skin over the area where you have pain. Ultrasound sends sound waves to the places you have pain. Both of these options may help to block pain messages to the brain and offer relief.
“Chronic pain can be debilitating. However, physical therapy is often an effective way to combat chronic pain and help individuals find relief and return to living full lives.”
Don’t let foot pain keep you from enjoying life! We help treat: • Bunions • Heel pain • Hammertoes • Ankle sprains • Arthritis of the foot • Corns • Toenail issues • Plantar fasciitis • Diabetes foot issues — Custom Fit Orthotics — We now offer Moore® Balance Braces to help reduce your chances of a fall. Four Corners Foot & Ankle Dr. Kayse Lake 575 Rivergate Lane, Suite 95, Durango, CO 81301 Voted Best Podiatrist (970) 259-5303 • www.4cornersfeet.com in Durango!
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Prime time
BY JOSEPH C. GAMBONE, DO, MPH
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eceiving the first invitation for membership from the American Association of Retired People (AARP) at the ‘tender age’ of fifty can be foreboding, but for many people in the U.S. it is during this decade of life that financial and relationship security is near or at its best. The fifties, now, can mark the beginning of the prime of life. It has not always been this way. Life expectancy, also referred to as longevity, has improved significantly over the last century. In 1900, men and women in the U.S. could expect to live, on average, until they were 48 years old. This low longevity was due to much higher death rates at birth and during the first year of life. Other factors such as a harsher life environment and less effective medical treatments played a role as well. Now, women in the U.S. can expect to live on average into their mid-to late 80s and men are only a few years behind them. So, life after the age of 55 may be as much as one-third of an entire lifetime. With many other medical advancements and life-style improvements since 1900, the quality of life now can be quite all right after the age of 55.
Longevity is largely affected by genetic makeup often referred to as the genome. As scientists are studying the human genome, they are finding there are far fewer genes than they initially expected. The latest count is down to about nineteen thousand genes in the human genome. Though that sounds like a lot, originally, scientists expected to find one hundred thousand or more genes in the genome. It is harder to explain how such a small number (nineteen thousand) of genes is able to direct all of the various and complicated processes that occur in our bodies day to day. As it turns out, each of these genes can be expressed (activated) in different ways. Thanks to research in reproductive medicine about how humans develop in utero we now know that in addition to our genome (genetic makeup) our bodies and biological processes are directed and affected by our epigenome. Epi means ‘on top of’ or in addition to the effects of our actual genetic makeup. Scientists observed the way genes affect biologic processes is influenced by external environment. In other words, individual genes can be changed in
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50+ terms of how they turn on or turn off our physiologic functions. The genes appear to be the same but the way they direct physiologic processes changes. This is called ‘gene expression.’ Babies, in the womb, exposed to too little or too much nutrition can be destined to develop chronic diseases like diabetes and chronic hypertension because of gene expression and their epigenome. And babies exposed to proper nutrition are less likely to develop these conditions. As more is discovered about the epigenome, we will learn more about
how the environment during early life outside of the womb and into adult life can help or harm overall life-expectancy or longevity. Life after 55 will be even more enjoyable once the ways to improve nutrition and physical surroundings that directly affect the epigenome are understood. Joseph C. Gambone, DO, MPH is a fertility specialist with Durango Reproductive and is American Board Certified in Reproductive Endocrinology and Infertility.
Adding years, losing sight BY DR. SARA J. HAUG
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ge-related macular degeneration (AMD) is a common condition that can cause permanent central vision loss. Though it almost never causes total blindness, it is the major cause of loss of vision in people over the age of 50. SYMPTOMS OF MACULAR DEGENERATION- An important indicator of macular degeneration is distortion of vision. This could mean straight lines will no longer appear straight. For example, a door frame may seem bent or crooked. Also, seeing a dark gray spot similar to the aftereffect caused by a bright flash of light in another symptom. Other symptoms you may notice include the size of an object appears different for each eye or colors don’t look the same for each eye. These changes in eyesight are important and anyone with these symptoms should see their eye doctor promptly. DRY MACULAR DEGENERATION- AMD usually starts with the appearance of yellow-colored spots in the macula, caused by the build-up of fatty deposits, called drusen. Drusen are considered to be a form of dry AMD. When drusen are present for a long time, the pigment layer under the macula may become thin and stop working. This is called atrophic macular degeneration and it often causes a slow and progressive loss of vision. Some people with the dry form of AMD notice blank areas in their central vision. Although dry AMD with atrophy can cause a large loss of detail vision, the damage done by atrophy is generally not as great as the damage that can be caused by wet AMD. Dry AMD occurs in approximately 85-90% of people with AMD, whereas wet macular degeneration occurs in about 10-15% of people with AMD. WET MACULAR DEGENERATION- In the wet form of AMD abnormal blood vessels grow under the retina and lift the retina up, very much like the roots of a tree pushing up a sidewalk. These abnormal blood vessels are called choroidal neovascularization (CNV) because they grow from the choroid, the blood vessel layer under the retina. CNV may leak fluid, bleed, lift up the retina, and create scar tissue. When this happens, central vision is reduced and often distorted. TREATMENT FOR AMD- A scientific study, the Age Related Eye Disease Study (AREDS), found that the use of specific high dose vitamins and nutritional supplements could reduce the risk of losing vision for some patients with macular degeneration. Patients helped by taking these vitamins include those with moderate AMD in both eyes or those with advanced dry or wet AMD in one eye. The AREDS Vitamin Formulation is as follows: Vitamin C 500mg, Vitamin E 400IU, Copper 2mg, Zing 80mg, Lutein 10mg and Zeaxanthine 2mg. Although there are not currently any FDA approved treatments for dry macular degeneration, smoking is a very important and avoidable risk factor. Cessation of smoking can help reduce the risk of visual loss from AMD. The mainstay of wet macular degeneration treatment is using injectable medications into the eye. The medicines injected into the center of the eye are anti-VEGF drugs. By blocking VEGF activity, the damage caused by choroidal neovascularization can be minimized or halted. These drugs, however, are not curative and require frequent treatments to be effective over a long period of time. Dr. Sara J. Haug received her PhD at Yale where she was awarded the Young Investigator Award from the Microcirculatory Society. She then obtained her Medical Degree and Ophthalmic Residency Training at the University of California in San Francisco. Her Vitreoretinal Fellowship was then completed at West Coast Retina.
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Hearing loss affects health T BY HUNTER HARRELL
he five senses provide a way to experience and interact with the surrounding environment, but they also play a vital role in one’s health and well-being. Because ‘hearing’ requires the ear to detect the sounds and the brain to interpret those sounds, hearing loss can affect the body in multiple ways. Increased trouble with balance is one way the body reacts to hearing loss. Some people with hearing loss experience social isolation, mostly due to the communication barrier, which can lead to an increase in brain atrophy. There is also evidence that hearing loss, if left untreated, decreases cognitive brain function and increases the risk of memory loss and dementia according to John Hopkins Medicine research. To understand the best option for treatment, it is important to know the three different types of hearing loss. Conductive hearing loss, commonly caused by wax or fluid build up in the ear, a punctured eardrum or damaged ossicles (bones in the ear), accounts for about five percent of cases. This type occurs when sound is interrupted through the outer or middle ear. The most common type of hearing loss is sensorineural hearing loss. It accounts for about 90 percent of cases. This type of hearing loss occurs when sound has issues with being transmitted in the inner ear. Causes of sensorineural hearing loss include exposure to loud noises, trauma, disease and the normal aging process. The third type, mixed hearing loss, is exactly that. Mixed hearing loss occurs when either the outer or middle ear and the inner have trouble processing the sounds. This type could be caused by blockage in the ear canal and damage to the cochlea. Treating conductive hearing loss usually requires medicine, and in few cases a hearing aid is needed too. However, sensorineural hearing loss is typically treated with only a hearing aid. Mixed hearing loss is treated with a combination of hearing aids and medicine. Understanding the types of hearing loss will better prepare one for the process of obtaining a hearing aid that best suits the individual. In order to begin the process to receive a hearing aid, make an appointment with a licensed physician, preferably an audiologist, for a hearing assessment and interview. The assessment should determine the severity of the hearing loss, while the interview is more beneficial in the selection of treatment that best fits an individual’s lifestyle. Following the assessment and interview, a physical examination of the ears will help diagnose the type of hearing loss. After a diagnostic hearing evaluation, the audiologist will review results with the patient and discuss treatment options. Treating hearing loss may begin with a fitting for a hearing aid. With the advancement of technology, there are a wide variety of hearing aids with different advantages available at varying costs to fit the patient’s lifestyle. No matter the lifestyle, a healthier life starts with taking care of the senses that allow us to experience the world.
Types of hearing aids In-the-Canal (ITC) Completely-in-Canal (CIC) Invisible-in-Canal (IIC) In-the-Ear 233087
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Remote Mic Custom Aids Extended Wear Behind-the-Ear (BTE) Behind-the-ear Aid Open Fitting
Choosing an oncologist • Seek a recommendation from your general practitioner. The doctor who diagnosed the cancer will likely be able to refer you to an oncologist. He or she may know which oncologists have a particularly good track record and can guide you in a certain direction. • Use searchable databases. Various cancer organizations have searchable databases through which you can learn about the various affiliated oncologists. • Consult with your insurance company. Cancer treatments can be expensive, and treatments may span several months and entail various therapies. Doctors and treatment centers that participate in your health insurance plan will be considerably less expensive than those operating outside of your coverage. • Look for a doctor who specializes in your type of cancer. Working with a doctor who specializes in your cancer may provide you with the peace of mind needed to fight the disease, and someone with a track record of fighting your particular disease may be more skilled at treating the cancer than someone whose experience lies elsewhere. • Look into oncologists who work at teaching hospitals. Oncologists working at teaching hospitals may have access to clinical trials or be required to continually update their credentials. Oncologists who also teach may be current on the latest therapies and be more capable of explaining your disease and treatment than doctors who do not teach. • Look for a convenient treatment location. Finding an oncologist who practices at a facility close to home can be an added bonus and one that shaves some of the stress off of the impending treatment. Short trips to and from treatment may help you maintain your energy levels.
C
ancer continues to affect people from all walks of life. The National Cancer Institute says approximately 39.6 percent of men and women will be diagnosed with cancer at some point during their lifetimes. However, the good news is that many people with cancer are seeing their diseases go into remission as survival rates continue to improve. This is thanks to many factors, including advancements in cancer treatments and therapies and the growing number of oncologists who specialize in targeted treatments. Oncologists are specialists who treat cancer, specifically with regard to managing a person’s care and treatment after he or she has been diagnosed. The field of oncology has three major areas, says The Journal of Clinical Oncology. These include medical, surgical and radiation. A medical oncologist treats cancer using chemotherapy or other targeted medications. A surgical oncologist specializes in tumor removal and will typically perform biopsies and other surgical procedures as they pertain to cancer treatment. A radiation oncologist works with radiation therapy to treat cancer. In addition to specializing in one field of oncology, oncologists also may have specific skills as they pertain to one type of cancer. For example, a gynecologic oncologist will be knowledgeable in gynecologic cancers, such as cancers of the uterus and cervix. Upon receiving a cancer diagnosis, patients are typically treated by a team of oncologists. That’s because cancer treatment is diverse and will often require a combination of therapeutic efforts. Patients can have a say in which oncologists they use and are advised to seek out different opinions to find treatment plans they are comfortable with. The following is some advice on how to guide those research efforts.
Cancer patients who find a capable oncologist they are comfortable with may find it easier to beat their disease and clear the hurdles they encounter during treatment. October 2016 | Four Corners Healthy Living | 21
Coping with the side effects of cancer treatments
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ffecting people all around the world, cancer does not discriminate based on gender, age or ethnicity. A cancer diagnosis and subsequent treatments can be overwhelming. Medical teams work together with patients and families to choose the best treatment plans. But while treatments are often highly effective, coping with both the emotional and physical side effects of cancer treatments is a big part of winning the fight against this disease. The National Cancer Institute says cancer treatments cause side effects because treatments not only affect cancerous cells, but also healthy tissues or organs. Side effects vary from person to person, even among those who get the same treatment. Side effects are particularly common among recipients
of chemotherapy. According to The Mesothelioma Center, fatigue is the most frequently reported side effect of chemotherapy, affecting up to 96 percent of cancer patients. Nausea and vomiting also occur in 70 to 80 percent of chemo patients. Cancer patients dealing with side effects like nausea, vomiting and fatigue can focus their efforts on feeling the best they can despite these effects. Nausea can occur during both radiation and chemo treatments. Patients undergoing treatments for cancers of the brain may also experience nausea, says the American Cancer Society. Patients can discuss alternative treatment plans with their physicians if nausea becomes overwhelming. Furthermore, there are medications designed to staunch the feelings of nausea that may help alleviate vomiting spells. Patients should always speak with their cancer care teams about how nausea or vomiting is affecting them, especially if it’s impacting how much nutrition they are able to receive. Fatigue is another common concern.
Exercising during cancer treatments can help reduce stress and increase your energy level.
MD Anderson Cancer Center says that fatigue is treatable, but many patients fail to discuss fatigue with their doctors. Cancer-related fatigue can have a trickle-down effect that leads to sleeping disorders; emotional distress, including depression; and added stress. A healthy lifestyle can help fight fatigue, and such a lifestyle includes healthy eating and exercise. Exercising while
undergoing cancer treatments can be challenging, but even a 20-minute walk during the day can help reduce stress and increase energy. People experiencing fatigue should resist the urge to nap too frequently. One 30-minute nap may be all you need to recharge. In addition, maintain a fatigue journal, which can help doctors identify potential fatigue triggers.
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Emotional effects of cancer treatment can be overwhelming, and some patients may not be eager to share such side effects with their physicians. But seeking help for depression, anxiety, fears, and any of the other myriad feelings that cancer and its treatments can produce can make a world of difference. Trained therapists who specialize in helping cancer patients routinely work with individuals to assist them in coping. When emotional health is in check, it’s much easier to focus on physical health. Cancer treatments may come with side effects. But these effects can often be mitigated so patients can direct their energy and focus to fighting the disease more effectively.
Fatigue is one of the most common side effects of cancer treatment. But cancer patients should know that fatigue is treatable.
What exactly is cancer? C
ancer can affect anyone. Sometimes it strikes with no warning, while other times people may have a genetic predisposition. Various medical organizations say there are between 100 and 200 different types of cancer. Everyone has heard of cancer, but some are still unsure of what cancer is.
Defining cancer
The organization Cancer Research UK defines cancer as abnormal cell growth. Cancer cells are cells that divide in an uncontrolled way. New human cells normally grow and divide to form new cells as the body requires them. As healthy cells grow old or become damaged, they die off and new cells take their place. However, when cancer develops, this process goes haywire. Damaged cells become even more abnormal and can survive when they would normally die. These cells keep multiplying and eventually can form lumps or masses of tissue called tumors. This is the case in most cancers, with the exception of leukemia, wherein cancer prohibits normal blood function due to abnormal cell division in the bloodstream. Not all lumps in the body are tumors. Lumps that remain in place and do not spread to other areas of the body can be harmless or benign. According to the American Cancer Society, cancerous tumors are malignant, which means they can spread into, or invade, nearby tissues. Cancer stages actually are determined based by how far cancerous cells have spread beyond their point of origin.
Cancer stages
Cancer is staged according to particular criteria based on each individual type of cancer. Generally speaking, lower stages of cancer, such as stage 1 or 2, refer to cancers that have not spread very far. Higher stages of cancer, such as 3, mean cancer has branched out more. Stage 4 refers to cancer that has spread considerably.
Common forms of cancer
Cancer can occur just about anywhere in the body. Cancers of the breast, lung, colon, and prostate cancers affect males and females in high numbers. Classifying cancer involves understanding where the cancer originated. Cancer Treatment Centers of America offers these classifications: • Carcinomas begin in the skin or tissues that line the internal organs. • Sarcomas develop in the bone, cartilage, fat, muscle or other connective tissues. • Leukemia begins in the blood and bone marrow. • Lymphomas start in the immune system. • Central nervous system cancers develop in the brain and spinal cord. Cancer is treated in various ways and depends on the cancer’s stage, type and effects on the body. A person’s age as well as his or her current health status also may play a role in treatment decisions made by both the patient and his or her medical team. Surgery may be conducted to remove a tumor, while chemotherapy employs chemicals to kill cancerous cells. Radiation therapy, which uses X-rays to direct radiation toward cancerous cells, is another potential cancer treatment. The side effects of each treatment vary, and there are ways to mitigate these effects.
Why does cancer occur?
Cancer develops for various reasons — some of which may not be fully understood. The National Cancer Institute states genetic changes that cause cancer can be inherited from a person’s parents. Cancers can also arise during a person’s lifetime as a result of errors that occur as cells divide or because of damage to DNA that results from certain environmental exposures. Cancer-causing substances include the chemicals in tobacco smoke. Ultraviolet rays from the sun also have been linked to cancer. Learning more about cancer can help people reduce their risk for developing this potentially deadly disease. Individuals should always speak with their physicians if they have specific questions about cancer.
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MEN & WOMEN
DID YOU KNOW?
Take control of your health, and help reduce your cancer risk by making healthy lifestyle choices!
WAYS TO PREVENT CANCER
Facts: • Some cancers can be prevented. • Cancer is easiest to treat if it’s found early – when it’s small and has not spread. • Cancer check-ups and screening tests to find cancer early can save lives!
Stay away from all forms of tobacco.
Limit how much alcohol you drink (if you drink at all).
Eat healthy with plenty of fruits and vegetables.
Get moving with regular physical activity.
Know yourself, your family history, and your risks.
Protect your skin from the sun.
Get to and stay at a healthy weight.
Get regular check-ups and cancer screening tests.
cancer.org
1.800.227.2345