7th October 2001
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Support base to fight Alzheimer's

Imagine every little thing you learned since the day you were born. That first smile, the day you recognized the significance of the word 'amma', the day you learned to walk, to talk, to do every little thing that is now no longer special because, you know how.

Just think of a disease which takes away, day by day, all you've learned and stored away in your memory, to use 'for the rest of your life'.

Alzheimer's is a disorder of the brain primarily affecting memory skills, and is seen mainly among people above the age of 65 years. No cause has been found yet, even though there are an estimated 18 million people around the world suffering from dementia, with two-thirds of this population living in Asia.

The number of Alzheimer's patients in Sri Lanka is yet unknown, but a survey is presently being carried out.

The Lanka Alzheimer's Foundation was launched this week, on October 3, with the Vice Chairman of Alzheimer's Disease International (ADI), Dr. K. Jacob Roy also the Chairman of Alzheimer's Related Disorders Society of India, arriving in Colombo for the occasion.

"Alzheimer's is going to be a real problem which we all have to address in the coming years," stressed Dr. Roy. "We can't ignore it. Even if we don't get Alzheimer's someone in our family definitely will be going through this. And we can't ignore it."

"We need to create ways to give more support to families who really go through hell looking after people with Alzheimer's," said Dr. Roy describing his feelings of helplessness watching his mother struggling to take care of his father who died eight years ago after suffering from Alzheimer's Disease.

"Even among health professionals, the understanding of this disease is low. There is an element of reluctance to get involved with this work because there is no known cure and you are dealing with a disease that has got a down road," said Dr. Roy.

This disease affects the patient's personality and a mother who was a caring person could turn into a demon, Dr. Asita de Silva, a Trustee on the Board of the Lanka Alzheimer's Foundation said.

A patient must never be closeted away, but kept in a place where he/she is open to as much stimuli as possible. Then stimulation will go on and it is believed that deterioration will be less rapid.

Patients, due to ignorance among family members are frequently blamed for their abnormal behaviour. They are sometimes indistinguishable from victims of dementia.

The problem for Sri Lanka could be significant. Sri Lanka currently has the highest rate of ageing in the world and a large population of elderly, some two million people over the age of 60. In 20 years this will double and by the year 2040 we will have six million people over 60 years. However, Sri Lanka does not have a single specialist for geriatric care.

Due to the difficulty in diagnosing Alzheimer's and because we do not know the cause, the available treatment is extremely unsatisfactory, Dr. de Silva said, adding that there are about three or four drugs registered in the world, and these are not yet available in Sri Lanka.

This is one condition where there is no known cure, so what is possible is care, said Dr. Roy, adding that we should aim at giving better care, rather than looking for cures. We need to train the families, we need to have more trained people to care for them, because there are stages when they need one-to-one care.

It is possible that by early detection and treatment, the onset of Alzheimer's, can be delayed, explained Dr. de Silva. Even putting it off by five years will ensure a higher quality of life for the individual and his family, he said.

Caring round the clock

Dr. Selvi Perera takes care of an Alzheimer's patient her mother, Clara (95).

"My mother is 95 and she lives with me. She is able to do the normal activities of daily living and can walk but is very forgetful. She will have breakfast, then say, "Why haven't you given me breakfast?" and get very angry when she is told that she has already had it.

"It's very difficult sometimes. After all, we are also human beings and with so many pressures. Sometimes it's a bit too much for even me as a doctor who understands the disease to cope. I feel embarrassed to say that but really it's the truth. So you have to have some kind of support base and that is what ADI is about, and that is what we are trying to do.

"As the Head of the Ceylon College of Physicians, in 1993 my theme was geriatrics, and I have tried in many ways to interest people in this speciality.

"We should have day care centres, and centres where these patients can come in for what is called respite care, where the care givers are given a respite by keeping the patients in the hospital," Dr. Perera said.

Bulge that gets under your skin

Hernias are the common- est reason why males seek surgery. It is not a serious condition though it can sometimes become complicated. However, what many do not realize is that it is also preventable to a significant extent. Here's how:

The muscles in the stomach-or abdominal wall- are those responsible for preventing the organs and intestines inside the body from falling out.

However, at times these muscles become weak and part of the intestine bulges through and appears as a lump under the skin - called a hernia. The commonest of these appear in the groins and are called inguinal hernias.

Any activity that raises the pressure within the abdomen, such as lifting heavy weights, coughing, even straining on the toilet, can cause a weakness or tear in these muscles. Vigorous exercise also often results in hernias. Sometimes the weakness is already present, for example, around the umbilicus (umbilical hernia) in children - or under the scar of an operation (incisional hernia).

The first sign of a hernia is the telltale lump, which doesn't hurt, and gets bigger if you cough. It is then prudent to see a doctor to ascertain whether it is, in fact, a hernia.

Although for most men, hernias just cause discomfort and are a bit of a nuisance, the real worry is that they can strangulate. When this happens, their blood supply is cut off, and this needs an emergency operation to prevent further complications.

Though conservative measures such as 'hernia belts' can be used to reduce the discomfort of a hernia the treatment of choice is a simple operation which not only removes the hernia but also repairs the abdominal wall to minimize the chances of a recurrence.

But, as always, prevention is better than cure. Maintaining an ideal weight helps. Lifting weights must be done correctly - with the back straight and bending at the knees. Stopping smoking will help prevent excessive coughing, and eating a good fibrous diet with plenty of water helps avoid constipation and the need to strain on the toilet. All these factors will help avoid having to go under the surgeon's scalpel unnecessarily.

Don't turn blind eye to symptoms

Glaucoma is an often unrecognized and ignored cause of blindness. Yet, if discovered early enough during the early stages of the condition it can be managed successfully, enabling a patient to retain near normal vision.

In glaucoma, the Optic nerve (the eyesight nerve) is damaged at the back of the eye, where it leaves the eyeball to travel to the brain. This damage is caused by either increased pressure within the eye or a weakness in the Optic nerve itself. In most people with glaucoma, both of these factors operate to some degree.

However, it is worthwhile noting that increased pressure within the eye is not usually related to blood pressure, but instead to poor drainage of fluid from the eye.

There are four different types of glaucoma: chronic, acute, secondary, and developmental. Developmental is the main type of glaucoma that affects babies and children.

In such cases, there will usually be evidence of impaired vision at an early age.

In chronic glaucoma, the drainage channels from the eye that allow fluid out, become blocked over the years, leading to a slow rise in pressure, and a gradual painless deterioration in vision (unlike acute glaucoma which can be very painful).

There is classically a loss of peripheral sight, leading to a condition known as tunnel vision.

If glaucoma is not treated, even this tunnel vision gradually disappears.

The damage is done by pressure on the Optic nerve. The amount of damage depends on many factors, including the degree of pressure, how quickly it develops and, the general state of the Optic nerve itself. Very high pressures can rapidly damage the nerve and, acute glaucoma needs immediate treatment. But in chronic glaucoma, the damage is so gradual and painless, that a patient may not realise that he has a problem until a considerable amount of damage has been done.

The main aims of treatment are to reduce pressure in the eye and improve the blood supply to the optic nerve. It includes eye drops to reduce the production of fluid in the eye or open up the drainage channels, or an operation to improve drainage.

Chronic glaucoma becomes more common with increasing age, so be alert for early symptoms. It is recommended that a person gets his eyes tested every two years after the age of 40.

The tests should include 3 specific tests for glaucoma: examination of the optic nerve, measurement of the pressure in the eye and checking of peripheral vision.

In many cases, the visual problems of chronic glaucoma can be almost completely stopped in their tracks if diagnosed without delay and, treated promptly and effectively.

It may not be possible to restore lost vision, but the damage can be kept to a minimum and, reasonably good sight (certainly good enough to drive) maintained.

Lack of iodine and swollen necks

A goitre simply means an enlargement of the thyroid gland, which can usually be seen as a smooth generalized swelling in the front of the neck, below the voice box or larynx. Confusingly, when a person has a goitre their thyroid gland may be overactive (a condition known as hyperthyroidism), under-active (hypothyroidism) or even just normally active (euthyroid).

There are several common situations which make the thyroid gland enlarge into a goitre but without disturbing its ability to make thyroid hormones. Changes in hormonal status, especially puberty, pregnancy or the oral contraceptive pill can all do this.

But perhaps the commonest cause around the world is a deficiency of iodine in the diet. The thyroid gland needs iodine to produce its main hormone, thyroxine, and a deficiency makes the gland swell. It may then manage to function normally or become hypothyroid.

Tumours or thyroid cancer can also cause swelling of the gland without a change in hormone levels, at least initially, but this swelling may be localized or lumpy- and this is an important reason why such swellings should be shown to a doctor, especially if it is enlarging.

A condition known as toxic goitre can develop in Graves disease - one of the commonest types of hyperthyroidism, where the body's antibodies stimulate thyroid hormone production - as well as in other types of hyperthyroidism. Typical symptoms of hyperthyroidism include weight loss, tremor, warm dry skin, increased appetite, nervous agitation, insomnia and muscle weakness. Drugs used to treat hyperthyroidism can also result in the development of a goitre.

A goitre may also occur in various conditions where the gland becomes inflamed, damaged and less active, including Hashimoto's thyroiditis (an autoimmune disease) and a condition called de Quervain's thyroiditis. Symptoms include tiredness, lethargy, muscle weakness, cramps, dry skin and hair, hair loss, husky voice, weight gain, depression and other psychiatric problems. However in many cases of hypothyroidism there is no goitre.

Now, differentiating between hyperthyroidism and hypothyroidism is made easy by the availability of tests to determine thyroid hormone levels.

The test is costly in the private sector but it can also be done in government hospitals.

Hypothyroidism in children is an important- an treatable cause of mental sub-normality- and therefore it is important for a newborn child to be assessed by a doctor, who will look for telltale signs of the condition. These children, of course, will not have a goitre!

Antibiotics: Used or abused?

Ever since Sir Alexander Fleming discovered penicillin almost fifty years ago, antibiotics would have saved millions of lives combating diseases that were until then fatal. But today, the widespread use-and abuse- of antibiotics has led to a different scenario. Diseases are becoming increasingly resistant to these drugs, patients are trying to medicate themselves and even doctors are being accused of over-prescribing antibiotics. What then, must be done?

Our current armoury of antibiotics may not be effective against bacteria which are responsible for many nasty and often fatal infections. For example, penicillin used to easily kill off the bacteria called streptococcus pneumoniae - a common cause of ear infections, pneumonia, and sometimes meningitis - now in about half of these infections penicillin doesn't work. More worrying is that some bacteria have learned to resist all currently available antibiotics. This has already happened in Japan. They have become the widely talked about "super-bugs".

No one person is to blame for the problem we face; everyone is at fault. The problem lies in the fact that the miracle discovery is wrongly believed to be a miracle cure. Until now doctors have regularly given in to patient demands and prescribed antibiotics inappropriately. This has meant that bacteria are given the opportunity to learn how to protect themselves. They do this by changing their structure and passing this knowledge on to other bacteria.

Doctors often feel pressurized by patients "to do something" to speed up their recovery when the real solution is time. Antibiotics only work against bacteria and are useless against viruses. The vast majority of sore throats, ear infections, coughs and colds are caused by viruses, not bacteria. So when a doctor diagnoses a viral infection don't insist on antibiotics. Taking antibiotics for the wrong reason will help the bacteria to become resistant. It may also cause unpleasant side effects leave the body open to far more dangerous infections.

However, if your doctor decides you do need antibiotic treatment he will recommend the most suitable one. This means that the antibiotic prescribed may be different to the one you've had previously, even if the same part of your body is affected. The course may be much shorter too. Always, follow the doctor's instructions in this regard and don't ask for a "stronger" antibiotic to get rid of the illness quickly.

Without doubt it is the people who do not finish their course of antibiotics completely who have contributed to the emergence of resistance. In future, even if you're feeling better, you must finish the course which usually lasts five to seven days.

And finally, never self-medicate: even if the present illness is similar to a previous ailment you had and you know what drug was used. Even pharmacists are guilty in this regard by offering antibiotics over the counter when they should be issued only on a doctor's prescription. Remember, repeated self-medication will only result in your body developing bacteria that are resistant to drugs!

When that dreaded pain comes on

Almost all females have known the mis- ery of period pains at one time or another. Surveys show that nearly three-fourths of young women regularly use painkillers for period pains and at least half of them say the pain seriously disrupts their life at times. Yet, can so common a symptom be called a disease?

The expectation that period pain is a normal part of life may explain why it takes, on average, eight years for the commonest 'disease' causing severe period pains, a condition called endometriosis, to be diagnosed. Most often women simply suffer through their menstrual pains.

In fact the pain of periods is caused by contractions of the uterus or womb. Such contractions occur through the muscular wall of the womb even without periods but women are usually unaware of them. During a period these contractions are stronger than normal, and during labour they are stronger still.

Each contraction causes the blood supply to the womb to be temporarily cut down as the blood vessels in the muscle wall are compressed. As the tissues are starved of oxygen, chemicals which trigger pain are released. At the same time the body is also releasing chemicals called prostaglandins, which induce stronger contractions, and which may directly cause pain in the womb. As the contractions get stronger, the pain increases.

The aim is to help the womb shed its delicate lining (as a period or bleed) so that a new lining can be grown each month ready for a fertilized egg to implant itself. This is an essential part of female fertility, but pain is a side effect. However, this pain is abnormal at times and it is important to find out if it is so. If severe period pain (known as dysmenorrhoea) has been experienced since around the time periods first started, then it's unlikely to be abnormal.

But if periods have become very painful later on- in the twenties and thirties- then it is more likely that a disease such as endometriosis may be to blame.

The best guide to seeking help is when the pain really begins to interfere with life or work. The first step is finding a simple treatment which works. These simple measures include exercise (swimming, walking or cycling) or painkillers (ibuprofen and aspirin can be particularly effective because they have anti-prostaglandin effects).

If these don't control the pain a doctor should be consulted. If the doctor thinks that endometriosis may be a possibility, then more detailed investigations may be recommended, such as ultrasound tests or a minor laparoscopy.

The final option, hysterectomy-or surgical removal of the womb- may seem drastic but the agony of period pains can be so great that for a few women who have completed their families, it is a rational choice.

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