“Doctor, I’m Dizzy”

This is a common complaint in most medical practices. When I hear it, I immediately remind myself to LISTEN, because the description of the dizziness determines the direction my assessment and treatment will take. Some dizziness is described as a “lightheaded” or “going to pass out” sensation. Some as a sense of “I’m going to fall as I am walking”. Some is a simple – “I’m just dizzy”. But a large number of patients describe a sense of spinning, tilting, or moving – either they are doing the spinning or the room is spinning around them. This is VERTIGO and will be the topic of this blog.

Vertigo is a symptom that arises when there is an asymmetry in the vestibular system – the system in our bodies that controls balance. The vestibular system is made up of the labyrinths (the inner ear organs that sense position), the vestibular nerve that carries information from the inner ear to the brain, and that portion of the brain that interprets this information. Damage or dysfunction of a labyrinth, the vestibular nerve, or the portion of the brain that receives vestibular information can cause vertigo symptoms.

Most of us have felt vertigo symptoms – it’s what you felt as a child when you spun in circles and then suddenly stopped – that tilting/swaying/spinning feeling that kept going even after you weren’t moving. In the majority of people, vertigo can be bothersome but not a serious problem. The most common causes of vertigo are inner ear problems. These include:
• Benign Paroxysmal Positional Vertigo (BPPV) – BPPV occurs when a small calcification develops in the inner ear. BPPV often presents itself upon awakening. The person will notice it when they sit or stand up from bed. If they hold still for a few minutes, the vertigo will disappear. But as soon as they move their head, the vertigo recurs. This can occur repetitively – hold still and the vertigo fades, move suddenly and it reappears. BPPV often resolves without any treatment. It can last a few hours or days. Doctors may prescribe medication (similar to what is used for sea-sickness) to decrease the vertigo sensation if it is incapacitating. There is also a repositioning maneuver that can be done by the doctor that causes the calcification to relocate itself and thereby stop the vertigo.

• Meniere Disease (also called Meniere’s Disease) – Meniere Disease occurs when there is a build up of fluid (called endolymph) in the inner ear. The cause of this fluid build up is unknown. Meniere’s manifests itself with repeated bouts of vertigo associated with tinnitus (buzzing, ringing, or hissing in the ear) and hearing loss (over time). There are many treatments that can be used for Meniere Disease, including avoidance of certain foods (typically salty, caffeinated, or MSG-containing), medication to help with the excess fluid in the ear, medication to treat the vertigo symptoms/nausea, and special physical therapies aimed at helping the brain to adapt its responses to the abnormal vestibular signals it is receiving.

• Vestibular neuritis (labyrinthitis) – Vestibular neuritis is likely due to a virus that causes swelling around the vestibular nerve. Patients who develop vestibular neuritis usually develop a very sudden and severe vertigo associated with vomiting and difficulty standing up. Like most viral illnesses, symptoms will usually go away after a few days. With vestibular neuritis, hearing is preserved. If there is a hearing loss associated with the symptoms, it is referred to as a “labyrinthitis”.

Other less common causes of vertigo include certain head injuries, a specific type of migraine (vestibular migraine), and brain abnormalities such as bleeding, a stroke, or multiple sclerosis. Diagnosing and treating the underlying brain disorder is the key to treating the vertigo in these situations.

To recap, vertigo is a sensation of spinning/tilting/swaying (either you are the one moving or the room about you is doing the moving). Most cases of vertigo are benign and either fade away by themselves or can be managed by a physician. If you experience persistent vertigo without other severe symptoms, it warrants a phone call and visit to the doctor. However, if you experience vertigo associated with any of the following symptoms, you should seek immediate care. These symptoms that require emergent attention include sudden vertigo with: a high fever, or a severe headache, or a change in vision, hearing, or speech, or weakness on one side of the body, or severe nausea with refractory vomiting. These associated symptoms could be signs of a more severe problem. Their presence with vertigo warrants an immediate evaluation and possibly special imaging studies.

For more detailed information on vertigo (and other types of dizziness), the following website is very helpful:www.nlm.nih.gov/medlineplus/dizzinessandvertigo.html.

Mary Beth Hardwicke, MD.

Behavioral Issues in Dementia

NPR recently aired a three part series on the use of anti-psychotic medications (risperidone, olanzapine, quetiapine) in Nursing Homes. This is a class of drugs with potentially serious side effects. The series reported that these medications are often inappropriately used to control behavioral problems in “dementia” patients. The series also reported that Nursing Homes have worked to decrease their dispensing of anti-psychotics. Some of this work has been due to federal mandates requiring Nursing Homes to decrease the percentage of their patients on these drugs. Listening to this series brought to mind several “rules” I learned while caring for my elderly patients.

RULE # 1: A dramatic change in behavior or mental status frequently indicates an underlying problem. For example, Jack has been a pleasantly demented father living peacefully with his loving daughter. The daughter calls the office in tears because Jack suddenly believes she and her husband are criminals who are trying to kill him. A doctor’s first thought is “what do I need to fix”. The list of possible precipitators for Jack’s behavioral change is long. It includes infections (especially urinary tract or pneumonia), metabolic abnormalities (altered sodium levels, abnormal sugars, dehydration), “brain” disorders (seizures, head injury, severe depression), unexpressed pain, and side effects from prescription or non-prescription drugs. These potentially treatable diagnoses must be sought and treated if present.

RULE # 2: Nursing Home placement is sometimes the only option for a patient – be it for short-term rehabilitation or for long-term care. I do not believe that all nursing homes are bad. I do believe that a patient’s FAMILY has an obligation to find the best Nursing Home they can and to CONTINUE TO LOVE THEIR LOVED ONE. In short, visit the Nursing Home often. Be actively involved in the patient’s care. Attend family meetings at the Nursing Home – all of them. Bring any changes in behavior to the attention of the staff. (No one knows mom as well as her family does.) Always be vigilant. If mom’s behavior changes, don’t be afraid to ask if she is on a new medication. Could she have a bladder infection? When she fell the other day, could she have bumped her head?

RULE # 3: Medications can be life-saving, life-altering, and life-enhancing. They can also be a great nuisance and wreak havoc. The art of prescribing medication is not readily taught. Busy medical practitioners often prescribe a pill when they should probably just sit quietly and listen instead. Managing medications in the elderly is particularly problematic, as aging can alter the distribution, metabolism, and elimination of medication – making toxicities and side effects more probable. Patients, their doctors, and their families should constantly be evaluating the necessity of each prescription taken.

RULE # 4: Your desires in life, especially for your later years, should be known. Putting your thoughts in an appropriate document can prevent great pain and sorrow later in life. I recently spoke with a life-loving woman I know. Her living will states “if I can’t drink a glass of Chardonnay, eat popcorn or ice cream, or carry on a meaningful conversation with people I love, don’t keep me alive”. Although this may sound flippant, it actually says a lot. If she has dementia and no longer recognizes family or is confined to a Nursing Home, she does not want her life to be prolonged. This kind of knowledge is hugely helpful. One question families should ask, especially if their loved one is battling dementia, is “what medications are necessary”. Does the high cholesterol really need to be treated at this point? Does the blood pressure really need three pills? When the goal becomes COMFORT and not prolongation of life, less is frequently more.

RULE # 5 (a corollary to rule # 3): Don’t automatically reach for a prescription pad. If a patient is exhibiting problem behaviors and no treatable cause can be found, stop and think. There are many forms of therapy being used in an effort to avoid sedating drugs. Music therapy, pet therapy, aromatherapy, massage therapy, and exercise therapy have all been used with some success in the agitated dementia patient. Trying to understand or re-direct a behavior can be helpful. If mom was an executive who now yells incessantly that she needs to get to the office, perhaps a small desk with papers that can be “filed” might occupy her time and alleviate her agitation. My partner’s family drove Up North to their cottage every weekend as she grew up. They always stopped on the way for ice cream. Later, whenever her elderly father became acutely agitated, a quick trip in the car “Up North” (which was really a ride to the nearest Dairy Queen) was all it took to soothe him. If mom’s weekly shower (given by a male attendant) repeatedly precipitates agitation, perhaps a female family member can show her love and take over that particular job.

RULE # 6: Managing severe hallucinations or delirium can be REALLY difficult. These symptoms can be terrifying to the patient. They can truly believe someone is trying to kill them, that strangers are coming through the walls, or that their bed is filled with spiders. Prudence dictates that family, health care providers, and caregivers collaborate to find something treatable when this happens. Sometimes, though, there is no underlying disorder to treat and all non-medication therapies have failed to help. When this happens and the patient’s symptoms are resulting in severe distress or harm, pharmacologic therapy may be necessary. Anti-psychotics are the only class of medication that has been found to be moderately effective at controlling severe agitation due to delirium/hallucinations in the dementia patient. They come with side effects that can include increased mortality. They contain an FDA black box warning. And they do not have formal FDA approval for treatment of behavioral problems in dementia patients. Sadly, however, there are times when treatment with medication is the only viable option for a patient’s severe distress. Should a patient require use of an anti-psychotic, it should be started at as low a dose as possible and only continued if its benefits are apparent. Discontinuation should be attempted at regular intervals, always weighing the risk of recurrent frightening delusions/hallucinations versus the risk of adverse medication effects.

To summarize, as always, patients are unique individuals and the right treatment will be unique to each. Medications can be life-saving, but as we age and our goals for life change, our medication requirements can change. If your family and your doctor know what you want for yourself as you near the end of life, decisions regarding your care can be rational and focused on your beliefs and desires.

Here’s to drinking Chardonnay and eating ice cream,
Mary Beth Hardwicke, M.D.

Should You Take Vitamins?

I am frequently asked if it is necessary to take vitamin supplements.  It is an age-old question that has been partially answered.  Here is the background.  Vitamins are substances that cannot be synthesized by humans (the exception is Vitamin D) and therefore need to be ingested.  They are involved in normal cell function, normal growth, and maintenance of health.  Thirteen essential vitamins have been described.  Four of these (vitamins A, D, E, and K) are “fat-soluble” – meaning they are absorbed by fat cells and can therefore accumulate in our bodies.  The other essential vitamins are “water-soluble” - whatever ingested portion of these that is not used up will be excreted in our urine rather than accumulated.  These water-soluble vitamins include eight “B” vitamins (thiamine (B1), riboflavin, niacin, pantothenic acid, pyridoxine (B6), biotin, cobalamin (B12), and folate) as well as Vitamin C.

Most experts recommend we get our vitamins from food rather than from supplements.  This is because eating foods that are rich in vitamins carries other health benefits.  You can get your daily requirements for Vitamin C by taking a pill.  Or you can meet your vitamin C requirement by eating an orange.  Eating food to get your essential vitamins has the additional benefit of providing other nutrients such as fiber, phytochemicals, calcium, and so on.  A balanced diet that would give a mature adult all the vitamins they need includes five servings of fruit/vegetables every day, three cups of fortified dairy products daily, 6 ounces of grain (predominantly “whole” grains) daily, and 5-6 ounces of lean meat products each day.  In addition, to allow our skin to manufacture the vitamin D we need, 10-15 minutes of sunlight at least three times/week is needed.  Someone who follows the above dietary regimen regularly and who gets sunlight several times/week does not likely need any vitamin supplements.

There are several scenarios, though, in which vitamin supplementation might be recommended.  People with milk or lactose intolerance, with food allergies, or without the resources to buy fresh and whole grain foods might benefit from a supplement.  Strict vegans can become B12 deficient as cobalamin (B12) is found predominantly in meat products.  Women considering pregnancy may benefit from folate supplementation to prevent neural tube defects in their babies.  Lack of sun exposure along with lack of D-supplemented foods may necessitate vitamin D supplementation.  Patients with weight-loss surgeries, inflammatory bowel conditions, or pancreatic insufficiency can lack the ability to absorb vitamins and may benefit from specific supplements.  There is also concern that the aging process can decrease B12 absorption and decrease vitamin D production, leading some experts to recommend a multivitamin that contains B12 (they pretty much all do) and vitamin D (at a dose of 800-1000 international units) to their elderly patients.

So, what is the answer?  Should the average, healthy mature adult take a simple multivitamin daily?  The technical answer is that there is no evidence to date to show that a multivitamin taken daily is beneficial.  However, there is also no evidence to show that a daily multivitamin is harmful!  I do take a multivitamin myself.  I tell my patients there is no hard data to support doing so, but because I don’t always eat as healthy a diet as I should and because I am getting older, I figure I will hedge my bets by taking something I know won’t harm me and might be helpful.  I shop for an inexpensive multivitamin that contains 50-100% of the recommended daily values of vitamins.  I choose one that has 800 international units of vitamin D.  I avoid buying “extras” – those “special” vitamins for heart health, with added coenzymes or extra amino acids, special herb supplements, etc.  These “vitamin plus” supplements usually add extra cost to the multivitamin with no added benefit.  If you choose to take a multivitamin supplement, keep it simple.  And always let your doctor know what you are taking.

Here’s to staying healthy.
Mary Beth Hardwicke, M.D.

Cholesterol, To Treat Or Not To Treat

I am frequently asked what a person’s cholesterol numbers mean.  I am also asked why doctors keep changing their minds about what cholesterol levels are acceptable.  Recommendations have changed several times over the past twenty years.  This has created some confusion in those patients who watch their numbers.  The most recently published guidelines are recommending less reliance on the numbers and more on the individual patient’s risk for vascular disease (blockage in the arteries).  Tools used to assess an individual’s vascular risk have been inconsistently validated, leaving doctors feeling somewhat confused as well.

Cholesterol is a substance found in our blood.  It is essential for the production of many things necessary to good health.  However, it can be problematic and lead to vascular blockages if it is present in excessive amounts.  Vascular (blood vessel) blockage, depending on its location, can cause angina or heart attacks, transient ischemic attacks or strokes, and pain with walking (claudication).

There are several different types of cholesterol.   Lab tests typically measure Total Cholesterol, LDL cholesterol (the “bad” or Lousy one), HDL cholesterol (the “good” or Healthy one), and the non-HDL cholesterol (the Total cholesterol minus the HDL component).  In addition, doctors often check Triglycerides.  Triglycerides (although not part of the cholesterol family) are a type of fat in the blood that can increase risk for vascular disease if present in excessive amounts.

In general (and I do mean “general”), in people who have NO history of vascular disease and who have no significant risk for developing vascular disease, we like to see the Total Cholesterol under 200-240, the LDL under 130, the HDL above 50-60, the non-HDL under 160-180, and the triglycerides under 150-200.  These “goals” can change as a person’s risk for vascular disease increases.  Your doctor can determine goal levels for you depending on your risk factors and your health needs.  

A high cholesterol is not always a problem, especially if you are at a low-risk for developing vascular disease.  The negative impact of high cholesterol on an individual’s health increases as that person’s risk for vascular blockage increases.  Other risk factors for developing vascular disease include diabetes, cigarette smoking, high blood pressure, and increasing age.  A history of vascular disease occurring in family members at a young age also increases your risk.  Young is defined as a male relative (father/brother) having heart disease or stroke when younger than 55 or a female relative (mother/sister) when younger than 65.  Being male increases risk as well.  Although women can obviously have vascular problems, men are at a higher risk than are women of the same age.

There are circumstances where your doctor may not even have a cholesterol goal but simply WANTS you on a medicine called a statin – even if your numbers are good. This is often the case in people who have had a prior heart attack or stroke or who are diabetic.  Diabetes is a VERY strong risk factor for vascular disease.  Studies have shown that statins can and do save lives in these patients, no matter what their cholesterol level is.

Any patients having high cholesterol should be told to eat a healthy, lower saturated fat diet, to lose weight if needed, and to be more active.  This is pretty standard advice for all of us who want to be healthy.  Whether or not a patient should be put on a medication is a decision that must occur on an individual basis.  Your doctor or health care provider should be able to discuss your cholesterol and triglyceride numbers with you, work with you to assess your overall risk for vascular disease, and make recommendations regarding medication use based on your individual situation.  Certainly, if you already have diabetes or vascular disease or if you are determined to be at high risk for a stroke or heart attack, a statin will likely be recommended - for very good reason.

Here’s to keeping your blood vessels healthy.
Mary Beth Hardwicke, M.D.

Diabetes – What is it?  How do I treat it? What if I ignore it?

Here are the facts… 

The prevalence of diabetes among adults in the US averages 8.5%.  The many complications that occur with poorly controlled diabetes account for 15% of our health care expenditures.  Diabetes is a condition that requires your doctor (or health care provider) and YOU to work as partners in keeping you healthy once the diagnosis is made.

Diabetes is a chronic condition that affects the body’s metabolism of glucose (sugar).  Glucose is a main source of energy for our cells.  It is moved from the bloodstream into our cells at the direction of Insulin (a hormone produced by beta cells in the pancreas).  Type 1 diabetics (formerly called Juvenile diabetics) have very little or no insulin in their bodies due to autoimmune destruction of their beta cells.  They require lifelong intensive insulin replacement therapy.  Type 2 diabetics (adult onset diabetics) account for 90% of the diabetes diagnosed in this country.  With type 2 Diabetes, the cells/tissues become resistant to insulin’s effects and the patient needs more and more insulin.  Over time, the pancreas becomes less able to keep up with demand.

There are well-known risk factors associated with developing type 2 Diabetes.  These include:

1)    being an overweight or obese adult

2)    having  “abdominal fat” distribution as opposed   to “hip/thigh” fat

3)    inactivity

4)   positive family history (parent or sibling with type 2 Diabetes)

5) race/ethnicity (African Americans, Asian Americans, Native Americans, Hispanics, and Pacific Islanders have a higher incidence)

6)    age (typically diagnosed after age 45)

7)  “pre-diabetes” (having sugars that are higher than normal but not high enough to diagnose diabetes)

8)  having had gestational diabetes (diabetes during a pregnancy)

9) delivering a baby that weighs more than 9 pounds

Symptoms of type 2 Diabetes develop slowly and frequently go unnoticed.  They can include increased thirst and urination, increased hunger, weight loss, fatigue, dizziness, blurry vision, and slow wound healing.  Unfortunately, many people do not have recognize they have developed type 2 diabetes until it has begun to cause damage.  This is why health care providers try to begin screening for diabetes when a person hits their mid-forties or earlier if a person has significant risk factors for developing diabetes.  Several screening tests are available to your doctor.  Regardless of the test used, experts recommend the test be repeated and found to be abnormal twice before giving a person the diagnosis of diabetes.

Diagnostic tests for diabetes include any one of the following:

1)  Hemoglobin A1C (HgbA1c, glycated Hgb) – a positive test is a result greater than or equal to (≥) 6.5%.  Normal is a level of 5.6 or less.  Results of 5.7 – 6.4 are consistent with having pre-diabetes.

2)   Fasting blood sugar (FBS) – positive value is ≥ 126 mg/dl.  Normal fasting blood sugar (drawn after 8 hours of fasting from food, water intake will not affect the test) should be less than 100 mg/dl.  FBS levels of 100-125 are diagnostic of a pre-diabetes state.

3)   Random blood sugar (RBS) – a value of ≥ 200 mg/dl with associated symptoms of diabetes is diagnostic (if positive on at least two separate tests).

4) Oral Glucose Tolerance Test (OGTT) – a glucose level of ≥ 200 mg/dl measured two hours after a 75 gm oral load of sugar (reproduced on two occasions) is diagnostic of diabetes.

Treatment of diabetes is an area of medical practice that must be individualized.  The patient must embrace the treatment path they and their doctor choose.  If not, success cannot occur.  In general, the goal will be to keep a patient’s A1C less than 7.0%.  This goal is flexible and may be higher or lower in certain circumstances.  Treatment plans will include medical nutrition therapy, a fancy term for a specific diet plan tailored to the individual patient.  This is usually done in tandem with a dietitian’s recommendations.  If a patient is overweight, they will receive instruction in calorie restrictions aimed at promoting weight loss.  In addition, increased vegetables and fruits, lean meats and other proteins, whole grains, healthy fats, and low-fat dairy products will be recommended.  In addition to diet, diabetics are advised to become physically active.  30 minutes of activity most days of the week is recommended.  Be sure to check with your doctor before embarking on a new exercise regimen.  In addition to weight loss, improved diet, and increased physical activity, most newly diagnosed type 2 diabetics will be started on a biguanide (metformin).  This is a well-tolerated medication that does not cause weight gain and will not cause sugars to drop below the normal range.  Many patients will require additional medications or the use of insulin to achieve optimal glucose control.  The list of medications available for treating diabetes is long.  This is an area where the patient and their health care provider will work together to determine what medications, potential side effects, etc. are acceptable in striving to reach their goal.

 So, why is it so darn important to have goals when treating diabetes?  The answer is simple: diabetics are at a high risk of developing life-threatening complications.  Happily, if they work with their doctor as a partner and strive to keep themselves healthy, the risk for developing the following diabetic complications drops precipitously.  However, complications that can be expected if a diabetic does not manage their disease include:

1) Heart and vascular disease – heart attacks, strokes, peripheral artery disease.

2)   Nerve damage (neuropathy) occurs in the feet and legs, hands, gut, and even the genitalia when the small blood vessels keeping those nerves alive are damaged by chronically elevated blood sugars.

3)   Kidney damage and kidney failure – the filtering system of the kidneys is composed of clusters of small vessels that can be damaged and killed with chronically elevated sugars.

4)   Eye damage – diabetic retinopathy can lead to blindness.

5)   Foot damage – nerve and blood vessel damage can lead to ulcers, joint destruction, difficult to treat infections, and gangrene.  The end result can be amputation of a toe, foot, or leg.

 We’ve talked about what diabetes is, how it is treated, and what happens if it isn’t treated optimally.  What do you, the individual patient, need to do if you are diagnosed with diabetes?  The answer is: don’t panic.  With today’s knowledge base, patients do not have to end up in the hospital hooked up to a dialysis machine while losing their limbs and their eyesight.  That being said, personal responsibility becomes REALLY important when treating diabetes.  Believe me, taking that responsibility is worth it.  Here is what all diabetic patients should do to manage their disease and partner with their health care provider.

1. Commit to managing your diabetes.  Learn all that you can.
2. Eat Healthy and Be Active.
3. Watch your ABC’s (and take medications that are prescribed)

        A1C goal should be discussed and you must work to           achieve and maintain it (typical goal is ≤ 7%)

        Blood pressure control – goal should be set and you         must work to reach it (typically a systolic (top) number         of 125-130).

        Cholesterol  - discuss your LDL goal (typically less             than 100) and  reach it.  Know that most diabetics are         advised to take a statin drug.  This advice has sound           science behind it.

4.  Schedule regular visits with your primary doctor (and            endocrinologist if you have one).  Also keep regular              ophthalmology appointments.

5.   If you aren’t taking a daily aspirin, ask your doctor if you       should be.

6.  Wear a medical ID bracelet or necklace.

7.  Stay up to date with your regular health maintenance,          including cancer screening and immunizations.

8.  Check your feet DAILY.  Your doctor can provide a              handout on how this is done.

9.  Keep your dental health appointments.

 Helpful Resources:

American Diabetes Association 1-800-342-2383 or www.diabetes.org

http://www.niddk.nih.gov/Pages/default.aspx