Understanding Grandpa (A case of Alzheimer's Disease)

Never ever fail to get a chance to talk to your grandparents or parents.  Never take them for granted, don't be too focused on your own life, money making or work.  Remember, you have them to thank for why you are here in the world.  I don't mean to be so dramatic but to tell you honestly, I made that mistake.  My grandpa has AD (Alzheimer's disease) while I was busy with my own life.  He used to pick me up when I was in high school.  We have loved his story about how he became number 1 in all his classes in his elementary days.  How can I tell him now that I love him?  How can I thank him for all the good things he has done for us?

Introduction and Etiology (Cause).  Unfortunately, the exact cause of AD is unknown.  It is the most common cause of dementia (memory loss, difficulty with thinking and speech and problem solving).  Dr. Alois Alzheimer, a German psychiatrist, first described this condition.  AD affects the brain, this disease evolves gradually from mild to severe brain cell destruction over time.  It is more common in 65 and above age group but can also appear in persons less than 65 years old (early-onset Alzheimer's).  

AD is common in persons 65 years old and above

We don't know the cause but certain factors are noted to increase the risk of developing the disease.  Age is the greatest risk factor.  The risk doubles every 5 years for persons above 65 years old.  Gender:  women are affected twice as compared to men (sigh of relief) for reasons that are unclear.  There are different opinions in literatures regarding Genetic inheritance.  Wikipedia says it's 70% genetic but some works describe that genetics play a minor role.  Although, for someone with a close relative (parent or sibling), the risk is increased compared to the general population.  However, AD is not inevitable, everyone can reduce the risk by living a healthy lifestyle.  More info below, promise.  Certain medical conditions such as diabetes, stroke, heart problems, hypertension (increased blood pressure), increased cholesterol and obesity in mid-life are all known to increase the risk of Alzheimer's.  Previous severe head injury is also noted to increase the risk.  

What happens in the brain in people with AD (pathophysiology)?  Proteins build up in the brain to form structures called 'plaques' and 'tangles', why, we don't know.  There are many theories though.  This leads to loss of connections between nerve cells and loss of brain tissue.  It is also noted that there is a shortage of some important chemicals which help transmit signals in the brain.  As the disease progress, gradual death of brain cells are observed.

Symptoms.  AD starts with mild symptoms and get worse over time.  In most people, the earliest symptoms are memory lapses.  They may have difficulty recalling recent events and learning new information.  Long term memory loss will manifest in the late stage of the disease.  Patients will have problems with thinking, reasoning, perception and communication.  They can also have mood changes like anxiety, irritability and depression.  They may even have hallucinations.  A typical behavioral change would be to repeat a question over and over again.  Eventually, problems with memory loss, communication, reasoning and orientation become severe and the patient will need to have full support and care.  The progression of the disease vary from person to person.  On average, AD patients will live 3-10 years after the appearance of the first symptoms.  AD is not actually the cause of death, pneumonia is commonly the culprit.  

Diagnosis.  Early identification of symptoms is the key.  No single laboratory test is available for AD.  The doctor will rule out first other conditions that have similar symptoms, such as infections, vitamin and thyroid deficiencies, depression and side effects of medication.  If AD is suspected, he/she is then referred to a specialist - Adult Psychiatrist, Neurologist or a Geriatrician.  A brain scan can be done to show the brain changes and rule out other pathology like tumor or stroke.  The scan will show that the hippocampus (part of the brain) has shrunk.  It is good to note that there is a criteria for the diagnosis of AD (let the doctor worry about that).

Treatment and Support.  With all the advance technology that we have, there is still no cure for AD.  However, there are numerous ways that can be done to enable someone to live well with the condition.  Drugs can temporarily alleviate some symptoms or slow the progression of the disease.  Donepezil, Rivastigmine and Galantamine are used for the early stages.  These can help with memory problems, improve concentration and motivation.  Memantine is used in advanced stage.  The three drugs used for the early stages prevent the destruction of acetylcholine, which is an enzyme needed for brain signal transmission.  Memantine, on the other hand, protects the brain cells from the destructive effects of glutamate.  

It is beneficial for a person with AD to keep up with activities that he/she enjoys.  Exercising the mind by reading or doing puzzles definitely help.  Over time, the patient will become agitated and/or aggressive, a sedative is likely to help him/her relax.  Anyone, caring for the person is likely to find the behaviour distressing.  Support for carers is very important too.

Lean meat, very minimal fats, with veggies

Prevention, as promised.  Staying physically fit and mentally active are the two important elements, not so difficult to do, right?  Evidence suggests that rates of dementia are lower in people who remain physically, mentally and socially active throughout their lives.  It is good to indulge in activities like reading, writing, learning a foreign language, playing musical instruments, playing sports, bowling and walking.  Long term use of NSAID's (pain relievers like paracetamol and ibuprofen) is associated with decreased risk of developing AD.  Do also remember that these drugs will also increase the incidence of gastritis and ulcers.  Japanese and Mediterranean diet are thought to lower the risk and diet with increased saturated fats and simple sugars can raise the risk.  So, let's go Jap food!

New Hope.  Researchers are still conducting trials of new drugs for AD.  One drug which prevents the formation of plaques in the brain was successfully tested in mice.  Human trials are next.  Amyloid therapy are also noted to slow the progression of the disease.

On a final note, especially to my siblings and cousins, give more attention and love to your/our parents and grandparents before it's too late.

Heartburn

For the hopeless romantic, heartburn occurs only on Valentines Day (wink).  For some people, it occurs almost everyday.  It is a common symptom but this should not be taken lightly.  Heartburn may be a sign of heart attack.  Consultation to a doctor should be done if you feel the symptom for the first time.  Chronic heartburn could lead to esophageal cancer.  Some patients will also experience asthma-like symptoms.

This condition is caused by acid from the stomach which goes up to the esophagus.  This result to burning pain in the chest which sometimes radiates to the back of the throat.  Pain is worse when lying down and the patient may have chronic cough.  Almost everyone has this kind of symptom but frequent attacks in a month can be a sign of GERD (Gastroesophageal Reflux Disease).

Let me give you a little bit of anatomy and physiology.  The food that we eat goes down to the pharynx, then to the esophagus then to the stomach.  The lower esophagus has a valve or a sphincter which prevents acid from the stomach to go up to the esophagus.  When the lower esophageal sphincter relaxes abnormally or weakens then the acid goes up.  The stomach has a protective lining which prevents the destructive effects of acid to take effect.  However, the esophagus do not have this kind of protection, so, the acid will irritate the esophageal lining.  This can cause inflammation, bleeding and eventually cancer.  When the acid reflux becomes so severe, it will reach up to the pharynx and then go to the air tubes.  The acid will cause irritation of the airways and the patient will have asthma symptoms - cough, dyspnea (difficulty of breathing), tachypnea (fast breathing) and wheezing.

Coffee can trigger heartburn.

If you have this symptom, it is best to avoid food and substances which trigger the attack.  Spicy foods, onions, citrus products, ketchup, fatty or fried foods, chocolate, alcohol, carbonated beverages, coffee and large meals will trigger the symptom.  Some drugs can also precipitate heartburn namely ibuprofen, naproxen, aspirin, antihypertensives and antidepressant meds.

Smoking can decrease the ability of the lower esophageal sphincter to function properly.  So, stop smoking, please.  It is good to elevated the head when lying down with pillows and not to eat large meals 3 hours prior to sleeping.  Midnight snacks is definitely out.

This disease, like any other illness, can be diagnosed through complete history and physical examination by a physician.  Adjunctive laboratories include endoscopy, monometry, barium swallow and ambulatory acid probe test.  In endoscopy, a tube will be inserted into the mouth and into the esophagus to see the damaged cells.  A biopsy is also taken to rule out cancer.  Monometry measures the pressure of the lower esophageal sphincter.

There are many over-the-counter antacids which can offer quick relief of symptoms.  Moderate-severe symptoms warrant the use of drugs like ranitidine or omeprazole.  All of these drugs reduce acid production which eventually allows the damaged esophageal cells to heal on its own.  If the symptoms are not controlled by intensive medical therapy then surgery is indicated.  A part of the stomach is wrapped around the lower esophagus to strengthen the sphincter to prevent acid reflux. This is called fundoplication.

As I have mentioned before, heartburn can also be a sign of impending heart attack.  An examination of the heart should be done to rule out this deadly disease especially in patients in the 4th - 6th decade of life.  

-Dr. A

Is it a Pose? Or Scoliosis?

Sometimes we can observe other people with one shoulder higher than the other.  Makes me wonder if it's just a pose or something pathologic (abnormal condition).   If the person is just standing, then maybe, it's a pose to accentuate her dress.  However, if she starts walking and the other shoulder is still higher than the other, then there must be something wrong.

The condition is called Scoliosis when the spine or backbone bends or curves to the side.  The spine has a normal forward and backward curvature, but never a sideward curve.  In Scoliosis, the spine curves to the right or to the left (C curve) or it can have two curves (S curve).  This disease can manifest at any age but commonly appears at 10 years and older.  The condition maybe mild, moderate or severe and this classification dictates which form of treatment to give.

Please pardon me for making the female species as an example for this disease but statistics show that females tend to develop worse symptoms.  Other signs to diagnose this illness are:  uneven leg lengths, one hip is more prominent than the other or the person may always lean on one side.  The change in curvature occurs very slowly, that's why it is unnoticed until it becomes severe.  Pain is also part of the symptoms but is not very common.  If the patient complains of pain, then other causes of pain should be investigated.  In severe cases, the heart and the lungs do not function properly because of the abnormal structure and these will be manifested as shortness of breath and/or occasional chest pains.

What is the cause of this illness?  In 80% of cases, the cause is unknown.   The other 20% is the result of hereditary factors (runs in the family), neuromuscular conditions, birth defects affecting development of bones and injuries or infections of the spine.

Physical examination can clinch the diagnosis with supporting laboratories like Xray, CT scan and MRI.

Majority of the cases, less than 25 degrees deviation, need no treatment but repeated clinic visits are required to monitor the progression of the disease.  Moderate cases with 25 - 40 degrees deviation from main spine axis need to have braces as treatment.  Braces prevent further curvature but cannot correct the existing curve.  Braces will reduce the need for surgery later in life.  Surgery, which is spinal fusion, is indicated for severe angulation greater than 40 degrees.  Metallic implants are put in place to hold the spine in a straight position.  Post surgery patients can engage in sports one year after the procedure.  The operation is not without risks, therefore make sure that the surgeon has vast experience with this disease before undergoing surgery.

Scoliotic patients with back pain may benefit from exercise, massage, physical therapy and yoga.

Aside from feeling insecure due to inappropriate posture, untreated scoliosis can result to kyphosis (hunchback), lung and heart problems, chronic back pain and spine arthritis.  Checking yourself regularly in front of the mirror is not totally narcissistic (wink), you can actually diagnose if you have Scoliosis.

Dr. A

"I can't breathe!" (A Case of Asthma)

I live with asthmatics.  It's really worrisome to see our loved ones during an asthma attack.  Shortness of breath, coughing and chest tightness are some of the symptoms.   It's like they can't catch their breath literally.  Coughing occurs any time of the day and is usually one of the early signs.

What happens inside the lungs during an attack?  There is obstruction of the airways, that is why the person has difficulty in breathing.  The air tubes react to certain substances which act as triggers to the disease process.  The air tubes are laden with muscles which can undergo spasm leading to decrease in the diameter.  Next, there will be increase in mucus production inside the tube, this also serves as an obstruction.  Inflammation also sets in, causing swelling of the tubes thus further limiting air entry and exit.  Unless this process is stopped, the obstruction will continue and will deprive the person with oxygen.  Once oxygen level in the brain is low, the patient will collapse.  Continued hypoxia (deficiency of oxygen) will result to death.

In the hospital setting, when the patient becomes unconscious because of asthma, we insert a tube to the airway to deliver air directly.  That is the worst case scenario. Please don't take for granted anyone who is suffering from an asthma attack.  They might have tolerance with a little hypoxia but their condition can get worse anytime if not treated.  Offer some assistance whenever you can, just by calling his/her doctor or the E.R would be a great help.

If you know the triggers then you may prevent an attack.   There are some triggers we can avoid, some, we simply can't.  1. Strong emotions (unavoidable? wink) can definitely start an attack. 2. Physical exercise can also cause an attack.  You can start with a few routines first and observe if your body can handle the workout.  If you will not have an attack with the less strenuous exercise then you can slowly increase the intensity of your routines.  3. Infections:  cold, cough and sinusitis.  4.   Tobacco smoke and strong perfumes  5. Allergy to food, common culprits include shrimps, crabs, squids and food additives.  6.  Allergy to medicine:  aspirin, ibuprofen and naproxen.  7. Dust mites thrive in mattresses, carpets, bedding, pillows, blankets or anywhere in the bedroom and/or kitchen. It is the enzyme from the mite's feces which can trigger an attack.  It is advisable to wash these linens with hot water.  Change the bedding and pillow case more often. 8. Smoke (from burning wood or grass) and pollution (from factories and cars).  9. Pets.  Be sure to keep pets away from the bedroom.  10. Heartburn or Gastroesophageal Reflux Disease (GERD) surprisingly can cause asthma.  Most adult onset asthma is caused this condition.  The upper part of our stomach has a valve which prevents acid from going up to the esophagus.  When the valve is defective, the acid goes up and eventually reaches the airways.  The acid will irritate the air tubes and start an asthma attack.

Asthma may or may not be hereditary.  If your parents are asthmatic, there is a high likelihood that you will develop asthma.  If there is no family history of asthma, you can still develop asthma due to environmental factors, some of which are discussed above.

If you develop the symptoms mentioned in the first paragraph then possibly you have asthma.  You will undergo additional tests, like chest xray and lung function tests to clinch the diagnosis.

Avoidance is the key to prevent asthma attack.  As I have said before, some triggers cannot be avoided.  Internal Medicine specialists divide the treatment of asthma according to its severity.  It is divided into steps 1-5 according to the GINA protocol.  Treatment usually starts with short acting beta agonist, an example is salbutamol inhaler.  More severe symptoms should be given inhaled corticosteroids plus salbutamol inhaler.  Review of the efficacy of the treatment will be done after 2-3 months.  The doctor will either add additional medication or discontinue one medication depending on the patient's response.  Regular visit with a doctor is a must for all patients diagnosed with asthma.

There are minimal side effects with inhaled corticosteroids contrary to the oral counterpart. This is because the inhaled steroids will go directly to the lungs and only very minimal amount enters the blood stream.  Hoarseness of voice (and not weight gain) is a common complaint.  Short acting beta agonist, like salbutamol, can cause dry mouth, dizziness and altered taste sensation.  Just take note that not all patients will experience the side effects.

Asthma can be very troublesome, but it can be controlled with strict compliance with the medications and regular check up.  Don't let it be a hindrance in achieving your goals.   That is what I always tell my wife and my eldest son.

Leave a comment if you have additional questions. :)


Dr. A

Kidney Stones Causing Severe Back Pain (in the Airplane!)

I had this slightly stressful ordeal on the flight going to Manila from Bahrain.  The woman sitting beside me was asked to transfer to another seat to give way to a female passenger so that she can sit beside her cousin because she is sick.  So, my doctor instinct kicked and did an initial assessment.

She was slightly pale, weak but able to walk. She didn't look that sick after all. But yes, paranoia also kicked in, maybe she was infectious.  During take off, she didn't complain and didn't have any symptoms. Two hours after, she started to moan and her cousin was massaging her back. Thinking that maybe she just had a nasty back pain, I resumed watching my favorite Pinoy movie.  After a couple of minutes, she was still moaning but this time little bit louder.  That's when I decided to be a concerned seatmate.

I asked her cousin the history of the illness, how many days did she have the symptoms, does she have any fever, etc... you know, complete medical history. Apparently, she had the symptoms for a month and no consultations done.  No medications taken. She was laid off from work because she is sick.

She changed position many times hoping to alleviate the pain. My first impression was renal colic (to be discussed later).  I called the cabin crew,  asked them what pain medications are available on board.  They only have paracetamol, I knew this will not help much.  I introduced myself that I am a doctor and told the cabin crew to give her two tablets.  After a minute, she became silent.  I was relieved.  But then again, the pain returned and she was moaning again.  The surrounding passengers started to notice her.  I asked the cabin crew what other medications are available, seeing that her condition is not getting better, they told me they have Tramadol . Now, that's promising. However, they cannot give it unless prescribed by a doctor, so, I showed them my ID.  They have protocols to follow before we can administer the drug.  They have to tell the captain and there is a possibility that we are going to have an emergency landing.  It took them a long time to decide whether they will release the Tramadol or not.  Fortunately, the pain again subsided.  Thank God.  Throughout the flight (8 1/2 hours), she was experiencing moderate-severe on and off pain.  Thankfully, we did not have an emergency landing and we arrived to our destination on time.

This is a classic picture of renal colic.  Colic means contraction of a hollow tube, in this case, the urinary tube.  It contracts when a stone from the kidney passes through it. It can cause severe pain and the patient moves and changes position hoping to stop the pain. Other patients vomit and feel dizzy. The pain is intermittent,  it comes and it goes.

Photo by:  Dr. M. Batucan

Formation of stones result from low fluid intake.  When your urine is very concentrated, there is a high chance of stone formation.  Other metabolic diseases and repeated urinary tract infection can also lead to stone formation.

A urine test, ultrasound of the urinary system and CT scan can detect the stones. If confirmed, medications will be prescribed.  Larger stones require shockwave lithotripsy and even surgery. Shockwave treatment is used to pulverize stones (2 cm or less) inside your kidney without cutting you open.  The pulverized stones will then be excreted as part of the urine.

What you need to do:  You should keep yourself hydrated, drink 8 glasses of water per day.  Avoid excessive salt and protein intake.  Urinary tract infections should be treated properly (I mean, by a doctor) and practice personal hygiene.

Morals of the story:  1. Don't fly if you are sick. 2. Don't fly if you think you are sick,  there is so little we can do inside the aircraft. 3. If you have felt the symptoms for a long time,  then something might be really wrong, do see a doctor.

It is quite stressful being on a plane with this kind of patient.  I mean, I know what to do in a hospital setting, but I'm so helpless inside the aircraft.  All I did really was to assure her that the pain will subside eventually and give the 2 tablets of paracetamol.  Maybe, something higher was at work there.  Why did they transfer to the seat next to me in the first place?

The Scary Ebola

Just because I travel to Africa doesn't mean I have Ebola.  People sometimes  generalize anyone coming from Africa to be infected with this deadly viral haemorrhagic illness.

Currently, Ebola is only concentrated in 3 countries, namely Sierra Leone, Guinea and Liberia. Africa is a very big continent and is composed of 55 countries.

Yes,  the three countries are located in West Africa but not all of West Africa has Ebola.  When we hear the news, it seems that all West African countries are infected with the disease. Ghana, Niger, Ivory Coast, Gambia belong to West Africa but not a single case of Ebola is seen there.

This deadly disease has plagued these nations for more than 12 months. It has taken thousands of lives and was believed to spread to the whole world if strict control measures were not undertaken by medical authorities.

It was really a scare when I had to go back to work during the time when the transmission of the disease was very rapid.  Rapid enough to affect nearby villages in just a couple of days.

Small knowledge is dangerous and will lead to unnecessary worry, so I read more.  A person infected with the disease cannot travel, because he is so sick to travel.  That rules out sick airplane passengers (thank God).  Symptoms include sudden onset of vomiting, dizziness, rash, headache, fever, diarrhea and abdominal pain.  The virus is transmitted through contact with body fluids of infected persons.  The virus resides in the blood, nasal secretions, urine, vomitus, stool, ejaculate and even sweat.  You can also get infected by touching objects harboring the virus.  The virus is not spread through the air.  The incubation period (the time from getting the virus to manifestation of symptoms) is 2-21 days, averaging at 7-9 days.

This disease is very deadly, 50%-90% of cases result in fatality.

Some airports use a screen monitor to detect passengers with a high temperature. Furthermore, many airlines have temporarily banned destinations to affected countries. If you see any sick person in the airport or any public transportation better keep your distance just to be sure.

Yes, Ebola is scary but only concentrated in the three aforementioned countries.  Let us hope and pray that the epidemic will be resolved soon.

Es Tee Ar Ee Es Es (Effects of STRESS)

If it took you several seconds to figure out the title then probably you are stressed-out.  STRESS can make you lose your focus especially if it's chronic (occurring for a long time) or uncontrolled.

Stress is a state of mental tension and worry caused by a problem.  It happens in the mind but it can also affect the physical body.  The most common manifestations are headache, stomach problems (diarrhea or constipation), chest pain, palpitations (fast heartbeat) and sleeping problems.  If the situation is very intense, some women will hyperventilate resulting to very fast breathing, feeling of numbness and cramps at the hands and feet, weakness and dizziness.  Stress also results to behavioral changes like anxiety, irritability, restlessness and lack of motivation.  You may think that these are manifestations of an underlying illness, you maybe right.  But when your doctor's examination results are all normal, stress must be the culprit.

I am no stranger to stress.  What I had was coupled with depression and I tell you, it's a vicious cycle. Because of stress at work, I did not want to get up in the morning, I laid in bed the whole day.  For us, who need to work to feed the family, we simply cannot do that.  

Stress is an everyday occurrence, we can never get away with it.  However, we can choose how to cope with it.  Some people, tend to undergo the negative coping mechanism.  They criticize themselves more, drink alcohol, light more cigars, eat too much or not eating at all.  These actions will surely pull you down even more.  If these will continue for a prolonged period, then serious diseases can set in like high blood pressure, heart disease, obesity, diabetes and gastritis or stomach ulcers.  You will know that your stress is uncontrolled when you fail to do even simple daily tasks properly, your relationships crumble down, you don't go out and you don't connect with other people.

I had a first hand experience with extreme stress, to the point that I wished the earth would swallow me up.  Yes, there was a time when I really hit rock bottom.  However, I was able to make the switch, a full 180 deg turn and i'm happy to share with you how I did it.

It started with a decision, I decided not to punish myself anymore.  I started to love myself and promised to do things that could make me happy.   I turned away from the negative coping mechanisms and I geared myself towards positivity.  Do you know that negative thoughts will bring more negative situations?  Yes, they do.  So, feed your mind with good thoughts.  Laugh, go out with friends, play with your pet, watch a movie or listen to music.  Do anything that makes you smile, give yourself a break and treat yourself.  If you believe in God, do remember, He said that He will provide. Sometimes, we think that the solution comes solely from us that's why we worry too much.

Support system is very important too, family and friends can lift your mood so spend more time with them.  I have my wife to thank for the undying support during those difficult years.  You should also set goals, challenge yourself and manage your time properly so that you can do what needs to be done.  Finally, arrange your priorities well, don't get stressed with minor problems. If your priority is family, then by all means do your best to provide for them.  If your priority is your job, then work hard, learn about new strategies to make your tasks easier, read books, don't be lazy. If you will love yourself, you will never do things which would hurt you, don't let stress defeat you. Take charge.