Monday, December 31, 2007

Menopause mind meets menopause moment

I gave my package addressed to Philadelphia, PA to the middle-aged clerk to weigh. She looked at the destination and smiled.

"I've been there," she said. "Alcatraz was fascinating."

That stopped me cold. Information went to central processing and did not compute. What was wrong with that statement?

"I loved the Golden Gate Bridge," she added.

Contact! Now in touch with destination neurons.

"Oh, I think you mean San Francisco," I finally countered. She nodded in agreement and gestured to the package.

"I've been there too! Next I'd like to go to Niagara Falls."

That's in Florida, right?
Want to know why you get menopause moments, or how to tell a menopause moment from the beginning of a real dementia deal, check out Menopause Moments. Please feel free to leave a moment of your own for others to share.

"My toe hurts!"

One of the many best things about being a doctor is that I can be first responder to medical complaints and questions from friends and family. I don't know what your average adult daughter of an elderly parent would do if Mom or Dad complained of a sore toe, but I sat her right down and pulled off her shoe and sock. Here's what I found:

All the toes on the foot, especially the big one, were a dusky red. As I raised her foot for a closer inspection, the color changed to a waxy white. Oh-oh, dependent rubor! That's medical shorthand for the color change that occurs in limbs with arterial insufficiency. When they're hanging down or dependent, gravity pulls red, oxygenated blood into the capillaries. When they're hoisted up, the capillaries empty out, and the foot pales.

Next step, I compared sore foot with other. Both feet were swollen, and have been for several weeks. That's a different story for a different post (venous insufficiency). But painful right foot was cool and shiny, relatively normal left foot was pink and warm, and the skin had a normal texture. Normal feet have two palpable pulses where arterial pulsation can be felt. I checked her dorsalis pedis pulse (top of the foot) and posterior tibial pulse (just behind the ankle bone on the big toe side) and found no pulses at all.

I then pulled out my reading glasses for a closer inspection. No ulcerations on any of the toes, but the tip of the big toe was especially tender to touch. The nails were thick and deformed, another sign of not enough blood flow.

So why did Mom complain of big toe pain while walking? The muscular activity in her leg called for more blood flow, and her aging arteries just couldn't deliver blood all the way to the tip of the toe. As soon as she sat down, she had enough blood to toe to relieve the pain.

So all the wiser for my exam, but what to do? I called the nurse and showed her what was going on. I asked her to leave my Mom in slippers through the day to reduce pressure and trauma to her foot. She hardly walks at all, so hopefully her sore toe, which is only sore on walking, will not be a bother to her. She's not a candidate for revascularization or bypassing narrowed arteries in her leg (a big deal operation with big deal complications for little old people), so it's just another step in the downward road.

Dinnertime chat

My Mom looked around the dining room thoughtfully as she chewed her sandwich.

"Did all these women commit some kind of crime?"

She was relieved to discover that she was not, after all, in a women's correctional facility. "I wondered what I'd done to be here."

After finishing another bit of sandwich, she asked, "Then where am I?"

Saturday, December 29, 2007

Slow-Eater-Tiny Bite-Taker

I used to take Aunt Lottie out to eat. We'd go to McDonald's, and she'd order a regular hamburger (39 cents in those days!). To my everlasting amazement, it would take her at least a half hour to finish the sandwich.

Last night, I sat with Mom through her dinner. About 1/3 of the way through her scoop of chocolate ice cream--and some 20 minutes into it--she declared "I just don't have patience for eating anymore. We laughed as I told her she'd become Aunt Lottie, and then I remembered the Mrs. Piggle Wiggle story about the Slow-Eater-Tiny Bite-Taker.

If you never read a Mrs. Piggle Wiggle book, then hurry out and get one from the library. This delightful lady was the savior of many a difficult child, returning domestic peace to their families by curing their bad habits. The Slow-Eater-Tiny Bite-Taker was driving his parents crazy as he minced his way particle by particle through his meals. Mrs. Piggle Wiggle eased him into normal eating habits through the use of successively smaller dishes and teenier portions until the young fellow was weak and famished, ready to devour a regular meal at a regular pace.

Mom enjoyed hearing about Mrs. PW's solution, so I brought the book in today to share with her. She was having a bad brain day, somewhat dazed and sleepy. I settled her into bed for a nap and read her the first chapter of the book, including the description of Mrs. PW's upside down house with a chandelier that sprouted out of the floor.

Mom had her eyes closed and a smile on her face the entire time I read. I finished the chapter unsure whether or not she was asleep, but pleased to see that the smile remained.

Thursday, December 20, 2007

Location, location, location

People watching at the ballet last night. Women wearing dresses the likes of which I will never wear again. Actually, the likes of which I've never owned in my life. The successful wearing of which depends entirely on the positioning of breasts on chest, and age plus a couple of kids puts mine south of success.

Sunday, December 16, 2007

Avast the Avandia

I give up, no more Avandia. The future is not rosy for rosiglitazone. This diabetic medication has been under fire for some time now as studies link it to increased risk of heart attack, congestive heart failure, and death.

The latest damning evidence comes from a study just published in the Journal of the American Medical Association. Previous negative statistics came from clinical trials, looking at studies studying the efficacy of this drug in controlling diabetes. On average, such research on diabetic drugs is conducted on patients younger than 65. This latest research looked at a 'real-world population,' the over-65 set that has the highest prevalence of diabetes of any age group.

Nearly 160,000 such oldsters were followed for nearly 4 years. As expected in this kind of group, a fair number--around 8%--were hospitalized for congestive heart failure (CHF), and a similar number experienced heart attacks (MI). 19% pitched over dead. Matching the unfortunates on Avandia compared with those on other classes of diabetic drugs, the Avandiful were at 1.6 times greater risk for CHF, 1.4 times higher for MI, and 1.29 times moreso for death.

Given that diabetics, particularly older diabetics, are a high risk group for heart-related troubles, these numbers are strong arguments against the use of Avandia. GlaxoSmithKline, the maker of Avandia, had this to say:

These conclusions are inconsistent with a more robust body of evidence from large, long-term, prospective, well-designed clinical studies, including A Diabetes Outcome Progression Trial (ADOPT) and the Rosiglitazone Evaluated for Cardiac Outcomes and Regulation of Glycemia in Diabetes (RECORD). These long-term trials in diabetic patients comparing rosiglitazone with other oral antidiabetic medicines show no increased risk for cardiovascular events compared with other commonly used medications, other than the well-known risk of congestive heart failure with thiazolidinediones.

Dr. Steve Nissen of the Cleveland Clinic, a long-time critic of Avandia, countered that it is: impossible to ignore the evidence of increased risk of MI with rosiglitazone, which has been shown in four meta-analyses and now in this independent observational study. The conclusion that rosiglitazone increases the risk of MI is simply inescapable. The contrary 'evidence' cited by GlaxoSmithKline is not credible.

I'm going with Steve on this one. We have good alternatives for diabetic treatment.

Friday, December 14, 2007

Parkinson's disease

I'm often found hanging around a nursing home lately, and my observations confirm that women live longer than men, AND women live more years with disability than men. My casual diagnoses in the dining room based on who can independently and successfully get food to mouth also support the gender statistics on Parkinson's Disease--I'd guess 2 out of 3 old gents at the men's table struggle with it compared with 3 in 20 of the women.

Parkinson's Disease takes out the dopamine-producing motor neurons in the brain in charge of ease and fluidity of movement. Ms. B at my mother's table demonstrates all 4 of the most common symptoms: tremor, slowness of movement, stiffness, and postural instability. As she sits near motionless, slumped sideways in her wheelchair, she also speaks in a whisper-soft voice, another characteristic of Parkinson's. By leaning in close this evening, my ear near her mouth, I could barely make out her German-accented recitation of the recipe for walnut torte.* Unfortunately for Ms. B, the rest of her tablemates are hard of hearing, so I bellowed her words to them...and the rest of the room.

Good heavens, how to save the dopaminergic neurons of my substantia nigra? Be female (check), keep up the estrogen (check), avoid pesticides (hmm?), drink coffee (oh yeah), smoke cigarettes (well, I'll pass on that), and maybe take neuroprotective supplements (melatonin? Prevagen?).
*Walnut torte, per Ms. B, is heavy on butter, nuts, and whipped cream. This is my kind of dessert. We were all eating institutional orange sherbet at the time.

Saturday, December 08, 2007

New Age Old Ladies

I had my favorite female bank president in yesterday for her annual exam. She in clunky black Merrill clogs, me in clunky black suede Clark's. Welcome to senescent high fashion.

Friday, December 07, 2007

A mother's work...

is never done. My patient M is 89. She lives in her own home, cooking for her grandson who lives with her, and for her son who lives next door. Bent over with lumbar stenosis,* she had to give up ironing several years ago due to pain.

But she wasn't in today about herself. She'd driven her seventy-something son over to the office because she was worried sick about his depression and overuse of pain medication. He suffers from esophageal dysplasia (abnormal cells in the esophagus with a high risk of progression to cancer), undiagnosed abdominal pain, anxiety, and depression. When I asked him why he had discontinued his antidepressant one month ago, first he said he was worried it would interact with his other medications, then he allowed as how he couldn't afford it. Out of the corner of my eye I could see M in the other consultation chair shaking her head. The monthly copay for a generic antidepressant was apparently not the problem. Occasionally she'd clear her throat to speak, but when she finally did, her son exploded in exasperation.

Good heavens, thought I as I moderated this geriatric family counseling session, is it possible that thirty-some years hence I'll be driving my son to the doctor's office?
*A condition where arthritis plus bulging discs in the lumbar spine narrow the space available for the spinal cord to pass through. As a result, nerve impingement causes pain, especially in the upright position. Bending forward from the waist relieves the pain...slightly.

Monday, December 03, 2007

When you just can't keep a promise...

I hadn't seen my eighty-something year old patient in months. She'd been going downhill with dementia and Parkinson's disease. When she came in last week, the immobility of the two diseases working together had made her so stiff she couldn't even get out of her wheelchair alone nor support her own weight once upright. She also was clearly suffering from that failure to thrive thing that turns the frail elderly into shrunken shadows of their former selves.

Her conversation rambled from completely coherent to totally out to lunch. When her caretaker eased her out of her chair, her backside had several 'hot spots,' red and tender areas where the skin was breaking down under pressure on its way to open bedsores. Her husband, who hovered anxiously by her side, also walked with a Parkinsonian shuffle and was in pain from degenerative disc disease and a torn rotator cuff.

"I promised her," he declared as we held a brief conversation out in the hall, "that I would never ever put her in a nursing home." I could've cried...well actually I did. I had made that promise to my Mom, and I couldn't keep it. How many make that pledge only to find out that even tiny little ladies are near impossible to move from bed to commode when they can no longer move themselves?

This is the conversation I wish I'd had with my Mom, and that I've already had with my daughter. Home is always preferable, but there are circumstances where it's just not feasible. When and if that happens, tell your loved ones now while you've got your wits intact that they have your permission to move you to a skilled care facility.

Saturday, December 01, 2007

An arterial spin on blood flow to brain

A new technique called arterial spin MRI somehow labels red cells in a way that allows researchers to track the rate of blood flow to various regions of the brain. As a result, they've discovered that persons with Alzheimer's Disease (AD) aren't sending normal amounts of oxygenated blood to areas in charge of memory function. And hypertension plus AD reduces blood flow even more to the parts of the brain where memories are formed and stored.

Previous studies have indicated that controlling blood pressure, particularly with a class of drugs such as Norvasc that dilate blood vessels, decreased risk of developing AD later in life. Dr. Cyrus Raji of the University of Pittsburgh noted: "We cannot say that hypertension triggers Alzheimer's disease, but there does appear to be a relationship to Alzheimer's disease pathology."

Hypertension is already linked to another kind of dementia that results from multiple strokes. Controlling blood pressure clearly is good for the brain.