 Good afternoon everybody and very good afternoon from Manipal Hospital, U.R.K.A. Today we are here to tell you about the topic of 60 years and going strong. And I have Dr. Yashaka Videsa, Dr. Gauravra Sovi and Dr. Agra. We are from different specialities of OBG Guyanese orthopedics and physiotherapy. As of now I'll be introducing Dr. Yashaka Videsa, who is the H.O.D. of obstetrics and gynecology department. Hello Abha. Hello. So over to you and we shall just start with the presentation and enlighten the audience about how to take care of them after 60 years and be strong. Okay. Good afternoon everyone. So we are going to talk on our very topic that is 60 years and going strong as we know the population here in India beyond 60 is increasing day by day. So we have to really take care of all the people who are above the 60 years of age. So there are a few aspects on which from a doctor's point of view and especially a gynecologist's point of view what all things you should take care of. So that is what I'll try to focus on. So we all know prevention is better than cure. So the life first of all I'd like to tell you that life begins at 60. The last 59 years have just been a practice. We all know that we have learned a lot and now we have to start our life because we know everything about the life. But still there are some mistakes which we are doing like many of the people above the age of 40 who should go for health checks are not going for health checks. So I would request yearly checkups after the age of 40 is required and as your doctor's discretion if she wants you to come a little early or wants you to get some investigations done every 3 years like cervical cancer screening is to be done every 3 years not to be done yearly. So your doctor will advise. We also know that we should all do walks, yoga, exercise to strengthen our bones, our muscles and to get fresh air. So please continue doing who are doing and who are not doing please start it. Don't postpone it for tomorrow. Start it from today though we know that during the day you are not able to do it for but still in many societies they have started allowing it so you can take a walk with full precautions of mass and sanitization. Then you should take your medications somebody has diabetes somebody has sugar somebody has BP somebody has cholesterol. So they should take their medicines in time. The problem which at the age of 60 people face is that they are not able to they are forgetting the time of the medicine they don't know how to maintain their charts and when to approach a doctor. First of all you should what my advice will be you should have some boxes kept ready if there are some young people at home they should help their elderly they should make some boxes for morning evening and night and put the medicines there so that they didn't they should not delay the medicines because somebody was hypertensive they missed their medicine they can have a high BP. So the same way and somebody at house who is there even the grandchildren remind their grandparents if they are forgetful your medicine is due especially people who are on insulin their medications should not be missed. They should take good sleep this actually is a little funny to say because most of the people and old age start sleeping very less or they have a little problem in initiation of sleep or maybe they have lots of interruptions in their sleep because of urination stress or because of many other reasons with age usually the sleep pattern disrupts and the sleep requirement also decreases alone. But if you have a healthy abdomen, healthy bowel system and you are exercising and then there is no problem in sleep. So first of all you should have a good bowel movement and your sleep is not disrupted and tired yourself a little bit do some type of exercise then you will have a good sleep. Healthy diet we all know what is healthy diet and what we should eat fruits everything should be decreased proteins should be increased our diet proteins is important for everyone young children pregnant ladies and the elderly. So these three age groups they should always take a lot of proteins in their diet so please do it so that you will not get sick we are talking about prevention here so please start taking the proteins any disease you have if you have not taken care it for you know that you have a little heart problem or you have some problem in your leg in your knees you have maybe a little bit of osteoarthritis but you are still not going to the doctor because you are scared if you will go that she will detect some other disease with you. So please don't do that get yourself treated because once the disease spreads a lot and damages the organs then that the treatment becomes little complicated. So if treated early you can get treatment with exercise also you can get cured with minimal medications you can get. If somebody has some sexual dysfunction at this age usually patients from some other other age always approach the doctor people are usually very ashamed of talking about such things sometimes the female partner is not interested sometimes the male partner is not interested but if both the partners have a little bit of interest they should talk to the doctor and solve those problems. If somebody is drinking smoking and some addiction they have they should decrease it so because it's not the age when you should be continuing with those addictions and my request to most of the people because parents who don't have insurance so I would tell all my elderly people and their children if they have insurance in their offices they should take insurance for their parents I have taken my insurance for my parents also. So take health insurance as early as possible children who are young and joined jobs they should ask their parents to take insurance give their parents insurance so that whenever they are sick in future they don't have lots of problems. Why we need to take care at 60? Why are we talking about this topic right now why was it not needed earlier because we all know the quality of life has improved so much though we talk about a lot of pollution and we talk about so many diseases coming up but we still know the quality of life life expectancy in our country has increased we have seen our grandparents and many other people in early there they used to diet 40 and 50 but now right now even at 60 and 80 they are still there with us and we are taking good care of them and their healthy and we expect them to stay with us for a long time so we because of the expectancy increases increasing we take care of our elderly and we should take care of our health health it's not that after 40, 50 or 60 we are bedridden we should at least have that much of capacity to take care of ourselves very well. So and we want and everybody who is elderly whose children are out of India or who are children are settled somewhere else they are staying alone they have to take care all the needs of the family the marketing, the shopping, the home and all the care everything has to be done by this couple only so they have to be healthy and active if they are not how will they manage so if one partner is sick at least the other partner should be healthy so that they can take care so they should prevent the falls they should take care of their partner be updated to the technology this is also a very important thing which I want all elderly to know because if I have faced this problem my parents they never wanted to change their phone they never wanted to upgrade their phones but nowadays you know everything is there you have online banking going to the bank at times can be difficult for elderly so these things are very safe if you have learned them properly so learn from your children and children who are listening to it should teach their parents so that they don't have this problem elderly should be very enthusiastic to learn it they should not say that it is a good so this is a chart which is just to show you how at the age after the 40 age you see how our bones start deteriorating in this slide you can see there is rapid loss menopause after menopause and this slide is showing before menopause also we have this chart with us so this is showing that even before menopause after the age of 40 our bones start deteriorating a little bit and after 40 it is a sharp decline and so we should take care and after menopause especially it is a very sharp decline so please take care of your bones after the age of 40 perimenopausal also people are suffering few problems like mood swings, cramps weight gain, nausea, irritability so you should meet your doctor and talk to her and some yesterday only I met a patient who was almost a case of premature menopause but she has been treated for a long time last 2-3 years taking some medications having her periods and then again going back to no periods but nobody had yet investigated her and confirmed her diagnosis because if somebody has a post premature menopause they should get treated otherwise what will happen mid premature menopause is having menopause at a very early age that is less than 40 so what will happen our bones will start getting weaker before that so what you should do is you should meet your doctor and take hormonal therapy you should not avoid it hormonal therapy is for your good and not for your back it might be bad for some patients that your doctor will decide whether you should not take hormonal therapy or you should take because there are lots of benefits with hormonal therapy then after the age of 45 when you are about to menopause the time is coming near when you are about to finish with your periods that is the time that hot flashes start coming people usually have a lot of sweating and they feel very heated up especially in the night time and then they get up the whole body is full with sweat so this is a sign that you are having hot flashes they might have tachycardia, and don't feel like eating anything so those things do happen and there is treatment for that few people have dryness and then after the age of 55-60 which we are talking is the osteoporosis stage which comes so because the osteoclastic activity starts when you are taking care of the bone part so I will not be talking in detail about that. So I just wanted to show you all these pictures you can see this first picture of the diet so this is what you have to take after the age of 40 all females especially males also have to take a lot of care of their bone health but especially the females they should take at least 4-5-6 servings of milk products but it is not possible so at least 2 glasses of milk 2 cattories of curd and every day you cannot take you can take lassi, cheese, paneer, chia seeds and lots of broccoli and all those have folic acid, mushrooms and almonds so please and those who are non-vegetarian they should take fishes because they have omega 3 people who are vegetarian they should take super-added omega 3 and some DHA products which are vegetarian are also out in the market. Vitamin D is very important because bone health cannot be prevented just with calcium we need vitamin D and phosphate also for that so if required you should be given and your doctor will also prescribe. Magnesium is also deficient in most of our patients multivitamin is deficient in most of our patients and the care of this you can see this picture of how the bone start becoming porous. Porous is like a sponge so how dense the bone was the calcium starts and becomes porous so what will happen if you have porous bone nothing will happen you will fall you will have a fracture otherwise if you fall what will happen you will not have a fracture you might just have a pain for some time and you will be okay but if you have a very porous bone especially females they have lots of hip fractures and wrist fractures which is the most maximum area where the bone density weakens and then the skin everybody is working everybody is going to the office everybody wants to look young so skin care is also very important in the postmenopause after the age of 60 so the treatment modalities harm on replacement therapy only after discussing with your doctor getting yourself investigated then we have management of urinary and rectal incontinence if you talk about urinary and rectal incontinence in India so it's the most underrated disease none of my patients will come to me with I will not say none few of them very few of them will come to this ma'am I have my urine leaks out or my motion leaks out but this is so common in most of our patients if I ask them a direct question can you have this problem they say yes they have this problem people have stopped being sexually active people stop going to social meetings gatherings because they are ashamed that they may have a urinary leak they may have a rectal incontinence they might have a lot of gas passing which is which will be uncomfortable but they never talk to the doctor and there are so many even in physiotherapy with Kegels and lots of other methods even in yoga, Kapal Bharti and many other diseases you can just cure a lot of a large part of urinary and rectal incontinence every person is not there needing a surgery only a very small group will need a surgery so you should go to a doctor they might be some some people have constipation so that is also leading to rectal incontinence and the passing of lot of gas and because of that pressure the vaginal area and the urinary area is prolapsed so if they be solved that problem also a lot of it improves because as we said as the AV start aging after 60 our muscle mass decreases because of less of protein in there we are not exercising and so muscles of the pelvic area also start losing their strength so if we keep on exercising in that area like we exercise for our body parts but we are not exercising in that there might be a lady who is going to the gym regularly she is exercising all other body parts but maybe she is not exercising her muscles of the pelvic area so she might have urinary incontinence when she is lifting weights so we have to teach her that you should do this and that will treat her so the pelvic fold dysfunction is there then we have cancer prevention and treatments for cervical breast, ovarian and uterine this is I am talking about the female part in male we have prostate cancer which is there at the later age which also has to be taken care though lung cancer mostly stays a very common cancer in the females also but cervical breast ovarian and uterine needs to be treated breast and cervical they have screening methods we can prevent ourselves from these two diseases ovarian and uterine I don't have a screening method uterine usually patients present with some or the other building irregularity in ovarian which is can be silent but lot of ovarian screening tests diagnosis and technology advancements are taking place maybe in future we will have something but still now there is nothing no diagnostic test for ovarian cancer then we have palliative care for people who are actually very sick and cannot be given any surgical modality so at home therapy just pain management therapy is there for them osteoarthritis we know lots of our elderly people have knee joint problems they are not able to walk properly with physiotherapy exercise at least they can walk maybe they will not be running but they will be walking so please treat it at the earliest we have osteoporosis osteopenia so bone density geometry needs to be done to know whether our bones are really very weak because after the age of 60 Dr. Gaurav will enlighten you on that phosphates decreases so patients should be very sure about that they are taking phosphates and they are given phosphates by their doctors and some patients might need injectable also some people might not need injectable so that has to be decided depending on your bone density and your levels and there are few patients I have come across they have been taking phosphates for a very long time without stopping and in that case the bones become brittle and if they fall they will have a fracture so please on your own don't take many patients come to us we should not take calcium they don't cause stone but they are not they are taking phosphate they are taking other things and they don't know what they should do but they are afraid of calcium what I feel is calcium tablets usually you take one tablet it is not even always 1000 milligram so even if you are taking one calcium tablet of 500 milligrams it is not going to cause stones in your body so please I think this is a myth that people think that if your doctor has specifically advised you your urologist not to take it then you stop taking it otherwise I think none of these patients should worry about the stone part in the after the age of 60 the mental health also is very important people might start having dementia, Alzheimer's these are the diseases in which people going for walks I am also very scared at times that my father might go for a walk and he might forget his way but right now he is healthy so not worried but they might be coming at a time that this might happen so if we treat it at the earliest we do exercises and we meet a neurologist and take medications and multibitamins so this can be delayed we cannot totally remove it from our life but it might happen not at 60 maybe at 80 but if it happens at 60 we can try to avoid it by taking medication in time. Then cosmetic care as we talked about that is required some people some females always want to look good some males also want to look good so they should also go for cosmetic care. What is the major causes of death in this age group heart disease is the most important because in female till they have not attained the menopause their heart is the most healthy and healthier than the males but as soon as the menopause their heart function starts decreasing and they should really take care good care of their heart and they should have regular checkups and many females have little bit arrhythmias which might need treatment because Ghabraha heart and misbeeds are very common in them so meet a cardiologist and scan whether you don't have any other super edit disease then we have cancers which is very common cause of death. Cancer is a cause of death only when not detected in time that is what I believe so please don't most of my patients say I don't want to go to the doctor because something or else will come because they will write a test and I will do a test and some disease will come but they are not forgetting it that if the disease is detected late then treatment modality will be difficult. Then the other thing is stroke then we have COPD chronic obstructive pulmonary disease lots of people have pulmonary diseases though in females the disease will be a little less because they are less smoking but lots of females are smoking these days we never know when they are 60 they might have these diseases but at present males are more prone to these diseases and we have pneumonia, influenza, diabetes and lots of patients die because of accidents also like I will say even the hip fracture can cause the death of a patient because of fat embolism, lot of blood loss and septicemia if not treated because at this age many times the patients the old people are not very receptive to any directions what the children say the doctors say they are very adamant to what they want so they should I think listen because the technology has advanced so much they should listen to their children listen to the doctors and let them treat them. We will just talk a little bit of the male partner because I think Dr. Charu is not there with us who would have highlighted a little bit more on the problems in the males I will say that prostate care is very important in males and the rest of the problems are almost similar as in males or in females after the age of 60 and all medical complications to be treated they should also exercise and walk and psychological health is very important and sexual health also is very important for the male partner so checkups and care so eye checkup hearing checkup dementia and depression they should also be checked if we have a suspicion that we are very forgetful it's very common to forget in old age when we have lots of work to do or because of old age little bit of dementia can be normal but if it's increasing at needs treatment you should meet the doctor and nutrition you should be very careful if you have still have doubts always meet a dietician or go to blogs go to internet go to facebook ask somebody dietician in your home see what is best for you treat your vitamin deficiencies calcium deficiencies vitamin D deficiencies take multivitamins proteins isoflavones is very important isoflavones are naturally estrogen so all my females are usually telling them to take we have calcium with isoflavones which I prefer to give to my patients because then they don't have to take it separately also at times because people usually don't take and we have this myth of not taking soya bean in our country everybody say most of the people are hypothyroid they say if you are treated a little bit of soya bean in your diet or twice twice in a week will not cause you any problem so soya bean is the richest source of protein in a vegetarian diet and most of our people are avoiding so I would suggest and I would prefer all of you to take a little we have soya milk we have soya buddy we have soya dal we have there and we have tofu with us so many sources of soya are there you can always take them and increase the natural estrogen in your body and phosphates and vaccination please all of you please take vaccination for all the diseases which I have mentioned pneumococcal influenza, booster hepatitis A, diphoid, hepatitis B so pneumococcal influenza and booster if taken will prevent you from lot of diseases if you get sick and if you are will be prevented lung infections will be prevented and footwear is very important for our old age footwear and foot care podiatry is increasing a lot in our country maybe in traffic it will have another department with us you should have a very good footwear you should not footwear come in main thing which we have to sure focus on footwear is they should not fall falling leads to fractures and lots of problems in and around so please be very careful talk to your doctor if you don't have an idea and all medications should be taken in time as I said and they should take the help of the family members if they think they are forgetting the medicines. Thanks everyone so we will take the questions after Dr. Gaurav and Afia has completed talk so I'll like to invite Dr. Gaurav is the consultant and in orthopedics at Manipal hospital and he will be of all our female patients after the age of 60 and the main patients so because in meals I don't think they have a lot of problems it's only the females who have to take a lot of care of their bone health. Hi everybody first and foremost I should thank Dr. Yashaka for such a nice introduction for me I'm Dr. Gaurav Silvi I'm an orthopedic surgeon working in Manipal hospital and why this talk is important because the most common problems people more than 60 years old have are musculoskeletal that is the bone and joint pains that is the most common reason why people more than 60 years old enter or visit the hospital so coming to bone health bone health is really important reason being fractured something which are responsible for a lot of morbidity now that is the number one cause of morbidity amongst people who are more than 60 years old now the current definition is changing we no longer call people more than 60 years old as elderly they are more mature right now bone health has six components in people who are more than 60 year old number one is exercise which is the most important thing which all of you have to do now I will elaborate further what kind of exercise you need to do and further details would be discussed by our senior physiotherapist Dr. Afia secondly I'm going to talk about osteoporosis osteoporosis I'm pretty sure that's not a new word for you it simply means soft bones and it is inevitable it happens with everybody now third thing which is very commonly asked to me in my clinic says nutrition what should I eat what should I not eat then vitamins vitamins are one of the most ignored topics recently but over the past 10 years the prominence has increased and now everybody is well versed vitamins especially vitamin D fall formation is something which Dr. Yashika has already talked about also Dr. Afia will be having a word about it and the last actually the most important is think strong right a sound body for a sound body a sound mind is important right if you are thinking strong nothing will happen to you right and I will also elaborate on why thinking strong is important so coming to exercises now all the people more than 60 year old both men and women they need to do moderate level exercises the question is that how do I know whether the exercise I am doing is a moderate level exercise or just severe intense exercise now the simple dictum is that if you can talk while doing the exercise then you are performing moderate level exercise like simply walking right you simply walk for 20 minutes in a day right while walking you can easily have conversation now that's a moderate level exercise for you group exercises are better for elderly for people with a six year old the reason being is that you do have interpersonal communication a lot of coordination when you are doing group exercises plus you honestly speaking you enjoy doing those exercises now amongst exercise what is important is that you should do 150 minutes of exercise in a week now roughly the translates to 15-20 minutes of exercise in a day which is actually not much considering the fact that you are 24 hours in a day one thing which you have to avoid is you have to avoid impact exercises now it's no point doing for a run right the moment you hit a treadmill you will surely visit me or one of my orthopedic colleagues because you will end up having knee pain so just avoid impact exercises what is more important for you is stretching now the western world has realizing importance of stretching so we have yoga out there we also have yoga here we are celebrating yoga days so yes you have to stretch your body that's important further details about it will be discussed by Dr. Aafir nutrition why is nutrition important because it's commonly seen that people who are overweight they have pain in the joints they have pain in the back so yes you have to maintain their idle weight which is easier said than done right what is important is balanced diet so diet which is rich in proteins rich in carbohydrates rich in fat but it also has essential minerals and essential vitamins so simple Indian diet of having root tea and dal is actually a balanced diet plus a lot of fruits right fruits fruits fruits eat a lot of fruits now fruits are easy to digest they have the vitamins they have the minerals but also fructose is much well tolerated by the body as compared to sucrose now fructose is a food sugar whereas sucrose is a normal sugar which we eat now as we grow old our body is more comfortable with smaller meals but on a more frequent basis so that instead of eating twice or thrice in a day we should we can eat four times or five times in a day only thing is the portions should be smaller so instead of eating three chapatis right you should be comfortable eating one chapati but you have to eat it around four to five times in a day now avoid binge eating so all those barbecue nation type buffets right that is something which you have to avoid right you have a buffet and then you definitely have some stomach upset and you will be visiting it out so that is something which you have to avoid now vitamins most of the vitamins that is the vitamin B complex vitamin A vitamin E are derived from balanced diet hence the importance of balanced diet however there are two vitamins which are notoriously not derived from diet and they are vitamin D and vitamin B12 and believe me vitamin D deficiency is is way more so it's some studies say that 60 to 70 percent normal population is deficient in vitamin D if you just look at the numbers right 1.3 billion strong country 50 percent of that whoa that's a hoping number now that's vitamin D is again important because that is crucial for bone health normally we require 1000 units a day that's a daily requirement so irrespective of your men your women right you need 1000 units a day the main source of vitamin D unfortunately sunlight right and I am pretty sure that not us many of us are spending 20 30 minutes in a day in sunlight with our neck, whole arms and the exposed right if you're doing that then you're having your daily requirement vitamin D and so that is actually encouraged now what is very important with Dr. Yashik also mentioned is animal checkup right these are really important in animal checkup your vitamin D and vitamin B12 should also be assessed now if they are low then you need to be put on supplements right now we're coming to vitamin B12 vitamin B12 is predominantly derived from non vegetarian diet in a country like ours where 60 percent of population is vegetarian vitamin B12 deficiency is not far from reality it is quite commonly seen and if that is less then supplementation helps Dr. Afia would be mentioning in a talk the vitamin B12 is also required for balance so if you are low in vitamin B12 then your balance would go haywire and you become more susceptible to bones now osteoborosis is inevitable everybody will have osteoborosis right what that you have to understand what happens with our bone density now when we are born right from that time till the time you become 30 to 35 years old the bone density increases gradually gradually and then it flat tubes and that starts declining after age of 35 years we cannot stop the decline but we can do control the rate of decline so instead of declining like this it will decline slowly slowly like this how do we decrease the rate of decline exercise right so that is the importance of exercise modern level exercise that's like an investment right and you are 20 minutes a day is an investment to keep your bones calm and to prevent you from fracture now in women especially menopause they contribute to osteoborosis which has been very nicely elaborated by Dr. Yashchika animal health checkups are important for osteoborosis so in animal health checkup do include bone densitometry assessment that is the extra in case your bone density is less than minus 2.5 that means your osteoporotic that means your higher risk of having a fracture in case you fall or even in case you trip on a loose piece like carpet right in that case you have to be on supplements which your doctor would prescribe you for prevention why are we talking about fall prevention because fractures are the number one cause of morbidity in this country majority of fractures can be prevented not everybody have their bones broken in an accident right so believe me domestic falls that is falls in your bathroom fall from stairs is way more common than accidents and the very common cause of fractures so simple things like preventing loose items in the house like I mean loose carpets furniture which has been just put you have kids in your family then they normally put toys at random places your grandsons or granddaughters and then you might trip on that and also you have to instruct your house elders or you have to instruct your sons and daughters to take care of that eyesight is really important if you are having refractory errors if you are not able to see then you are at higher risk of falling again medicines certain medicines like BP that can cause dizziness and something called orthostatic hypertension and the moment you stand you feel dizzy so you have to in case this is happening to you then kindly contact your physician they might need to alter those medicines you have to check your hearing also because hearing problems are commonly associated with balance problems our inner ear not only helps in hearing it is also the balance center of our body now quickly talking about these things the do's and do's especially now knee is the most common joint affected in aging knee osteoarthritis is rather the most common geographic problem noted it is even more common in refractory errors everybody will have problems in the knee as they age now common question people ask us which is better Indian commode or western commode now for knee specifically you have to avoid squatting so you have to avoid going all the way down so western commode is better so stairs is something which you have to be careful of you have to avoid climbing stairs on a fast basis you have to climb it on a step by step basis and again a very commonly asked question not related to this is if knee replacement is required then when should I get a knee replacement done now the answer is that if you are not able to walk 400 yards if you are not able to perform your activities and daily living like changing clothes, wearing socks, taking out socks or any painkillers if the pain is wearable and you need not take any painkiller or a frequent basis then probably you can avoid getting a knee replacement now shoulder diabetes is the number one enemy of shoulder so if you are diabetic you have to stretch your shoulder otherwise your shoulder will become stiff you have to take care whether your diabetes is controlled or not in case your diabetes goes a wire then the number one indication is your shoulder starts hurting so conversely if you are diabetic and your shoulder starts hurting then you also have to visit your diabetologist or endocrinologist to see whether your sugars are normal or not now again a very common cause of pain in elderly population is pro-practice shoulders these are shoulders which come forward now that is predominantly positional when you are working on laptop or we are writing something of a shoulder they have tendency to come forward we have to voluntarily retract it that is very important in fact okay so that is some exercise which you have to do you have to ensure that your position is not going wrong in case you are bending forward then probably you will end up compressing your spine so you need to have a proper position that is very important foot now footwear people ask which footwear is good for me should I wear plaid should I wear heels should I wear closed footwear should I wear open footwear but the answer is open footwear is better closed footwear because it avoids problems associated with sweat the footwear should not have a narrow box now narrow box means that it should not be narrow pointed because otherwise it will crumble upon your toes and you might end up having deformity of your grid too which you would have seen called as bunion and halux like this but sport shoes should always be preferred so whenever you are going for your morning walk please wear sport shoes you can easily purchase them if you are if you need to wear heels right if there is a marriage in the house and of course you cannot attend it in sport shoes we understand that especially for all the women out there then you have to wear platform heels right you should shoot upwards till it goes you have more chance of having imbalance on it you have more chance of falling and if you fall you come to me thinking strong is important because it says that you are old only when you think that you are old say if you are young in your mind right then you will not age well that is not an elixir for you but thinking strong is very important think that you are a young person think that you can do what is what you can do now happy mind releases endorphins and that helps you if you are under stress suffering or stress in your muscles especially the muscles in the back of the neck muscles in the lower back they become tight and that is a very common cause of pain in the neck and the back meditate that really helps right one more thing is keep yourself active as much as possible try to do your household chores yourself right try to do the cleaning and the dusting the more you do it the better it is right you should cook good for yourself just do not be a lazy person sitting on a cow singing that I am old and everybody will help me right the day you think like that the day you become old and the day you invite problems so with that thing thank everybody for watching this webinar I hope I was able to convey what I wanted to convey now next in line is Dr. Afia she is a senior physiotherapist and she will be elaborating more on what I was telling and she will tell you fantastically what ageing is by the way hello everyone thank you Gaurav sir and Dr. Lashika for like inviting us to talk about the topic 60 years and going strong first of all I would like to wish every senior citizen because today is then senior citizen day and we are enlightening you with all these 60 years and going strong and according to me ageing is not at all and it is a natural condition that need to be nurtured and advanced so basically I will be talking about the physiological the main issues and what all preventions we can take because we don't have one to one solution for all we just give you a prevention tips we can give you some like exercises we can tell you some like what all changes you can made at home but every every person is unique so they need if they for any problem they need a proper tailor made exercise protocol if they have like any disease any neurological any musculoskeletal we just brief you about like the problems and the solution but not that only that is only the solution okay so basically let's talk about like what are the normal physiological ageing so first body composition there is all the gradual loss of lean mass usually so basically muscle mass loss so everything any part of the body will be connected to each other so you need to screen your own so so increased body composition loss then increase in fat bone mineral loss as Dr. Gaurav had also told you bone mineral is the resorption of formation imbalance with ageing because it's a natural physiology in our body so usually bone osteoporotic and slowly above 60, above 50 we say so this is the main reason that we lost our bone minerals then we are also having more falls because of our postural changes our gait changes usually what happen like in old age or usually above like 60 years old our head thrust increase head thrust in the sense we start developing this kind of posture we want to sit like even if the old people want to hear if he just move his head towards you then with this there is an extension because are normally we have this curvature of our cervical spine due to this posture our head spine gets started extending like straightening of the spine and with this we have a like with ageing we develop this kind of posture usually so we have a situated then in response to that we have impact on the lower spine that is the straightening of spine and then we usually old age people develop the low back because one thing is connected to the other and usually when you go to do this problem starts with the spine then we have a scapula protraction and ulna deviation of hand and ultimately all these postural leads to our central of the gravity and it leads to normally falls usually you will see that bathroom slips are common because of sudden posture changes and then they have a fall or trips we have our skin changes also like it reduces, epidermal reduces, elasticity and sensitivity to touch pain and temperature and even the vibratory sense of the old age people reduces so hence they are more susceptible to injuries because we don't feel much time usually you will see diabetic in India is very common because we say foot care is always a little size bigger because of this touch pain and sensitivity and it leads to some problems some scars that they don't know and in diabetics it takes time to heal so you need to take care of your every body part and don't worry if you have to take care of one thing in a day then all things will come in one line take care of small things and big things will come to your place along with that the gate is very important usually women in their pelvic area are not very big they walk in a bedding type of gate like a type they usually walk in bedding gate and their base of support is narrow because they keep their legs straight and in contrast the men take small steps and with that their base gets wider so whenever you walk or if your parents or grandparents take you on a walk you people are very important and give them auditory clues like grandmothers and grandmothers walk straight even if they don't walk more than 5 minutes then they should walk in a proper way if they take a walking aid then walking aid and opposite leg gradually the diagonal pattern is going on in this the swing phase decreases the leg of the leg decreases and the time of support increases so when the leg of our body increases the energy cost increases and the walking speed increases and the walking speed increases so whoever is with us never say that grandmothers and grandmothers walk fast this is a normal physiology they should walk freely and always remember that whenever you walk your heels touch the toes then we also have a cardiopulmonary changes like our cardiac reserve decreases contractile function and heart rate decreases so our response to exercise also decreases so whenever we see patients in OPD their children are very reluctant they complain that they used to walk this much and now they get tired so it is very important to accept everything that is the main thing one need to accept that changes will come okay we are walking for 5 minutes atleast we are not isolated we are bedridden that is the main thing if we eat something after 1 age we used to eat 5 rotis because our demand is more so we get good supply but now after 60 our physical demand also decreases if we eat 2 rotis that is enough so that thing after 60 years the golden period should not be compared to the previous age sometimes these pulmonary functions become less like we said usually in males so if you are doing breathing exercises breathing technique normal breathing pattern increase the expansion of your lungs that is it do not worry if you are not walking every day suddenly you will walk because your heart and lungs are not adapted so you have to adapt slowly these are the physical changes these are natural changes you cannot do anything about it so basically you have to worry about it the response you have to give you need to focus on that okay we are doing 5 minutes walk 10 minutes walk breathing exercise in 10 minutes walk if you are doing deep breathing and along with along there is no issue then we have a neurological changes because our nerves also start degenerating usually people have tendency of tremor atrophy of introsiais which is called Dymnish muscle strength usually lower limb muscle strength starts working because those are the bearing joints so it has to work along with that our bone minerals are decreasing muscle strength means a lot of load so that is why it gets a little Dymnish slowly you will see whenever you see this in your parents or in your grandparents whatever is above 60s their muscle time starts because there is a habit that their response is very alert all the time you will see their neck as flexible as we are they will move they will move to the side because slowly their tone there is a psychological stress they will have to work their tone is increasing slowly their flexibility exercises means whatever it is not spending, flexibility you do all the exercise in one day no one has to make their own routine 3 days a week 3 days a month rest a day as Dr. Gaurav also said 150 minutes per week means 10 to 15 minutes normally you have to do it now I will give you the most important thing accommodation whatever you want to be strong it is your physiological changes which are only body but we need to accommodate for these changes these effects are irreversible and the important thing is education of family and even the patients they are not patients usually old age people this is a natural aging you have to understand it it is not going to work we need to accommodate if I write 20 to 25 minutes in the morning 10 minutes that is enough so without that you have to modify your lifestyle and do not increase the stress exercises most important because in this age osteoporosis, osteopenia and fractures are chances usually not impact aerobic exercises usually very light weight bearing aerobic exercises must for osteoporosis so a wadski theory use it or lost it because our muscles are the most important if you will not use it for 10 days you will lose your power so it is better to keep a functional active just functional active there is no stress that after this age you have to take very heavy things it is very excessive work maintain a good optimum health flexibility and functional strength that I can work all day without tiredness third thing is important stress should also be there and as soon as the impure muscle has little problems always seek medical help and the stabilisation of any impure thing it is important to have stabilisation heart rate is increasing or if you are a doctor annual checkups are very important in this age annual checkups are important and not necessary many people think that if we do then we have to go again and again take your exercise protocol take your medicine chart once that you will go 3-4 months don't go everyday because nowadays everyone is working they don't have to go to the hospital they have to go to the hospital because everyone is busy in their life so it is okay to consult one time whatever they are taking care of whatever they are doing ask them to learn and understand so that they continue at home it is best to consult once for them whatever is the best because everyone is unique so it is best for everyone that you come and meet once make their chart once or make a diet chart once then you follow for 3-6 months or whatever is the best possible way then major issues which are still following that is falls falls are 30% of old age people usually it is stairs like those who are at home they are taking care of it in the bathroom they have to take care of it that is very important because of that the percentage of 30% we can reduce and whenever falls hip fractures become very common because the impact that comes from the floor from the surface it always joins the hip and then we need a arthroscopy for the same and as if I said when the pelvis and forearm fall on the corner then their fractures become very common and remember in old age regeneration power is less so the pain is more the time is more I mean to cure it and maybe someone needs surgery for the same so it is always better to prevent it so ultimately once one fall it is a vicious cycle so once it falls then a fear comes in old age that we can fall we are not going alone so what happens is that we are not going to the washroom of the bed someone comes in front of it so this increases the immobility and as you are doing the urine then the incontinence or any such problem can start and ultimately leads to weakness and isolation of one person and isolation leads to depression then with that depression your muscles and joints will have an effect this vicious cycle is going on so that is why the most important thing is to take care of small things take care of big things what are the strategies what are the risks how can we reduce them first of all visual impairment check up your reflection go for your eyesight if someone is catrack then catrack instruction is important and home safety assessment if a small rugs like if they want to stay in this area in our house then they should not have small rugs below them so they should not fall or if any such hindrance is not there then mobility area is free audio, vestibular dysfunction make your earvex clear make an audiological evaluation hearing aids, whatever we are using first of all because always remember that eyesight, vision, hearing and proper reception there are 3 things that keeps your balance so if your balance is not there then there are more chances of your fall and habitual exercises simple exercise which you can do make your parents or grandfathers do at home we just need to focus on 2 things like you without movement of neck you have to do eye movement that leads to your brain your extremeness and habitual exercises we are talking about this vestibular reflexes so you can do it at home by using a 2 pants or just focus on your nails on your thumb keep this in front of you and just eye ball movement both your thumbs same way up and down sideways you can do both sides easily then strategies dysfunctions vitamin D12 food intake cervical spondylysis balance exercises narrow waist you need a family member you can do a small narrow waist of support stand and close your eyes some unstable surface standing for 3 minutes this is a balance exercises that you are challenging your body to activate so always during this time keep one family member with you use appropriate walking aid because it is very important that people come to old age and they are scared that what will they do if it is must then it is must correctly size footwear with a firm sole a good sole which should be raised high on the inside because what happens when you go to flat feet along with weight your shoes will be right so the shock absorption and weight bearing joints normally our weight lines will fall on the right normals musculoskeletal disorders foot disorders diabetic people need to take care of their body and postural hypertension never in a hurry this tip is for old age people that if you are old then don't stand for 2 minutes because it takes time for your body to adapt then we have common impairments arthritis is very common you usually try to make a normal home regimen that at least your functional impairment and if it is free or any austere arthritis then talk to the orthopedic consultant what is the use of taking so much pain to live your quality of life why do you have to spoil it talk to the contractor once fractures are common because osteoporosis always do light just stand and move your hands move your legs a little light exercise so that your bones have weight and aerobic exercises usually for osteoporosis tbi traumatic brain injuries may be due to accident break fall, strips, BP Parkinson's disease I have seen a lot of patients in my OPD people say that it has no cure it has no cure but we can forge the progression of that disease we can improve their quality of life for them the balance is very complicated so we need to take care of all these things visual impairment check hearing loss and neuropathy because usually the peripheral loves are affected these are our senses so go for everything checkups must for home safety the most important elevated toilet seats are available in every market even the toilet seats are available for pediatric populations so go must buy for your parents buy for your grandparents because always falls usually does not get up grab handles apply the bath so that they have a firm support to get up no slippery bathrooms no skit floor mats like washrooms usually have mats keep in mind never fall all these things are home safety profiles that you need to this adjustment of high distance from padela to floor is important because sometimes the height gets too high these days soft floors 10 inches and all that whenever they get up the foot on the surface does not touch most of the chances are slip or fall so always if there is a lot of pressure in any house then adjust the mattress wherever the bed height is like this where the sleeping area touches the padela if they are sleeping usually for agurination they have to sleep so for that if they are coming in the dark then they have to run so for that you need a lot of adjustment and the low-chairs and couches if there is a problem with the muscles if the bones are weak then there will be more overload so always optimum height chairs or sofas should be all if they have a stick or if they have to pick up some objects then they have to reach the shelves are very high so for them you can see all this in your house and change them a little thank you and once a good professional tennis player said why are people afraid of getting older you feel wiser you feel more mature you feel like you know yourself better you would trade that for softer skin so always remember it's a normal aging process these are physiological changes now we have to adapt in these things we don't have to worry about small things see our social responsibilities by age of 60 are also reduced because we don't have to worry about anyone we don't have to worry about people who are over 60 so the new social responsibilities of grandchildren or yourself are very important thank you so much now we have a question and answer round so we have few questions with us one of the questions is what all things I can add in diet of my old age parents for reducing and muscle aches so many things we have already discovered but I will just repeat them again first of all we should take lots of proteins in vitamin D vitamin D in food products is usually not available and we don't have fortified vitamin D milk in our country so what else we can do we can have little bit of vitamin D is there little bit in mushrooms and vegetables and milk we should take them for fatigue and muscle ache the main problem detection is very important what is the cause the deficiencies is a cause but there can be because of the muscle weakness or there might be some injury in some part of the body or the ligament in the tendon so you should get in yourself checked with the doctor once and then you can start taking these vitamins these will overall help calcium is there and in calcium you have to take milk even if some people are in old age you have to digest milk so then they can take curd you can take lacy charge so any product paneer is also very good so that will also lead to strong muscles and strong bones and fatigue and muscle aches can be and there are lot of deficiencies of minerals and micro minerals so those like we have magnesium and zinc and you would like to access it as you said minerals fatigue is sodium and potassium deficiency also magnesium and selenium deficiency these are considered these are essentially minerals which are available in fruits available in vegetables so a normal Indian diet is actually minerals what we normally avoid is proteins as Dr. Yashika writes you should have diet in proteins because it is very simple it has become egg white because it is very rich in proteins very easily digestible and if you feel that minerals are lacking it is simple like neemu that has vitamin C if you add rock salt becomes rich in potassium sodium so that helps a lot same way psychological health is important because the stress here can also cause a muscle pain and people feel lethargic so you need to take care you need to involve you need to have a even a good spiritual mind also everything should be balanced diet, physical activity and your emotional health so these three components are interconnected with each other if there is psychological stress food is not good basically everything is connected so one must be taken care of food, physical activity and the cycle emotional managing of the patient or old age people ok thank you what do about supplements what should we do about sleeplessness in old age ok so usually sleeplessness happens in old age because our physical demand is lower so for that even in some apps like youtube also we have alphabets binaural music so before sleeping just ask them to listen to those music for 5-10 minutes these are just beats for help releases the armholes in our body relaxation armholes and your chin also releases in our body induces the sleep sleep cycle with this some kind of postures also like induces the sleep like lying down in supine position and just like a foot in this way and just move your knee up and down for 4-5 times and then relax in that same position for 3-4 minutes and it will help you to induce your sleeplessness like a butterfly yeah one more thing regarding sleeplessness is that it is actually seen in all ages but more in all ages is the use of screen suppose if you are watching tv and suddenly you close your tv and think that I will go to sleep then that normally doesn't happen or you check your cell phone the moment the LED goes on your mind gets activated so to sleep you have to avoid any sensory input so no hearing no seeing something the moment you see a bright screen your mind gets activated as if you are it goes an alert mode so of course you won't be able to sleep immediately after that so that is something I have seen many people and I simply ask them do you check your whatsapp before sleeping and believe me majority of the time the answer is yes I do check my whatsapp before sleeping and I say ok that is the cause why you are not able to sleep I just like to add like what we have discussed is that we should all have a sleep curriculum or a practice at night before going to sleep so this is all included in that like what time you have to go to sleep before that 10-15 minutes before wash your face wash your legs change your clothes get into a comfortable attire you can even put on a soft music and a small dim light in elderly you will all suggest all of us I think will agree that there should be a light in the room the toilet doors should not be closed and the comfortable footwear will be there should be there because they should not fall so because most of the elderly in my house also they want the lights should be totally off but even if not in the room in the bathroom some light should be open so and before sleeping like you are listening to the music you can take a book if you are not able to sleep you read a book and most of the time what I have seen most of the people have some bubble issues that is the reason they are not able to sleep or correct your bubble issues and exercise a little bit that will help you to induce I think the last question is especially for Dr. Bauravani coming to whether knee replacement is indicated after 85 years of age I will just point to perspective a lot of studies about undergoing knee replacement in elderly that is more than 80 years old studies says that you have a higher chance of complications after 80 years of age irrespective of the age what basically determines whether you can undergo knee replacement or not is how physically active you are see if I am a 75 year old I have kidney problems I have diabetes then yes knee replacement is not a surgery for me but if I am a very fit and active 85 year old who is not having any medical problem or just simple DPH etc but if I am having pain in my knee previously also I was walking kilometers and kilometers then yes I will benefit from knee replacement what literature currently says is that in case you are 80 years old and you are undergoing knee replacement then you should undergo one knee replacement at a time right so normally we do we replace both the knees at the same time but there is a very clear cut literature by time from nights that is an issue of clinical excellence in England which clearly mentioned that you have to replace knees one by one after once you have a patient who is more than 80 years old right so if you are asking can I ask my parents to have a knee replacement they are 85 years old then I will simply answer that depends upon their fitness if they are fit, if they are able to do their household chores themselves if they are independent then yes you can go ahead with knee replacement but it will be one knee at a time if they are frail if they have a lot of medical problems if besides knee they also have issues in their back issues with their heart issues with their lungs then we should avoid having knee replaced I would like to ask not to bore one thing because many of my patients also asked me this question after knee replacement what is the way how can they get back to the normal life and how much days they will be starting to walk and how much days they will be can walk much better and because of the old because many old people are very scared whether they should go for it or not that fear is always there and it takes us hours and hours of counseling and if the relatives do counsel their parents they let us know that now is the time you have been eating painkillers for so long to get the needed place but many people are afraid so the answer is that you have to understand that it is a major surgery it is not something which we are doing in a matter of minutes it is a very invasive procedure it is a major surgery it has its own recovery times you have been having knees which have been deformed bad for 15 years and do not expect you to be alright in a matter of few days after knee replacement you are allowed to walk that is the beauty of it you can put full weight on it and you can walk on it normally we allow walking after the next day but there is a dashboard of all now which says that you start walking immediately after the surgery the moment you are the fetus panel sees you after 4 hours and you are walking right on the day of the surgery after 4 to 5 hours of surgery so you can be alright but yes you will need walker to replace the knee we have to go through the main mother muscle of the knee which is your quadriceps that is extension muscles so that muscle takes time to recover so initially you will be walking only with the help of walker yes you will have some difficulties but we do have a very good team of physiotherapists to help you go through the recovery period and we expect you to get data walker in 6 weeks of time some people do get data walker much earlier in 4 weeks some people take a bit longer what is more important is your muscle strength the stronger the muscles are the meri radius if you are having very strong muscles then you will recover very fast after knee replacement that is the role of pre-operative physiotherapy pre-operative exercises if you are somebody who is having depom needs very weak muscles then probably knee replacement would reap its benefits in some say 6 to 8 months on an average its 3 months that is the time which we say that majority of people they become alright after knee replacement one thing you have to understand is knee replacement is a very brutal procedure but it breaks down your pain from a score of 10 out of 10 to say 2 out of 10 or 1 out of 10 do feel a bit of aches slight heaviness in your knee sometimes your knee might pain but majority of people are happy with it so and physiotherapy should be continued for all of us for at least one month any of the people who have weak muscles only will be beaten or exercise the thing the moment usually patient for that surgery was treated in 10 days in 15 days means every body, muscle, bone density is different so the most important thing is to treat any patient with this thing that he will be treated so soon or he will be in pain so many people take the same questions that his or her child was treated in 10 days so every body who gives 3 months of protocol a time limit the chances of getting better are very good after knee surgery what all things they cannot do for everyone I mean there is no current victim as to what you cannot do you have to just understand the knee replacement of the knee implant it's just like a car it's made of machine it's made of steel and plastic the life of my car depends on the way I am driving suppose I am going to drive very fast certain breaks but if I take care of that car if I am not driving it in a rash manner then I cannot go easily in the last 15 years the same thing happens in the knee if you squat squatting is possible even after knee replacement and the current implants are even designed to allow you to squat so squatting is possible but the moment you squat there is not a lot of load on that artificial knee so all the forces that may be your natural knee under the wear and tear those forces will also cause your artificial knee to undergo wear and tear so the moving squat and every time you squat and you are getting up you are facing a lot of load on that knee so yes your knee would wear and tear much earlier than if you would have not been squatting so that is why we simply advise them that if you can avoid squatting then that's very good so if you are in puja and you have to sit down then you can sit again but you do not have to sit you will have to change the toilet if you are in Indian mode then you have to use western mode because your daily squatting will reduce the requirement so this is done why do you come on running honestly speaking there are people who ask me that I love running but again the movement you run you are putting a lot of load on those things right now I am saying that wear and tear will be a little bit faster but it is a popular concept SAV patients are looking who actually want training trips and they have come back from areas like Trivand and other beautiful places right after having any replacement they were not able to do it for a very long time they were missing it one question is there another is in law is diabetic and her kidney is also just 40% working she is 70% overweight can you suggest some diet plan for her like we can see that there are two conditions the patient has diabetes and then she has kidney problems so with diabetes obviously she needs a lot of to take care of her diabetes and she should take a diabetic diet and that also we have not mentioned whether she is on medication or an insulin then she needs medication along with the diet chart and diabetic diet along with kidney disease I think she should need a dietician to take a proper diet chart and if her diabetes is and she is overweight so overweight she has to lose weight to get corrected her diabetes because ultimately even if you are overweight and you are taking proper care of your diet but you are not going to lose weight there is no use and your diabetes will not get corrected diabetes can be cured everybody should understand if you lose weight if we go back to our BMI almost your diabetes is 80 to 90% cured it is not a disease which will stay with you but it may be at an age of 70 it will be very difficult for us to treat her for that and ask her to change her dietary habit but if she is motivated enough you can do and with the kidney I think high protein diet cannot be given if she has uric acid is high and few kidneys let it all work but we should not worry so main kidney is the main place where your blood gets filtered so salt is something which your kidney has to handle a lot so if you are actually salt lover then that is something which you have to stop it is said that you should not need added salt so doctor it takes so much salt in vegetables that should be enough if you are having kidney problems you should not put added salt into it that is important right you have to avoid foods which are I mean it is certainly released a lot of salt in the body like banana is one food which has a lot of potassium and it can lead to potassium over so yes that is something but my recommendation my general advice for you is that if she is having so much problem then she should have proper diet plan started and for that a diet issue would be a better person one thing I would like to add on this thing lots of my old patients and they have had attention they are taking senda namak please senda namak is very rich in potassium they have stopped taking normal salt and their potassium is increasing please stop to get rid of that habit take normal salt in less amount if you are going to have something on salad you can put a senda namak in that but don't make senda namak your staple diet I think many of the patients are doing this wrongly so we should avoid doing that one last question I think we can take if we have time one last question is from my side to Dr. Gaurav I have lots of patients who have big bones after the age of 60 and the one thing I would like to know for them the bone density of military when they should be done and what all medications like I usually give calcium and vitamin D, phosphates also I give but there are some injectables are required in phosphates sometimes when they are very low so how to detect it and when they should come for bone densitometry and when that patient should come to you directly for her treatment so basically they say that prevention is better than cure getting bone densitometry is more a modality of prevention now Karatine says that women the moment you have your menopause you should get your bone density tested not during the time you are having your menopause you should be more with that that is only 50 to 51 years old get your bone density done in men the Karatine says 65 years so 65 years age when men should have their bone density tested and that is prevention but if you are having recurrent fractures some countries like Singapore for every patient who ends up having a hip fracture they will test the bone density so they may be mandatory for women on hospital to hospital but prevention for proposal prevention get your bone density checked when you are 50 to 51 years old the moment you have your menopause in case you have premature menopause you can even get your bone density checked before that in men 65 years any family history in which you should get your bone density early then yes it is mandatory that there will be a proper bone screening procedure there are conditions rare conditions like in case you are having a recurrent fractures in case you are having repeated fractures and fractures by a trigger trauma like you sustain the job you just put your hand on the table and you broke your wrist that is a trigger trauma so in case you are having specific fractures you have to get your bone density checked there are a lot of genetic conditions where your bone density will be low but then the incidence of that is so rare that is why these guidelines say there is an age parameter we have to remember the most common cause of osteoporosis is actually menopause which is a physiological process and the next most common is senile that is aging so again a physiological process so these both causes are the most common cause of osteoporosis yes if you are having recurrent fractures or dial heart recurrent fractures or something like that you can get your bone density checked the moment you become skeleton mature that means why is your 2021 age if you are very strong at this rate only at that time what is your take on taking calcium thoroughly after menopause because many of my patients say that my doctor has said that I will have kidney stones if I take calcium but my take is that they should take calcium because diet will not supplement with the adequate amount the reason for having stones if you take calcium is vitamin D deficiency what happens if you are rich in vitamin D then the moment you take a calcium it will be absorbed from your start that is the role of vitamin D and vitamin D will simply take the calcium and put it in the bone conversely if you are deficient in vitamin D you will take calcium most of it will not be absorbed some that is absorbed will not be able to void your bone because you are not having vitamin D so what happens this calcium is then passed via kidneys in the urine so when you have high concentration of calcium in the urine plus if you are dehydrated if you do not have a habit of drinking a lot of water then this calcium gets concentrated and you form stones so help it is not a calcium topic help it is a fact that you are deficient in vitamin D all the screening procedures now all the health checks now they insist on getting vitamin D and vitamin B that is the role so the old ladies who are most proposal they should take calcium regularly yes, for calcium the dictum has 2 months 1 month rule you do not have to take calcium indefinitely regularly take it for 2 months leave for 1 month then take it for 2 months leave for 1 month but yes calcium you have to take it if your diet is not rich in calcium lots of patients are like I think you remember one of the patient who was taking phosphates for a long time and you told me that she will have brittle bones so I think the dog patients who are at home and taking the same medication for last 1 to 2 years they should visit doctor and just update their perception they should keep on taking them or not the problem in treating osteoporosis is that all the medication which we have in the market for treating osteoporosis you cannot take them indefinitely the problem is doctor is talking about those tablets which you are taking once in a week or once in a month the moment you take them for a duration more than 2 years they can actually end up damaging your bone bone construction and destruction is something which keeps on happening bone destruction is not bad that is important for demodulating so once a new bone is formed and then what body does is the body destroys that agent bone and then deposits new bone in that what these tablets, all these medicines for osteoporosis they do is they remove the body's ability to destroy that bone so there is a mechanism in our body which are responsible for destroying those bones now what happens is that when you remove that mechanism these medicines will suppress the bone destruction mechanism the bone which was formed say 5 years ago, 6 years ago now becomes agent and will soon crumble under stress you end up actually having presently fractures problem with these fractures are very nasty very difficult to treat their higher chances are not uniting despite the fact you might not hate on them you might put bone grafts so that is why we advise all our patients who take this hospital they will not take them more than 2 years. Now coming to injection thing, you would have worried about injection that my doctors advised me injections which I had to inject myself to increase bone density those injections are expensive they cost me around 6-7,000 rupees a month right, again the same thing with that those injections are teleprotide injections they are again for bones to increase the bone density but again you cannot take them for more than 2 years because there are studies that continuous administration of teleprotide can lead to a kind of bone cancer but there are theoretical studies till now there has been no case report of somebody having more cancer because of teleprotide administration on a long basis but there are a lot of theoretical reports about that so that is why we simply ask you to not take them. Now another thing you would have heard is nasal sprays right, so a lot of people have advised nasal spray to take and for long term again the limit for nasal spray is around 6-8 months you cannot take it for more than 6-8 months because it decreases the blood supply of your nose so in the nose you have a bridge what is nasal septum so continuous take of carcinoma nasal spray can actually lead to these septal correlations so again we do not take it for more than 6-8 months so and those who are having very similar osteoporosis anabolic steroids which are returning so anabolic steroids are first introduced for treatment of osteoporosis they initially became very popular then they had this problems with the heart so but we do give them and for very early patients they actually are much safer than vespostor and teleprotide injections and they are much cheaper than either of these but again you cannot give them you cannot give more than 10 injections and they are not around 14-18 weeks so all these medicines they have their own limits they are not free of side effects that is why prevention is better than cure that is why exercise that is why take a good diet exercise properly if you are suffering or you are talking about some stupid things just have a habit of doing more things that is very important to have healthy moods thank you Dr. Gaurav because you have enlightened me I can picture everything very well Afiya just to end with the last question Afiya can you just tell the old people which exercises they can do at home and specify the bone which is important in that area actually for old age people we don't need to have high impact aerobic exercises or strength training we just want our old age people to be healthy, functionally independent we need to be functionally independent for this you can go for a light walk for 10 minutes in morning 10 minutes in just a light walk taking care of your gait pattern because usually the gait pattern is altered in old age so one should take care of the gait pattern walking straight with a proper base of support with a proper swinging of arms and one should take care because with age change the lower body muscle strength decreases because of the bone mineral loss and even overall stress on the muscles on the lower limb muscles so one need to take care of doing light exercises if one has hypertension problem no one will go for isometric exercise on lower limb because it increases the pressure on the upper so one should take care for that just light movement exercises including the large muscle group if one can do mini squat sitting and taking the knee up to the chest including all the large muscle groups you can do that every joint mobile flexible and then you can have a strength which is for your functional movement or due to the activity that you don't feel any fatigue or over stress on the muscles thank you everyone