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Thyroid Cancer - Carotid Artery Disease: Causes, Symptoms, Tests, and Treatment

Thyroid Cancer

Thyroid cancer facts
  • What is the thyroid?
  • What is cancer, and what are the types of thyroid cancer?
  • What causes thyroid cancer, and what are risk factors for thyroid cancer?
  • What are symptoms of thyroid cancer?
  • How is thyroid cancer diagnosed?
  • How is staging determined for thyroid cancer?
  • What is the treatment for thyroid cancer?
  • Methods of treatment
  • What are side effects of cancer treatment?
  • What about followup care for thyroid cancer?
  • What's new in thyroid cancer research?
  • Where can people get more information about thyroid cancer?
  • Patient Discussions: Thyroid Cancer - Treatments
  • Patient Discussions: Thyroid Cancer - Symptoms At Onset Of Disease
  • Find a local Oncologist in your town

Thyroid cancer facts

  • The thyroid gland produces thyroid hormones which are important in the normal regulation of the metabolism of the body.
  • Thyroid cancer is three times more common in women than in men.
  • There are four major types of thyroid cancer: papillary, follicular, medullary, and anaplastic.
  • The cause of thyroid cancer is unknown, but certain risk factors have been identified and include a family history of goiter, exposure to high levels of radiation, and certain hereditary syndromes.
  • The National Cancer Institute recommends that anyone who received radiation to the head or neck in childhood be examined by a doctor every one to two years to detect potential thyroid cancer.
  • The most common signs and symptoms of thyroid cancer include a lump, or thyroid nodule, that can be felt in the neck, trouble swallowing, throat or neck pain, swollen lymph nodes in the neck, cough, and vocal changes.
  • The only certain way to tell whether a thyroid lump is cancerous is by examining the thyroid tissue obtained using a needle or surgery for biopsy. A CEA blood test, physical exam, X-rays, CT scans, PET scans, ultrasounds, and MRIs may also be used to help establish a definitive diagnosis and determine staging.
  • Surgery is the most common form of treatment for thyroid cancer that has not spread to other areas of the body. Radiation therapy, chemotherapy, and radioactive iodine treatment are also treatment options for thyroid cancer.
  • The survival rate and prognosis of thyroid cancer depends upon a few factors, including the individual's age, the size of the tumor, and whether the cancer has metastasized.
  • It is not possible to prevent most cases of thyroid cancer.

 

What is the thyroid?

The thyroid is a gland in the neck. It has two kinds of cells that make hormones. Follicular cells make thyroid hormone, which affects heart rate, body temperature, and energy level. C cells make calcitonin, a hormone that helps control the level of calcium in the blood.

The thyroid is shaped like a butterfly and lies at the front of the neck, beneath the voice box (larynx). It has two parts, or lobes. The two lobes are separated by a thin section called the isthmus.

A healthy thyroid is a little larger than a quarter. It usually cannot be felt through the skin. A swollen lobe might look or feel like a lump in the front of the neck. A swollen thyroid is called a goiter. Most goiters are caused by not enough iodine in the diet. Iodine is a substance found in shellfish and iodized salt.

What is cancer, and what are the types of thyroid cancer?

Cancer is a group of many related diseases. All cancers begin in cells, the body's basic unit of life. Cells make up tissues, and tissues make up the organs of the body.

Normally, cells grow and divide to form new cells as the body needs them. When cells grow old and die, new cells take their place.

Sometimes this orderly process goes wrong. New cells form when the body does not need them, and old cells do not die when they should. These extra cells can form a mass of tissue called a growth or tumor. Growths on the thyroid are usually called nodules.

Thyroid nodules can be benign or malignant:

  • Benign nodules are not cancer. Cells from benign nodules do not spread to other parts of the body. They are usually not a threat to life. Most thyroid nodules (more than 90 percent) are benign.
  • Malignant nodules are cancer. They are generally more serious and may sometimes be life threatening. Cancer cells can invade and damage nearby tissues and organs. Also, cancer cells can break away from a malignant nodule and enter the bloodstream or the lymphatic system. That is how cancer spreads from the original cancer (primary tumor) to form new tumors in other organs. The spread of cancer is called metastasis.

The following are the major types of thyroid cancer:

  • Papillary and follicular thyroid cancers account for 80 to 90 percent of all thyroid cancers. Both types begin in the follicular cells of the thyroid. Most papillary and follicular thyroid cancers tend to grow slowly. If they are detected early, most can be treated successfully.
  • Medullary thyroid cancer accounts for 5 to 10 percent of thyroid cancer cases. It arises in C cells, not follicular cells. Medullary thyroid cancer is easier to control if it is found and treated before it spreads to other parts of the body.
  • Anaplastic thyroid cancer is the least common type of thyroid cancer (only 1 to 2 percent of cases). It arises in the follicular cells. The cancer cells are highly abnormal and difficult to recognize. This type of cancer is usually very hard to control because the cancer cells tend to grow and spread very quickly.

If thyroid cancer spreads (metastasizes) outside the thyroid, cancer cells are often found in nearby lymph nodes, nerves, or blood vessels. If the cancer has reached these lymph nodes, cancer cells may have also spread to other lymph nodes or to other organs, such as the lungs or bones.

When cancer spreads from its original place to another part of the body, the new tumor has the same kind of abnormal cells and the same name as the primary tumor. For example, if thyroid cancer spreads to the lungs, the cancer cells in the lungs are thyroid cancer cells. The disease is metastatic thyroid cancer, not lung cancer. It is treated as thyroid cancer, not as lung cancer. Doctors sometimes call the new tumor "distant" or metastatic disease.

Thyroid Gland illustration - Thyroid Cancer

 

 

 

What causes thyroid cancer, and what are risk factors of thyroid cancer?

No one knows the exact causes of thyroid cancer. Doctors can seldom explain why one person gets this disease and another does not. However, it is clear that thyroid cancer is not contagious. No one can "catch" cancer from another person.

Research has shown that people with certain risk factors are more likely than others to develop thyroid cancer. A risk factor is anything that increases a person's chance of developing a disease.

The following risk factors are associated with an increased chance of developing thyroid cancer:

  • Radiation. People exposed to high levels of radiation are much more likely than others to develop papillary or follicular thyroid cancer.

    One important source of radiation exposure is treatment with x-rays. Between the 1920s and the 1950s, doctors used high-dose x-rays to treat children who had enlarged tonsils, acne, and other problems affecting the head and neck. Later, scientists found that some people who had received this kind of treatment developed thyroid cancer. (Routine diagnostic x-rays—such as dental x-rays or chest x-rays—use very small doses of radiation. Their benefits nearly always outweigh their risks. However, repeated exposure could be harmful, so it is a good idea for people to talk with their dentist and doctor about the need for each x-ray and to ask about the use of shields to protect other parts of the body.)

    Another source of radiation is radioactive fallout. This includes fallout from atomic weapons testing (such as the testing in the United States and elsewhere in the world, mainly in the 1950s and 1960s), nuclear power plant accidents (such as the Chornobyl [also called Chernobyl] accident in 1986), and releases from atomic weapons production plants (such as the Hanford facility in Washington state in the late 1940s). Such radioactive fallout contains radioactive iodine (I-131). People who were exposed to one or more sources of I-131, especially if they were children at the time of their exposure, may have an increased risk for thyroid diseases.

    People who are concerned about their exposure to radiation from medical treatments or radioactive fallout may wish to ask the Cancer Information Service at 1-800-4-CANCER about additional sources of information.

  • Family history. Medullary thyroid cancer can be caused by a change, or alteration, in a gene called RET. The altered RET gene can be passed from parent to child. Nearly everyone with the altered RET gene will develop medullary thyroid cancer. A blood test can detect an altered RET gene. If the abnormal gene is found in a person with medullary thyroid cancer, the doctor may suggest that family members be tested. For those found to carry the altered RET gene, the doctor may recommend frequent lab tests or surgery to remove the thyroid before cancer develops. When medullary thyroid cancer runs in a family, the doctor may call this "familial medullary thyroid cancer" or "multiple endocrine neoplasia (MEN) syndrome." People with the MEN syndrome tend to develop certain other types of cancer.

    A small number of people with a family history of goiter or certain precancerous polyps in the colon are at risk for developing papillary thyroid cancer.

  • Being female. In the United States, women are two to three times more likely than men to develop thyroid cancer.
  • Age. Most patients with thyroid cancer are more than 40 years old. People with anaplastic thyroid cancer are usually more than 65 years old.
  • Race. In the United States, white people are more likely than African Americans to be diagnosed with thyroid cancer.
  • Not enough iodine in the diet. The thyroid needs iodine to make thyroid hormone. In the United States, iodine is added to salt to protect people from thyroid problems. Thyroid cancer seems to be less common in the United States than in countries where iodine is not part of the diet.

Most people who have known risk factors do not get thyroid cancer. On the other hand, many who do get the disease have none of these risk factors. People who think they may be at risk for thyroid cancer should discuss this concern with their doctor. The doctor may suggest ways to reduce the risk and can plan an appropriate schedule for checkups.

What are symptoms of thyroid cancer?

Early thyroid cancer often does not cause symptoms. But as the cancer grows, symptoms may include:

  • A lump, or nodule, in the front of the neck near the Adam's apple;
  • Hoarseness or difficulty speaking in a normal voice;
  • Swollen lymph nodes, especially in the neck;
  • Difficulty swallowing or breathing; or
  • Pain in the throat or neck.

These symptoms are not sure signs of thyroid cancer. An infection, a benign goiter, or another problem also could cause these symptoms. Anyone with these symptoms should see a doctor as soon as possible. Only a doctor can diagnose and treat the problem.

How is thyroid cancer diagnosed?

If a person has symptoms that suggest thyroid cancer, the doctor may perform a physical exam and ask about the patient's personal and family medical history. The doctor also may order laboratory tests and imaging tests to produce pictures of the thyroid and other areas.

The exams and tests may include the following:

  • Physical exam—The doctor will feel the neck, thyroid, voice box, and lymph nodes in the neck for unusual growths (nodules) or swelling.
  • Blood tests—The doctor may test for abnormal levels (too low or too high) of thyroid-stimulating hormone (TSH) in the blood. TSH is made by the pituitary gland in the brain. It stimulates the release of thyroid hormone. TSH also controls how fast thyroid follicular cells grow.

    If medullary thyroid cancer is suspected, the doctor may check for abnormally high levels of calcium in the blood. The doctor also may order blood tests to detect an altered RET gene or to look for a high level of calcitonin.

  • Ultrasonography—The ultrasound device uses sound waves that people cannot hear. The waves bounce off the thyroid, and a computer uses the echoes to create a picture called a sonogram. From the picture, the doctor can see how many nodules are present, how big they are, and whether they are solid or filled with fluid.
  • Radionuclide scanning—The doctor may order a nuclear medicine scan that uses a very small amount of radioactive material to make thyroid nodules show up on a picture. Nodules that absorb less radioactive material than the surrounding thyroid tissue are called cold nodules. Cold nodules may be benign or malignant. Hot nodules take up more radioactive material than surrounding thyroid tissue and are usually benign.
  • Biopsy—The removal of tissue to look for cancer cells is called a biopsy. A biopsy can show cancer, tissue changes that may lead to cancer, and other conditions. A biopsy is the only sure way to know whether a nodule is cancerous.

    The doctor may remove tissue through a needle or during surgery:

    • Fine-needle aspiration: For most patients, the doctor removes a sample of tissue from a thyroid nodule with a thin needle. A pathologist looks at the cells under a microscope to check for cancer. Sometimes, the doctor uses an ultrasound device to guide the needle through the nodule.
    • Surgical biopsy: If a diagnosis cannot be made from the fine-needle aspiration, the doctor may operate to remove the nodule. A pathologist then checks the tissue for cancer cells.

 

A person who needs a biopsy may want to ask the doctor the following questions:

  • What kind of biopsy will I have?
  • How long will the procedure take? Will I be awake? Will it hurt?
  • Will I have a scar on my neck after the biopsy?
  • How soon will you have the results? Who will explain them to me?
  • If I do have cancer, who will talk to me about treatment? When?

How is staging determined for thyroid cancer?

If the diagnosis is thyroid cancer, the doctor needs to know the stage, or extent, of the disease to plan the best treatment. Staging is a careful attempt to learn whether the cancer has spread and, if so, to what parts of the body.

The doctor may use ultrasonography, magnetic resonance imaging (MRI), or computed tomography (CT) to find out whether the cancer has spread to the lymph nodes or other areas within the neck. The doctor may use a nuclear medicine scan of the entire body, such as a radionuclide scan known as the "diagnostic I-131 whole body scan," or other imaging tests to learn whether thyroid cancer has spread to distant sites.

What is the treatment for thyroid cancer?

People with thyroid cancer often want to take an active part in making decisions about their medical care. They want to learn all they can about their disease and their treatment choices. However, the shock and stress that people may feel after a diagnosis of cancer can make it hard for them to think of everything they want to ask the doctor. It often helps to make a list of questions before an appointment. To help remember what the doctor says, patients may take notes or ask whether they may use a tape recorder. Some also want to have a family member or friend with them when they talk to the doctor—to take part in the discussion, to take notes, or just to listen.

The doctor may refer patients to doctors (oncologists) who specialize in treating cancer, or patients may ask for a referral. Specialists who treat thyroid cancer include surgeons, endocrinologists (some of whom are called thyroidologists because they specialize in thyroid diseases), medical oncologists, and radiation oncologists. Treatment generally begins within a few weeks after the diagnosis. There will be time for patients to talk with the doctor about treatment choices, get a second opinion, and learn more about thyroid cancer.

Getting a second opinion

Before starting treatment, the patient might want a second opinion about the diagnosis and the treatment plan. Some insurance companies require a second opinion; others may cover a second opinion if the patient or doctor requests it. Gathering medical records and arranging to see another doctor may take a little time. In most cases, a brief delay does not make treatment less effective.

There are a number of ways to find a doctor for a second opinion:

  • The patient's doctor may refer the patient to one or more specialists. At cancer centers, several specialists often work together as a team.
  • The Cancer Information Service, at 1-800-4-CANCER, can tell callers about treatment facilities, including cancer centers and other programs supported by the National Cancer Institute.
  • A local medical society, a nearby hospital, or a medical school can usually provide the name of specialists.
  • The American Board of Medical Specialties (ABMS) has a list of doctors who have met certain education and training requirements and have passed specialty examinations. The Official ABMS Directory of Board Certified Medical Specialists lists doctors' names along with their specialty and their educational background. The directory is available in most public libraries. Also, ABMS offers this information on the Internet at http://www.abms.org. (Click on "Who's Certified.")

Preparing for treatment

The doctor can describe treatment choices and discuss the results expected with each treatment option. The doctor and patient can work together to develop a treatment plan that fits the patient's needs.

Treatment depends on a number of factors, including the type of thyroid cancer, the size of the nodule, the patient's age, and whether the cancer has spread.

These are some questions a person may want to ask the doctor before treatment begins:

  • What type of thyroid cancer do I have?
  • Has the cancer spread? What is the stage of the disease?
  • Do I need any more tests to check for spread of the disease?
  • What are my treatment choices? Which do you recommend for me? Why?
  • What are the benefits of each kind of treatment?
  • What are the risks and possible side effects of each treatment?
  • What is the treatment likely to cost?
  • How will the treatment affect my normal activities?
  • Would a clinical trial (research study) be appropriate for me? Can you help me find one?

People do not need to ask all of their questions or understand all of the answers at one time. They will have other chances to ask the doctor to explain things that are not clear and to ask for more information.

Methods of treatment

People with thyroid cancer have many treatment options. Depending on the type and stage, thyroid cancer may be treated with surgery, radioactive iodine, hormone treatment, external radiation, or chemotherapy. Some patients receive a combination of treatments.

The doctor is the best person to describe the treatment choices and discuss the expected results.

A patient may want to talk to the doctor about taking part in a clinical trial, a research study of new treatment methods. The section on "The Promise of Cancer Research" has more information about clinical trials.

Surgery is the most common treatment for thyroid cancer. The surgeon may remove all or part of the thyroid. The type of surgery depends on the type and stage of thyroid cancer, the size of the nodule, and the patient's age.

  • Total thyroidectomy—Surgery to remove the entire thyroid is called a total thyroidectomy. The surgeon removes the thyroid through an incision in the neck. Nearby lymph nodes are sometimes removed, too. If the pathologist finds cancer cells in the lymph nodes, it means that the disease could spread to other parts of the body. In a small number of cases, the surgeon removes other tissues in the neck that have been affected by the cancer. Some patients who have a total thyroidectomy also receive radioactive iodine or external radiation therapy.
  • Lobectomy—Some patients with papillary or follicular thyroid cancer may be treated with lobectomy. The lobe with the cancerous nodule is removed. The surgeon also may remove part of the remaining thyroid tissue or nearby lymph nodes. Some patients who have a lobectomy receive radioactive iodine therapy or additional surgery to remove remaining thyroid tissue.

Nearly all patients who have part or all of the thyroid removed will take thyroid hormone pills to replace the natural hormone.

After the initial surgery, the doctor may need to operate on the neck again for thyroid cancer that has spread. Patients who have this surgery also may receive I-131 therapy or external radiation therapy to treat thyroid cancer that has spread.

These are some questions a person may want to ask the doctor before having surgery:

  • What kind of operation will I have?
  • How will I feel after the operation?
  • What will you do for me if I have pain?
  • How long will I be in the hospital?
  • Will I have any long-term effects?
  • When can I get back to my normal activities?
  • What will my scar look like?
  • What is my chance of a full recovery?
  • Will I need to take thyroid hormone pills?
  • How often will I need checkups?

Radioactive iodine therapy (also called radioiodine therapy) uses radioactive iodine (I-131) to destroy thyroid cancer cells anywhere in the body. The therapy usually is given by mouth (liquid or capsules) in a small dose that causes no problems for people who are allergic to iodine. The intestine absorbs the I-131, which flows through the bloodstream and collects in thyroid cells. Thyroid cancer cells remaining in the neck and those that have spread to other parts of the body are killed when they absorb I-131.

If the dose of I-131 is low enough, the patient usually receives I-131 as an outpatient. If the dose is high, the doctor may protect others from radiation exposure by isolating the patient in the hospital during the treatment. Most radiation is gone in a few days. Within 3 weeks, only traces of radioactive iodine remain in the body.

Patients with medullary thyroid cancer or anaplastic thyroid cancer generally do not receive I-131 treatment. These types of thyroid cancer rarely respond to I-131 therapy.

Hormone treatment after surgery is usually part of the treatment plan for papillary and follicular cancer. When a patient takes thyroid hormone pills, the growth of any remaining thyroid cancer cells slows down, which lowers the chance that the disease will return.

After surgery or I-131 therapy (which removes or destroys thyroid tissue), people with thyroid cancer may need to take thyroid hormone pills to replace the natural thyroid hormone.

People may want to ask these questions about radioactive iodine (I-131) therapy or hormone therapy:

  • Why do I need this treatment?
  • What will it do?
  • Will I need to stay in the hospital for this treatment?
  • Will it cause side effects? What can I do about them?
  • How long will I be on this treatment?
  • How often will I need checkups?

External radiation therapy (also called radiotherapy) uses high-energy rays to kill cancer cells. A large machine directs radiation at the neck or at parts of the body where the cancer has spread.

External radiation therapy is local therapy. It affects cancer cells only in the treated area. External radiation therapy is used mainly to treat people with advanced thyroid cancer that does not respond to radioactive iodine therapy. For external radiation therapy, patients go to the hospital or clinic, usually 5 days a week for several weeks. External radiation may also be used to relieve pain or other problems.

These are some questions a person may want to ask the doctor before having external radiation therapy:

  • Why do I need this treatment?
  • When will the treatments begin? When will they end?
  • How will I feel during therapy? Are there side effects?
  • What can I do to take care of myself during therapy?
  • How will we know if the radiation is working?
  • Will I be able to continue my normal activities during treatment?
  • How often will I need checkups?

Chemotherapy, the use of drugs to kill cancer cells, is sometimes used to treat thyroid cancer. Chemotherapy is known as systemic therapy because the drugs enter the bloodstream and travel throughout the body. For some patients, chemotherapy may be combined with external radiation therapy.

 

Patients may want to ask these questions about chemotherapy:

  • Why do I need this treatment?
  • What will it do?
  • Will I have side effects? What can I do about them?
  • How long will I be on this treatment?
  • How often will I need checkups?

What are side effects of cancer treatment?

Because cancer treatment may damage healthy cells and tissues, unwanted side effects sometimes occur. These side effects depend on many factors, including the type and extent of the treatment. Side effects may not be the same for each person, and they may even change from one treatment session to the next. Before treatment starts, the health care team will explain possible side effects and suggest ways to help the patient manage them.

The NCI provides helpful booklets about cancer treatments and coping with side effects, such as Radiation Therapy and You, Chemotherapy and You, and Eating Hints for Cancer Patients. See the sections "National Cancer Institute Information Resources" and "National Cancer Institute Booklets" for other sources of information about side effects.

Surgery

Patients are often uncomfortable for the first few days after surgery. However, medicine can usually control their pain. Patients should feel free to discuss pain relief with the doctor or nurse. It is also common for patients to feel tired or weak. The length of time it takes to recover from an operation varies for each patient.

After surgery to remove the thyroid and nearby tissues or organs, such as the parathyroid glands, patients may need to take medicine (thyroid hormone) or vitamin and mineral supplements (vitamin D and calcium) to replace the lost functions of these organs. In a few cases, certain nerves or muscles may be damaged or removed during surgery. If this happens, the patient may have voice problems or one shoulder may be lower than the other.

Radioactive iodine (I-131) therapy

Some patients have nausea and vomiting on the first day of I-131 therapy. Thyroid tissue remaining in the neck after surgery may become swollen and painful. If the thyroid cancer has spread to other parts of the body, the I-131 that collects there may cause pain and swelling.

Patients also may have a dry mouth or lose their sense of taste or smell for a short time after I-131 therapy. Chewing sugar-free gum or sucking on sugar-free hard candy may help.

During treatment, patients are encouraged to drink lots of water and other fluids. Because fluids help I-131 pass out of the body more quickly, the bladder's exposure to I-131 is reduced.

Because radioactive iodine therapy destroys the cells that make thyroid hormone, patients may need to take thyroid hormone pills to replace the natural hormone.

A rare side effect in men who received large doses of I-131 is loss of fertility. In women, I-131 may not cause loss of fertility, but some doctors suggest that women avoid pregnancy for one year after I-131 therapy.

Researchers have reported that a very small number of patients may develop leukemia years after treatment with high doses of I-131.

Hormone treatment

Thyroid hormone pills seldom cause side effects. However, a few patients may get a rash or lose some of their hair during the first months of treatment.

The doctor will closely monitor the level of thyroid hormone in the blood during followup visits. Too much thyroid hormone may cause patients to lose weight and to feel hot and sweaty. It also may cause chest pain, cramps, and diarrhea. (The doctor may call this condition "hyperthyroidism.") If the thyroid hormone level is too low, the patient may gain weight, feel cold, and have dry skin and hair. (The doctor may call this condition "hypothyroidism.") If necessary, the doctor will adjust the dose so that the patient takes the right amount.

External radiation therapy

External radiation therapy may cause patients to become very tired as treatment continues. Resting is important, but doctors usually advise patients to try to stay as active as they can. In addition, when patients receive external radiation therapy, it is common for their skin to become red, dry, and tender in the treated area. When the neck is treated with external radiation therapy, patients may feel hoarse or have trouble swallowing. Other side effects depend on the area of the body that is treated. If chemotherapy is given at the same time, the side effects may worsen. The doctor can suggest ways to ease these problems.

Chemotherapy

The side effects of chemotherapy depend mainly on the specific drugs that are used. The most common side effects include nausea and vomiting, mouth sores, loss of appetite, and hair loss. Some side effects may be relieved with medicine.

What about followup care for thyroid cancer?

Followup care after treatment for thyroid cancer is an important part of the overall treatment plan. Regular checkups ensure that any changes in health are noted. Problems can be found and treated as soon as possible. Checkups may include a careful physical exam, x-rays and other imaging tests (such as a nuclear medicine scan), and laboratory tests (such as a blood test for calcitonin). The doctor can explain the followup plan—how often the patient must visit the doctor and which types of tests are needed.

An important test after thyroid cancer treatment measures the level of thyroglobulin in the blood. Thyroid hormone is stored in the thyroid as thyroglobulin. If the thyroid has been removed, there should be very little or no thyroglobulin in the blood. A high level of thyroglobulin may mean that thyroid cancer cells have returned.

For six weeks before the thyroglobulin test, patients must stop taking their usual thyroid hormone pill. For part of this time, some patients may take a different, shorter-lasting thyroid hormone pill. But all patients must stop taking any type of thyroid hormone pill for the last two weeks right before the test. Without adequate levels of thyroid hormone, patients are likely to feel uncomfortable. They may gain weight and feel very tired. It may be helpful to talk with the doctor or nurse about ways to cope with such problems. After the test, patients go back to their usual treatment with thyroid hormone pills.

The doctor may request an I-131 scan of the entire body. This may be called a "diagnostic I-131 whole body scan." For a short time (usually six weeks) before this scan, the patient stops taking thyroid hormone pills. Thyroid cancer cells anywhere in the body will show up on the scan. After the test, the doctor will tell the patient when to start taking thyroid hormone pills again.

Support for people with thyroid cancer

Living with a serious disease such as cancer is not easy. Some people find they need help coping with the emotional and practical aspects of their disease. Support groups can help. In these groups, patients or their family members get together to share what they have learned about coping with the disease and the effects of treatment. Patients may want to talk with a member of their health care team about finding a support group. Groups may offer support in person, over the telephone, or on the Internet.

People living with cancer may worry about caring for their families, keeping their jobs, or continuing daily activities. Concerns about treatments and managing side effects, hospital stays, and medical bills are also common. Doctors, nurses, and other members of the health care team can answer questions about treatment, working, or other activities. Meeting with a social worker, counselor, or member of the clergy can be helpful to those who want to talk about their feelings or discuss their concerns. Often, a social worker can suggest resources for financial aid, transportation, home care, or emotional support.

The Cancer Information Service can provide information to help patients and their families locate programs, services, and publications.

What's new in thyroid cancer research?

The promise of cancer research

Doctors all over the country are conducting many types of clinical trials. These are research studies in which people take part voluntarily. Studies include new ways to treat thyroid cancer. Research already has led to advances, and researchers continue to search for more effective approaches.

Patients who join these studies have the first chance to benefit from treatments that have shown promise in earlier research. They also make an important contribution to medical science by helping doctors learn more about the disease. Although clinical trials may pose some risks, researchers take very careful steps to protect their patients.

Patients who are interested in being part of a clinical trial should talk with their doctor. They may want to read Taking Part in Clinical Trials: What Cancer Patients Need to Know. This NCI booklet describes how research studies are carried out and explains their possible benefits and risks. NCI's Web site at http://www.cancer.gov provides general information about clinical trials. It also offers detailed information about specific ongoing studies of thyroid cancer by linking to PDQ®, NCI's cancer information database. The Cancer Information Service at 1-800-4-CANCER can answer questions and provide information from the PDQ database.

Another agency of the Federal Government, the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), conducts a Thyroid Research Program. NIDDK performs laboratory studies and conducts clinical trials on thyroid cancer. NIDDK clinical trials are listed in the PDQ database. The Web site address of the NIDDK is http://www.niddk.nih.gov.

Where can people get more information about thyroid cancer?

National Cancer Institute information resources

You may want more information for yourself, your family, and your doctor. The following National Cancer Institute (NCI) services are available to help you.

Telephone

Cancer Information Service (CIS)
Provides accurate, up-to-date information on cancer to patients and their families, health professionals, and the general public. Information specialists translate the latest scientific information into understandable language and respond in English, Spanish, or on TTY equipment.

    Toll-free: 1-800-4-CANCER (1-800-422-6237)
    TTY (for deaf and hard of hearing callers): 1-800-332-8615

Internet

http://www.cancer.gov
NCI's Web site contains comprehensive information about cancer causes and prevention, screening and diagnosis, treatment and survivorship; clinical trials; statistics; funding, training, and employment opportunities; and the Institute and its programs.

 



 

Sudden Cardiac Arrest
(Sudden Cardiac Death)

  • Introduction to sudden cardiac arrest
  • What are the causes of sudden cardiac arrest?
  • What about sudden cardiac arrest in the young?
  • What are the symptoms of sudden cardiac arrest?
  • How is sudden cardiac arrest diagnosed?
  • What is the treatment for sudden cardiac arrest?
  • Can sudden cardiac arrest be prevented?
  • What is the prognosis sudden cardiac arrest?
  • Patient Discussions: Sudden Cardiac Arrest: Experience

Introduction to sudden cardiac arrest

A natural disaster hits, the power goes off and the lights go out. It's a common scene that plays out during hurricane and tornado seasons, and it's very similar in trying to explain sudden cardiac arrest. The heart sustains an insult, the electricity is short circuited, the heart can't pump, and the body dies.

The heart is an electrical pump, where the electricity is generated in special pacemaker cells in the upper chamber, or atrium, of the heart. This electrical spark is carried through pathways in the heart so that all the muscle cells contract at once and produce a heart beat. This pumps blood through the heart valves and into all the organs of the body so that they can do their work.

This mechanism can break down in a variety of ways, but the final pathway in sudden death is the same: the electrical system is irritated and fails to produce electrical activity that causes the heart to beat. The heart muscle can't supply blood to the body, particularly the brain, and the body dies. Ventricular fibrillation (V Fib) is the most common reason for sudden death in patients. Without a coordinated electrical signal, the bottom chambers of the heart (ventricles) stop beating and instead, jiggle like Jello. Ventricular Fibrillation is treated with electrical shock, but for it to be effective, the shock usually needs to happen within less than four to six minutes, not only for it to be effective, but also to minimize brain damage from lack of blood and oxygen supply. Automatic external defibrillators (AEDs) are commonly available in public places to allow almost anybody to treat sudden death. Less commonly, the heart can just stop beating. The absence of a heart beat is known as asystole (asystole: a=no + systole=beat).

What are the causes of sudden cardiac arrest?

Sudden death is most often caused by heart disease. When blood vessels narrow, the heart muscle can become irritated because of lack of blood supply. In heart attack (acute myocardial infarction), a blood vessel becomes completely blocked by a blood clot, and there is enough irritability of the muscle to cause ventricular fibrillation. In fact, the reason many people with chest pain are admitted to the hospital is to monitor their heart rate and rhythm for signs that might lead to ventricular fibrillation. Sudden death may also be the first presentation of heart disease.

Congestive heart failure and heart valve problems, like aortic stenosis (narrowing of the aortic valve) also increase the risk of sudden cardiac arrest.

Cardiomyopathy is a broad category of heart disease where the heart muscle does not contract properly for whatever reason. Often it is ischemic, where part of the heart muscle doesn't get an adequate blood supply for a prolonged period of time and no longer can efficiently pump blood. People whose ejection fractions (the amount of blood pumped out of the heart with each heart beat) is less than 30% are at greater risk for sudden death (a normal ejection fraction is above 50%). In some people, cardiomyopathy may develop in the absence of ischemic heart disease.

Inflammation of the heart muscle, known as myocarditis (myo=muscle + card=heart + itis= inflammation), can also cause rhythm disturbances. Diseases like sarcoidosis, amyloidosis, and infections can cause inflammation of the heart muscle.

Some people are born with electrical conducting systems that are faulty, which place them at higher risk for rhythm disturbances. Some are due to the wiring, or electrical conduction system, like Wolff-Parkinson-White syndrome, while others are due to the structural basic structural problems within the heart, like Marfan syndrome.

Pulmonary embolus, a blood clot to the lung, can also cause sudden death. Clots form in the leg or arm and may break off and flow to the lung where they decrease the lung's ability to get oxygen from the air to the body. Risk factors for blood clots include surgery, prolonged immobilization (for example, hospitalization, long car rides or plane trips), trauma, or certain diseases like cancer.

Blunt chest trauma, such is in a motor vehicle accident, may result in ventricular fibrillation. (please see commotio cordis below)

What about sudden cardiac arrest in the young?

In younger people, sudden death is a rare event, but since it often involves people involved in athletics, cases are often reported in the press. The most common cause is hypertrophic cardiomyopathy (hypertrophy=to grow abnormally large + cardio=heart + myopathy = diseased muscle). This disease is often hereditary, and the walls of the ventricle are larger than they should be. This makes the pumping chamber of the heart smaller, and the heart has to work harder to pump blood out of the heart. As well, the thickened muscle narrows the space for the blood to flow through the aortic valve and to the rest of the body. During exercise, this decreased blood flow can irritate the heart muscle itself and cause ventricular fibrillation, collapse, and sudden death.

Anomalous coronary arteries can also cause sudden death in the young. The heart is a muscle itself, and like any muscle, it needs blood supply to provide oxygen for it to work. Normally, the coronary arteries lie on the surface of the heart. Anomalous arteries dive into the heart muscle itself and may be occluded when the heart muscle that surrounds the abnormally placed artery squeezes aggressively, as with exercise, shutting off blood supply to part of the heart. This irritates the electrical system and can cause ventricular fibrillation and sudden death.

The pre-participation athletic physical examination is a useful tool to screen children and adolescents for their risk of sudden cardiac arrest.

Commotio cordis is a situation in which the heart stops when the chest is hit by an object. News stories occasionally report of baseball players who are hit in the chest by a ball and collapse because their heart stops beating. The heart sits behind the breastbone, and the electrical system can be short circuited when a direct blow is sustained.

What are the symptoms of sudden cardiac arrest?

In sudden cardiac arrest, the heart stops beating, and blood is not supplied to the body. The presentation is not subtle. Almost immediate loss of consciousness occurs, and the affected person will not be able to be aroused. The person will fall or slump over. No pulse will be able to be palpated, and there will be no signs of breathing.

What is the diagnosis for sudden cardiac arrest?

Sudden cardiac arrest is an unexpected death in a person who had no known previous diagnosis of a fatal disease or condition. The person may or may not have heart disease.

What is the treatment for sudden cardiac arrest?

The vast majority of people whose heart stops beating unexpectedly have ventricular fibrillation. The definitive treatment for this is defibrillation using electricity to shock the heart back into a regular rhythm. With technological advances, AEDs are now a routine sight wherever people congregate.

Communities which institute public CPR education, use of AEDs, and rapid activation of 911 emergency medical services have dramatically increased survival rates from sudden cardiac arrest. Unfortunately, because the brain is so sensitive to the lack of oxygen and blood flow, unless treatment occurs within four to six minutes, there is a high risk of some permanent brain damage.

Should the patient survive to be transported to the hospital, the reason for collapse and sudden death will need to be diagnosed. Regardless, the ABCs of resuscitation will be re-evaluated. Airway, Breathing, and Circulation (heart beat and blood pressure) will be supported, and admission to an intensive care unit is most likely.

Diagnostic tests may include repeated electrocardiograms (EKGs), echocardiogram (ultrasounds of the heart), and cardiac catheterization and electrophysiologic studies, in which the electrical pathways of the heart are mapped.

Recent research involving the treatment of survivors of cardiac arrest suggests that prompt institution of hypothermia (cooling of the body) may prevent or lessen the degree of brain injury.

Survivors of sudden cardiac arrest are often candidates for implantable cardiac defibrillators.

Can sudden cardiac arrest be prevented?

Death is best treated by prevention. Most sudden death is associated with heart disease, so the at-risk population remains males older than 40 years of age who smoke, have high blood pressure, and diabetes (the risk factors for heart attack). Other risks include syncope (fainting or loss of consciousness) and known heart disease.

Syncope, or loss of consciousness, is a significant risk factor for sudden death. While some reasons for passing out are benign, there is always a concern that the reason was an abnormal heart rhythm that subsequently spontaneously corrected. The fear is that the next episode will be a sudden cardiac arrest. Depending on the healthcare provider's suspicion based on the patient's history, physical examination, laboratory tests, and EKG, the healthcare practitioner may recommend inpatient or outpatient heart monitoring to try to find a clue as to whether the passing out was due to a deadly heart rhythm. Unfortunately, the potentially suspect rhythm may not recur and depending on the situation, prolonged outpatient monitoring lasting weeks and months may be necessary. Use of electrophysiologic testing may help identify high risk patients (the electrical pathways are mapped using techniques similar to heart catheterization).

In people who present to their doctor with chest pain, aside from making the diagnosis, monitoring both the heart rate and rhythm are emphasized. The purpose of watching people with chest pain in a hospital setting is to prevent sudden cardiac arrest.

Using implantable defibrillators in high risk patients, especially those with markedly decreased ejection fractions can reduce the incidence of sudden cardiac arrest. These devices are placed under the skin in the chest wall and have wires that are attached to the heart itself. When they detect ventricular fibrillation, a shock is automatically delivered to the heart, restoring a heart beat and averting sudden death.

What is the prognosis for sudden cardiac arrest?

The frequency of sudden cardiac arrest is related to the frequency of coronary artery disease. If public health initiatives work to decrease risk the factors for heart disease, the risk for sudden death should decrease as well.

In the adolescent population, increased awareness of hypertrophic cardiomyopathy and appropriate screening may decrease the frequency of sudden death.

Public education and widespread availability of AEDs will increase survival.

 



 

Heart Disease and Cardiac Catheterization


  • Why do I need a cardiac catheterization?
  • What are the risks associated with cardiac catheterization?
  • How should I prepare for cardiac catheterization?
  • How long does cardiac catheterization last?
  • What happens during the cardiac catheterization?
  • What happens after the cardiac catheterization?
  • Patient Discussions: Cardiac Catheterization
  • Find a local Cardiologist in your town

Cardiac catheterization (also called cardiac cath or coronary angiogram) is an invasive imaging procedure that tests for heart disease by allowing your doctor to "see" how well your heart is functioning. During the test, a long, narrow tube, called a catheter, is inserted into a blood vessel in your arm or leg and guided to your heart with the aid of a special X-ray machine. Contrast dye is injected through the catheter so that X-ray movies of your valves, coronary arteries, and heart chambers can be created.

Why Do I Need a Cardiac Catheterization?

Your doctor uses cardiac cath to:

  • Evaluate or confirm the presence of heart disease (such as coronary artery disease, heart valve disease, or disease of the aorta).
  • Evaluate heart muscle function.
  • Determine the need for further treatment (such as an interventional procedure or bypass surgery).
  • At many hospitals, several interventional, or therapeutic, procedures to open blocked arteries are performed after the diagnostic part of the cardiac catheterization is complete. Interventional procedures include balloon angioplasty, brachytherapy, atherectomy, rotoblation, cutting balloon, and stent placements.

What Are the Risks Associated With Cardiac Catheterization?

Cardiac catheterization is generally safe. However, as with any invasive procedure, there are risks. Special precautions are taken to decrease these risks. Your doctor will discuss the risks of the procedure with you.

Risks are rare but can include:

  • Bleeding around the point of puncture
  • Abnormal heart rhythms
  • Blood clots
  • Infection
  • Allergic reaction to the dye
  • Stroke
  • Heart attack
  • Perforation of a blood vessel
  • Air embolism (introduction of air into a blood vessel, which can be life-threatening)

Be sure to ask your doctor any questions you may have before undergoing cardiac catheterization or other tests for heart disease.

How Should I Prepare for Cardiac Catheterization?

Before cardiac catheterization, most people will need to have a routine chest X-ray, blood tests, electrocardiogram, and urinalysis performed within two weeks before having the test.

You can wear whatever you like to the hospital. You will wear a hospital gown during the procedure.

Leave all valuables at home. If you normally wear dentures, glasses, or a hearing device, plan to wear them during the procedure.

Your doctor or nurse will give you specific instructions about what you can and cannot eat or drink before the procedure.

Tell your doctor all of the medications you are currently taking, including herbal preparations and dietary supplements.

Ask your doctor what medications should be taken on the day of your test. You may be told to stop taking certain medications, such as Coumadin (a blood thinner), for a few days before the procedure.

 

If you have diabetes, ask your doctor how to adjust your diabetes medications the day of your cardiac cath.

Tell your doctor and/or nurses if you are allergic to anything, especially iodine, shellfish, X-ray dye, latex, or rubber products (such as rubber gloves or balloons) or penicillin-type medications.

You may or may not return home the day of your procedure. Bring items with you (such as a robe, slippers, and toothbrush) to make your stay more comfortable. When you are able to return home, arrange for someone to bring you home.

How Long Does Cardiac Catheterization Last?

Cardiac catheterization usually takes about 30 minutes, but the preparation and recovery time add several hours. Plan on being at the hospital all day for the procedure.

What Happens During Cardiac Catheterization?

You will be given a hospital gown to wear during your cardiac catheterization. A nurse will start an intravenous (IV) line in your arm so that medications and fluids can be administered through your vein during the procedure.

The cardiac catheterization room is cool and dimly lit. You will lie on a special table. If you look above, you will see a large camera and several TV monitors. You can watch the pictures of your cardiac cath on the monitors.

The nurse will clean your skin (and possibly shave) the site where the catheter will be inserted (arm or groin). Sterile drapes are used to cover the site and help prevent infection. It is important that you keep your arms and hands down at your sides and not disturb the drapes.

Electrodes (small, flat, sticky patches) will be placed on your chest. The electrodes are attached to an electrocardiogram (ECG) machine that charts your heart's electrical activity.

A urinary catheter may be necessary for the procedure.

You will be given a mild sedative to help you relax, but you will be awake and conscious during the entire procedure. The doctor will use a local anesthetic to numb the catheter insertion site.

If the catheter is to be inserted into your arm (at the bend of the elbow, called the "brachial" approach), a local anesthetic will be injected into a vein in your arm to numb the area. A small incision will be made over the blood vessel through which the catheter introducer sheath (a tube through which the catheter is passed) and catheter will be inserted. The catheter will be inserted through the sheath and threaded to the arteries of your heart. Although you may feel pressure as the incision is made or when the sheath and catheter are inserted, you should not feel pain; tell your health care providers if you do.

If the catheter is to be inserted at the groin (called the "femoral" approach), a local anesthetic will be injected to numb the area. A small incision will be made over the blood vessel through which the catheter and introducer sheath will be inserted. The catheter will be inserted through the sheath and threaded to the arteries of your heart. Again, if you feel pain, tell your health care providers.

When the catheter is in place, the lights will be dimmed and a small amount of dye (or "contrast material") will be injected through the catheters into your arteries and heart chambers. The contrast material outlines the vessels, valves, and chambers.

When the contrast material is injected into your heart, you may feel hot or flushed for several seconds. This is normal and will go away in a few seconds. Please tell the doctor or nurses if you feel itching or tightness in the throat, nausea, chest discomfort, or any other symptoms.

The X-ray camera will be used to take photographs of the arteries and heart chambers. Your doctor may ask you to take a deep breath, hold your breath, or to cough during the procedure. You will be asked to hold your breath while the X-rays are taken. When all the photos have been taken, the catheter will be removed and the lights will be turned on.

What Happens After a Cardiac Catheterization?

If the catheter was inserted in your arm for your cardiac catheterization, the catheter and sheath are removed. The incision will be closed with stitches and bandaged. You will need to keep your arm straight for at least an hour. You will be able to walk around. You will be observed for a few hours to make sure you are feeling well after the procedure. You may receive medication to relieve discomfort in your arm after the anesthetic wears off. You will be given instructions regarding how to care for your arm when you return home. Tell your nurse if you think you are bleeding or feel any numbness or tingling in your fingers.

If the catheter was inserted in your groin, the introducer sheath will be removed and the incision will be closed with stitches, a collagen seal, or applied pressure. In some situations, the introducer sheath may be sutured into place and removed after the bleeding stops. A collagen seal is a protein material that works with your body's natural healing processes to form a clot in the artery.

A sterile dressing will be placed on the groin area to prevent infection. You will need to lay flat and keep the leg straight for two to six hours to prevent bleeding. Your head can not be raised more than two pillows high (about 30 degrees). Do not raise your head off the pillows, as this can cause strain in your abdomen and groin. Do not try to sit or stand. The nurse will check your bandage regularly, but tell your nurse if you think you are bleeding (have a wet, warm sensation) or if your toes begin to tingle or feel numb. You may receive medication to relieve discomfort in the groin area after the anesthetic wears off. Your nurse will help you out of bed when you are allowed to get up.

Your doctor's orders will determine when you will be allowed out of bed to go to the bathroom after your cardiac catheterization. You will need assistance getting out of bed, so ask for help. The nurse will help you sit up and dangle your legs on the side of the bed.

You will need to drink plenty of liquids to clear the contrast material from your body.

You may feel the need to urinate more frequently. This is normal. If a urinary catheter was not placed during the procedure, you will need to use a bedpan or urinal until you are able to get out of bed.

Your doctor will tell you if you are able to return home or will need to stay overnight. In either case, you will be monitored for several hours after the procedure.

Treatment, including medications, dietary changes, and future procedures will be discussed with you prior to going home. Care of the wound site, activity, and follow-up care will also be discussed.

Please ask your doctor if you have any questions about cardiac catheterization.

 



 

Coronary Angiogram

What is a coronary angiogram?
  • How is a coronary angiogram performed?
  • What does a coronary angiogram demonstrate?
  • Find a local Cardiologist in your town

What is an angiogram?

An angiogram is an X-ray image of blood vessels after they are filled with a contrast material. An angiogram of the heart, a coronary angiogram, is the "gold standard" for the evaluation of coronary artery disease (CAD). A coronary angiogram can be used to identify the exact location and severity of CAD.

How is a coronary angiogram performed?

Coronary angiography is performed with the use of local anesthesia and intravenous sedation, and is generally not significantly uncomfortable.

  • In performing a coronary angiogram, a doctor inserts a small catheter (a thin hollow tube with a diameter of 2-3 mm) through the skin into an artery in either the groin or the arm.
  • Guided with the assistance of a fluoroscope (a special x-ray viewing instrument), the catheter is then advanced to the opening of the coronary arteries (the blood vessels supplying blood to the heart).
  • Next, a small amount of radiographic contrast (a solution containing iodine, which is easily visualized with X-ray images) is injected into each coronary artery. The images that are produced are called the angiogram.
  • The procedure takes approximately 20-30 minutes.
  • After the procedure, the catheter is removed and the artery in the leg or arm is either sutured, "sealed," or treated with manual compression to prevent bleeding.
  • Often, if an angioplasty or stent is indicated, it will be performed as part of the same procedure.

What does a coronary angiogram demonstrate?

Angiographic images accurately reveal the extent and severity of all coronary artery blockages. For patients with severe angina or heart attack (myocardial infarction), or those who have markedly abnormal noninvasive tests for CAD (such as stress tests), the angiogram also helps the doctor select the optimal treatment. Treatments may then include medications, balloon angioplasty, coronary stenting, atherectomy ("roto-rooter"), or coronary artery bypass surgery

 



 

Heart Disease and Stress Tests

  • Exercise stress test introduction
  • What is an exercise stress test?
  • Why do I need an exercise stress test?
  • What types of stress tests are there?
  • How should I prepare for the exercise stress test?
  • What if I have diabetes?
  • What should I wear the day of the exercise stress test?
  • What happens during the exercise stress test?
  • Find a local Cardiologist in your town

Exercise Stress Test Introduction

A stress test can be used to test for heart disease. Stress tests are tests performed by a doctor and/or trained technician to determine the amount of stress that your heart can manage before developing either an abnormal rhythm or evidence of ischemia (not enough blood flow to the heart muscle). The most commonly performed stress test is the exercise stress test.

What Is an Exercise Stress Test?

The exercise stress test -- also called a stress test, exercise electrocardiogram, treadmill test, graded exercise test, or stress ECG -- is a test used to provide information about how the heart responds to exertion. It usually involves walking on a treadmill or pedaling a stationary bike at increasing levels of difficulty, while your electrocardiogram, heart rate, and blood pressure are monitored.

Why Do I Need a Stress Test?

Your doctor uses the stress test to:

  • Determine if there is adequate blood flow to your heart during increasing levels of activity.
  • Evaluate the effectiveness of your heart medications to control angina and ischemia.
  • Determine the likelihood of having coronary heart disease and the need for further evaluation.
  • Check the effectiveness of procedures done to improve blood flow within the heart vessels in people with coronary heart disease.
  • Identify abnormal heart rhythms.
  • Help you develop a safe exercise program.

What Types of Stress Tests Are There?

There are many different types of stress tests, including:

  • Dobutamine or Adenosine Stress Test: This test is used in people who are unable to exercise. A drug is given to make the heart respond as if the person were exercising. This way the doctor can still determine how the heart responds to stress, but no exercise is required.
  • Stress echocardiogram: An echocardiogram (often called "echo") is a graphic outline of the heart's movement. A stress echo can accurately visualize the motion of the heart's walls and pumping action when the heart is stressed; it may reveal a lack of blood flow that isn't always apparent on other heart tests.
  • Nuclear stress test: This test helps to determine which parts of the heart are healthy and function normally and which are not. A very small and harmless amount of radioactive substance is injected into the patient. Then the doctor uses a special camera to identify the rays emitted from the substance within the body; this produces clear pictures of the heart tissue on a monitor. These pictures are done both at rest and after exercise. Using this technique, a less than normal amount of thallium will be seen in those areas of the heart that have a decreased blood supply.

Preparation for these types of stress tests will vary from preparation for the exercise stress test. Ask your doctor about any specific instructions.

How Should I Prepare for the Exercise Stress Test?

  • Do not eat or drink anything except water for four hours before the test.
  • Do not drink or eat foods containing caffeine for 12 hours before the test. Caffeine will interfere with the results of your test.
  • Do not take the following heart medications on the day of your test unless your doctor tells you otherwise, or if the medication is needed to treat chest discomfort the day of the test: Isosorbide dinitrate (for example, Isordil, Dilatrate SR); Isosorbide mononitrate (for example, ISMO, Imdur, Monoket); Nitroglycerin (for example, Deponit, Nitrostat, Nitro-bid). Your doctor may also ask you to stop taking other heart medications on the day of your test. If you have any questions about your medications, ask your doctor. Do not discontinue any medication without first talking with your doctor.
  • If you use an inhaler for your breathing, please bring it to the test.

 

What If I have Diabetes?

  • If you take insulin to control your blood sugar, ask your doctor what amount of your medication you should take the day of the test. Often, you will take only half of your usual morning dose and eat a light meal 4 hours before the test.
  • If you take pills to control your blood sugar, do not take your medication until after the test is complete.
  • Do not take your diabetes medication and skip a meal before the test.
  • If you own a glucose monitor, bring it with you to check your blood sugar levels before and after your exercise stress test. If you think that your blood sugar is low, tell the lab personnel immediately.
  • Plan to eat and take your blood sugar medication following your stress test.

What Should I Wear the Day of the Test?

On the day of your stress test, wear soft-soled shoes suitable for walking and comfortable clothes. Do not bring valuables.

What Happens During the Exercise Stress Test?

First, during a stress test, a technician will gently clean 10 small areas on your chest and place electrodes (small, flat, sticky patches) on these areas. The electrodes are attached to an electrocardiograph monitor (ECG or EKG) that charts your heart's electrical activity during the test.

Before you start exercising, the technician will perform an EKG, to measure your heart rate at rest and will take your blood pressure.

You will begin to exercise by walking on a treadmill or pedaling a stationary bicycle. The rate of exercise, or degree of difficulty will gradually increase. You will be asked to exercise until you feel exhausted.

At regular intervals, the lab personnel will ask how you are feeling. Please tell them if you feel chest, arm or jaw pain or discomfort, short of breath, dizzy, lightheaded, or any other unusual symptoms. It is normal for your heart rate, blood pressure, breathing rate, and perspiration to increase during the test. The lab personnel will watch for any symptoms or changes on the ECG monitor that suggest the test should be stopped.

After the test you will walk or pedal slowly for a couple of minutes to cool down. Your heart rate, blood pressure and ECG will continue to be monitored until the levels begin returning to normal.

Although the appointment lasts about 60 minutes, the actual exercise time is usually between seven and 12 minutes.

 



 

Pulmonary Edema


  • What is pulmonary edema?
  • What causes pulmonary edema?
  • What are the risk factors for pulmonary edema?
  • What are the symptoms of pulmonary edema?
  • When should I seek medical care for pulmonary edema?
  • How is pulmonary edema diagnosed?
  • What is the treatment for pulmonary edema?
  • What are the complications of pulmonary edema?
  • How can pulmonary edema be prevented?
  • Pulmonary Edema At A Glance
  • Related pulmonary edema article:
    Pulmonary Edema - on eMedicineHealth
  • Patient Discussions: Pulmonary Edema

 

What is pulmonary edema?

Edema, in general, means swelling. This typically occurs when fluid from inside blood vessels seeps outside the blood vessel into the surrounding tissues, causing swelling. This can happen either because of too much pressure in the blood vessels or not enough proteins in the bloodstream to hold on to the fluid in the plasma (the part of the blood that does not contain any blood cells).

Pulmonary edema is the term used when edema happens in the lungs. The immediate area outside of the small blood vessels in the lungs is occupied by very tiny air sacs called the alveoli. This is where oxygen from the air is picked up by the blood passing by, and carbon dioxide in the blood is passed into the alveoli to be exhaled out. Alveoli normally have a thin wall that allows for this air exchange, and fluids are usually kept out of the alveoli unless these walls lose their integrity.

Picture of the alveoli and lung
Picture of the alveoli and lung

Pulmonary edema occurs when the alveoli fill up with excess fluid seeped out of the blood vessels in the lung instead of air. This can cause problems with the exchange of gas (oxygen and carbon dioxide), resulting in breathing difficulty and poor oxygenation of blood. Sometimes, this can be referred to as "water in the lungs" when describing the condition to patients.

Pulmonary edema can be caused by many different factors. It can be related to heart failure, called cardiogenic pulmonary edema, or related to other causes, referred to as non-cardiogenic pulmonary edema.

What causes pulmonary edema?

As mentioned earlier, pulmonary edema can be broadly divided into cardiogenic and non-cardiogenic causes. Some of the common causes are listed below.

Cardiogenic causes of pulmonary edema

Cardiogenic causes of pulmonary edema results from high pressure in the blood vessels of the lung due to poor heart function. Congestive heart failure due to poor heart pumping function (arising from various causes such as arrhythmias and diseases or weakness of the heart muscle), heart attacks, or abnormal heart valves can lead to accumulation of more than the usual amount of blood in the blood vessels of the lungs. This can, in turn, cause the fluid from the blood vessels to be pushed out to the alveoli as the pressure builds up.

Non-cardiogenic pulmonary edema

Non-cardiogenic pulmonary edema can be commonly caused by the following:

  • Acute respiratory distress syndrome (ARDS), a potentially serious condition caused by severe infections, trauma, lung injury, inhalation of toxins, lung infections, cocaine smoking, or radiation to the lungs. In ARDS, the integrity of the alveoli become compromised as a result of underlying inflammatory response, and this leads to leaky alveoli that can fill up with fluid from the blood vessels.
  • Kidney failure and inability to excrete fluid from the body can cause fluid build-up in the blood vessels, resulting in pulmonary edema. In people with advanced kidney disease, dialysis may be necessary to remove the excess body fluid.
  • High altitude pulmonary edema, which can happen due to rapid ascent to high altitudes of more than 10,000 feet.
  • Brain trauma, bleeding in the brain (intracranial hemorrhage), severe seizures, or brain surgery can sometimes result in fluid accumulation in the lungs, causing neurogenic pulmonary edema.
  • A rapidly expanding lung can sometimes cause re-expansion pulmonary edema. This may happen in cases when the lung collapses (pneumothorax) or a large amount of fluid around the lung (pleural effusion) is removed, resulting in rapid expansion of the lung. This can result in pulmonary edema on the affected side only (unilateral pulmonary edema).
  • Rarely, an overdose on heroin or methadone can lead to pulmonary edema.
  • Aspirin overdose or chronic high dose use of aspirin can lead to aspirin intoxication, especially in the elderly, which may cause pulmonary edema.
  • Other more rare causes of non-cardiogenic pulmonary edema may include pulmonary embolism (blood clot which has traveled to the lungs), transfusion-related acute lung injury (TRALI), some viral infections, or eclampsia in pregnant women.

What are the risk factors for pulmonary edema?

The risk factors for pulmonary edema are essentially the underlying causes of the condition. There isn't any specific risk factor for pulmonary edema other than risk factors for the causative conditions.

What are the symptoms of pulmonary edema?

The most common symptom of pulmonary edema is shortness of breath or breathlessness. This may be of gradual onset if the process slowly develops, or it can have a sudden onset in the case of acute pulmonary edema.

Other common symptoms may include easy fatigue, more rapidly developing shortness of breath than normal with usual activity (dyspnea on exertion), rapid breathing (tachypnea), dizziness, or weakness.

Low blood oxygen level (hypoxia) may be detected in patients with pulmonary edema. Furthermore, upon examination of the lungs with a stethoscope, the doctor may listen for abnormal lung sounds, such as rales or crackles (discontinuous short bubbling sounds corresponding to the splashing of the fluid in the alveoli during breathing).

When should I seek medical care for pulmonary edema?

Medical attention should be sought for anyone who is diagnosed with pulmonary edema of any cause. Many causes of pulmonary edema require hospitalization, especially if they are caused acutely. In some cases of chronic (long term) pulmonary edema, for example, with congestive heart failure, routine follow-up visits with the treating doctor may be recommended.

Most cases of pulmonary edema are treated by internal medicine doctors (internists), heart specialists (cardiologists), or lung doctors (pulmonologists).

How is pulmonary edema diagnosed?

Pulmonary edema is typically diagnosed by a chest X-ray. A normal chest radiograph (X-ray) consists of a central white area pertaining to the heart and its main blood vessels plus the bones of the vertebral column, with the lung fields showing as darker fields on either side, enclosed by the bony structures of the chest wall.

A typical chest X-ray with pulmonary edema may show a more white appearance over both lung fields than usual. More severe cases of pulmonary edema can demonstrate significant opacification (whitening) over the lungs with minimal visualization of the normal lung fields. This whitening represents filling of the alveoli as a result of pulmonary edema, but it may give minimal information about the possible underlying cause.

To identify the cause of pulmonary edema, a thorough assessment of the patient's clinical picture is essential. A careful medical history and physical examination often provide invaluable information regarding the cause.

Other diagnostics tools used in assessing the underlying cause of pulmonary edema include the measurement of plasma B-type natriuretic peptide (BNP) or N-terminal pro-BNP. This is a protein marker (a hormone) that will rise in the blood due to the stretch of the chambers of the heart. Elevation of the BNP nanogram (one billionth of a gram) per liter greater than a few hundred (300 or more) is highly suggestive of cardiac pulmonary edema. On the other hand, values less than 100 essentially rule out heart failure as the cause.

More invasive methods are occasionally necessary to distinguish between cardiac and noncardiac pulmonary edema in more complicated and critical situations. A pulmonary artery catheter (Swan-Ganz) is a thin, long tube (catheter) inserted into the large veins of the chest or the neck and advanced through the right-sided chambers of the heart and lodged into the pulmonary capillaries (small branches of the blood vessels of the lungs). This device has the capability of directly measuring the pressure in the pulmonary vessels, called the pulmonary artery wedge pressure.

  • A wedge pressure of 18 mmHg or higher is consistent with cardiogenic pulmonary edema,
  • whereas a wedge pressure of less than 18 mmHg usually favors a non-cardiogenic cause of pulmonary edema.

A Swan-Ganz catheter placement and data interpretation is done only in the intensive care unit (ICU) setting.

What is the treatment for pulmonary edema?

The treatment of pulmonary edema largely depends on its cause and severity.

Most cases of cardiac pulmonary edema are treated by using diuretics (water pills) along with other medications for heart failure. In the majority of situations, appropriate treatment can be achieved as an outpatient by taking oral medications. If the pulmonary edema is more severe or it is not responsive to oral medications, then hospitalization and the use of intravenous diuretic medications may be necessary.

The treatment for noncardiac causes of pulmonary edema varies depending on the cause. For example, severe infection (sepsis) needs to treated with antibiotics and other supportive measures, or kidney failure needs to be properly evaluated and managed.

Oxygen supplementation is sometimes necessary if the measured oxygen level in the blood is too low. In serious conditions, such as ARDS, placing a patient on an artificial breathing machine is necessary to support their breathing while other measures are taken to treat pulmonary edema and its underlying cause.

What are the complications of pulmonary edema?

Most complications of pulmonary edema may arise from the complications associated with the underlying cause. More specifically, pulmonary edema can cause severely compromised oxygenation of the blood by the lungs. This poor oxygenation (hypoxia) can potentially lead to diminished oxygen delivery to different body organs, such as the brain.

How can pulmonary edema be prevented?

In terms of preventive measures, depending on the cause of pulmonary edema, some steps can be taken. Long-term prevention of heart disease and heart attacks, slow elevation to high altitudes, or avoidance of drug overdose can be considered preventive.

On the other hand, some causes may not completely avoidable or preventable, such as ARDS due to an overwhelming infection or a trauma.

Pulmonary edema At A Glance
  • Pulmonary edema is typically caused by filling of alveoli in the lungs by fluid leaking out of the blood.
  • Pulmonary edema may be caused by a number of cardiac or non-cardiac conditions.
  • Breathing difficulty is the main manifestation of pulmonary edema.
  • Treatment of the underlying cause of pulmonary edema is an essential step in the management of pulmonary edema.


Antiphospholipid Syndrome


  • What is antiphospholipid syndrome?
  • What laboratory tests can support the diagnosis of antiphospholipid syndrome?
  • What causes antiphospholipid syndrome?
  • How is antiphospholipid syndrome treated?
  • What is catastrophic antiphospholipid syndrome?
  • Antiphospholipid Syndrome At A Glance
  • Patient Discussions: Antiphospholipid Syndrome
  • Find a local Rheumatologist in your town

What is antiphospholipid syndrome?

The antiphospholipid syndrome is a disorder of the immune system that is characterized by excessive clotting of blood and/or certain complications of pregnancy (premature miscarriages, unexplained fetal death, or premature birth) and the presence of antiphospholipid antibodies (cardiolipin or lupus anticoagulant antibodies) in the blood. Patients with antiphospholipid syndrome have developed abnormal symptoms while having antiphospholipid antibodies that are detectable with blood testing.

Antiphospholipid syndrome is also called phospholipid antibody syndrome. Antiphospholipid syndrome has been referred to as Hughes syndrome in honor of the doctor who first described it.

It is important to note that antiphospholipid antibodies can also be found in the blood of individuals without any disease process. In fact, antiphospholipid antibodies have been reported in approximately 2% of the normal population. Harmless antiphospholipid antibodies can be detected in the blood for a brief period occasionally in association with a wide variety of conditions, including bacterial, viral (hepatitis, HIV), and parasite (malaria) infections. Certain drugs can cause antiphospholipid antibodies to be produced in the blood, including antibiotics, cocaine, hydralazine, procainamide, and quinine.

Nevertheless, the antiphospholipid antibody (a protein) is not considered a normal blood protein and has been found in patients to be associated with a number of illnesses. These illnesses include abnormal clotting (thrombosis) of arteries (stroke, infarction) and/or veins (phlebitis), premature miscarriages (spontaneous abortions), abnormally low blood platelet counts (thrombocytopenia), purplish mottling discoloration of the skin (livedo reticularis), migraine headaches, and a rare form of inflammation of the nervous tissue of the brain or spinal cord, called transverse myelitis. Antiphospholipid antibodies have also been detected in over half of patients with the immune disease systemic lupus erythematosus.

Researchers are recently also finding that there are patients with slowly progressive memory problems and patients with a form of "atypical multiple sclerosis" and antiphospholipid antibodies detectable in their blood.

What laboratory tests can support the diagnosis of antiphospholipid syndrome?

Patients with the antiphospholipid syndrome can have a variety of antibodies to molecules called phospholipids in their blood. These antibodies include VDRL/RPR (a syphilis test that can be falsely positive in these patients), lupus anticoagulant, prolonged PTT, and cardiolipin antibody. As mentioned above, the anticardiolipin antibody has also been found in patients with the immune disease systemic lupus erythematosus, which is characterized by the production of a variety of abnormal antibodies.

What causes antiphospholipid syndrome?

The cause of antiphospholipid syndrome is not completely known. Antiphospholipid antibodies reduce the levels of annexin V, a protein that binds phospholipids and has potent clot-blocking (anticoagulant) activity. The reduction of annexin V levels is thought to be a possible mechanism underlying the increased tendency of blood to clot and the propensity to pregnancy loss characteristic of the antiphospholipid syndrome.

Antiphospholipid antibodies, such as anticardiolipin, have also been associated with decreased levels of prostacyclin, a chemical that prevents the clumping together of normal blood clotting elements called platelets.

How is antiphospholipid syndrome treated?

The treatment of patients with anticardiolipin syndrome has substantially evolved since they were discovered to be clinically important in the mid-1980s. Each manifestation of the antiphospholipid syndrome, and each individual patient with the condition, is treated uniquely.

Because many of the features of illness with anticardiolipin syndrome are associated with an abnormal grouping of normal blood clotting elements (platelets), treatment is often directed toward preventing clotting by thinning the blood. Patients with this disorder have an abnormal tendency to form blood clots (thrombosis). The abnormal blood clotting can affect the function of virtually any organ. Medications that thin (anticoagulate) the blood, such as heparin (Hep-Lock, Liquaemin) and warfarin (Coumadin) (powerful blood thinners), are used for treatment. Aspirin has an affect on platelets that inhibits their grouping (aggregation) and has also been used in low doses to thin the blood of selected patients. Cortisone-related medications, such as prednisone, have been used to suppress the immune activity and inflammation in patients with certain features of the condition. For patients with systemic lupus erythematosus who also have antiphospholipid syndrome, hydroxychloroquine (Plaquenil) has been reported to add some protection against blood clotting.

Other reported treatments include the use of intravenous gamma globulin for selected patients with histories of premature miscarriage and those with low blood-clotting elements (platelets) during pregnancy. Recent research studies, however, suggest that intravenous gamma globulin may be no more effective than combination aspirin and heparin treatment.

What is catastrophic antiphospholipid syndrome?

Catastrophic antiphospholipid syndrome is a variant of antiphospholipid syndrome that is characterized by blockage of many blood vessels throughout the body. As a result of catastrophic antiphospholipid syndrome, many organs can be affected, including the skin, lungs, brain, heart, kidneys, and bowels. Catastrophic antiphospholipid syndrome is treated with anticoagulation, corticosteroids (cortisone medication), and plasmapheresis (plasma exchange).

Catastrophic antiphospholipid syndrome is rare, affecting less than 1% of those with antiphospholipid syndrome. Catastrophic antiphospholipid syndrome is sometimes referred to as Asherson's syndrome after the researcher who described it in the early 1990s.

Antiphospholipid Syndrome At A Glance
  • Antiphospholipid syndrome is an immune disorder that can affect virtually any organ.
  • Patients with antiphospholipid syndrome can have a variety of antibodies to phospholipids in their blood.
  • Antiphospholipid syndrome involves abnormal tendency toward clotting of blood.
  • Each individual patient with the antiphospholipid syndrome is treated uniquely according to what symptoms are present.

 


 

Heart Disease: Dilated Cardiomyopathy

What Is dilated cardiomyopathy?

  • What are the symptoms of Dilated Cardiomyopathy?
  • What causes Dilated Cardiomyopathy?
  • How is Dilated Cardiomyopathy diagnosed?
  • What is the treatment for Dilated Cardiomyopathy?
  • What drugs are used to treat Dilated Cardiomyopathy?
  • What lifestyle changes are recommended with Dilated Cardiomyopathy?
  • What surgeries are used to treat Dilated Cardiomyopathy?
  • Find a local Cardiologist in your town

What Is Dilated Cardiomyopathy?

 

Dilated cardiomyopathy (DCM) is a condition in which the heart's ability to pump blood is decreased because the heart's main pumping chamber, the left ventricle, is enlarged and weakened; this causes a decreased ejection fraction (the amount of blood pumped out with each heart beat). In some cases, it prevents the heart from relaxing and filling with blood as it should. Over time, it can affect the other heart chambers as well.

What Are the Symptoms of DCM?

Many people with DCM have no symptoms or only minor symptoms, and live a normal life. Other people develop symptoms, which may progress and worsen as heart function worsens.

Symptoms of DCM can occur at any age and may include:

  • Heart failure symptoms (shortness of breath and fatigue).
  • Swelling of the lower extremities.
  • Fatigue (feeling overly tired).
  • Weight gain.
  • Fainting (caused by conditions such as irregular heart rhythms, abnormal responses of the blood vessels during exercise, or no cause may be found).
  • Palpitations (fluttering in the chest due to abnormal heart rhythms).
  • Dizziness or lightheadedness.
  • Blood clots due to blood flowing more slowly through the body. If a blood clot breaks off, it can be carried to the lungs (pulmonary emboli), kidney (renal emboli), brain (cerebral emboli or stroke), or limbs (peripheral emboli).
  • Chest pain or pressure (occurs usually with exercise or physical activity, but can also occur with rest or after meals).

What Causes DCM?

DCM can be inherited (familial DCM), but it is primarily caused by a variety of other factors, including:

  • Severe coronary artery disease
  • Alcoholism
  • Thyroid disease
  • Diabetes
  • Viral infections of the heart
  • Heart valve abnormalities
  • Drugs that are toxic (or cause damage) to the heart

It can also occur in women after childbirth (postpartum cardiomyopathy).

Most cases of DCM are idiopathic (an exact cause is not known). When that's the case, the condition is called idiopathic dilated cardiomyopathy or dilated nonischemic cardiomyopathy.

 

How Is DCM Diagnosed?

DCM is diagnosed based on medical history (your symptoms and family history), physical exam, and tests: such as blood tests, electrocardiogram, chest X-ray, echocardiogram, exercise stress test, cardiac catheterization, CT scan, and MRI.

Another test rarely done to determine the cause of a cardiomyopathy is a myocardial biopsy, or heart biopsy, where a tissue sample is taken from the heart and examined under a microsope to determine the cause of the symptoms.

Relatives of those with familial DCM should be screened for DCM. Testing would be the same as mentioned above (medical history, physical exam, ECG, echocardiogram, etc.). Genetic testing may also be available to identify abnormal genes.

What Is the Treatment for DCM?

Treatment of DCM is aimed at correcting the cause of the condition wherever possible. Another major goal is to decrease the heart size and decrease the substances (hormones) in the bloodstream that enlarge the heart and ultimately lead to worsened symptoms. Patients usually take several medications to treat the heart failure. Doctors also recommend a variety of lifestyle changes.

What Drugs Are Used to Treat DCM?

To manage heart failure, most people improve by taking drugs, such as a beta-blocker,ACE inhibitorsor an ARB, and/or diuretics. If you have an arrhythmia, your doctor may give you a medication to control your heart rate or lessen the occurrence of arrhythmias. Blood thinners may be used to prevent blood clots from occurring. Your doctor will discuss what medications are best for you.

What Lifestyle Changes Are Recommended With DCM?

Lifestyle change can make a big difference in DCM and your heart health. Changes which are recommended include:

  • Diet. If heart failure is a problem, sodium (salt) should be restricted to 2,000 to 3,000 mg per day. This diet should be continued even once the symptoms abate.
  • Exercise. Your doctor will tell you if you may exercise or not. Most people with cardiomyopathy are encouraged to do non-competitive aerobic exercise. Heavy weight lifting is not recommended.

What Surgeries Are Used to Treat DCM?

People with severe DCM may need one of the following surgeries:

  • Cardiac resynchronization (CRT) by biventricular pacemaker. For some individuals, stimulating (pacing) both the right and left ventricles improves the heart's ability to contract with more force, thereby improving symptoms and increasing the length of time you are able to exercise. You may be a candidate for this special pacemaker if your electrocardiogram (ECG) and echocardiogram reveal specific characteristics, and you are still having symptoms of heart failure although you're receiving optimal medical therapy. This pacemaker also will help people with heart block or some bradycardias (slow heart rates).
  • Implantable cardioverter defibrillators (ICD). ICDs are suggested for people at risk for life-threatening arrhythmias or sudden cardiac death. The ICD constantly monitors the heart rhythm. When it detects a very fast, abnormal heart rhythm, it delivers energy to the heart muscle to cause the heart to beat in a normal rhythm again.
  • Surgery such as conventional surgeries used to treat coronary artery disease or valve disease may be used. Some individuals may be eligible for surgical repair of the left ventricle or other devices.
  • Heart transplant

 


 

Heart Disease: Hypertrophic Cardiomyopathy

What is hypertrophic cardiopmyopathy?
  • What are the symptoms of hypertrophic cardiopmyopathy?
  • What causes hypertrophic cardiopmyopathy?
  • How is hypertrophic cardiopmyopathy diagnosed?
  • How is hypertrophic cardiopmyopathy treated?
  • What lifestyle changes are recommended to treat hypertrophic cardiopmyopathy?
  • What medications are used for hypertrophic cardiopmyopathy?
  • What surgical procedures are used to treat hypertrophic cardiopmyopathy?
  • How can I prevent endocarditis?
  • Related cardiomyopathy article:
    Cardiomyopathy - on eMedicineHealth
  • Find a local Cardiologist in your town

What Is Hypertrophic Cardiomyopathy?

Hypertrophic cardiomyopathy (HCM) is associated with thickening of the heart muscle, most commonly at the septum between the ventricles, below the aortic valve. This leads to stiffening of the walls of the heart and abnormal aortic and mitral heart valve function, both of which may impede normal blood flow out of the heart.

What Are the Symptoms of HCM?

Many people with HCM have no symptoms or only minor symptoms, and live a normal life. Other people develop symptoms, which progress and worsen as heart function worsens.

Symptoms of HCM can occur at any age and may include:

  • Chest pain or pressure (occurs usually with exercise or physical activity, but can also occur with rest or after meals).
  • Shortness of breath (dyspnea), especially with exertion.
  • Fatigue (feeling overly tired).
  • Fainting (caused by irregular heart rhythms, abnormal responses of the blood vessels during exercise, or no cause may be found).
  • Palpitations (fluttering in the chest) due to abnormal heart rhythms (arrhythmias), such as atrial fibrillation or ventricular tachycardia.
  • Sudden death occurs in a small number of patients with HCM.

What Causes HCM?

HCM can run in families, but the condition may also be acquired as a part of aging or high blood pressure. In other instances, the cause is unknown.

How Is HCM Diagnosed?

HCM is diagnosed based on medical history (your symptoms and family history), a physical exam, and echocardiogram results. Additional tests may include blood tests, electrocardiogram, chest X-ray, exercise stress test, cardiac catheterization, CT scan, and MRI.

How Is HCM Treated?

Treatment of HCM depends on whether there is narrowing in the path that blood takes to leave the heart (called the outflow tract); how the heart is functioning; and if arrhythmias are present. Treatment is aimed at preventing symptoms and complications and includes risk identification and regular follow-up, lifestyle changes, medications, and procedures as needed.

What Lifestyle Changes Are Recommended to Treat HCM?

  • Diet. Drinking at least six to eight, 8-ounce glasses of water a day is important, unless fluids are restricted. In hot weather, you should increase your fluid intake. Fluid and salt restrictions may be necessary for some patients if heart failure symptoms are present. Ask your doctor about specific fluid and dietary guidelines, including information about alcoholic beverages and caffeinated products.
  • Exercise. Your doctor will tell you if you may exercise or not. Most people with cardiomyopathy are able to do non-competitive aerobic exercise. However, your doctor may ask you not to exercise, based on your symptoms and the severity of your disease. Heavy weight lifting is not recommended.
  • Regular follow-up visits. Patients with HCM should have an annual follow-up visit with their cardiologist to monitor their condition. Follow-up appointments may be more frequent when HCM is first diagnosed.

What Medications Are Used?

Often, drugs are used to treat symptoms and prevent further complications of HCM. Medications can help relax the heart and reduce the degree of obstruction so the heart can pump more efficiently. Beta-blockers and calcium channel blocker blockers are two classes of medications that may be prescribed. If you have an arrhythmia, your doctor may prescribe medications to control your heart rate or decrease the occurrence of arrhythmias.

You may be told to avoid certain medications, such as nitrates, because they lower blood pressure, or digoxin, because it increases the force of the heart's contraction.

Non-obstructive HCM symptoms may be treated with medications. If heart failure occurs, treatment is aimed at controlling it through heart failure medications and diet changes.

Your doctor will discuss which medications are best for you.

 

What Surgical Procedures Are Used to Treat HCM?

Surgical procedures used to treat HCM include:

  • Septal myectomy. During this surgical procedure, the surgeon removes a small amount of the thickened septal wall of the heart to widen the outflow tract (the path the blood takes) from the left ventricle to the aorta.
  • Ethanol ablation. First, a cardiologist (heart doctor) performs a cardiac catheterization to locate the small coronary artery that supplies blood flow to the septum. A balloon catheter is inserted into the artery and inflated. A contrast agent is injected to locate the swollen septal wall that narrows the passageway from the left ventricle to the aorta. When the bulge is located, a tiny amount of pure alcohol is injected through the catheter. The alcohol kills the cells on contact, causing a small "controlled" heart attack. The septum then shrinks back to a more normal size over the following months, widening the passage for blood flow.
  • Implantable Cardioverter Defibrillators (ICD). ICDs are suggested for people at risk for life-threatening arrhythmias or sudden cardiac death. The ICD constantly monitors the heart rhythm. When it detects a very fast, abnormal heart rhythm, it delivers energy to the heart muscle to cause the heart to beat in a normal rhythm again.

How Can I Prevent Endocarditis?

People with obstructive HCM may be at increased risk for infective endocarditis, a potentially life-threatening condition. Ask your doctor if you need to take endocarditis precautions, which include:

  • Tell all your doctors and dentist you have HCM. They should prescribe antibiotics to prevent an infection before performing any procedures on you that may cause bleeding (dental, respiratory, and gastrointestinal procedures).
  • Call your doctor if you have symptoms of an infection.
  • Take good care of your teeth and gums.

 


 

Heart Disease and Restrictive Cardiomyopathy

What is restrictive cardiomyopathy?
  • What are the symptoms of restrictive cardiomyopathy?
  • What causes restrictive cardiomyopathy?
  • How is restrictive cardiomyopathy diagnosed?
  • What is the treatment for restrictive cardiomyopathy?
  • What lifestyle changes are recommended for restrictive cardiomyopathy?
  • What medications are used for restrictive cardiomyopathy?
  • Can surgery treat restrictive cardiomyopathy?
  • Related cardiomyopathy article:
    Cardiomyopathy - on eMedicineHealth
  • Find a local Cardiologist in your town

What Is Restrictive Cardiomyopathy?

Restrictive cardiomyopathy, the rarest form of cardiomyopathy, is a condition in which the walls of the lower chambers of the heart (the ventricles) are abnormally rigid and lack the flexibility to expand as the ventricles fill with blood.

The pumping or systolic function of the ventricle may be normal but the diastolic function (the ability of the heart to fill with blood) is abnormal. Therefore, it is harder for the ventricles to fill with blood, and with time, the heart loses the ability to pump blood properly, leading to heart failure.

What Are the Symptoms of Restrictive Cardiomyopathy?

Many people with restrictive cardiomyopathy have no symptoms or only minor symptoms, and live a normal life. Other people develop symptoms, which progress and worsen as heart function worsens.

Symptoms of restrictive cardiomyopathy can occur at any age and may include:

  • Shortness of breath (at first with exercise; but over time it occurs at rest).
  • Fatigue (feeling overly tired).
  • Inability to exercise.
  • Swelling of the legs and feet
  • Weight gain
  • Nausea, bloating, and poor appetite (related to fluid retention).
  • Palpitations (fluttering in the chest due to abnormal heart rhythms).

Less common symptoms of restrictive cardiomyopathy:

  • Fainting (caused by irregular heart rhythms, abnormal responses of the blood vessels during exercise, or no cause may be found).
  • Chest pain or pressure (occurs usually with exercise or physical activity, but can also occur with rest or after meals).

What Causes Restrictive Cardiomyopathy?

Restrictive cardiomyopathy is not usually inherited and its cause is often unknown. Known causes of restrictive cardiomyopathy may include:

  • Build-up of scar tissue (often for no known reason).
  • Build-up of abnormal proteins (amyloidosis) in the heart muscle.
  • Chemotherapy or chest exposure to radiation.
  • Excess iron (hemochromatosis) in the heart.
  • Other systemic diseases (sarcoidosis).

How is Restrictive Cardiomyopathy Diagnosed?

The size of the heart may remain normal with restrictive cardiomyopathy. In some cases, restrictive cardiomyopathy may be confused with constrictive pericarditis, a condition in which the layers of the pericardium (the sac that surrounds the heart) become thickened, calcified, and stiff.

Restrictive cardiomyopathy is diagnosed based on medical history (your symptoms and family history), physical exam, and tests: such as blood tests, electrocardiogram, chest X-ray, echocardiogram, exercise stress test, cardiac catheterization, CT scan, and MRI.

A myocardial biopsy, or biopsy of the heart muscle, occasionally is done to determine the cause of cardiomyopathy. During a myocardial biopsy, a small tissue sample is taken from the heart and examined under a microscope to examine the cause of the symptoms.

 

What Is the Treatment for Restrictive Cardiomyopathy?

Treatment of restrictive cardiomyopathy is difficult. Treatment is usually focused on treating the cause of this condition. Doctors recommend lifestyle changes and medications to treat heart failure.

What Lifestyle Changes Are Recommended for Restrictive Cardiomyopathy?

Treatment of restrictive cardiomyopathy is difficult. Treatment is usually focused on treating the cause of this condition. Doctors recommend lifestyle changes and medications to treat heart failure.

What Medications Are Used for Restrictive Cardiomyopathy?

Often, medications are used to treat symptoms of restrictive cardiomyopathy and prevent further complications. To manage heart failure, some people may improve by taking a beta-blocker and angiotensin-converting enzyme (ACE) inhibitor. If symptoms occur, digoxin, diuretics, and aldosterone inhibitors may be added. If you have an arrhythmia, your doctor may prescribe a medication to control your heart rate or lessen the occurrence of arrhythmia. Therapy may also be given to treat certain conditions, such as sarcoidosis, amyloidosis, and hemochromatosis. Your doctor will discuss what medications are best for you.

Can Surgery Treat Restrictive Cardiomyopathy?

In some cases, if the condition is severe, heart transplant surgery may be considered for restrictive cardiomyopathy.

 



 

Alzheimer's Disease Patient Caregiver Guide

Tips for caregivers of persons with Alzheimer's disease
  • Dealing with the diagnosis of Alzheimer's disease
  • Communicating with a person with Alzheimer's disease
  • Bathing a person with Alzheimer's disease
  • Dressing a person with Alzheimer's disease
  • Eating: getting a person with Alzheimer's disease to eat
  • Activities for a person with Alzheimer's disease
  • Exercise for a person with Alzheimer's disease
  • Incontinence in a person with Alzheimer's disease
  • Sleep problems for caregivers and a person with Alzheimer's disease
  • Hallucinations and delusions in a person with Alzheimer's disease
  • Wandering: a problem for a person with Alzheimer's disease
  • Home safety for a person with Alzheimer's disease
  • Driving: decisions for a person with Alzheimer's disease
  • Visiting the doctor with a person with Alzheimer's disease
  • Coping with holidays with a person with Alzheimer's disease
  • Visiting a person with Alzheimer's disease
  • Choosing a nursing home for a person with Alzheimer's disease
  • For more information about Alzheimer's disease
  • Find a local Geriatrician in your town

Tips for Caregivers of a Person with Alzheimer's Disease

Caring for a person with Alzheimer's disease at home is a difficult task and can become overwhelming at times. Each day brings new challenges as the caregiver copes with changing levels of ability and new patterns of behavior. Research has shown that caregivers themselves often are at increased risk for depression and illness, especially if they do not receive adequate support from family, friends, and the community.

One of the biggest struggles caregivers face is dealing with the difficult behaviors of the person they are caring for. Dressing, bathing, eating—basic activities of daily living—often become difficult to manage for both the person with Alzheimer's and the caregiver. Having a plan for getting through the day can help caregivers cope. Many caregivers have found it helpful to use strategies for dealing with difficult behaviors and stressful situations. Through trial and error you will find that some of the following tips work, while others do not. Each person with Alzheimer's is unique and will respond differently, and each person changes over the course of the disease. Do the best you can, and remind yourself to take breaks.

Dealing with the Diagnosis of Alzheimer's Disease

Finding out that a loved one has Alzheimer's disease can be stressful, frightening, and overwhelming. As you begin to take stock of the situation, here are some tips that may help:

  • Ask the doctor any questions you have about Alzheimer's disease. Find out what treatments might work best to alleviate symptoms or address behavior problems.
  • Contact organizations such as the Alzheimer's Association and the Alzheimer's Disease Education and Referral (ADEAR) Center for more information about the disease, treatment options, and caregiving resources. Some community groups may offer classes to teach caregiving, problem-solving, and management skills. See "For More Information" below to contact the ADEAR Center and a variety of other helpful organizations.
  • Find a support group where you can share your feelings and concerns. Members of support groups often have helpful ideas or know of useful resources based on their own experiences. Online support groups make it possible for caregivers to receive support without having to leave home. The Alzheimer's Association and other organizations sponsor support groups.
  • Study your day to see if you can develop a routine that makes things go more smoothly. If there are times of day when the person with Alzheimer's is less confused or more cooperative, plan your routine to make the most of those moments. Keep in mind that the way the person functions may change from day to day, so try to be flexible and adapt your routine as needed.
  • Consider using adult day care or respite services to ease the day-to-day demands of caregiving. These services allow you to have a break while knowing that the person with Alzheimer's is being well cared for.
  • Begin to plan for the future. This may include getting financial and legal documents in order, investigating long-term care options, and determining what services are covered by health insurance and Medicare.

Communicating with a Person with Alzheimer's Disease

Trying to communicate with a person who has Alzheimer's disease can be a challenge. Both understanding and being understood may be difficult.

  • Choose simple words and short sentences and use a gentle, calm tone of voice.
  • Avoid talking to the person with Alzheimer's like a baby or talking about the person as if he or she weren't there.
  • Minimize distractions and noise—such as the television or radio—to help the person focus on what you are saying.
  • Make eye contact and call the person by name, making sure you have his or her attention before speaking.
  • Allow enough time for a response. Be careful not to interrupt.
  • If the person with Alzheimer's is struggling to find a word or communicate a thought, gently try to provide the word he or she is looking for.
  • Try to frame questions and instructions in a positive way.
  • Be open to the person's concerns, even if he or she is hard to understand.

Bathing a Person with Alzheimer's Disease

While some people with Alzheimer's disease don't mind bathing, for others it is a frightening, confusing experience. Advance planning can help make bath time better for both of you.

  • Plan the bath or shower for the time of day when the person is most calm and agreeable. Be consistent. Try to develop a routine.
  • Respect the fact that bathing is scary and uncomfortable for some people with Alzheimer's. Be gentle and respectful. Be patient and calm.
  • Tell the person what you are going to do, step by step, and allow him or her to do as much as possible.
  • Prepare in advance. Make sure you have everything you need ready and in the bathroom before beginning. Draw the bath ahead of time.
  • Be sensitive to the temperature. Warm up the room beforehand if necessary and keep extra towels and a robe nearby. Test the water temperature before beginning the bath or shower.
  • Minimize safety risks by using a handheld showerhead, shower bench, grab bars, and nonskid bath mats. Never leave the person alone in the bath or shower.
  • Try a sponge bath. Bathing may not be necessary every day. A sponge bath can be effective between showers or baths.

Dressing a Person with Alzheimer's Disease

For someone who has Alzheimer's, getting dressed presents a series of challenges: choosing what to wear, getting some clothes off and other clothes on, and struggling with buttons and zippers. Minimizing the challenges may make a difference.

  • Try to have the person get dressed at the same time each day so he or she will come to expect it as part of the daily routine.
  • Encourage the person to dress himself or herself to whatever degree possible. Plan to allow extra time so there is no pressure or rush.
  • Allow the person to choose from a limited selection of outfits. If he or she has a favorite outfit, consider buying several identical sets.
  • Store some clothes in another room to reduce the number of choices. Keep only one or two outfits in the closet or dresser.
  • Arrange the clothes in the order they are to be put on to help the person move through the process.
  • Hand the person one item at a time or give clear, step-by-step instructions if the person needs prompting.
  • Choose clothing that is comfortable, easy to get on and off, and easy to care for. Elastic waists and Velcro® enclosures minimize struggles with buttons and zippers.

Eating: Getting a Person with Alzheimer's Disease to Eat

Eating can be a challenge. Some people with Alzheimer's disease want to eat all the time, while others have to be encouraged to maintain a good diet.

  • View mealtimes as opportunities for social interaction and success for the person with Alzheimer's. Try to be patient and avoid rushing, and be sensitive to confusion and anxiety.
  • Aim for a quiet, calm, reassuring mealtime atmosphere by limiting noise and other distractions.
  • Maintain familiar mealtime routines, but adapt to the person's changing needs.
  • Give the person food choices, but limit the number of choices. Try to offer appealing foods that have familiar flavors, varied textures, and different colors.
  • Serve small portions or several small meals throughout the day. Make healthy snacks, finger foods, and shakes available. In the earlier stages of dementia, be aware of the possibility of overeating.
  • Choose dishes and eating tools that promote independence. If the person has trouble using utensils, use a bowl instead of a plate, or offer utensils with large or built-up handles. Use straws or cups with lids to make drinking easier.
  • Encourage the person to drink plenty of fluids throughout the day to avoid dehydration.
  • As the disease progresses, be aware of the increased risk of choking because of chewing and swallowing problems.
  • Maintain routine dental checkups and daily oral health care to keep the mouth and teeth healthy.

Activities for a Person with Alzheimer's Disease

What to do all day? Finding activities that the person with Alzheimer's disease can do and is interested in can be a challenge. Building on current skills generally works better than trying to teach something new.

  • Don't expect too much. Simple activities often are best, especially when they use current abilities.
  • Help the person get started on an activity. Break the activity down into small steps and praise the person for each step he or she completes.
  • Watch for signs of agitation or frustration with an activity. Gently help or distract the person to something else.
  • Incorporate activities the person seems to enjoy into your daily routine and try to do them at a similar time each day.
  • Try to include the person with Alzheimer's in the entire activity process. For instance, at mealtimes, encourage the person to help prepare the food, set the table, pull out the chairs, or put away the dishes. This can help maintain functional skills, enhance feelings of personal control, and make good use of time.
  • Take advantage of adult day services, which provide various activities for the person with Alzheimer's, as well as an opportunity for caregivers to gain temporary relief from tasks associated with caregiving. Transportation and meals often are provided.

Exercise for a Person with Alzheimer's Disease

Incorporating exercise into the daily routine has benefits for both the person with Alzheimer's disease and the caregiver. Not only can it improve health, but it also can provide a meaningful activity for both of you to share.

  • Think about what kind of physical activities you both enjoy, perhaps walking, swimming, tennis, dancing, or gardening. Determine the time of day and place where this type of activity would work best.
  • Be realistic in your expectations. Build slowly, perhaps just starting with a short walk around the yard, for example, before progressing to a walk around the block.
  • Be aware of any discomfort or signs of overexertion. Talk to the person's doctor if this happens.
  • Allow as much independence as possible, even if it means a less-than-perfect garden or a scoreless tennis match.
  • See what kinds of exercise programs are available in your area. Senior centers may have group programs for people who enjoy exercising with others. Local malls often have walking clubs and provide a place to exercise when the weather is bad.
  • Encourage physical activities. Spend time outside when the weather permits. Exercise often helps everyone sleep better.

Incontinence in a Person with Alzheimer's Disease

As the disease progresses, many people with Alzheimer's begin to experience incontinence, or the inability to control their bladder and/or bowels. Incontinence can be upsetting to the person and difficult for the caregiver. Sometimes incontinence is due to physical illness, so be sure to discuss it with the person's doctor.

  • Have a routine for taking the person to the bathroom and stick to it as closely as possible. For example, take the person to the bathroom every 3 hours or so during the day. Don't wait for the person to ask.
  • Watch for signs that the person may have to go to the bathroom, such as restlessness or pulling at clothes. Respond quickly.
  • Be understanding when accidents occur. Stay calm and reassure the person if he or she is upset. Try to keep track of when accidents happen to help plan ways to avoid them.
  • To help prevent nighttime accidents, limit certain types of fluids—such as those with caffeine—in the evening.
  • If you are going to be out with the person, plan ahead. Know where restrooms are located, and have the person wear simple, easy-to-remove clothing. Take an extra set of clothing along in case of an accident.

Sleep Problems for Caregivers and a Person with Alzheimer's Disease

For the exhausted caregiver, sleep can't come too soon. For many people with Alzheimer's disease, however, the approach of nighttime may be a difficult time. Many people with Alzheimer's become restless, agitated, and irritable around dinnertime, often referred to as "sundowning" syndrome. Getting the person to go to bed and stay there may require some advance planning.

  • Encourage exercise during the day and limit daytime napping, but make sure that the person gets adequate rest during the day because fatigue can increase the likelihood of late afternoon restlessness.
  • Try to schedule physically demanding activities earlier in the day. For example, bathing could be done in the morning, or the largest family meal could be served at midday.
  • Set a quiet, peaceful tone in the evening to encourage sleep. Keep the lights dim, eliminate loud noises, even play soothing music if the person seems to enjoy it.
  • Try to keep bedtime at a similar time each evening. Developing a bedtime routine may help.
  • Limit caffeine.
  • Use night-lights in the bedroom, hall, and bathroom if the darkness is frightening or disorienting.

Hallucinations and Delusions in a Person with Alzheimer's Disease

As the disease progresses, a person with Alzheimer's disease may experience hallucinations and/or delusions. Hallucinations are when the person sees, hears, smells, tastes, or feels something that is not there. Delusions are false beliefs that the person thinks are real.

  • Sometimes hallucinations and delusions are signs of physical illness. Keep track of what the person is experiencing and discuss it with the doctor.
  • Avoid arguing with the person about what he or she sees or hears. Try to respond to the feelings he or she is expressing. Comfort the person if he or she is afraid.
  • Try to distract the person to another topic or activity. Sometimes moving to another room or going outside for a walk may help.
  • Turn off the television set when violent or disturbing programs are on. The person with Alzheimer's may not be able to distinguish television programming from reality.
  • Make sure the person is safe and does not have access to anything he or she could use to harm anyone.
  • Discuss with the doctor any illness the person has had or medicines he or she is taking. Sometimes an illness or medicine may cause hallucinations or delusions.

Wandering: A Problem for a Person with Alzheimer's Disease

Keeping the person safe is one of the most important aspects of caregiving. Some people with Alzheimer's disease have a tendency to wander away from their home or their caregiver. Knowing how to limit wandering can protect a person from getting lost.

  • Make sure that the person carries some kind of identification or wears a medical bracelet.
  • Consider enrolling the person in the Alzheimer's Association Safe Return program if the program is available in your area. If the person gets lost and is unable to communicate adequately, identification will alert others to the person's medical condition.
  • Notify neighbors and local authorities in advance that the person has a tendency to wander.
  • Keep a recent photograph or videotape of the person with Alzheimer's to assist police if the person becomes lost.
  • Keep doors locked. Consider a keyed deadbolt or an additional lock up high or down low on the door. If the person can open a lock because it is familiar, a new latch or lock may help.
  • Install an "announcing system" that chimes when the door opens.

Home Safety for a Person with Alzheimer's Disease

Caregivers of people with Alzheimer's disease often have to look at their homes through new eyes to identify and correct safety risks. Creating a safe environment can prevent many stressful and dangerous situations. The ADEAR Center offers the booklet, Home Safety for People with Alzheimer's Disease, which lists many helpful tips. See "For More Information" to contact the ADEAR Center.

  • Install secure locks on all outside windows and doors, especially if the person is prone to wandering. Remove the locks on bathroom doors to prevent the person from accidentally locking himself or herself in.
  • Use childproof latches on kitchen cabinets and anyplace where cleaning supplies or other chemicals are kept.
  • Label medications and keep them locked up. Also make sure knives, lighters and matches, and guns are secured and out of reach.
  • Keep the house free from clutter. Remove scatter rugs and anything else that might contribute to a fall.
  • Make sure lighting is good both inside and outside the home.
  • Be alert to and address kitchen-safety issues, such as the person forgetting to turn off the stove after cooking. Consider installing an automatic shut-off switch on the stove to prevent burns or fire.
  • Be sure to secure or put away anything that could cause danger, both inside and outside the home.

Driving: Decisions for a Person with Alzheimer's Disease

Making the decision that a person with Alzheimer's is no longer safe to drive is difficult, and it needs to be communicated carefully and sensitively. Even though the person may be upset by the loss of independence, safety must be the priority.

  • Look for clues that safe driving is no longer possible, including getting lost in familiar places, driving too fast or too slow, disregarding traffic signs, or getting angry or confused.
  • Be sensitive to the person's feelings about losing the ability to drive, but be firm in your request that he or she no longer do so. Be consistent—don't allow the person to drive on "good days" but forbid it on "bad days."
  • Ask the doctor to help. The person may view the doctor as an authority and be willing to stop driving. The doctor also can contact the Department of Motor Vehicles and request that the person be reevaluated.
  • If necessary, take the car keys. If just having keys is important to the person, substitute a different set of keys.
  • If all else fails, disable the car or move it to a location where the person cannot see it or gain access to it.
  • Ask family or friends to drive the person or find out about services that help people with disabilities get around their community.

Visiting the Doctor with a Person with Alzheimer's Disease

It is important that the person with Alzheimer's disease receive regular medical care. Advance planning can help the trip to the doctor's office go more smoothly.

  • Try to schedule the appointment for the person's best time of day. Also, ask the office staff what time of day the office is least crowded.
  • Let the office staff know in advance that this person may be confused because of Alzheimer's disease. Ask them for help to make the visit go smoothly.
  • Don't tell the person about the appointment until the day of the visit or even shortly before it is time to go. Be positive and matter-of-fact.
  • Bring along something for the person to eat and drink and any materials or activities that he or she enjoys.
  • Have a friend or another family member go with you on the trip, so that one of you can be with the person while the other speaks with the doctor.
  • Take a brief summary listing the person's medical history, primary care doctor, and current medications.

Coping with Holidays for Caregivers and a Person with Alzheimer's Disease

Holidays are bittersweet for many Alzheimer's disease caregivers. The happy memories of the past contrast with the difficulties of the present, and extra demands on time and energy can seem overwhelming. Finding a balance between rest and activity can help.

  • Keep or adapt family traditions that are important to you. Include the person with Alzheimer's as much as possible.
  • Recognize that things will be different, and be realistic about what you can do.
  • Encourage friends and family to visit. Limit the number of visitors at one time, and try to schedule visits during the time of day when the person is at his or her best.
  • Avoid crowds, changes in routine, and strange places that may cause confusion or agitation.
  • Do your best to enjoy yourself. Try to find time for the holiday things you like to do.
  • Ask a friend or family member to spend time with the person while you are out.
  • At larger gatherings such as weddings or family reunions, try to have a space available where the person can rest, be alone, or spend some time with a smaller number of people, if needed.

Visiting a Person with Alzheimer's Disease

Visitors are important to people with Alzheimer's. They may not always remember who the visitors are, but the human connection has value. Here are some ideas to share with someone who is planning to visit a person with the disease.

  • Plan the visit for the time of day when the person with Alzheimer's is at his or her best.
  • Consider bringing along an activity, such as something familiar to read or photo albums to look at, but be prepared to skip it if necessary.
  • Be calm and quiet. Avoid using a loud tone of voice or talking to the person as if he or she were a child.
  • Respect the person's personal space and don't get too close.
  • Try to establish eye contact and call the person by name to get his or her attention.
  • Remind the person who you are if he or she doesn't seem to recognize you.
  • Don't argue if the person is confused. Respond to the feelings you hear being communicated, and distract the person to a different topic if necessary.
  • Remember not to take it personally if the person doesn't recognize you, is unkind, or responds angrily. He or she is reacting out of confusion.

Choosing a Nursing Home for a Person with Alzheimer's Disease

For many caregivers, there comes a point when they are no longer able to take care of their loved one at home. Choosing a residential care facility—a group home, assisted living facility, or nursing home—is a big decision, and it can be hard to know where to start.

  • It's helpful to gather information about services and options before the need actually arises. This gives you time to explore fully all the possibilities before making a decision.
  • Determine what facilities are in your area. Doctors, friends and relatives, hospital social workers, and religious organizations may be able to help you identify specific facilities.
  • Make a list of questions you would like to ask the staff. Think about what is important to you, such as activity programs, transportation, or special units for people with Alzheimer's disease.
  • Contact the places that interest you and make an appointment to visit. Talk to the administration, nursing staff, and residents.
  • Observe the way the facility runs and how residents are treated. You may want to drop by again unannounced to see if your impressions are the same.
  • Find out what kinds of programs and services are offered for people with Alzheimer's and their families. Ask about staff training in dementia care, and check to see what the policy is about family participation in planning patient care.
  • Check on room availability, cost and method of payment, and participation in Medicare or Medicaid. You may want to place your name on a waiting list even if you are not ready to make an immediate decision about long-term care.
  • Once you have made a decision, be sure you understand the terms of the contract and financial agreement. You may want to have a lawyer review the documents with you before signing.
  • Moving is a big change for both the person with Alzheimer's disease and the caregiver. A social worker may be able to help you plan for and adjust to the move. It is important to have support during this difficult transition.

 


 

Caregiving

  • What is a caregiver?
  • Who are our nation's caregivers?
  • What is caregiver stress?
  • How can I tell if caregiving is putting too much stress on me?
  • What can I do to prevent stress or relieve stress?
  • What is respite care?
  • What is the National Family Caregiver Support Program (NFCSP)?
  • How can I find out about caregiving resources in my community?
  • What kind of caregiver services can I find in my community?
  • What kind of home care help is available?
  • How will I pay for home health care?
  • Who is eligible for Medicare home health care services?
  • Will Medicaid help pay for home health care?
  • For more information

What is a caregiver?

Caregivers are people who take care of other adults, most often parents or spouses, who are ill or disabled. The people who receive care usually need help with basic daily tasks. Caregivers help with many things such as:

  • Grocery shopping
  • House cleaning
  • Cooking
  • Shopping
  • Paying bills
  • Giving medicine
  • Toileting
  • Bathing
  • Dressing
  • Eating

Usually caregivers take care of elderly people. Less often, caregivers are grandparents who are raising their grandchildren. The terms informal caregiver and family caregiver refer to people who are not paid to provide care. As the American population ages, the number of caregivers and the demands placed on them will grow.

Who are our nation's caregivers?

About one in four American families or 22.4 million households care for someone over the age of 50. The number of American households involved in caregiving may reach 39 million by 2007.

  • About 75% of caregivers are women.
  • Two-thirds of caregivers in the United States have jobs in addition to caring for another person.
  • Most caregivers are middle-aged: 35-64 years old.

What is caregiver stress?

Caregiver stress is the emotional strain of caregiving. Studies show that caregiving takes a toll on physical and emotional health. Caregivers are more likely to suffer from depression than their peers. Limited research suggests that caregivers may also be more likely to have health problems like diabetes and heart disease than non-caregivers.

Caring for another person takes a lot of time, effort, and work. Plus, most caregivers juggle caregiving with full-time jobs and parenting. In the process, caregivers put their own needs aside. Caregivers often report that it is difficult to look after their own health in terms of exercise, nutrition, and doctor's visits. So, caregivers often end up feeling angry, anxious, isolated, and sad.

Caregivers for people with Alzheimer's disease (AD) or other kinds of dementia are particularly vulnerable to burnout. Research shows that most dementia caregivers suffer from depression and stress. Also, studies show that the more hours spent on caregiving, the greater the risk of anxiety and depression.

Women caregivers are particularly prone to feeling stress and overwhelmed. Studies show that female caregivers have more emotional and physical health problems, employment-related problems, and financial strain than male caregivers. Other research shows that people who care for their spouses are more prone to caregiving-related stress than those who care for other family members.

It is important to note that caring for another person can also create positive emotional change. Aside from feeling stress, many caregivers say their role has had many positive effects on their lives. For example, caregivers report that caregiving has given them a sense of purpose. They say that their role makes them feel useful, capable and that they are making a difference in the life of a loved one.

How can I tell if caregiving is putting too much stress on me?

If you have any of the following symptoms, caregiving may be putting too much strain on you:

  • Sleeping problems—sleeping too much or too little
  • Change in eating habits—resulting in weight gain or loss
  • Feeling tired or without energy most of the time
  • Loss of interest in activities you used to enjoy such as going out with friends, walking, or reading
  • Easily irritated, angered, or saddened
  • Frequent headaches, stomach aches, or other physical problems

What can I do to prevent or relieve stress?

Take care of yourself. In the process, you'll become a better caregiver. Take the following steps to make your health a priority:

  • Find out about community caregiving resources.
  • Ask for and accept help.
  • Stay in touch with friends and family. Social activities can help you feel connected and may reduce stress.
  • Find time for exercise most days of the week.
  • Prioritize, make lists and establish a daily routine.
  • Look to faith-based groups for support and help.
  • Join a support group for caregivers in your situation (like caring for a person with dementia). Many support groups can be found in the community or on the Internet.
  • See your doctor for a checkup. Talk to her about symptoms of depression or sickness you may be having.
  • Try to get enough sleep and rest.
  • Eat a healthy diet rich in fruits, vegetables, and whole grains and low in saturated fat.
  • Ask your doctor about taking a multivitamin.
  • Take one day at a time.

Caregivers who work outside the home should consider taking some time off. If you are feeling overwhelmed, taking a break from your job may help you get back on track. Employees covered under the federal Family and Medical Leave Act may be able to take up to 12 weeks of unpaid leave per year to care for relatives. Ask your human resources office about options for unpaid leave.

What is respite care?

The term respite care means care that gives the regular caregiver some time off. Respite care gives family caregivers a much-needed break. In the process, respite care reduces caregiver stress. Respite care may be provided by:

  • Home health care workers
  • Adult day-care centers
  • Short-term nursing homes
  • Assisted living homes

Respite care is essential to family caregivers. Studies show that respite care helps caregivers keep their loved ones at home for longer periods of time.

 

What is the National Family Caregiver Support Program (NFCSP)?

The National Family Caregiver Support Program (NFCSP) is a federally-funded program through the Older Americans Act. The NFCSP helps states provide services that assist family caregivers. To be eligible for the NFCS, caregivers must:

  • Care for adults aged 60 years and older, or
  • Be grandparents or relatives caring for a child under the age of 18.

Each state offers different amounts and types of services. These include:

  • Information about available services
  • Help accessing support services
  • Individual counseling and organization of support groups
  • Caregiver training
  • Respite care
  • Limited supplemental services to complement the care provided by caregivers.

How can I find out about caregiving resources in my community?

A number of resources can help direct you to the caregiver services you need. These agencies will be able to tell you:

  • What kind of services are available in your community
  • If these services are right for you
  • If you are eligible for these services
  • Whom to contact and hours of operation

People who need help caring for an older person should contact their local Area Agency on Aging (AAA). AAAs are usually listed in the government sections of the telephone directory under "Aging" or "Social Services." A listing of state and area agencies on aging is also available online at: http://www.aoa.gov/eldfam/How_To_Find/Agencies/Agencies.asp The National Eldercare Locator, a toll-free service of the Administration on Aging, is another good resource. They can be reached by telephone at 1-800-677-1116 or online at www.eldercare.gov. The Eldercare Locator can help find your local or state AAA. Operators are available Monday through Friday, 9:00 a.m. to 8:00 p.m., Eastern Time. When contacting the Eldercare Locator, callers should have the address, zip code, and county of residence for the person needing assistance.

What kind of caregiver services can I find in my community?

There are many kinds of community care services such as:

  • Transportation
  • Meals
  • Adult day care
  • Home care
  • Cleaning and yard work services
  • Home modification
  • Senior centers
  • Hospice care
  • Support groups
  • Legal and financial counseling

What kind of home care is available?

There are two kinds of home care: home health care and non-medical home care services. Both types help sick and disabled people live independently in their homes for as long as possible. Caregivers and doctors decide what services are necessary and most helpful.

Home health care includes health-related services such as:

  • Medicine assistance
  • Nursing services
  • Physical therapy

Non-medical home care services include:

  • Housekeeping
  • Cooking
  • Companionship

How will I pay for home health care?

Medicare, Medicaid and some private insurance companies will cover the cost of limited home care. Coverage varies from state to state. Other times, you will have to pay out of pocket for these services.

The cost of home care depends on what types of services are used. Non-medical workers like housekeepers are much less expensive than nurses or physical therapists. Also, some home care agencies are cheaper than others.

Who is eligible for Medicare home health care services?

To get Medicare home health care, a person must meet all of the following four conditions:

  • A doctor must decide that the person needs medical care in the home and make a plan for care at home.
  • The person must need at least one of the following: sporadic (and not full time) skilled nursing care, physical therapy, speech language pathology services, or continue to need occupational therapy.
  • The person must be homebound. This means that he or she is normally unable to leave home. When the person leaves home, it must be infrequent, for a short time, or to get medical care, or to attend religious services.
  • The home health agency caring for the person must be approved by the Medicare program.

To find out if a person is eligible for Medicare home health care services, call the Regional Home Health Intermediary at 1-800-MEDICARE or visit the Medicare Web site at: www.medicare.gov and select "Helpful Contacts."

Will Medicaid help pay for home health care?

To qualify for Medicaid, a person must have a low income and few other assets. Medicaid coverage differs from state to state. In all states, Medicaid pays for basic home health care and medical equipment. In some cases, Medicaid will pay for a homemaker, personal care, and other services not covered by Medicare.



Caring for a Continent Ileostomy or K-Pouch

What is a continent ileostomy?
  • How often do I drain the pouch or continent ileostomy?
  • General guidelines for draining the k-pouch
  • How do I care for the continuous draining catheter or tube and my skin
  • Other helpful tips about K-pouch care

What Is a Continent Ileostomy?

The continent ileostomy, or K-pouch, is a connection of the end of the small intestine, called the ileum, to the skin of your abdomen. It allows waste to be drained. Unlike other ileostomies, the K-pouch or Kock ileostomy, has a valve made by sewing the intestine in a special way so that waste material doesn't leak out but rather a tube called a catheter is inserted when it's time to empty the pouch.

As the pouch fills with intestinal contents (liquids, partly digested food, etc.), pressure builds up on the pouch and its many stitches. If this is not relieved the pouch could perforate or tear from the excessive stretching or the valve could slip or leak.

How Often Do I Drain the K-Pouch or Continent Ileostomy?

The best way to prevent problems is to drain your K-pouch as instructed by your doctor. How often to drain the pouch varies from person to person but there are some general guidelines. Right after the operation you will have what doctors call an indwelling catheter, meaning that the drainage tube will be left in the pouch to drain continuously. This will last for about three to four weeks to allow the pouch to mature. After the catheter is removed you will drain the pouch several times per day. The number of times you need to drain the pouch each day becomes less over time.

Please discuss you specific needs with your doctor, surgeon, or enterostomal therapist (ET), a nurse who specializes in the care of stomas. Most likely this person will meet or has met with you before the operation and has or will be instructing you on how to take care of your stoma, ostomy, or pouch.

General Guidelines for Draining the K-Pouch

As mentioned above, please discuss your individual case with your health care providers. The following are general guidelines for draining the K-pouch. Constant drainage is recommended for the first three to four weeks for a new pouch. If the catheter or tube accidentally falls out before that time, you can easily put it back with these simple steps.

  • Relax your abdominal muscles. It may be helpful to bend your knee as you relax your muscles.
  • Relubricate the catheter with water-soluble lubricant (such as K-Y Jelly, Surgical Lubricant, or Surgilube; DO NOT use Vaseline or products containing petroleum jelly).
  • Reinsert the catheter up to the preset mark. If you have difficulty with this, relax, change positions and try again.
  • During this initial period, you will need to irrigate the catheter serveral times a day with 1 ounce of tap water and let it drain off. (See below "Instructions for Catheter Care" for a step-by-step guide to skin and catheter care.)

If, at any time, you think pouch drainage has stopped during the course of the day, then check by:

  • Irrigating the catheter
  • Pinching the catheter between your finger and thumb and check if a fluid or air column can be seen moving up and down
  • Checking for fluid return
  • "Wiggling" the catheter in and out for about an inch

If you still think pouch drainage has stopped, remove the catheter in case food particles or debris have blocked it. Flush the catheter with cool tap water then reinsert it.

After the first three to four weeks you can stop the continuous draining and start draining several times per day or as instructed by your doctor or health care providers. Though you usually make this change after seeing your doctor for the first time after the operation, sometimes your doctor will tell you to start doing the following earlier.

  • Drain the pouch every two hours during the day while you are awake.
  • Drain at bedtime and first thing in the morning.
  • Do not drink or eat within two hours of bedtime.
  • During the night, you will usually set the catheter to constant drainage. You may also choose to set your alarm clock to wake you to empty the pouch.

Over the next several weeks, the time interval between pouch drainages will increase. At night, you may be able to stop the constant drainage and go for longer periods without waking to drain the pouch.

Three months after surgery, there are usually no specific restrictions. Sound practice is to empty the pouch four to six times per day and use irrigation on two of these times. However, any time you feel full, bloated, or distended, drain the pouch. Just as you would empty your bladder before engaging in physical activity or going to bed, so should you empty the continent ileostomy.

 

How Do I Care for the Continuous Draining Catheter or Tube and my Skin

Good skin and catheter care need to be continued after you go home from the hospital. It is important to keep the skin around the catheter clean and protected, as well as make sure the catheter is open and draining. The following guidelines will help you properly care for your catheter.

1. Gather the following supplies

  • Washcloths or paper towels
  • Non-oily soap (Ivory and Dial are recommended brands)
  • Plastic bag or newspaper
  • Dressing
  • Irrigation supplies: tap water, bulb syringe, and basin

2. Wash your hands with soap and warm water and dry them with a clean towel.

3. Irrigate the catheter

  • Remove the dressing over the stoma and discard it.
  • Separate the catheter from the drainage bag and drain the contents of the catheter into the basin.
  • Collect 30 cc (1 ounce) of tap water into the bulb syringe. Tip: Highlight the 30 cc mark on the bulb syringe with permanent marker or nail polish for accurate, easy measurement.
  • Insert the 30 cc of tap water into the catheter by slowly squeezing the bulb syringe to release the water.
  • While holding the syringe bulb down with your thumb, pinch the catheter and separate the bulb syringe from the catheter.
  • Unpinch the catheter and drain its contents into the basin. Do not withdraw the fluid from the catheter into the syringe.
  • If the fluid you just put in seems to be taking a long time to come back out, or if mucus blocks the catheter, repeat the previous irrigation steps as needed until stool flows freely through the catheter. If water doesn't go in or come back out, the tube may be blocked. You may have to remove the catheter from the stoma and rinse it with cool tap water to clean any mucus built up inside the catheter. Then reinsert the catheter. Do not put in more than 60cc (or 2 ounces) of water without the pouch contents emptying.
  • When the stool flow has stopped, continue to step four.

4. Reconnect the catheter

5. Cleanse the skin around the stoma and catheter

  • Wash the skin around the stoma and catheter with non-oily soap and warm water.
  • Rinse the skin thoroughly with warm water.
  • Pat the skin dry with a soft towel or paper towel.
  • Apply two layers of "split" dry gauze dressing around the catheter and over the stoma. Secure with tape as needed.
  • Discard the waste.
  • Wash the basin and the bulb syringe with soap and warm water. Let the supplies air dry, or dry with a clean towel.
  • Wash, rinse, and dry your hands.

Other Helpful Tips About K-Pouch Care

These other tips can help you properly care for your K-pouch:

  • Inspect the catheter frequently to be sure drainage is flowing freely through the tube.
  • Irrigate the catheter twice a day, or as instructed by your ET nurse or doctor. Irrigate with 1 ounce of tap water, and let it drain off.
  • As a general rule, most patients will have continuous drainage into a drainage bag until their first follow-up appointment after surgery. During this time, you should not experience: Pressure beneath the pouch; Absence of stool draining from the catheter; Stool leaking around the catheter.
  • If any of these signs or symptoms occur: Check the catheter for kinks; Irrigate the catheter; Pinch the catheter between your finger and thumb and check if a fluid or air column can be seen moving up and down. If the above steps do not work to relieve symptoms, remove the catheter, clean it, and replace it. Call your doctor if problems continue.
  • Inspect the stoma daily. It should look shiny, moist, and red. Report any changes to your doctor.
  • If stool becomes too thick and movement through the catheter appears slow or difficult, increase your fluid intake to 10-12 eight-ounce glasses of fluid daily. Include water, juice, and other non-caffeinated beverages.
  • Never take laxative preparations, as they can cause diarrhea and lead to dehydration.

 


 

Alzheimer's Disease Patient Caregiver Guide

  • Tips for caregivers of persons with Alzheimer's disease
  • Dealing with the diagnosis of Alzheimer's disease
  • Communicating with a person with Alzheimer's disease
  • Bathing a person with Alzheimer's disease
  • Dressing a person with Alzheimer's disease
  • Eating: getting a person with Alzheimer's disease to eat
  • Activities for a person with Alzheimer's disease
  • Exercise for a person with Alzheimer's disease
  • Incontinence in a person with Alzheimer's disease
  • Sleep problems for caregivers and a person with Alzheimer's disease
  • Hallucinations and delusions in a person with Alzheimer's disease
  • Wandering: a problem for a person with Alzheimer's disease
  • Home safety for a person with Alzheimer's disease
  • Driving: decisions for a person with Alzheimer's disease
  • Visiting the doctor with a person with Alzheimer's disease
  • Coping with holidays with a person with Alzheimer's disease
  • Visiting a person with Alzheimer's disease
  • Choosing a nursing home for a person with Alzheimer's disease
  • For more information about Alzheimer's disease
  • Find a local Geriatrician in your town

Tips for Caregivers of a Person with Alzheimer's Disease

Caring for a person with Alzheimer's disease at home is a difficult task and can become overwhelming at times. Each day brings new challenges as the caregiver copes with changing levels of ability and new patterns of behavior. Research has shown that caregivers themselves often are at increased risk for depression and illness, especially if they do not receive adequate support from family, friends, and the community.

One of the biggest struggles caregivers face is dealing with the difficult behaviors of the person they are caring for. Dressing, bathing, eating—basic activities of daily living—often become difficult to manage for both the person with Alzheimer's and the caregiver. Having a plan for getting through the day can help caregivers cope. Many caregivers have found it helpful to use strategies for dealing with difficult behaviors and stressful situations. Through trial and error you will find that some of the following tips work, while others do not. Each person with Alzheimer's is unique and will respond differently, and each person changes over the course of the disease. Do the best you can, and remind yourself to take breaks.

Dealing with the Diagnosis of Alzheimer's Disease

Finding out that a loved one has Alzheimer's disease can be stressful, frightening, and overwhelming. As you begin to take stock of the situation, here are some tips that may help:

  • Ask the doctor any questions you have about Alzheimer's disease. Find out what treatments might work best to alleviate symptoms or address behavior problems.
  • Contact organizations such as the Alzheimer's Association and the Alzheimer's Disease Education and Referral (ADEAR) Center for more information about the disease, treatment options, and caregiving resources. Some community groups may offer classes to teach caregiving, problem-solving, and management skills. See "For More Information" below to contact the ADEAR Center and a variety of other helpful organizations.
  • Find a support group where you can share your feelings and concerns. Members of support groups often have helpful ideas or know of useful resources based on their own experiences. Online support groups make it possible for caregivers to receive support without having to leave home. The Alzheimer's Association and other organizations sponsor support groups.
  • Study your day to see if you can develop a routine that makes things go more smoothly. If there are times of day when the person with Alzheimer's is less confused or more cooperative, plan your routine to make the most of those moments. Keep in mind that the way the person functions may change from day to day, so try to be flexible and adapt your routine as needed.
  • Consider using adult day care or respite services to ease the day-to-day demands of caregiving. These services allow you to have a break while knowing that the person with Alzheimer's is being well cared for.
  • Begin to plan for the future. This may include getting financial and legal documents in order, investigating long-term care options, and determining what services are covered by health insurance and Medicare.

Communicating with a Person with Alzheimer's Disease

Trying to communicate with a person who has Alzheimer's disease can be a challenge. Both understanding and being understood may be difficult.

  • Choose simple words and short sentences and use a gentle, calm tone of voice.
  • Avoid talking to the person with Alzheimer's like a baby or talking about the person as if he or she weren't there.
  • Minimize distractions and noise—such as the television or radio—to help the person focus on what you are saying.
  • Make eye contact and call the person by name, making sure you have his or her attention before speaking.
  • Allow enough time for a response. Be careful not to interrupt.
  • If the person with Alzheimer's is struggling to find a word or communicate a thought, gently try to provide the word he or she is looking for.
  • Try to frame questions and instructions in a positive way.
  • Be open to the person's concerns, even if he or she is hard to understand.

Bathing a Person with Alzheimer's Disease

While some people with Alzheimer's disease don't mind bathing, for others it is a frightening, confusing experience. Advance planning can help make bath time better for both of you.

  • Plan the bath or shower for the time of day when the person is most calm and agreeable. Be consistent. Try to develop a routine.
  • Respect the fact that bathing is scary and uncomfortable for some people with Alzheimer's. Be gentle and respectful. Be patient and calm.
  • Tell the person what you are going to do, step by step, and allow him or her to do as much as possible.
  • Prepare in advance. Make sure you have everything you need ready and in the bathroom before beginning. Draw the bath ahead of time.
  • Be sensitive to the temperature. Warm up the room beforehand if necessary and keep extra towels and a robe nearby. Test the water temperature before beginning the bath or shower.
  • Minimize safety risks by using a handheld showerhead, shower bench, grab bars, and nonskid bath mats. Never leave the person alone in the bath or shower.
  • Try a sponge bath. Bathing may not be necessary every day. A sponge bath can be effective between showers or baths.

Dressing a Person with Alzheimer's Disease

For someone who has Alzheimer's, getting dressed presents a series of challenges: choosing what to wear, getting some clothes off and other clothes on, and struggling with buttons and zippers. Minimizing the challenges may make a difference.

  • Try to have the person get dressed at the same time each day so he or she will come to expect it as part of the daily routine.
  • Encourage the person to dress himself or herself to whatever degree possible. Plan to allow extra time so there is no pressure or rush.
  • Allow the person to choose from a limited selection of outfits. If he or she has a favorite outfit, consider buying several identical sets.
  • Store some clothes in another room to reduce the number of choices. Keep only one or two outfits in the closet or dresser.
  • Arrange the clothes in the order they are to be put on to help the person move through the process.
  • Hand the person one item at a time or give clear, step-by-step instructions if the person needs prompting.
  • Choose clothing that is comfortable, easy to get on and off, and easy to care for. Elastic waists and Velcro® enclosures minimize struggles with buttons and zippers.

Eating: Getting a Person with Alzheimer's Disease to Eat

Eating can be a challenge. Some people with Alzheimer's disease want to eat all the time, while others have to be encouraged to maintain a good diet.

  • View mealtimes as opportunities for social interaction and success for the person with Alzheimer's. Try to be patient and avoid rushing, and be sensitive to confusion and anxiety.
  • Aim for a quiet, calm, reassuring mealtime atmosphere by limiting noise and other distractions.
  • Maintain familiar mealtime routines, but adapt to the person's changing needs.
  • Give the person food choices, but limit the number of choices. Try to offer appealing foods that have familiar flavors, varied textures, and different colors.
  • Serve small portions or several small meals throughout the day. Make healthy snacks, finger foods, and shakes available. In the earlier stages of dementia, be aware of the possibility of overeating.
  • Choose dishes and eating tools that promote independence. If the person has trouble using utensils, use a bowl instead of a plate, or offer utensils with large or built-up handles. Use straws or cups with lids to make drinking easier.
  • Encourage the person to drink plenty of fluids throughout the day to avoid dehydration.
  • As the disease progresses, be aware of the increased risk of choking because of chewing and swallowing problems.
  • Maintain routine dental checkups and daily oral health care to keep the mouth and teeth healthy.

Activities for a Person with Alzheimer's Disease

What to do all day? Finding activities that the person with Alzheimer's disease can do and is interested in can be a challenge. Building on current skills generally works better than trying to teach something new.

  • Don't expect too much. Simple activities often are best, especially when they use current abilities.
  • Help the person get started on an activity. Break the activity down into small steps and praise the person for each step he or she completes.
  • Watch for signs of agitation or frustration with an activity. Gently help or distract the person to something else.
  • Incorporate activities the person seems to enjoy into your daily routine and try to do them at a similar time each day.
  • Try to include the person with Alzheimer's in the entire activity process. For instance, at mealtimes, encourage the person to help prepare the food, set the table, pull out the chairs, or put away the dishes. This can help maintain functional skills, enhance feelings of personal control, and make good use of time.
  • Take advantage of adult day services, which provide various activities for the person with Alzheimer's, as well as an opportunity for caregivers to gain temporary relief from tasks associated with caregiving. Transportation and meals often are provided.

Exercise for a Person with Alzheimer's Disease

Incorporating exercise into the daily routine has benefits for both the person with Alzheimer's disease and the caregiver. Not only can it improve health, but it also can provide a meaningful activity for both of you to share.

  • Think about what kind of physical activities you both enjoy, perhaps walking, swimming, tennis, dancing, or gardening. Determine the time of day and place where this type of activity would work best.
  • Be realistic in your expectations. Build slowly, perhaps just starting with a short walk around the yard, for example, before progressing to a walk around the block.
  • Be aware of any discomfort or signs of overexertion. Talk to the person's doctor if this happens.
  • Allow as much independence as possible, even if it means a less-than-perfect garden or a scoreless tennis match.
  • See what kinds of exercise programs are available in your area. Senior centers may have group programs for people who enjoy exercising with others. Local malls often have walking clubs and provide a place to exercise when the weather is bad.
  • Encourage physical activities. Spend time outside when the weather permits. Exercise often helps everyone sleep better.

Incontinence in a Person with Alzheimer's Disease

As the disease progresses, many people with Alzheimer's begin to experience incontinence, or the inability to control their bladder and/or bowels. Incontinence can be upsetting to the person and difficult for the caregiver. Sometimes incontinence is due to physical illness, so be sure to discuss it with the person's doctor.

  • Have a routine for taking the person to the bathroom and stick to it as closely as possible. For example, take the person to the bathroom every 3 hours or so during the day. Don't wait for the person to ask.
  • Watch for signs that the person may have to go to the bathroom, such as restlessness or pulling at clothes. Respond quickly.
  • Be understanding when accidents occur. Stay calm and reassure the person if he or she is upset. Try to keep track of when accidents happen to help plan ways to avoid them.
  • To help prevent nighttime accidents, limit certain types of fluids—such as those with caffeine—in the evening.
  • If you are going to be out with the person, plan ahead. Know where restrooms are located, and have the person wear simple, easy-to-remove clothing. Take an extra set of clothing along in case of an accident.

Sleep Problems for Caregivers and a Person with Alzheimer's Disease

For the exhausted caregiver, sleep can't come too soon. For many people with Alzheimer's disease, however, the approach of nighttime may be a difficult time. Many people with Alzheimer's become restless, agitated, and irritable around dinnertime, often referred to as "sundowning" syndrome. Getting the person to go to bed and stay there may require some advance planning.

  • Encourage exercise during the day and limit daytime napping, but make sure that the person gets adequate rest during the day because fatigue can increase the likelihood of late afternoon restlessness.
  • Try to schedule physically demanding activities earlier in the day. For example, bathing could be done in the morning, or the largest family meal could be served at midday.
  • Set a quiet, peaceful tone in the evening to encourage sleep. Keep the lights dim, eliminate loud noises, even play soothing music if the person seems to enjoy it.
  • Try to keep bedtime at a similar time each evening. Developing a bedtime routine may help.
  • Limit caffeine.
  • Use night-lights in the bedroom, hall, and bathroom if the darkness is frightening or disorienting.

Hallucinations and Delusions in a Person with Alzheimer's Disease

As the disease progresses, a person with Alzheimer's disease may experience hallucinations and/or delusions. Hallucinations are when the person sees, hears, smells, tastes, or feels something that is not there. Delusions are false beliefs that the person thinks are real.

  • Sometimes hallucinations and delusions are signs of physical illness. Keep track of what the person is experiencing and discuss it with the doctor.
  • Avoid arguing with the person about what he or she sees or hears. Try to respond to the feelings he or she is expressing. Comfort the person if he or she is afraid.
  • Try to distract the person to another topic or activity. Sometimes moving to another room or going outside for a walk may help.
  • Turn off the television set when violent or disturbing programs are on. The person with Alzheimer's may not be able to distinguish television programming from reality.
  • Make sure the person is safe and does not have access to anything he or she could use to harm anyone.
  • Discuss with the doctor any illness the person has had or medicines he or she is taking. Sometimes an illness or medicine may cause hallucinations or delusions.

Wandering: A Problem for a Person with Alzheimer's Disease

Keeping the person safe is one of the most important aspects of caregiving. Some people with Alzheimer's disease have a tendency to wander away from their home or their caregiver. Knowing how to limit wandering can protect a person from getting lost.

  • Make sure that the person carries some kind of identification or wears a medical bracelet.
  • Consider enrolling the person in the Alzheimer's Association Safe Return program if the program is available in your area. If the person gets lost and is unable to communicate adequately, identification will alert others to the person's medical condition.
  • Notify neighbors and local authorities in advance that the person has a tendency to wander.
  • Keep a recent photograph or videotape of the person with Alzheimer's to assist police if the person becomes lost.
  • Keep doors locked. Consider a keyed deadbolt or an additional lock up high or down low on the door. If the person can open a lock because it is familiar, a new latch or lock may help.
  • Install an "announcing system" that chimes when the door opens.

Home Safety for a Person with Alzheimer's Disease

Caregivers of people with Alzheimer's disease often have to look at their homes through new eyes to identify and correct safety risks. Creating a safe environment can prevent many stressful and dangerous situations. The ADEAR Center offers the booklet, Home Safety for People with Alzheimer's Disease, which lists many helpful tips. See "For More Information" to contact the ADEAR Center.

  • Install secure locks on all outside windows and doors, especially if the person is prone to wandering. Remove the locks on bathroom doors to prevent the person from accidentally locking himself or herself in.
  • Use childproof latches on kitchen cabinets and anyplace where cleaning supplies or other chemicals are kept.
  • Label medications and keep them locked up. Also make sure knives, lighters and matches, and guns are secured and out of reach.
  • Keep the house free from clutter. Remove scatter rugs and anything else that might contribute to a fall.
  • Make sure lighting is good both inside and outside the home.
  • Be alert to and address kitchen-safety issues, such as the person forgetting to turn off the stove after cooking. Consider installing an automatic shut-off switch on the stove to prevent burns or fire.
  • Be sure to secure or put away anything that could cause danger, both inside and outside the home.

Driving: Decisions for a Person with Alzheimer's Disease

Making the decision that a person with Alzheimer's is no longer safe to drive is difficult, and it needs to be communicated carefully and sensitively. Even though the person may be upset by the loss of independence, safety must be the priority.

  • Look for clues that safe driving is no longer possible, including getting lost in familiar places, driving too fast or too slow, disregarding traffic signs, or getting angry or confused.
  • Be sensitive to the person's feelings about losing the ability to drive, but be firm in your request that he or she no longer do so. Be consistent—don't allow the person to drive on "good days" but forbid it on "bad days."
  • Ask the doctor to help. The person may view the doctor as an authority and be willing to stop driving. The doctor also can contact the Department of Motor Vehicles and request that the person be reevaluated.
  • If necessary, take the car keys. If just having keys is important to the person, substitute a different set of keys.
  • If all else fails, disable the car or move it to a location where the person cannot see it or gain access to it.
  • Ask family or friends to drive the person or find out about services that help people with disabilities get around their community.

Visiting the Doctor with a Person with Alzheimer's Disease

It is important that the person with Alzheimer's disease receive regular medical care. Advance planning can help the trip to the doctor's office go more smoothly.

  • Try to schedule the appointment for the person's best time of day. Also, ask the office staff what time of day the office is least crowded.
  • Let the office staff know in advance that this person may be confused because of Alzheimer's disease. Ask them for help to make the visit go smoothly.
  • Don't tell the person about the appointment until the day of the visit or even shortly before it is time to go. Be positive and matter-of-fact.
  • Bring along something for the person to eat and drink and any materials or activities that he or she enjoys.
  • Have a friend or another family member go with you on the trip, so that one of you can be with the person while the other speaks with the doctor.
  • Take a brief summary listing the person's medical history, primary care doctor, and current medications.

Coping with Holidays for Caregivers and a Person with Alzheimer's Disease

Holidays are bittersweet for many Alzheimer's disease caregivers. The happy memories of the past contrast with the difficulties of the present, and extra demands on time and energy can seem overwhelming. Finding a balance between rest and activity can help.

  • Keep or adapt family traditions that are important to you. Include the person with Alzheimer's as much as possible.
  • Recognize that things will be different, and be realistic about what you can do.
  • Encourage friends and family to visit. Limit the number of visitors at one time, and try to schedule visits during the time of day when the person is at his or her best.
  • Avoid crowds, changes in routine, and strange places that may cause confusion or agitation.
  • Do your best to enjoy yourself. Try to find time for the holiday things you like to do.
  • Ask a friend or family member to spend time with the person while you are out.
  • At larger gatherings such as weddings or family reunions, try to have a space available where the person can rest, be alone, or spend some time with a smaller number of people, if needed.

Visiting a Person with Alzheimer's Disease

Visitors are important to people with Alzheimer's. They may not always remember who the visitors are, but the human connection has value. Here are some ideas to share with someone who is planning to visit a person with the disease.

  • Plan the visit for the time of day when the person with Alzheimer's is at his or her best.
  • Consider bringing along an activity, such as something familiar to read or photo albums to look at, but be prepared to skip it if necessary.
  • Be calm and quiet. Avoid using a loud tone of voice or talking to the person as if he or she were a child.
  • Respect the person's personal space and don't get too close.
  • Try to establish eye contact and call the person by name to get his or her attention.
  • Remind the person who you are if he or she doesn't seem to recognize you.
  • Don't argue if the person is confused. Respond to the feelings you hear being communicated, and distract the person to a different topic if necessary.
  • Remember not to take it personally if the person doesn't recognize you, is unkind, or responds angrily. He or she is reacting out of confusion.

Choosing a Nursing Home for a Person with Alzheimer's Disease

For many caregivers, there comes a point when they are no longer able to take care of their loved one at home. Choosing a residential care facility—a group home, assisted living facility, or nursing home—is a big decision, and it can be hard to know where to start.

  • It's helpful to gather information about services and options before the need actually arises. This gives you time to explore fully all the possibilities before making a decision.
  • Determine what facilities are in your area. Doctors, friends and relatives, hospital social workers, and religious organizations may be able to help you identify specific facilities.
  • Make a list of questions you would like to ask the staff. Think about what is important to you, such as activity programs, transportation, or special units for people with Alzheimer's disease.
  • Contact the places that interest you and make an appointment to visit. Talk to the administration, nursing staff, and residents.
  • Observe the way the facility runs and how residents are treated. You may want to drop by again unannounced to see if your impressions are the same.
  • Find out what kinds of programs and services are offered for people with Alzheimer's and their families. Ask about staff training in dementia care, and check to see what the policy is about family participation in planning patient care.
  • Check on room availability, cost and method of payment, and participation in Medicare or Medicaid. You may want to place your name on a waiting list even if you are not ready to make an immediate decision about long-term care.
  • Once you have made a decision, be sure you understand the terms of the contract and financial agreement. You may want to have a lawyer review the documents with you before signing.
  • Moving is a big change for both the person with Alzheimer's disease and the caregiver. A social worker may be able to help you plan for and adjust to the move. It is important to have support during this difficult transition.


Caring for Teeth With Braces or Retainers


  • Special brushing and flossing instructions
  • Foods to avoid while wearing braces
  • Playing sports while wearing braces
  • Caring for retainers
  • What to do if a bracket or wire breaks
  • Other problems
  • Find a local Doctor in your town

Braces, wires, springs, rubber bands, and other appliances can attract food and plaque, which can stain your teeth if not brushed away. Most orthodontists recommend brushing after every meal or snack with fluoride toothpaste and carefully removing any food that may have gotten stuck in your braces. Some orthodontists will also prescribe or recommend a fluoride mouthwash, which can get into places in your mouth that a toothbrush can't.

Special Brushing & Flossing Instructions

To floss your teeth, feed the short end of the floss through the space between the main arch wire and the upper portion of the tooth closest to the gum. Use a gentle sawing motion to work the floss on each side of the two teeth the floss is between. Be careful not to pull with too much force around the arch wire. Begin brushing your teeth by using a regular soft toothbrush. Brush down from the top and then up from the bottom on each tooth with braces. Next, brush your teeth with a proxabrush or "Christmas tree" brush. This brush is specially designed for cleaning between two braces. Insert the brush down from the top and then up from the bottom between two braces. Use several strokes in each direction before moving on to the next space between two braces. Repeat the procedure until all teeth have been cleaned.

Foods to Avoid While Wearing Braces

Most of the foods you like can still be eaten if you cut them into small pieces that can be easily chewed. There are certain foods, however, that can break or loosen your braces and should be avoided, such as:

  1. Hard or tough-to-bite foods, such as apples or bagels
  2. Chewy foods, such as taffy or caramels
  3. Corn on the cob
  4. Hard pretzels, popcorn, nuts and carrots

In addition to foods, do not chew ice or bubble gum.

Caring for Retainers

Every time you brush your teeth, brush your retainer as well. Once a day or at least once a week, disinfect your retainer by soaking it in a denture cleanser, such as Efferdent or Polident or other brand name solutions. Add the cleanser to a cup full of warm -- but never hot -- water. Thoroughly rinse the retainer with plain water before placing it back in your mouth.

Playing Sports While Wearing Braces

You can continue to participate in any sport you choose. When playing sports where there is a possibility of getting hit in the mouth, a specially designed mouthguard will need to be worn. The mouthguard, made of durable plastic, is designed to fit comfortably over your braces and will protect the soft tissues inside your mouth.

What to Do if a Bracket or Wire Breaks

Broken braces, loose bands or protruding wires can cause problems but rarely require emergency treatment. However, do call your orthodontist to set up an office visit to fix the problem. If you suffer a more severe mouth or facial injury, seek immediate help. Here's some tips to get you through some of the more common problems until you are able to see your orthodontist:

  • Loose brackets. Apply a small piece of orthodontic wax to temporarily reattach loose brackets or place wax over the bracket to provide a cushion between the bracket and your gums and other soft tissues of your mouth. Your orthodontist usually provides orthodontic wax to you when you first get your braces.
  • Loose bands. These will need to be replaced or recemented into place. Save the band and schedule an appointment for the repair.
  • Protruding or broken wire. Use an eraser end of a pencil to move the wire to a less bothersome position. If you can't move it out of the way, apply a small amount of orthodontic wax over the protruding end. Do not attempt to cut the wire because you might accidentally swallow it or inhale it into your lungs. If a mouth sore develops from the wire poking the inside of your mouth, rinse your mouth with warm salt water or an antiseptic rinse. An over-the-counter dental anesthetic can also be applied to numb the area.
  • Loose spacers. These will need to be repositioned or replaced if they slip or fall out completely.

Other Problems

Because braces brush up against the inside surface of your mouth, you may be more prone to developing canker sores. If a canker sore develops, your orthodontist or dentist may prescribe a corticosteroid ointment or a prescription or nonprescription pain-reliever solution to reduce the pain and irritation and help heal the sore.



Dental Health: Caring for Your Dentures


  • Can I make adjustments or repairs to my dentures?
  • Will my dentures need to be replaced?
  • How should I care for my mouth and gums?
  • How often should I see the dentist?
  • Find a local Doctor in your town

Proper denture care is important for both the health of your dentures and mouth. Here are some tips.

 

  • Handle dentures with great care. To avoid accidentally dropping them, stand over a folded towel or a full sink of water when handling dentures.
  • Brush and rinse your dentures daily. Like natural teeth, dentures must be brushed daily to remove food and plaque. Brushing also helps prevent the development of permanent stains on the dentures. Use a brush with soft bristles that is specifically designed for cleaning dentures. Avoid using a hard-bristled brush; it can damage dentures. Gently brush all surfaces of the denture and be careful not to damage the plastic or bend attachments. In between brushings, rinse your dentures after every meal.
  • Clean with a denture cleanser. Hand soap or mild dishwashing liquid can be used for cleaning dentures. Household cleansers and many toothpastes may be too abrasive for your dentures and should not be used. Also, avoid using bleach, as this may whiten the pink portion of the denture. Ultrasonic cleaners can be used to care for dentures. These cleaners are small bathtub-like devices that contain a cleaning solution. The denture is immersed in the tub and then sound waves create a wave motion that dislodges the undesirable deposits. Use of an ultrasonic cleaner, however, does not replace a thorough daily brushing. Products with the American Dental Association Seal of Acceptance are recommended since they have been evaluated for safety and effectiveness.
  • Denture care when not being worn. Dentures need to be kept moist when not being worn so they do not dry out or lose their shape. When not worn, dentures should be placed in a denture cleanser soaking solution or in water. However, if your denture has metal attachments, the attachments could tarnish if placed in a soaking solution. Your dentist can recommend the best methods for caring for your particular denture. Dentures should never be placed in hot water, as it can cause them to warp.

Can I Make Adjustments or Repairs to My Dentures?

One or more follow-up appointments are generally needed soon after you receive your denture so that your oral health care provider can make any necessary adjustments. Never attempt to adjust or repair your dentures yourself. Never bend any part of the clasp or metal attachments yourself; doing so can weaken the metal structure. "Do-it-yourself" repair kits can permanently damage your dentures and over-the-counter glues may contain harmful chemicals.

Dentures that don't fit properly can cause irritation and sores in your mouth and on your gums. Be sure to contact your oral health care provider if your denture breaks, cracks, chips or if one of the teeth becomes loose. Oftentimes, he or she can make the necessary adjustment or repair on the same day. For some complicated repairs, your denture may have to be sent to a special dental laboratory.

Will My Dentures Need to Be Replaced?

Over time, dentures will need to be relined, rebased or remade due to normal wear, natural age-related changes to your face, jaw bones and gums, or if the dentures become loose. To reline or rebase a denture, the dentist or prosthodontist refits the denture base or makes a new denture base and reuses the existing teeth. Generally, complete dentures should be used for 5 to 7 years before a replacement is necessary.

How Should I Care for My Mouth and Gums?

Even with full dentures, it is important to brush your gums, tongue and palate with a soft-bristled brush every morning before you put in your dentures. This removes plaque and stimulates circulation in the mouth. Pay special attention to cleaning teeth that fit under the denture's metal clasps. Plaque that becomes trapped under the clasps will increase the risk of tooth decay. If you wear a partial denture, be sure to remove it before you brush your natural teeth. Clean, rest, and massage the gums regularly. Rinsing your mouth daily with lukewarm salt water will help clean your gums. Eat a balanced diet so that proper nutrition and a healthy mouth can be maintained.

How Often Should I See the Dentist?

Your dentist or prosthodontist will advise you about how often you need to visit, but every 6 months should be the norm. Regular dental visits are important so that your denture and mouth can be examined for proper denture fit, to look for signs of oral diseases including cancer, and to have your teeth professionally cleaned.



Carotid Artery Disease: Causes, Symptoms, Tests, and Treatment

Carotid artery disease introduction
  • How does carotid artery disease happen?
  • What are the risk factors for carotid artery disease?
  • What are the symptoms of carotid artery disease?
  • What is a transient ischemic attack (TIA)?
  • How is carotid artery disease diagnosed
  • What's the treatment for carotid artery disease?
  • What are the recommended lifestyle changes for carotid artery disease?
  • Which drugs can reduce the risk of stroke?
  • What medical procedures treat carotid artery disease
  • Find a local Cardiologist in your town

Carotid Artery Disease Introduction

Carotid artery disease is also called carotid artery stenosis. The term refers to the narrowing of the carotid arteries. This narrowing is usually caused by the buildup of fatty substances and cholesterol deposits, called plaque. Carotid artery occlusion refers to complete blockage of the artery. When the carotid arteries are obstructed, you are at an increased risk for a stroke, the third leading cause of death in the U.S.

How Does Carotid Artery Disease Happen?

Like the arteries that supply blood to the heart -- the coronary arteries -- the carotid arteries can also develop atherosclerosis or “hardening of the arteries” on the inside of the vessels.

Over time, the buildup of fatty substances and cholesterol narrows the carotid arteries. This decreases blood flow to the brain and increases the risk of a stroke.

A stroke -- sometimes called a “brain attack” -- is similar to a heart attack. It occurs when blood flow is cut off from part of the brain. If the lack of blood flow lasts for more than 3 to 6 hours, the damage is usually permanent. A stroke can occur if:

  • the artery becomes extremely narrowed
  • there's a rupture in an artery to the brain that has atherosclerosis
  • a piece of plaque breaks off and travels to the smaller arteries of the brain
  • a blood clot forms and obstructs a blood vessel

Strokes can occur as a result of other conditions besides carotid artery disease. For example, sudden bleeding in the brain, called intracerebral hemorrhage, can cause a stroke. Other possible causes include:

  • sudden bleeding in the spinal fluid space -- subarachnoid hemorrhage
  • atrial fibrillation
  • cardiomyopathy
  • blockage of tiny arteries inside the brain

What Are the Risk Factors for Carotid Artery Disease?

The risk factors for carotid artery disease are similar to those for other types of heart disease. They include:

  • age
  • smoking
  • hypertension (high blood pressure) -- the most important treatable risk factor for stroke
  • abnormal lipids or high cholesterol
  • diet high in saturated fats
  • insulin resistance
  • diabetes
  • obesity
  • sedentary lifestyle
  • family history of atherosclerosis, either coronary artery disease or carotid artery disease

Men under the age of 75 have a greater risk than women. Women have a greater risk over the age of 75. People who have coronary artery disease have an increased risk of developing carotid artery disease. Typically, the carotid arteries become diseased a few years later than the coronary arteries.

What Are the Symptoms of Carotid Artery Disease

You may not have any symptoms of carotid artery disease. Plaque builds up in the carotid arteries over time with no warning signs until you have a transient ischemic attack (TIA) or a stroke.

Signs of a stroke may include:

  • sudden loss of vision, blurred vision, or difficulty in seeing out of one or both eyes
  • weakness, tingling, or numbness on one side of the face, one side of the body, or in one arm or leg
  • sudden difficulty in walking, loss of balance, lack of coordination
  • sudden dizziness and/or confusion
  • difficulty speaking (called aphasia)
  • confusion
  • sudden severe headache
  • problems with memory
  • difficulty swallowing (called dysphagia)

What Is a Transient Ischemic Attack (TIA)?

A TIA occurs when there is a low flow of blood or a clot briefly blocks an artery that supplies blood to the brain. With a TIA, you may have the same above symptoms as you would have for a stroke. But the symptoms only last a few minutes or few hours and then resolve.

A TIA is a medical emergency because it is impossible to predict whether it will progress into a major stroke. If you or someone you know experiences any of the above symptoms, get emergency help. Immediate treatment can save your life and increase your chance of a full recovery.

Findings show that someone who has experienced a TIA is 10 times more likely to suffer a major stroke than a person who has not had a TIA.

How Is Carotid Artery Disease Diagnosed?

There are often no symptoms of carotid artery disease until you have a TIA or stroke. That's why it's important to see your doctor regularly for physical examinations. Your doctor may listen to the arteries in your neck with a stethoscope. If an abnormal sound, called a bruit, is heard over an artery or vascular channel, it may reflect turbulent blood flow. That could indicate carotid artery disease.

Listening for a bruit in the neck is a simple, safe, and inexpensive way to screen for stenosis (narrowing) of the carotid artery. As a screening test, though, it's inexact. Some experts believe that bruits may be better predictors of atherosclerotic disease rather than risk of stroke. Be sure to let your doctor know if you have had any symptoms, such as those listed above.

Your doctor may also use a test to diagnose carotid artery disease. Possible tests include the following:

  • Carotid ultrasound (standard or Doppler). This noninvasive, painless screening test uses high-frequency sound waves to view the carotid arteries. It looks for plaques and blood clots and determines whether the arteries are narrowed or blocked. A Doppler ultrasound shows the movement of blood through the blood vessels. Ultrasound imaging does not use ionizing radiation (X-rays).
  • Magnetic resonance angiography (MRA). This newer imaging technique uses radio waves and a powerful magnet to gather accurate information about the brain and arteries. Then a computer uses this information to generate high-resolution images. An MRA can often detect even small strokes in the brain.
  • Computerized tomography angiography (CTA). More detailed than an X-ray, a CT uses X-rays and computer technology to produce cross sectional images of the carotid arteries. Images of the brain can be collected as well. With this imaging test, the scan may reveal areas of damage on the brain. The CT scan uses a low level of radiation.
  • Cerebral angiography (carotid angiogram). This procedure is considered the gold standard for imaging the carotid arteries. It is an invasive procedure that lets a doctor see blood flow through the carotid arteries in real time. Cerebral angiography allows the doctor to see narrowing or blockages on a live X-ray screen as contrast dye is injected in the carotid arteries. The procedure provides the best information. It does carry a small risk of serious complications.

What's The Treatment For Carotid Artery Disease

To effectively treat carotid artery disease, doctors recommend the following:

  • following recommended lifestyle habits
  • taking medications as prescribed
  • considering a procedure to improve blood flow, if your doctor believes it could help

What Are the Recommended Lifestyle Changes for Carotid Artery Disease?

To keep carotid artery disease from progressing, the following lifestyle changes are recommended:

  • Quit smoking.
  • Control high blood pressure (optimal blood pressure is 120/80 mmHg).
  • Control diabetes.
  • Have regular check-ups with your doctor.
  • Have your doctor check your cholesterol and get treatment, if necessary.
  • Eat foods low in saturated fats, trans fats, cholesterol, and salt.
  • Eat only enough calories to maintain a healthy weight; avoid weight gain.
  • Increase exercise to at least 30 minutes of physical activity most days of the week.
  • Limit alcohol to one drink per day for women, two for men.

Which Drugs Can Reduce the Risk of Stroke?

Your doctor may recommend antiplatelet medications such as aspirin and clopidogrel (Plavix) to decrease the risk of stroke due to blood clots. Your doctor may also prescribe medications to lower cholesterol and/or antihypertensives to lower your blood pressure. In some cases, Coumadin (warfarin), a blood thinner, may be prescribed.

What Medical Procedures Treat Carotid Artery Disease?

If there is severe narrowing or blockage in the carotid artery, a procedure can be done to open the artery. This will increase blood flow to the brain to prevent future stroke. Your doctor may suggest either of the following procedures:

  • Carotid endarterectomy (CEA). This has been the commonly performed procedure for patients who have carotid atherosclerosis and TIAs or mild strokes. While you're under general anesthesia, an incision is made in the neck at the location of the blockage. The surgeon isolates the artery and surgically removes the plaque and diseased portions of the artery. Then, the artery is sewn back together to allow improved blood flow to the brain. The risks and benefits of CEA depend on your age, the degree of blockage, and whether you've had a stroke or TIA.
  • Carotid artery stenting (CAS). Carotid artery stenting (CAS) is a newer treatment option. It's less invasive than carotid endarterectomy and is performed in a catheterization laboratory. With CAS, a small puncture is made in the groin. A specially designed catheter is threaded to the area of narrowing in the carotid artery. Once in place, a small balloon tip is inflated for a few seconds to open the artery. Then, a stent is placed in the artery and expanded to hold the artery open. A stent is a small stainless steel mesh tube that acts as a scaffold to provide support inside your artery. The stent stays in place permanently. CAS is still a new procedure and there is significant controversy as to how well it prevents strokes caused by carotid artery disease.

 


 

Carpal Tunnel Syndrome and
Tarsal Tunnel Syndrome


  • What is carpal tunnel syndrome?
  • What is tarsal tunnel syndrome?
  • What conditions and diseases cause carpal tunnel syndrome?
  • What are carpal tunnel syndrome symptoms?
  • How is carpal tunnel syndrome diagnosed?
  • What is the treatment for carpal tunnel syndrome? Can carpal tunnel syndrome be prevented?
  • Carpal Tunnel Syndrome and Tarsal Tunnel Syndrome At A Glance
  • Patient Discussions: Carpal Tunnel Syndrome And Tarsal Tunnel Syndrome - Symptoms and Signs
  • Patient Discussions: Carpal Tunnel Syndrome - Treatment
  • Patient Discussions: Carpal Tunnel Syndrome or Tarsal Tunnel Syndrome - Describe Your Experience
  • Find a local Rheumatologist in your town

What is carpal tunnel syndrome?

Carpus is a word derived from the Greek word karpos, which means "wrist." The wrist is surrounded by a band of fibrous tissue that normally functions as a support for the joint. The tight space between this fibrous band and the wrist bone is called the carpal tunnel. The median nerve passes through the carpal tunnel to receive sensations from the thumb, index, and middle fingers of the hand. Any condition that causes swelling or a change in position of the tissue within the carpal tunnel can squeeze and irritate the median nerve. Irritation of the median nerve in this manner causes tingling and numbness of the thumb, index, and the middle fingers -- a condition known as "carpal tunnel syndrome."

What is tarsal tunnel syndrome?

Anatomy similar to that of the wrist and hand exists in the ankle and foot. Tarsal is a word derived from the Latin word for "ankle." When the sensory nerve that passes through the tarsal tunnel is irritated by pressure in the tunnel, numbness and tingling of the foot and toes can be felt. This condition is referred to as "tarsal tunnel syndrome." Tarsal tunnel syndrome is analogous to, but far less common, than carpal tunnel syndrome. It is treated similarly.

 

What conditions and diseases cause carpal tunnel syndrome?

For most patients, the cause of their carpal tunnel syndrome is unknown. Any condition that exerts pressure on the median nerve at the wrist can cause carpal tunnel syndrome. Common conditions that can lead to carpal tunnel syndrome include obesity, pregnancy, hypothyroidism, arthritis, diabetes, and trauma. Tendon inflammation resulting from repetitive work, such as uninterrupted typing, can also cause carpal tunnel symptoms. Carpal tunnel syndrome from repetitive maneuvers has been referred to as one of the repetitive stress injuries. Some rare diseases can cause deposition of abnormal substances in and around the carpal tunnel, leading to nerve irritation. These diseases include amyloidosis, sarcoidosis, multiple myeloma, and leukemia.

What are carpal tunnel syndrome symptoms?

People with carpal tunnel syndrome initially feel numbness and tingling of the hand in the distribution of the median nerve (the thumb, index, middle, and part of the fourth fingers). These sensations are often more pronounced at night and can awaken people from sleep. The reason symptoms are worse at night may be related to the flexed-wrist sleeping position and/or fluid accumulating around the wrist and hand while lying flat. Carpal tunnel syndrome may be a temporary condition that completely resolves or it can persist and progress.

Picture of carpal tunnel syndrome
Picture of carpal tunnel syndrome

 

 

As the disease progresses, patients can develop a burning sensation, and/or cramping and weakness of the hand. Decreased grip strength can lead to frequent dropping of objects from the hand. Occasionally, sharp shooting pains can be felt in the forearm. Chronic carpal tunnel syndrome can also lead to wasting (atrophy) of the hand muscles, particularly those near the base of the thumb in the palm of the hand.

How is carpal tunnel syndrome diagnosed?

The diagnosis of carpal tunnel syndrome is suspected based on the symptoms and the distribution of the hand numbness. Examination of the neck, shoulder, elbow, pulses, and reflexes can be performed to exclude other conditions that can mimic carpal tunnel syndrome. The wrist can be examined for swelling, warmth, tenderness, deformity, and discoloration. Sometimes tapping the front of the wrist can reproduce tingling of the hand, and is referred to as Tinel's sign of carpal tunnel syndrome. Symptoms can also at times be reproduced by the examiner by bending the wrist forward (referred to as Phalen's maneuver).

The diagnosis is strongly suggested when a nerve conduction velocity test is abnormal. This test involves measuring the rate of speed of electrical impulses as they travel down a nerve. In carpal tunnel syndrome, the impulse slows as it crosses through the carpal tunnel. A test of muscles of the extremity, electromyogram (EMG), is sometimes performed to exclude or detect other conditions that might mimic carpal tunnel syndrome.

Blood tests may be performed to identify medical conditions associated with carpal tunnel syndrome. These tests include thyroid hormone levels, complete blood counts, and blood sugar and protein analysis. X-ray tests of the wrist and hand might also be helpful to identify abnormalities of the bones and joints of the wrist.

What is the treatment for carpal tunnel syndrome? Can carpal tunnel syndrome be prevented?

The choice of treatment for carpal tunnel syndrome depends on the severity of the symptoms and any underlying disease that might be causing the symptoms.

Initial treatment usually includes rest, immobilization of the wrist in a splint, and occasionally ice application. Those whose occupations are aggravating the symptoms should modify their activities. For example, computer keyboards and chair height may need to be adjusted to optimize comfort. These measures, as well as periodic resting and range of motion stretching exercise of the wrists can actually prevent the symptoms of carpal tunnel syndrome that are caused by repetitive overuse. Underlying conditions or diseases are treated individually. Fractures can require orthopedic management. Obese individuals will be advised regarding weight reduction. Rheumatoid disease is treated with measures directed against the underlying arthritis. Wrist swelling that can be associated with pregnancy resolves in time after delivery of the baby.

Several types of medications have been used in the treatment of carpal tunnel syndrome. Vitamin B6 (pyridoxine) has been reported to relieve some symptoms of carpal tunnel syndrome, although it is not known how this medication works. Nonsteroidal anti-inflammatory drugs can also be helpful in decreasing inflammation and reducing pain. Side effects include gastrointestinal upset and even ulceration of the stomach. These medications should be taken with food, and abdominal symptoms should be reported to the doctor. Corticosteroids can be given by mouth or injected directly into the involved wrist joint. They can bring rapid relief of the persistent symptoms of carpal tunnel syndrome. Side effects of these medications, when given in short courses, for carpal tunnel syndrome are minimal. However, corticosteroids can aggravate diabetes and should be avoided in the presence of infections.

Most patients with carpal tunnel syndrome improve with conservative measures and medications. Occasionally, chronic pressure on the median nerve can result in persistent numbness and weakness. In order to avoid serious and permanent nerve and muscle consequences of carpal tunnel syndrome, surgical treatment is considered. Surgery involves severing the band of tissue around the wrist to reduce pressure on the median nerve. This surgical procedure is called "carpal tunnel release." It can now be performed with a small diameter viewing tube, called an arthroscope, or by open wrist procedure. After carpal tunnel release, patients often undergo exercise rehabilitation. Though it is uncommon, symptoms can recur.

Carpal Tunnel Syndrome and Tarsal Tunnel Syndrome At A Glance
  • Carpal tunnel syndrome is caused by irritation of the median nerve at the wrist.
  • Any condition that exerts pressure on the median nerve can cause carpal tunnel syndrome.
  • Symptoms of carpal tunnel syndrome include numbness and tingling of the hand.
  • Diagnosis of carpal tunnel syndrome is suspected based on symptoms, supported by physical examination signs, and confirmed by nerve conduction testing.
  • Treatment of carpal tunnel syndrome depends on the severity of symptoms and the underlying cause.

 


 

Computerized Axial Tomography
(CAT Scan/CT Scan)


  • What is a CT scan?
  • Why are CT scans performed?
  • Are there risks in obtaining a CT scan?
  • How does a patient prepare for CT scanning, and how is it performed?
  • CT Scan At A Glance
  • Patient Discussions: CT Scan (Computerized Axial Tomography) - Causes
  • Patient Discussions: Ct Scan - Helped With Your Diagnosis
  • Find a local Doctor in your town

What is a CT scan?

A computerized axial tomography scan is an x-ray procedure that combines many x-ray images with the aid of a computer to generate cross-sectional views and, if needed, three-dimensional images of the internal organs and structures of the body. Computerized axial tomography is more commonly known by its abbreviated names, CT scan or CAT scan. A CT scan is used to define normal and abnormal structures in the body and/or assist in procedures by helping to accurately guide the placement of instruments or treatments.

A large donut-shaped x-ray machine takes x-ray images at many different angles around the body. These images are processed by a computer to produce cross-sectional pictures of the body. In each of these pictures the body is seen as an x-ray "slice" of the body, which is recorded on a film. This recorded image is called a tomogram. "Computerized Axial Tomography" refers to the recorded tomogram "sections" at different levels of the body.

Imagine the body as a loaf of bread and you are looking at one end of the loaf. As you remove each slice of bread, you can see the entire surface of that slice from the crust to the center. The body is seen on CT scan slices in a similar fashion from the skin to the central part of the body being examined. When these levels are further "added" together, a three-dimensional picture of an organ or abnormal body structure can be obtained.

Why are CT scans performed?

CT scans are performed to analyze the internal structures of various parts of the body. This includes the head, where traumatic injuries, (such as blood clots or skull fractures), tumors, and infections can be identified. In the spine, the bony structure of the vertebrae can be accurately defined, as can the anatomy of the intervertebral discs and spinal cord. In fact, CT scan methods can be used to accurately measure the density of bone in evaluating osteoporosis.

Occasionally, contrast material (an x-ray dye) is placed into the spinal fluid to further enhance the scan and the various structural relationships of the spine, the spinal cord, and its nerves. Contrast material is also often administered intravenously or through other routes prior to obtaining a CT scan (see below). CT scans are also used in the chest to identify tumors, cysts, or infections that may be suspected on a chest x-ray. CT scans of the abdomen are extremely helpful in defining body organ anatomy, including visualizing the liver, gallbladder, pancreas, spleen, aorta, kidneys, uterus, and ovaries. CT scans in this area are used to verify the presence or absence of tumors, infection, abnormal anatomy, or changes of the body from trauma.

The technique is painless and can provide extremely accurate images of body structures in addition to guiding the radiologist in performing certain procedures, such as biopsies of suspected cancers, removal of internal body fluids for various tests, and the draining of abscesses which are deep in the body. Many of these procedures are minimally invasive and have markedly decreased the need to perform surgery to accomplish the same goal.

Are there risks in obtaining a CT scan?

A CT scan is a very low-risk procedure. The most common problem is an adverse reaction to intravenous contrast material. Intravenous contrast is usually an iodine-based liquid given in the vein, which makes many organs and structures, such as the kidneys and blood vessels much more visible on the CT scan. There may be resulting itching, a rash, hives, or a feeling of warmth throughout the body. These are usually self-limiting reactions that go away rather quickly. If needed, antihistamines can be given to help relieve the symptoms. A more serious allergic reaction to intravenous contrast is called an anaphylactic reaction. When this occurs, the patient may experience severe hives and/or extreme difficulty in breathing. This reaction is quite rare, but is potentially life-threatening if not treated. Medications which may include corticosteroids, antihistamines, and epinephrine can reverse this adverse reaction.

Toxicity to the kidneys which can result in kidney failure is an extremely rare complication of the intravenous contrast material used in CT scans. People with diabetes, dehydrated individuals, or patients who already have impaired kidney function are most prone to this reaction. Newer intravenous contrast agents have been developed, such as Isovue, which have nearly eliminated this complication.

The amount of radiation a person receives during a CT scan is minimal. In men and non-pregnant women, it has not been shown to produce any adverse effects. If a woman is pregnant, there may be a potential risk to the fetus, especially in the first trimester of the pregnancy. If a woman is pregnant, she should inform her doctor of her condition and discuss other potential methods of imaging, such as an ultrasound, which are not harmful to the fetus.

How does a patient prepare for CT scanning, and how is it performed?

In preparation for a CT scan, patients are often asked to avoid food, especially when contrast material is to be used. Contrast material may be injected intravenously, or administered by mouth or by an enema in order to increase the distinction between various organs or areas of the body. Therefore, fluids and food may be restricted for several hours prior to the examination. If the patient has a history of allergy to contrast material (such as iodine), the requesting physician and radiology staff should be notified. All metallic materials and certain clothing around the body are removed because they can interfere with the clarity of the images.

Patients are placed on a movable table, and the table is slipped into the center of a large donut-shaped machine which takes the x-ray images around the body. The actual procedure can take from a half an hour to an hour and a half. If specific tests, biopsies, or intervention are performed by the radiologist during CT scanning, additional time and monitoring may be required. It is important during the CT scan procedure that the patient minimize any body movement by remaining as still and quiet as is possible. This significantly increases the clarity of the x-ray images. The CT scan technologist tells the patient when to breathe or hold his/her breath during scans of the chest and abdomen. If any problems are experienced during the CT scan, the technologist should be informed immediately. The technologist directly watches the patient through an observation window during the procedure, and there is an intercom system in the room for added patient safety.

CT scans have vastly improved the ability of doctors to diagnose many diseases earlier in their course and with much less risk than previous methods. Further refinements in CT scan technology continue to evolve which promise even better picture quality and patient safety. Newer CT scans called "spiral" or "helical" CT scans can provide more rapid and accurate visualization of internal organs. For example, many trauma centers are using these scans to more rapidly diagnose internal injuries after serious body trauma. High resolution CT scans (HRCT) are used to accurately assess the lungs for inflammation and scarring.

CT Scan At A Glance
  • CT scanning adds x-ray images with the aid of a computer to generate cross-sectional views of anatomy.
  • CT scanning can identify normal and abnormal structures and be used to guide procedures.
  • CT scanning is painless.
  • Iodine-containing contrast material is sometimes used in CT scanning. Patients with a history of allergy to iodine or contrast materials should notify their physicians and radiology staff.

 


 

Cat Scratch Disease
Bartonella henselae Infection

  • What is cat scratch disease?
  • Can my cat transmit Bartonella henselae to me?
  • How can I reduce my risk of getting cat scratch disease from my cat?
  • How can I find more information about cat scratch disease?

What is cat scratch disease?

Cat scratch disease (CSD) is a bacterial disease caused by Bartonella henselae. Most people with CSD have been bitten or scratched by a cat and developed a mild infection at the point of injury. Lymph nodes, especially those around the head, neck, and upper limbs, become swollen. Additionally, a person with CSD may experience fever, headache, fatigue, and a poor appetite. Rare complications of B. henselae infection are bacillary angiomatosis and Parinaud's oculolandular syndrome.

Can my cat transmit Bartonella henselae to me?

Sometimes, yes, cats can spread B. henselae to people. Most people get CSD from cat bites and scratches. Kittens are more likely to be infected and to pass the bacterium to people. About 40% of cats carry B. henselae at some time in their lives. Cats that carry B. henselae do not show any signs of illness; therefore, you cannot tell which cats can spread the disease to you. People with immunocompromised conditions, such as those undergoing immunosuppressive treatments for cancer, organ transplant patients, and people with HIV/AIDS, are more likely than others to have complications of CSD. Although B. henselae has been found in fleas, so far there is no evidence that a bite from an infected flea can give you CSD.

How can I reduce my risk of getting cat scratch disease from my cat?

  • Avoid "rough play" with cats, especially kittens. This includes any activity that may lead to cat scratches and bites.
  • Wash cat bites and scratches immediately and thoroughly with running water and soap.
  • Do not allow cats to lick open wounds that you may have.
  • Control fleas.
  • If you develop an infection (with pus and pronounced swelling) where you were scratched or bitten by a cat or develop symptoms, including fever, headache, swollen lymph nodes, and fatigue, contact your physician.

 


 

Narcolepsy


  • What is narcolepsy?
  • How common is narcolepsy?
  • What causes narcolepsy?
  • What are the symptoms of narcolepsy?
  • Excessive daytime sleepiness (EDS)
  • Cataplexy
  • Hypnagogic hallucinations
  • Sleep paralysis
  • Additional symptoms
  • How is narcolepsy diagnosed?
  • How is narcolepsy treated?
  • Medications
  • Non-drug treatments
  • What is the outcome (prognosis) for patients with narcolepsy?
  • What's in the future for narcolepsy?
  • Narcolepsy At A Glance
  • For more information
  • Patient Discussions: Narcolepsy
  • Patient Discussions: Narcolepsy
  • Find a local Sleep Specialist in your town

What is narcolepsy?

Narcolepsy is a chronic disease of the central nervous system. Excessive daytime sleepiness (EDS) is the main symptom and is present in 100% of patients with narcolepsy. Other primary symptoms of narcolepsy include:

  • loss of muscle tone (cataplexy),
  • distorted perceptions (hypnagogic hallucinations), and
  • inability to move or talk (sleep paralysis).

Additional symptoms include disturbed nocturnal sleep and automatic behavior (patients carry out certain actions without conscious awareness). All of the symptoms of narcolepsy may be present in various combinations and degrees of severity.

Narcolepsy usually begins in teenagers or young adults and affects both sexes equally. The first symptom to appear is excessive daytime sleepiness, which may remain unrecognized for a long time in that it develops gradually over time. The other symptoms can follow excessive daytime sleepiness by months or years.

How common is narcolepsy?

The prevalence of narcolepsy is similar to that of Parkinson's disease and multiple sclerosis. In the United States, the National Institute of Neurological Disorders and Stroke estimates narcolepsy affects one in every 2,000 people. However, in some countries (for example, Israel), the prevalence of narcolepsy is much lower (one per 500,000) while in other countries (for example, Japan), it is much higher (one per 600). The American Sleep Association estimates that approximately 125,000 to 200,000 Americans suffer from narcolepsy, but only fewer than 50,000 are properly diagnosed.

Narcolepsy often remains undiagnosed or misdiagnosed for several years. This may occur because physicians do not consider the diagnosis of narcolepsy frequently enough. They may think of narcolepsy only in people who have the main symptom of excessive daytime sleepiness. Narcolepsy may not be considered in the evaluation of patients who come to doctors complaining of fatigue, tiredness, or problems with concentration, attention, memory, and performance, and other illnesses (seizures, mental illness, etc.).

What causes narcolepsy?

Advances have been made in the last few years in determining the cause of narcolepsy. The newest discovery has been the finding of abnormalities in the structure and function of a particular group of nerve cells, called hypocretin neurons, in the brains of patients with narcolepsy. These cells are located in a part of the brain called the hypothalamus and they normally secrete neurotransmitter substances (chemicals released by nerve cells to transmit messages to other cells) called hypocretins.

Abnormalities in the hypocretin system may be responsible for the daytime sleepiness and abnormal REM sleep found in narcolepsy. (See the section below on sleep laboratory tests for a discussion of REM sleep.)

Experiments in dogs and mice with narcolepsy point to an abnormal hypocretin system as a cause for the development of their narcolepsy. People with narcolepsy have been found to have a markedly decreased number of hypocretin nerve cells in the brain. They also have a decreased level of hypocretins in the cerebrospinal fluid (the fluid that surrounds the brain and the spinal cord).

Narcolepsy is associated with a specific type of human leukocyte antigen (HLA). HLAs are genetically determined proteins on the surface of white blood cells. They are a part of the body's immune (defense) system. The finding of a very high HLA-association in narcolepsy led to the proposal that narcolepsy is an autoimmune disease, similar to other HLA-associated diseases such as multiple sclerosis and ankylosing spondylitis.

It is theorized that an autoimmune reaction causes the loss of nerve cells in the brain in patients with narcolepsy. The environment (for example, infection or trauma) might trigger an autoimmune reaction where normal brain cells are attacked by the body's own immune system. As a result, the neurons are damaged and ultimately destroyed, and they and their neurotransmitter chemicals disappear. Whether narcolepsy is an autoimmune disease remains to be proven.

The role of heredity in humans with narcolepsy is not completely understood. No consistent pattern of heredity has been recognized in families so far. It is estimated that relatives of patients with narcolepsy may have a higher predisposition to develop narcolepsy or sleep-related abnormalities, such as increased daytime sleepiness, increased REM sleep, or others. In dogs with narcolepsy, the disease is inherited in a predictable pattern. In these animals, the narcolepsy is caused by a mutation in a particular gene that is normally responsible for producing a receptor (binder) in the brain for the hypocretin neurotransmitter.

What are the symptoms of narcolepsy?

Symptoms of narcolepsy include (each of these are discussed in detail):

  • excessive daytime sleepiness
  • cataplexy
  • hypnagogic hallucinations
  • sleep paralysis
  • disturbed nocturnal sleep
  • automatic behavior
  • other complaints such as blurred vision, double vision, or droopy eyelids

Excessive daytime sleepiness (EDS)

The main symptom of narcolepsy, excessive daytime sleepiness (EDS), causes the patient to tend to fall asleep easily. This can happen in relaxed situations and also at inappropriate times and places. Patients may fall asleep while watching TV, reading a book, driving, attending a meeting, or engaging in a conversation. The daytime sleepiness is present even after normal nighttime sleep. Patients may describe this symptom as being tired, fatigued, sleepy, feeling lazy, or having low energy.

Excessive daytime sleepiness is present throughout the day but the patient, with extreme effort, may be able to resist the sleepiness for some time. Finally, it becomes overwhelming and results in a sleep episode of varied duration (seconds to minutes). In addition to daytime sleepiness, repetitive, irresistible, and unintentional sleep attacks may occur throughout the day. Excessive daytime sleepiness usually impairs a patient's functioning because it reduces motivation and vigilance, interferes with concentration and memory, and increases irritability.

Cataplexy

Cataplexy is a sudden, temporary loss of muscle control in a person with narcolepsy. An attack of cataplexy usually is triggered by strong emotional reactions such as laughter, excitement, surprise, or anger. Factors that contribute to the attacks of cataplexy include physical fatigue, stress, and sleepiness.

Severe attacks of cataplexy may result in a complete body collapse with a fall to the ground and risk of injury. Milder forms of cataplexy are more common. These involve regional muscle groups and result in symptoms such as a drooping head, sagging jaw, slurred speech, buckling of the knees, or weakness in the arms. This muscle weakness can be quite subtle. The patient is conscious but usually unable to speak.

Cataplectic attacks may last from a few seconds to several minutes. They may vary from a few per year to numerous attacks per day that could disable the patient. Cataplexy is present in nearly 75% of patients with narcolepsy, according to the National Institutes of Health. The onset of cataplexy may coincide with the onset of excessive daytime sleepiness. However, cataplexy often develops years later. Therefore, the absence of cataplexy should not rule out the diagnosis of narcolepsy.

Hypnagogic hallucinations

Hypnagogic hallucinations may be present in up to 50% of patients with narcolepsy. Hypnagogic hallucinations are dream-like experiences that occur during the transition from wakefulness to sleep, whereas hypnopompic hallucinations occur during the transition from sleep to wakefulness. These hallucinations may involve hearing, vision, touch, balance, or movement. They often incorporate images of the patient's environment into the dream-like images. The hallucinations are frequently vivid, bizarre, frightening, and disturbing for the patients. As a result, the patients may become fearful that they have or will develop a mental illness.

Sleep paralysis

Sleep paralysis may be present in up to 50% of patients with narcolepsy. Sleep paralysis is a temporary inability to move or talk that occurs during sleep-to-wake or wake-to-sleep transitions. Episodes of sleep paralysis may last seconds to minutes. They can occur at the same time as hypnagogic (or hypnopompic) hallucinations. During sleep paralysis, breathing is maintained, although some patients may experience a frightening sensation of not being able to breathe.

Cataplexy, hypnagogic hallucinations, and sleep paralysis in patients with narcolepsy are referred to as REM related abnormalities because they are caused by REM sleep intrusions into wakefulness. (See the discussion of REM sleep in the section on sleep laboratory tests below.)

Additional symptoms

Disturbed nocturnal sleep with frequent awakenings and increased body movements may develop after the onset of the primary symptoms of narcolepsy. This additional symptom, along with excessive daytime sleepiness and the REM related abnormalities (cataplexy, hypnagogic hallucinations, and sleep paralysis), from the so-called "narcolepsy pentad" (a set of five symptoms).

Automatic behavior may occur in 60% to 80% of patients with narcolepsy. Automatic behavior is when patients carry out certain actions without conscious awareness, often with the unusual use of words (irrelevant words, lapses in speech). This behavior occurs while the patient is fluctuating between sleep and wakefulness.

Other complaints associated with narcolepsy may include eye disturbances due to sleepiness, such as blurred vision, double vision, and droopy eyelids.

How is narcolepsy diagnosed?

The diagnosis of narcolepsy is based on a clinical evaluation, specific questionnaires, sleep logs or diaries, and the results of sleep laboratory tests.

Clinical evaluation

Clinical evaluation includes a detailed medical history and physical examination by a physician.

Questionnaires

Questionnaires may be used in the assessment of patients with symptoms that suggest narcolepsy. The Stanford Narcolepsy Questionnaire is an extensive questionnaire that can provide the physician with valuable information on all symptoms of narcolepsy, but especially on cataplexy. The Epworth Sleepiness Scale is a brief self-administered questionnaire that provides an estimate of the degree of daytime sleepiness. A person rates the likelihood of falling asleep during specific activities. Using the scale from 0-3 below, the person ranks their risk of dozing in the chart below.

 

0 = Unlikely to fall asleep
1 = Slight risk of falling asleep
2 = Moderate risk of falling asleep
3 = High likelihood of falling asleep
Situation Risk of Dozing
Sitting and reading
Watching television
Sitting inactive in a public place
As a passenger in a car riding for an hour, no breaks
Lying down to rest in the afternoon
Sitting and talking with someone
Sitting quietly after lunch, without alcohol
In a car, while stopped for a few minutes in traffic

 

After ranking each category, the total score is calculated. The range is 0-24, with the higher the score the more sleepiness.

Scoring:

  • 0-9 = Average daytime sleepiness
  • 10-15 = Excessive daytime sleepiness
  • 16-24 = Moderate to severe daytime sleepiness

Sleep logs or sleep diaries

Sleep logs or sleep diaries for two to three weeks are recommended in the evaluation of any patient with excessive daytime sleepiness. Sleep diaries record the patient's usual sleep patterns (sleep deprivation, irregular sleep/wake pattern, interrupted sleep), alcohol and/or drug use, and common behaviors that cause the patient to lose sleep (for example, Internet syndrome - surfing the Internet until late at night, causing sleep deprivation and daytime sleepiness.) This information may be helpful in the evaluation of a patient with excessive daytime sleepiness.

Sleep laboratory tests

Sleep laboratory tests ("sleep studies") for narcolepsy include polysomnography (PSG) and the multiple sleep latency test (MSLT). Polysomnography (PSG) is a full night recording of several different physiological factors of a patient's sleep. The PSG is followed the next day by the multiple sleep latency test (MSLT), which is a recording of the patient's tendency to fall asleep during the day. These procedures provide objective measures of daytime sleepiness and REM sleep abnormalities.

Daytime sleepiness is measured in the MSLT by the sleep latency (SL) time. This is the time from the beginning of the recording to the onset of sleep. In healthy individuals, the SL time is more than 10 minutes, whereas in narcolepsy, it could be as short as 0.5 minutes (an almost immediate onset of sleep).

REM sleep

REM sleep is named for the rapid eye movements (REM) that characterize this phase of sleep. In REM sleep dreams are vivid, muscle activity is suppressed, and brain activity is high. The REM sleep abnormality that is characteristic of narcolepsy is referred to as sleep onset REM periods. In healthy individuals, the first REM sleep period occurs about 80 to 120 minutes after the onset of sleep. By contrast, in narcolepsy, the initial REM sleep period usually occurs within 15 minutes of the onset of sleep. In addition, narcolepsy patients will have two or more sleep onset REM periods during the multiple sleep latency test (MSLT) in the daytime.

PSG is also helpful in excluding other causes of daytime sleepiness, such as sleep apnea syndrome (SAS), periodic limb movements in sleep (PLMS), and sleep disruptions. In some cases, repeat tests may be recommended if there is worsening of the symptoms of narcolepsy despite treatment or if an additional sleep disorder is suspected (for example, sleep apnea syndrome).

Maintenance of wakefulness test (MWT)

Maintenance of wakefulness test (MWT) may be used to evaluate the effects of the treatment for narcolepsy. This test is a recording that measures the ability of a subject to stay awake during the day.

The diagnostic criteria for narcolepsy are described in the International Classification of Sleep Disorders. These criteria indicate that the diagnosis may be based on clinical symptoms alone if both excessive daytime sleepiness and cataplexy are present. If cataplexy is not present, however, the diagnosis should be based on the clinical symptoms and polysomnographic findings.

The blood test for a type of HLA

The blood test for a type of HLA (Human Leukocyte Antigen) has been observed to have a very high association with narcolepsy. Certain types of HLA are part of an individual's genetic or hereditary makeup and can be characteristic of certain conditions, especially autoimmune diseases. The particular HLA type associated with narcolepsy is not unique for this condition as it is also found in 20% of the general population. Therefore, HLA typing should not be used for the diagnosis of narcolepsy.

How is narcolepsy treated?

The treatment of narcolepsy includes drug and behavioral therapies. Treatment options are individualized depending on the severity of the symptoms, life conditions (for example, type of work or responsibilities) of the patients, and the specific goals (for example, relief of certain symptoms) of therapy. Management of symptoms takes weeks to months to achieve and requires continued communication among the physician, patient, family members, and others. Good treatment management typically produces significant improvement of the symptoms rather than a resolution of all symptoms.

Medications

The types, number, and severity of the symptoms determine which drugs are used to treat the narcolepsy.

  • Severe daytime sleepiness may require treatment with high doses of stimulant medication, and sometimes a combination of stimulants may be needed.
  • Rare or infrequent cataplexy and other associated symptoms may not require any drug treatment, or treatment on an "as needed" regimen may be adequate.
  • Insomnia and depression may also require treatment.
  • Therapy should be catered to the individual needs of the patient. For example, improved alertness may be critical throughout the day for most students and working adults, but may be critical only at certain times of the day (for example, driving times) for other people.

Alerting medications are used for the treatment of excessive daytime sleepiness.

Amphetamines [for example, dextroamphetamine (Dexedrine), methamphetamine hydrochloride (Desoxyn), dextroamphetamine (Dextrostat), amphetamine and dextroamphetamine (Adderall)] and methylphenidate (Ritalin) are generalized central nervous system stimulants. These medications are used in narcolepsy to decrease sleepiness and improve alertness. However, they can also produce undesirable side effects including elevation of blood pressure, nervousness, irritability, and rarely, paranoid reactions. Alerting medications can also lead to drug dependency due to the feeling of euphoria they can cause. However, drug dependency has rarely been described in individuals with narcolepsy.

 

Pemoline (Cylert) is used as an alerting medication but it is less effective than traditional stimulants. This drug has the potential risk of toxic side effects on the liver and liver blood tests need to be monitored frequently.

 

Modafinil (Provigil), approved by the Food and Drug Administration (FDA) in 1999, has alerting effects similar to those of the traditional stimulant. Modafinil is not a general CNS stimulant like amphetamines, but the precise way it works is unknown. This drug has a much lower risk for high blood pressure and mental side effects because it acts in a different way than classic stimulants. It does not have significant effects on the sympathetic nervous system and does not cause mood changes, euphoria, or dependence. Furthermore, modafinil does not become ineffective with prolonged use. Headache and nausea are the most commonly reported side effects, and they are usually mild and temporary. These side effects can be reduced by a slow increase from a low initial dose up to the desired dose. This medication does not affect cataplexy and other REM sleep symptoms.

 

Modafinil is usually used in a single daily dose. Switching patients from amphetamines to modafinil may cause the reappearance of cataplexy in patients previously well controlled. Increasing the dose or adding an anti-cataplectic medication usually solves this problem.

Armodafinil (Nuvigil): Approved by the FDA in June 2007, is an oral drug used to promote wakefulness. It is similar to modafinil (Provigil). Armodafinil promotes wakefulness by stimulating the brain; however, the exact mechanism of action of armodafinil is unknown. Armodafinil may work by increasing the amount of dopamine (a chemical neurotransmitter that nerves use to communicate with each other) in the brain by reducing the reuptake of dopamine into nerves. The most common side effect of ararmodafinil is headache. Other side effects including anxiety, dizziness, diarrhea, dry mouth, insomnia, nausea, fatigue, and rash may occur. The drug is recommended for single daily dosing, either in the morning, or one hour prior to a work shift.

 

Monoamine oxidase inhibitors (MAOIs): A class of antidepressants called monoamine oxidase inhibitors (MAOIs) can also be used for treatment of excessive daytime sleepiness. This includes phenelzine (Nardil) and selegiline (Eldepryl).

 

Anticataplectic medication is the general name for drugs that are used to treat cataplexy. These drugs may also be used for the other REM related symptoms, such as hypnagogic hallucinations and sleep paralysis. Tricyclic antidepressants (TCAs), used in lower than antidepressant doses, are often effective in controlling cataplexy. These medications act on neurotransmitter systems to produce suppression of REM sleep and consequently improve the symptoms of cataplexy.

In some cases, the side effects may limit the use of TCAs, although in most cases the side effects are temporary. The most frequent side effects are called "anticholinergic side effects," including dry mouth, dry eyes, blurred vision, urine retention, constipation, impotence, increased appetite, drowsiness, nervousness, confusion, restlessness, and headache. Some of the TCAs may increase periodic limb movements in sleep, which could further disrupt already disturbed nighttime sleep in narcoleptic patients. If TCAs are abruptly discontinued, a significant worsening of the cataplexy and other REM related symptoms could occur. This "rebound phenomenon" may appear in 72 hours after discontinuation of the medication and peak in approximately 10 days from the withdrawal.

The most frequently used TCAs for the treatment of cataplexy and other REM related symptoms are protriptyline (Vivactil), imipramine (Tofranil), clomipramine (Anafranil), desipramine (Norpramine), and amitriptyline (Elavil). Sedating TCAs such as clomipramine, amitriptyline, and imipramine, are usually prescribed for evening use, whereas the alerting ones (protriptyline and desipramine) are recommended for use during the day.

 

Selective serotonin reuptake inhibitors (SSRIs) are also useful in treating cataplexy at doses that are comparable to those used to treat depression. The most frequently used SSRIs for treatment of cataplexy and REM related symptoms are fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa), and venlafaxine (Effexor). The SSRIs may not be as effective as the TCAs, but they have fewer side effects. The most frequently reported side effects are dizziness, lightheadedness, nausea, and mild tremor. Rarely, mild constipation or diarrhea may occur. Fluoxetine (Prozac) given late in the day may cause insomnia.

 

Sodium oxybate (Xyrem), also known as gamma-hydroxybutyrate or GHB, was approved by the FDA in 2002 to treat cataplexy, and in 2005 was also approved to treat excessive daytime sleepiness (EDS). This drug is usually administered in two doses; the first is given at bedtime and the second four hours later. It unifies sleep and improves the disturbed nighttime sleep characteristic of narcolepsy. This nighttime benefit may help decrease daytime drowsiness and cataplexy. Sodium oxybate is unrelated to drugs that are known to be sleep-inducing (hypnotic) and is not used for insomnia. It can cause drowsiness and should only be taken at night.

Non-drug treatments

Non-drug treatments include education of the patient and family members and modification of behavior patterns. Understanding the symptoms of narcolepsy may help relieve some of the frustrations, fears, anger, depression, and resentment of patients and family members. Emotional reactions are responses to both the unusual nature of the symptoms and society's ignorance of this disease. National organizations and local narcolepsy support groups are additional sources of information and assistance. (See "For more information" below.)

Behavioral approaches include establishing a regular, structured sleep-wake schedule. Planned naps of 15 to 30 minutes or longer may be beneficial in reducing daytime sleepiness. Certain dietary restrictions should be observed (for example, avoidance of large meals and alcohol). Regular exercise and exposure to bright light can improve alertness. Occupational, marriage, and family counseling may help improve the patient's quality of life.

Special considerations may be needed for school schedules and working conditions. Occupations that require working in shifts, changing the work schedule, or driving should be avoided. The dangers of driving while sleepy and/or experiencing cataplexy need to be addressed and the patients should be advised to avoid driving with these symptoms. However, many patients with narcolepsy are able to drive for short distances at certain times of the day and after taking their stimulant medications. Reporting requirements to the Department of Motor Vehicles (DMV) differ from state to state. Some states require that individuals who have any lapses of consciousness or sleepiness be reported to the DMV.

What is the outcome (prognosis) for patients with narcolepsy?

Narcolepsy is a life-long disease. The symptoms may vary in severity during the patient's lifespan, but they never disappear completely. Symptoms usually gradually worsen over time, and then tend to become stable. Even then, the excessive daytime sleepiness may become more pronounced and require additional medication. At other times, cataplexy or the other symptoms may decrease or even disappear for a time.

Different factors contribute to changes in a patient's symptoms, including an irregular sleep/wake schedule, the use of substances or drugs that affect the central nervous system, infections of the brain, and the development of additional sleep disorders, such as sleep apnea syndrome (SAS), periodic limb movements in sleep syndrome (PLMS), or others. Regular doctor check-ups and adherence to the drug plan and behavioral treatment may diminish these fluctuations and improve the patient's symptoms and quality of life.

A primary care physician, usually in collaboration with a sleep medicine specialist, can recognize the symptoms of narcolepsy, initiate the proper evaluation, and manage the treatment that is recommended by the specialist.

What's in the future for narcolepsy?

The discovery that a lack of hypocretins in the cerebrospinal fluid (CSF) may be related to the cause of narcolepsy could lead to the development of tests to determine the level of hypocretins in the CSF. Such tests could help in the diagnosis of narcolepsy. The expectation is that these tests will be simple (drawing blood), and will reflect the level of hypocretins in the CSF. In addition, the discovery of the role of hypocretins in the development of narcolepsy may lead to the development of new drugs for the treatment of narcolepsy.

Narcolepsy At A Glance

  • Narcolepsy is a chronic disease of the central nervous system. The symptoms include excessive daytime sleepiness (EDS), loss of muscle tone (cataplexy), distorted perceptions (hypnagogic hallucinations), inability to move or talk (sleep paralysis), disturbed nocturnal sleep, and automatic behavior.
  • Narcolepsy usually begins in teenagers or young adults and affects both sexes equally.
  • The prevalence of narcolepsy is similar to that of Parkinson's disease and multiple sclerosis. Approximately 125,000 to 200,000 Americans are estimated to suffer from narcolepsy, but only fewer than 50,000 are actually properly diagnosed.
  • Abnormalities in the structure and function of a particular group of nerve cells in the brain called hypocretin neurons are thought to play a role in the development of narcolepsy.
  • The diagnosis of narcolepsy is based on a clinical evaluation, specific questionnaires, sleep logs or diaries, and the results of sleep laboratory tests (polysomnography and multiple sleep latency test).
  • Treatment options for narcolepsy include drug and behavioral modification therapies and disease-specific education of the patient and family members. The treatment should be individualized, depending on the types and severity of the symptoms, the life conditions of the patients, and the specific goals of therapy.
  • Optimal management usually takes weeks to months to achieve and requires continued communication among the physician, patient, family members, and others.
  • Alerting medications are used for the treatment of excessive daytime sleepiness. Amphetamines and methylphenidate (Ritalin) are general CNS stimulants that decrease sleepiness and improve alertness. Modafinil (Provigil) has alerting effects similar to those of the traditional stimulants but has less undesirable side effects.
  • Anticataplectic medications are used to treat cataplexy, hypnagogic hallucinations, and sleep paralysis. Tricyclic antidepressants (TCAs) are often effective in controlling cataplexy, but also frequently produce side effects that could limit their use.
  • Selective serotonin reuptake inhibitors (SSRIs) are also useful in the treatment of cataplexy and their side effects are milder. Sodium oxybate (Xyrem) is a medication with anticataplectic effects that also improves disturbed nocturnal sleep.
  • Behavioral approaches to treating narcolepsy include establishing a structured sleep-wake cycle and planned naps, and involve diet, exercise, and occupational, marriage, and family counseling.

 


 

Cataract Surgery

What is a cataract?
  • What are the symptoms and signs of cataracts?
  • How are cataracts diagnosed?
  • Who is a candidate for cataract surgery?
  • What are the different types of cataract surgery?
  • What are the different types of intraocular lenses implanted after cataract surgery?
  • What should one expect prior to and on the day of cataract surgery?
  • What should one expect after the cataract surgery?
  • What are potential complications of cataract surgery?
  • Cataract Surgery At A Glance
  • Patient Discussions: Cataract Surgery - Side effects
  • Patient Discussions: Cataract Surgery - Describe Your Experience
  • Find a local Eye Doctor in your town

What is a cataract?

A cataract is an eye disease in which the normally clear lens of the eye becomes cloudy or opaque, causing a decrease in vision. The lens is important for focusing light onto the back of the eye (the retina) so that images appear clear and without distortion, and the clouding of this lens during cataract formation distorts our vision. Cataracts are usually a very gradual process of normal aging but can occasionally develop rapidly. They commonly affect both eyes, but it is not uncommon for a cataract in one eye to advance more rapidly. Cataracts are very common, affecting roughly 60% of people over the age of 60, and over 1.5 million cataract surgeries are performed in the United States each year.

Precisely why cataracts occur is unknown; however, most cataracts appear to be caused by changes in the protein structures within the lens that occur over many years and cause the lens to become cloudy. Rarely, cataracts can present at birth or in early childhood as a result of hereditary enzyme defects, other genetic disease, or systemic congenital infections. Severe trauma to the eye, eye surgery, or intraocular inflammation can also cause cataracts to develop more rapidly. Other factors that may lead to development of cataracts at an earlier age include excessive ultraviolet light exposure, exposure to ionizing radiation, diabetes, smoking, or the use of certain medications, such as oral, topical, or inhaled steroids. Other medications that are more weakly associated with cataracts include the long-term use of statins and phenothiazines.

Experts have estimated that in the United States, visual disability associated with cataracts accounts for over 8 million physician office visits a year. This number will likely continue to increase as the number of people over the age of 60 rises. When people develop cataracts, they begin to have difficulty doing activities they enjoy. Some of the most common complaints include difficulty driving at night, reading, or traveling. These are all activities for which clear vision is essential.

What are the symptoms and signs of cataracts?

Cataract development is often equated to looking through a dirty windshield of a car or smearing grease over the lens of a camera. Cataracts may cause a variety of complaints and visual changes, including blurred vision, difficulty with glare (often with bright sun or automobile headlights while driving at night), dull color vision, increased nearsightedness accompanied by frequent changes in eyeglass prescription, and occasionally double vision in one eye. A change in glasses may initially help once vision begins to change from a cataract; however, as the cataract continues to become more dense and cloudy, vision also becomes more cloudy, and stronger glasses or contact lenses will no longer improve sight.

Cataracts typically develop gradually and are usually not painful or associated with any eye redness or other symptoms unless they become extremely advanced. Rapid and/or painful changes in vision raise suspicion for other eye diseases and should be evaluated by an eye-care professional.

How are cataracts diagnosed?

Cataracts are detected by the finding of lens opacification during a medical eye examination by an eye-care professional. The abnormal lens can be seen using a variety of specialized viewing instruments. Using a variety of tests, your doctor is able to tell how much a cataract may be affecting your vision. Usual eye tests include testing visual acuity, glare sensitivity, color vision, contrast sensitivity, and a thorough examination of all other parts of the eye. Your doctor will make sure vision loss is not due to other common eye problems, including diabetes, glaucoma, or macular degeneration.

Most cataracts associated with aging develop slowly, and many patients may not notice visual loss until it is fairly advanced. Despite being told that you have cataracts, it is not imperative to have surgery to remove them until they begin to affect your vision. The development of cataracts is unpredictable; some cataracts remain less dense and never progress to the point where they cause cloudy vision and require treatment, while others progress more quickly. Thus, the decision and timing to proceed with cataract surgery is individualized for each patient. Your doctor will be able to tell you how much of your vision loss is due to cataracts and the type of visual recovery that may be expected if surgery is chosen.

Who is a candidate for cataract surgery?

Eye-care professionals may mention during a routine eye exam that you have early cataract development even if you are not yet experiencing visual symptoms. Although your doctor will be able to tell when you first begin to develop cataracts, you will generally be the first person to notice changes in your vision that may require cataract surgery. Clouding of the lens may start to be seen at any age, but it is uncommon before the age of 40. However, a large majority of people will not begin to have symptoms from their cataracts until many years after they begin to develop. Cataracts can be safely observed without treatment until you notice changes in your vision.

Surgery is recommended for most individuals who have significant vision loss and are symptomatic secondary to cataract. If you have significant other eye disease unrelated to cataracts that limits your vision, your ophthalmologist may not recommend surgery. Sometimes after trauma to the eye or previous eye surgery, a cataract may make it difficult for your eye-care professional to see the retina at the back of the eye; in these cases, it may still be appropriate to remove the cataract so that further retinal or optic nerve evaluation and treatment can occur. The mode of surgery can be tailored to individuals based on coexisting medical problems. Cataract surgery is generally performed with minimal sedation and typically takes less than 30 minutes. Therefore the surgery does not put significant strain on the heart or the lungs.

Prior refractive surgery such as LASIK is not a contraindication to cataract surgery.

A cataract is a medical condition, and insurance companies usually cover part or all of the cost of cataract surgery, including pre- and postoperative care. Ask your physician any questions you may have about the cost involved.

What are the different types of cataract surgery?

The standard cataract surgical procedure is performed in a hospital or in an ambulatory surgery center on an outpatient basis. The most common form of cataract surgery today involves a process called phacoemulsification. With the use of an operating microscope, your surgeon will make a very small incision in the surface of the eye in or near the cornea. A thin ultrasound probe, which is often confused with a laser by patients, is inserted into the eye and uses ultrasonic vibrations to dissolve (phacoemulsify) the clouded lens. These tiny fragmented pieces are then suctioned out through the same ultrasound probe. Once the cataract is removed, an artificial lens is placed into the thin capsular bag that the cataract previously occupied. This lens is essential to help your eye focus after surgery.

There are three basic techniques for cataract surgery:

    1. Phacoemulsification: This is the most common form of cataract removal as explained above. In this most modern method, cataract surgery can usually be performed in less than 30 minutes and usually requires only minimal sedation. Numbing eyedrops or an injection around the eye is used and, in general, no stitches are used to close the wound, and often no eye patch is required after surgery.

    2. Extracapsular cataract surgery: This procedure is used mainly for very advanced cataracts where the lens is too dense to dissolve into fragments (phacoemulsify). This technique requires a larger incision so that the cataract can be removed in one piece without being fragmented inside the eye. An artificial lens is placed in the same capsular bag as with the phacoemulsification technique. This surgical technique requires a various number of sutures to close the larger wound, and visual recovery is often slower. Extracapsular cataract extraction usually requires an injection of numbing medication around the eye and an eye patch after surgery.

    3. Intracapsular cataract surgery: This surgical technique requires an even larger wound than extracapsular surgery, and the surgeon removes the entire lens and the surrounding capsule together. This technique requires the intraocular lens to be placed in a different location, in front of the iris. This method is rarely used today but can still be useful in cases of significant trauma.

What are the different types of intraocular lenses implanted after cataract surgery?

As the natural lens plays a vital role in focusing light for clear vision, artificial lens implantation at the time of cataract surgery is necessary as a replacement for the natural lens to yield the best visual results. Because the implant is placed in or near the original position of the removed natural lens, vision is restored, and peripheral vision, depth perception, and image size are not affected. Artificial lenses usually remain permanently in place, require no maintenance or handling, and are neither felt by the patient nor noticed by others.

There are a variety of intraocular lens styles available for implantation, including monofocal, toric, and multifocal intraocular lenses.

    1. Monofocal lens: These lenses are the most commonly implanted lenses today. They have equal power in all regions of the lens and can provide high-quality distance vision, usually with only a light pair of spectacles. Monofocal lenses are in sharpest focus at only one distance. They do not correct pre-existing astigmatism, a result of irregular corneal shape that can distort vision at all distances. Your surgeon may correct the astigmatism at the time of cataract surgery by making one or two additional incisions in the periphery of the cornea. This does not make the surgery more dangerous. People with significant astigmatism require corrective lenses for sharpest vision at all distances. Patients who have had monofocal intraocular lenses implanted usually require reading glasses.

    2. Toric lens: Toric lenses have more power in one specific region in the lens to correct astigmatism as well as distance vision. Due to the difference in lens power in different areas, the correction of astigmatism with a toric lens requires that the lens be positioned in a very specific configuration. While toric lenses can improve distance vision and astigmatism, the patient still will require corrective lenses for all near tasks, such as reading or writing.

    3. Multifocal lens: Multifocal intraocular lenses are one of the latest advancements in lens technology. These lenses have a variety of regions with different power that allows some individuals to see at a variety of distances, including distance, intermediate, and near. While promising, multifocal lenses are not for everyone. They can cause significantly more glare than monofocal or toric lenses. Multifocal lenses cannot correct astigmatism, and some patients still require spectacles or contact lenses for clearest vision.

What should one expect prior to and on the day of cataract surgery?

Prior to the day of surgery, your ophthalmologist will discuss the steps that will occur during surgery. Your ophthalmologist or a staff member will ask you a variety of questions about your medical history and perform a brief physical exam. You should discuss with your ophthalmologist which, if any, of your routine medications you should avoid prior to surgery. Prior to surgery, several calculations will be made to determine the appropriate power of intraocular lens to implant. A specific artificial lens is chosen based on the length of the eye and the curvature of the cornea (the clear portion of the front of the eye).

It is important to remember to follow all of your preoperative instructions, which will usually include not eating or drinking anything after midnight the day prior to your surgery. As cataract surgery is an outpatient procedure, arrangements should be made with family or friends to transport you home after the surgery is complete. Most cataract surgery occurs in either an ambulatory surgery center or a hospital. You will be required to report several hours before the scheduled time for your surgery. You will meet with the anesthesiologist who will work with the ophthalmologist to determine the type of sedation that will be necessary. Most cataract surgery is done with only minimal sedation without having to put you to sleep. Numbing drops or an injection around the eye will be used to decrease sensation of the eye.

During the actual procedure, there will be several people in the operating room in addition to your ophthalmologist. These include anesthesiologists and operating-room technicians. While cataract surgery does not normally involve a significant amount of pain, medications are used to minimize the amount of discomfort. The actual removal of the clouded lens will take approximately 20 minutes. You may notice the sensation of pressure from the various instruments used during the procedure. After leaving the operating room, you will be brought to a recovery room where your doctor will prescribe several eyedrops that you will need to take for a few weeks postoperatively. While you may notice some discomfort, most patients do not experience significant pain following surgery; if you do you experience decreasing vision or significant pain, you should contact your ophthalmologist immediately.

What should one expect after the cataract surgery?

Following surgery, you will need to return for visits within the first few days and again within the first few weeks after surgery. During this time period, you will be using several eyedrops which help protect against infection and inflammation. Within several days, most people notice that their vision is improving and that they are able to return to work. During the several office visits that follow, your doctor will monitor for complications. Once vision has stabilized, your doctor will fit you with glasses if needed. The type of intraocular lens you have implanted will determine to some extent the type of glasses required for optimal vision.

What are potential complications of cataract surgery?

While cataract surgery is one of the safest procedures available with a high rate of success, rare complications can arise. Your ophthalmologist will discuss the specific potential complications of the procedures that are unique to your eye prior to having you sign a consent form. The most common difficulties arising after surgery are persistent inflammation, changes in eye pressure, infection, or swelling of the retina at the back of the eye (cystoid macular edema), and retinal detachment. If the delicate bag the lens sits in is injured, then the artificial lens may need to be placed in a different location. In some cases, the intraocular lens moves or does not function properly and may need to be repositioned, exchanged, or removed. All of these complications are rare but can lead to significant visual loss; thus, close follow-up is required after surgery. If you have pre-existing macular degeneration or floaters, these will not be made better by cataract surgery.

In some cases, within months to years after surgery, the thin lens capsule may become cloudy, causing blurred vision after cataract surgery. You may have the sensation that the cataract is returning because your vision is becoming blurry again. This process is termed posterior capsular opacification, or a "secondary cataract." To restore vision, a laser is used in the office to painlessly create a hole in the cloudy bag. This procedure takes only a few minutes in the office, and vision usually improves rapidly.

Cataract Surgery At A Glance
  • Early symptoms of cataracts include blurred vision, glare, and difficulty reading.
  • Cataracts will affect most people and become more prominent as we age.
  • Cataracts can be diagnosed when the doctor examines the eyes with specialized viewing instruments.
  • The decision to proceed with surgery is primarily based on the amount of difficulty you have performing your routine daily activities.
  • Treatment for cataracts is surgical removal of the cataract with implantation of an artificial lens.
  • There are a variety of intraocular lens types that can restore vision in different ways.
  • Cataract surgery is a safe and effective way to restore vision with serious complications being unusual.

 


 

Cataracts


  • Facts about cataracts
  • What is a cataract?
  • What are the different types of cataracts?
  • What are causes of cataracts?
  • What are risk factors for cataracts?
  • What are the symptoms of cataracts?
  • What are the signs of cataracts?
  • How are cataracts diagnosed?
  • What is the treatment for cataracts?
  • What are the different types of cataract surgery, and what risks are involved?
  • What is the prognosis of cataracts?
  • Can cataracts be prevented?
  • Where can people get more information on cataracts?
  • Find a local Eye Doctor in your town

Facts about cataracts

  • A cataract is a clouding of the lens of the eye.
  • Cataracts are extremely common, and most cataracts are a result of the aging process.
  • Although many cataracts are not significant enough to require treatment, surgical removal of cataracts is usually safe and effective, resulting in improvement of vision.
  • Cataract surgery should be performed when the visual loss from the cataract significantly impacts the lifestyle of the individual patient.

What is a cataract?

A cataract is an eye disease in which the clear lens of the eye becomes cloudy opaque, causing decrease in vision. Although the word cataract to describe this condition has been part of the English language only since the middle of the 16th century, the eye disease has been recognized and surgically treated since ancient times.

Eyeball Illustration - Cataracts

The lens is a portion of the eye that is normally clear. It assists in focusing rays of light entering the eye onto the retina, the light-sensitive tissue at the back of the eye. In order to get a clear image onto the retina, the portions of the eye in front of the retina, including the lens, must be clear and transparent. Once light reaches the retina, the light initiates a chemical reaction within the retina. The chemical reaction, in turn, initiates an electrical response which is carried to the brain through the optic nerve. The brain then interprets what the eye sees.

In a normal eye, light passes through the transparent lens to the retina. The lens must be clear for the retina to receive a sharp image. If the lens is cloudy from a cataract, the image striking the retina will be blurry and the vision will be blurry. The extent of the visual disturbance is dependent upon the degree of cloudiness of the lens.

Most cataracts are related to aging. Cataracts are very common in older people. By age 80, more than half of all Americans either have some degree of cataract or have already undergone cataract surgery in one or both eyes. By age 95, this percentage increases to almost 100%. A cataract can occur in either or both eyes. Individuals with a cataract in one eye usually go on to develop a cataract in the other eye as well. A cataract is not contagious and cannot spread from one eye to the other or from person to person. Cataracts do not cause the eye to tear abnormally. They are neither painful nor make the eye itchy or red.

Although vision can be restored in most people with cataracts, age-related cataracts are still the most common cause of blindness in the world, primarily because many third-world nations lack appropriate surgical services.

As life span increases in the developed world due to modern technology and new methods of treatment of acute and chronic disease, the incidence of age-related cataracts will continue to increase.

What are the different types of cataracts?

Cataracts can be classified by anatomical location within the lens, degree of clouding of the lens, or by the cause of the cataract.

The lens of the human eye is shaped similar to an M&M's candy. It has a front (anterior) part and a back (posterior) part. The central portion of the lens is called the lens nucleus, and the outer portion is called the lens capsule. Between the inner nucleus and the outer capsule is a portion of the lens called the cortex. Clouding of the lens can occur only in the nucleus, in which case the term nuclear cataract or nuclear sclerosis is used. If the clouding occurs in the lens cortex only, the cataract is termed a cortical cataract. If the loss of clarity of the lens is primarily in the capsule, the term subcapsular cataract is used. The location of the clouding can also be defined as being anterior or posterior, central, or peripheral. Often the clouding of the lens may affect multiple portions of the lens. The most common type of cataract that is related to age is sometimes termed a senile cataract. This type of cataract primarily involves the nucleus of the lens. Cataracts that develop in the posterior subcapsular area (in the rear region of the lens capsule) are more common in a younger age group.

Any degree of loss of the normal transparency of the lens is called a cataract. The more cloudy the, lens the more advanced the degree of cataract. A cataract may be mild, moderate, or severe. It may be early or advanced. If the lens is totally opaque it is termed a "mature" cataract. Any cataract that is not opaque is therefore termed an "immature" cataract. Most mature cataracts are white in color.

What are causes of cataracts?

The lens is made of mostly water and protein. The protein is arranged in a specific way that keeps the lens clear and allows light to pass through it to focus a clear image onto the retinal surface. As we age, some of the protein may clump together and start to cloud a small area of the lens. This is our understanding of the cause of an age-related cataract. Over time, the cataract may become more dense or cloud more of the lens, making it more difficult to see through. A cataract is not a growth or tumor.

There are many causes of non age-related cataracts or secondary cataracts. Secondary cataracts are a result of similar changes to the protein of the lens, also resulting in visual blurring or visual loss.

Blunt or penetrating injury to the eye may cause secondary cataracts, either immediately after the injury or some weeks to years afterward. A cataract following an injury may appear and then not increase in density (be stationary) or be progressive. Eye surgery for other conditions can also cause cataracts. Excessive exposure to ionizing radiation (X-ray), infrared radiation (as in glass blowers), or ultraviolet radiation cause secondary cataracts.

Diabetes is associated with the development of secondary cataracts. Inflammatory disease of the eye, such as iritis or uveitis, may cause or accelerate the development of cataract in the involved eye.

There are many genetic illnesses that are associated with the development of secondary cataracts. These include myotonic dystrophy, galactosemia, homocystinuria, Wilson's disease and Down syndrome, plus many others. Congenital infections with herpes simplex, rubella, toxoplasmosis, syphilis, and cytomegalic inclusion disease may also result in cataracts.

There are many medications which, when taken over a long period of time, can cause secondary cataracts. The most common of these are oral corticosteroids, such as prednisone, which are used for a wide variety of medical conditions.

The term "congenital cataract" is used when a baby is born with any clouding of the lens. This may be present in one or both eyes, be stationary or be progressive. Causes include genetic disorders or intrauterine developmental disorders, both often associated with other physical abnormalities of the baby.

Atopic dermatitis, other diseases of the skin and mucous membranes, hypothyroidism, and hyperparathyroidism are associated with the early development of cataracts.

Patients who develop cataracts in both eyes at an early age often have family members who have also developed cataracts prematurely, implying a genetic cause, even in the absence of a recognized underlying disease.

What are risk factors for cataracts?

Advanced age is a significant risk factor for the development of cataracts. A family history for early development of cataracts, the presence of diabetes, tobacco use, and prolonged exposure to sunlight are also risk factors.

What are the symptoms of cataracts?

You may not notice any symptoms with early cataracts. As a cataract becomes more advanced, decrease in clarity of vision, not fully correctable with glasses, is noticed. There is a loss of contrast sensitivity, so that shadows and color vision are less vivid. Disturbing glare may be noted as light is into the eye scattered by the cataract. Haloes may be observed around lights. Night vision will be diminished. In certain types of cataracts, double vision may be noted in the affected eye. Some patients note that they require frequent changes in their eyeglass or contact lens prescriptions and may be aware that their near vision is improving as their distance vision declines.

A cataract does not routinely cause discomfort or pain in the eye or alter the external appearance of the eye

What are the signs of cataracts?

Family members of a person affected by cataracts in both eyes may notice he or she appears not to be seeing as well as previously. The eye will appear normal to the untrained observer, unless the cataract is mature and white. In that situation the pupil of the eye, which normally appears black, will look grey or white to the observer.

The examining physician will find diminished visual acuity in the affected eye or eyes. This visual loss is not fully corrected by a change in the glasses. The lens of the eye can be easily examined by an ophthalmologist and the changes in the lens characteristic of cataract can actually be seen using a slit lamp, which is an illuminating and magnifying device used to painlessly examine the structures within the front of the eye, including the lens.

How are cataracts diagnosed?

Cataracts are relatively simple to diagnose by an ophthalmologist or an optometrist during a routine eye examination. It is important, when making the diagnosis of cataract, to also examine the entire eye for evidence of any other eye disease which may be compromising the vision. In addition to taking a medical and ocular history and visual acuity test, the ophthalmologist will check eye movements and pupillary responses, measure the pressure inside the eyes and examine the front and back of the eyes after the pupils have been dilated with drops.

What is the treatment for cataracts?

People with early cataract will find that changing their glasses, using sunglasses to decrease glare and having better lighting to read can significantly alleviate their symptoms. Magnifying lenses for close work and reading fine print may also be helpful.

Many cataracts are not bothersome, causing few symptoms. In that situation, no surgical treatment is necessary. However, the only true treatment for cataract is surgical removal of the cloudy lens. Surgery is suggested if the patient loses the ability to perform necessary activities of everyday life, such as driving, reading, or looking at computer or video screens, even with glasses, and there is the expectation that vision will improve as a result of the surgery.

Depending on a patient's specific visual needs, surgery is sometimes done on cataracts that are not very dense or surgery can wait until the cataract and the vision gets more cloudy. Patients' responses to cataracts vary. A cataract in only one eye may be disturbing to a particular patient and may not cause significant symptoms in another patient.

Cataracts usually do not harm your eye, so you can have surgery when it is convenient for you. Once you understand the benefits and risks of surgery, you can make an informed decision about whether cataract surgery is right for you. In most cases, delaying cataract surgery will not cause long-term damage to your eye or make the surgery more difficult.

If the eye has other diseases that have caused visual loss such as glaucoma, macular degeneration, diabetic retinopathy, or optic nerve damage from glaucoma, cataract surgery may not improve the vision.

Occasionally, your doctor may recommend removal of a cataract if it prevents diagnosis or treatment of another eye problem, such as macular degeneration or diabetic retinopathy.

If both eyes have cataracts and surgery is agreed upon, the surgery on the second eye is generally planned at least a week after the first eye. There is usually no harm in waiting a much longer period of time between the two eye operations.

Since the lens of the eye is necessary to accurately focus light onto the retinal surface and removal of the cataract involves removal of the lens, modern cataract surgery combines removal of the lens with placement of a new artificial lens into the eye. Measurements for the size, shape, and power of this lens will be taken at least a week prior to the surgery so that the lens can be ordered and available at the time of surgery.

More than 2 million cataract surgeries are performed annually in the United States. It is extremely safe and effective, improving vision in the vast majority of patients.

What are the different types of cataract surgery, and what risks are involved?

Cataract surgery is usually performed as an outpatient procedure under local anesthesia. Some sedation is ordinarily given intravenously just before the beginning of the surgery, which usually takes under a half-hour.

Most cataract surgery today is done through a small incision by phaco-emulsification or by other extracapsular means through a slightly larger incision. In more than 95% of cases, a new lens, known as a lens implant or intraocular lens is inserted at the same time as the cataract removal. You will not feel the new lens within the eye. Most patients need to limit their activities for only a few days and recovery time is brief.

Although modern techniques have made cataract surgery quite safe, complications can occur with any surgical procedure, including cataract extraction. These include hemorrhage, infection, loss of a portion of the cataract into the eye, displacement of the intraocular lens, glaucoma, and retinal detachment. Fortunately, all these complications are rare and usually can be managed. Blindness is a rare complication of cataract surgery.

Modern cataract surgery involves leaving a portion of the lens capsule within the eye to support the intraocular lens. This capsule may become cloudy at a later time, necessitating opening of the capsule through the use of a laser. This outpatient procedure is called a YAG laser capsulotomy. It is painless and rarely results in increased eye pressure or other eye problems.

What are complications of cataracts?

Occasionally, a very dense cataract of long-standing duration may enlarge in size and interfere with fluid drainage within the eye. In addition, a far advanced cataract may leak protein into the eye, causing inflammation of the eye. Your doctor will advise you of these possibilities and may recommend surgery to avoid these complications even if the decrease in vision is not bothering you.

The presence of a cataract may make evaluation of diseases of the retina more difficult, since the physician must look through the cataract to examine the retina.

What is the prognosis of cataracts?

The rate of progression of cataracts is usually predictable and surgery is successful in restoring vision in a large majority of cases. If other diseases are present within the eye, the degree of visual improvement will be limited by the other disease process. Ophthalmologists can usually determine this in advance.

Can cataracts be prevented?

Everyone, if they live long enough, will develop cataracts. There is no scientifically proven method that prevents the inevitable. Progression of cataracts can be slowed by avoiding large amounts of ultraviolet light, not smoking, and following a healthy diet. Wearing UV-protection sunglasses when exposed to sunlight can be helpful.

Where can people get more information on cataracts?

National Eye Institute (http://www.nei.nih.gov/health/cataract/cataract_facts.asp)

Cataracts Info Center (http://www.cataractsinfocenter.com/)

Cataract Surgery: A Patient's Guide to Cataract Treatment by Julius Shulman, MD

 


 

Eye Problems and Diabetes

 

  • Eye problems and diabetes introduction
  • Cataracts and diabetes
  • Glaucoma and diabetes
  • Diabetic retinopathy
  • Prevention of eye problems with diabetes
  • When to contact your doctor about eye problems in diabetes
  • Find a local Eye Doctor in your town

Eye problems and diabetes introduction

If you have diabetes, regular visits to your ophthalmologist for eye exams are important to avoid eye problems. High blood sugar (glucose) increases the risk of diabetes eye problems. In fact, diabetes is the leading cause of blindness in adults age 20 to 74.

If you have eye problems and diabetes, don't buy a new pair of glasses when you notice you have blurred vision. It could just be a temporary eye problem that develops rapidly with diabetes and is caused by high blood sugar levels.

High blood sugar in diabetes causes the lens of the eye to swell, which changes your ability to see. To correct this kind of eye problem, you need to get your blood sugar back into the target range (90-130 milligrams per deciliter or mg/dL before meals, and less than 180 mg/dL one to two hours after a meal). It may take as long as three months after your blood sugar is well controlled for your vision to fully get back to normal.

Blurred vision can also be a symptom of more serious eye problem with diabetes. The three major eye problems that people with diabetes may develop and should be aware of are cataracts, glaucoma, and retinopathy.

Cataracts and Diabetes

A cataract is a clouding or fogging of the normally clear lens of the eye. The lens is what allows us to see and focus on an image just like a camera. Although anyone can get cataracts, people with diabetes get these eye problems at an earlier age than most and the condition progresses more rapidly than in people without diabetes.

If you have a cataract with diabetes, your eye cannot focus light and your vision is impaired. Symptoms of this eye problem in diabetes include blurred or glared vision.

Treatment is usually surgery followed by placement of a lens implant, with glasses or contact lenses as needed to further correct vision.

Picture of Cataract of the Eye

Glaucoma and Diabetes

When fluid inside the eye does not drain properly from a buildup of pressure inside the eye, it results in another eye problem with diabetes called glaucoma. The pressure damages nerves and the vessels in the eye, causing changes in vision.

In the most common form of glaucoma, there may be no symptoms of this eye problem at all until the disease is very advanced and there is significant vision loss. In the less common form of this eye problem, symptoms can include headaches, eye aches or pain, blurred vision, watering eyes, halos around lights, and loss of vision.

Treatment of this eye problem in diabetes can include special eye drops, laser procedures, medicine, or surgery. You can prevent serious eye problems in diabetes problems by getting an annual glaucoma screening from your eye doctor.

Picture of Glaucoma of the Eye

Diabetic Retinopathy

The retina is a group of specialized cells that convert light as it enters though the lens into images. The eye nerve or optic nerve transmits visual information to the brain.

Diabetic retinopathy is one of the vascular (blood-vessel related) complications related to diabetes. This diabetes eye problem is due to damage of small vessels and is called a "microvascular complication." Kidney disease and nerve damage due to diabetes are also microvascular complications. Large blood vessel damage (also called macrovascular complications) includes complications like heart disease and stroke.

The microvascular complications have, in numerous studies, been shown to be related to high blood sugar levels. You can reduce your risk of these eye problems in diabetes complications by improving your blood sugar control.

Diabetic retinopathy is the leading cause of irreversible blindness in industrialized nations. The duration of diabetes is the single most important risk for developing retinopathy. So the longer you have diabetes, the greater the risk of this very serious eye problem. If retinopathy is not found early or is not treated, it can lead to blindness.

People with type 1 diabetes rarely develop retinopathy before puberty. In adults with type 1 diabetes, it is also rare to see retinopathy before five years' duration of diabetes. The risks of retinal damage increase with progressive duration of diabetes. Intensive control of blood sugar levels will reduce your risks of developing retinopathy. The DCCT, a large study of people with type 1 diabetes showed that people with diabetes who achieved tight control of their blood sugars with either an insulin pump or multiple daily injections of insulin were 50%-75% less likely to develop retinopathy, nephropathy (kidney disease), or nerve damage (all microvascular complications).

People with type 2 diabetes usually have signs of eye problems when diabetes is diagnosed. In this case, control of blood sugar, blood pressure, and blood cholesterol with diabetes have an important role in slowing the progression of retinopathy and other eye problems.

Types of Retinopathy in Diabetes:

  • Background retinopathy. Sometimes the blood vessel damage exists, but there is no vision problem. This is called background retinopathy. It's important to carefully manage your diabetes at this stage to prevent background retinopathy from progressing to more serious eye disease.
  • Maculopathy. In maculopathy, the person has developed damage in a critical area called the macula. Because this occurs in an area that is critical to vision, this type of eye problem can significantly reduce vision.
  • Proliferative retinopathy. New blood vessels start to grow in the back of the eye. Because retinopathy is a microvascular complication of diabetes, a disease of small vessels, this type of retinopathy develops because of an increasing lack of oxygen to the eye from vascular disease. Vessels in the eye are thinned and occluded and they start to remodel.

Picture of Diabetic Retinopathy of the Eye

Here, it is important to address the risks factors that can worsen the occluded vessels. Smoking cessation, high blood pressure control, cholesterol management, and blood sugar control must take place in order to stop the progression of new vessels from forming into the orbit of the eye. These are fragile vessels that can bleed and eventually cause a clot to form in the orbit, which scars and causes detachment of the retina. This eventually leads to irreversible vision loss.

Treatment of diabetic retinopathy may involve laser procedures or surgery. In a study of people with diabetes with early retinopathy, laser therapy to burn the fragile vessel resulted in a 50% reduction of blindness.

To prevent retinopathy with diabetes, have your eye doctor screen your eyes annually. Women with diabetes who later become pregnant should have a comprehensive eye exam during the first trimester and close follow-up with an eye doctor during the rest of their pregnancy to avoid serious eye problems with diabetes. (This recommendation does not apply to women who develop gestational diabetes, since they are not at risk for retinopathy.)

How Can I Prevent Eye Problems With Diabetes?

The American Diabetes Association offers these eye care guidelines for people with diabetes to help prevent eye problems:

  • People with type 1 diabetes should have a dilated eye exam by an ophthalmologist or optometrist within three to five years after diagnosis.
  • People with type 2 diabetes should have a dilated eye exam by an ophthalmologist or optometrist shortly after diagnosis.
  • Annual eye exams should be done with both type 1 and type 2 diabetes by an ophthalmologist or optometrist; more frequently if necessary.
  • When considering pregnancy, women with a history of diabetes should have an eye exam prior and during pregnancy. This does not pertain to women with gestational diabetes.

To prevent eye problems in diabetes, you should:

  • Control your blood sugar
  • Control high blood pressure

When to Contact Your Doctor About Eye Problems in Diabetes

If you have diabetes, contact your doctor about any eye problems in if any of the following occur:

  • Black spots in your vision.
  • Flashes of light.
  • "Holes" in your vision.
  • Blurred vision.

 


 

Melanosis Coli
(Pseudomelanosis Coli)

  • What is melanosis coli?
  • What are the symptoms of melanosis coli?
  • What causes melanosis coli?
  • How is melanosis coli diagnosed?
  • What is the prognosis (outcome) of melanosis coli?
  • Find a local Gastroenterologist in your town

What is melanosis coli?

Melanosis coli is a condition usually associated with chronic laxative use in which dark pigment is deposited in the lamina propria (one of the lining layers) of the large intestine (colon). The pigment deposition results in a characteristic dark brown to black discoloration of the lining of the large intestine. This condition is sometimes called pseudomelanosis coli because the pigment deposits consist of a pigment known as lipofuscin and do not contain melanin as implied by the term "melanosis." Lipofuscin is a cellular pigment that forms when cells are destroyed, often called "wear and tear" pigment that can be found throughout the body.

The dark color of the intestinal lining may be uniform or patterned, and the discoloration may be slight or very pronounced. The intensity and pattern of the discoloration may even vary among different sites in the colon of a patient. The condition may also be reversed upon discontinuation of laxative use. In some cases, the wall of the colon appears normal to the eye, but microscopic evaluation of biopsies by a pathologist reveals areas of pigment in the colon's lining. The pigment in melanosis coli does not accumulate in polyps or tumors of the large intestine.

What are the symptoms of melanosis coli?

Melanosis coli does not cause symptoms.

What causes melanosis coli?

Melanosis coli usually results from chronic use of laxatives of the anthranoid group. Some examples of anthranoid laxatives are senna and rhubarb derivatives. Many of these laxatives have been in use for hundreds of years. In 1997, the U.S. Food and Drug Administration (FDA) banned the use of the popular anthranoid laxative phenolphthalein due to fears that it might be carcinogenic (cancer-causing). Animal studies had shown that extremely high doses of phenolphthalein led to tumors in animals, but it has never been shown to cause cancers in humans.

The anthranoid laxatives pass through the gastrointestinal tract unabsorbed until they reach the large intestine, where they are changed into their active forms. The resulting active compounds cause damage to the cells in the lining of the intestine and leads to apoptosis (a form of cell death). The damaged (apoptotic) cells appear as darkly pigmented bodies that may be taken up by scavenger cells known as macrophages. When enough cells have been damaged, the characteristic pigmentation of the bowel wall develops.

How is melanosis coli diagnosed?

Melanosis coli can be observed during endoscopic procedures that examine the large intestine, such as colonoscopy and sigmoidoscopy . Sometimes the diagnosis is made upon microscopic examination of biopsies taken during endoscopic procedures.

What is the prognosis (outcome) of melanosis coli?

If a person stops using anthranoid laxatives, the changes associated with melanosis coli lessen over time and may disappear.

Early studies suggested that anthranoid laxatives might have carcinogenic or tumor-promoting activities in humans and that the presence of melanosis coli might signal an increased risk for the development of colorectal cancer. However, more recent follow-up studies have failed to show an association between colon cancer and anthranoid laxative use or between colon cancer and the finding of melanosis coli.

 


 

Cauda Equina Syndrome


  • What is cauda equina syndrome?
  • What are the causes of cauda equina syndrome?
  • What are the symptoms of cauda equina syndrome?
  • How is cauda equina syndrome diagnosed?
  • What is the treatment for cauda equina syndrome?
  • Can cauda equina syndrome be prevented?
  • What is the outlook (prognosis) for cauda equina syndrome?
  • Cauda Equina Syndrome At A Glance

What is cauda equina syndrome?

Cauda equina syndrome is an uncommon compression of the nerves at the end of the spinal cord within the spinal canal. The terminology, "cauda equina," literally means tail of horse and refers to the normal anatomy of the end of the spinal cord in the low back where it divides into many bundles of nerve tracts resembling a horse's tail. Compression of the spinal cord at this level can lead to a number of typical symptoms of the syndrome (low back pain, sciatica, saddle sensory changes, bladder and bowel incontinence, and lower extremity motor and sensory loss).

What are the causes of cauda equina syndrome?

Cauda equina syndrome can be caused by any condition that results in direct irritation or pinching of the nerves at the end of the spinal cord. Causes of cauda equina syndrome include herniation of lumbar intervertebral discs, abnormal growths (tumor or cancer) adjacent to the lower spinal cord, localized infection near the spinal cord (epidural abscess), and localized bleeding (epidural hematoma) causing pressure on the spinal cord in the low back.

Localized lumbar tumors that can lead to cauda equine syndrome include ependymomas, metastatic cancer, and Paget's disease of bone. Localized infection near the spinal cord can be caused by staphylococcus bacteria, tuberculosis bacteria (Mycobacterium tuberculosis from Pott's disease), and others.

What are the symptoms of cauda equina syndrome?

Symptoms of cauda equina syndrome include low back pain, numbness and/or tingling in the buttocks and lower extremities (sciatica), weakness in the legs, and incontinence of bladder and/or bowels. The numbness of cauda equina syndrome typically is in the distribution of where the body would touch a saddle when sitting upon a horse, and is referred to as "saddle anesthesia."

Partial cauda equina syndrome is the terminology that applies when there is incomplete compression of the nerves of the lower spinal cord. This can elicit various degrees and combinations of the symptoms listed above. With complete cauda equina syndrome, the array of symptoms listed above is commonplace.

How is cauda equina syndrome diagnosed?

Cauda equina syndrome is clinically diagnosed based on the characteristic symptoms described above. Often, the physical examination can reveal hyperactive reflexes of the lower extremities. Because the syndrome is a medical emergency, neurosurgery or spinal surgery consultants should be notified immediately. Cauda equina syndrome can be confirmed with neurologic and radiology testing but such testing should not be delayed.

Specialized neurologic nerve testing of the lower extremities, such as nerve conduction velocity (NCV) and electromyography (EMG) tests can indicate nerve irritation effects in the low back. Radiologic testing such as CT (computerized axial tomography) and MRI (magnetic resonance imaging) scanning can document the compressed spinal cord tissue.

What is the treatment for cauda equina syndrome?

Cauda equina syndrome is a medical emergency. Compression of the spinal nerves of the spinal cord can lead to permanent dysfunction of the lower extremities, bladder, and bowels. Once the precise cause of cauda equina syndrome is determined (see above), generally aggressive operative intervention with surgical decompression is initiated. If infection is present, antibiotics are given, usually intravenously. If a tumor is responsible for compression, after surgical decompression, radiotherapy or chemotherapy may be needed.

The long-term management of cauda equina syndrome depends on whether or not there are persisting symptoms after surgical decompression of the irritated nerve tissue. This can require pain medicine, physical therapy, supportive braces, urinary catheters, and other treatments etc. until optimal nerve and muscle recovery occurs.

Can cauda equina syndrome be prevented?

Cauda equina syndrome occurs as a result of conditions which are not predictable and is therefore not a preventable syndrome. However, cauda equina syndrome caused by infections initiated by IV drug abuse can be prevented by not using illegal IV drugs.

What is the outlook (prognosis) for cauda equina syndrome?

Ultimately, the outlook for patients affected by cauda equina syndrome is determined by the extent of damage to involved nerve tissue. In general, the longer the duration of the compression of the spinal cord, the longer the recovery period and less likely complete recovery can occur.

Cauda Equina Syndrome At A Glance
  • Cauda equina syndrome is an uncommon compression of the nerves at the end of the spinal cord within the spinal canal.
  • Cauda equina syndrome can be caused by any condition that results in direct irritation or pinching of the nerves at the end of the spinal cord.
  • Symptoms of cauda equina syndrome include low back pain, numbness and/or tingling in the buttocks and lower extremities (sciatica), weakness in the legs, and incontinence of bladder and/or bowels.
  • Cauda equina syndrome is diagnosed based on the characteristic symptoms and confirmed by neurologic and radiology testing.
  • Cauda equina syndrome is a medical emergency generally requiring a surgical decompression operation.
  • The outlook for patients affected by cauda equina syndrome is determined by the extent of damage to involved nerve tissue.

 


 

Cauliflower Ear


  • What is cauliflower ear?
  • How is cauliflower ear treated?
  • What is the prognosis for cauliflower ear?
  • How can cauliflower ear be prevented?

What is cauliflower ear?

Cauliflower ear (boxer's ear, wrestler's ear) is an acquired deformity of the outer ear. In this injury, the ear can shrivel up and fold in on itself and appear pale, giving it a cauliflower-like appearance, hence the term cauliflower ear. Wrestlers, boxers and martial artists in particular are susceptible to this type of injury. When the ear is struck and a blood clot develops under the skin, or the skin is sheared from the cartilage, the connection of the skin to the cartilage is disrupted.

The ear is vulnerable to blunt trauma. The cartilage of the ear has no other blood supply except that supplied by the overlying skin. When the skin is pulled from the cartilage, and/or separated from the cartilage by blood (as with accumulated, localized blood from injury, called a hematoma) or infection, the cartilage is deprived of important nutrients. Ultimately, the cartilage dies and the risk of infection is increased.

Untreated, the ear cartilage begins to contract on itself forming a shriveled up outer ear classically known as the cauliflower ear deformity. Once there is cartilage death and scarring (fibrosis), the resulting deformity is very difficult to reconstruct. The ear may also appear pale, due to loss of blood supply. In some cases, cosmetic procedures may be able to improve appearance of the ear, but often the victim can be left with a permanent deformity.

Because the ear is vulnerable to infection, it's important to treat these hematomas, even if the patient is not concerned with the cosmetic appearance of the ear. If the ear drum is also injured (ruptured), the wound may be treated with stitches. However, significant hearing loss may still occur.

How is cauliflower ear treated?

The goals of treatment are to drain blood from the hematoma, treat any infection, and re-establish the connection of the skin to the underlying cartilage. Treatment usually requires draining accumulated blood (the hematoma) through an incision in the ear and applying a compressive dressing to sandwich the two sides of the skin against the cartilage. Antibiotics are given to prevent infection.

What is the prognosis for cauliflower ear?

When treated aggressively and promptly, cauliflower ear deformity is unlikely. Any delay in diagnosis leads to more difficulty in managing the problem, increased chances for insufficient blood supply to the ear cartilage, and escalated risk of deformity.

How can cauliflower ear be prevented?

Protective headgear and helmets worn during sporting activities can help prevent this condition. Helmets can also protect from serious head injury.

See a doctor (preferably an otolaryngologist-ear, nose and throat specialist or plastic surgeon) for definitive care as soon as possible after the injury.

 


 

Reflex Sympathetic Dystrophy Syndrome (RSDS)

  • What is reflex sympathetic dystrophy?
  • What causes reflex sympathetic dystrophy?
  • What are the symptoms of reflex sympathetic dystrophy?
  • How is reflex sympathetic dystrophy diagnosed?
  • What is the treatment for reflex sympathetic dystrophy?
  • Reflex Sympathetic Dystrophy Syndrome At A Glance

What is reflex sympathetic dystrophy?

Reflex sympathetic dystrophy syndrome (RSDS) is a condition that features a group of typical symptoms, including pain (often "burning" type), tenderness, and swelling of an extremity associated with varying degrees of sweating, warmth and/or coolness, flushing, discoloration, and shiny skin.

What causes reflex sympathetic dystrophy?

RSDS is also referred to as "the shoulder-hand syndrome," "causalgia," and "Sudeck's atrophy." The exact mechanism of how RSDS develops is poorly understood. The theories include irritation and abnormal excitation of nervous tissue, leading to abnormal impulses along nerves that affect blood vessels and skin. A variety of events can trigger the condition, including trauma, surgery, heart disease, degenerative arthritis of the neck, stroke or other brain diseases, nerve irritation by entrapment (such as carpal tunnel syndrome) or shingles, shoulder problems, breast cancer, and drugs for tuberculosis and barbiturates. There is no associated event in one-third of patients.

What are the symptoms of reflex sympathetic dystrophy?

The onset of the RSDS symptoms may be rapid on gradual. The condition may not display all features. It has been bilateral in up to half of the patients. There are several stages:

  • Acute: (three to six months) burning, flushing, blanching, sweating, swelling, pain, and tenderness. This stage can show early x- ray changes of patchy bone thinning.
  • Dystrophic: (three to six months) early skin changes of shiny, thickened skin and contracture with persistent pain, but diminished swelling and flushing.
  • Atrophic: (may be long-standing) loss of motion and function of the involved hand or foot with contracture (flexed scarring process), thinning of the fatty layers under the skin. X-ray can show significant osteoporosis.

How is reflex sympathetic dystrophy diagnosed?

RSDS is diagnosed based on the clinical features described above. Blood testing is not abnormal because of RSDS but may be with one of its associated conditions as described above. X-rays can show patchy thinning or significant osteoporosis. Nuclear bone scanning can demonstrate characteristic uptake patterns.

What is the treatment for reflex sympathetic dystrophy?

Response to treatment is greater in earlier stages than later stages. Cool, moist applications can provide some relief of burning symptoms. Gradual exercising can prevent contracture. Medications for pain and inflammation can also reduce symptoms. For persisting symptoms, high doses of prednisone (cortisone) are used for periods of weeks, depending on response, then gradually reduced. Occasionally, a nerve block with anesthetic injected into a specialized area of the involuntary nervous system (stellate ganglion blockade) can help. Sometimes a series of these blocks is tried.

Other treatments include surgically interrupting the nerves (the sympathetic nerves) of the involuntary nervous system (surgical sympathectomy), pain drug pumps implanted into the spinal canal (intrathecal drug pumps), and spinal cord stimulation devices.

Reflex Sympathetic Dystrophy Syndrome At A Glance
  • RSDS is characterized by a group of symptoms, including pain (often "burning" type), tenderness, and swelling of an extremity associated with varying degrees of sweating, warmth and/or coolness, flushing, discoloration, and shiny skin.
  • How RSDS occurs is not known, but there can be trigger events.
  • Symptoms of RSDS often occur in three stages: acute, dystrophic, atrophic.
  • Diagnosis of RSDS is based on clinical findings, supported by radiological tests.
  • Treatment of RSDS is most effective in earlier stages.

 


 

Hepatic Hemangioma

 

  • What is a hepatic hemangioma?
  • What are the symptoms of a hepatic hemangioma?
  • How is the diagnosis of a hepatic hemangioma made?
  • What is the treatment for hepatic hemangioma?
  • Patient Discussions: Hepatic Hemangioma
  • Find a local Gastroenterologist in your town

What is a hepatic hemangioma?

Hepatic hemangiomas are thought to be present in as many as 7% of healthy people. Hemangiomas are four to six times more common in women than in men. Female hormones may promote the formation and growth of hemangiomas. Hemangiomas, although referred to as tumors, are not malignant and do not become cancerous. Hemangiomas are not unique to the liver and can occur almost anywhere in the body.

What are the symptoms of a hepatic hemangioma?

Hemangiomas usually are small, measuring only a quarter inch in diameter, but they can be several inches in diameter or even larger. The vast majority of hemangiomas of the liver never cause symptoms or health problems. Most hepatic hemangiomas are discovered incidentally at the time of testing for unrelated medical problems, most commonly with ultrasound imaging or CT (computerized tomography) scanning of the abdomen. Very large hemangiomas can cause symptoms, especially if they are positioned near other organs. Pain, nausea, or enlargement of the liver can occur. Rarely, larger hemangiomas can rupture, causing severe pain and bleeding into the abdomen that may be severe or even life threatening.

How is the diagnosis of a hepatic hemangioma made?

When a hemangioma is suspected, the challenge for the physician is to be sure that it is in fact a hemangioma and not another type of tumor, particularly a malignant one. With specialized tests, however, doctors can reassure patients that the tumor is with little doubt a hemangioma. Such special testing may include scintigraphy (using a tiny amount of a radioactive substance to identify the hemangioma), CT scanning, or MRI (magnetic resonance imaging). In general, a biopsy of suspected hemangiomas is avoided because of their benign nature and the potential risk of bleeding from the biopsy.

What is the treatment for hepatic hemangioma?

The vast majority of hepatic hemangiomas require no treatment. If a hepatic hemangioma is large, especially if it is causing symptoms, surgical removal is an option.

 


 

Dental Health and Cavities


  • What are causes and risk factors for cavities?
  • What are symptoms and signs of cavities?
  • What is the treatment for cavities?
  • Find a local Doctor in your town

Cavities occur as a result of tooth decay. Tooth decay is the destruction of tooth structure. Tooth decay can affect both the enamel (the outer coating of the tooth) and the dentin (the inner layer of the tooth).

Tooth decay occurs when foods containing carbohydrates (sugars and starches) such as breads, cereals, milk, soda, fruits, cakes, or candy are left on the teeth. Bacteria that live in the mouth digest these foods, turning them into acids. The bacteria, acid, food debris, and saliva combine to form plaque, which clings to the teeth. The acids in plaque dissolve the enamel surface of the teeth, creating holes in the teeth called cavities, or caries.

Who Gets Cavities?

Many people think cavities only affect children, but changes that occur with aging make cavities an adult problem too. Recession of the gums (a pulling away of gum tissue from the teeth), often associated with an increased incidence of gingivitis (gum disease), can expose tooth roots to plaque. Also, sugary food cravings in pregnant women can make them more vulnerable to developing cavities.

Decay around the edges of cavity fillings is also common in older adults. Because many older adults lacked the benefits of fluoride and modern preventive dental care when they were growing up, they often have a number of dental fillings. Over the years, these fillings may weaken and can fracture, allowing bacteria to accumulate in the tiny crevices causing tooth decay.

How Do I Know if I Have a Cavity?

Your dentist can discover cavities during your regular dental check-up. The tooth surface feels soft when probed by your dentist with a dental instrument. X-rays can also show cavities before they become visible to the eye.

In advanced stages of tooth decay, you might experience a toothache, especially after consuming sweet, hot, or cold foods or drinks. Other signs of tooth decay are visible pits or holes in the teeth.

What Is the Treatment for Cavities?

There are a number of different treatments for cavities depending on the extent of tooth decay. If decay is not extensive, the decayed portion of the tooth is removed by drilling and replaced with a filling made of silver alloy, gold, porcelain, or a composite resin. Materials used in fillings are considered safe. Concerns have been raised over the safety of mercury-based, silver amalgams in particular, but the American Dental Association (ADA), FDA, and other public health agencies continue to support the safety of this restorative material. Allergies to silver amalgam are rare as are allergies to other restorative materials.

If the tooth decay is extensive and there is limited tooth structure remaining, crowns will be used. If a crown is needed, the decayed or weakened area of the tooth is removed and repaired and a crown is fitted over the remainder of the tooth. Crowns are made from gold, porcelain, or porcelain fused to metal.

If the decay causes the nerve or pulp of the tooth to die, a root canal will be performed. During a root canal, the center of the tooth (including the nerve, blood vessel, and tissue) is removed along with the decayed portions of the tooth. The roots are then filled with a sealing material. If necessary, a crown can be placed over the filled tooth.

Several new cavity treatments are under development. One experimental technique uses fluorescent light to detect the development of cavities long before they can be detected by traditional means, such as x-rays or a dental exam. In many cases, if cavities can be detected early, the tooth decay process can be stopped or reversed.

Researchers are also working on a "smart filling" to prevent further tooth decay by slowly releasing fluoride over time around fillings and in adjacent teeth.

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