Confusing Medical Ailments With Mental Illness
By Melinda Beck : WSJ : August 9, 2011
An elderly woman's sudden depression turns out to be a side effect of her high blood-pressure medication.
A new mother's exhaustion and disinterest in her baby seem like postpartum depression—but actually signal a postpartum thyroid imbalance that medication can correct.
A middle-aged manager has angry outbursts at work and frequently feels "ready to explode." A brain scan reveals temporal-lobe seizures, a type of epilepsy that can be treated with surgery or medication.
More than 100 medical disorders can masquerade as psychological conditions, according to Harvard psychiatrist Barbara Schildkrout, who cited these examples among others in "Unmasking Psychological Symptoms," a book aimed at helping therapists broaden their diagnostic skills.
Different DiagnosesMore than 100 medical disorders can masquerade as psychological conditions or contribute to them, complicating treatment decisions.
WHAT SEEMS LIKE......MAY ACTUALLY BE......
Depression:
Underactive thyroid; low vitamin D or B-12 or folate; diabetes; hormonal changes; heart disease; Lyme disease; lupus; head trauma, sleep disorders; some cancers and cancer drugs
Anxiety:
Overactive thyroid; respiratory problems; very low blood pressure; concussion; anaphylactic shock
Irritability:
Brain injury; temporal lobe epilepsy; Alzheimer's disease and early stage dementia; parasitic infection; hormonal changes
Hallucinations:
Epilepsy; brain tumor; fever; narcolepsy; substance abuse
Cognitive changes:
Brain injury or infection; Alzheimer's; Parkinson's; liver failure; mercury or lead poisoning
Psychosis:
Venereal disease; brain tumors and cysts; stroke; epilepsy; steroids; substance abuse
Studies have suggested that medical conditions may cause mental-health issues in as many as 25% of psychiatric patients and contribute to them in more than 75%.
Untangling cause and effect can challenge even seasoned clinicians, and the potential for missed diagnoses is growing these days, said Dr. Schildkrout, who has more than 25 years of clinical practice in the Boston area. Most mental-health counselors rely on primary-care doctors to spot medical issues, but those physicians are increasingly time-pressed and may not know their patients well. Neither do the psychiatrists who mainly write prescriptions and see patients only briefly, she said in an interview.
Common culprits include under- or over-active thyroid glands, which can cause depression and anxiety, respectively. Deficiencies of vitamins D, B-12 and folate, as well as hormonal changes and sleep disorders have also been linked to depression.
Diabetes, lupus and Lyme disease can have a variety of psychiatric symptoms, as can mercury and lead poisoning and sexually transmitted diseases. Many medications also list mood changes among their side effects, and substance abuse is notorious for causing psychiatric problems.
Some underlying conditions are readily treatable. Others, such as Alzheimer's and Parkinson's disease and some brain tumors, are not. But a correct diagnosis can save months or years of frustration and ineffective treatment.
In some cases, a psychological problem is just the first sign of a serious medical issue. "Depression predicts heart disease and heart disease predicts depression," said Gary Kennedy, director of the geriatric psychiatry at Montefiore Medical Center in Bronx, N.Y.
About one-third of people who have their first episode of depression after age 55 have changes in brain circuits that are associated with hypertension, diabetes and heart attacks. Such patients are usually apathetic, have difficulty with executive planning and don't respond well to antidepressants. Making sure their blood pressure and blood-sugar levels are on target is crucial, though medical and psychotherapy may be needed as well, Dr. Kennedy said.
Recognizing an underlying medical condition can be particularly difficult when there is also a psychological explanation for a patient's dark moods. For example, victims of domestic violence are often anxious, depressed and withdrawn—but mild brain injury could be causing such symptoms, too.
Warning Signs
When to suspect a mental problem may be medical:
• Sudden change in mood or personality
• History of head trauma
• Depression that occurs for the first time after age 55
• Recent travel or exposure to infections
• Any rash, swelling, drooping eyelid; facial tic
• Standard medication or therapy isn't effective
Similarly, a former college athlete who becomes angry and irritable in his 40s could be suffering a midlife crisis—or delayed reaction to head injuries sustained decades earlier. "We now know that multiple concussions can have a sleeper effect for years. Then one day, out of the blue, you start acting explosive and depressed," due to a brain swelling known as chronic trauma encephalopathy, said Jerrold Pollak, a neuropsychologist at Seacoast Mental Health Center in Portsmouth, N.H., and lead author of an article on distinguishing mental from medical disorders in the Journal of Clinical Psychology Practice this spring.
If the head-injury diagnosis is missed, Dr. Pollak added, the patient could be in psychotherapy for months, "thinking that he has trouble with his father or feels like a failure for not becoming a pro athlete."
Giving every patient who seeks psychological help a brain scan first would be prohibitively expensive and likely yield many confusing results. But experts say mental-health counselors should ask patients about their medical histories as well as emotional issues, and make sure they've had a recent physical exam.
Tell-tale signs of underlying medical problems include significant changes in energy, weight, appetite or sleep, which could be due to an endocrine disorder. Sudden changes in mood or personality, visual hallucinations and alternations in smell, taste or tactile senses could signal a brain tumor or other abnormality.
Sometimes a single physical sign can broaden a clinician's diagnostic thinking. Manhattan psychiatrist Drew Ramsey recalled that early in his career, he examined a patient with daily panic attacks and noticed a swelling on her shins, a classic sign of Graves' disease, a form of overactive thyroid that can cause severe anxiety.
Like other psychiatrists, Dr. Ramsey said he always takes a medical history and orders blood tests for patients. He found that one was anemic and improved markedly when meat was added to her diet. Another who was depressed and drinking heavily was low on vitamins D and B-12.
Similarly, Dr. Schildkrout once treated a 50-year-old woman for mood swings and noticed a slight slurring to her speech. While it could have been dismissed as ill-fitting dentures, it turned out to be the first sign of amyotrophic lateral sclerosis, which also causes severe fatigue and odd jags of laughing and crying in its early stages.
Some patients may benefit from both psychological counseling and medical help. Therapists need not turn patients away while medical issues are being explored, experts say. "Clinicians can say, 'While we work on these issues, let's also discuss any possible medical conditions that could be contributing, so we can at least rule them out,"' Dr. Pollak said.
Finally clarifying a diagnosis can be a relief to clinicians and patients—particularly when therapy hasn't been working or patients have spent years blaming themselves. "When you find the right diagnosis, not only is there appropriate treatment, but it can make a dramatic improvement in terms of healing their self esteem," Dr. Schildkrout said.
By Melinda Beck : WSJ : August 9, 2011
An elderly woman's sudden depression turns out to be a side effect of her high blood-pressure medication.
A new mother's exhaustion and disinterest in her baby seem like postpartum depression—but actually signal a postpartum thyroid imbalance that medication can correct.
A middle-aged manager has angry outbursts at work and frequently feels "ready to explode." A brain scan reveals temporal-lobe seizures, a type of epilepsy that can be treated with surgery or medication.
More than 100 medical disorders can masquerade as psychological conditions, according to Harvard psychiatrist Barbara Schildkrout, who cited these examples among others in "Unmasking Psychological Symptoms," a book aimed at helping therapists broaden their diagnostic skills.
Different DiagnosesMore than 100 medical disorders can masquerade as psychological conditions or contribute to them, complicating treatment decisions.
WHAT SEEMS LIKE......MAY ACTUALLY BE......
Depression:
Underactive thyroid; low vitamin D or B-12 or folate; diabetes; hormonal changes; heart disease; Lyme disease; lupus; head trauma, sleep disorders; some cancers and cancer drugs
Anxiety:
Overactive thyroid; respiratory problems; very low blood pressure; concussion; anaphylactic shock
Irritability:
Brain injury; temporal lobe epilepsy; Alzheimer's disease and early stage dementia; parasitic infection; hormonal changes
Hallucinations:
Epilepsy; brain tumor; fever; narcolepsy; substance abuse
Cognitive changes:
Brain injury or infection; Alzheimer's; Parkinson's; liver failure; mercury or lead poisoning
Psychosis:
Venereal disease; brain tumors and cysts; stroke; epilepsy; steroids; substance abuse
Studies have suggested that medical conditions may cause mental-health issues in as many as 25% of psychiatric patients and contribute to them in more than 75%.
Untangling cause and effect can challenge even seasoned clinicians, and the potential for missed diagnoses is growing these days, said Dr. Schildkrout, who has more than 25 years of clinical practice in the Boston area. Most mental-health counselors rely on primary-care doctors to spot medical issues, but those physicians are increasingly time-pressed and may not know their patients well. Neither do the psychiatrists who mainly write prescriptions and see patients only briefly, she said in an interview.
Common culprits include under- or over-active thyroid glands, which can cause depression and anxiety, respectively. Deficiencies of vitamins D, B-12 and folate, as well as hormonal changes and sleep disorders have also been linked to depression.
Diabetes, lupus and Lyme disease can have a variety of psychiatric symptoms, as can mercury and lead poisoning and sexually transmitted diseases. Many medications also list mood changes among their side effects, and substance abuse is notorious for causing psychiatric problems.
Some underlying conditions are readily treatable. Others, such as Alzheimer's and Parkinson's disease and some brain tumors, are not. But a correct diagnosis can save months or years of frustration and ineffective treatment.
In some cases, a psychological problem is just the first sign of a serious medical issue. "Depression predicts heart disease and heart disease predicts depression," said Gary Kennedy, director of the geriatric psychiatry at Montefiore Medical Center in Bronx, N.Y.
About one-third of people who have their first episode of depression after age 55 have changes in brain circuits that are associated with hypertension, diabetes and heart attacks. Such patients are usually apathetic, have difficulty with executive planning and don't respond well to antidepressants. Making sure their blood pressure and blood-sugar levels are on target is crucial, though medical and psychotherapy may be needed as well, Dr. Kennedy said.
Recognizing an underlying medical condition can be particularly difficult when there is also a psychological explanation for a patient's dark moods. For example, victims of domestic violence are often anxious, depressed and withdrawn—but mild brain injury could be causing such symptoms, too.
Warning Signs
When to suspect a mental problem may be medical:
• Sudden change in mood or personality
• History of head trauma
• Depression that occurs for the first time after age 55
• Recent travel or exposure to infections
• Any rash, swelling, drooping eyelid; facial tic
• Standard medication or therapy isn't effective
Similarly, a former college athlete who becomes angry and irritable in his 40s could be suffering a midlife crisis—or delayed reaction to head injuries sustained decades earlier. "We now know that multiple concussions can have a sleeper effect for years. Then one day, out of the blue, you start acting explosive and depressed," due to a brain swelling known as chronic trauma encephalopathy, said Jerrold Pollak, a neuropsychologist at Seacoast Mental Health Center in Portsmouth, N.H., and lead author of an article on distinguishing mental from medical disorders in the Journal of Clinical Psychology Practice this spring.
If the head-injury diagnosis is missed, Dr. Pollak added, the patient could be in psychotherapy for months, "thinking that he has trouble with his father or feels like a failure for not becoming a pro athlete."
Giving every patient who seeks psychological help a brain scan first would be prohibitively expensive and likely yield many confusing results. But experts say mental-health counselors should ask patients about their medical histories as well as emotional issues, and make sure they've had a recent physical exam.
Tell-tale signs of underlying medical problems include significant changes in energy, weight, appetite or sleep, which could be due to an endocrine disorder. Sudden changes in mood or personality, visual hallucinations and alternations in smell, taste or tactile senses could signal a brain tumor or other abnormality.
Sometimes a single physical sign can broaden a clinician's diagnostic thinking. Manhattan psychiatrist Drew Ramsey recalled that early in his career, he examined a patient with daily panic attacks and noticed a swelling on her shins, a classic sign of Graves' disease, a form of overactive thyroid that can cause severe anxiety.
Like other psychiatrists, Dr. Ramsey said he always takes a medical history and orders blood tests for patients. He found that one was anemic and improved markedly when meat was added to her diet. Another who was depressed and drinking heavily was low on vitamins D and B-12.
Similarly, Dr. Schildkrout once treated a 50-year-old woman for mood swings and noticed a slight slurring to her speech. While it could have been dismissed as ill-fitting dentures, it turned out to be the first sign of amyotrophic lateral sclerosis, which also causes severe fatigue and odd jags of laughing and crying in its early stages.
Some patients may benefit from both psychological counseling and medical help. Therapists need not turn patients away while medical issues are being explored, experts say. "Clinicians can say, 'While we work on these issues, let's also discuss any possible medical conditions that could be contributing, so we can at least rule them out,"' Dr. Pollak said.
Finally clarifying a diagnosis can be a relief to clinicians and patients—particularly when therapy hasn't been working or patients have spent years blaming themselves. "When you find the right diagnosis, not only is there appropriate treatment, but it can make a dramatic improvement in terms of healing their self esteem," Dr. Schildkrout said.
Vitamin B12 as Protection for the Aging Brain
Jane E. Brody : NY Times : Sept 6, 2016
As a woman of a certain age who consumes a well-balanced diet of all the usual food groups, including reasonable amounts of animal protein, I tend to dismiss advice to take a multivitamin supplement. I’ve been told repeatedly by nutrition experts that the overuse of dietary supplements for “nutritional insurance” has given Americans the most expensive urine in the world.
I do take a daily supplement of vitamin D, based on considerable evidence of its multiple health benefits, especially for older people. However, based on advice from the National Academy of Medicine and an examination of accumulating research, I’m prompted to consider also taking a vitamin B12 supplement in hopes of protecting my aging brain.
Animal protein foods — meat, fish, milk, cheese and eggs — are the only reliable natural dietary sources of B12, and I do get ample amounts of several in my regular diet. But now at age 75, I wonder whether I’m still able to reap the full benefit of what I ingest.
You see, the ability to absorb B12 naturally present in foods depends on the presence of adequate stomach acid, the enzyme pepsin and a gastric protein called intrinsic factor to release the vitamin from the food protein it is attached to. Only then can the vitamin be absorbed by the small intestine. As people age, acid-producing cells in the stomach may gradually cease to function, a condition called atrophic gastritis.
A century ago, researchers discovered that some people — most likely including Mary Todd Lincoln — had a condition called pernicious anemia, a deficiency of red blood cells ultimately identified as an autoimmune disease that causes a loss of stomach cells needed for B12 absorption. Mrs. Lincoln was known to behave erratically and was ultimately committed to a mental hospital.
“Depression, dementia and mental impairment are often associated with” a deficiency of B12 and its companion B vitamin folate, “especially in the elderly,” Dr. Rajaprabhakaran Rajarethinam, a psychiatrist at Wayne State University School of Medicine, has written.
He described a 66-year-old woman hospitalized with severe depression, psychosis and a loss of energy and interest in life who had extremely low blood levels of B12 and whose symptoms were almost entirely reversed by injections of the vitamin.
European researchers have also shown that giving B12 to people deficient in the vitamin helped protect many of the areas of the brain damaged by Alzheimer’s disease. In a two-year study at the University of Oxford of 270 people older than 70 with mild cognitive impairment and low B12 levels, Dr. Helga Refsum, a professor of nutrition at the University of Oslo, found reduced cerebral atrophy in those treated with high doses of the vitamin.
“A B12 vitamin deficiency as a cause of cognitive issues is more common than we think, especially among the elderly who live alone and don’t eat properly,” Dr. Rajarethinam said.
The academy estimates that between 10 percent and 30 percent of people older than 50 produce too little stomach acid to release B12 from its carrier protein in foods, and as the years advance, the percentage of low-acid producers rises.
But many people do not know they produce inadequate amounts of stomach acid. In fact, evidence from a study of young adults called the Framingham Offspring Study suggests that insufficient absorption of B12 from foods may even be common among adults aged 26 to 49, so the following advice may pertain to them as well.
The academy recommends that adults older than 50 get most of their daily requirement of B12 — 2.4 micrograms for people 14 and older, slightly more for women who are pregnant or nursing — from a synthetic form of the vitamin found in foods fortified with B12 or in a multivitamin supplement. Synthetic B12 is not attached to protein and thus bypasses the need for stomach acid. Given that I eat very few fortified foods, a supplement with B12 is likely to be my best option.
Certain groups besides older people are also at risk of a B12 deficiency. They include vegetarians and vegans who consume little or no animal foods; people with disorders of the stomach and small intestine like celiac disease and Crohn’s disease; chronic users of proton-pump inhibitors to control acid reflux; and people whose digestive systems were surgically reduced for weight-loss or treatment for cancer or ulcerative colitis.
Among those most likely to be B12 deficient are the older patients in nursing homes whose diets are limited, and this deficiency may account in part for the symptoms of cognitive dysfunction so common among nursing home residents.
While a B12 deficiency can take years to develop, encroaching symptoms can be distressing and eventually devastating. It can also be challenging to link such symptoms to a nutrient deficiency.
In an online posting in July, David G. Schardt, the senior nutritionist for the Center for Science in the Public Interest, noted that symptoms of B12 deficiency include fatigue, tingling and numbness in the hands and feet, muscle weakness and loss of reflexes, which may progress to confusion, depression, memory loss and dementia as the deficiency grows more severe.
Early symptoms can be reversed by treatment with high doses of B12, usually given by injection. But symptoms related to nerve damage and dementia are more likely to be permanent. Thus, it is especially important for people at risk of a B12 deficiency to have their blood tested for it periodically. For example, experts at Kaiser Permanente in Oakland, Calif., suggest that chronic users of proton-pump inhibitors should have their B12 level tested every two years.
3COMMENTSVegetarians and vegans need not despair. In addition to B12 supplements, various commercially prepared plant-based foods, like some breakfast cereals, nondairy milks and soy products and one type of nutritional yeast, are fortified with synthetic B12. The Vegan Society recommends eating two to three servings a day of fortified foods to get at least three micrograms of B12.
However, Dr. Ralph Carmel, a retired hematologist now affiliated with New York University who studied the effects of B12 for decades, cautions against taking megadoses of the vitamin. He said in an interview that too often, “People who really need B12 don’t get it, and those who don’t need it, like athletes, often take huge doses — 2,000 or 5,000 micrograms a day. We don’t know what such doses can do in the long run. If an older person has low-ish B12 levels, I don’t object to taking 500 or 1,000 micrograms a day, but 5,000 is ridiculous.”
Jane E. Brody : NY Times : Sept 6, 2016
As a woman of a certain age who consumes a well-balanced diet of all the usual food groups, including reasonable amounts of animal protein, I tend to dismiss advice to take a multivitamin supplement. I’ve been told repeatedly by nutrition experts that the overuse of dietary supplements for “nutritional insurance” has given Americans the most expensive urine in the world.
I do take a daily supplement of vitamin D, based on considerable evidence of its multiple health benefits, especially for older people. However, based on advice from the National Academy of Medicine and an examination of accumulating research, I’m prompted to consider also taking a vitamin B12 supplement in hopes of protecting my aging brain.
Animal protein foods — meat, fish, milk, cheese and eggs — are the only reliable natural dietary sources of B12, and I do get ample amounts of several in my regular diet. But now at age 75, I wonder whether I’m still able to reap the full benefit of what I ingest.
You see, the ability to absorb B12 naturally present in foods depends on the presence of adequate stomach acid, the enzyme pepsin and a gastric protein called intrinsic factor to release the vitamin from the food protein it is attached to. Only then can the vitamin be absorbed by the small intestine. As people age, acid-producing cells in the stomach may gradually cease to function, a condition called atrophic gastritis.
A century ago, researchers discovered that some people — most likely including Mary Todd Lincoln — had a condition called pernicious anemia, a deficiency of red blood cells ultimately identified as an autoimmune disease that causes a loss of stomach cells needed for B12 absorption. Mrs. Lincoln was known to behave erratically and was ultimately committed to a mental hospital.
“Depression, dementia and mental impairment are often associated with” a deficiency of B12 and its companion B vitamin folate, “especially in the elderly,” Dr. Rajaprabhakaran Rajarethinam, a psychiatrist at Wayne State University School of Medicine, has written.
He described a 66-year-old woman hospitalized with severe depression, psychosis and a loss of energy and interest in life who had extremely low blood levels of B12 and whose symptoms were almost entirely reversed by injections of the vitamin.
European researchers have also shown that giving B12 to people deficient in the vitamin helped protect many of the areas of the brain damaged by Alzheimer’s disease. In a two-year study at the University of Oxford of 270 people older than 70 with mild cognitive impairment and low B12 levels, Dr. Helga Refsum, a professor of nutrition at the University of Oslo, found reduced cerebral atrophy in those treated with high doses of the vitamin.
“A B12 vitamin deficiency as a cause of cognitive issues is more common than we think, especially among the elderly who live alone and don’t eat properly,” Dr. Rajarethinam said.
The academy estimates that between 10 percent and 30 percent of people older than 50 produce too little stomach acid to release B12 from its carrier protein in foods, and as the years advance, the percentage of low-acid producers rises.
But many people do not know they produce inadequate amounts of stomach acid. In fact, evidence from a study of young adults called the Framingham Offspring Study suggests that insufficient absorption of B12 from foods may even be common among adults aged 26 to 49, so the following advice may pertain to them as well.
The academy recommends that adults older than 50 get most of their daily requirement of B12 — 2.4 micrograms for people 14 and older, slightly more for women who are pregnant or nursing — from a synthetic form of the vitamin found in foods fortified with B12 or in a multivitamin supplement. Synthetic B12 is not attached to protein and thus bypasses the need for stomach acid. Given that I eat very few fortified foods, a supplement with B12 is likely to be my best option.
Certain groups besides older people are also at risk of a B12 deficiency. They include vegetarians and vegans who consume little or no animal foods; people with disorders of the stomach and small intestine like celiac disease and Crohn’s disease; chronic users of proton-pump inhibitors to control acid reflux; and people whose digestive systems were surgically reduced for weight-loss or treatment for cancer or ulcerative colitis.
Among those most likely to be B12 deficient are the older patients in nursing homes whose diets are limited, and this deficiency may account in part for the symptoms of cognitive dysfunction so common among nursing home residents.
While a B12 deficiency can take years to develop, encroaching symptoms can be distressing and eventually devastating. It can also be challenging to link such symptoms to a nutrient deficiency.
In an online posting in July, David G. Schardt, the senior nutritionist for the Center for Science in the Public Interest, noted that symptoms of B12 deficiency include fatigue, tingling and numbness in the hands and feet, muscle weakness and loss of reflexes, which may progress to confusion, depression, memory loss and dementia as the deficiency grows more severe.
Early symptoms can be reversed by treatment with high doses of B12, usually given by injection. But symptoms related to nerve damage and dementia are more likely to be permanent. Thus, it is especially important for people at risk of a B12 deficiency to have their blood tested for it periodically. For example, experts at Kaiser Permanente in Oakland, Calif., suggest that chronic users of proton-pump inhibitors should have their B12 level tested every two years.
3COMMENTSVegetarians and vegans need not despair. In addition to B12 supplements, various commercially prepared plant-based foods, like some breakfast cereals, nondairy milks and soy products and one type of nutritional yeast, are fortified with synthetic B12. The Vegan Society recommends eating two to three servings a day of fortified foods to get at least three micrograms of B12.
However, Dr. Ralph Carmel, a retired hematologist now affiliated with New York University who studied the effects of B12 for decades, cautions against taking megadoses of the vitamin. He said in an interview that too often, “People who really need B12 don’t get it, and those who don’t need it, like athletes, often take huge doses — 2,000 or 5,000 micrograms a day. We don’t know what such doses can do in the long run. If an older person has low-ish B12 levels, I don’t object to taking 500 or 1,000 micrograms a day, but 5,000 is ridiculous.”
For Older Adults, a Rising Risk of Subdural Hematoma
By Jane E. Brody : NY Times : April 6, 2015
You don’t have to hit your head to develop an insidious bleed between the soft covering of your brain and the brain itself that in days, weeks or months can threaten your health or life.
The condition, called chronic subdural hematoma, is becoming increasingly common as the population ages, prompting an NYU Langone Medical Center neurosurgeon, Dr. Uzma Samadani, to urge her colleagues to gear up for a growing number of cases likely to require neurological intervention.
By 2030, when a fifth to a quarter of the American population will be older than 65, chronic subdural hematoma, or SDH, is expected to afflict 60,000 Americans a year, which would make it the most common reason for brain surgery, surpassing brain tumors and metastases, Dr. Samadani and colleagues reported last month in The Journal of Neurosurgery.
Head trauma from, say, a fall or another accident remains an important cause of the disorder, though in a third to a half of cases, patients cannot recall an injury that might account for it. In many instances, the trauma, if there was one, was so trivial it was forgotten, like walking into an open cupboard door or hitting one’s head getting in or out of a car.
Indirect trauma that jostles the brain is more common. About half of patients who report having fallen did so without hitting their heads.
The incidence of chronic SDH has been rising steadily since 1967, with a third of cases occurring in people over 80. The recent report identified 695 new cases among 875,842 patients seen at the V.A.’s New York Harbor Healthcare System from 2000 to 2012. The condition is much more common among V.A. patients, compared with the general population — they are typically older men with a higher rate of additional risk factors, including heavy drinking or a history of brain injury, Dr. Samadani said.
Heavy drinking causes liver damage that can disrupt the blood’s clotting functions, she explained. Likewise, the chance of developing a chronic SDH is significantly higher among those on anticoagulant medication, like Coumadin (warfarin), commonly prescribed to prevent heart attacks, strokes and blood clots, especially for older adults. As many as 24 percent of patients with the disorder were on warfarin or an antiplatelet drug to prevent clots, according to a study by researchers in Wales.
As many as 10 percent of patients had a history of alcoholism or epilepsy, the Welsh team reported. Obesity can be a contributing factor by increasing estrogen levels in the body, Dr. Samadani said.
However, older age remains the leading predisposing factor. As people age, the brain shrinks, creating a space into which fluid can collect. The veins that drain the brain must traverse this space, and even the slightest jolt can cause them to leak, leaving blood trapped against the brain. Also with advancing years, these “bridging veins” become more fragile and susceptible to tears.
Chronic SDH has been described as “the great neurological imitator” because it often presents a confusing array of possible symptoms that can resemble, alternatively, a psychiatric disorder, dementia, a migraine, epilepsy, Parkinson’s disease, a stroke or a transient ischemic attack, also known as a ministroke.
Patients may develop a rather severe headache and weakness on one side of the body, have difficulty walking, seem confused or have trouble speaking, Dr. Samadani said. She added that chronic SDH “is a common treatable cause of dementia.”
Symptoms of the disorder tend to develop rather suddenly, often without apparent explanation. Patients and their doctors need to be aware of the various symptoms and signs, and follow up with a CT scan that most often can reveal or rule out a subdural hematoma. The scan may need to be repeated using a dye if initial results are unclear.
The Welsh team noted that the most important factor in diagnosing chronic SDH was “a high index of suspicion” in patients whether or not they had a head injury or other trauma. Warning signs include headache; a change in mental status or worsening of pre-existing neurological or psychological illness; and neurological problems in a specific location like one side of the face, an arm or even a small area of the tongue.
Treatment of a chronic SDH is not always needed, though patients with a seemingly stable hematoma must be monitored, with prompt treatment if symptoms worsen. If bleeding into the subdural space continues unchecked, it increases pressure on the brain that can lead to a loss of consciousness, permanent disability or death.
Only a third of patients require surgical treatment, Dr. Samadani said. In the remaining two-thirds, the hematoma is gradually reabsorbed by the body without invasive treatment. Patients can also be given medication to help speed the process, she said.
While many chronic subdural hematomas cannot be prevented, the risk of developing one can be lowered by avoiding alcohol abuse, reducing the risk of falls and maintaining a normal body weight.
While there is no certain way yet to minimize brain shrinkage with age, Dr. Steven R. Flanagan, chairman of rehabilitative medicine at NYU Langone Medical Center, said, “Regular cardiovascular aerobic exercise is good not only for the heart and lungs, but also for cognitive function. Evidence suggests it increases brain-derived neurotrophic factor,” which promotes survival of the brain’s neurons.
Yet another reason to get — and stay — moving as you get older.
By Jane E. Brody : NY Times : April 6, 2015
You don’t have to hit your head to develop an insidious bleed between the soft covering of your brain and the brain itself that in days, weeks or months can threaten your health or life.
The condition, called chronic subdural hematoma, is becoming increasingly common as the population ages, prompting an NYU Langone Medical Center neurosurgeon, Dr. Uzma Samadani, to urge her colleagues to gear up for a growing number of cases likely to require neurological intervention.
By 2030, when a fifth to a quarter of the American population will be older than 65, chronic subdural hematoma, or SDH, is expected to afflict 60,000 Americans a year, which would make it the most common reason for brain surgery, surpassing brain tumors and metastases, Dr. Samadani and colleagues reported last month in The Journal of Neurosurgery.
Head trauma from, say, a fall or another accident remains an important cause of the disorder, though in a third to a half of cases, patients cannot recall an injury that might account for it. In many instances, the trauma, if there was one, was so trivial it was forgotten, like walking into an open cupboard door or hitting one’s head getting in or out of a car.
Indirect trauma that jostles the brain is more common. About half of patients who report having fallen did so without hitting their heads.
The incidence of chronic SDH has been rising steadily since 1967, with a third of cases occurring in people over 80. The recent report identified 695 new cases among 875,842 patients seen at the V.A.’s New York Harbor Healthcare System from 2000 to 2012. The condition is much more common among V.A. patients, compared with the general population — they are typically older men with a higher rate of additional risk factors, including heavy drinking or a history of brain injury, Dr. Samadani said.
Heavy drinking causes liver damage that can disrupt the blood’s clotting functions, she explained. Likewise, the chance of developing a chronic SDH is significantly higher among those on anticoagulant medication, like Coumadin (warfarin), commonly prescribed to prevent heart attacks, strokes and blood clots, especially for older adults. As many as 24 percent of patients with the disorder were on warfarin or an antiplatelet drug to prevent clots, according to a study by researchers in Wales.
As many as 10 percent of patients had a history of alcoholism or epilepsy, the Welsh team reported. Obesity can be a contributing factor by increasing estrogen levels in the body, Dr. Samadani said.
However, older age remains the leading predisposing factor. As people age, the brain shrinks, creating a space into which fluid can collect. The veins that drain the brain must traverse this space, and even the slightest jolt can cause them to leak, leaving blood trapped against the brain. Also with advancing years, these “bridging veins” become more fragile and susceptible to tears.
Chronic SDH has been described as “the great neurological imitator” because it often presents a confusing array of possible symptoms that can resemble, alternatively, a psychiatric disorder, dementia, a migraine, epilepsy, Parkinson’s disease, a stroke or a transient ischemic attack, also known as a ministroke.
Patients may develop a rather severe headache and weakness on one side of the body, have difficulty walking, seem confused or have trouble speaking, Dr. Samadani said. She added that chronic SDH “is a common treatable cause of dementia.”
Symptoms of the disorder tend to develop rather suddenly, often without apparent explanation. Patients and their doctors need to be aware of the various symptoms and signs, and follow up with a CT scan that most often can reveal or rule out a subdural hematoma. The scan may need to be repeated using a dye if initial results are unclear.
The Welsh team noted that the most important factor in diagnosing chronic SDH was “a high index of suspicion” in patients whether or not they had a head injury or other trauma. Warning signs include headache; a change in mental status or worsening of pre-existing neurological or psychological illness; and neurological problems in a specific location like one side of the face, an arm or even a small area of the tongue.
Treatment of a chronic SDH is not always needed, though patients with a seemingly stable hematoma must be monitored, with prompt treatment if symptoms worsen. If bleeding into the subdural space continues unchecked, it increases pressure on the brain that can lead to a loss of consciousness, permanent disability or death.
Only a third of patients require surgical treatment, Dr. Samadani said. In the remaining two-thirds, the hematoma is gradually reabsorbed by the body without invasive treatment. Patients can also be given medication to help speed the process, she said.
While many chronic subdural hematomas cannot be prevented, the risk of developing one can be lowered by avoiding alcohol abuse, reducing the risk of falls and maintaining a normal body weight.
While there is no certain way yet to minimize brain shrinkage with age, Dr. Steven R. Flanagan, chairman of rehabilitative medicine at NYU Langone Medical Center, said, “Regular cardiovascular aerobic exercise is good not only for the heart and lungs, but also for cognitive function. Evidence suggests it increases brain-derived neurotrophic factor,” which promotes survival of the brain’s neurons.
Yet another reason to get — and stay — moving as you get older.
Vigilance About the Dangers of Delirium
By Jane E. Brody : NY Times : October 1, 2012
You don't have to be elderly, or even very old, to develop delirium, a kind of brain attack often accompanied by hallucinations, agitation and disorientation that can exacerbate illness, increase medical costs and even hasten death.
Experts say delirium could be prevented in up to 40 percent of cases if doctors, nurses and patients' families were aware of its causes and made small but meaningful changes in how patients are treated. Prompt recognition of the symptoms and proper management can shorten the duration of the episode, alleviate suffering and reduce costs.
At least one in five hospital patients over 65 experiences delirium-related complications, some of which - like worsened dementia - may never completely resolve.
Yet, more often than not, delirium is misdiagnosed and mistreated.
Dr. Bree Johnston, a geriatrician at the University of California, San Francisco, tells of a woman, 70, with a history of bipolar disorder who became increasingly depressed, then agitated and uncooperative. She was taken to the emergency room, where a consulting psychiatrist prescribed clonazepam, a benzodiazepine sedative that only made things worse. She became uncontrollable and lapsed in and out of consciousness.
When the woman was hospitalized, doctors discovered that the real cause of her delirium was a mild heart attack. Proper treatment gradually reversed her brain disorder.
Many Causes and Consequences
Conditions that can trigger delirium include urinary tract infection, thyroid or kidney dysfunction, a coronary event or stroke, malnutrition, and an imbalance of electrolytes like sodium or potassium. Anyone with mild cognitive disorder or dementia is at increased risk, and cognitive dysfunction can worsen abruptly following an attack.
Certain medications, like benzodiazepines, can cause or contribute to the extreme confusion characteristic of delirium. Other drugs that have been linked to delirium include antihistamines, muscle relaxants, narcotic painkillers and even some antibiotics.
Just being hospitalized can result in delirium, as Susan Seliger recounted last year in The New Old Age, a New York Times blog. After hip surgery, her 85-year-old mother became disoriented, complaining about the lack of amenities in her "hotel" room. Soon she was tugging at the sheets, saying repeatedly, "We have to clean up this mess!" Eventually she had to be restrained.
A reader told me that when she had knee surgery in her 80s she suffered from terrible hallucinations, feared everyone and could not recapture reality when she awoke.
"In my nightmares," she wrote, "I saw nurses digging their long nails into my flesh because they accused me of trying to seduce the doctor. On other nights they left me alone in the middle of a wilderness to sit and cry." Even five years later, she said, "I am still not out of the woods."
About one-third of patients over 70 experience delirium during hospitalization. Rates are higher among those having surgery or treatment in the intensive care unit, where nothing is familiar, there is no difference between night and day, sleep is often disrupted, and patients are subjected to frightening noises, equipment and procedures.
An I.C.U. patient at the Johns Hopkins Hospital told of trying to get a crystal to the "good" aliens she saw in her mind but being thwarted by a robot. She said the experience was "a terrifying nightmare that no one should have to go through."
Dr. Ondria C. Gleason, a psychiatrist at the University of Oklahoma College of Medicine, described delirium as "any sudden change over the course of hours or days in a person's mental state, such as confusion, hallucinations, disorientation and personality changes like agitation or irritability."
There are three types:
- hyperactive, as afflicted the patients described above;
- hypoactive, often overlooked because, like depression, it is characterized by apathy and sluggishness;
- and a mixed state, with both hyperactive and hypoactive periods.
Delirium does not occur simply in a person's imagination. Dr. Tamara G. Fong, a neurologist at Hebrew Senior Life in Boston, and colleagues described biological changes in the delirious brain that could account for the symptoms: an imbalance of neurotransmitters and increase in inflammatory substances that disrupt communications among nerves; a metabolic disturbance or shortage of oxygen that injures the brain; and high levels of cortisol released during acute stress, causing a form of psychosis.
Prevention and Treatment
"We used to think of delirium as inevitable, almost normal," said Dr. Dale Needham, a critical care specialist at Johns Hopkins. "We now know there are things we can do to reduce the risk."
No. 1, he said, is to use little or no sedation. Although sedating an agitated patient may seem logical, he said, it can worsen and extend the length of delirium.
"It's better if patients remain awake and aware and maintain contact with reality," he said. "We can talk to the patient, ask if anything is needed, if they're in pain, if they'd like to watch television or listen to music."
Intensive care specialists at Johns Hopkins have also found that patients do better if occupational and physical therapy is started early. "The therapy seems to help the brain as well as the body," Dr. Needham said.
It also helps to keep patients oriented as to the time of day, the day of the week, where they are and why. This can be done both by the hospital staff and by family members or friends, who are encouraged to spend as much time as possible with patients and help them stay in touch with reality.
Knowing that interrupted sleep increases the risk of delirium, the I.C.U. staff at Johns Hopkins keeps nighttime disruptions to a minimum. "Lights are shut, curtains drawn and overhead announcements stopped at night to create a sleep-friendly I.C.U.," Dr. Needham said.
Using a test for confusion developed at Vanderbilt University Medical Center, I.C.U. patients at Johns Hopkins have the degree of delirium measured twice a day to assure the condition is not overlooked.
Dr. Fong said it was also helpful to avoid physically restraining patients, which can increase their terror, and to make sure they remain adequately nourished and hydrated and their senses stimulated. They should be provided glasses or hearing aids, if needed.
Dr. Gleason said family members might bring some familiar items to the patient's room, and should remain calm and reassuring if the patient becomes agitated.
