Advance Health Care

Best Anti-Aging Tip At Home

The best anti-aging treatment is one you do at home.

As my past and current patients and clients can tell you, I will keep explaining what sunscreen is for and why sunscreen is so important until you understand or pretend to so I stop talking.

My focus changed from working as an acne specialist at a top-rated dermatologist for over 15 years to include the ever-growing field of anti-aging treatments just 7 years ago in two San Diego offices. Switching from the damage of scarring caused sunburns to acne to having firsthand proof of what photo aging looks and feels like from my personal experience of growing up tan and working for major a suntan company was natural.

Today we understand sunscreens are a vital tool in the fight against skin cancer, and are highly effective in preventing skin aging caused by the sun, wrinkles, pigmentation irregula­rities, dehydrated and sagging skin

Intentional vs. Incidental Exposure

If I had a nickel every time one of my patients said “I didn't wear sunscreen today, I didn’t go in the sun today” I would be working at my future five-star resort for Alzheimer’s cure with acres of room for an animal shelter, funding research for the cure for mental illness! Meanwhile, I did not collect those nickels so back at the office I try to make everyone understand incidental sun adds up. Driving, walking to the car, going to lunch, picking up kids, etc.

Everyone should wear sunscreen every day.

Farah Ahmed and Curtis Cole, Ph.D. breaks it down for us.

Products that contain sun screening ultraviolet (UV) filters intended to provide sunburn protection can be divided into two basic categories. The first is when there is “intentional” exposure to sunlight for extended periods of time. This is typically associated with recreational activities such as swimming, hiking, sports activities, etc., with exposure to sunlight during the period of highest sunburn potential—10 am to 4 pm. These activities often induce sweating and may also include exposure to water for a significant amount of time. Sunscreen products for these activities are designed to resist removal by sweat or water by incorporating polymer substances and emulsifiers that lock the sunscreen filters onto the surface of the skin.

The second category of sunscreens typically performs a primary function other than sun protection, and is therefore intended for “incidental” sun exposure. The primary functions may be for moisturi­zation; to cosmetically improve the skin’s appearance and even out skin tone, such as tinted foundations; or to correct blotchy or uneven skin tone. Typically these products are for the face or “spot” use, such as on the hands, arms or décolleté, which are exposed and the most visible during the day.

These “cosmetic” products containing UV filters and providing a measurable sun protection factor (SPF) are also categorized by the FDA as drug products, and require the same exact labeling instructions and description as the “intentional” or “recreat­ional” sunscreen products. “Incidental” sun exposure products typically have a lower SPF as they are intended to be used only for short periods of sun exposure. Yet, they fulfill a critical role in providing the constant protection that is vital to maintaining healthy skin against cancer, wrinkles and age spots.1

Fundamen­tally, the two types of products are formulated with the same basic categories of ingredients, with the exception of film-forming polymers in the first category to provide protection against sweating and water resistance. Let’s look at the “skeleton” of these products to see how they are constructed, how they are similar, and how they differ.

The primary categories of ingredients are: spreading vehicles, emulsifiers, film-forming agents, additional benefit agents, colorants, fragrances and preserva­tives. In the Categories of Sunscreen Ingredients sidebar, examples of ingredients are provided for both the intentional, recreational sunscreens and the incidental, daily use sunscreens.

Sunscreen Active Delivery Systems

Products containing sunscreen filter actives are available in a wide variety of delivery systems designed to fit specific use conditions and consumer preferences. Compliant sunscreen protection requires convenience and product elegance to ensure the products are used regularly and in sufficient quantity. The effectiveness of a sunscreen-containing product is critically dependent on the amount used and the way the user applies it to their skin. Several studies2, 3 have shown a direct linear relationship between the amount of sunscreen applied to skin, and the resulting SPF. In short, if a user applies only half of the recommended amount that was used during clinical SPF testing of the sunscreen (2 mg/cm2), then the resulting SPF the user actually gets will be half of the amount stated on the product label.

Convenient packaging can support user compliance by making sunscreens readily available, such as a in stick applicator that can be carried in a purse or pocket, a spray product that is “easy” to apply to wiggling children, or a lotion bottle with a pump dispenser placed on a dressing table or makeup counter.

Small packages of lotion or powder products with sunscreen actives can also be carried in a purse for touch-up applications, or tucked away in the glove box of a car for access at a moment’s notice.

Each of these product forms has different vehicle constituents to fit the storage and use conditions, but all have the same intent—to deliver a thin film of sunscreen filter actives to the skin and provide an optical barrier to UV rays from the sun or other UV light sources, such as indoor fluorescent lighting.4 Let’s look at each vehicle type and examine the components.

Lotions and Creams. Lotions and creams comprised the majority of the sunscreen product category until the mid-2000s. Both of these forms are mixtures of water and oil, with the sunscreen filters dissolved into one or both of the two phases. Lotions and creams are typically oil-in-water (o/w) emulsions, which can be described as droplets of oil swimming in a sea of water, held in a stable matrix by ingredients called emulsifiers that physically and chemically maintain equilibrium between the oil droplets and the sea of water. Without the emulsifiers and physical energy used to form the emulsion, the two phases would separate into a layer of oil floating on a layer of water—like your oil and vinegar salad dressing before you shake it.

After the lotion or cream is spread onto the skin, the water evaporates and the emulsion “breaks,” leaving the layer of oil containing the sunscreen actives to spread and remain on the surface of the skin.

Cream products are simply “thicker” versions of lotions, where more viscous oils, waxes or thickeners are added to make the product more moisturizing. Water-in-oil (w/o) emulsions are also possible, wherein you can imagine water droplets floating in a sea of oil. These “reverse” emulsion products tend to be heavier to spread on the skin and slower to dry down, as they typically have a much higher proportion of oil to water, compared with the more common o/w products that are typically 60% or more water. W/O products can leave a thicker oil film on the skin surface and are naturally more water resistant. However, the trade-off is they can be considered more “greasy” to the touch.

There is no easy way to read a product label and determine if it is an o/w or w/o emulsion. A simple test is to put a drop of the emulsion product in a glass of water and see if it easily disperses with slight agitation, or forms tight balls. If it disperses, it is an o/w emulsion; if not, it is a w/o emulsion.

Both emulsion types are effective vehicles for delivering sun protection. It is simply a matter of consumer preference for the product type based on its esthetic properties, the level of moisturi­zation desired and the level of protection perceived.

Spray products. In the mid-2000s, spray sunscreens became a popular format and remain the highest selling category of the “recreat­ional” sun care market, with more than 50% of total sales. The vast majority of spray sunscreen products are solutions of alcohol containing UV filters, with some additional oils to form the film layer on the surface of skin. The alcohols provide a quickly evaporating vehicle, as well as a solvent that conveniently solubilizes and distributes the sunscreen actives in the container to evenly disperse them on skin. While concerns have been raised by the media and consumer advocates regarding the safety of inhaling of spray sunscreens, this risk is mitigated by the use of spray systems that provide droplet sizes in excess of 10 microns in diameter—a size shown to prevent deep inhalation into the lungs.

Stick products. Stick sunscreens are a convenient dosage form for spot applications such as the nose, ears and around the eyes. These consist of various moisturizers or emollients that can solubilize oil-soluble UV filters and provide a vehicle for any particulate sunscreens; i.e., those whose particles physically block, scatter and reflect UV, including titanium dioxide and zinc oxide. Also incorporated are waxes, thickening agents and polymers to help the product hold its shape at temperatures above around 120°F. When rubbed across skin, it leaves a continuous film of compounds containing the sunscreen filters that resists wash-off.

Powder products. Facial powder sunscreens consist primarily of titanium dioxide and zinc oxide powders that provide UV protection, together with emollient binders and mineral pigments that provide color and glow. These products help to even out and brighten skin tone while providing protection against damaging UV radiation.


1. TJ Phillips, J Bhawan, M Yaar, Y Bello, D Lopiccolo and JF Nash, Effect of daily versus intermittent sunscreen application on solar simulated UV radiation induces skin responses in humans, J Am Acad Dermatol 43(4) 610-618 (2000)

2. R Bimczok et al, Influence of applied quantity of sunscreen products on the sun protection factor–A multicenter study organized by the DGK Task Force Sun Protection, Skin Pharmacol Physiol 20 57–64 (2007)

3. H Ou-Yang, J Stanfield, C Cole, Y Appa and D Rigel, High SPF sunscreens (SPF>70) may provide ultraviolet protection above minimal recommended levels by adequately compensating for lower sunscreen used application amounts, J Amer Acad Dermatol 67 6 1220–1227 (2012)

CA Cole, PD Forbes, RE Davies and F Urbach, Effects of indoor lighting on normal skin. Annals NY Acad Sci 453 305316 (19

Optimizing Risk Factors of Aging, Make Easy Changes for 2019

A transformation starts with you.   Optimizing risk factors of aging and enjoying life along the way.

Where to start? Well, we always say at the beginning. This is usually the best place to start. In this case since the beginning for us is in the past, let’s start where we are, this is as good a place as any. While setting a goal to start a new goal can lead to procrastination, pick just a few things and start making changes now.  Right this minute.  You know yourself better than anyone, look at the list below. Set your intentions now.  This means really pick one or two things or maybe all things that you INTEND TO DO.  My advice is start small.  What is important is your mindset. You are the vision in your mind’s eye, you are already the person making positive changes.   When you look at the list, imagine yourself already doing it. Push the images out of your mind of past experiences. These memories especially the negative ones are no longer important. Example, your vision of drinking 100oz.of water and reaching your goal is what you see.  See yourself at the end of the day with a big smile on your face and sense of accomplishment with an empty glass.


1.     Exercising or moving (see below)

2.     Drinking more water ½ your weight in ounces

3.     Thinking positive thoughts

4.     Being kind to others, cultivate relationships

5.     Eating healthy foods, choose fresh without preventives if possible

6.     Look at food labels for hidden sugar

7.     Give up fast food.  Just say no.

8.     Sleep 7 hours min.

9.     Make a list of the things to do so it is easier to plan

10.   Reach outside your comfort zone and say hello to someone new

11.   Ask your partner or spouse how they are doing and listen until they are finished

12.   Smile, practice smiling does help J

13.   Relax your jaw and shoulders

14.   Remind yourself how lucky you are, don’t take things for granted

15.   Keep your word, if you say you will do it.

16.   Don’t be afraid to ask for help, others will help if they can.

17.   Meditate, focus your mind on a mantra.


Let’s start with exercise.  We have scientific evidence that exercising has a positive effect on the aging brain.  Exercise helps different areas of your body in different ways.  There are hormones released in your bones when you exercise, endorphins are directly related to that euphoric feeling during and after exercise. Science has proven your gut reacts to exercise in a positive way.  Even the amount of happiness you feel can be factored in to moving your body!  Some say for as little as 7 minutes.


The Subject You MUST Bring Up

This holiday season take the time to start this conversation.

Advance care planning is not just about old age. At any age, a medical crisis could leave you too ill to make your own healthcare decisions. Even if you are not sick now, planning for health care in the future is an important step toward making sure you get the medical care you would want, if you are unable to speak for yourself and doctors and family members are making the decisions for you.

Start by thinking about what kind of treatment you do or do not want in a medical emergency. It might help to talk with your doctor about how your current health conditions might influence your health in the future. 

If you don't have any medical issues now, your family medical history might be a clue to help you think about the future. 

In considering treatment decisions, your personal values are key. Is your main desire to have the most days of life? Or, would your focus be on quality of life, as you see it? What if an illness leaves you paralyzed or in a permanent coma and you need to be on a ventilator? Would you want that?

There are two main elements in an advance care directive:

 Living will. A living will is a written document that helps you tell doctors how you want to be treated if you are dying or permanently unconscious and cannot make your own decisions about emergency treatment. In a living will, you can say which of the procedures described in the Decisions That Could Come Up section you would want, which ones you wouldn't want, and under which conditions each of your choices applies.

Durable power of attorney for health care. A durable power of attorney for health care is a legal document naming a healthcare proxy, someone to make medical decisions for you at times when you are unable to do so. Your proxy, also known as a representative, surrogate, or agent, should be familiar with your values and wishes. This means that he or she will be able to decide as you would when treatment decisions need to be made. A proxy can be chosen in addition to or instead of a living will. Having a healthcare proxy helps you plan for situations that cannot be foreseen, like a serious auto accident.

Some people are reluctant to put specific health decisions in writing. For them, naming a healthcare agent might be a good approach, especially if there is someone they feel comfortable talking with about their values and preferences. A named proxy can evaluate each situation or treatment option independently.

Other advance care planning documents. You might also want to prepare documents to express your wishes about a single medical issue or something not already covered in your advance directive. A living will usually covers only the specific life-sustaining treatments discussed earlier. You might want to give your healthcare proxy specific instructions about other issues, such as blood transfusion or kidney dialysis. This is especially important if your doctor suggests that, given your health condition, such treatments might be needed in the future.

Medical issues that might arise at the end of life include:

  • DNR orders

  • Organ and tissue donation

  • POLST and MOLST forms

DNR (do not resuscitate) order tells medical staff in a hospital or nursing facility that you do not want them to try to return your heart to a normal rhythm if it stops or is beating unsustainably using CPR or other life-support measures. Sometimes this document is referred to as a DNAR (do not attempt resuscitation) or an AND (allow natural death) order. Even though a living will might say CPR is not wanted, it is helpful to have a DNR order as part of your medical file if you go to a hospital. Posting a DNR next to your bed might avoid confusion in an emergency situation. Without a DNR order, medical staff will make every effort to restore your breathing and the normal rhythm of your heart.

A similar document, called a DNI (do not intubate) order,tells medical staff in a hospital or nursing facility that you do not want to be put on a breathing machine.

non-hospital DNR order will alert emergency medical personnel to your wishes regarding measures to restore your heartbeat or breathing if you are not in the hospital.

Organ and tissue donation allows organs or body parts from a generally healthy person who has died to be transplanted into people who need them. Commonly, the heart, lungs, pancreas, kidneys, corneas, liver, and skin are donated. There is no age limit for organ and tissue donation. You can carry a donation card in your wallet. Some states allow you to add this decision to your driver's license. Some people also include organ donation in their advance care planning documents.

At the time of death, family members may be asked about organ donation. If those close to you, especially your proxy, know how you feel about organ donation, they will be ready to respond. There is no cost to the donor's family for this gift of life. If the person has requested a DNR order but wants to donate organs, he or she might have to indicate that the desire to donate supersedes the DNR. That is because it might be necessary to use machines to keep the heart beating until the medical staff is ready to remove the donated organs.

Learn more about organ and tissue donation.

POLST and MOLST forms provide guidance about your medical care preferences in the form of a doctor's orders. Typically you create a POLST (Physician Orders for Life-Sustaining Treatment) or MOLST (Medical Orders for Life-Sustaining Treatment) when you are near the end of life or critically ill and know the specific decisions that might need to be made on your behalf. These forms serve as a medical order in addition to your advance directive. They make it possible for you to provide guidance that healthcare professionals can act on immediately in an emergency.

A number of states use POLST and MOLST forms, which are filled out by your doctor or sometimes by a nurse practitioner or physician's assistant. The doctor fills out a POLST or MOLST after discussing your wishes with you and your family. Once signed by your doctor, this form has the same authority as any other medical order. Check with your state department of health to find out if these forms are available where you live.

What About Pacemakers and ICDs?

Some people have pacemakers to help their hearts beat regularly. If you have one and are near death, it may not necessarily keep you alive. But, you might have an ICD (implantable cardioverter-defibrillator) placed under your skin to shock your heart back into regular beatings if the rhythm becomes irregular. If you decline other life-sustaining measures, the ICD may be turned off. You need to state in your advance directive what you want done if the doctor suggests it is time to turn it off.

Selecting Your Healthcare Proxy

If you decide to choose a proxy, think about people you know who share your views and values about life and medical decisions. Your proxy might be a family member, a friend, your lawyer, or someone in your social or spiritual community. It's a good idea to also name an alternate proxy. It is especially important to have a detailed living will if you choose not to name a proxy.

You can decide how much authority your proxy has over your medical care—whether he or she is entitled to make a wide range of decisions or only a few specific ones. Try not to include guidelines that make it impossible for the proxy to fulfill his or her duties. For example, it's probably not unusual for someone to say in conversation, "I don't want to go to a nursing home," but think carefully about whether you want a restriction like that in your advance directive. Sometimes, for financial or medical reasons, that may be the best choice for you.

Of course, check with those you choose as your healthcare proxy and alternate before you name them officially. Make sure they are comfortable with this responsibility.

Making It Official

Once you have talked with your doctor and have an idea of the types of decisions that could come up in the future and whom you would like as a proxy, if you want one at all, the next step is to fill out the legal forms detailing your wishes. A lawyer can help but is not required. If you decide to use a lawyer, don't depend on him or her to help you understand different medical treatments. Start the planning process by talking with your doctor.

Many states have their own advance directive forms. Your local Area Agency on Aging can help you locate the right forms. You can find your area agency phone number by calling the Eldercare Locator toll-free at 1-800-677-1116 or by visiting

Some states require your advance directive to be witnessed; a few require your signature to be notarized. A notary is a person licensed by the state to witness signatures. You might find a notary at your bank, post office, or local library, or call your insurance agent. Some notaries charge a fee.

Some states have registries that can store your advance directive for quick access by healthcare providers, your proxy, and anyone else to whom you have given permission. Private firms also will store your advance directive. There may be a fee for storing your form in a registry. If you store your advance directive in a registry and later make changes, you must replace the original with the updated version in the registry.

Some people spend a lot of time in more than one state—for example, visiting children and grandchildren. If that's your situation, consider preparing an advance directive using forms for each state—and keep a copy in each place, too.

After You Set Up Your Advance Directive

Give copies of your advance directive to your healthcare proxy and alternate proxy. Give your doctor a copy for your medical records. Tell close family members and friends where you keep a copy. If you have to go to the hospital, give staff there a copy to include in your records. Because you might change your advance directive in the future, it's a good idea to keep track of who receives a copy.

Review your advance care planning decisions from time to time—for example, every 10 years, if not more often. You might want to revise your preferences for care if your situation or your health changes. Or, you might want to make adjustments if you receive a serious diagnosis; if you get married, separated, or divorced; if your spouse dies; or if something happens to your proxy or alternate. If your preferences change, you will want to make sure your doctor, proxy, and family know about them.

Talking About Your Wishes

It can be helpful to have conversations with the people close to you about how you want to be cared for in a medical emergency or at the end of life. These talks can help you think through the wishes you want to put in your advance directive.

It's especially helpful to talk about your thoughts, beliefs, and values with your healthcare proxy. This will help prepare him or her to make medical decisions that best reflect your values.

After you have completed your advance directive, talk about your decisions with your healthcare proxy, loved ones, and your doctor to explain what you have decided. This way, they are not surprised by your wishes if there is an emergency.

Another way to convey your wishes is to make a video of yourself talking about them. This lets you express your wishes in your own words. Videos do not replace an advance directive, but they can be helpful for your healthcare proxy and your loved ones.

Be Prepared

What happens if you have no advance directive or have made no plans and you become unable to speak for yourself? In such cases, the state where you live will assign someone to make medical decisions on your behalf. This will probably be your spouse, your parents if they are available, or your children if they are adults. If you have no family members, the state will choose someone to represent your best interests.

Always remember: an advance directive is only used if you are in danger of dying and need certain emergency or special measures to keep you alive, but you are not able to make those decisions on your own. An advance directive allows you to make your wishes about medical treatment known.

It is difficult to predict the future with certainty. You may never face a medical situation where you are unable to speak for yourself and make your wishes known. But having an advance directive may give you and those close to you some peace of mind.

Advance Directive Wallet Card

You might want to make a card to carry in your wallet indicating that you have an advance directive and where it is kept. Here is an example of the wallet card offered by the American Hospital Association. You might want to print this to fill out and carry with you. A PDF can be found online(PDF, 40 KB).

Read about this topic in Spanish. Lea sobre este tema en español.

For More Information About Healthcare Directives

National Hospice and Palliative Care Organization
1-800-658-8898 (toll-free)

Center for Practical Bioethics
1-800-344-3829 (toll-free)
Health Resources & Services Administration

National POLST Paradigm

Put It In Writing
American Hospital Association

Content reviewed: January 15, 2018