Recently, I was awed by a truly heartwarming article that was featured in The Honolulu Advertiser about a local couple coping with the challenges of a loved one stricken with Alzheimer's disease. In many ways it was quite sad, but at the same time, such a deeply inspiring story of devotion. Just to read about how incredibly difficult a situation some people can find themselves in was quite an eye-opener for me.  In very serious situations like these, one of two things will usually happen. Either things will slowly (or rapidly) fall apart, or as in this amazing couple's case, life's challenges will cement them even closer together. Today, I decided to turn the focus of this blog on a broad overview of this devastating disease to help shed some light on the topic and to increase our awareness.

In 1906, an unusual brain disorder was described by a German physician by the name of Alois Alzheimer. Over the past century, much research has been done on the disease. Researchers currently know that Alzheimer's disease is both progressive and fatal. The disease progressively destroys a person's brain cells and leads to memory loss. This gradually causes defects in behavior and thinking--eventually becoming serious enough to affect a person's social life, work, hobbies, and daily functioning. This (currently) incurable disease is the most common form of dementia and is the cause of between 50 to 70% of all dementia cases.

In Alzheimer's disease, brain cells that control our thinking and higher functions are damaged by the two main killers that are characteristic of the disease. The first, known as amyloid plaques, are protein clumps that form between nerve cells in the brain. The second, neurofibrillary tangles, or twisted and tangled fibers are made up of another protein that replaces the internal structure of dying nerve cells. The true role of these damaging components of Alzheimer's disease are still not clearly known. However, it is suspected that they play a major role in causing some kind of blockage of the vital pathways in these nerves that allows them to communicate with each other and to survive in general. It is thought that in Alzheimer's patients, this damage is already going on somewhere between 10 to 20 years before any signs of the disease even becomes evident.

Here are 10 signs to watch for in Alzheimer's disease (as taken from the Alzheimer's Association):

• Memory loss to the extent that it disrupts daily life--the most common sign. Usually about recent information
• A change in one's ability to follow or form plans and solve problems--doing bills, following a recipe, doing math
• Problems with doing familiar tasks--unable to drive to a known place, no longer able to play games that are usually familiar to them
• Losing track of place or time--lost dates, seasons, time.
• Problems with interpreting spatial relationships and visual images--difficulty with judging distance or reading, determining color. May not recognize themselves in a mirror.
• Problems with spoken or written language--repeating themselves, unable to finish conversations, vocabulary problems, unable to name common/familiar objects
• Starting to frequently misplace or lose things--also do not have the ability to backtrack their steps to find a lost object
• New onset of poor judgment--decision making becomes questionable. i.e. with personal grooming or money
• Changes in social activities or work--person stops doing previously liked hobbies, sports, or social activities
• Personality or mood may change--when outside their comfort zone, they can get easily upset, confused, fearful, or anxious. Unable to tolerate disruptions in routines they have formed.

If you suspect a loved one or someone you know may have Alzheimer's disease, help them to get checked. Encourage them to discuss it with their personal physician--or be a good friend and go with them for moral support. Either way, the main thing is to get evaluated promptly. Early detection and treatment of the disease can possibly help to preserve the person's functional capacity for a longer period of time vs later detection when the disease is more advanced.

How is Alzheimer's disease diagnosed? First of all, not to be morbid, but the only definitive way to clearly diagnose someone as having the disease is at autopsy when the person's brain can be microscopically analyzed and the characteristic plaques and tangles are found. However, there are several methods used to determine if someone most likely has Alzheimer's disease. Here are some methods below:

• The first important point is that (currently) there is no established test that can prove a person has Alzheimer's disease by itself. Although much research continues in more accurate detection and diagnosis.
• Dementia screening tests used by primary care providers, psychologists, and psychiatrists
• Careful review of a person's medical history--as genetics can give clues here
• Mental status testing--checking a person's general awareness; orientation to person, place, time, and events; calculation skills; and memory. Most commonly used test is the Mini-Mental State Exam
• Mini-cog test--quickly evaluates short term memory and ability to correctly draw a clock (Alzheimer's patients have much difficulty with these tasks)
• Diagnostic laboratory tests--to rule out other metabolic causes that may show themselves as dementia
• Careful physical exam and history taking--medications used, past medical history, drug use, alcohol use
• Thorough neurological exam--checking the functions of the nervous system and brain
• Imaging studies--CT Scans or MRI scans of the brain to look for possible structural causes of symptoms
• Promising research with use of the PET scan--checking actual function of the brain

Alzheimer's disease has a total of 7 diagnostic stages. These are beyond the scope of this general overview of the topic, but include from Stage 1 which shows no impairment to Stage 7 which is very severe decline or impairment. There are some risk factors that research has discovered. Some of them we may have control over.

Alzheimer's disease risk factors:

• Increasing age is the greatest risk factor--most Alzheimer's patients are over 65 years old. However, it can and does hit a much younger population in some cases.
• Family history of Alzheimer's disease--you are at higher risk if you have a sibling, child, or parent with the disease. If you have more than one family member involved, your risk increases
• Your heredity or genetics is a risk factor--Alzheimer's disease has been linked to 2 main groups of genes in research. One set of genes are suspected to increase your likelihood of developing Alzheimer's. Although it may not happen with certainty. The other is a very rare set of genes that was found in families with multiple generations of the disease. This gene may possibly be directly linked to developing the disease. Research is ongoing.
• Brain health is a function of heart health--your heart pumps blood that nourishes your brain. Research shows some evidence that similar medical conditions that can damage the heart may also increase your risk of Alzheimer's disease. High cholesterol, high blood pressure, diabetes, heart disease, and stroke are a few mentioned. Some of these factors are under our control.
• Evidence for a link between increased risk of developing Alzheimer's disease and severe head injury--protect your head at all times.
• General healthy mental and physical lifestyle--some evidence hints at aging with a healthy lifestyle both mentally and physically helps to contribute to decreasing the development of Alzheimer's disease. Research also ongoing on this.

The actual treatment for Alzheimer's disease is multi-factorial and multidisciplinary. In other words, there is no single method to managing the disease. It involves a team approach that encompasses the support of the person's doctors, family, and friends. Some components of treatment can make use of several FDA approved medications that are available. Support is vital to an Alzheimer patient's caregivers and family. Unfortunately, the bottom line is that Alzheimer's disease is a progressive and devastating disease for which there currently is no cure...there are only strategies to manage it.

To the couple who's story of devotion was shared in The Honolulu Advertiser: You are both a remarkable example of how true love can transcend any of life's hardships--something we can all learn from. I wish the best to both of you.

So until next time...take care of each other...and Stay Healthy Hawaii!

GW

For more information on Alzheimer's disease visit these websites: Alzheimer's Association at http://www.alz.org or The National Institutes of Health at http://www.nih.gov or Alzheimer's Disease Education and Referral Center at www.nia.nih.gov/Alzheimers

"Eh doc, should be OK if I only suntan sometimes at the beach right?" "Well, Mr. W., any amount of suntanning is not the best thing for you. Let me tell you why."

Those old days of very dark tans when we were teenagers are gone. Well, what did we know back then right? The research on skin damage from the sun was not very conclusive back then. And, to top it all off, the benefits of attracting a cute guy or gal with that killer tan way outweighed the risks that we had no clue about right?

The truth of the matter is that now clinical research has pretty much determined that the ultraviolet radiation or UV from the sun damages the skin and related tissues in many ways. Somewhere around 10 years or so ago, the National Institutes of Health placed UV radiation exposure on the known list of carcinogens (things that cause cancer). There are mainly 3 types of UV radiation we need to be concerned about. Well, technically only two. UVA and UVB do the most damage to our skin and connective tissue structures.

UVA is the most plentiful component. It is credited with most of the skin and connective tissue damage as it penetrates our exposed skin the deepest. Once it does its damage there, it is responsible for a large proportion of UV's potential for causing different types of skin cancers. UVB is also an important component in the sun's attack on our skin. However, its rays do not penetrate as deeply into our tissues. Nevertheless, it still has a role in the damage that can cause skin cancer--in fact, it is the component mostly responsible for causing sunburns. UVC is also present, but most of it is absorbed as it enters our Earth's atmosphere, so it is not usually as big a player in the destructive process.

How can we protect ourselves from these forces of nature?

• If at all possible, avoid or limit your sun exposure between 10 am to 4 pm--when the sun is most intense
• Protect all your exposed skin areas with a high Sun Protection Factor (SPF)--30 is good
• Use a good pair of sunglasses with 100% UVA and UVB protection to protect your eyes
• Don't be fooled into not using protection on cloudy or overcast days--burning UV rays are still present
• Wear high SPF protective clothing in the sun--UV protective "rash guards" for swimming, hats, UV protective shirts
• Always apply your sunscreen at least 15 to 30 minutes BEFORE sun exposure--reapply every 2 hours and after swimming or heavy perspiring
• Protect children under age 6 months from sun exposure by avoiding the sun--sunscreen is not recommended on those younger than 6 months
• Snow, sand, and water easily reflect burning UV radiation--you are not protected by sitting in the shade under these conditions as you are exposed to UV from the side and below
• Very important! If the expiration date on the sunscreen has passed, throw it out. It is no longer effective at protecting you.
• Make sure you talk to your doctor to see if any of your medications make sun exposure more dangerous for you

Overexposure to the sun's UV radiation causes several problems.The most common is sunburn--literally a burn to the skin surface that was overexposed to UV radiation. Next on the list are 3 common skin cancers that may develop at a later time after overexposure to UV radiation. Basal Cell, Squamous Cell, and Melanoma. Of these three, malignant melanoma usually carries the gravest prognosis--sometimes, even if it is diagnosed very early on. Basal cell and squamous cell carcinoma are usually very curable if detected early. If you notice something suspicious on your skin that just does not look right, make sure to show it to your primary care provider for evaluation.

Use the A, B, C, D's of skin cancer detection:

• A: asymetry or half of the irregular skin area does not look like the other half
• B: borders of the suspicious skin area are irregular
• C: color is not uniform across the abnormal looking skin area, it may show very different colors in some areas
• D: diameter of the questionable skin area is greater than 6 milimeters or a little bigger than the side of a pencil eraser--although not always the case so beware
• Any suspicious looking skin area that never heals
• Any of the above means to show the questionable area of your skin to your doctor

A large study on melanoma determined that adolescents and children are at the highest risk for permanent damage from UV overexposure. As a consequence, getting a sunburn at this stage in life seems to hold the most risk of future skin cancer development. So it is especially VERY important to protect our youngsters from the sun.

Come on outdoors and enjoy our beautiful Hawaii--but do it with sun smarts.

Until next time...Stay Healthy Hawaii!

GW

If you believe there is no way you could possibly have Attention Deficit Hyperactivity Disorder (ADHD) just because you are an adult...think again. Amazingly, close to 60% of children who have ADHD have symptoms that can continue into adulthood. Many adults in the United States go undiagnosed and untreated. As for the number of adults who ARE identified, the numbers fall somewhere between 1 to 5% of the adult population in the US. After doing the math, this comes out to somewhere around 8 million adults! So it looks like being an adult does not make us immune (so to speak) to having ADHD.

ADHD in children has been widely recognized as a developmental disorder. It is often noted for a child showing unusual amounts of impulsiveness, inattention, and hyperactivity. ADHD that is suspected in adults is often identified when there are persistent problems with concentration, completing work on time, remembering information that was presented, organizing tasks, or just simply having problems following directions in general.

Here are some common findings in Adult ADHD:

• Employment problems--poor performance and frequent job changes
• May have issues with controlling anger properly
• Anxiety
• Procrastination
• Often chronically late
• Often forgetful and impulsive
• May have issues with low self-esteem
• May experience chronic boredom with activities
• Mood swings, easily frustrated, sometimes depressed
• Problems in their relationships with other people
• Have difficulty with organizational skills
• May have problems concentrating when trying to read
• Often have addiction and substance abuse issues
• More likely to have driving violations

Many of these signs appear in a broad range of degrees. They may be intermittent and even absent under certain situations within the same individual. This is what makes identification and diagnosis of ADHD in adults so much more difficult. Although researchers usually cannot agree on the exact time frame in childhood when ADHD begins, most are in agreement that it is not an adult onset problem. Many of the signs and symptoms can be identified earlier in their childhood and are often found retrospectively in an adult's school reports and self-reported accounts. Some of these early signs are as follows:

• School report cards with comments about poor focus, underachievement, poor effort, other behavior problems
• Records of discussions with the child's parents regarding these issues
• Evidence documented showing conflicts with peers, school failure, comments about being made to "sit in the corner" etc., bed wetting, school suspensions
• Record of a strong family history of ADHD
• Not performing well on standardized achievement testing or IQ testing

How can adult ADHD be managed? The first step is to seek help from your primary care provider who can discuss your particular situation with you. After doing so, your doctor can help you get in touch with the proper professional to assist you in managing your situation. Medically, the classic "stimulant" type of prescriptions that typically benefit the child with ADHD, often helps the adult.

As research continues on ADHD, other medications that are not stimulants are being approved and used as treatment. Again, your particular regimen of treatment is best left up to your own primary care provider's discretion. However, if you ARE taking medicine for your ADHD, one of the most important things you can do to help yourself is to take your medication exactly as it is prescribed. This helps to reduce problems that could otherwise arise.

Here are some suggestions to help you deal with adult ADHD:

• Behavioral coaching to help the person learn organizational strategies
• Education of family and friends to help others understand what you are dealing with
• Enhancement of self-esteem by use of behavioral and cognitive therapy
• Channel any excess energy into other constructive outlets--new sport, new interest, new hobby etc
• Stress management training
• Relaxation therapy training
• Job mentoring or coaching to help improve work relationships and job performance
• Learn strategies to help to control your impulsive behavior. Stop and think before you act--instead of regretting something done impulsively later
• Learn to organize--use tools available to you like to-do lists, daily planners, notes
• Keep distractions to a minimum--identify what distracts you and reduce your exposure. i.e. noisy places, TV

Living with adult ADHD can be a daily struggle for those who are affected. You do not have to go through the turmoil alone. There are people who can help. ADHD is a very treatable disorder that, given the proper intervention by the right team of professionals, can be effectively managed. The very first step is seeking help and having your problem identified. No one can help you fix something that they don't know is there. If this is worrying you--have a talk with your doctor.

For more information on ADHD visit the web at: www.help4adhd.org This website is a national clearinghouse that encompasses most of the current research and information about ADHD and is funded by The Centers for Disease Control and Prevention.

So until next time...Stay Healthy Hawaii!

GW

"Doc, I went to my nephew's first birthday luau last night and ate all kinds of yummy stuff. I even had some awesome seafood and a couple of  ice cold beers to wash it all down. This morning I woke up with my big toe so sore I can't even walk. What happened?" "Hmmm...Mr. W, sounds like you might have found out the hard way that you may have gout. Here...let me see your foot so I can check this out...You know, your story is very common. So the food was that good huh?"

What is gout? Gout is an acute joint inflammation that is caused by the accumulation of uric acid crystals in the tissue around or near the painful joint. The crystals get there because the person has a metabolic problem where the uric acid cannot be properly broken down and disposed of as it should. It most frequently occurs in middle-aged men and, oddly enough, in the big toe. Although it can happen in just about any other joint in the body and can also involve women.

Common signs to look out for in gout--although other conditions can cause similar signs:

• Sudden and severe pain in a large joint or big toe (most common)
• Involved joint is hot, red, swollen, very tender
• Sometimes there may be a fever
• Usually, no apparent acute trauma has happened to the joint--although a previous injury can trigger gout

Gout is diagnosed by finding uric acid crystals in the fluid that is sampled from the painful joint. The crystals look like small needles under a microscope. Alternatively, a blood test can be done to check your uric acid level.  If it is high, it may be due to presumed gout. But the real diagnostic confirmation is finding the crystals in the joint fluid.

Here are some of the risk factors for gout:

• Being a middle-aged male
• Family history of gout
• Eating foods that are high in purines--anchovies, sardines, seafood, turkey, pork, organ meats like liver and kidney
• Drinking alcohol--especially beer or red wine
• Having other chronic disorders like blood diseases, thyroid problems, kidney problems, high cholesterol, high blood pressure, diabetes
• Previous trauma to the joint
• Use of "water pills" or diuretic drugs
• Use of certain antibiotics
• Obesity

Prevention of attacks is aimed at modifying those factors above that ARE under your control. Seeking early treatment and diagnosis is important. A much more serious infection in the joint can often look a lot like gout--for that reason, among others, it is important to have your doctor check you out to be sure. Also, untreated chronic gout can sometimes lead to deformed and crippled joints, as well as other chronic inflammation in tendons and ligaments. If uric acid levels are left very high, it can sometimes also lead to kidney stone formation.

Gout is usually treated with nonsteroidal anti-inflammatory medications or drugs that are cousins to aspirin. Depending on the particular situation, it can also be treated with other types of medications and, for chronic problems with gout, it is sometimes treated with daily medications that help rid the body of uric acid or help the body produce less of it. The best treatment for your particular case should be left to the discretion of your primary care physician.

Yet another good reason  for each of us to use moderation in our daily lifestyle...

So until next time...Stay Healthy Hawaii!

GW

"Hi Doc. I am wondering about my husband. He is always tired during the day. At night he snores like you would not believe. But the thing that has me worried is that he sometimes stops breathing while he is sleeping. Then he suddenly wakes up with a loud grunting and sometimes gasping noise. Is something wrong with him?" "It does seem like there is something wrong here Mrs. W...It sounds like your husband may have a sleep disorder. I suspect sleep apnea, but we need to check him out first. Let's have him come in as soon as possible."

Sleep apnea is a disorder where a person will repeatedly stop and start breathing while asleep. This results in feeling very tired and sleepy during the waking hours because the person never remains in a deep sleep. There are basically 2 major categories of sleep apnea. obstructive sleep apnea, that is usually a result of relaxing throat muscles during sleep. The second is central sleep apnea, which is a disorder of breathing signals coming from the brain. However, there is also a separate category called complex sleep apnea, which is a combination of both. We will discuss obstructive sleep apnea today.

Here are some common signs to watch for that may point to sleep apnea:

• Very loud, disturbing snoring
• Extreme fatigue or sleepiness during your normal waking hours
• Someone actually observing episodes when your breathing stops while you are asleep
• Suddenly finding yourself awake and sometimes having brief shortness of breath
• Insomnia--difficulty falling asleep
• Having a sore throat or very dry mouth when you awaken
• Sometimes, a morning headache

Why can sleep apnea be a potentially dangerous disorder?

• First of all, just the situation of the extreme fatigue and sleepiness alone can make potentially dangerous activities even more risky--for example, driving or operating dangerous equipment. It is not hard to imagine what could happen should you fall asleep at these times
• The persistent fatigue and sleepiness can help contribute to irritability, moodiness, and even depression
• Students with sleep apnea may have a more difficult time with performing well in school
• Morning headaches and memory problems
• When apnea is occurring, it puts a strain on the cardiovascular system as blood oxygen levels drop
• Your risk of having high blood pressure can be as high as tripled if you have sleep apnea when compared to other people who don't have apnea
• People who already have heart disorders are at even higher risk of sudden death from a cardiac event due to the repeated episodes of low blood oxygen levels during apnea
• Much higher risk of strokes due to the repeated drops in blood oxygen levels--the brain always needs lots of oxygen to be happy and healthy

The major cause of obstructive sleep apnea is due to relaxation of the muscles in the back of the mouth and throat during deep sleep. This relaxation starts off causing that nasty, loud snoring that occurs first. Then, as it progresses on in the sleep cycle, it eventually causes the airway to close off completely--this is the apnea part. The person will completely stop breathing. Soon, the blood oxygen levels will begin to drop off sharply, eventually resulting in awaking from the deep levels of sleep to force the body to once again breathe--this is the loud snorting and gasping part that people hear as they begin to breathe again. This cycle will repeat itself constantly throughout the night. Resulting in a very restless night of sleep for everyone.

Here are the major risk factors that can affect obstructive sleep apnea:

• Being overweight--more fatty tissue around the neck area
• High blood pressure
• Being an older male
• Having a family history of sleep apnea
• A neck circumference of greater than 17.5 inches--associated with narrowed airways (a risk factor in itself)
• Narrowed airways for any reason--for example, large tonsils
• Smoking
• Alcohol and sedative use can increase the relaxation of throat tissues, worsening apnea

If sleep apnea is suspected, your physician can diagnose it by use of a sleep study. This is when you spend the night at a sleep lab and many monitor sensors are attached to you to monitor your blood pressure, brain activity, heart rate, eye movements, leg movements, your oxygen level, and your breathing--among other things. After this study is completed, it can be determined if you have sleep apnea and if you have it, to what severity.

There are many forms of treatment for sleep apnea that can include sleeping with a pressurized mask or even surgery. However, your physician, usually in consult with a sleep medicine specialist, will help you decide which alternatives are best for you.

Here are a few tips that may sometimes help--but should not replace a visit to your doctor:

• Sleep on your abdomen or side instead of flat on your back
• Do not use sleep medication, sedatives, or alcohol--these worsen the situation
• Keep your nasal passages clear at night. Consider a saline nasal spray--no decongestants as they can affect your ability to sleep also
• Lose weight

Getting a good, restful night of sleep should not be such a struggle. If it is for you, talk to your primary care provider and discuss your concerns. A good night's sleep can do wonders for you. A bad night's sleep does nothing for you and may cause harm in the long run. If you or someone else is worried about you, get checked.

Well folks, it's getting kind of late. I better sign off and grab my 40 winks. So until next time....Stay Healthy Hawaii!

GW