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NEUROLOGY/PSYCHIATRY

WHAT IS SCHIZOPHRENIA

OVERVIEW

 

Schizophrenia is a chronic and often debilitating mental illness. The disease can cause you to withdraw from the people and activities in the world around you and to retreat into a world of delusions or separate reality.

Schizophrenia is a kind of psychosis, which is an impairment of thinking in which the interpretation of reality is abnormal. Psychosis is a symptom of a disordered brain.

The illness affects approximately 1 percent of the population worldwide. It most commonly appears between the ages of 13 and 25, and often earlier in males than in females. In men, schizophrenia typically emerges in the teens or 20s. In women, the onset typically is in the 20s or early 30s.

There’s often no cure for the illness, but by working closely with a psychologist and other mental health professionals, schizo- phrenia can be managed successfully — especially with an early diagnosis. Fortunately, newer medications continue to make this poorly understood disorder more manageable.

Signs and symptoms of schizophrenia may include:

 

 

SIGNS AND SYMPTOMS

 

  • Delusions — personal beliefs not based in reality, such as paranoia that you’re being persecuted or conspired against
  • Bizarre delusions — for example, a belief in Martians controlling your thoughts
  • Hallucinations — sensing things that don’t exist, such as imaginary voices
  • Incoherence
  • Lack of emotions or inappropriate display of emotions
  • Trouble functioning at work or in social situations
  • Difficulty with personal hygiene

 

Generally, schizophrenia causes a slowly progressive deterioration in the ability to function in various roles, especially in one’s job and personal life. The signs and symptoms of schizophrenia vary greatly. A person may behave differently at different times. He or she may become extremely agitated and distressed, or fall into a catatonic (trance-like, immobile, unresponsive) state, or behave normally much of the time. Signs and symptoms that occur continuously and progressively for at least six months often indicate schizophrenia.

In general, schizophrenia has negative signs and positive signs:

 

NEGATIVE SIGNS

 

Negative signs may appear early in the disease, and a person may not think he or she needs treatment. Negative signs generally accompany a slow deterioration of function, leading to your becoming less sociable. Such signs may include dulled emotions (lack of expression), inappropriate emotions (laughing while expressing terrifying images) and a change in speech (speaking in a dull monotone).

 

POSITIVE SIGNS

 

Positive signs often include hallucinations and delusions:

  • Hallucinations. Hallucinations occur when you sense things that don’t exist. The most common hallucination in schizophrenia is hearing voices. You may carry on a conversation with voices that no one else can hear. Or you may perceive that voices are pro- viding you instructions on what to do. Hallucinations may result in injuries to other people.
  • Delusions. Delusions are firmly held personal beliefs that have no basis in reality. The most common subtype of schizophrenia is paranoid schizophrenia, in which you hold irrational beliefs that others are persecuting you or conspiring against you. For example, some people with schizophrenia may believe that the television is directing their behavior or that outside forces are controlling their thoughts.

 

Causes

Researchers haven’t identified the cause or causes of schizophrenia, although they believe genetic factors play a role. Chemical or subtle structural abnormalities in the brain may contribute to causing this illness.

Schizophrenia may exist alone or in combination with other psychiatric or medical conditions. Misconceptions about schizophrenia and its relation to other mental illnesses abound. The following truths will help clarify what it is and is not:

  • Schizophrenia isn’t the same as a split or multiple personality. Multiple personality disorder is a separate, rare condition.
  • Although some people with schizophrenia develop violent tendencies, most don’t. Many withdraw into themselves rather than interact with others.

WHEN TO SEEK MEDICAL ADVICE

 

By its nature, schizophrenia often isn’t an illness for which someone is likely to voluntarily seek treatment. To a person with schizophrenia, the delusions and hallucinations are real, and often he or she may perceive that there’s no need for medical help. If you’re a family member or friend of someone who is exhibiting possible signs of schizophrenia or another mental disorder, you may need to be the one who takes him or her to a medical professional for evaluation.

  • Not everyone who acts paranoid or distrustful has schizophrenia. Some people have a paranoid personality disorder, a tendency to be suspicious or distrustful of others, without the other features of schizophrenia.

*Not everyone who hears voices is schizophrenic. Some people with depression may hear voices.

 

SCREENING AND DIAGNSOSIS

 

Early diagnosis and treatment of schizophrenia are important. Before making a diagnosis of schizophrenia, your doctor likely will rule out other possible causes of the signs that may suggest schizophrenia. It’s possible that other mental or physical illnesses may cause signs similar to schizophrenia.

Your doctor will want to discuss your family and medical history and do a physical examination. Your doctor may ask for blood or urine samples to see if medications, substance abuse or another physical illness may be a factor in your signs.

Among the other mental illnesses that may at least partly resemble schizophrenia are depression, bipolar disorder, other psycho- ses, and abuse of alcohol and other drugs.

It’s also possible that physical illnesses such as certain infections, cancers, nervous system disorders, thyroid disorders, immune system disorders and others may produce some psychotic signs. Psychosis is also a possible side effect of some medications. If no other underlying cause is found, doctors diagnose schizophrenia based on the signs and symptoms summarized above.

 

TREATMENT

 

Antipsychotic medications, also known as neuroleptics, are the cornerstone of treatment. Until the 1990s, antipsychotics generally were much more effective in controlling positive symptoms than negative symptoms. A new generation of antipsychotics provides more effective management of both positive and negative symptoms. These newer antipsychotics include clozapine (Clozaril), risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon/Zeldox) and aripiprazole (Abilify). According to the American Diabetes Association, certain antipsychotic drugs may increase the risk of diabetes, obesity and high blood pressure. For this reason, a study published in the February 2004 issue of Diabetes Care recommends that doctors screen and monitor people who take Clozaril, Risperdal, Zyprexa, Seroquel, Geodon or Abilify.

Newer antipsychotic medications have fewer side effects. For example, there’s a lower incidence of tardive dyskinesia (TD) with the newer drugs than with the older medications. TD results in involuntary movements of your mouth, lips, tongue and other parts of the body. Other

 

COPING SKILLS

 

For family members and friends of people with schizophrenia, coping with the illness may involve a significant commitment of time and effort.

 

SUPPORT GROUPS

 

Support groups can be a valuable part of a wider network of social support that includes health care professionals, family, friends and a place of religious worship.

Various support groups bring together people, family and friends who are coping with any of a wide variety of physical or mental health problems. Support groups for schizophrenia provide a setting in which people can share their common problems and pro- vide ongoing support to one another.

 

FOLLOW-THROUGH

 

A family member or friend of someone with schizophrenia, can make a big difference in the success of treatment. Taking antipsychotic medications is a mainstay of treatment of schizophrenia, as are nonmedication approaches such as individual therapy. Helping a person with schizophrenia keep to his or her schedule of medications and follow-up treatment will help prevent relapses. The friend/family members should be observant about unusual behavior or signs of a relapse that may indicate a need for immediate medical attention.

 

Try to keep the right tone in supporting your friend or family member who has schizophrenia. Keep in mind that positive support and encouragement may work much better than criticism and pressure.

Alzheimer’s disease is the most common form of dementia. Dementia is the loss of intellectual and social abilities severe enough to interfere with daily functioning. It occurs in people with Alzheimer’s disease because — for reasons unclear — healthy brain tis- sue degenerates, causing a steady decline in memory and mental abilities.

More than 4 million older Americans have Alzheimer’s, a disease that usually develops in those age 65 or older. This number is expected to triple in the next 20 years as more people live into their 80s and 90s.

Although there’s no cure or surefire way to prevent Alzheimer’s disease, researchers have made progress in the last 5 years. Treatments are available that help improve the quality of life for people with Alzheimer’s. Also, more drugs are being studied, and scientists have discovered several genes associated with Alzheimer’s, which may lead to new treatments to block progression of this complex disease.

In the meantime, caring for someone with Alzheimer’s takes patience and a focus on the things a person can still do and enjoy. Those with Alzheimer’s — as well as those who care for them — need support and affection from friends and family to cope.

 

WHAT IS ALZHEIMER’S DISEASE

 

 

SIGNS AND SYMPTOMS

 

Everyone has occasional lapses in memory. It’s often quite normal to forget the names of people whom you rarely see. But it’s not a normal part of aging to forget the names of familiar people and objects.

Alzheimer’s disease — which is a progressive, or degenerative, brain disease — goes beyond simple forgetfulness. It may start with slight memory loss and confusion, but it eventually leads to severe, irreversible mental impairment that destroys a person’s ability to remember, reason, learn and imagine.

 

Most people with Alzheimer’s share certain signs of the disease. These may include:

  • Increasing and persistent forgetfulness. At its onset, Alzheimer’s disease is marked by periods of forgetfulness, especially of recent events or simple directions. But what begins as mild forgetfulness persists and increases. People with Alzheimer’s may repeat things and forget conversations or appointments. They routinely misplace things, often putting them in illogical locations. They frequently forget names, and, eventually, they may forget the names of family members and everyday objects such as a comb or a watch.
  • Difficulties with abstract thinking. People with Alzheimer’s may initially have trouble balancing their checkbook, a problem that progresses to trouble understanding and recognizing numbers.
  • Difficulty finding the right word. It may be a challenge for those with Alzheimer’s to find the right words to express thoughts or even follow conversations. Eventually, reading and writing are also affected.
  • Disorientation. People with Alzheimer’s may lose a sense of time and dates. They may find themselves lost in familiar surroundings. Eventually, they may even wander from home.
  • Loss of judgment. Solving everyday problems, such as knowing what to do if food on the stove is burning, becomes increasingly impossible. Alzheimer’s is characterized by greater difficulty in doing things that require planning, decision making and judgment.
  • Difficulty performing familiar tasks. Once-routine tasks that require sequential steps, such as cooking, become a struggle as the disease progresses. Eventually, people with Alzheimer’s may forget how to do the most basic things, like brushing their teeth.
  • Personality changes. People with Alzheimer’s may exhibit mood swings. They may express distrust in others, show increased stubbornness and withdraw socially. Early on, this may be a response to the frustration they feel as they notice uncontrollable changes in their memory. Depression often coexists with Alzheimer’s disease. Restlessness is also a common sign. As the disease progresses, people with Alzheimer’s may become anxious or aggressive and behave inappropriately.

 

Typically, loved ones notice gradual — not sudden — changes in a person with Alzheimer’s. As the disease progresses, symptoms become serious and noticeable enough to cause people with Alzheimer’s or their family members to seek medical help. Many people with Alzheimer’s disease realize that something is happening to their memory, which can be frightening.

 

The course the disease takes and how rapidly changes occur vary from person to person. For some, the progression from simple forgetfulness to severe dementia takes 5 years. For others, it can take a decade or longer.

 

Alzheimer’s generally progresses from mild to moderate to severe. People with mild Alzheimer’s can usually live alone and func- tion fairly well. Persons with moderate Alzheimer’s may have greater difficulty coping without supervision. People with advanced Alzheimer’s generally can no longer care for themselves.

 

Mayo Clinic researchers have recently identified a state of memory loss called mild cognitive impairment that could potentially be known as a pre-Alzheimer’s period. This memory loss falls somewhere between what’s associated with normal aging and what’s common in Alzheimer’s disease. People with mild cognitive impairment may experience forgetfulness beyond what’s typical for their age, yet they don’t have the dementia of Alzheimer’s. Identification of this category of memory loss could help physicians more accurately diagnose and advise patients. It could also alert patients to a greater risk of developing Alzheimer’s disease.

 

CAUSES

 

The causes of Alzheimer’s aren’t well understood. But researchers have found that people with Alzheimer’s have brain cells that become damaged and die for unknown reasons.

A healthy brain has about 140 billion nerve cells called neurons. Neurons generate electrical and chemical signals that are relayed from neuron to neuron to help you think, remember and feel. Chemicals called neurotransmitters help these signals flow seamlessly between neurons.

 

In people with Alzheimer’s, neurons in the brain slowly die. As they die, lower levels of neurotransmitters are produced, creating signaling problems in the brain.

Alzheimer’s disease is named after German neurologist Dr. Alois Alzheimer. In 1906 he autopsied the brain of a woman who had died after years of progressive dementia. Her brain tissue showed abnormal clumps and irregular knots of brain cells. Today, these clumps (now called plaques) and knots (now called tangles) are considered hallmarks of Alzheimer’s disease.

Researchers continue to study these abnormal structures — plaques and tangles — to better understand why brain cells slowly die in people with Alzheimer’s. In the meantime, scientists have theories that may explain how these structures are involved in Alzheimer’s disease:

 

  • Plaques. Plaques are made up of a normally harmless protein called amyloid-beta. It’s believed plaque deposits form between neurons early on in the disease process, before neurons begin to die and symptoms develop. Although the ultimate cause of neuron death in Alzheimer’s isn’t known, mounting evidence suggests that a form of amyloid-beta protein may be the culprit.
  • Tangles. The internal support structure for brain neurons depends on the normal functioning of a protein called tau. In people with Alzheimer’s, threads of tau protein undergo alterations that cause them to become twisted. Many researchers believe this may seriously damage neurons, causing them to die.

 

Researchers are also studying the role genetics play in Alzheimer’s. The presence of certain defective genes is known to increase a person’s risk of developing Alzheimer’s. Some scientists believe that a slow-developing viral infection that causes brain inflammation may also be involved in Alzheimer’s.

 

RISK FACTORS

 

Alzheimer’s is a complex disease that’s likely to be caused by a variety of influences. Although all of these influences may never be known, scientists have identified several risk factors that may increase the likelihood of developing Alzheimer’s disease. They include:

  • Age. Alzheimer’s usually affects people older than age 65, but can, rarely, affect those younger than age 40. The average age at diagnosis is about 80. Only one to two people in 100 have Alzheimer’s at age 65, but that risk increases to about one in five by age 80. By age 90 half of all people have some symptoms. Women are more likely than men to develop the disease, in part because they live longer.
  • Heredity. Your risk of developing Alzheimer’s appears to be slightly higher if a first-degree relative (parent, sister or brother) has the disease. Although the genetic mechanisms of Alzheimer’s among families remain largely unexplained, researchers have identified a few genetic mutations that greatly increase risk in some families.
  • Environment. Researchers are studying environmental factors to discover both possible causes and prevention of Alzheimer’s. For example, some people with Alzheimer’s have deposits of aluminum in their brain. But scientists who’ve studied environ- mental sources of aluminum — everything from antiperspirants to drinking water — haven’t found a link between aluminum and Alzheimer’s.

 

SCREENING AND DIAGNOSIS

 

Right now there’s no one test to diagnose Alzheimer’s disease. Instead, Alzheimer’s disease is diagnosed through a process of elimination — to rule out other diseases and conditions that can also cause memory loss.

Small, undetected strokes, for example, can cause dementia by temporarily interrupting blood flow to the brain. People with Parkinson’s disease, a degenerative nerve disease, also can develop dementia. Depression can cause lapses in memory. In addition, many older people are on multiple medications that may impair their ability to think clearly.

To help diagnose Alzheimer’s disease from other causes of memory loss — which are often treatable — doctors typically rely on the following:

  • Medical history. Doctors may ask about a person’s general health and past medical problems. They will want to know about any problems a person may have in carrying out daily activities. It’s likely doctors will also want to speak with a person’s family or friends to get more information.
  • Basic medical tests. Blood and urine tests may be done to help doctors rule out other potential causes of the dementia. In some cases testing a small amount of spinal fluid also may help.
  • Mental status tests. These tests are used to evaluate memory, problem solving abilities, attention spans, counting skills and language. They help doctors pinpoint specific problems a person may have with cognition. For instance, doctors might test recent and long-term memory by asking: What day is it today? Or, when was World War II? Recall tests are another example. Doctors may list familiar objects and then ask a person to repeat them immediately, and again 5 minutes later.
  • Brain scans. Doctors may want to take a picture of the brain using a brain scan. Several types of brain scans are available — including a computerized tomography (CT) scan, a magnetic resonance imaging (MRI) scan and a positron emission tomography (PET) scan. By looking at a picture of the brain, doctors may be able to pinpoint any visible abnormalities.

Using the methods above, doctors can accurately diagnose 90 percent of Alzheimer’s cases. Alzheimer’s can only be diagnosed with 100 percent accuracy from a brain autopsy — which can check for plaques and tangles — after a person has died. Genetic testing for Alzheimer’s is in its infancy stages. Blood tests are available that can tell whether a person carries genetic mutations believed associated with Alzheimer’s, but the tests can’t tell who will or will not get the disease.

 

COMPLICATIONS

 

Most people with Alzheimer’s don’t die from the disease itself but from a secondary illness, such as pneumonia or an infection. In advanced Alzheimer’s disease, people may lose all ability to care for themselves. They may have difficulty eating, become incontinent or be unable to take a walk and find their way back home.

 

These inabilities can increase the risk of complicating health problems such as:

  • Pneumonia. Difficulty swallowing food and liquids may cause people with Alzheimer’s to inhale some of what they eat and drink

 into their airways and lungs, which can lead to pneumonia.

  • Infections. Urinary incontinence may require the placement of a urinary catheter, which increases the risk of urinary tract infections. Untreated urinary tract infections can lead to more serious, life-threatening infections.
  • Falls and their complications. People with Alzheimer’s may become disoriented, increasing their risk of falls. Falls can lead to bone fractures. In addition, falls are a common cause of serious head injuries, such as bleeding in the brain. Surgery to repair injury from a fall carries risks as well. For instance, prolonged immobilization — which may be necessary to recover from injuries related to a fall — increases the risk of a blood clot in the brain or heart and pulmonary embolism (blood clot in the lungs), all of which can be life-threatening.

 

TREATMENT

 

Currently, there’s no cure for Alzheimer’s disease. Medications and caregiving are the primary treatments.

 

MEDICATIONS

Current medications for Alzheimer’s can’t stop or reverse the underlying disease process. But they may slow it down, lessening symptoms. Medications commonly recommended for people with Alzheimer’s include:

  • Tacrine (Cognex). Tacrine can improve mental abilities in about 30 percent of people with mild to moderate Alzheimer’s disease by slowing the breakdown of neurotransmitters in the brain. However, the drug has been linked to liver complications.
  • Donepezil (Aricept). This medication also decreases mild to moderate symptoms of Alzheimer’s by improving levels of neu- rotransmitters in the brain. Its side effects, which include nausea, diarrhea and fatigue, are usually mild and don’t last long.
  • Rivastigamine (Exelon). Like tacrine and donepezil, rivastigamine blocks the breakdown of neurotransmitters in the brain, less- ening symptoms. Side effects may include nausea and vomiting.

 

Doctors also sometimes prescribe drugs to improve behavioral symptoms that often accompany Alzheimer’s, including sleepless- ness, wandering, anxiety, agitation and depression.

Today, treatment of Alzheimer’s disease is still in its infancy. But researchers are confident that in the not-too-distant future, new medications should be available that do more than treat the symptoms of Alzheimer’s. Mayo Clinic researchers are now studying a breed of mice with Alzheimer’s-like symptoms. This research is expected to accelerate the study of drugs that can delay or slow the progression of Alzheimer’s.

 

CARE GIVING

 

Until there’s a cure for Alzheimer’s, people with the disease will need caregiving. According to the National Alzheimer’s Association, 1 in 10 families have a relative with Alzheimer’s disease. Of the 4 million people with Alzheimer’s disease in the United States, 70 percent live at home — often receiving part- or full-time care from family members.

Caregiving can be a challenge. The slow and unpredictable decline that may last more than a decade requires caregivers to exer- cise patience, understanding, compassion and, often, creativity.

The key to caregiving is focusing on things that the person with Alzheimer’s can still do and enjoy. In fact, learning ways to reduce the impact of impaired abilities and behavior problems can help avoid some of the most difficult aspects the disease.

 

Each person with Alzheimer’s disease experiences its symptoms and progression differently. Consequently, the techniques to care for each person should vary. You may have to adapt the following tips to your specific caregiving situation:

  • Use memory aids. Memory aids may help a friend or family member remain independent. Write out a list of the day’s activities, the phone numbers that can be used to call for help and instructions on how to do simple tasks, like make a cup of tea or use the telephone.
  • Provide structure. A home environment that provides serenity and stability reduces behavior problems. New situations, noise, large groups of people, being rushed or pressed to remember or being asked to do a task that’s too difficult can cause anxiety. As a person with Alzheimer’s becomes upset, the ability to think clearly declines even more.
  • Monitor wandering. Wandering is a common problem. In some cases, a pocket card with simple instructions, such as “Call home” (with a phone number below) may help. Make sure your loved one wears a bracelet with his or her name, phone number and a notation such as “memory impaired.” The Alzheimer’s Association offers this resource through its national Safe Return Program. Also try to determine the cause of wandering. It may simply be a signal that the person with Alzheimer’s is looking for something, such as a bathroom, or is seeking a meaningful activity or reassurance. Some experts believe taking your loved one for a vigorous daily walk helps reduce wandering.
  • Establish a nighttime ritual. Behavior is often worse at night. Try to establish going-to-bed rituals that are calming and away from the noise of television, meal cleanup and active family members. Leave night lights on to prevent disorientation. Limiting caf- feine during the day, discouraging daytime napping and offering opportunities for exercise during the day may help prevent night- time restlessness.
  • Enhance communication. When talking with your loved one, stand where you can be seen and touch his or her arm or shoul- der to focus attention. Speak slowly, in simply sentences and don’t rush the response. Present only one idea or instruction at a time. Use gestures and cues, such as pointing to objects. Avoid asking questions or offering difficult choices because trying to come up with answers may prove frustrating.
  • Create a safe environment. Make your home familiar and safe. Keep furniture in the same place to avoid clutter and help prevent falls. Install locks on cabinets containing medicines, alcohol, guns, toxic substances and dangerous utensils and tools. Remove electrical appliances from your bathroom to prevent shocks, set your water heater no higher than 120 F to prevent scald- ing, and install grab rails to prevent falls.
  • Encourage exercise. Exercise carries many benefits for someone with Alzheimer’s disease. The fact that these benefits often are the same for people without Alzheimer’s disease does not lessen their importance. In fact, it just makes exercise a more important activity for caregivers and people with Alzheimer’s to engage in together. The main benefits of exercise include improved strength, endurance and cardiovascular health. Exercise also can improve energy, sleep, circulation, stamina and mood. For peo- ple with Alzheimer’s disease, exercise can also help retain motor skills, impart a sense of meaning or purpose, create a calming

 

effect and sustain strength, flexibility and balance — lessening the risk of serious injury from a fall.

 

In addition to helping someone with Alzheimer’s deal with daily challenges, family members and loved ones should begin to try and answer practical, long-term questions about caregiving as soon as possible. These questions may involve personal, legal and financial issues. Some examples might include:

  • How long can a person with Alzheimer’s safely drive, work or live alone?
  • Can family or friends provide the care necessary for the current phase and later progression of the disease?
  • Is money available for professional in-home care or a care facility now or in the future if the need arises?

It’s important for people with Alzheimer’s, their doctors and their families to discuss these matters early on in the disease. In general, people with Alzheimer’s should be afforded as much independence as is safely possible, for as long as possible.

 

PREVENTION

 

Right now, there’s no way to prevent the onset of Alzheimer’s disease. But researchers continue to look for ways to reduce risk of the disease. Several leads are hopeful, but preliminary. They include:

  • Nonsteroidal anti-inflammatory drugs (NSAIDs). A study released in 1996 showed that the NSAIDs ibuprofen (Advil, Motrin, Nuprin), naproxen sodium (Aleve) and indomethacin (Indocin) reduced the risk of Alzheimer’s by 30 percent to 60 percent. Doctors believe brain inflammation occurs as one part in the development of Alzheimer’s. Investigators were uncertain why aspirin, which is also an anti-inflammatory drug, and acetaminophen (Tylenol), which is not, had no effect. The study reinforced an earlier one that compared NSAID use in twins. That study found that a twin who used NSAIDs regularly, usually for arthritis, was 10 times less likely to develop Alzheimer’s than the twin who wasn’t taking an NSAID. But doctors don’t recommend taking NSAIDs, which can cause gastrointestinal bleeding, solely to prevent Alzheimer’s until more research confirms these results.
  • Vitamin E and selegiline hydrochloride. Researchers are studying whether vitamin E and selegiline (Eldepryl), a drug used to treat Parkinson’s disease, may hold a possible protective effect against the progression of Alzheimer’s. These substances may slow the rate of decline in people with moderately severe Alzheimer’s. Vitamin E and selegiline are antioxidants and may help prevent brain cell damage by destroying toxic free radicals. Free radicals are byproducts of normal cell function. Some scientists believe free radicals are discharged by immune cells that are in the brain responding to chronic brain inflammation from Alzheimer’s. The free radicals may attach to molecules in brain cells and disrupt brain cell function.
  • Estrogen. Alzheimer’s disease in older women may be related to estrogen deficiency. Estrogen helps keep the brain healthy by boosting production of a key neurotransmitter, helping prevent plaque deposits and improving blood flow to the brain. Studies show that hormone replacement therapy after menopause can reduce a woman’s risk of developing Alzheimer’s by 30 percent to 40 percent. But because the impact of estrogen still isn’t proven, women shouldn’t begin hormone replacement therapy solely to prevent Alzheimer’s without the approval of their doctor.
  • Mental fitness. Studies show that maintaining mental fitness may delay onset of dementia. One such study focused on a large order of nuns reported to have significantly lower rates of Alzheimer’s, even though their average age was 85 and many were in their 90s. Many of the nuns had advanced academic degrees and led an intellectually challenging life into old age. Some research- ers believe that lifelong mental exercise and learning may promote the growth of additional synapses, the connections between neurons, and delay the onset of dementia. Other researchers argue that advanced education gives a person more experience

with the types of memory and thinking tests used to measure dementia. This advanced level of education simply may help some people “cover” their condition until later.

 

COPING SKILLS

 

People with Alzheimer’s disease often experience a mixture of emotions — confusion, frustration, anger, fear, uncertainty, grief and depression. You can help a person cope with the disease by being there to listen, reassuring the person that life can still be enjoyed, providing unconditional love and doing your best to help the person retain dignity and self-respect.

 

Caring for a person with Alzheimer’s disease can be an all-absorbing experience. The physical and emotional demands of caregiv- ing can be exhausting. Feelings of anger and guilt, frustration and discouragement, worry and grief and social isolation are com- mon. If you’re a caregiver for someone with Alzheimer’s disease, you can help yourself and help prevent caregiver burnout by:

  • Asking friends or other family members for help when you need it.
  • Taking care of your health.
  • Learning as much about the disease as you can. Ask questions of doctors, social workers and others involved in the care of your loved one.
  • Joining a support group.

 

Many people with Alzheimer’s and their families can benefit from counseling or local support groups. Contact your local Alzheimer’s Association affiliate to get connected with support groups, physicians, resources and referrals, home-care agencies, supervised living facilities, a telephone help line and educational seminars.

 

COMPLEMENTARY AND ALTERNATIVE MEDICINE

 

Some alternative medicines may benefit a person with Alzheimer’s. The herb gingko biloba continues to be studied for its brain-enhancing effects in both healthy people and people with Alzheimer’s. But it’s not proven to improve memory or prevent Alzheimer’s.

Some limited studies suggest that aromatherapy — using fragrant plant oils to relax and affect the body — and massage can play a supportive role in Alzheimer treatment.

 

DS00161

October 06, 2000

© 1998-2002 Mayo Foundation for Medical Education and Research (MFMER). All rights reserved.

 

MULTIPLE SCLEROSIS

 

Multiple sclerosis (MS) is a chronic, potentially debilitating disease that affects your brain and spinal cord (central nervous system). The illness is probably an autoimmune disease, which means your immune system responds as if part of your body is a foreign substance.

In the case of MS, your body directs antibodies and white blood cells against proteins in the myelin sheath surrounding nerves in the brain and spinal cord. This causes inflammation and injury to the sheath and ultimately to the nerves. The result may be multiple areas of scarring (sclerosis). The damage slows or blocks muscle coordination, visual sensation and other nerve signals.

MS occurs in five main types:

  • Benign. In 10 percent to 15 percent of people with MS, symptoms are mild to moderate, don’t worsen and don’t lead to permanent disability.
  • Relapsing-remitting. In this type, one or two flare-ups of MS occur every 1 to 3 years, followed by periods of remission. The flare-ups typically appear suddenly, last a few weeks or months and then gradually disappear. Symptoms may accumulate with each recurrence. About 85 percent of people with MS begin with this form, and more than half have this form of the disease at any one time.
  • Primary progressive. After symptoms first appear, deterioration occurs without periods of remission. About 15 percent to 20 percent of people with MS begin with this pattern of the disease.
  • Secondary progressive. Usually after years of relapsing-remitting MS, at least half of people with relapsing-remitting MS enter a stage of continuous deterioration. Sudden relapses may occur, superimposed upon the continuous deterioration that has developed.
  • Progressive relapsing. This is primary progressive MS with the addition of sudden episodes of new symptoms or worsened existing ones. This form is rare, occurring in less than 5 percent of people with MS, and behaves in a manner similar to primary progressive MS.

 

MS generally first occurs in people between the ages of 20 and 40. An estimated 330,000 Americans have MS. The disease is twice as common in women as in men.

 

SIGNS AND SYMPTOMS

 

Symptoms of MS vary depending on the location of your affected nerve fibers. Signs and symptoms may include:

  • Numbness, weakness or paralysis in one or more limbs
  • Brief pain, tingling or electric shock sensations
  • Tremor, lack of coordination or unsteady gait
  • Impaired vision with pain during movement in one eye
  • Disordered eye movements, causing double vision or moving field of vision
  • Fatigue
  • Dizziness

As the disease gradually worsens, muscle spasms, slurred speech, vision loss, problems with bladder, bowel or sexual function and paralysis may develop. Occasionally, mental changes such as forgetfulness or confusion occur.

 

CAUSES

 

Your central nervous system contains millions of nerve cells joined by nerve fibers. Electrical impulses originate in nerve cells and travel along the nerve fibers to and from your brain. Myelin, a fatty substance, coats and protects the fibers, similar to the way insulation shields electrical wires.

Strong evidence suggests that MS results from an autoimmune process. Before symptoms of MS develop, immune cells flood into the central nervous system. These cells normally circulate into and out of the brain, checking for viruses and helping fight disease. But doctors believe that with MS, the immune cells that have been primed outside the brain by a protein that mimics myelin mis- takenly destroy the cells that produce the myelin sheath.

Myelin becomes inflamed, swollen and detached from the fibers. Eventually, the detached myelin is destroyed. Firm or hardened (sclerosed) patches of scar tissue form over the fibers. When nerve impulses reach a damaged area, some impulses are blocked or delayed from traveling to or from your brain. Ultimately, this process leads to degeneration of the nerves themselves, which likely accounts for the permanent disabilities that develop in MS.

No one knows what triggers this process. Some researchers suspect a virus in either immune cells or in sheath-producing cells.

 

 

 

These factors may increase your risk of developing MS:

 

 

RISK FACTORS

 

  • Heredity. People of Northern European descent, especially those of Scandinavian heritage, may be genetically predisposed to MS. The disease appears to run in families. As many as 20 percent of people with MS have at least one affected relative. Compared with the general population, if you’re a first degree relative (child, sibling) of someone with MS you have a 20- to 40-fold increase in risk of eventually having MS.
  • Exposure to common viruses. Viruses such as the human herpes virus 6 (HHV-6) or bacteria may trigger the disease in some people with a genetic tendency. This requirement of an environmental trigger on top of a genetic predisposition may explain why in identical twins, only one twin develops MS 70 percent of the time.

 

WHEN TO SEEK MEDICAL ADVICE

 

Numbness and tingling in your arms, legs or elsewhere in your body and double vision are among the early indications of mul- tiple sclerosis. Although numbness most often does not indicate MS, if you have these symptoms, see your doctor to determine whether a neurological condition such as MS may be the cause.

Your doctor may base a diagnosis of MS on the following:

 

DIAGNOSIS

 

  • Medical history. This involves your doctor reviewing with you your symptoms and the pattern of the symptoms.
  • Neurological examination. This examination systematically tests various parts of your nervous system, including your reflexes, muscle strength, muscle tone and sensations of pain, heat, touch and vibration. Your doctor may also observe your gait, posture, coordination and balance, and ask you questions to help determine the clarity of your thinking, judgment and memory.
  • Magnetic resonance imaging (MRI) scan. The cylinder-shaped MRI scanner creates tissue slice images on a computer from data generated by a powerful magnetic field and radio waves. Your doctor can view these images from any direction or plane. Examinations of the brain, neck, spinal cord and soft tissues are best seen by an MRI scan. Your doctor may be able to see areas of your nervous system where damage to myelin has occurred.
  • Spinal tap (lumbar puncture). This procedure can determine the concentration of immune cells and proteins in your cerebrospinal fluid, the fluid that surrounds your brain and spinal cord. While you lie on your side with knees pulled to your chest, your doctor uses a thin, hollow needle to remove small samples of your cerebrospinal fluid from within your spinal canal for laboratory analysis.

 

TREATMENT

 

If your attacks are mild or infrequent, your doctor may advise a wait-and-see approach, with counseling and observation. However, if your diagnosis is a relapsing form of the disease, the form that affects the great majority of people with MS, your doc- tor may recommend treatment with disease-modifying medications as soon as possible.

 

These medications include:

  • Beta interferons. Interferon beta-1B (Betaseron) and interferon beta-1A (Avonex) are genetically engineered copies of proteins that occur naturally in your body. They help fight viral infection and regulate your immune system. You inject yourself with Betaseron every other day or with Avonex once a week. These medications have reduced flares of MS by up to 30 percent. It’s uncertain which of their many actions lead to a reduction in disease activity and what their long-term benefits are. The Food and Drug Administration has approved beta interferons only for people with relapsing forms of MS who can still walk. Beta interferons don’t reverse damage and haven’t been proven to prevent permanent disability. A small percentage of people develop antibodies to beta interferons, which may make them less effective. Other people can’t tolerate the side effects, which may include symptoms similar to those of influenza (flu). Mayo Clinic neurologists generally recommend beta interferons for people who have more than one severe attack of MS a year and those who don’t recover well from flare-ups. The treatment may also be used for people who have a significant buildup of new lesions as seen on an MRI scan, even when there may not be major new symptoms of dis- ease activity.
  • Glatiramer. This medication is an alternative to beta interferons if you have relapsing-remitting MS. Glatiramer (Copaxone) is as effective as beta interferons in curbing MS attacks. Doctors believe that Copaxone works by blocking your immune system’s attack on myelin. You must inject Copaxone once daily. Side effects may include flushing and shortness of breath following injection.

 

Medications to relieve symptoms in progressive MS may include:

  • Corticosteroids. Doctors most often prescribe oral or intravenous corticosteroids to reduce inflammation in nerve tissue and shorten the duration of flare-ups. Prolonged use of these medications, however, may cause side effects such as osteoporosis and hypertension.
  • Muscle relaxants. Tizanidine (Zanaflex) and baclofen (Lioresal) are oral treatments for muscle spasticity. If you have MS, you may experience muscle stiffening or spasms, particularly in your legs, which can be painful and uncontrollable. Lioresal often increases weakness in the legs. Zanaflex appears to control muscle spasms without leaving your legs feeling weak but can be associated with drowsiness or a dry mouth.
  • Medications to reduce fatigue. These may include the antidepressant medication fluoxetine (Prozac), the antiviral drug amanta- dine (Symmetrel) or a medication for narcolespy called modafinil (Provigil). All appear to work because of their stimulant properties.

 

Many different medications may be used for the muscle stiffness, depression, pain and bladder control problems often associated with MS. Drugs for arthritis and medications that suppress the immune system may slow MS in some cases.

 

In addition to medications, these treatments may relieve symptoms of MS:

  • Physical and occupational therapy. The goal is to preserve independence by having you do strengthening exercises and use devices to ease daily tasks.
  • Counseling. Individual or group therapy may help you and your family cope with MS and relieve emotional stress.

 

Researchers are evaluating various experimental approaches to treating MS:

  • Plasma exchange. This procedure involves removing your blood and mechanically separating the blood cells from the fluid (plasma). Your blood cells then are mixed with a replacement solution, typically albumin, or a synthetic fluid with properties like plasma. The solu- tion with your blood then is returned to your body. It’s uncertain why plasma exchange works. Replacing your plasma may dilute the activity of the destructive factors in your immune system and help you to recover. This treatment isn’t for everyone. It may be an option for people with sudden, severe attacks of MS-related disability who don’t respond to high doses of steroid treatment. The treatment is most helpful for people with a relatively mild pre-existing disability before the attack. Plasma exchange has no proven benefit beyond 3 months from the onset of the neurological symptoms.
  • Intravenous immunoglobulin (IVIg). This involves your receiving injections of antibodies from a group of donors. Studies in Europe have shown that IVIg can reduce the number of attacks in relapsing forms of MS. Although IVIg has been studied at Mayo Clinic for the potential to stimulate growth of myelin, current commercial preparations of IVIg seem to be ineffective in doing so. It’s possible that more specific antibodies that have been found to promote myelin growth in animals with diseases that mimic MS may be found to be effective in humans in the future.
  • Antiviral medications. Doctors may one day use antiviral treatments, such as the drug acyclovir, to treat MS. A study found that more

 

than one-third of people with MS had detectable levels of the human herpes virus 6 (HHV-6). However, individuals without MS also may show evidence of prior infection with HHV-6, so the significance of this finding is not fully known.

 

SELF CARE

 

Here are steps you can take to relieve symptoms of multiple sclerosis:

  • Get enough rest. Fatigue is a common symptom of MS, and getting your rest may make you feel less tired.
  • Exercise. Aerobic exercise may offer significant benefits if you have mild to moderate MS. Those benefits include improved strength, muscle tone, balance and coordination, and help with depression.

* Be careful with hot tubs. Soaking too long in hot water may cause extreme muscle weakness. Although some people with MS aren’t bothered by heat and may enjoy warm baths and showers, until you know how you’ll react be very careful before exposing yourself to any extremely warm situation. Don’t get into a hot tub unless there’s someone nearby who can pull you out if neces- sary. If you do experience heat-related worsening of symptoms, merely cooling down for a few hours usually will return you to your normal state.

  • Consider air conditioning. If you experience heat-related worsening of MS symptoms and you live in a hot and humid area, strongly consider having air conditioning in your home.
  • Eat a well-balanced diet. A healthy diet and taking vitamins can help keep your immune system strong.
  • Increase the amount of fiber in your diet. Constipation commonly occurs with multiple sclerosis. A diet high in fiber, with plenty of whole grains, fruits and vegetables, can counter constipation.

 

COPING STRATEGIES

 

As is true with other chronic diseases, living with multiple sclerosis can place you on a roller coaster of emotions. Here are some suggestions to help you even out the ups and downs:

  • Maintain normal daily activities as best you can.
  • Stay connected with friends and family.
  • Continue to pursue hobbies that you enjoy and are able to do.

 

If MS impairs your ability to do things you enjoy, talk with your doctor about possible ways to get around the obstacles. Remember that your physical health can directly impact your mental health. Denial, anger and frustration are not uncommon when you learn life has dealt you something painful and unexpected. Professionals, such as therapists or behavioral psychologists, may help you put things in perspective. They can also teach you coping skills, including relaxation techniques, that may be helpful. Sometimes, joining a support group, where you can share experiences and feelings with other people, is a good approach. Ask your doctor what support groups are available in your community.

In addition, many chronic illnesses are associated with an increased risk of depression. This isn’t a failure to cope but may indi- cate a disruption in the body’s neurochemistry that can be helped with appropriate medical treatment.

If you have a chronic illness such as MS, there’s no denying that it affects your life. But how much you allow it to determine the quality of your life depends, to some extent, on the way you choose to live day to day.

 

Additional Resources

National Institute of Neurological Disorders and Stroke International MS Support Foundation

The Multiple Sclerosis Foundation National Multiple Sclerosis Society Multiple Sclerosis Association of America DS00188

April 13, 2001

© 1998-2002 Mayo Foundation for Medical Education and Research (MFMER). All rights reserved.

 

TREATMENT OF BIPOLAR DISORDERS

 

Most people with bipolar disorder take medication to regulate their moods. Lithium has been widely used as a mood stabilizer. Also used widely as a mood regulator are the antiseizure medications valproic acid and divalproex. Sometimes, doctors also use antidepressant medications to treat bipolar disorder. These may include paroxetine, fluoxetine, sertraline or bupropion, among others. In other circumstances, doctors may use antipsychotic medications such as risperidone, olanzapine or quetiapine, among others. You may need to take medications for several weeks before they reach their full effect.

 

TREATMENT OF EPILEPSY

 

Finding the right medication and dosage can be complex. It might take more than one drug, or trying several different drugs until the right one is found. Medications available for the treatment of seizures include phenytoin, carbamazepine, valproic acid, divalproex, levetiracetam, gabapentin, phenobarbital, ethosuximide, clonazepam, lorazepam, diazepam, primidone, oxcar- bazepine, lamotrigine, topiramate, felbamate, tiagabine and zonisamide.

All of these medications have some side effects, which may include mild fatigue, dizziness and weight gain.

As weight gain is a common side effect of antidepressants, antiepileptic drugs, mood stabilizers and antipsychotics, we find it proper to mention the consequences of obesity.

 

PERIPHERAL NEUROPATHY

 

OVERVIEW

 

Peripheral neuropathy is a term used to describe disorders of your peripheral nervous system. Your peripheral nervous system includes nerves in your face, arms, legs, torso, and some nerves in your skull. In fact, all of your nerves not located in your central nervous system — which includes the brain and the spinal cord — are peripheral nerves.

Neuropathies may affect just one nerve (mononeuropathy) or several nerves (polyneuropathy). Your nerves provide communication between your brain and your muscles, skin, internal organs and blood vessels. When damaged, your nerves can’t communicate properly, and that miscommunication causes symptoms such as pain or numbness.

Peripheral neuropathy often affects people with diabetes and autoimmune diseases such as rheumatoid arthritis and lupus. Certain vitamin deficiencies, some medications and alcoholism can also damage peripheral nerves.

Treating the underlying condition may relieve some cases of peripheral neuropathy. In other cases, treatment of peripheral neuropathy may focus on managing pain. Peripheral nerves have a remarkable ability to regenerate themselves, and new treatments for peripheral neuropathy using nerve growth factors or gene therapy may offer even better chances for recovery in the future.

 

SIGNS AND SYMPTOMS

 

Neurological symptoms may occur related to your central nervous system, which consists of your brain and spinal cord, or your peripheral nervous system, which links your spinal cord and brain to all other parts of your body. The extensive network of peripheral nerves includes the motor nerves, which help your muscles contract, and the sensory nerves, which allow you to feel a range of sensations. In addition, your peripheral nerves help control some of the involuntary functions of the autonomic nervous system, which regulates your internal organs, sweat glands and blood pressure.

Unfortunately, peripheral nerves are fragile and easily damaged. Damage to a peripheral nerve can interfere with the communication between the area it serves and your brain, affecting your ability to move certain muscles or feel normal sensations. Your symptoms will depend on the cause of your neuropathy and on which nerve or nerves are involved.

 

If a sensory nerve is damaged, you’re likely to experience symptoms that may include:

*Pain

*Numbness

*Tingling

*Muscle weakness

*Burning

*Loss of feeling

These symptoms often begin gradually. You may have a tingling sensation or numbness that starts in your toes or the balls of your feet and spreads upward. Tingling might also begin in your hands and extend up your arms. In some cases your skin may become so sensitive that the slightest touch is agonizing. You may also have numbness, or even a complete lack of feeling, in your hands or feet.

 

At times your symptoms may be barely noticeable, and some people go years without realizing anything is wrong. For others, symptoms are constant, and especially at night may be almost unbearable. Signs and symptoms may include:

*The sensation that you’re wearing an invisible glove or sock

*Burning pain

*Sharp, jabbing or electric-like pain

*Extreme sensitivity to touch, even light touch

*Lack of coordination

If your motor nerves are affected, you may have weakness or paralysis of the muscles controlled by those nerves. And if you have damage to nerves that control certain functions of the autonomic nervous system, you might have bowel or bladder problems, reduced sweating or impotence. You might also experience a sharp fall in your blood pressure when you stand up, which may cause you to faint or feel lightheaded.

 

CAUSES

 

A number of factors can cause neuropathies. When a single nerve is affected, the most likely cause is trauma or some type of repetitive use that puts pressure on the nerve. Nerve pressure can result from using a cast or crutches, spending a long time in an unnatural position — such as typing at a computer keyboard — or having a tumor or abnormal bone growth.

When damage occurs to several nerves, the cause frequently is diabetes. At least half of all people with diabetes develop some type of neuropathy. Other common causes include alcoholism, HIV/AIDS, inherited disorders, amyloidosis and a deficiency of certain vitamins, especially B vitamins.

 

Other causes of peripheral nerve damage may include:

*Other diseases. These include autoimmune diseases, such as lupus and rheumatoid arthritis, kidney disease, liver disease and an underactive thyroid (hypothyroidism).

*Exposure to poisons. These may include some toxic substances and certain medications — especially those used to treat cancer.

*Genetic makeup. You may inherit a tendency to develop peripheral neuropathy.

*Bacterial or viral infections. An acute condition called Guillain-Barre syndrome frequently causes severe damage to all or part of your peripheral nerves by destroying the myelin sheath that covers nerve fibers. The myelin sheath acts as an insulator for your nerves and helps conduct nerve impulses. Although the exact cause of Guillain-Barre syndrome isn’t known, most cases occur after an infection, surgery or immunization.

 

Unfortunately, it’s not always easy to pinpoint the cause of peripheral neuropathy. In fact, if your neuropathy isn’t associated with diabetes, it’s possible the cause may never be found.

 

RISK FACTORS

 

Having diabetes places you at high risk of developing peripheral nerve damage. In fact, at least half of people with diabetes have some form of neuropathy. The risk increases the longer you have diabetes, and is highest for those who’ve had the disease for more than 25 years. Your risk is even greater if you are older than 40 or have difficulty controlling your blood sugar level.

 

Although researchers don’t understand exactly how damage occurs, a high blood sugar level seems to impair your nerves’ ability to transmit signals. You can help reduce your risk by carefully following a medically approved plan for keeping your blood sugar level as close to normal as possible.

 

Your risk of developing peripheral neuropathy is also higher if you have one or more of the following risk factors:

*Alcohol abuse. Excessive drinking of alcoho

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