FitSugar

Fit Tip: Trade Your Office Chair For an Exercise Ball

FitSugar — Mon, 10 Nov 2008 14:30:00 -0800

I really don't believe we evolved to sit all day long. Sitting creates tight hips and hamstrings, causes a tight neck and shoulders, and often leads to back pain. If you suffer from these ailments, ditch your regular office chair and replace it with an exercise ball ($27).

When you sit on a firmly inflated ball, you'll improve your balance and tone your core muscles from your desk. It allows you to focus on keeping your spine long, and you can even use the fitness ball for wall squats or other exercises during the day. Sitting on a ball has also been proven to help kids focus and do better in school. If it works for them, it'll work for you, too.

If you're worried about the ball being too roly-poly, and not having a back support to lean on, then check out Gaiam's BalanceBall Chair ($99). I know it's kind of pricey, but if it can prevent discomfort while you work, then isn't it worth it? To see a video of this ball in action read more.

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Burn Office Calories

FitSugar — Thu, 30 Oct 2008 05:30:00 -0700

So what if you sit at a desk all day? There are hundreds of opportunities to burn calories from nine to five, and avoid job-related weight gain. According to Fitness magazine, there are some easy ways to stay fit and still keep your job. To see the list, read more.

Activity	Calories Burned
Typing (120 minutes)	230
Heel raises while sitting at your desk (5 minutes)	19
Walk the stairs on your lunch break (15 minutes)	128
Touch up your makeup (5 minutes)	10
Clean your desk and drawers (15 minutes)	40
Stand while on the phone (30 minutes)	58
Desk stretches (15 minutes)	59
Go for a jog on your lunch break (20 minutes)	158
Bike to and from work (20 minutes)	118
Do some strength training with dumbbells (5 minutes)	15

Want a few more ideas on how to stay active during your workday? Check out these tips for working it.
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Sit All Day? You Can Still Be Healthy

FitSugar — Wed, 06 Aug 2008 03:00:00 -0700

Let's face it: most of us are more sedentary than we want to be. We're desk-bound at the office, and sitting during our commutes. All this sitting is not exactly the best for your body. Not moving around translates to fewer calories burned throughout the day, which can lead to unhealthy weight gain. Sitting for more than eight hours a day can also cause back pain, a tense neck and shoulders, and leg cramps. Sixwise offers some tips on keeping your body and mind healthy while on the job.

Check your posture and your desk set-up. Your thighs should be parallel to the floor, and if you type at a keyboard, your hands, wrists, and forearms should also be parallel to the floor. Make sure your chair is padded yet firm, so the natural curve in your spine is supported and you're not sinking into your seat.
Carpal tunnel syndrome is a big office buzz word, so you want to work on preventing this and other injuries by avoiding repetitive motions. If you use a mouse, purchase a new one that places your hand and wrist in a different position (like a vertical mouse). Try to rearrange the things on your desk often, like your coffee cup or your pens, so you have to reach for them with a different hand.
Just because you sit at a desk all day doesn't mean you're glued to your seat. Be sure to stand up and move around every 20 minutes or so, for at least 30 seconds. Do some desk stretches, take a walk to visit your co-worker, or go to the kitchen to refill your glass of water. Not only will this circulate blood to your muscles, but it'll also prevent boredom.

For more desk tips, read more.

Don't forget about your eyes. Be sure to look away from your screen often to reduce eye strain, which can cause headaches. I like to close my eyes and do circle exercises. If you find your eyes are getting dry, blink often or keep some eye drops on your desk.
Check your desk and equipment for cleanliness. Even though it's only you using this stuff, germs and bacteria can move in and make you sick. So clean your mouse and your phone, dust off your desk and monitor, and disinfect your keyboard.
Ditch the snacks on your desk. Even if they're healthy snacks, you don't want to end up mindlessly reaching for bites. Pick a snack time and keep food in your desk drawer or the office kitchen. Not only will it give you a much-needed break from work, but taking time to eat will also allow you to really enjoy your food.

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It's True! We Really Do Crave Fatty Foods When We're Stressed

FitSugar — Tue, 10 Nov 2009 03:00:42 -0800

If your chocolate cravings are any indication, you may have already suspected that high-fat foods are a woman's go-to snack when stressed. Now there's evidence to confirm your suspicions - UCSF recently conducted a study to examine the relationship between eating habits and chronic stress.

Researchers surveyed 600 overweight or obese women regarding their diet and stress. Issues classified as chronic stressors included job dissatisfaction, financial worries (like inability to pay rent or mortgage), or dealing with an ailing loved one. The women dealing with these taxing personal issues reported a higher likelihood of being unable to control what they ate, and a tendency to eat more fattening foods. Chronically stressed women were also more likely to force themselves to keep a regimented, strict diet to control weight gain, even skipping meals. The downside is that it's hard to keep up a regimented program, and being stressed means a plan like this is bound to backfire - ultimately there's a breaking point, and we're more likely to overeat.

To learn more about stressed-out eating, just read more.

While this study may not offer any groundbreaking info, it does serve as a healthy reminder: Be conscious of when you're actually hungry, and remember, there is such a thing as emotional eating. Be more mindful of your mental health and how it affects your food choices, and make healthy eating a priority. If you need some creative, healthy snack alternatives, visit our Snack Attack group for ideas.

Stress

FitSugar — Wed, 08 Oct 2008 17:35:26 -0700

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Some people are pre-programmed for a heightened response to stress by conditions in the womb. Pregnant women under stress who eat a diet high in protein and low in carbohydrates have babies with higher cortisol levels. Later on, these levels increase in response to stress.
The impact of stress on the heart and circulation system is becoming more clear. Stress causes the body to release inflammatory markers that may worsen heart and circulatory diseases as well as inflammatory disease, such as rheumatoid arthritis. High levels of inflammatory markers are associated with increased risk of heart attack and stroke. Extreme stress can also produce a condition that mimics a heart attack, but is reversible. People under severe stress can experience irregular heart beats that make them susceptible to sudden cardiac death.
Stress also increases the risk of developing type 2 diabetes in women.
Traumatic stress has long been known to cause amnesia, emotional numbness, nightmares, and memory problems. Now it is known that traumatic emotional stress can cause permanent changes in the brain that interfere with the normal way information is accepted, coded, and retrieved.
The good news is that our physical response to stress is increasingly understood. Knowing what occurs at the cellular level may help researchers find more ways to counteract the detrimental physical and emotional effects of stress.

Introduction

Stress affects most people in some way. Acute (sudden, short-term) stress leads to rapid changes throughout the body. Almost all body systems (the heart and blood vessels, the immune system, the lungs, the digestive system, the sensory organs, and brain) gear up to meet the perceived danger.

These stresses could prove beneficial in a critical, life-or-death situation. Over time, however, repeated stressful situations put a strain on the body that may contribute to physical and psychological problems. Chronic (long-term) stress can have real health consequences and should be addressed like any other health concern.

Fortunately, research is showing that lifestyle changes and stress-reduction techniques can help people learn to manage their stress.

People can experience stress from external or internal factors.

External stressors include adverse physical conditions (such as pain or hot or cold temperatures) or stressful psychological environments (such as poor working conditions or abusive relationships). Humans, like animals, can also experience external stressors.
Internal stressors can also be physical (infections, inflammation) or psychological (such as intense worry about a harmful event that may or may not occur). As far as anyone can tell, internal psychological stressors are rare or absent in most animals except humans.

Stressors can also be defined as short-term (acute) or long-term (chronic).

Acute Stress. Acute stress is the reaction to an immediate threat, commonly known as the fight or flight response. The threat can be any situation that is perceived, even subconsciously or falsely, as a danger.

Common acute stressors include:

Noise (which can trigger a stress response even during sleep)
Crowding
Isolation
Hunger
Danger
Infection
High technology effects (playing video games, frequently ringing mobile phones)
Imagining a threat or remembering a dangerous event

Under most circumstances, once the acute threat has passed, levels of stress hormones return to normal. This is called the relaxation response.

Chronic Stress. Frequently, modern life poses ongoing stressful situations that are not short-lived. The urge to act (to fight or flee) must therefore be controlled. Stress, then, becomes chronic.

Common chronic stressors include:

On-going highly pressured work
Long-term relationship problems
Loneliness
Persistent financial worries

The Body's Response

The best way to envision the effect of acute stress is to imagine yourself in a primitive situation, such as being chased by a bear.

In response to seeing the bear, a part of the brain called the hypothalamic-pituitary-adrenal (HPA) system is activated.

Release of Steroid Hormones and the Stress Hormone Cortisol. The HPA systems trigger the production and release of steroid hormones (glucocorticoids), including the primary stress hormone cortisol. Cortisol is very important in organizing systems throughout the body (including the heart, lungs, circulation, metabolism, immune systems, and skin) to deal quickly with the bear.

Release of Catecholamines. The HPA system also releases certain neurotransmitters (chemical messengers) called catecholamines, particularly those known as dopamine, norepinephrine, and epinephrine (also called adrenaline).

Catecholamines activate an area inside the brain called the amygdala, which appears to trigger an emotional response to a stressful event. In the case of the bear, this emotion is most likely fear.

Release of Neuropeptide S. The brain releases neuropeptide S, a small protein that modulates stress by decreasing sleep and increasing alertness and a sense of anxiety. This gives the person a sense of urgency to run away from the bear.

Effects on Long- and Short-Term Memory. During the stressful event, catecholamines also suppress activity in areas at the front of the brain concerned with short-term memory, concentration, inhibition, and rational thought. This sequence of mental events allows a person to react quickly, either to fight the bear or to flee from it. It also interferes with the ability to handle difficult social or intellectual tasks and behaviors during that time.

On the other hand, neurotransmitters at the same time signal the hippocampus (a nearby area in the brain) to store the emotionally loaded experience in long-term memory. In primitive times, this brain action would have been essential for survival, since long-lasting memories of dangerous stimuli (such as the large bear) would be critical for avoiding such threats in the future.

The stress response also affects the heart, lungs, and circulation:

As the bear comes closer, the heart rate and blood pressure increase instantaneously.
Breathing becomes rapid, and the lungs take in more oxygen.
The spleen discharges red and white blood cells, allowing the blood to transport more oxygen throughout the body. Blood flow may actually increase 300 - 400%, priming the muscles, lungs, and brain for added demands.

The effect on the immune system from confrontation with the bear is similar to organizing a defensive line of soldiers to potentially critical areas. The steroid hormones reduce the activity in parts of the immune system, so that specific infection fighters (including important white blood cells) or other immune molecules can be repositioned. These immune-boosting troops are sent to the body's front lines where injury or infection is most likely to occur, such as the skin and the lymph nodes.

As the bear gets closer, fluids are diverted from nonessential locations, including the mouth. This causes dryness and difficulty in talking. In addition, stress can cause spasms of the throat muscles, making it difficult to swallow.

The stress effect moves blood flow away from the skin to support the heart and muscle tissues. This also reduces blood loss in the event that the bear causes a wound. The physical effect is a cool, clammy, sweaty skin. The scalp also tightens so that the hair seems to stand up.

Stress shuts down digestive activity, a nonessential body function during short-term periods of hard physical work or crisis.

Once the threat has passed and the effect has not been harmful (for example, the bear has not wounded the human), the stress hormones return to normal. This is known as the relaxation response. In turn, the body's systems also return to normal.

Complications

In prehistoric times, the physical changes in response to stress were an essential adaptation for meeting natural threats. Even in the modern world, the stress response can be an asset for raising levels of performance during critical events, such as a sports activity, an important meeting, or in situations of actual danger or crisis.

If stress becomes persistent and low-level, however, all parts of the body's stress apparatus (the brain, heart, lungs, vessels, and muscles) become chronically over- or under-activated. Such chronic stress may produce physical or psychological damage over time. Acute stress can also be harmful in certain situations, particularly in individuals with preexisting heart conditions.

Studies suggest that the inability to adapt to stress is associated with the onset of depression or anxiety. In one study, two-thirds of subjects who experienced a stressful situation had nearly 6 times the risk of developing depression within that month.

Some evidence suggests that repeated release of stress hormones produces hyperactivity in the hypothalamic-pituitary-adrenal (HPA) system, and disrupts normal levels of serotonin, the nerve chemical that is critical for feelings of well-being. Some people appear to be more at risk for an overactive HPA system under stress, including those with the personality traits that cause perfectionism. Certainly, on a more obvious level, stress reduces the quality of life by reducing feelings of pleasure and accomplishment. In addition, relationships are often threatened in times of stress.

The full impact of mental stress on heart disease is just coming to light, but the underlying mechanisms are not always clear. Stress can certainly influence the activity of the heart when it activates the automatic part of the nervous system that affects many organs, including the heart. Such actions and others could theoretically affect the heart badly in several ways:

Sudden stress increases the pumping action and rate of the heart, while at the same time causing the arteries to constrict (narrow). This restricts blood flow to the heart. A 2002 study suggested that such actions may be responsible for some cases of acute stress that have been associated with a higher risk for serious heart problems. These problems include heart rhythm abnormalities and heart attacks, and even death in people with heart disease.
Emotional effects of stress alter the heart rhythms, which could pose a risk for serious arrhythmias (rhythm abnormalities) in people with existing heart rhythm disturbances.
Stress causes blood to become stickier (possibly in preparation of potential injury), increasing the likelihood of an artery-clogging blood clot.
Stress appears to impair the clearance of fat molecules in the body, raising blood-cholesterol levels, at least temporarily.
Stress that leads to depression appears to be associated with increased intima-medial thickness, a measure of the arteries that signifies worsening blood vessel disease.
Chronic stress may lead to the production of immune factors called cytokines, although study results vary widely. Cytokines produce an inflammatory response that is now believed to be responsible for damaging the arteries. Such damage contributes to heart disease. New studies indicate that some people under stress may have increased levels of C-reactive protein (CRP), a risk marker for heart attack. Each 1 mg/L increase in CRP has been linked to a 20% increased risk of myocaridal ischemia, a condition that signals poor blood flow to the heart muscle.
Stress causes the body to release inflammatory markers into the bloodstream. These markers may worsen heart disease or increase the risk of heart attack or stroke.
Studies have reported an association between stress and high blood pressure, which may be more pronounced in men than in women. According to some evidence, people who regularly experience sudden spikes in blood pressure (caused by mental stress) may, over time, develop injuries in the inner lining of their blood vessels. In one 20-year study, for example, men who periodically measured highest on the stress scale were twice as likely to have high blood pressure as those with normal stress.

Evidence is still needed to confirm any clear-cut relationship between stress and heart disease. For example, a 2002 study in Scotland found no greater risk for actual heart disease or heart events even in men who reported higher mental stress. In fact, higher stress was associated with fewer heart events. Men with high stress levels did tend to complain of chest pain and to go to the hospital for it more often than those with lower stress. They also went to the hospital more often.

Evidence links stress to heart disease in men, particularly in work situations where they lack control. The association between stress and heart problems in women is weaker, and there is some evidence that the ways women cope with stress may be more heart-protective. In one study, men were more apt than women to use alcohol or eat less healthily in response to stress, which might account for their higher heart risks from stress. Different stressors may affect genders differently. In one study, work stress was associated with a higher risk for heart disease in men, but marital stress -- not work stress -- was associated with more severe heart disease in women with existing heart problems.

A condition called stress cardiomyopathy (or Takotsubo cardiomyopathy) is widely recognized. In this disease, intense emotional or physical stress causes severe but reversible heart dysfunction. The patient experiences chest pain, and EKGs and echocardiograms indicate a heart attack, but further tests show no underlying obstructive coronary artery disease.

Acute emotional stress can create abnormal heartbeats. MRI studies show that asymmetric brain activity may play a role in making a stressed heart susceptible to ventricular arrhythmias by creating electrical instability. In some patients, this can cause sudden cardiac death.

Psychological stress is also recognized as a possible cause of acute coronary syndrome (ACS), a collection of symptoms that signify heart attack or approaching heart attack. In one study of men who suffered ACS at work or up to 2 hours after work, many of the men were found to have anger and negative emotions. A 2007 review of studies on blood qualities, coagulation, fibrinolysis, and platelet reactivity found that high levels of psychological stress are associated with harmful changes to the blood. The research suggests that stress has the potential to trigger ACS, particularly in patients with heart disease. The studies also suggest that the risk is greatest immediately after the stressful incident, rather than during it.

Stress Reduction and Heart Disease. Studies suggest that treatments that reduce psychological distress improve long-term outlook in people with heart disease, including after a heart attack. Evidence indicates that stress management programs may reduce the risk of heart attacks by up to 75% in people with heart disease. Specific stress management techniques may help some problems but not others. For example, acupuncture in one study helped people with heart failure but had no effect on blood pressure. Relaxation methods, on the other hand, may help people with high blood pressure.

One survey revealed that men who had a more intense response to stressful situations, such as waiting in line or problems at work, were more likely to have strokes than those who did not report such distress. In some people, prolonged or frequent mental stress causes an exaggerated increase in blood pressure.

Chronic stress affects the immune system in complicated ways, and may have various results.

Susceptibility to Infections. Chronic stress appears to blunt the immune system's response to infections, and may even impair a person's response to immunizations. Several studies have shown that people under chronic stress have low white blood cell counts and are vulnerable to colds. Once a person catches a cold or flu, stress can make symptoms worse. People who carry the herpes virus or HIV may be more susceptible to viral activation following exposure to stress. Even more serious, some research has found that HIV-infected men with high stress levels progress more rapidly to AIDS when compared to those with lower stress levels.

Inflammatory Response. Some evidence suggests that chronic stress triggers an over-production of certain immune factors called cytokines. In excess levels, these chemicals can have very damaging effects. A recent study found that students unable to cope with stress had high levels of TNF-alpha, an inflammatory cytokine. Such findings may partly explain the association between chronic stress and numerous diseases, including heart disease and asthma.

Whether or not stress causes or aggravates cancer is not entirely clear. One study reported no association between stressful life events and recurrence in women who had been treated for breast cancer. Nevertheless, some animal studies suggest that lack of control over stress (not simply stress itself) had negative effects on immune function and contributed to tumor growth.

That being said, a 2007 study found that stress activates a gene that may cause metastatic cancer, as measured by increasing levels of the marker AGR2.

Although stress reduction techniques have no effect on survival rates, studies show that they are very helpful in improving a cancer patient's quality of life. Stress is also known to be one cause of hyponatremia (low plasma sodium levels) in cancer patients. Fortunately, this imbalance can be corrected with drugs called AVP-receptor agonists, developed for use in heart failure.

The brain and intestines are strongly related, and are controlled by many of the same hormones and parts of the nervous system. Indeed, some research suggests that the gut itself has features of a primitive brain. It is not surprising then that prolonged stress can disrupt the digestive system, irritating the large intestine and causing diarrhea, constipation, cramping, and bloating. Excessive production of digestive acids in the stomach may cause a painful burning.

Irritable Bowel Syndrome. Irritable bowel syndrome (or spastic colon) is strongly related to stress. With this condition, the large intestine becomes irritated, and its muscular contractions are spastic rather than smooth and wave-like. The abdomen is bloated, and the patient experiences cramping and alternating periods of constipation and diarrhea. Sleep disturbances due to stress can make irritable bowel syndrome even worse.

Peptic Ulcers. It is now well-established that most peptic ulcers are either caused by the H. pylori bacteria or the use of nonsteroidal anti-inflammatory (NSAID) medications (such as aspirin and ibuprofen). Nevertheless, studies still suggest that stress may predispose someone to ulcers, or sustain existing ulcers. Some experts estimate that social and psychological factors play some contributing role in 30 - 60% of peptic ulcer cases, whether they are caused by H. pylori or NSAIDs. In any case, some experts believe that the anecdotal relationship between stress and ulcers is so strong that attention to psychological factors is still warranted.

Inflammatory Bowel Disease. Although stress is not a cause of inflammatory bowel disease (Crohn's disease or ulcerative colitis), there are reports of an association between stress and symptom flare-ups. One study, for example, found that while short-term (over the previous month) stress did not significantly exacerbate ulcerative colitis symptoms, long-term perceived stress tripled the rate of flare-ups compared to patients who did not report feelings of stress.

Stress can have varying effects on eating problems and weight.

Weight Gain. Often stress is related to weight gain and obesity. Many people develop cravings for salt, fat, and sugar to counteract tension. As a result, they gain weight. Weight gain can occur even with a healthy diet, however, in some people exposed to stress. In addition, the weight gained is often abdominal fat, a predictor of diabetes and heart problems.

The release of cortisol, a major stress hormone, appears to encourage abdominal fat and may be the primary connection between stress and weight gain. Cortisol is a glucocorticoid. These hormones, along with insulin, appear to be responsible for stress-related food cravings. A 2005 study showed that hormonally induced cravings for "comfort foods" may have a biological benefit for managing stress. Eating comfort foods appears to reduce the negative hormonal and behavioral changes associated with stress, which might lessen the impact of stress on an individual. Carbohydrates in particular have been found to significantly increase levels of tryptophan and large neutral amino acids. This produces serotonin, which improves mood and performance under stress.

A 2007 study proposes a "reward-based stress eating" model. In this theory, stress and tasty, high-calorie foods cause the brain to make chemicals called endogenous opioids. These neurotransmitters help protect against the harmful effects of stress by slowing activity of a brain process called the hypothalamic-pituitary-adrenal (HPA) axis, thus weakening the stress response. Repeated stimulation of the reward pathways through stress-induced HPA stimulation, eating tasty food, or both, may lead to changes in the brain that cause compulsive overeating.

Weight Loss. Some people suffer a loss of appetite and lose weight during periods of stress. In rare cases, stress may trigger hyperactivity of the thyroid gland, stimulating appetite but causing the body to burn up calories at a faster than normal rate.

Eating Disorders. Chronically elevated levels of stress chemicals have been observed in patients with anorexia and bulimia. Some studies, however, have not found any strong link between stress and eating disorders. More work is needed to determine if changes in stress hormones are a cause or result of eating disorders.

Chronic stress has been associated with the development of insulin resistance, a condition in which the body is unable to use insulin effectively to regulate glucose (blood sugar). Insulin resistance is a primary factor in diabetes. In the Healthy Women Study, a large population of healthy women was studied for 15 years. Very stressful life events and severe depression greatly increased the risk of developing insulin resistance.

In another study of more than 33,000 Swedish workers, the development of type 2 diabetes was strongly correlated with work stress and low emotional support. However, the effect was seen in women, but not in men.

Stress can also exacerbate existing diabetes by impairing the patient's ability to manage the disease effectively.

Researchers are attempting to find the relationship between pain and emotion, but the area is complicated by many factors, including effects of personality types, fear of pain, and stress itself. A recent study suggests that chronic pain may impair the action of neutrophils, thereby weakening the immune response.

Muscular and Joint Pain. Stress may intensify chronic pain caused by arthritis and other conditions. According to a study on patients with rheumatoid arthritis, however, stress management techniques do not appear to have much effect on arthritic pain. Psychological distress also plays a significant role in the severity of back pain. Some studies have clearly associated job dissatisfaction and depression to back problems, although it is still unclear if stress is a direct cause of the back pain.

Headaches. Tension-type headaches are highly associated with stress and stressful events. Sometimes the headache does not start until long after the stressful event has ended. Additionally, stress can contribute to the development of headaches or cause headaches to occur more often.

Some research suggests that people who suffer from tension-type headaches may have some biological predisposition for translating stress into muscle contractions. Among the wide range of possible migraine triggers is emotional stress (although the headaches often erupt after the stress has eased). One study suggested that women with migraines tend to have personalities that over-respond to stressful situations.

The tensions of unresolved stress frequently cause insomnia, generally keeping the stressed person awake or causing awakening in the middle of the night or early morning. This appears to be due to the fact that stress causes physiological arousal during non-rapid eye movement (NREM) sleep.

Sexual Function. Stress can lead to diminished sexual desire and an inability to achieve orgasm in women. Stress response can cause androgen levels to drop, causing temporary impotence in men. Part of the stress response involves the release of brain chemicals that constrict the smooth muscles of the penis and its arteries. This constriction reduces the blood flow into and increases the blood flow out of the penis, which can prevent erection.

Premenstrual Syndrome. Some studies indicate that the stress response in women with premenstrual syndrome may be more intense than in those without the syndrome.

Fertility. Stress may even affect fertility. Stress hormones have an impact on the hypothalamus gland, which produces reproductive hormones. Severely elevated cortisol levels can even shut down menstruation. One small study reported a significantly higher incidence of pregnancy loss in women who had both high stress and prolonged menstrual cycles. Another reported that women with stressful jobs had shorter periods than women with low-stress jobs.

Effects on Pregnancy. Old wives' tales about a pregnant woman's emotions affecting her baby may have some credence. Stress may cause physiologic alterations, such as increased adrenal hormone levels or resistance in the arteries, which may interfere with normal blood flow to the placenta. Maternal stress during pregnancy has been linked to a higher risk for miscarriage, lower birth weights, and increased incidence of premature births. Some evidence also suggests that stress experienced by expectant mothers can even influence the way in which the baby's brain and nervous system will react to stressful events. Indeed, one study found a higher rate of crying and low attention in infants of mothers who had been stressed during pregnancy.

Menopause. A drop in estrogen levels during perimenopause and menopause may be responsible for changes in mood precipitated by stress. Estrogen replacement therapy can soften this response to stressful events.

Stress affects the brain, particularly memory, but the effects vary widely depending on whether the stress is acute or chronic.

Effect of Acute Stress on Memory and Concentration. Studies indicate that the immediate effect of acute stress impairs short-term memory, particularly verbal memory. On the plus side, high levels of stress hormone during short-term stress have been associated with enhanced memory storage and greater concentration on immediate events. The difference in effect may be due to how cortisol impacts glucocorticoid receptors in the hippocampus and prefrontal cortex. In a study of 20 men and 20 women, those whose cortisol levels increased in response to unpleasant, emotionally arousing photos had less memory recall later than those whose cortisol levels did not rise.

Effect of Chronic Stress on Memory. If stress becomes chronic, sufferers often experience loss of concentration at work and home, and they may become inefficient and accident-prone. In children, the physiologic responses to chronic stress can clearly inhibit learning. Chronic stress in older people may play an even more important role in memory loss than the aging process. In one study, for example, older adults with low stress hormone levels tested as well as younger adults in cognitive tests; those with higher stress levels tested 20 - 50% lower.

Studies have connected long-term exposure to excess amounts of cortisol (a major stress hormone) to shrinking of the hippocampus, the brain’s memory center. For example, two studies reported that groups who suffered from post-traumatic stress disorder (Vietnam veterans and women who suffered from sexual abuse) displayed up to 8% shrinking of the hippocampus. It is not yet known if this shrinking is reversible.

Allergies. Stress has been related to skin allergies. Some research suggests that stress, not indoor pollutants, may actually be a cause of the so-called sick-building syndrome. Sick-building syndrome produces allergy-like symptoms, such as eczema, headaches, asthma, and sinus problems, in office workers.

Compulsive Hoarding. People with obsessive-compulsive disorder (OCD) and compulsive hoarding are far more likely to have experienced a traumatically stressful event than people with OCD who are not hoarders. Hoarders who have experienced traumatic events have significantly more severe hoarding than those who have not been traumatized. The strongest association with traumatic stress is found in the clutter factor of compulsive hoarding, rather than in difficulty discarding objects.

Chronic Fatigue. Stress increases the risk of developing chronic fatigue syndrome, although studies suggest that high levels of emotional instability may genetically predispose someone to the syndrome.

Skin Disorders. Stress plays a role in worsening numerous skin conditions, including hives, psoriasis, acne, rosacea, and eczema, and is one of the most common causes of eczema. Unexplained itching may also be caused by stress. Evidence suggests that experiencing the stress of a traumatic event (parental divorce or separation, or a severe disease in a family member) before age 2 increases the risk of developing eczema.

Unexplained Hair Loss (Alopecia Areata). Alopecia areata is hair loss that occurs in localized (individual) patches. The cause is unknown, but stress is suspected as a player in this condition. For example, hair loss often occurs during periods of intense stress, such as mourning.

Teeth and Gums. Stress has now been implicated in increasing the risk for periodontal disease, which is disease in the gums that can cause tooth loss.

People under chronic stress often turn to alcohol abuse or tobacco use for relief. The damage these self-destructive habits cause under ordinary circumstances is compounded by the physiological effects of stress itself. Many people also resort to abnormal eating patterns or passive activities, such as watching television. The results of a national survey, released in February 2006, show that: "Americans engage in unhealthy behaviors such as comfort eating, poor diet choices, smoking and inactivity to help deal with stress."

Alcohol affects receptors in the brain that reduce stress. Lack of nicotine increases stress in smokers, which creates a cycle of dependency on smoking. One study indicated that nicotine has calming effects in women but not in men. In fact, in the study, smoking increased aggression in men.

The cycle is self-perpetuating: a sedentary routine, an unhealthy diet, alcohol abuse, and smoking all promote heart disease. They also interfere with sleep patterns, and lead to increased rather than reduced tension levels. Drinking four or five cups of coffee, for example, can cause changes in blood pressure and stress hormone levels similar to those produced by chronic stress. Animal fats, simple sugars, and salt are known contributors to health problems.

Conditions with Similar Symptoms

The physical symptoms of anxiety disorders mirror many symptoms of stress, including:

A fast heart rate
Rapid, shallow breathing
Increased muscle tension

Anxiety is an emotional disorder, however, and is characterized by feelings of apprehension, uncertainty, fear, or panic. Unlike stress, the triggers for anxiety are not necessarily or even usually associated with specific stressful or threatening conditions. Some individuals with anxiety disorders have numerous physical complaints, such as headaches, gastrointestinal disturbances, dizziness, and chest pain. Severe cases of anxiety disorders are debilitating, and interfere with career, family, and social spheres.

Depression can be a disabling condition, and, like anxiety disorders, may result from chronic stress. A 2005 study of Canadian workers found that individuals with a high level of work-related stress are more than twice as likely to experience a major depressive episode, compared with people under less stress. Evidence also suggests that certain people may be genetically susceptible to depression after stressful life events. Depression also mimics some of the symptoms of stress, including changes in appetite, sleep patterns, and concentration. Serious depression, however, is distinguished from stress by feelings of sadness, hopelessness, loss of interest in life, and, sometimes, thoughts of suicide. Acute depression is also accompanied by significant changes in the patient's functioning. Professional therapy may be needed in order to determine if depression is caused by stress, or if it is the primary problem.

Post-traumatic stress disorder (PTSD) is a reaction to a very traumatic event, and it is actually classified as an anxiety disorder. The event that brings on PTSD is usually outside the norm of human experience, such as intense combat or sexual assault. The patient struggles to forget the traumatic event and frequently develops emotional numbness and event-related amnesia. Often, however, there is a mental flashback, and the patient re-experiences the painful circumstance in the form of dreams and disturbing thoughts and memories. These thoughts and dreams resemble or recall the trauma. Other symptoms may include lack of pleasure in formerly enjoyed activities, hopelessness, irritability, mood swings, sleep problems, inability to concentrate, and an excessive startle-response to noise.

Treatment

Perhaps the best general approach for treating stress can be found in the elegant passage by Reinhold Niebuhr, "Grant me the courage to change the things I can change, the serenity to accept the things I can't change, and the wisdom to know the difference." The process of learning to control stress is life-long, and will not only contribute to better health, but a greater ability to succeed in one's own agenda.

Stress can be a factor in a variety of physical and emotional illnesses, which should be professionally treated. Many stress symptoms are mild and can be managed by over-the-counter medications (for example, aspirin, acetaminophen, or ibuprofen for tension headaches; antacids, anti-diarrhea medications, or laxatives for mild stomach distress). A physician should be consulted, however, for physical symptoms that are out of the ordinary, particularly those that get worse or wake a person up at night. A mental health professional should be consulted for unmanageable acute stress or for severe anxiety or depression. Often short-term therapy can resolve stress-related emotional problems.

In choosing specific strategies for treating stress, several factors should be considered.

No single method is always successful: A combination of approaches is generally most effective.
What works for one person does not necessarily work for someone else.
Stress can be positive as well as negative. Appropriate and controllable stress provides interest and excitement and motivates the individual to greater achievement. A lack of stress may lead to boredom and depression.

Stress may play a part in making people vulnerable to illness. A physician or psychologist should be consulted if there are any indications of accompanying medical or psychological conditions, such as heart symptoms, significant pain, anxiety, or depression.

People often succeed in relieving stress for the short term. However, they go back to previous ways of stressful thinking and behaving because of outside pressure, long-held beliefs, or habits. The following are some obstacles to managing stress:

The fight or flight urge: The very idea of relaxation can feel threatening, because it is perceived as letting down one's guard. For example, an over-demanding boss may put a subordinate into a psychological state of fighting-readiness, even though there is no safe opportunity for the subordinate to fight back or express anger. Stress builds up, but the worker has the illusion, even subconsciously, that the stress itself is providing safety or preparedness. For this reason, the employee does nothing to correct the condition.
Many people are afraid of being perceived as selfish if they engage in stress-reducing activities that benefit only themselves. The truth is that self-sacrifice (in the form of not reducing one’s stress) may be inappropriate and even damaging, if the person making the sacrifice is unhappy, angry, or physically unwell.
Some people believe that certain emotional responses to stress, such as anger, are natural and unchangeable features of personality. Research has shown, however, that with cognitive behavioral therapy, individuals can be taught to change their emotional reactions to stressful events.

It is essential to remember that reducing stress and staying relaxed clears the mind, so it can begin appropriate actions to get rid of the stress-ridden conditions.

Although treating stress cannot cure medical problems, stress management can be a very important part of medical treatment. Specific stress reduction approaches may benefit different medical problems. For example, acupuncture in one study helped reduce harmful heart muscle actions in people with heart failure, but it had no effect on blood pressure. Relaxation methods, on the other hand, may help people with high blood pressure. Stress reduction may improve well-being and quality of life for many patients who are experiencing stress because of severe or chronic medical conditions.

Important Note: Never use stress reduction techniques as the only treatment, or in place of proven treatments, for any medical condition.

Risk Factors

At some point in their lives virtually everyone will experience stressful events or situations that overwhelm their natural coping mechanisms. In one poll, 89% of respondents indicated that they had experienced serious stress in their lives. Some people are simply biologically prone to stress. Many outside factors influence susceptibility as well.

Conditions Most Likely To Produce Stress-Related Health Problems. Conditions that are most likely to be associated with stress and negative physical effects include the following:

An accumulation of persistent stressful situations, particularly those that a person cannot easily control (for example, high-pressured work plus an unhappy relationship)
Persistent stress following a severe acute response to a traumatic event (such as an automobile accident)
Acute stress accompanying serious illness, such as heart disease

Factors That Influence the Response to Stress. People respond to stress differently, depending on different factors:

Early nurturing: Abusive behavior towards children may cause long-term abnormalities in the hypothalamus-pituitary system, which regulates stress.
Personality traits: Certain people have personality traits that cause them to over-respond to stressful events.
Genetic factors: Some people have genetic factors that affect stress, such as having a more or less efficient relaxation response. One study found a genetic abnormality in serotonin regulation that was connected with a heightened reaction of heart rates and blood pressure in response to stress. (Serotonin is a brain chemical involved with feelings of well-being.)
Immune regulated diseases: Certain diseases that are associated with immune abnormalities (such as rheumatoid arthritis or eczema) may actually weaken a response to stress.
The length and quality of stressors: Naturally, the longer the duration and more intense the stressors, the more harmful the effects.

Individuals at Higher Risk for Stress. Studies indicate that the following people are more vulnerable to the effects of stress than others:

Older adults: As people age, achieving a relaxation response after a stressful event becomes more difficult. Aging may simply wear out the systems in the brain that respond to stress, so that they become inefficient. The elderly, too, are very often exposed to major stressors such as medical problems, the loss of a spouse and friends, a change in a living situation, and financial worries. No one is immune to stress, however, and it may simply go unnoticed in the very young and old.
Women in general and working mothers specifically: Working mothers, regardless of whether they are married or single, face higher stress levels and possibly adverse health effects, most likely because they bear a greater and more diffuse work load than men or other women. This has been observed in women in the U.S. and in Europe. Such stress may also have a domino and harmful effect on their children. It is not clear, however, if stress has the same adverse effects on women's hearts as it does on men's.
Less educated individuals.
Divorced or widowed individuals: Numerous studies indicate that unmarried people generally do not live as long as their married contemporaries.
Anyone experiencing financial strain, particularly long-term unemployed and those without health insurance.
People who are isolated or lonely.
People who are targets of racial or sexual discrimination.
People who live in cities.

Children are frequent victims of stress because they are often unable to communicate their feelings accurately. They also have trouble communicating their responses to events over which they have no control. Certain physical symptoms, notably repeated abdominal pain without a known cause, may be indicators of stress in children.

Various conditions can affect their susceptibility to stress.

Low Birth Weight. One study reported that low birth weight and slow growth up until age 7 was related to stress in adulthood.

Parental Stress. Parental stress, especially in mothers, is a particularly powerful source of stress in children, even more important than poverty or overcrowding. In a 2002 study, for example, young children of mothers who were highly stressed (particularly if they were depressed) tended to be at high risk for developing stress-related problems. This was especially true if the mothers were stressed during both the child's infancy and early years. Some evidence even supports the old idea that stress during pregnancy can have adverse effects on the infant's mood and behavior. Older children with stressed mothers may become aggressive and anti-social. One study suggested that stress-reduction techniques in parents may improve their children's behavior.

Gender Differences in Adolescent Stress. Adolescent boys and girls experience equal amounts of stress, but the source and effects may differ. Girls tend to become stressed from interpersonal situations, and stress is more likely to lead to depression in girls than in boys. For boys, however, specific events, such as changing schools or getting poor grades, appear to be the major sources of stress.

A report issued in October 2006 by the American Academy of Pediatrics recommends more unstructured play time for children. The report notes that today’s overscheduled, hurried lifestyle that many children experience is a source of stress and anxiety in some children.

In a 1999 study of 46,000 workers, health care costs were 147% higher in workers who were stressed or depressed than in others who were not. Furthermore, according to one survey, 40% of American workers describe their jobs as very stressful, making job-related stress an important and preventable health hazard.

Several studies are now suggesting that job-related stress is as great a threat to health as smoking or not exercising. Stress impairs concentration, causes sleeplessness, and increases the risk for illness, back problems, accidents, and lost time from work. Work stress can lead to harassment or even violence while on the job. At its most extreme, chronic stress places a burden on the heart and circulation that in some cases may be fatal. The Japanese even have a word for sudden death due to overwork, karoushi.

Not all work stress is harmful. However, studies suggest the following job-related stressors may increase people's -- particularly men's -- health risks:

Having no say in decisions that affect one's responsibilities
Unrelenting and unreasonable performance demands
Lack of effective communication and conflict-resolution methods among workers and employers
Lack of job security
Night-shift work, long hours, or both
Too much time spent away from home and family
Wages not matching levels of responsibility

Reducing Stress on the Job. Many institutions within the current culture, while paying lip service to stress reduction, put intense pressure on individuals to behave in ways that increase tension. Yet, there are numerous effective management tools and techniques available to reduce stress. Furthermore, treatment for work-related stress has proven benefits for both the employee and employer. In one study, at the end of 2 years, a company that instituted a stress management program saved nearly $150,000 in workers compensations costs (the cost of the program was only $6,000). Other studies have reported specific health benefits resulting from workplace stress-management programs. In one of the studies, workers with hypertension experienced reduced blood pressure after even a brief (16-hour) program that helped them manage stress behaviorally.

In general, however, few workplaces offer stress management programs, and it is usually up to the employee to find their own ways to reduce stress. Here are some suggestions:

Seek out someone in the Human Resources department or a sympathetic manager and communicate concerns about job stress. Work with them in a non-confrontational way to improve working conditions, letting them know that productivity can be improved if some of the pressure is off.
Establish or reinforce a network of friends at work and at home.
Restructure priorities and eliminate unnecessary tasks.
Learn to focus on positive outcomes.
If the job is unendurable, plan and execute a career change. Send out resumes or work on transfers within the company.
If this isn't possible, be sure to schedule daily pleasant activities and physical exercise during free time.

It may be helpful to keep in mind that bosses are also victimized by the same stressful conditions they are imposing. For example, in one study of male managers in three Swedish companies, those who worked in a bureaucracy had greater stress-related heart risks than those who worked in companies with social supports.

Caregivers of Family Members. Studies show that caregivers of physically or mentally disabled family members are at risk for chronic stress. One study reported that overall mortality rates were over 60% higher in caregivers who were under constant stress. Spouses caring for a disabled partner are particularly vulnerable to a range of stress-related health threats, including influenza, depression, heart disease, and even poorer survival rates. Caring for a spouse with even minor disabilities can induce severe stress.

Specific risk factors that put caregivers at higher risk for severe stress, or stress-related illnesses, include:

Caregiving wives: Some studies suggest that wives experience significantly greater stress from caregiving than husbands do.
Having a low income.
Being African-American: African-American people tend to be in poorer physical health, and have lower incomes, than Caucasians. They therefore face greater stress as caregivers to their spouses than their white counterparts.
Living alone with the patient.
Helping a highly dependent patient.
Having a difficult relationship with the patient.

Intervention programs that are aimed at helping the caregiver approach the situation positively can reduce stress, and help the caregiver maintain a positive attitude. A 2002 program also demonstrated that moderate-intensity exercise was very helpful in reducing stress and improving sleep in caregivers.

Health Professional Caregivers. Caregiving among the health professionals is also a high risk factor for stress. One study, for example, found that registered nurses with low job control, high job demands, and low work-related social support experienced very dramatic health declines, both physically and emotionally.

People who are less emotionally stable or have high anxiety levels tend to experience specific events as more stressful than others. Some doctors describe an exaggerated negative response to stress as "catastrophizing" the event (turning it into a catastrophe). Nevertheless, a 2003 study of patients with anxiety disorder did not find any differences in actual physical response to stress (heart rate, blood pressure, release of stress hormones) compared to people without anxiety.

The lack of an established network of family and friends predisposes one to stress disorders and stress-related health problems, including heart disease and infections. A study, meanwhile, reported that older people who maintain active relationships with their adult children are buffered against the adverse health effects of chronic stress-inducing situations, such as low income or lower social class. Another study suggested this may be because people who live alone are unable to discuss negative feelings as a means to relieve their stress.

Studies of people who remain happy and healthy despite many life stresses conclude that most have very good networks of social support. One study indicated that support even from strangers reduced blood pressure surges in people undergoing a stressful event. Many studies suggest that having a pet helps reduce medical problems aggravated by stress, including heart disease and high blood pressure.

Lifestyle Changes

A healthy lifestyle is an essential companion to any stress-reduction program. General health and stress resistance can be enhanced by regular exercise, a diet rich in a variety of whole grains, vegetables, and fruits, and by avoiding excessive alcohol, caffeine, and tobacco.

Of interest, a 2003 study suggested that fish oil, which has been associated with a lower risk for heart disease and stroke, may blunt some of the harmful effects of mental stress on the heart.

In one study, high doses of vitamin C reduced stress levels and blood pressure. The doses given were higher than the recommended upper limit of 2,000 mg per day. High doses may cause headaches and diarrhea. Long-term use increases risk for kidney stones and has other adverse effects in specific individuals.

Exercise in combination with stress management techniques is extremely important for many reasons:

Exercise is an effective distraction from stressful events.
Exercise may directly blunt the harmful effects of stress on blood pressure and the heart (exercise protects the heart in any case).

Usually, a varied exercise regime is more interesting, and thus easier to stick to. Start slowly. Strenuous exercise in people who are not used to it can be very dangerous and any exercise program should be discussed with a physician. In addition, half of all people who begin a vigorous training regime drop out within a year. The key is to find activities that are exciting, challenging, and satisfying. The following are some suggestions:

Sign up for aerobics classes at a gym.
Brisk walking is an excellent aerobic exercise that is free and available to nearly anyone. Even short brisk walks can relieve bouts of stress.
Swimming is an ideal exercise for many stressed people, including pregnant women, individuals with musculoskeletal problems, and those who suffer exercise-induced asthma.
Yoga or Tai Chi can be very effective, combining many of the benefits of breathing, muscle relaxation, and meditation while toning and stretching the muscles. The benefits of yoga may be considerable. Numerous studies have found it beneficial for many conditions in which stress is an important factor, such as anxiety, headaches, high blood pressure, and asthma. It also elevates mood and improves concentration and the ability to focus.

As in other areas of stress management, making a plan and executing it successfully develops feelings of mastery and control, which are very beneficial in and of themselves. Start small. Just 10 minutes of exercise three times a week can build a good base for novices. Gradually build up the length of these every-other-day sessions to 30 minutes or more.

Cognitive-behavioral techniques (CBT) are among the most effective ways of reducing stress. A 2005 study found that CBT training can have a long-term impact one’s ability to cope with stress. In the study, participants received CBT training and were exposed to a stressful situation 4 months later. The participants who had received CBT training had significantly less stress-induced cortisol responses compared with individuals who had received no stress management training. This effect was observed in both men and women, although the CBT had a greater effect on men. CBT may be particularly helpful when the source of stress is chronic pain or a chronic disease. In fact, in a study of patients with HIV, CBT was more helpful than support groups for improving well-being and quality-of-life.

A typical CBT approach includes identifying sources of stress, restructuring priorities, changing one's response to stress, and finding methods for managing and reducing stress.

Identifying Sources of Stress. One key component in most CBT approaches is a diary that keeps an informal inventory of daily events and activities. While this exercise might itself seem stress producing (and yet one more chore), it need not be done in painstaking detail. A few words accompanying a time and date are usually enough to serve as reminders of significant events or activities.

The first step is to note activities that put a strain on energy and time, trigger anger or anxiety, or precipitate a negative physical response (such as a sour stomach or headache).

Also note positive experiences, such as those that are mentally or physically refreshing or produce a sense of accomplishment.

After a week or two, try to identify two or three events or activities that have been significantly upsetting or overwhelming.

Questioning the Sources of Stress. Individuals should then ask themselves the following questions:

Do these stressful activities meet my goals or someone else's?
Have I taken on tasks that I can reasonably accomplish?
Which tasks are under my control and which ones aren't?

Restructuring Priorities: Adding Stress Reducing Activities. The next step is to attempt to shift the balance from stress-producing to stress-reducing activities. Eliminating stress is rarely practical or feasible, but there are many ways to reduce its impact.

Consider as many relief options as possible. Examples include:

Listen to music. Music is an effective stress reducer in both healthy individuals and people with health problems. In one study, for example, students who listened to a well-known gentle classical piece of music during a stressful task had reduced feelings of anxiety, heart rate, and blood pressure.
Take long weekends or, ideally, vacations.
If the source of stress is in the home, plan times away, even if it is only an hour or two a week.
Replace unnecessary time-consuming chores with pleasurable or interesting activities.
Make time for recreation. This is as essential as paying bills or shopping for groceries.
Own a pet. In a study of people with high blood pressure, pet owners had much lower blood pressure increase in response to stress than non-owners. Note that owning a pet was beneficial only for people who like animals to begin with.

Discuss Feelings. The concept of communication and letting your feelings out has been so excessively promoted and parodied that it has nearly lost its value as good psychological advice. Nevertheless, feelings of anger or frustration that are not expressed in an acceptable way may lead to hostility, a sense of helplessness, and depression.

Expressing feelings does not mean venting frustration on waiters and subordinates, boring friends with emotional minutia, or wallowing in self-pity. In fact, because blood pressure may spike when certain chronically hostile individuals become angry, some therapists strongly advise that just talking, not simply venting anger, is the best approach, especially for these people.

The primary goal is to explain and assert one's needs to a trusted individual in as positive a way as possible. Direct communication may not even be necessary. Writing in a journal, writing a poem, or composing a letter that is never mailed may be sufficient.

Expressing one's feelings solves only half of the communication puzzle. Learning to listen, empathize, and respond to others with understanding is just as important for maintaining the strong relationships necessary for emotional fulfillment and reduced stress.

Keep Perspective and Look for the Positive. Reversing negative ideas and learning to focus on positive outcomes helps reduce tension and achieve goals. The following steps, using an example of a person who is alarmed at the prospect of giving a speech, may be useful:

First, identify the worst possible outcomes (forgetting the speech, stumbling over words, humiliation, audience contempt).
Rate the likelihood of these bad outcomes happening (probably very low or that speaker wouldn't have been selected in the first place).
Envision a favorable result (a well-rounded, articulate presentation with rewarding applause).
Develop a specific plan to achieve the positive outcome (preparing in front of a mirror, using a video camera or tape recorder, relaxation exercises).
Try to recall previous situations that initially seemed negative but ended well.

Use Humor. Research has shown that humor is a very effective mechanism for coping with acute stress. Keeping a sense of humor during difficult situations is a common recommendation from stress management experts. Laughter not only releases the tension of pent-up feelings and helps keep perspective, but it appears to have actual physical effects that reduce stress hormone levels. It is not uncommon for people to recall laughing intensely even during tragic events, such as the death of a loved one, and to remember this laughter as helping them to endure the emotional pain.

Relaxation Methods. Since stress is here to stay, everyone needs to develop methods to promote the relaxation response, the natural unwinding of the stress response. Relaxation lowers blood pressure, respiration, and pulse rates, releases muscle tension, and eases emotional strains. This response is highly individualized, but there are certain approaches that seem to work.

Combinations are probably best. For example, in a study of children and adolescents with adjustment disorder and depression, a combination of yoga, a brief massage, and progressive muscle relaxation effectively reduced both feelings of anxiety and stress hormone levels. A 2005 study of organ transplant recipients showed that training in meditation and gentle yoga led to significant improvements in quality of sleep and lessened anxiety and depression.

No one should expect a total resolution of stress from these approaches, but if done regularly, these programs can be very effective.

Acupuncture. Some evidence suggests that acupuncture may also be helpful. It might even improve some physical factors associated with stress and health problems. For example, in a study of heart failure patients, acupuncture improved stress-related heart muscle activity, which could be an important benefit in these patients. However, acupuncture had no effect on stress-related blood pressure or heart rate.

Hypnosis. Hypnosis may also benefit some people with severe stress. In one study of patients with irritable bowel, stress reduction by hypnosis correlated with improvement in many bowel symptoms.


*Deep Breathing Exercises.* During stress, breathing becomes shallow and rapid. Taking a deep breath is an automatic and effective technique for winding down. Deep breathing exercises consciously intensify this natural physiologic reaction and can be very useful during a stressful situation, or for maintaining a relaxed state during the day.	Inhale through the nose slowly and deeply to the count of 10. Make sure that the stomach and abdomen expand, but the chest does not rise. Exhale through the nose, slowly and completely, also to the count of 10. To help quiet the mind, concentrate fully on breathing and counting through each cycle. Repeat five to 10 times, and make a habit of doing the exercise several times each day, even when not feeling stressed.
*Muscle Relaxation.* Muscle relaxation techniques, often combined with deep breathing, are simple to learn and very useful for getting to sleep. In the beginning it is useful to have a friend or partner check for tension by lifting an arm and dropping it. The arm should fall freely. Practice makes the exercise much more effective and produces relaxation much more rapidly. Small studies have reported beneficial effects on blood pressure in patients with high blood pressure who use this technique.	After lying down in a comfortable position without crossing the limbs, concentrate on each part of the body. Maintain a slow, deep breathing pattern throughout this exercise. Tense each muscle as tightly as possible for a count of five to 10, and then release it completely. Experience the muscle as totally relaxed and lead-heavy. Begin with the top of the head and progress downward to focus on all the muscles in the body. Be sure to include the forehead, ears, eyes, mouth, neck, shoulders, arms and hands, fingers, chest, belly, thighs, calves, and feet. Once the external review is complete, imagine tensing and releasing internal muscles.
*Meditation.* Meditation, used for many years in Eastern cultures, is now widely accepted in this country as a relaxation technique. The goal of all meditative procedures, both religious and therapeutic, is to quiet the mind (essentially, to relax thought). Small studies have suggested that regular meditation can benefit the heart and help reduce blood pressure. Better research is needed, however, to confirm such claims. Some recommend meditating for no longer than 20 minutes in the morning after awakening and then again in early evening before dinner. Even once a day is helpful. Note: Meditating before going to bed may cause some people to wake up in the middle of the night, alert and unable to return to sleep. New practitioners should understand that it can be difficult to quiet the mind, and should not be discouraged by lack of immediate results. Several techniques are available. A few are discussed here. The only potential risks from meditating are in people with psychosis, in whom meditating may trigger a psychotic event.	Mindfulness Meditation. Mindfulness is a common practice that focuses on breathing. It employs the basic technique used in other forms of meditation. Sit upright with the spine straight, either cross-legged or sitting on a firm chair with both feet on the floor, uncrossed. With the eyes closed or gently looking a few feet ahead, observe the exhalation of the breath. As the mind wanders, simply note it as a fact and returns to the "out" breath. It may be helpful to imagine your thoughts as clouds dissipating away. Transcendental Meditation (TM). TM uses a mantra (a word that has a specific chanting sound but no meaning). The person meditating repeats the word silently, letting thoughts come and go. In one study, TM was as effective as exercise in elevating mood. Mini-Meditation. The method involves heightening awareness of the immediate surrounding environment. Choose a routine activity when alone. For example: While washing dishes, concentrate on the feel of the water and dishes. Allow the mind to wander to any immediate sensory experience (sounds outside the window, smells from the stove, colors in the room). If the mind begins to think about the past or future, or fills with unformed thoughts or worries, redirect it gently back. This redirection of brain activity from your thoughts and worries to your senses disrupts the stress response and prompts relaxation. It also helps promote an emotional and sensual appreciation of simple pleasures already present in a person's life.
*Biofeedback.* Biofeedback is a technique that measures bodily functions, like breathing, heart rate, blood pressure, skin temperature, and muscle tension. By watching these measurements, you can learn how to alter these functions by relaxing or holding pleasant images in your mind.	During biofeedback, electric leads are taped to a subject's head. The person is encouraged to relax using methods such as those described above. Brain waves are measured and an audible signal is emitted when alpha waves are detected, a frequency which coincides with a state of deep relaxation. By repeating the process, subjects associate the sound with the relaxed state and learn to achieve relaxation by themselves.
*Massage Therapy.* A 2005 report that reviewed data from multiple studies showed that massage therapy decreases cortisol levels. Another 2005 study showed that massage from a stable romantic partner can reduce physiological responses to a subsequent stressful event. In the study, women who received instructed shoulder-neck-massage from their partners before being exposed to stress had lowered cortisol responses, and smaller heart rate increases after the stressful event. Interestingly, massage was more beneficial than receiving social support from the partner, indicating the power of physical touch in managing stress. Several massage therapies are available.	Many massage techniques are available, such as the following: Swedish massage is the standard massage technique. It uses long smooth strokes, and kneading and tapping of the muscles. Shiatsu applies intense pressure to the same points targeted in acupuncture. It can be painful, but people report deep relaxation afterward. Reflexology manipulates acupuncture points in the hands and feet.

Some people who experience chronic stress seek herbal or natural remedies. It should be strongly noted, however, that just as with standard drugs, so-called natural remedies can cause problems, sometimes serious ones.

Probiotics. Probiotics are helpful bacterial strains that by themselves may provide a barrier against harmful bacteria. They do so through various mechanisms, such as excreting certain acids (for example, lactate, acetate) that inhibit harmful bacteria. They may also compete with them for nutrients. Stress reduces levels of these bacteria. Research even suggests that probiotics may help maintain remission in patients with IBD. In one small study, people suffering from stress and exhaustion significantly reduced their stress symptoms and gastrointestinal complaints when they took a probiotic supplement for 6 months. The specific bacteria that might be beneficial, however, are not fully known. The most well-known probiotics are the lactobacilli strains, such as acidophilus, which is found in yogurt and other fermented milk products. Others, however, may prove to be more important, such as bifidobacteria and GG lactobacilli. Other probiotics include the lactobacilli rhamnosus, casel, plantarium, bulgaricus, and salivarius, and also Enterococcus faecium and Streptococcus thermophilus.

Aromatherapy. The smell of lavender has long been associated with a calming effect. In a Japanese study, 14 women who were put in a room with a lavender scent experienced reduced mental stress. Several aromatherapies are now used for relaxation. Use caution, however, as some of the exotic plant extracts in these formulas have been associated with a wide range of skin allergies.

Valerian. Valerian is an herb that has sedative qualities and may reduce stress and associated physical effects. This herb is on the FDA's list of generally safe products. Of note, however, the herb's effects could be dangerously increased if it is used with standard sedatives. Other interactions and long-term side effects are unknown. Side effects include vivid dreams. High doses of valerian can cause blurred vision, excitability, and changes in heart rhythm.

Generally, manufacturers of herbal remedies and dietary supplements do not need FDA approval to sell their products. Just like a drug, however, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been numerous reported cases of serious and even lethal side effects from herbal products. Always check with your doctor before using any herbal remedies or dietary supplements.

Special Warning on Kava. Kava has been commonly used to reduce anxiety and stress. It is now highly associated with liver injury and even liver failure in a few cases. Experts now strongly warn against its use.

People seeking relief from stress should be wary of things that promise a quick cure, or plans that include the purchase of expensive treatments. These treatments may be useless and sometimes even dangerous.

Resources

www.nimh.nih.gov -- National Institute of Mental Health
www.nami.org -- National Alliance for the Mentally Ill
www.nmha.org -- National Mental Health Association
www.amtamassage.org -- American Massage Therapy Association
www.cognitivetherapynyc.com -- American Institute for Cognitive Therapy
www.aabt.org -- Association for the Advancement of Behavior Therapy
www.healthyminds.org -- The American Psychiatric Association
www.naswdc.org -- The National Association of Social Workers
www.aacap.org -- American Academy of Child and Adolescent Psychiatry
www.stress.org -- The American Institute of Stress

References

Ginsburg KR and the Committee on Communications and Committee on Psychosocial Aspects of Child and Family Health. Clinical Report: The Importance of Play in Promoting Healthy Child Development and Maintaining Strong Parent-ChildBonds.Last accessed on 17 October, 2006.

Dallman MF, Pecoraro NC, la Fleur SE. Chronic stress and comfort foods: self-medication and abdominal obesity. Brain Behav Immun. 2005;19:275-280.

Wang J. Work stress as a risk factor for major depressive episode(s). Psychol Med. 2005;35:865-871.

Hammerfald K, Grau M, et al. Persistent effects of cognitive-behavioral stress management on cortisol responses to acute stress in healthy subjects-A randomized controlled trial. Psychoneuroendocrinology. 2005 Sep 22; epub ahead of print.

Kreitzer MJ, Gross CR, Ye X, et al. Longitudinal impact of mindfulness meditation on illness burden in solid-organ transplant recipients. Prog Transplant. 2005;15:166-172.

Field T, Hernandez-Reif M, Diego M, et al. Cortisol decreases and serotonin and dopamine increase following massage therapy. Int J Neurosci. 2005;115:1397-1413.

Ditzen B, Neumann I, Bodenmann G, et al. Romantic Partner Interaction Reduces Endocrine and Autonomic Stress Responses in Women. New Research Abstracts, Annual Meeting of the American Psychiatric Association. Washington, D.C. 2005. Abstract NR140.

Review Date:
10/16/2007
Reviewed By:
Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial policy, editorial process and privacy policy. A.D.A.M. is also a founding member of Hi-Ethics and subscribes to the principles of the Health on the Net Foundation (www.hon.ch).

A.D.A.M. Copyright

The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997-2009 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.

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Smoking

FitSugar — Wed, 08 Oct 2008 17:34:57 -0700

In This Report

Highlights
Introduction
Nicotine Addiction
Health Risks
Secondhand Smoke
Smoking Bans
Quitting Smoking
Symptoms of Withdrawal
Failure to Quit
Lifestyle Changes
Resources
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Smoking and Your Health

Smoking may worsen knee osteoarthritis in men. A study published in the Annals of Rheumatic Disease found that male smokers have more pain and cartilage loss than men who do not smoke. Previous studies have not found such a link.
Smoking greatly increases the risk of age-related macular degeneration. An Australian study reports that smokers are four times more likely to develop the eye condition than those who have never smoked. Smokers also developed the condition at an earlier age.
Analysis of several studies suggests that smoking cigarettes and, in some cases, cigars or pipes, may reduce the risk of Parkinson's disease. However, smoking causes many other serious health conditions and should not be considered a means for preventing Parkinson's.
A small study suggests that infants who are breastfed just after their mother smokes sleep less than those whose mothers did not smoke.

Smoking Cessation

Certain genes may make it easier for you to quit smoking. Researchers at Duke University have identified more than 200 genes that distinguish those who have successfully kicked the habit. It is the first time such genes have been identified. The findings could lead to new smoking cessation therapies that target a person's specific genetic makeup.

Smoke Free Zones

More and more households in the United States are banning smoking. The U.S. Centers for Disease Control and Prevention (CDC) reports that 75% of households now forbid smoking at any time or place in the home.

Smoking in the Movies

Teens who see actors smoke on screen are more likely to become established smokers, according to an updated study in the Archives of Pediatric Adolescent Medicine. Study authors say the likelihood of smoking increases with exposure to movies that depict such behavior.

Introduction

More than 20% of adults in the United States smoke, according to a 2006 report by the U.S. Centers for Disease Control and Prevention (CDC). More than 80% of them smoke every day. Although smoking had steadily declined among adults in recent years, the trend now appears to have stalled. Between 2004 and 2005, the CDC says there was no observable change in smoking rates among U.S. adults.

The addictive effects of tobacco have been well documented. Tobacco is considered to be a mood and behavior altering substance that is psychoactive and abusable. Tobacco is believed to be as potentially addictive as alcohol, cocaine, and morphine. Tobacco and its various components increase the risk of cancer (especially in the lung, mouth, larynx, esophagus, bladder, kidney, pancreas, and cervix), heart attacks, strokes, and chronic lung disease.

The younger children start smoking, the more likely they will smoke as an adult. Smoking is often immediately addictive. According to the American Cancer Society, the earlier you start smoking, the more likely you are to develop long-term nicotine addiction.

In the past, advertising was responsible for encouraging some teens to smoke. New regulations have made it much more difficult for advertisers to promote smoking to young people. However, scenes that show people smoking are still common in movies and television shows, often in a positive light. This may be a major influence on the attitude toward smoking in children and adolescents. An updated study in the Archives of Pediatric Adolescent Medicine found that adolescents that watch movies that portray smoking are more likely to become established smokers.

To prevent children from smoking, parents should not smoke, and they should tell their child that they disapprove of smoking. Schoolchildren who believed that both their parents strongly disapproved of smoking were less than half as likely to smoke as those kids whose parents did not show as much disapproval towards smoking. Other research has supported these findings.

Children whose parents closely monitor their television and music-listening habits are less likely to drink, use drugs, and smoke cigarettes.

Neglected children, or children with absentee parents, were four times as likely to abuse drugs, drink, and smoke as children living with parents who were regularly present and who offered a structured lifestyle.

In a 2002 study, children who regularly attended religious services were also less likely to smoke.

Doctors can have a major effect on young people. However, in one survey, less than half of teenagers had ever been asked by their doctors if they smoked or were counseled not to smoke, even though most teen smokers said they would admit to it if asked.

More American men smoke than women. The following chart details the rate of current smoking in the United States among adults aged 18 years and over, grouped by age and sex:

Age	Total	Men	Women
18 - 44 years	24.1%	27.1%	21.2%
45 - 64 years	21.9%	25.2%	18.8%
65 years and older	8.6%	8.9%	8.3%

Source: CDC/National Health Interview Survey 2005

While the number of adults over 65 who smoke is lower than those in other age groups, older adults usually have smoked for a long time (about 40 years) and tend to be heavier smokers, according to the American Lung Association. Because of this, older smokers are more likely to have smoking-related illnesses.

Caucasian students (under age 18) are more likely to smoke than Hispanics and African-Americans. In 2005, the rate of smoking was highest among American Indians and Alaskan natives. Hispanics and Asians had the lowest rates.

In general, the rate of smoking is highest in the Midwest and South and lowest in the Northeast and West. Utah has the lowest rate of smoking in the United States.

A major U.S. government study reported that people who have not graduated from high school or received their General Education Development (GED) certificate tend to have higher smoking rates than those who attended college.

Higher rates of cigarette smoking have been reported among adults who have earned a GED and those with a 9 – 11 grade education. The lowest rates are seen among those with advanced college degrees.

People with low self-esteem and adolescents with behavioral problems have a higher risk for smoking. Men and women with mental disorders are 50% more likely to smoke than those without such illness.

For example, depression and schizophrenia are known risk factors for smoking. Both may actually have biologic effects that are responsible for this higher risk.

Smoking is much more common among persons with disabilities than those without emotional, mental, or physical limitations. A 2007 Centers for Disease Control study found that the rate of smoking is nearly 50% higher among persons with disabilities. The CDC survey included those with mental illness and drug and alcohol addictions in the disabled group.

Evidence now strongly supports the idea that genes play a role in a person's dependence on nicotine. Researchers are now targeting specific genes that may be responsible for nicotine dependence. So far, research has been shown that there is a common genetic vulnerability to both nicotine and alcohol dependence.

Some studies suggest that the cheaper it is to buy cigarettes and smoke, the more widespread smoking will be. For example, states that have low taxes on cigarettes have a high proportion of smokers. Making it more expensive to smoke may reduce the number of smokers.

Nicotine Addiction

Nicotine is the chemical in cigarettes that makes them addictive. Higher levels of nicotine in a cigarette can make it harder to quit smoking. A report by the Massachusetts Department of Health found that the amount of nicotine in cigarettes has steadily increased over the last 6 years. Higher nicotine levels were found in all cigarette categories, including “light" brands. Massachusetts is one of several states that require tobacco manufacturers to submit yearly reports regarding cigarettes.

Some researchers feel nicotine is as addictive as heroin. In fact, nicotine has actions similar to heroin and cocaine, and the chemical affects the same area of the brain.

Depending on the amount taken in, nicotine can act as either a stimulant or a sedative. Cigarette smoking has definite immediate positive effects. For example, it can:

Boost mood and relieve minor depression
Suppress little fits of anger
Enhance concentration and short-term memory
Produce a modest sense of well-being

Most smokers have a special fondness for the first cigarette of the day because of the way brain cells respond to the day's first nicotine rush. Nicotine, particularly taken in the first few cigarettes of the day, increases the activity of dopamine, a chemical in the brain that elicits pleasurable sensations, a feeling similar to achieving a reward.

Over the course of a day, however, the nerve cells become desensitized to nicotine. Smoking becomes less pleasurable, and smokers may be likely to increase their intake to get their "reward." A smoker develops tolerance to these effects very quickly and requires increasingly higher levels of nicotine.

A smoker may "forget" their craving for nicotine if a part of the brain called the insula becomes damaged. A 2007 study published in the journal Science found that smokers with brain damage to this area were 136 times more likely to forget their addiction to nicotine. The findings may one day lead to new drugs that better help a person quit.

Smokeless tobacco, also called spit tobacco, includes chewing tobacco (dip and chew), tobacco powder (snuff), as well as flavored tobacco lozenges. These products also contain nicotine. There are two forms of spit tobacco.

These products allow tobacco to be absorbed by the digestive system or through mucous membranes. Smokeless tobacco contains at least 28 cancer-causing substances. Smokeless tobacco is not a safe substitute for smoking cigarettes or cigars. According to the National Institutes of Health, chewing on an average-size piece of chewing tobacco for 30 minutes can deliver as much nicotine as smoking three cigarettes.

Although research is inconsistent, some evidence suggests that smokeless tobacco produces a 50-fold increase in the risk of oral cancer, gingivitis, and tooth loss.

Health Risks

Smoking -- even just a few cigarettes a day -- has been linked to many serious health risks. Some are listed below.

According to the American Lung Association, smoking is directly responsible for about 90% of the deaths due to lung cancer. Smoking is also responsible for the majority of deaths due to chronic obstructive pulmonary disease (COPD), which includes emphysema and chronic bronchitis.

A study in the July 2006 American Journal of Respiratory and Critical Care Medicine showed that smokers with asthma who give up smoking can improve their lung function in as little as 1 week. The small study involved 21 smokers with asthma. Ten of them quit smoking for 10 weeks, while the others continued to smoke. After just a week, lung function test scores in those who stopped smoking improved considerably. In less than 2 months, lung function scores among those who stopped smoking improved by more than 15%.

Study authors say their findings show that there is a “reversible component to the harmful effects of smoking on the airways in asthma.”

All forms of tobacco raise heart attack risk. Smoking, chewing tobacco, and being exposed to secondhand smoke greatly increase the risk of a heart attack. In some cases, the risk of heart problems in people who smoke or are exposed to smoke may be three times greater, according to a study published in the journal Lancet. However, the study also found that the risk of a heart attack among those who stopped smoking slowly decreased over time.

Smoking has a negative affect on a man's sexuality and fertility. Heavy smoking is frequently cited as a contributory factor in impotence because it decreases the amount of blood flowing into the penis. One study noted that among men with high blood pressure, smoking caused a 26-fold increase in impotence.

Smoking impairs sperm motility, reduces sperm lifespan, and may cause genetic changes that can affect a man's offspring. One 2002 trial found that men or women who smoke have lower success rates with fertility treatments. An earlier study reported that men who smoke also have lower sex drives and less frequent sex.

Studies have linked cigarette smoking to many reproductive problems. Continuing to smoke during pregnancy may also cause health problems in the baby.

Negative effects of smoking on female fertility include:

Greater risk for infertility. Women at greatest risk for fertility problems are those who smoke one or more packs a day and who started smoking before age 18.
Earlier menopause. Women who smoke tend to start menopause at an earlier age than nonsmokers, perhaps because toxins in cigarette smoke damage eggs.
Pregnancy complications. Women who smoke have a greater risk for ectopic pregnancy and miscarriage.

Click the icon to see an image of an ectopic pregnancy.

Effects on Unborn Child. Smoking during pregnancy increases the risk for stillbirth, prematurity, and low birth weight in their babies. Women who smoke during pregnancy have lower levels of folate, a B vitamin that is important for preventing birth defects.

Children of mothers who smoke during pregnancy may also be at increased risk for obesity and diabetes.

Some women have particular genes that may make them especially likely to deliver low birth weight infants if they smoke, although newborns of all female smokers have a greater risk for low weight. The good news is that women who quit before becoming pregnant or even during the first trimester reduce the risk for a low birth weight baby to that of women who never smoked.

Women who want to become pregnant should make every attempt to quit and should use smoking cessation aids before they try to conceive. After birth, if new mothers cannot quit, they should at least be sure not to smoke in the same room as their infant.

Smoking and Breastfeeding. Smoking right before breastfeeding may interrupt the child's sleep patterns. A small study found that such infants sleep less than other infants, and that their sleep time dropped significantly as levels of nicotine in breast milk increased.

Smoking has many harmful effects on bones and joints:

Smoking can keep new bone from forming. Women who smoke are at high risk for loss of bone density and osteoporosis.

Click the icon to see an image of osteoporosis.

Postmenopausal women who smoke have a significantly greater risk for hip fracture than those who do not.
Men who smoke may have more severe symptoms of knee arthritis, according to a study published in the Annals of Rheumatic Disease.
Smokers are more apt to develop degenerative disorders and injuries in the spine.
Smokers have more trouble recovering from surgeries, including knee or hip replacements. A 2006 study published in the Journal of Bone & Joint Surgery suggests that smoking delays tendon-bone healing, which may lead to a slower recovery after rotator cuff repair surgery.
Smokers whose jobs involve lifting heavy objects are more likely to develop low back pain than nonsmokers.
Smoking may increase the risk of rheumatoid arthritis in some older women. A 2006 study in Annals of the Rheumatic Diseases showed that smoking nearly doubled the risk of rheumatoid arthritis in postmenopausal women who did not have the most established genetic risk factor for the disease, a genotype called HLA-DRB1 SE.

Click the icon to see an image of rheumatoid arthritis.

Smoking may increase the risk of developing diabetes. Researchers involved in the Insulin Resistance Atherosclerosis Study (IRAS) looked at the relationship between smoking and diabetes and found that 25% of smokers who started the trial with normal blood sugar had diabetes 5 years later compared to 14% of nonsmokers. The results were published in Diabetes Care.

A study released in 2006 supports earlier beliefs that smokers have a higher risk of developing glucose intolerance, a condition that precedes diabetes. The study, published in the British Medical Journal, involved 4,572 people. The findings suggest that chemicals in smoke could affect the pancreas. The pancreas is the organ that produces insulin, which helps control blood sugar (glucose) levels.

Smoking increases acid production in the stomach. It also reduces blood flow and production of compounds that protect the stomach lining.

Diverticulitis. One study suggested that smoking was a major risk factor in diverticulitis, a condition in which small bumps develop in the wall of the colon. In addition, smokers were at risk for complications from diverticulitis, including bleeding and abscess. Diverticulitis mostly affects people over age 50.

Inflammatory Bowel Disease. Smoking has mixed effects on inflammatory bowel disease. Inflammatory bowel disease is the collective term for ulcerative colitis and Crohn's disease. Smokers have been shown to have lower than average rates of ulcerative colitis, but higher than average rates of Crohn's disease. Smokers with Crohn's disease who quit are said to have less severe symptoms.

Click the icon to see an image of inflammatory bowel disease.

Peptic Ulcers. Results of studies on the effect of smoking on ulcers are mixed. Some evidence suggests that smoking delays the healing of gastric and duodenal ulcers. One study reported that after ulcers healed, about half of smokers relapsed after a year, and that all heavy smokers relapsed after 3 months. Other studies, however, have found no increased risk for ulcers in smokers. Smoking does not appear to increase susceptibility to Helicobacter pylori (H. pylori), the bacteria that causes many peptic ulcers.

Click the icon to see an image of peptic ulcers.

Hepatitis and Cirrhosis. Smoking is linked to increased liver scarring (cirrhosis) caused by either excessive drinking or chronic hepatitis B or C viruses.

Cyanide, a chemical found in tobacco smoke, interferes with thyroid hormone production. Smoking triples the risk for developing thyroid disease, particularly hyperthyroidism and hypothyroidism. Women smokers with subclinical hypothyroidism (a symptom-free condition in which the thyroid gland is mildly underactive) have a higher risk for developing full-blown hypothyroidism than their nonsmoking peers. Smoking has also been linked to goiter, a swelling of the thyroid that occurs in people who do not get enough iodine.

Click the icon to see an image of the thyroid.

Smokers are at increased risk for heart and circulatory problems and delayed wound healing after surgery. In one study, patients who were able to cut down or quit smoking 6 - 8 weeks prior to knee or hip replacement surgery were much less likely to suffer complications.

The following age-related conditions occur at higher rates in smokers than nonsmokers:

Cataracts. Quitting smoking reduces your chances of needing cataract surgery in the future, although not to the level seen with nonsmokers.

Click the icon to see an image of a cataract.

Age-related macular degeneration (AMD). AMD is a leading cause of blindness in older people. An Australian study, published in 2007 found that the condition is four times more likely in persons who smoke than those who have never done so. Symptoms of macular degeneration include a loss of central vision, which makes it difficult to read.
Gum disease and tooth loss. A government study found that more than half of the cases of severe gum disease in adults in the United States may be due to cigarette smoking.
Wrinkles. Studies confirm that smokers are nearly five times more likely to develop more and deeper wrinkles as they age compared to nonsmokers.
Baldness and premature gray hair. Certain chemicals in smoke break down in hair cells, which leads to hair damage.
Hearing loss, particularly high-frequency hearing loss. Some experts believe that losing the ability to hear high pitched sound in smokers may be due to a decrease in blood flow to the cochlea, the part of the ear that carries sound to the brain.
Incontinence. One study of 600 women indicated that smokers and former smokers are twice as likely to develop incontinence as women who never smoked.

Secondhand Smoke

Secondhand smoke is produced by a burning cigarette or other tobacco product. An estimated 4 million children a year get sick from being around secondhand smoke. Parental smoking has been shown to affect the lungs of infants as early as the first 2 - 10 weeks of life, and such abnormal lung function could persist throughout life.

Exposure to secondhand smoke in the home increases the risk for asthma and asthma-related emergency room visits in children who have existing asthma.

Parental smoking is believed to increase the risk for lower respiratory tract infections (such as bronchitis or pneumonia) by 50%. Environmental exposure to smoke is thought to be responsible for 150,000 - 300,000 such cases every year.

Smoking Bans

Smoking bans have spread across the country. By October 2007, at least 22 states and the District of Columbia have passed some type of law banning smoking in almost all public places and workplaces, including restaurants and bars. The date an individual state's ban takes effect varies greatly; some do not take effect until 2008 or 2009.

As of January 1, 2006, nine states were considered "smoke-free" -- California, Connecticut, Delaware, Massachusetts, Maine, New York, Rhode Island, Vermont, and Washington.

Quitting Smoking

It's never too late to quit smoking. According to the American Cancer Society, about half of all smokers who keep smoking will die from a smoking-related disease. Quitting has immediate health benefits.


Time after last cigarette	Physical Response
20 minutes	Blood pressure and pulse rates return to normal.
8 hours	Levels of carbon monoxide and oxygen in the blood return to normal.
24 hours	Chance of heart attack begins to decreases.
48 hours	Nerve endings start to regrow. Your ability to taste and smell increases.
72 hours	Bronchial tubes relax and the lungs can fill with more air.
2 weeks to 3 months	Improved circulation; lung function increases up to 30%.
1 to 9 months	Decreased rates of coughing, sinus infection, fatigue, and shortness of breath; regrowth of cilia in the airways, increasing the ability to clear mucus and clean the lungs and reducing the chance of infection; overall energy level increases.
Long-Term Effects	After a year, the risk of dying from heart attack and stroke is reduced by up to 50%.

According to the National Institutes of Health, about 40% of smokers who want to quit make a serious attempt to do so each year, but fewer than 5% actually succeed. A June 2006 report published by the NIH says that the available smoking cessation products and therapies are greatly underused. If more smokers asked for or were offered such help, the agency says quit rates could double or triple.

Some people have certain genes that make quitting easier. Researchers at Duke University have identified more than 200 genes that distinguish those who have successfully kicked the habit. It is the first time such genes have been identified. The findings could lead to new smoking cessation therapies that target a person's specific genetic makeup.

Methods of quitting smoking include counseling and support groups, nicotine patches, gums, lozenges, and sprays, smoking cessation pills, and slowly cutting back on the number of cigarettes smoked (incremental reduction).

About 4% of smokers who quit without any outside help succeed. Nevertheless, most people try to quit alone, and many have reported activities that can help the process of withdrawal. The primary obstacle in trying to quit alone is making the behavioral changes necessary to eliminate the habits associated with smoking. Excellent books, tapes, and manuals are available and are strongly recommended to help people who want to quit without other assistance.

Nicotine replacement therapy involves the use of products that provide low doses of nicotine that do not contain the contaminant found in smoke. The goal of therapy is to relieve cravings for nicotine and ease the symptoms of withdrawal.

In general, nicotine replacement therapy benefits moderate-to-heavy smokers the most. However, it does appear somewhat helpful for light smokers (people who smoke fewer than 15 cigarettes a day).

Nicotine Patches. Nicotine patches deliver nicotine through the skin. This is called transdermal nicotine delivery. It is effective in reducing symptoms during withdrawal. Nicotine patches are available over the counter.

Patches may work in different ways:

Step-Down Approach. Patches that use this method include NicoDerm CQ. The patches come in three strengths (21, 14, and 7 mg). You use the strongest dose first and reduce it gradually over a period of 8 - 10 weeks. A 21 mg patch is about equal to 15 cigarettes. A heavy smoker may need to wear two patches at first.
Single-Step Approach. The single-step patch (Nicotrol) can be taken off after 16 hours and replaced 8 hours later. It can be used for only 6 weeks.

Patches are applied and used in similar ways:

A single patch is worn each day and replaced after 24 hours.
To avoid skin irritation it is applied to different hairless locations above the waist and below the neck each day.
People can wear the patches for 24 hours, but some have reported odd dreams and have disliked the sensation of the patch during the night. People who wear the patch all the time, however, have fewer withdrawal symptoms and slightly better abstinence rates than those who take it off at night.
Patches should be stored and discarded safely, particularly in homes with small children. Small children have been poisoned and gotten sick from wearing, chewing, or sucking on nicotine patches. There have been no reports of death from children who have been poisoned.
The FDA recommends using the patches for 3 - 5 months, although some studies suggest that using them for 8 weeks achieves the maximum benefits.

Children should not come in contact with the patches, even while the smoker is wearing them. If the child has worn the patch, the affected skin should be washed right away. Urgent medical care may be required if the child has eaten nicotine or worn a patch for a prolonged time.

Nicotine Gum. Nicotine gum (Nicorette) is available over the counter and has helped many people quit. Some prefer it to the patch because they can control the nicotine dosage, and chewing satisfies the oral urge associated with smoking.

Tips for using the gum:

If you are just starting to quit, chew 1 - 2 pieces each hour. A smoker should not chew more than 20 pieces a day.
The goal is to stop using the gum by 6 months, but about 3% of people continue to use it long after they have quit smoking.
The gum must be chewed slowly until it develops a peppery taste. It is then tucked between the gum and cheek where it is stored so that the nicotine can be absorbed.
Coffee, tea, soft drinks, and acidic beverages may interfere with nicotine absorption, so people should wait at least 15 minutes after drinking before chewing a piece of gum.

Some people prefer other methods or cannot use the gum for the following reasons:

They find the gum unpleasant tasting.
Side effects specific to the gum may include upset stomach, mouth ulcers, hiccups, and throat irritation.
They are embarrassed by chewing gum.
They wear dentures.

Long-term dependence may be a problem with the gum. Although such dependence is probably safer than smoking, research is needed to confirm this, and experts recommend people chew gum for no more than 6 months.

The Nicotine Inhaler. The nicotine inhaler resembles a plastic cigarette holder. It comes with a number of nicotine cartridges, which are inserted into the inhaler and "puffed" for about 20 minutes, up to 16 times a day. The dose is gradually decreased. It requires a prescription in the United States. Several studies have reported that the inhaler triples abstinence rates (between 17 - 28%) compared with placebo (6 - 9%) after 6 months. It has some specific advantages over other nicotine replacement products:

The inhaler provides varying doses of nicotine on demand (as opposed to continuously with the patch or the gum) and is relatively fast-acting. Blood nicotine levels peak about 20 minutes after using the inhaler, comparable to the gum and faster than the 2 - 4 hours seen with the patch.
It satisfies oral urges.
Most of the nicotine vapor is delivered in the mouth, not into the lung airways (although some people experience mouth or throat irritation and cough).

Using a combination of the inhaler and the patch may be particularly effective. In one study, the combination led to an abstinence rate of over 60% after 6 weeks. While this percentage dropped off over time, it was still a large improvement over the use of the inhaler and a placebo patch.

The Nicotine Nasal Spray. The nasal spray satisfies immediate cravings by providing doses of nicotine rapidly and thus may play a useful role in conjunction with slower-acting nicotine replacement therapies. (Nicotine levels peak within 5 - 10 minutes after administering the spray). The spray can irritate the nose, eyes, and throat, so it may not be suitable for those with allergies or sinus infections. Most people, however, can tolerate the side effects, which usually go away within the first few days.

Nicotine Lozenge. A nicotine lozenge (Commit) is available over the counter. It is made from pressed tobacco and comes in two strengths for heavier or lighter smokers. In a large 2002 study, 15 - 18% of smokers who used it remained smoke free, compared to 6 - 10% who were given a dummy lozenge. Side effects included heartburn, hiccups, nausea, headaches, and cough. The Commit lozenge also contains phenylalanine, a chemical that certain people may need to avoid.

Facts about Nicotine Replacement Therapy:

Not cheating on the very first day of nicotine-replacement use increases the chance of quitting permanently by tenfold.
The more cigarettes a patient smokes, the higher the dose of nicotine replacement may be required at the start.
Adding a counseling program may boost the effect of any nicotine replacement program.
Do not smoke while using nicotine replacement. It can cause nicotine to build up to toxic levels.
Nicotine replacement helps prevent weight gain while it is being used, but people are still at higher risk for gaining weight when they stop all nicotine.

Side Effects. Side effects of any nicotine replacement product may include headaches, nausea, and other gastrointestinal problems. People often experience sleeplessness in the first few days, particularly with the patch, but the insomnia usually passes. Patients using very high doses are more likely to have symptoms. Reducing the dose can prevent them.

Special Concerns for Specific Individuals. There has been some concern that the patch might be harmful for people with heart or circulatory disease, but studies are finding that it poses no danger for these individuals. In fact, it may help reduce angina attacks brought on by exercise. However, unhealthy cholesterol levels (lower HDL levels) caused by smoking remain abnormal with use of the nicotine patch. HDL levels improve when all nicotine is stopped.

Nicotine replacement may not be completely safe in pregnant women, although it has been used successfully in this group without ill effect. There is an increase in heart rates in unborn children of women who use the patch as compared with those who smoke.

Keep all nicotine products away from children. Nicotine is a poison. All nicotine products should be kept safely away from small children. A parent should call a physician or a poison control center immediately if a child has been exposed to a nicotine replacement product, even for a short duration. Parents should also call the doctor if a small child has been exposed to a nicotine product and has any symptoms, including stomach upset, irritability, headaches, a rash, or fatigue.

Warnings Against Long-Term Use. No one should use nicotine replacement therapies as a long-term substitute for smoking. Any nicotine replacement therapy should be temporary. In one study, use of nicotine gum for more than a year was associated with insulin resistance, an abnormality that occurs in diabetes. Some studies have now suggested that nicotine itself may have properties that increase the risk for cancer, independent of carcinogenic chemicals in smoke. More studies are needed.

Bupropion (Zyban, Wellbutrin) is a type of antidepressant that is also an FDA-approved product for smoking cessation. It differs from most other antidepressants because it increases the effects of dopamine, the brain chemical that appears to play a strong role in nicotine addiction. Using Zyban along with nicotine replacement therapy may help you better control cigarette smoking cravings. Zyban does not contain nicotine. In most cases, Zyban is taken a week or two before quitting, and must be taken for 7 - 12 weeks. The usual maintenance dose is 150 mg tablet twice a day. No single dose should be higher than 150 mg.

Side effects of bupropion include gastrointestinal problems, headaches, insomnia, dry mouth, and irritation. In very rare cases, seizures have occurred, although usually in people who exceeded the recommended dose or who already had risk factors for seizures.

A newer drug called varenicline (Chantrix) may significantly reduce cigarette cravings and work better than Zyban. A study in the Archives of Internal Medicine found that almost 50% of those who took varenicline successfully quit. Varenicline mimics some effects of nicotine on the brain, but blocks others. Previous studies published in the Journal of the American Medical Association showed that Chantrix works twice as well as Zyban and quadruples one’s chances of successfully quitting. The FDA approved Chantrix as a smoking cessation aid in May 2006. It is for use in cigarette smokers age 18 and older. It should not be combined with nicotine replacement therapy.

The tricyclic antidepressant nortriptyline (Pamelor, Aventyl) may help reduce nicotine action. Quit rates with either of these medicines are as high as 30%. Long-term abstinent rates are more than twice those of placebo. Most other antidepressants, including fluoxetine (Prozac), have no additional benefits for smokers.

Nortriptyline has been specifically studied for helping smokers. It is best to start taking the medication 10 - 28 days before your intended quit date. Studies have reported quit rates of 14 - 24%. Side effects of nortriptyline include dry mouth and changes in taste. It should be noted that in rare cases, tricyclics can have serious side effects, and overdose can be deadly. Tricyclics may pose a danger for some patients with certain types of heart disease.

Smokers who use outside help have the best record for quitting, with success rates of 25 - 35%. Those who are counseled in addition to using nicotine replacement and Zyban have the best chance. Brochures, audio tapes, and other self-help materials are often ineffective when used alone, but may be helpful in conjunction with a counseling program.

Types of behavioral approaches:

Problem Solving or Coping Strategies. Smokers more likely to quit smoking when they learn thinking (cognitive) and behavioral techniques for breaking the link between certain cues and smoking, stress management techniques, and ways to handle the symptoms of withdrawal and the urge to relapse. The more intense the counseling program, the better. Smokers should look for programs that offer the following:

Session lengths of 20 - 30 minutes
Four to seven sessions
A 2-week program
Additional 2 weeks or more of follow-up contact

Scheduled Reduction. Scheduled reduction is a gradual way to stop smoking.

Divide the number of minutes per day that you are awake by the number of daily cigarettes you smoke. The number you get is how long you wait between smokes.
Week 1: Set up a schedule with time intervals based on this result and using a timer, smoke only at those intervals. If the "cigarette appointment" is missed by more than 5 minutes, you must skip that cigarette.
Week 2: Reduce the number of cigarettes you smoke by one-third and recalculate your time between smokes based on the lower number.
Week 3: Reduce the count again.
Week 4: Quit smoking

Those who are unable to smoke during working hours could try calculating the intervals based on the usual smoking times of the day.

The Staged Approach. The intent of the staged approach is to plan quitting interventions customized for each individual rather than imposing some general method for quitting. The approach takes the smoker through six stages with behavioral interventions at each point:

Pre-contemplation
Contemplation
Preparation
Action
Maintenance
Termination

Although some studies report this approach is significantly more effective than non-staged methods, an analysis of 23 trials did not find the staged approach to be any more effective than other methods. Most studies, however, were weak, and better research is needed on this approach.

People who follow this approach do not proceed from one stage to another in a simple, step-by-step fashion. They actually cycle or spiral back and forth, so that they may move from stage 1 to 2 to 3, and then back to 2 again. They may stay in maintenance mode for years and then fall back to stage 2. Remember that this is normal -- if you tried quitting in the past and didn't stick with it, don't consider yourself a failure. Just try again.

Stage 1: Pre-Contemplation.

People at this stage have no plans or desire to stop smoking. They aren't even considering quitting. People at this stage are generally unaware of the specific benefits that quitting can bring. Or, they may simply have "failed" in the past and have given up. There's no point in talking about how to start a cessation program at this stage. Instead, it is important to think about how quitting will help you feel better, have more confidence, or live longer. The benefits must be identified before a person will consider quitting. If you are at this stage, a good activity is to ask several friends or family members why they quit.

Stage 2: Contemplation.

A person at this stage is thinking, "I think I should probably quit, but I need help getting started." People at this stage know that quitting is good for them, but it seems like a daunting task or they don't think they can pull it off. Some may have tried and failed in the past. It's important for people at this stage to consider some of the truths and falsehoods of quitting. If you are at this stage, write down (brainstorm) all your potential roadblocks -- the things that you believe make quitting difficult -- and learn strategies for overcoming or side-stepping those hurdles. People at this stage might benefit from making a pledge, contract, or other commitment that they are going to get more active in the near future. The goal is to identify the roadblocks and ways to overcome these hurdles, and make a commitment to quitting.

Stage 3: Preparation.

Smokers at this stage are ready to quit. The goal of this stage is to create a specific action plan that takes all factors into account, so that quitting is successful. People at this stage need to know what methods work and what support exists to help them. If you are at this stage, you should consider some backup plans -- what to do when the urge to smoke hits you.

Stage 4: Action!

People at this stage have just quit. This stage is where the most behavioral change occurs. It requires significant commitment and energy. If you are at this stage, keep talking to friends and family for inspiration. Review your backup plans. Reward yourself for small achievements. Having a fellow smoker quit with you can be a huge support as you both get through this stage.

Stage 5: Maintenance.

People at this stage have been smoke-free at least 6 months. The goal now is to prevent relapse. If you are at this stage, continue to be wary of roadblocks and keep reminding yourself of the benefits you have gained. Think about what you have found most enjoyable about being smoke-free.

Hypnosis. Although rigorous studies are lacking, some people report successful cessation from smoking when hypnosis is given in individual sessions. The process is effective only if you trust the therapist and can feel completely at ease in the vulnerable and passive state necessary for hypnotic suggestion.

During a typical session, the hypnotherapist will use various techniques (such as imagery, silent counting) to put you in a relaxed state.

When you are very relaxed, but not asleep, the hypnotherapist quietly suggests motivations for not smoking. The hypnotherapist should also reinforce a positive self-image while you are in deep relaxation. This helps many people avoid the depression that accompanies withdrawal.

The sessions usually takes about 1 hour.

You should be taught methods of self-hypnosis to use at home, and follow-up once to reinforce what you've learned.

Acupuncture and Acupressure. The acupuncture technique for quitting smoking usually uses very tiny curved staples inserted into three different points around the edge of the ear. The procedure is painless. You will be told to press each staple in a certain order for a few seconds whenever the craving for a cigarette occurs. The acupuncturist may also use acupuncture points elsewhere on the body. There are no side effects except for some soreness if the acupuncture staple is pressed too hard.

A related technique called acupressure involves simply pressing select points on the body when a craving hits. Some studies have reported good quit rates with acupuncture, but few rigorous studies have been conducted using this approach.

Aim to Quit Completely

Everyone who quits should aim to quit completely. Most people who return to smoking "cheat" in the first few weeks. Quitting completely is essential to regain good health and reverse bad effects caused by smoking. Reducing smoking, even by half, does not eliminate the risk for cancer and other health problems. Although smokers take in less smoke and nicotine, the body is still unable to heal itself from the ongoing intake of toxins. It should also be noted that changing to low-tar cigarettes is not a solution. In fact, smokers of these cigarettes tend to inhale deeper, perhaps even increasing health risks.

Create a List

Write down 10 reasons to quit. In addition to health reasons, the list might include having better smelling hair, clothes, and breath; having fewer wrinkles; enjoying the taste of food; and saving money. Read the list often during the quitting process to help stay motivated.

Decide on a Specific Quit Date

Some people find it helpful to choose a particular date to quit when little or no stress is anticipated for at least the first 3 days. Women affected by PMS should avoid quitting right before their menstrual cycle. It may help to write out a quit contract, putting the date on paper, and getting a friend to sign it. Discard all smoking paraphernalia on the eve before the quit date, and make plans to stay busy on the day itself, and especially at night, when the urge to smoke will be high.

Make an Oath

Take an extreme oath. For example, "If I smoke one more cigarette my dog will die." Although this seems absurd, some people, even well-educated individuals, who have failed all other methods have reported that they quit completely and successfully after taking such an oath.

Let the Body and Mind Heal During Withdrawal

Retreat from the world when cravings become overwhelming. Take naps, warm baths or showers, meditate, or read novels.
Help your body get rid of nicotine. Drink plenty of water, eat fresh fruits, vegetables, whole grains, and fiber-rich foods. Carrots, apples, and celery are good munching foods.
When cravings occur, hold your breath as long as possible or take a few deep rhythmic breaths.
Use meditation or relaxation and deep breathing exercises. In fact, taking deep breaths when the urge to smoke occurs is a good stopgap measure.

Get Family and Friends Involved

Tell all your friends and family that you've already quit, so you'll be embarrassed if they catch you smoking.
Pay a family member or friend if they catch you smoking. The amount should be large enough ($5 - 20) to be a deterrent, but not so large as to be ridiculous.
If your partner or friend smokes, try persuading them to quit or, at the very least, not to smoke around you and others.

Exercise

Studies continue to show that smokers who exercise can greatly increase their ability to quit smoking while reducing their risk for weight gain. Move the muscles when cravings occur. Dance, run, walk, jump up and down, stretch, do push-ups. Yoga is an excellent exercise program for quitting. Older people and anyone with health problems should consult their health care provider before starting such a program.

Maintain a Healthy Diet

Eat plenty of fresh, crunchy fruits and vegetables. This is also a useful way of satisfying oral cravings without adding many calories.
Drink plenty of water and healthy beverages.
Moderate intake of coffee or tea may be helpful. A small study suggested that drinking caffeinated beverages (such as coffee or tea) while on nicotine replacement may enhance energy expenditure and may help prevent weight gain. Moderate coffee intake may also have antidepressant properties. Avoid caffeine in the evening, however, since sleep disturbances can be a problem during withdrawal.

Change Daily Habits

Change your daily schedule, particularly eating times, as much as possible. Eat at different times or eat many small meals instead of three large ones. Sit in a different chair or even a different room.
If you smoke after eating, find other ways to end a meal. Play a tape or CD, eat a piece of fruit, get up and make a phone call, or take a walk (a good distraction that burns calories as well). For example, if you normally have a cigarette with coffee, drink tea instead or use a different cup.
Substitute oral habits by eating celery, chewing sugarless gum, sucking on a cinnamon stick, or carrying worry beads.
Go to public places and restaurants where smoking is prohibited or restricted.
Set short-term quitting goals and reward yourself when they are met.
Every day put the money normally spent on cigarettes in a jar and buy something pleasurable at the end of a predetermined period of time.
Find activities that focus the hands and mind but are not taxing or fattening: Computer games, solitaire, knitting, sewing, whittling, and crossword puzzles.

Denormalization is the idea that smoking is no longer normal. This concept of denormalization is best instituted by laws and local regulations making smoking inaccessible in public places, raising prices, and putting stricter limitations on cigarette advertising.

Increasing taxes on cigarettes may be one of the most important methods for reducing smoking in the population, particularly in younger people.

Evidence is suggesting that banning smoking in work and public places may be leading to a higher quit rate than in places where smoking is permitted.

Denormalization can also work on a personal level. A British study showed that when one spouse makes healthy changes, including quitting smoking, the other one follows. In couples where smoking continues, it usually continues in both.

Symptoms of Withdrawal

After you quit smoking, you with have some withdrawal symptoms. Such symptoms generally peak in intensity 3 -5 days after you quit, and usually disappear after 2 weeks, although some may persist for several months.

The symptoms of withdrawal include both physical and mental difficulties.

Physical Symptoms.

Tingling in the hands and feet
Sweating
Intestinal disorders (cramps, nausea)
Headaches
Sore throat, coughing, and signs of a cold

Withdrawal symptoms should be treated accordingly, just as you would with physical symptoms due to an illness or disease.

Mental and Emotional Symptoms. Tension and craving build up during periods of withdrawal, sometimes to a nearly intolerable point. Nearly every moderate-to-heavy smoker experiences more than one of the following strong emotional and mental responses to withdrawal:

Temper tantrums, intense needs, feelings of dependency, and a state of near paralysis
Insomnia
Mental confusion, vagueness, or difficulty concentrating
Irritability, restlessness, impatience, or anger
Anxiety
Depression

The first signs of nicotine withdrawal seem to appear within 30 minutes of a smoker’s last cigarette. The findings, published in Psychopharmacology, are believed to be the first to show just how early nicotine withdrawal occurs. The study involved 50 people who smoked a pack of cigarettes daily. Half refrained from smoking for 4 hours, while the others smoked as usual. After 30 minutes, those who did not have a cigarette craved one and did more poorly on tasks requiring attention than those in the smoking group. Within 3 hours, the non-smoking group showed increases in anxiety, sadness, and difficulty concentrating.

Depression is common during withdrawal and over the long term. In the short term, it may mimic the feelings of grief felt when a loved one is lost. A smoker should plan on a period of actual mourning in order to get through the early withdrawal depression.

There is a significant association between cigarette smoking and a susceptibility to depression. People who are prone to depression face a 25% chance of becoming depressed when they quit smoking, and this increased risk persists for at least 6 months. What's more, depressed smokers have a very low level of success. Only about 6% remain smoke-free after a year. There are strong reasons for this:

Smoking may be masking depression, which can become severe even after the early stages of withdrawal have passed.
For some smokers, the future physical damage incurred by smoking is an abstraction, which fails to motivate quitting when measured up against the very real emotional pain triggered by nicotine withdrawal.
Not only does the smoker suffer, but the negative emotions often harm relationships with friends and family, who might even urge the ex-smoker to take up cigarettes again.

People who suffer from depression while quitting might do better using a combination of emotionally supportive therapy (as opposed to behavioral therapy), nicotine replacements, and antidepressants, such as bupropion (Zyban). If severe depression lasts beyond the withdrawal period, professional help should be sought as soon as possible.

Quitting smoking does increase the risk for weight gain. But, kicking the habit of smoking may cause more weight gain than previously thought. A study in Health Services Research found that the average weight gain among former smokers was about 21 pounds, rather than the 5 - 15 pounds commonly cited. But, fear of weight gain shouldn’t stop a person from quitting smoking. Instead, the study authors encourage weight-control measures after quitting. To come up with a new average, the scientists re-analyzed data from the 1998 Lung Health Study of 5,887 American smokers. That study found that those who quit smoking gained about 12 pounds.

Smoking uses up calories -- about 200 a day according to one study. Burning calories helps you lose weight. After quitting, the body's metabolism slows down, and food is digested better. Insulin levels increase, enabling the body to process more sugar for energy. When you quit smoking, you may snack more frequently.

How to Keep the Weight Off After Smoking. Exercise is very helpful in controlling weight. To burn the same amount of calories as you did while smoking, you need only take an extra 15-minute daily walk and eliminate 100 calories a day from meals. Just a moderate increase in physical activity can help keep weight gain to a minimum.

Nicotine replacement therapy can help protect against weight gain. See the section on "Quitting Smoking" in this report.

Failure to Quit

Biologic, psychological, behavioral, and cultural factors all play a role in nicotine addiction, making smoking one of the hardest addictions to beat. About half of people who quit return to smoking. Even after years of not smoking, some ex-smokers still have occasional cravings for cigarettes.

Some experts suggest that, in addition to depression, there are three major areas responsible for the inability to quit:

Mental performance. Nicotine improves concentration and thinking. Quitting smoking temporarily impairs one's mental performance.
Stress. Although smoking many not reduce stress, stopping certainly increases it.
Weight gain. Quitting smoking can cause you to gain weight. Studies are mixed on whether weight gain is permanent in most smokers or not. Certainly, it is a major factor in relapse. [See "Weight Gain" section in this report.]

How well a person does in the first 2 weeks is critical to their success. Smokers should not be shy about seeking all the help they can during this period. Although withdrawal symptoms can be intense, treatments are available to reduce them.

Attempts to quit are never a waste of time, since the amount of smoking is reduced during these periods. People who keep trying still have a 50 - 50 chance of finally quitting.

Researchers have been trying to discover individual risk factors or sets of behaviors that can help predict why specific people fail to quit. Some factors include:

Being female
Being a heavy smoker
Inhaling deeply
Being a long-term smoker
Having severe withdrawal symptoms

Among many studies, however, only one found a single consistent factor for failure to quit:

Cheating during the first 2 weeks of withdrawal, even with the patch, nearly guarantees that a person will smoke again in 6 months.

Studies show that women have a harder time trying to quit smoking and have less success with abstinence programs than men. There are many proposed reasons for this:

Nicotine has different effects on mood in women compared to men. Women who quit may have greater anxiety and stress than men who quit.
Women are not as physically dependent on nicotine as men, but they are more addicted to the actual behavior of smoking, which is the more powerful deterrent to quitting. This may be the reason why nicotine replacement, which only reduces cravings, tends not to be as effective in women.
Women may fear weight gain after quitting more than men.
Certain phases in the menstrual cycle may reduce the response to drugs that are used to help women quit smoking.
Men may be less supportive than women in helping their partners to quit.
Women trying to quit may miss the feeling of control associated with smoking more than men.

On the positive side, evidence suggests that when women quit, their lung function seems to improve more rapidly than in men who quit.

Lifestyle Changes

Smokers and former smokers should immediately begin to implement a healthier lifestyle and change any other behaviors that might be damaging their health.

Everyone should also maintain a healthy diet, with foods rich in whole grains and fruits and vegetables (particularly dark colored ones). Avoid saturated fats and instead choose monounsaturated fats, which are found in olive oil or fats from oily fish. Two studies have indicated that eating fish more than twice a week might help limit the tobacco damage in people who do not smoke more than a pack and a half a day.

Even with a healthful diet, however, smoking reduces the levels of a number of vitamins, importantly vitamin C. Some research suggests that supplementation of folic acid, a B vitamin, and the antioxidants vitamins E and C and selenium may improve lung function or reduce the damage done by cigarette smoke. Studies have shown that daily vitamin E supplements are associated with reduced risk for prostate cancer among smokers and that higher levels of vitamin E are linked to a lower risk for lung cancer. The best way of achieving healthy levels of important nutrients is from healthy foods.

Click the icon to see an image of the benefits of vitamin E.

Click the icon to see an image of the sources of vitamin E.

Women who are pregnant and continue to smoke must be sure to take appropriate vitamins, particularly folic acid. In this way, they might reduce the increased risk of fetal injury and death, although they do not eliminate that risk.

Regular exercise reduces a smoker's risk of heart disease (although still not to the level of a nonsmoker). Exercise does not lower a smoker's risk for lung cancer or emphysema.

If you smoke, you should be screened for any smoking-related disorders. Have your cholesterol and blood pressure checked regularly. Women should have annual Pap smears to detect cervical cancer. All older adults should be screened for colon cancer. Computed tomography (CT) screening programs, which are becoming increasingly available, may detect lung cancer at an early stage. Ask your health care provider if you should have this test, and if your insurance will cover it.

Resources

www.cancer.org -- American Cancer Society
www.lungusa.org -- The American Lung Association

References

Alati R, Al Mamun A, O'Callaghan M, Najman JM, Williams GM. In utero and postnatal maternal smoking and asthma in adolescence. Epidemiology. 2006 Mar;17(2):138-44.

Amin S, Niu J, Guermazi A, et al. Cigarette smoking and the risk for cartilage loss and knee pain in men with knee osteoarthritis. Ann Rheum Dis. 2007 Jan;66(1):18-22. Epub 2006 Dec 7.

Breslau N., Novak SP, Kessler RC. Psychiatric disorders and stages of smoking. Biological Psychiatry. 55(1):69-76, 2004.

Centers for Disease Control and Prevention (CDC). Tobacco use among adults -- United States, 2005. MMWR. 2006 Oct 27;55(42):1145-8.

Centers for Disease Control and Prevention (CDC). Annual smoking-attributable mortality, years of potential life lost, and productivity losses -- United States, 1997-2001. MMWR. 2005;54:625-628.

Centers for Disease Control and Prevention (CDC). State-specific prevalence of smoke-free home rules -- United States, 1992-2003. MMWR. 2007 May 25;56(20):501-4.

Chaudhuri R, Livingston E, McMahon AD, et al. Effects of smoking cessation on lung function and airway inflammation in smokers with asthma. Am J Respir Crit Care Med. 2006 Jul 15;174(2):127-33.

Dobson R. Smoking may increase abdominal obesity. BMJ. 2005 Sep 17;331(7517):596.

Eisenberg D, Quinn BC. Estimating the effect of smoking cessation on weight gain: an instrumental variable approach. Health Services Research. 2006 July 6; (early online version).

Galatz LM, Silva MJ, Rothermich SY, Zaegel MA, Havlioglu N, Thomopoulos S. Nicotine delays tendon-to-bone healing in a rat shoulder model. J Bone Joint Surg Am. 2006 Sep;88(9):2027-34.

Health, United States, 2005, with Chartbook on Trends in the Health of Americans. Hyattsville, Md. National Center for Health Statistics; 2005.

Hendricks P, Ditre J, Drobes D, Brandon T. The early time course of smoking withdrawal effects. Psychopharmacology. 2006;187(3): 385-396.

Houston TK, Person SD, Pletcher MJ, Liu K, Iribarren C, Kiefe CI. Active and passive smoking and development of glucose intolerance among young adults in a prospective cohort: CARDIA study. BMJ. 2006 May 6;332(7549):1064-9.

Linn-Rasker SP, van der Helm-van Mil AHM, van Gaalen FA, et al. Smoking is a risk factor for anti-CCP antibodies only in rheumatoid arthritis patients who carry HLA-DRB1 shared epitope alleles. Ann Rheum Dis. 2006;65:366-371.

Li YF, Langholz B, Salam MT, Gilliland FD. Maternal and grandmaternal smoking patterns are associated with early childhood asthma. Chest. 2005 Apr;127(4):1232-41.

Mennella JA, Yourshaw LM, Morgan LK. Breastfeeding and smoking: short-term effects on infant feeding and sleep. Pediatrics. 2007 Sep;120(3):497-502.

Naqvi NH, Rudrauf D, Damasio H, Bechara A. Damage to the insula disrupts addiction to cigarette smoking. Science. 2007 Jan 26;315(5811):531-4.

Nides M, Oncken C, Gonzales D, et al. Smoking cessation with varenicline, a selective alpha4beta2 nicotinic receptor partial agonist: results from a 7-week, randomized, placebo- and bupropion-controlled trial with 1-year follow-up. Arch Intern Med. 2006 Aug 14-28;166(15):1561-8.

Oncken C, Gonzales D, Nides M, Rennard S, Watsky E, Billing CB, Anziano R, Reeves K. Efficacy and safety of the novel selective nicotinic acetylcholine receptor partial agonist, varenicline, for smoking cessation. Arch Intern Med. 2006 Aug 14-28;166(15):1571-7.

Ritz B, Ascherio A, Checkoway H, et al. Pooled analysis of tobacco use and risk of Parkinson disease. Arch Neurol. 2007 Jul;64(7):990-7.

Sargent JD, Stoolmiller M, Worth KA, et al. Exposure to smoking depictions in movies: its association with established adolescent smoking. Arch Pediatr Adolesc Med. 2007 Sep;161(9):849-56.

Teo KK, Ounpuu S, Hawken S, et al. Tobacco use and risk of myocardial infarction in 52 countries in the INTERHEART study: a case-control study. Lancet. 2006 Aug 19;368(9536):647-58.

The Health Consequences Of Smoking: A Report Of The Surgeon General. Atlanta, GA: US Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, US Dept of Health and Human Services; 2004.

Tonnesen P, Mikkelsen K, Bremann L. Nurse-conducted smoking cessation in patients with COPD using nicotine sublingual tablets and behavioral support. Chest. 2006 Aug;130(2):334-42.

Uhl GR, Liu QR, Drgon T, Johnson C, Walther D, Rose JE. Molecular genetics of nicotine dependence and abstinence: whole genome association using 520,000 SNPs. BMC Genet. 2007 Apr 3;8:10.

Wagena EJ, Knipschild P, Zeegers MP. Should nortriptyline be used as a first-line aid to help smokers quit? Results from a systematic review and meta-analysis. Addiction. 2005;100:317-326.

Review Date:
10/8/2007
Reviewed By:
Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital

A.D.A.M. Copyright

adam.com

Alcoholism

FitSugar — Wed, 08 Oct 2008 17:35:36 -0700

In This Report

Highlights
Introduction
Causes
Risk Factors
Complications
Diagnosis
Treatment for Alcoholism...
Treatment for Alcohol Withd...
Therapy
Medications
Resources
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Drug Research

Topiramate (Topamax), an anticonvulsant drug used to treat epilepsy, is showing promise as a treatment for alcohol dependence. In a 2007 study published in the Journal of the American Medical Association, patients who took topiramate had fewer heavy drinking days, fewer drinks per day, and more days of not drinking at all than patients who received placebo.

Alcohol and Heart Disease

Heart disease is one of the leading causes of death among people who are heavy drinkers. Alcohol abuse and dependence increase the risks for unhealthy cholesterol levels, high blood pressure, heart failure, and stroke. Although the heart benefits of moderate alcohol use are widely discussed in the popular media, to date there are no definitive scientific studies that prove that alcohol consumption is beneficial to overall health.

The American Heart Association recommends that people who drink alcohol do so in moderation (one to two drinks a day for men, one drink a day for women). If you don’t drink, the American Heart Association advises against starting to drink to reduce the risk of heart disease. The best methods for preventing heart disease are exercise, healthy diet, and avoiding all forms of tobacco exposure.

Alcohol and Cancer

Long-term heavy alcohol use may increase the risks for many types of cancer including stomach, colorectal, mouth, tongue, throat, liver, and breast cancers. To reduce breast cancer risk, the American Cancer Society recommends that women limit their amount of alcohol consumption. Women who are at high risk for breast cancer should consider not drinking at all.

Introduction

Alcoholism is a chronic, progressive, and often fatal disease. It is a primary disorder and not a symptom of other diseases or emotional problems. The chemistry of alcohol allows it to affect nearly every type of cell in the body, including those in the central nervous system. After prolonged exposure to alcohol, the brain becomes dependent on it. The severity of this disease is influenced by factors such as genetics, psychology, culture, and response to physical pain.

Alcoholism is a chronic illness marked by dependence on alcohol consumption. It interferes with physical or mental health, and social, family, or job responsibilities. This addiction can lead to liver, circulatory, and neurological problems. Pregnant women who drink alcohol in any amount may harm the fetus.

Alcoholism, alcohol dependence, and alcohol abuse are associated with the following:

The only indication of early alcoholism may be the unpleasant physical responses to withdrawal that occur during even brief periods of abstinence.
Alcoholics have little or no control over the quantity they drink or the duration or frequency of their drinking.
Alcoholics are preoccupied with drinking, deny their own addiction, and continue to drink even though they are aware of the dangers.
Over time, some alcoholics become tolerant to the effects of drinking and require more alcohol to become intoxicated, creating the illusion that they can "hold their liquor."
Alcoholics may have blackouts after drinking and have frequent hangovers that cause them to miss work and other normal activities.
Alcoholics might drink alone and start their drinking early in the day.
Alcoholics periodically quit drinking or switch from hard liquor to beer or wine, but these periods rarely last.
Severe alcoholics often have a history of accidents, marital and work instability, and alcohol-related health problems.
Episodic violent and abusive incidents involving spouses and children and a history of unexplained or frequent accidents are often signs of drug or alcohol abuse.

Alcoholism can develop insidiously, and often there is no clear line between problem drinking and alcoholism. Eventually alcohol dominates thinking, emotions, and actions and becomes the primary means through which a person can deal with people, work, and life.

In addition to alcohol dependence, experts are now defining alcohol use by levels of harm that it may be causing. This information is useful to determine possible interventions at earlier stages. The following categories of alcohol use and abuse use a definition of one drink as 12 ounces of beer, 5 ounces of wine, or 1.5 ounces (a jigger) of 90-proof liquor.

Moderate Drinking. Moderate drinking, particularly red wine, appears to offer health benefits. Moderate drinking is defined as equal to or less than two drinks a day for men and one drink a day for women.

Hazardous (Heavy) Drinking. Hazardous drinking puts people at risk for adverse health events. People who are heavy drinkers consume:

More than 14 drinks per week, or four to five drinks at one sitting, for men
More than seven drinks per week, or three drinks at one sitting, for women
Frequent intoxication

Harmful Drinking. Drinking is considered harmful when alcohol consumption has actually caused physical or psychologic harm. This is determined by:

Clear evidence that alcohol is responsible for such harm.
The nature of that harm can be identified.
Alcohol consumption has persisted for at least a month or has occurred repeatedly for the past year.

Certain people are at much higher risk for harmful drinking, such as older individuals with high blood pressure or those taking medications for arthritis or pain.

Alcohol Abuse. People with alcohol abuse have one or more of the following alcohol-related problems over a period of 1 year:

Failure to fulfill work or personal obligations
Recurrent use in potentially dangerous situations
Problems with the law
Continued use in spite of harm being done to social or personal relationships

Alcohol Dependence. People who are alcohol dependent have three or more of the following alcohol-related problems over a year:

Increased amounts of alcohol are needed to produce an effect
Withdrawal symptoms or drinking alcohol is used to avoid these symptoms
Drinks more over a given period than intended
Unsuccessful attempts to quit or cut down
Gives up significant leisure or work activities
Continues to drink in spite of the knowledge of its physical or psychological harm to oneself or others

Two-thirds of those with alcohol dependence continued to be dependent on alcohol after 5 years.

Causes

People have been drinking alcohol for about 15,000 years. Drinking steadily and consistently over time can produce dependence and cause withdrawal symptoms during periods of abstinence. This physical dependence, however, is not the sole cause of alcoholism. To develop alcoholism, other factors usually come into play, including biology, genetics, culture, and psychology.

Genetic factors play a significant role in alcoholism and may account for about half of the total risk for alcoholism. The role that genetics plays in alcoholism is complex, however, and it is likely that many different genes are involved. Research suggests that alcohol dependence, and other substance addictions, may be associated with genetic variations in 51 different chromosomal regions.

Researchers are investigating a number of inherited traits that make particular individuals susceptible to this disorder:

The amygdala is an area of the brain thought to play a role in the emotional aspects of craving, which can lead to addiction. Some studies indicate that the amygdala is smaller in subjects with family histories of alcoholism, suggesting that inherited differences in brain structure may affect risk. Other studies suggest that certain brain chemicals (neurotransmitters) and proteins in the amygdala region may be involved in the link between anxiety and alcoholism.
Some studies indicate that people may inherit a lack of the warning signals that ordinarily make people stop drinking. Research suggests this factor may contribute to 40 - 60% of alcoholism cases related to genetic factors. (Even in the absence of genetic factors, repeated exposure to alcohol increases the ability to tolerate larger amounts before experiencing behavioral impairment.)
Some people with alcoholism may have an inherited dysfunction in the transmission of serotonin. Serotonin is a brain chemical messenger (neurotransmitter). It is important for well-being and associated behaviors (eating, relaxation, and sleep). Abnormal serotonin levels are associated with high levels of tolerance for alcohol. They are also linked to impulsivity and aggressiveness. These behaviors can predispose people to drink and can increase the risk for dangerous behaviors and suicide in people who are alcohol dependent.
Dopamine is another neurotransmitter associated with alcoholism and other addictions. Research indicates that high levels of the D2 dopamine receptor may help inhibit behavioral responses to alcohol, and protect against alcoholism, in people with a family history of alcohol dependence.

Even if genetic factors can be identified, however, they are unlikely to explain all cases of alcoholism. It is important to understand that whether they inherit the disorder or not, people with alcoholism are still legally responsible for their actions. Inheriting genetic traits does not doom a child to an alcoholic future. Environment, personality, and emotional factors also play a strong role.

Alcohol has widespread effects on the brain and can affect neurons (nerve cells), brain chemistry, and blood flow within the frontal lobes of the brain. Researchers are particularly interested in systems of neurotransmitters (chemical messengers) in the brain that are affected by alcohol. Some research is focusing on the way these neurotransmitters are employed in the brain after long-term alcohol use in order to adapt to the cravings and pain of withdrawal. Such chemical changes may lead to dependency or to relapse after quitting in two ways:

They increase the need to reduce agitation
They increase the desire to restore pleasurable feelings

When a person who is dependent on alcohol stops drinking, chemical responses create an overexcited nervous system and agitation by changing the level of chemicals that inhibit impulsivity or stress and excitation. High norepinephrine levels, a chemical the brain produces more of when drinking is stopped, in fact, may be the primary factor in withdrawal symptoms, such as an increase in blood pressure and heart rate. This hyperactivity in the brain produces an intense need to calm down and to use more alcohol. One study suggested that the need to relieve agitation may be the more important factor in causing a relapse than restoring mood.

Drinking alcohol stimulates the release of neurotransmitters (serotonin, dopamine, and opioid peptides) that produce pleasurable feelings such as euphoria, a sensation of being rewarded, and a sense of well-being.

Over time, however, heavy alcohol use appears to deplete the stores of dopamine and serotonin. Persistent drinking, therefore, eventually fails to restore mood, but by then the drinker has been conditioned to believe that alcohol will improve spirits (even though it does not).

Between 80 - 90% of people treated for alcoholism relapse, even after years of abstinence. Patients and their caregivers should understand that relapses of alcoholism are analogous to recurrent flare-ups of chronic physical diseases. Factors that place a person at high risk for relapse include:

Frustration and anger
Social pressure
Internal temptation

Mental and Emotional Stress. Alcohol blocks out emotional pain and is often perceived as a loyal friend when human relationships fail. It is also associated with freedom and with a loss of inhibition that offsets the tedium of daily routines. When the alcoholic tries to quit drinking, the brain seeks to restore what it perceives to be its equilibrium. The brain's best weapons to achieve this are depression, anxiety, and stress (the emotional equivalents of physical pain), which are produced by brain chemical imbalances. These negative moods continue to tempt alcoholics to return to drinking long after physical withdrawal symptoms have abated.

It is important to realize that any life change, even changes for the better, may cause temporary grief and anxiety. With time and the substitution of healthier pleasures, this emotional turmoil weakens and can be overcome.

Co-dependency. Many aspects of the ex-drinker's relationships change when drinking stops, making it difficult to remain abstinent:

One of the most difficult problems that occur is being around other people who are able to drink socially without danger of addiction. A sense of isolation, a loss of enjoyment, and the ex-drinker's belief that pity, not respect, is guiding a friend's attitude can lead to loneliness, low self-esteem, and a strong desire to drink again.
Friends may not easily accept the sober, perhaps more subdued, ex-drinker. Close friends and even intimate partners may have difficulty in changing their responses to this newly sober person and, even worse, may encourage a return to drinking.
To preserve marriages, spouses of alcoholics often build their own self-images on surviving or handling their mates' difficult behavior and then discover that they find it difficult to adjust to new roles and behaviors.

In such cases, separation from these "enablers" may be necessary for survival. It is no wonder that, when faced with such losses, even if they are temporary, a person returns to drinking. The best course in these cases is to encourage close friends and family members to seek help as well. Fortunately, groups such as Al-Anon exist for this purpose.

Social and Cultural Pressures. The media portrays the pleasures of drinking in advertising and programming. The medical benefits of light-to-moderate drinking are frequently publicized, giving ex-drinkers the spurious excuse of returning to alcohol for their health. These messages must be categorically ignored and acknowledged for what they are: An industry's attempt to profit from potentially great harm to individuals.

Risk Factors

About 90% of adults in the U.S. drink alcohol. Every day, more than 700,000 Americans are being treated for alcoholism. In addition, up to half of American men have problems that are caused by alcohol.

Some researchers have categorized people with alcoholism as Type 1 or Type 2.

Type 1 individuals are more often women. They typically become alcoholic at a later age, have less severe symptoms or fewer psychiatric problems, and have a better outlook on life than those classified as type 2.
Type 2 people are more likely to be male. They tend to become alcoholic at an early age and have a high family risk for alcoholism, more severe symptoms, and a negative outlook on life.

Not only do these two groups tend to respond differently to psychotherapeutic approaches, but they may also respond differently to medications.

Drinking in Adolescence. About half of under-age Americans have used alcohol. About 2 million people ages 12 - 20 are considered heavy drinkers, and 4.4 million are binge drinkers. Anyone who begins drinking in adolescence is at risk for developing alcoholism. The earlier a person begins drinking, the greater the risk. A 2006 survey of over 40,000 adults indicated that among those who began drinking before age 14, nearly half had become alcoholic dependent by the age of 21. In contrast, only 9% of people who began drinking after the age of 21 developed alcoholism.

Young people at highest risk for early drinking are those with a history of abuse, family violence, depression, and stressful life events. People with a family history of alcoholism are also more likely to begin drinking before the age of 20 and to become alcoholic. Such adolescent drinkers are also more apt to underestimate the effects of drinking and to make judgment errors, such as going on binges or driving after drinking, than young drinkers without a family history of alcoholism.

Drinking in the Elderly Population. Although alcoholism usually develops in early adulthood, the elderly are not exempt. In fact, doctors may overlook alcoholism when evaluating elderly patients, mistakenly attributing the signs of alcohol abuse to the normal effects of the aging process. A survey of adults over 60 reported that 15% of men and 12% of women were hazardous drinkers, and 9% of men and 3% of women were alcohol dependent.

Alcohol also affects the older body differently. People who maintain the same drinking patterns as they age can easily develop alcohol dependency without realizing it. It takes fewer drinks to become intoxicated, and older organs can be damaged by smaller amounts of alcohol than those of younger people. Also, up to one-half of the 100 most prescribed drugs for older people react adversely with alcohol. Medications used for arthritis or pain pose a particular danger for interaction with alcohol.

Most alcoholics are men, but the incidence of alcoholism in women has been increasing over the past 30 years. Studies indicate that about 7% of men and 2.5% of women abuse alcohol. However, studies suggest that women are more vulnerable than men to many of the long-term consequences of alcoholism. For example, women are more likely than men to develop alcoholic hepatitis and to die from cirrhosis, and women are more vulnerable to the brain cell damage caused by alcohol.

Individuals who were abused as children have a higher risk for substance abuse later on. In one study, 72% of women and 27% of men with substance abuse disorders reported physical or sexual abuse or both. They also had worse response to treatment than those without such a history.

Overall, there is no difference in alcoholic prevalence among African-Americans, Caucasians, and Hispanic-Americans. Some population groups, however, such as Native Americans, have an increased incidence of alcoholism while others, such as Jewish and Asian Americans, have a lower risk. Although the biological or cultural causes of such different risks are not known, certain people in these population groups may have a genetic susceptibility or invulnerability to alcoholism because of the way they metabolize alcohol.

Psychiatric Disorders. Severely depressed or anxious people are at high risk for alcoholism, smoking, and other forms of addiction. Likewise, a large proportion of alcohol-dependent people suffer from an accompanying psychiatric or substance abuse disorder. Either anxiety or depression may increase the risk for self-medication with alcohol. Depression is the most common psychiatric problem in people with alcoholism or substance abuse.

Depression is less reported in the male population, but this may be caused by male tendency to mask emotional disorders with behavior such as alcohol abuse.

Specific anxiety disorders, such as panic disorders and social phobia, may pose particular risks for alcohol and substance abuse. Social phobia causes an intense fear of being publicly scrutinized and humiliated. Panic disorders cause intense anxiety and panic attacks. People with these disorders may use alcohol as a way to become less inhibited in public situations or to calm feelings of panic. While anxiety disorders are found in about 15% of adults overall, over 50% of people with alcohol abuse problems suffer from these conditions. People who have anxiety disorders are more likely to resume drinking after treatment for alcohol dependence. [For more information, see In-Depth Report #28: Anxiety.]

Long-term alcoholism itself may cause chemical changes that produce anxiety and depression. In fact, a study on elderly people with depression reported that when even moderate drinkers reduced consumption, their mood improved. Studies also indicate that alcohol use may promote panic attacks. It is not always clear, then, whether people with emotional disorders are self-medicating with alcohol, or whether alcohol itself is producing mood swings.

Behavioral Disorders and Lack of Impulse Control. Studies are also finding that alcoholism is strongly related to impulsive, excitable, and novelty-seeking behavior, and such patterns are established early on. Children who later become alcoholics or who abuse drugs are more likely to have less fear of new situations than others, even if there is a greater risk for harm than in nonalcoholics. Specifically, children with attention deficit hyperactivity disorder (ADHD), a condition that shares these behaviors, have a higher risk for alcoholism in adulthood. The risk is especially high in children with ADHD and conduct disorder.

Alcoholism is not restricted to any social or economic levels. For example, a thorough 1996 study reported no higher prevalence of alcoholism among adult welfare recipients than in the general population (about 7%). There was also no difference in prevalence between African-Americans and Caucasians in low-income groups. On the other hand, people in low-income groups who drank did display some tendencies that differed from the general population of drinkers. For instance, in one study as many women as men were heavy drinkers in lower income groups. Excessive drinking may also be more dangerous in lower income groups. One study found that alcohol was a major factor in the higher death rate of people, particularly men, in lower socioeconomic groups compared with those in higher groups.

Complications

Alcoholism reduces life expectancy by 10 - 12 years. Next to smoking, it is the most common preventable cause of death in America. Although studies indicate that adults who drink moderately (about one drink a day for women and two drinks a day for men) have a lower mortality rate than their nondrinking peers, their risk for untimely death increases with heavier drinking. The earlier a person begins drinking heavily, the greater their chance of developing serious illnesses later on. Once one becomes dependent on alcohol, it is very difficult to quit.

Alcohol can affect the body in so many ways that researchers have a hard time determining exactly what the consequences are from drinking. Interestingly, although heavy drinking is associated with earlier death, studies suggest it is not from a higher risk of the more common serious health problems, such as heart attack, heart failure, diabetes, lung disease, or stroke. It is well known, however, that chronic consumption leads to many problems that can increase the risk for death:

In general, people who drink regularly have a higher rate of death from injury or violence.
Alcohol overdose can lead to death. This is a particular danger for adolescents who may want to impress their friends with their ability to drink alcohol but cannot yet gauge its effects. However, alcohol overdose doesn't only occur from any one heavy drinking incident, but may also occur from a constant infusion of alcohol in the bloodstream.
Severe withdrawal and delirium tremens. Delirium tremens occurs in about 5% of alcoholics. It includes progressively severe withdrawal symptoms and altered mental states. In some cases, it can be fatal.
Frequent, heavy alcohol use directly harms many areas in the body and produce dangerous health conditions (liver damage, pancreatitis, anemia, upper gastrointestinal bleeding, nerve damage, and impotence).
Alcohol abusers who need surgery have an increased risk of postoperative complications, including infections, bleeding, insufficient heart and lung functions, and problems with wound healing. Alcohol withdrawal symptoms after surgery may impose further stress on the patient and hinder recuperation.

Although not traditionally thought of as a medical problem, a review of studies found that hangovers have significant consequences that include changes in liver function, hormonal balance, and mental functioning and an increased risk for depression and cardiac events. Hangovers can impair job performance, increasing the risk for mistakes and accidents. Interestingly, hangovers are generally more common in light-to-moderate drinkers than heavy and chronic drinkers, suggesting that binge drinking can be as threatening as chronic drinking. Any man who drinks more than five drinks or any woman who has more than three drinks is at risk for a hangover.

Alcohol plays a large role in accidents, suicide, and crime:

Alcohol plays a major role in more than half of all automobile fatalities.
Alcohol-related automobile accidents are the leading causes of death in young people.
Fewer than two drinks can impair the ability to drive. Even one drink may double the risk of injury, and more than four drinks increases the risk by 11 times.
Alcoholism is the primary diagnosis in one-quarter of all people who commit suicide.
Alcohol is implicated in 67% of all murders.

Alcoholic households are less cohesive and have more conflicts, and their members are less independent and expressive than households with nonalcoholic or recovering alcoholic parents. Domestic violence is a common consequence of alcohol abuse.

Effect on Women. Research suggests that for women, the most serious risk factor for injury from domestic violence may be a history of alcohol abuse in her male partner.

Effect on Children. Alcoholism in parents also increases the risk for violent behavior and abuse toward their children. Children of alcoholics tend to do worse academically than others, have a higher incidence of depression, anxiety, and stress and lower self-esteem than their peers. In addition to their own inherited risk for later alcoholism, many children of alcoholics have serious coping problems that may last their entire life.

Adult children of alcoholic parents are at higher risk for divorce and for psychiatric symptoms. One study concluded that the only events with greater psychological impact on children are sexual and physical abuse.

Researchers are finding common genetic factors in alcohol and nicotine addiction, which may explain, in part, why alcoholics are often smokers. Alcoholics who smoke compound their health problems. More alcoholics die from tobacco-related illnesses, such as heart disease or cancer, than from chronic liver disease, cirrhosis, or other conditions that are more directly tied to excessive drinking. Abuse of other substance is also common among alcoholics.

Alcoholic Hepatitis and Cirrhosis. Alcohol is absorbed in the small intestine and passes directly into the liver, where it becomes the preferred energy source. The liver, then, is particularly endangered by alcoholism. In the liver, alcohol converts to toxic chemicals, notably acetaldehyde, which trigger the production of immune factors called cytokines. In large amounts, these factors cause inflammation and tissue injury.

Cirrhosis is a chronic liver disease that causes damage to liver tissue, scarring of the liver (fibrosis; nodular regeneration), progressive decrease in liver function. Consequences of a failing liver include excessive fluid in the abdomen (ascites), bleeding disorders (coagulopathy), increased pressure in the blood vessels (portal hypertension), and brain function disorders (hepatic encephalopathy). Excessive alcohol use is the leading cause of cirrhosis.

Even moderate alcohol intake can produce pain in the upper right quarter of the abdomen -- a possible symptom of liver involvement. In many cases, such symptoms may be an indication of fatty liver or alcohol hepatitis, which are reversible liver conditions.

Between 10 - 20% of people who drink heavily (five or more drinks a day) develop cirrhosis, a progressive and irreversible scarring of the liver that can eventually be fatal. Alcoholic cirrhosis (also sometimes referred to as portal, Laennec’s, nutritional, or micronodular cirrhosis) is the primary cause of cirrhosis in the U.S. [For more information, see In-Depth Report #75: Cirrhosis.]

Not eating when drinking and consuming a variety of alcoholic beverages increase the risk for liver damage. Nevertheless, the amount of alcohol consumed and the patterns of drinking are only weak predictions of risk. Up to 90% of heavy drinkers do not develop advanced irreversible liver disease. Other risk factors have been identified that may increase the danger to the liver in heavy drinkers:

Obesity is a major factor for all stages of liver disease.
Women develop liver disease at lower quantities of alcohol intake than men.
Genetic factors that regulate the immune responses also play role.

Viral Hepatitis B and C. People with alcoholism tend to have lifestyles that put them at higher risk for hepatitis B and C, which are caused by viruses. Chronic forms of viral hepatitis pose risks for cirrhosis and liver cancer, and alcoholism significantly increases these risks. People with alcoholism should be immunized against hepatitis B. They may need a higher-than-normal dose of the vaccine for it to be effective. There is no vaccine for hepatitis C. [For more informaiton, see In-Depth Report #59: Hepatitis.]

Alcoholism can cause many problems in the gastrointestinal tract. Violent vomiting can produce tears in the junction between the stomach and esophagus. Alcoholism poses a high risk for diarrhea and hemorrhoids. It increases the risk for ulcers, particularly in people taking the painkillers known as nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen. It can also lead to swollen veins in the esophagus (esophagitis), called varices, which can lead to bleeding.

Click the icon to see an image of ulcer emergencies.

Alcohol can contribute to serious and chronic inflammation of the pancreas (pancreatitis) in people who are susceptible to this condition. There is some evidence of a higher risk for pancreatic cancer in people with alcoholism, although this higher risk may occur only in people who are also smokers.

Click the icon to see an image of the pancreas.

Moderate amounts (one to two drinks a day) of alcohol can improve some heart disease risk factors, such as increasing HDL (“good cholesterol”) levels. However, at this time there is no definitive proof that moderate drinking improves overall health, and the American Heart Association does not recommend drinking alcoholic beverages solely to reduce cardiovascular risk.

Excessive drinking clearly has negative effects on heart health. In fact, heart disease is one of the leading causes of death for alcoholics. Alcohol abuse increases levels of triglycerides (unhealthy fats) and increases the risks for high blood pressure, heart failure, and stroke. In addition, the extra calories in alcohol can contribute to obesity, a major risk factor for many heart problems.

Click the icon to see an image of the heart.

Alcohol abuse and dependence may increase the risk for certain type of cancers. In particular, heavy alcohol use appears to increase the risks for mouth, throat, esophageal, gastrointestinal, liver, colorectal, and breast cancers. Women who are at high risk for breast cancer should consider not drinking at all.

Pneumonia. Over time, chronic alcoholism can cause severe reductions in white blood cells, which increase the risk for community-acquired pneumonia (pneumonia acquired outside of hospitals or nursing homes). Patients who abuse alcoholism have a greater risk for developing severe pneumonia. Doctors recommend that patients with alcohol dependence should receive an annual pneumococcal pneumonia vaccination. The initial signs of pneumococcal pneumonia are high fever, cough, and stabbing chest pains. Immediately contact your doctor if you experience these symptoms.

Click the icon to see an image of pneumonia.

Severe alcoholism is associated with osteoporosis (loss of bone density), muscular deterioration, skin sores, and itching. Alcohol-dependent women seem to face a higher risk than men for damage to muscles, including muscles of the heart, from the toxic effects of alcohol.

Click the icon to see an image of osteoporosis.

Effects Sexual Function and Fertility. Alcoholism increases levels of the female hormone estrogen and reduces levels of the male hormone testosterone, factors that possibly contribute to impotence in men and infertility in women. Such changes may also be responsible for the higher risks for absent periods and abnormal uterine bleeding in women with alcoholism.

Drinking During Pregnancy and Effects on the Infant. Even moderate amounts of alcohol can have damaging effects on the developing fetus, including low birth weight and an increased risk for miscarriage. High amounts can cause fetal alcohol syndrome, a condition that can cause mental and growth retardation. Although there is no specific amount of alcohol intake, the risk of developing the syndrome is increased depending on the time of alcohol exposure during pregnancy, a patter of drinking (four or more drinks per occasion), and how often alcohol consumption occurs.

Moderate alcohol consumption may help protect the hearts of adults with type 2 diabetes. Heavy drinking however is associated with obesity, which is a risk factor for this form of diabetes. In addition, alcohol can cause hypoglycemia, a drop in blood sugar, which is especially dangerous for people with diabetes who are taking insulin. Intoxicated diabetics may not be able to recognize symptoms of hypoglycemia, a potentially hazardous condition.

Drinking too much alcohol can cause immediate mild neurologic problems in anyone, including insomnia and headache. Long-term alcohol use may even physically affect the brain. Depending on length and severity of alcohol abuse, neurologic damage may not be permanent, and abstinence nearly always leads to eventual recovery of normal mental function.

Effect on Mental Functioning. Studies have reported less blood flow in the frontal lobes of the brain, which may reflect links to deeper levels. In one study, even recent high alcohol use (within the last 3 months) was associated with some loss of verbal memory and slower reaction times. Over time, chronic alcohol abuse can impair so-called "executive functions," which include problem solving, mental flexibility, short-term memory, and attention. These problems are usually mild to moderate and can last for weeks or even years after a person quits drinking. In fact, such persistent problems in judgment are possibly one reason for the difficulty in quitting. Alcoholic patients who have co-existing psychiatric or neurologic problems are at particular risk for mental confusion and depression.

Wernicke-Korsakoff Syndrome. Wernicke-Korsakoff syndrome is a serious consequence of severe thiamin (vitamin B1) deficiency in alcoholism. Symptoms of this syndrome include severe loss of balance, confusion, and memory loss. Eventually, it can result in permanent brain damage and death. Once the syndrome develops, oral supplements have no effect, and only adequate and rapid intravenous vitamin B1 can treat this serious condition.

Peripheral Neuropathy. Vitamin B1 deficiencies can also lead to peripheral neuropathy, a condition that causes pain, tingling, and other abnormal sensations in the arms and legs.

Click the icon to see an image of the nervous system.

People with alcoholism should be sure to take vitamin and mineral supplements. Even apparently well-nourished people with alcoholism may be deficient in important nutrients. Deficiencies in vitamin B are particularly health risks in people with alcoholism. Other vitamin and mineral deficiencies, however, can also cause widespread health problems.

Folate Deficiencies. Alcohol interferes with the metabolism of folate, a very important B vitamin, called folic acid when used as a supplement. Folate deficiencies can cause severe anemia. Deficiencies during pregnancy can lead to birth defects in the infant.

Vitamin B1 Deficiencies. Many of the B vitamins are essential for nerve protection. Severe deficiencies are common in alcoholism and can have serious consequences on the central nervous system, notably peripheral neuropathy and, in very severe cases, Wernicke-Korsakoff syndrome.

The effects of many medications are strengthened by alcohol, while others are inhibited. Of particular importance is alcohol's reinforcing effect on anti-anxiety drugs, sedatives, antidepressants, and antipsychotic medications. Alcohol also interacts with many drugs used by people with diabetes. It interferes with drugs that prevent seizures or blood clotting. It increases the risk for gastrointestinal bleeding in people taking aspirin or other nonsteroidal inflammatory drugs (NSAIDs) including ibuprofen and naproxen. Chronic alcohol abusers have a particularly high risk for adverse side effects from consuming alcohol while taking certain antibiotics. These side effects include flushing, headache, nausea, and vomiting. In other words, taking almost any medication should preclude drinking alcohol.

Diagnosis

Even when people with alcoholism experience withdrawal symptoms, they nearly always deny the problem, leaving it up to co-workers, friends, or relatives to recognize the symptoms and to take the first steps toward encouraging treatment. Denial, in fact, may be an important warning signal for alcoholism.

Family members cannot always rely on a doctor to make an initial diagnosis. Although 15 - 30% of people who are hospitalized have alcoholism or alcohol dependence, doctors often fail to screen for the problem. In addition, doctors themselves often do not recognize the symptoms. Even when doctors identify an alcohol problem, however, they are frequently reluctant to confront the patient with a diagnosis that might lead to treatment for addiction.

A doctor who suspects alcohol abuse should ask the patient questions about current and past drinking habits to distinguish moderate from heavy, or hazardous, drinking. Screening tests for alcohol problems in older people should account for possible medical problems or medications that might place them at higher risk for hazardous drinking than younger individuals.

A number of short screening tests are available, which a person can even take on their own. Because people with alcoholism often deny their problem or otherwise attempt to hide it, the tests are designed to elicit answers related to problems associated with drinking rather than the amount of liquor consumed or other specific drinking habits.

CAGE Test. The CAGE test is an acronym for the following questions and is the quickest test:

Attempts to CUT (C) down on drinking
ANNOYANCE (A) with criticisms about drinking
GUILT (G) about drinking
Use of alcohol as an EYE-OPENER (E) in the morning

This test and another called the Self-Administered Alcoholism Screening Test (SAAST) appear to be most useful in detecting possible alcoholism in white, middle-aged males. They are not very accurate for identifying alcohol abuse in older people, white women, and African-Americans and Mexican Americans.

T-ACE Test. The T-ACE test is a four-question test that appears to be quite accurate in identifying alcoholism in both men and women. It asks the following questions:

Does it TAKE (T) more than three drinks to make you feel high?
Have you ever been ANNOYED (A) by people's criticism of your drinking?
Are you trying to CUT DOWN (C) on drinking?
Have you ever used alcohol as an EYE OPENER (E) in the morning?

A positive response to two of these four questions is considered to indicate possible alcohol abuse or dependence.

AUDIT Test. A more effective and important test for most people may be the Alcohol Use Disorders Identification Test (AUDIT), which is the only test specifically designed to identify hazardous or harmful drinking. It asks three questions about amount and frequency of drinking, three questions about alcohol dependence, and four questions about problems related to alcohol consumption.

A Single-Question. One simple question may be as sensitive as the CAGE or AUDIT: "When was the last time you had more than five drinks (for men) or four drinks (for women) in one day?" An answer of "within 3 months" accurately identified about half of people who were problem drinkers. Problem drinking is defined as hazardous drinking within the last month or some alcohol-use disorder during the past year.

Other Screening Tests. Other short screening tests are the Michigan Alcoholism Screening Test (MAST) and the Alcohol Dependence Scale (ADS).

Some symptoms of alcoholism may be attributed to other disorders, particularly in the elderly, where symptoms of confusion, memory loss, or falling may be attributed to the aging process alone. Heavy drinkers may be more likely to complain to their doctors about so-called somatization symptoms, which are vague ailments, such as joint pain, intestinal problems, or general weakness, that have no identifiable physical cause. Such complaints should signal the doctor to follow-up with screening tests for alcoholism.

Alcoholism is particularly less likely to be recognized in elderly women. In fact, only 1% of older women who need treatment for alcoholism are diagnosed accurately and treated appropriately. Instead, they are often diagnosed with depression and may even be prescribed anti-anxiety drugs or antidepressants that can have dangerous interactions with alcohol.

Physical Examination. A physical examination and other tests should be performed to uncover any related medical problems.

Laboratory Tests. Tests for alcohol levels in the blood are not useful for diagnosing alcoholism because they reflect consumption at only one point in time and not long-term usage. Certain blood tests, however, may provide biologic markers that suggest medical problems associated with alcoholism or indications of alcohol abuse:

Carbohydrate-deficient transferrin (CDT). This compound is a marker for heavy drinking and can be helpful in monitoring patients for progress towards abstinence.
Gamma-glutamyltransferase (GGT). This liver enzyme is very sensitive to alcohol and can be elevated after moderate alcohol intake and in chronic alcoholism.
Aspartate (AST) and alanine aminotransaminases (ALT). These are liver enzymes and are markers for liver damage.
Testosterone. Male hormone levels in men with alcoholism may be low. (Such results sometimes persuade men with alcoholism to seek help.)
Mean corpuscular volume (MCV). This blood test measures the size of red blood cells, which increase with alcohol use over time.

Treatment for Alcoholism

Once a diagnosis of alcoholism is made, the next major step is getting the patient to seek treatment. The main reasons alcoholics do not seek treatment are:

Lack of confidence in successful therapies
Denial of their own alcoholism
Social stigma attached to the condition and its treatment

The alcoholic patient and everyone involved should fully understand that alcoholism is a disease. Furthermore, the responses to this disease (need, craving, fear of withdrawal) are not character flaws but symptoms, just as pain or discomfort are symptoms of other illnesses. They should also realize that treatment is difficult and sometimes painful, just as are treatments for other life-threatening diseases, such as cancer, but that treatment is the only hope for a cure.

Interventions by family members, employers, and therapists can be very effective in motivating a person to quit and in reducing drinking over the short term. Even brief interventions from a primary care doctor and self-help information can be helpful in reducing harmful drinking. Studies report, however, that only regular follow-up and reinforcement will sustain quit rates and possibly even improve survival rates.

Personal Intervention Meetings. The best approaches for motivating a patient to seek treatment are interventional group meetings between people with alcoholism and their friends and family members who have been affected by the alcoholic behavior. Using this approach, each person affected offers a compassionate but direct and honest report describing specifically how they have been hurt by their loved one's alcoholism. The family and friends should express their affection for the patient and their intentions for supporting the patient through recovery, but they must strongly and consistently demand that the patient seek treatment. Children may even be involved in this process, depending on their level of maturity and ability to handle the situation.

Employer Intervention. Employers can be particularly effective. Their approach should also be compassionate but strong, threatening the employee with loss of employment if they do not seek help. Some large companies provide access to inexpensive or free treatment programs for their workers. Studies suggest that such interventions are effective at helping the worker at least to cut back on drinking.

The ideal goals of long-term treatment by many doctors and organizations such as Alcoholics Anonymous (AA) are total abstinence. Patients who secure total abstinence have better survival rates, mental health, and marriages, and they are more responsible parents and employees than those who continue to drink or relapse. To achieve this, the patient aims to avoid high-risk situations and replace the addictive patterns with satisfying, time-filling behaviors.

Because abstinence is so difficult to attain, however, many professionals choose to treat alcoholism as a chronic disease. In other words, patients should expect and accept relapse but should aim for as long a remission period as possible. Even merely reducing alcohol intake can lower the risk for alcohol-related medical problems.

AA and other alcoholic treatment groups are greatly worried by treatment approaches that do not aim for strict abstinence, however. Many people with alcoholism are eager for any excuse to start drinking again. There is also no way to determine which people can stop after one drink and which ones cannot.

Evidence strongly suggests that seeking total abstinence and avoiding high-risk situations are the optimal goal for people with alcoholism.

A number of treatment options now exist for alcoholism. It is first important to determine whether inpatient or outpatient care would best benefit the individual. A variety of treatment options exist that do not require overnight stay in a hospital. Structured programs exist that involve anywhere from a couple of hours a day for several days a week to 20 or more hours per week (sometimes called partial hospitalization) of monitoring. Withdrawal and subsequent abstinence monitoring using outpatient visits to a doctor is occasionally tried for select, low-risk patients.

Inpatient care may also be performed in a general or psychiatric hospital or in a center dedicated to treatment of alcohol and other substance abuse. Factors that indicate a need for this type of treatment include:

Coexisting medical or psychiatric disorder
Delirium tremens
Potential harm to selves or others
Failure to respond to conservative treatments
Disruptive home environment

A typical inpatient regimen may include the following stages:

A physical and psychiatric work-up for any physical or mental disorders
Detoxification -- this phase involves initiating abstinence, managing withdrawal symptoms and complications, and ensuring that the patient remains in treatment
On-going treatment with medications in some cases
Psychotherapy, usually cognitive behavioral therapy
An introduction to Alcoholics Anonymous

Some -- but not all -- studies have reported better success rates with inpatient treatment of patients with alcoholism. However, newer studies strongly suggest that alcoholism can be effectively treated in a doctor’s office.

The new approach to outpatient treatment uses “medical management” -- a disease management approach that is used for chronic illnesses such as diabetes. With medical management, patients receive regular 20-minute sessions with a health care provider. The provider monitors the patient’s medical condition, medication, and alcohol consumption.

A medical management approach generally involves one or both of the following:

Drug treatment with naltrexone (ReVia, Vivitrol)
Behavioral counseling with a therapy technique called combined behavioral intervention (CBI)

Outpatient Treatment Options. People with mild-to-moderate withdrawal symptoms are usually treated as outpatients. Treatments are similar to those in inpatient situations and include:

Psychotherapy or counseling
Medications that target brain chemicals involved in addiction
Social support groups such as Alcoholics Anonymous
Cognitive therapies
Quitting smoking (smoking interferes with the brain’s recovery from alcoholism)
Involvement of family and other significant people in patient's life

After-Care and Work Therapy. After-care employs services that help alcoholics maintain sobriety. For example, in some cities, sober-living houses provide residences for people who are trying to stay sober. They do not offer formal treatment services, but the people living there offer each other support and maintain an abstinent environment. One study reported that work therapy improved the outcome for homeless veterans who were being treated for substance abuse.

About 25% of people are continuously abstinent following treatment, and another 10% use alcohol moderately and without problems. Most studies strongly suggest that intensive and prolonged treatment is important for successful recovery, whether the patient is treated within or outside a treatment center.

Certain factors play a role in success or failure. Patients from low-income groups tend to have worse results in general. Their difficulties are often intensified by lack of insurance, low self-esteem, and minimal social support.

Severe alcoholism is often complicated by the presence of serious medical illnesses. People with alcoholism should try at least to maintain a healthy diet and take vitamin supplements. Such deficiencies are a major cause of health problems in people with alcoholism. Women are particularly endangered.

A program called integrated outpatient treatment (IOT) may be specifically helpful for medically ill alcoholics. The patient visits a clinic once a month and receives both intensive alcohol treatment and a physical check-up, which includes tracking factors, such as liver function, that are affected by drinking.

Treatment for patients with both alcoholism and mental illness is particularly difficult. The greater the psychiatric distress a person is experiencing, the more the person is tempted to drink, particularly in negative situations.

There has been some concern that self-help programs, such as Alcoholics Anonymous (AA), are not effective for patients with dual diagnoses of mental illness and alcoholism, because the focus of the organization is on addiction, not psychiatric problems. Studies, however, have reported that they are also effective in many of these patients. (AA may not be as helpful for people with schizophrenia and schizoaffective disorder.) In one study, individuals with a dual diagnosis achieved better abstinence rates after being treated only for alcoholism compared to patients treated for the mental disorder as well. (Cognitive-behavioral therapy was used for both groups.)

Newer antidepressants such as selective serotonin reuptake inhibitors (SSRIs) are proving to be very useful complements to AA or counseling sessions. Anti-anxiety medications are also available for people with anxiety. People with alcoholism and more severe problems such as schizophrenia or severe bipolar disorder may require other types of medications.

Treatment for Alcohol Withdrawal

When a person with alcoholism stops drinking, withdrawal symptoms begin within 6 - 48 hours and peak about 24 - 35 hours after the last drink. During this period, the inhibition of brain activity caused by alcohol is abruptly reversed. Stress hormones are overproduced, and the central nervous system becomes overexcited. Common symptoms include:

Anxiety
Irritability
Agitation
Insomnia

Additional symptoms may include:

Extremely aggressive behavior
Fever
Rapid heartbeat
Changes in blood pressure (either higher or lower)
Mental disturbances
Seizures occur in about 10% of adults during withdrawal. In about 60% of these patients, the seizures are multiple. The time between the first and last seizure is usually 6 hours or less.
Delirium tremens (DTs) are withdrawal symptoms that become progressively severe and include altered mental states (hallucinations, confusion, severe agitation) or generalized seizures. DTs are potentially fatal. They develop in up to 5% of alcoholic patients, usually 2 - 4 days after the last drink, although it may take 2 or more days to peak.

It is not clear if older people with alcoholism are at higher risk for more severe symptoms than younger patients. However, several studies have indicated that they may suffer more complications during withdrawal, including delirium, falls, and a decreased ability to perform normal activities.

Upon entering a hospital due to alcohol withdrawal, patients should be given a physical examination for any injuries or medical conditions. They should be treated, if possible, for any potentially serious problems, such as high blood pressure, anemia, liver damage, or irregular heartbeat.

The immediate goal of treatment is to calm the patient as quickly as possible. Patients should be observed for at least 2 hours to determine the severity of withdrawal symptoms. Doctors may use assessment tests, such as the Clinical Institute Withdrawal Assessment (CIWA) scale, to help determine treatment and whether the symptoms will progress in severity.

About 95% of people have mild-to-moderate withdrawal symptoms, including agitation, trembling, disturbed sleep, and lack of appetite. In 15 - 20% of people with moderate symptoms, brief seizures and hallucinations may occur, but they do not progress to full-blown delirium tremens. Such patients often can be treated as outpatients. After being examined and observed, the patient is usually sent home with a 4-day supply of anti-anxiety medication, scheduled for follow-up and rehabilitation, and advised to return to the emergency room if withdrawal symptoms increase in severity. If possible, a family member or friend should support the patient through the next few days of withdrawal.

Benzodiazepines. Anti-anxiety drugs known as benzodiazepines inhibit nerve-cell excitability in the brain and are considered to be the treatment of choice. They relieve withdrawal symptoms, help prevent progression to delirium tremens, and reduce the risk for seizures. Long-acting drugs, such as chlordiazepoxide (Libritabs, Librium), oxazepam (Serax), and halazepam (Paxipam) are preferred. They pose less risk for abuse than the shorter-acting drugs, which include diazepam (Valium), alprazolam (Xanax), and lorazepam (Ativan).

Assessing symptoms frequently and administering benzodiazepine doses as needed (instead of giving to a fixed dose at regular intervals) may reduce the incidence of withdrawal symptoms and other adverse events, including delirium, seizures, and transfer to the intensive care unit.

Some doctors question the use of any anti-anxiety medication for mild withdrawal symptoms, since these drugs are subject to abuse. Others believe that repeated withdrawal episodes, even mild forms, that are inadequately treated may result in increasingly severe and frequent seizures with possible brain damage. In any case, benzodiazepines are usually not prescribed for more than 2 weeks or administered for more than 3 nights per week. Problems with benzodiazepines include:

Side Effects. Common side effects of benzodiazepines are daytime drowsiness and a hung-over feeling. In rare cases, they actually cause agitation. Respiratory problems may be worsened. The drugs stimulate eating and can cause weight gain. Benzodiazepines can interact with certain drugs, including cimetidine (Tagamet), antihistamines, and oral contraceptives. Benzodiazepines are potentially dangerous when used in combination with alcohol. Overdoses are serious, although rarely fatal. Elderly people are more susceptible to side effects and should usually start at half the dose prescribed for younger people. Benzodiazepines are associated with birth defects and should not be used by pregnant women or nursing mothers.
Loss of Effectiveness and Dependence. The primary problem with these drugs is their loss of effectiveness over time with continued use at the same dosage. As a result, patients may increase their dosage level to prevent anxiety. Patients then can become dependent. In fact, some evidence suggests that people with alcoholism, or even a family history of alcoholism, may be more susceptible to benzodiazepine abuse than nonalcoholics. This is a common danger and can occur after as short a time as 3 months. (These drugs do not cause euphoria, a so-called "high," so such drugs are not addictive in the same way narcotics are.)
Withdrawal Symptoms. People who discontinue benzodiazepines after taking them for even 4 weeks can experience mild rebound symptoms. The longer the drugs are taken and the higher the dose, the more severe the symptoms. They include sleep disturbance and anxiety, which can develop within hours or days after stopping the medication. Some patients experience withdrawal symptoms, including stomach distress, sweating, and insomnia, that can last from 1 - 3 weeks. Sleep changes, in fact, can persist or months or years after quitting and may be a major factor in relapse.

Antiseizure Medications. Antiseizure drugs, such as carbamazepine (Tegretol) or divalproex sodium (Depakote), may be useful for reducing the requirements of a benzodiazepine. When used by themselves, however, they do not appear to reduce seizures or delirium associated with withdrawal.

Other Supportive Drugs. Beta-blockers, such as propranolol (Inderal) and atenolol (Tenormin), are sometimes used in combination with benzodiazepines. They slow heart rate and reduce tremors. They may also reduce cravings.

Note on Treating Alcohol Withdrawal with Alcohol. Some medical centers give patients alcohol to help with withdrawal. Experts do not recommend this approach. There is no evidence that this approach is safe or effective, while there is substantial evidence on the safety and effectiveness of benzodiazepines.

Treating Delirium Tremens. People with symptoms of delirium tremens must be treated immediately. Untreated delirium tremens has a fatality rate that can be as high as 20%. Treatment usually involves intravenous anti-anxiety medications. It is extremely important that fluids be administered. Restraints may be necessary to prevent injury to the patient or to others.

Treating Seizures. Seizures are usually self-limited and treated with a benzodiazepine. Intravenous phenytoin (Dilantin) along with a benzodiazepine may be used in patients who have a history of seizures, who have epilepsy, or in those with ongoing seizures. Because phenytoin may lower blood pressure, the patient's heart should be monitored during treatment. Chlormethiazole, a derivative of vitamin B1, is used in Europe for reducing agitation and seizures.

Psychosis. For hallucinations or extremely aggressive behavior, antipsychotic drugs, particularly haloperidol (Haldol), may be administered. Korsakoff's psychosis (Wernicke-Korsakoff syndrome) is caused by severe vitamin B1 (thiamine) deficiencies, which cannot be replaced orally. Rapid and immediate injection of the B vitamin thiamin is necessary.

Therapy

Standard forms of therapy for alcoholism include:

Cognitive-behavioral therapy
Combined behavioral intervention
Interactional group psychotherapy based on the Alcoholics Anonymous (AA) 12-step program

Comparison studies have reported that these approaches are equally effective when the program is competently administered. Specific people may do better with one program than another. One study, for example, examined the differences in success rates on type 1 or type 2 alcoholics:

People in the type 1 group did well with the 12-step approach. They did not do as well with cognitive-behavioral therapy. (Type 1 individuals become alcoholic at a later age, have less severe symptoms or fewer psychiatric problems, and have a better outlook on life than those classified as type 2. They are more likely to be women.)
The people in the type 2 group tended to do better with cognitive-behavioral therapy. (Type 2 people are more likely to be male, become alcoholic at an early age, have a high family risk for alcoholism, have more severe symptoms, and have a negative outlook on life.)

This difference in response to the two forms of treatment held up after 2 years. Other studies have also reported that people with fewer psychiatric problems do best with the AA approach.

AA, founded in 1935, is an excellent example of interactional group psychotherapy and remains the most well-known program for helping people with alcoholism. It offers a very strong support network using group meetings open 7 days a week in locations all over the world. A buddy system, group understanding of alcoholism, and forgiveness for relapses are AA's standard methods for building self-worth and alleviating feelings of isolation.

AA's 12-step approach to recovery includes a spiritual component that might deter people who lack religious convictions. Prayer and meditation, however, have been known to be of great value in the healing process of many diseases, even in people with no particular religious assignation. AA emphasizes that the "higher power" component of its program need not refer to any specific belief system. Associated membership programs, Al-Anon and Alateen, offer help for family members and friends.

We admit we were powerless over alcohol -- that our lives have become unmanageable.
We have come to believe that a Power greater than ourselves could restore us to sanity.
We have made a decision to turn our will and our lives over to the care of God, as we understand what this Power is.
We have made a searching and fearless moral inventory of ourselves.
We have admitted to God, to ourselves and to another human being the exact nature of our wrongs.
We are entirely ready to have God remove all these defects of character.
We have humbly asked God to remove our shortcomings.
We have made a list of all persons we had harmed and have become willing to make amends to them all.
We have made direct amends to such people wherever possible, except when to do so would injure them or others.
We have continued to take personal inventory and when we were wrong promptly admitted it.
We have sought through prayer and meditation to improve our conscious contact with God as we understand what this higher Power is, praying only for knowledge of God's will for us and the power to carry that out.
Having had a spiritual awakening as the result of these steps, we have tried to carry this message to alcoholics and to practice these principles in all our affairs.

Cognitive-behavioral therapy (CBT) uses a structured teaching approach and may be better than AA for people with severe alcoholism. Patients are given instruction and homework assignments intended to improve their ability to cope with basic living situations, control their behavior, and change the way they think about drinking. The following are examples of approaches:

Patients might write a history of their drinking experiences and describe what they consider to be risky situations.
They are then assigned activities to help them cope when exposed to "cues" (places or circumstances that trigger their desire to drink).
Patients may also be given tasks that are designed to replace drinking. An interesting and successful example of such a program was one that enlisted patients in a softball team. This gave them the opportunity to practice coping skills, develop supportive relationships, and engage in healthy alternative activities.

CBT may be especially effective when used in combination with opioid antagonists, such as naltrexone. CBT that addresses alcoholism and depression also may be an important treatment for patients with both conditions.

Combined behavioral intervention (CBI) is a new form of therapy that uses special counseling techniques to help motivate people with alcoholism to change their drinking behavior. CBI combines elements from other psychotherapy treatments such as cognitive behavioral therapy, motivational enhancement therapy, and 12-step programs. Patients are taught how to cope with drinking triggers. Patients also learn strategies for refusing alcohol so that they can achieve and maintain abstinence. In a 2006 study in the Journal of the American Medical Association, CBI -- combined with regular doctor’s office visits (medical management) -- worked as well as naltrexone in successfully treating alcoholism.

Partners of people with alcoholism can also benefit greatly from behavioral approaches that help them cope with their mate. Children of an alcoholic mother or father may do better if both parents participate in couples-based therapy, rather than just treating the parent with alcoholism.

Nearly all patients who are alcohol dependent suffer from insomnia and sleep problems, which can last months to years after abstinence. Sleep disturbances may even be important factors in relapse. Available therapies include sleep hygiene, bright light therapy, meditation, relaxation methods, and other nondrug approaches. Many medications for inducing sleep are not recommended in people with alcoholism. [For more information, see In-Depth Report #27: Insomnia.]

Some people try alternative methods, such as acupuncture or hypnosis. Such approaches are not harmful. In one study, acupuncture reduced the desire for alcohol in nearly half of people, although it was not significantly more helpful than conventional treatments.

Medications

In the U.S., three drugs are specifically approved to treat alcohol dependence:

Naltrexone (ReVia, Vivitrol)
Acamprosate (Campral)
Disulfiram (Antabuse)

Naltrexone and acamprosate are categorized as anticraving drugs. Disulfiram is an aversion drug. Other types of medications, such as antidepressants, may also be used to treat patients with alcoholism.

Anticraving drugs are opioid antagonists. These drugs reduce the intoxicating effects of alcohol and the urge to drink

Naltrexone. Naltrexone (ReVia, Vivitrol) is approved for the treatment of alcoholism and helps reduce alcohol dependence in the short term for people with low-to-moderate alcohol dependency. ReVia is a pill that is taken daily by mouth. In 2006, the FDA approved Vivitrol, a once-a-month injectable form of naltrexone.

Naltrexone is usually prescribed along with psychotherapy. The most common side effect is nausea, which is usually mild and temporary. High doses can cause liver damage. The drug should not be given to anyone who has used narcotics within 7 - 10 days. For ReVia, it is important that patients take the pill on a daily basis. Because many patients have difficulty sticking to this daily regimen, a monthly injection of Vivitrol may be an easier option.

Naltrexone does not work in all patients. Some studies suggest that people with a specific genetic variant may respond better to the drug than those without the gene. The gene regulates receptors that affect the response to opioids. A 2005 study indicated that naltrexone works best for patients who have a family history of alcoholism, began drinking at an early age, and abuse other drugs.

Research is being conducted on the effects of combining naltrexone with acamprosate (Campral), particularly for individuals who have not responded to single drug treatment. In a 2006 study in the Journal of the American Medical Association that examined various outpatient drug and behavioral treatments, naltrexone worked as well as psychotherapy in preventing relapse to heavy drinking for patients who had recently abstained from alcohol. However, the study showed no benefit for acamprosate either when combined with naltrexone or used alone.

Acamprosate. Acamprosate (Campral) is the newest drug to be approved for treatment of alcoholism. Acamprosate calms the brain and reduces cravings by inhibiting the transmission of the neurotransmitter gamma aminobutyric acid (GABA). Studies indicate that it reduces the frequency of drinking and, in concert with psychotherapy, improves quality of life even in patients with severe alcohol dependence. One study reported that 60% of patients remained abstinent for 12 weeks, and in another 43% were still abstinent after nearly a year. The drug may cause occasional diarrhea and headache. It also can impair certain memory functions but does not alter short-term working memory or mood. People with kidney problems should use acamprosate cautiously. For some patients, combination therapy with naltrexone or disulfiram may provide greater benefit than acamprosate alone.

Disulfiram. Some drugs have properties that interact with alcohol to produce distressing side effects. Disulfiram (Antabuse) causes flushing, headache, nausea, and vomiting if a person drinks alcohol while taking the drug. The symptoms can be triggered after drinking half a glass of wine or half a shot of liquor and may last from half an hour to 2 hours, depending on dosage of the drug and the amount of alcohol consumed. One dose of disulfiram is usually effective for 1 - 2 weeks. Overdose can be dangerous, causing low blood pressure, chest pain, shortness of breath, and even death. The drug is more effective if patients have family or social support, including AA "buddies," who are close by and vigilant to ensure that they take it.

Topiramate. Topiramate (Topamax) is an anti-seizure drug used to treat epilepsy. It also helps control impulsivity. Studies indicate it may be a promising treatment for alcohol dependence. In one well-designed study, patients who took topirimate had fewer heavy drinking days, fewer drinks per day, and more continuous days of abstinence than patients who received placebo. Side effects included burning and itching skin sensations, change in taste sensation, loss of appetite, and difficulty concentrating.

Resources

www.niaaa.nih.gov -- National Institute on Alcohol Abuse and Alcoholism
www.samhsa.gov -- Substance Abuse and Mental Health Services Administration
www.ncadi.samhsa.gov -- National Clearinghouse for Alcohol and Drug Information
www.aca-usa.org -- American Council on Alcoholism
www.ncadd.org -- National Council on Alcoholism
www.alcoholics-anonymous.org -- Alcoholics Anonymous
www.al-anon-alateen.org -- Al-Anon Family Group Headquarters
www.nofas.org -- National Organization on Fetal Alcohol Syndrome

References

Anton RF, O'Malley SS, Ciraulo DA, Cisler RA, Couper D, Donovan DM, et al. Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized controlled trial. JAMA. 2006 May 3;295(17):2003-17.

Chudley AE, Conry J, Cook JL, Loock C, Rosales T, LeBlanc N. Fetal alcohol spectrum disorder: Canadian guidelines for diagnosis. CMAJ. 2005 Mar 1;172(5 Suppl):S1-S21.

de Roux A, Cavalcanti M, Marcos MA, Garcia E, Ewig S, Mensa J, et al. Impact of alcohol abuse in the etiology and severity of community-acquired pneumonia. Chest. 2006 May;129(5):1219-25.

Gazdzinski S, Durazzo T, Jahng GH, Ezekiel F, Banys P, Meyerhoff D. Effects of chronic alcohol dependence and chronic cigarette smoking on cerebral perfusion: a preliminary magnetic resonance study. Alcohol Clin Exp Res. 2006 Jun;30(6):947-58.

Hingson RW, Heeren T, Winter MR. Age at drinking onset and alcohol dependence: age at onset, duration, and severity. Arch Pediatr Adolesc Med. 2006 Jul;160(7):739-46.

Johnson C, Drgon T, Liu QR, Walther D, Edenberg H, Rice J, et al. Pooled association genome scanning for alcohol dependence using 104,268 SNPs: Validation and use to identify alcoholism vulnerability loci in unrelated individuals from the collaborative study on the genetics of alcoholism. Am J Med Genet B Neuropsychiatr Genet. 2006 Aug 7; [Epub ahead of print]

McKenna W. In: Goldman L and Ausiello DA, eds. Cecil Medicine. 23rd edition. Saunders; 2007.

O'Connor PG. In: Goldman L and Ausiello DA, eds. Cecil Medicine. 23rd edition. Saunders; 2007.

Volkow ND, Wang GJ, Begleiter H, Porjesz B, Fowler JS, Telang F, et al. High levels of dopamine D2 receptors in unaffected members of alcoholic families: possible protective factors. Arch Gen Psychiatry. 2006 Sep;63(9):999-1008.

Review Date:
12/28/2007
Reviewed By:
Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

A.D.A.M. Copyright

adam.com

Carpal tunnel syndrome

FitSugar — Wed, 08 Oct 2008 17:34:56 -0700

In This Report

Highlights
Introduction
Symptoms
Causes
Risk Factors
Prognosis
Prevention
Diagnosis
Treatment
Surgery
Resources
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Overview

Several medical conditions can increase the risk for, or even cause, carpal tunnel syndrome (CTS). Diabetes, hypothyroidism, rheumatoid arthritis, osteoarthritis, obesity, and pregnancy are the main conditions associated with CTS. Many of the underlying diseases that contribute to the development of CTS are also associated with more severe forms of CTS.

Most workers who use their hands and wrists repetitively are at risk for CTS. This is especially true if they work in cold temperatures and have medical conditions that make them susceptible to CTS.

Being overweight consistently turns up as a risk factor for CTS and may play a direct causal role in CTS.

Treatment News:

Several physical therapy techniques have been shown to improve hand strength and function in patients with mild-to-moderate CTS.
Short periods of traction have also been successful in producing long-term relief in patients who have failed other conventional treatments.
Injections of botulinum toxin (Botox) show promise in treating carpal tunnel syndrome.

Risk Factors:

A Swedish study of neurological diseases found CTS to be the second most commonly occurring nerve, nerve root, and nerve plexus disorder among siblings hospitalized with the same condition. Although the study could not distinguish between genetic and environmental causes, clusters of CTS in families may suggest an inherited predisposition.

Introduction

Carpal tunnel syndrome (CTS) is a disorder marked by weakness and pain in the hand and wrist. CTS occurs in the nerves of the hands -- not the muscles, as some people believe. The symptoms of CTS can be incapacitating.

To understand how carpal tunnel syndrome arises, it is important to know the parts of the hand and wrist that are involved.

The Carpal Tunnel. The carpal tunnel is a passageway that forms beneath the strong, broad transverse ligament. This ligament is a bridge that extends across the lower palm and connects the bones of the wrist (carpals), which form an arch below the tunnel.

The Median Nerve and Flexor Tendons. The median nerve and nine flexor tendons pass under the ligament bridge and through the carpal tunnel (similar to a river). They extend from the forearm and up into the hand:

The flexor tendons are fibrous cords that connect to muscles of the fingers (two to each finger) and one to the thumb. They allow flexing of the fingers and clenching of the fist.
The median nerve plays two important roles. It supplies sensation to the thumb, index, middle, and ring fingers, and to the flexor tendons. It provides function for the muscles at the base of the thumb (the thenar muscle).

The median nerve travels through a compartment in the wrist called the carpal tunnel. The ligaments that transverse the nerve are not very flexible. Any swelling within the wrist compartment can put excessive pressure on structures such as the blood vessels and the median nerve. Excessive pressure can constrict blood flow and cause nerve damage. The symptoms from the compression cause pain, loss of sensation, and decreased function in the hand.

It is not completely known how the process leading to carpal tunnel syndrome actually evolves, and how nerve conduction (the passing of the nerve signal) through the wrist becomes changed. In general, carpal tunnel syndrome develops when the tissues around the median nerve swell and press on the nerve. Early in the disorder, the process is reversible. Over time, however, the insulation on the nerves may wear away, and permanent nerve damage may develop.

The following events have been observed in the hands of people with carpal tunnel syndrome:

The protective lining of tendons (called the tenosynovium) swells within the carpal tunnel. Some research suggests that this swelling is caused by build-up of fluid (called synovial fluid) under the lining. Synovial fluid lubricates and protects the tendons.
The transverse ligament, the band of fibrous tissue that forms the roof over the median nerve, becomes thicker and broader.
The swollen tendons and thickened ligament compress the median nerve fibers, just as stepping on a hose slows the flow of water through it. The effect is to reduce blood flow and oxygen supply to the nerve, slowing the transmission of nerve signals through the carpal tunnel. Some cases of carpal tunnel syndrome may be due to enlargement of the median nerve rather than compression by surrounding tissues.

The result is pain, numbness, and tingling in the wrist, hand, and fingers. Only the little finger is unaffected by the median nerve.

Click the icon to see a depiction of carpal tunnel syndrome.

Symptoms

Symptoms of carpal tunnel syndrome usually progress gradually over weeks and months and sometimes years. Anyone with recurrent or persistent pain, numbness and tingling, or weakness of the hand should consult a doctor for a diagnosis. Symptoms often develop as follows:

Initial symptoms include pain in the wrist and hand. Symptoms commonly occur in both hands. (Even when only one hand is painful, the other hand often shows signs of nerve conduction abnormalities on testing.)
Early on, the patient also usually reports numbness, tingling, burning, or some combination on the palm side of the index, middle, and ring fingers. (Typically the fifth finger has no symptoms.) Such sensations may radiate to the forearm or shoulder.
Over time, the hand may become numb, and patients may lose the ability to feel heat and cold. Patients may experience a sense of weakness and a tendency to drop things.
Patients may feel that their hands are swollen even though there is no visible swelling. This symptom may actually prove to be an important indicator of greater severity.

Symptoms may occur not only when the hand is being used but also at night when the patient is at rest. Even in cases where work is suspected as the cause, symptoms typically first occur outside of work. In fact, the disorder may be distinguished from similar conditions by pain occurring at night after going to bed.

Causes

Biologic Causes. Carpal tunnel syndrome (CTS) is considered an inflammatory disorder caused by repetitive stress, physical injury, or medical conditions. It is often very difficult, however, to determine the precise cause of carpal tunnel syndrome. No tests are available to identify a specific cause. Except in patients with certain underlying diseases, the biologic mechanisms leading to carpal tunnel syndrome are unknown. Although an overactive immune response that causes inflammation and damage in the joints or muscles is responsible for a number of arthritic conditions, similar problems are not likely to play an important role in CTS. More likely, reduced blood flow and lack of oxygen are important in the process leading to progressive swelling and scarring.

Working Conditions versus Medical Problems. Although some studies suggest that more than half of CTS cases are associated with workplace factors, there is no strong evidence of a cause and effect relationship. In fact, most studies now strongly suggest that carpal tunnel syndrome is primarily associated with medical or physical conditions such as diabetes, osteoarthritis, hypothyroidism, and rheumatoid arthritis. CTS also tends to occur in people with certain genetic or environmental risk factors such as obesity, smoking, alcohol abuse, or significant mental stress. Of all nerve, nerve root, and nerve plexus disorders, CTS has one of the highest familial risks, implying some type of genetic origin. When such susceptible people are subjected to repetitive hand or wrist work, the risk for CTS can become significant. CTS, then, is very likely to be due to convergences of factors that lead to nerve damage in the hand.

Worker's Compensation and CTS. The issues surrounding workers' compensation are particularly troubling in determining accurately whether labor conditions cause carpal tunnel pain. CTS is a major contributor to workers' compensation cases.

High Force and Vibration. Even though medical and physical conditions may be the initial culprits leading to CTS, certain working conditions are especially related to nerve damage -- if not to pure cases of CTS. Work that involves high force or vibration is particularly hazardous, as is repetitive hand and wrist work in cold temperatures.

In addition to CTS, other disorders of hand and wrist result from these work-related movements. They include the following:

Hand-arm vibration syndrome -- tingling and numbing that persist even after the vibration stops
Cumulative trauma (repetitive stress) disorder
Overuse syndromes
Chronic upper limb pain syndrome

All of these problems are generally associated with repetitive and forceful use of the hands, resulting in damaged muscles and bones of the upper arms.

Psychosocial Factors in the Workplace. Studies indicate that psychosocial factors in the workplace, such as intense deadlines, a poor social work environment, and low levels of job satisfaction, are major contributors to carpal tunnel pain. Such psychosocial conditions are more likely to be important factors in contributing to CTS in office workers, although they also complicate the condition in workers whose work is primarily physical.

A number of medical conditions increase the risk for or even cause CTS. The main conditions associated with CTS are diabetes, hypothyroidism, rheumatoid arthritis, osteoarthritis, obesity, and pregnancy. Many of the underlying diseases that contribute to the development of CTS are also associated with more severe forms of CTS.

Diabetes. CTS is a very common feature of diabetic neuropathy, one of the major complications of diabetes. Neuropathy is decreased or distorted nerve function; it particularly affects sensation. Symptoms include numbness, tingling, weakness, and burning sensations, usually starting in the fingers and toes and moving up to the arms and legs. About 6% of patients with CTS have diabetes. A 2005 study reported that an estimated 85% of patients with type 1 diabetes develop CTS. Development of CTS was related to the patient's age and the length of time they had diabetes. The development of diabetes-related complications, such as kidney disease, is not related to the development of CTS in people with diabetes.

Autoimmune Diseases. In autoimmune diseases, the body's immune system abnormally attacks its own tissue, causing widespread inflammation, which, in many cases, affects the carpal tunnel of the hand. Such autoimmune diseases include rheumatoid arthritis, systemic lupus erythematosus, and hypothyroidism. Some experts believe that CTS may actually be one of the first symptoms in a number of these diseases. Studies also suggest that CTS patients with these disorders are more likely to have severe CTS that requires surgery.

Diseases that Affect Muscle and Bones. Arthritis, gout, and other medical conditions that damage the muscles, joints, or bones in the hand may cause changes that lead to CTS. In fact, in one 2000 study, susceptibility to muscle and bone diseases was the major risk factor for CTS in British women. Osteoporosis (loss of bone density), although not a direct cause of CTS, increases the risk for wrist fractures that can lead to CTS.

Injuries and Previous Surgeries. Injuries, fractures, and operations that affect the forearm, wrist, or hand may lead to CTS, sometimes many years after the event.

Structural Abnormalities. Inborn abnormalities in the bones of the hand, wrist, or forearm may contribute to CTS.

Chronic Kidney Insufficiency. People who undergo hemodialysis for chronic kidney damage often experience a build-up in the hand of a certain type of protein called beta 2-microglobulin. This build-up can result in CTS. The longer the person has been receiving hemodialysis, the greater the risk of CTS. Certain drugs and procedures (particularly one procedure called hemodiafiltration) are being investigated as having the potential to reduce microglobulin build-up. It is hoped such new methods will delay the need for carpal tunnel surgery in patients undergoing long-term hemodialysis.

Other Diseases. A number of other medical conditions may cause or increase susceptibility to CTS:

Down syndrome
Amyloidosis (a progressive disorder of the connective tissues)
Acromegaly (a disease that leads to abnormally large hands and feet due to excessive growth hormone)
Tumor on the median nerve (removal of the tumor often resolves the CTS in such cases)

Medications. According to case reports, a number of medications may increase the risk for temporary CTS. They include certain medications that affect the immune system (such as interleukin-2), and anticlotting drugs (such as warfarin). There has been conflicting evidence as to whether corticosteroids and hormone replacement therapy may increase risk. More research is warranted before a causal association can be established.

Bone dislocations and fractures can narrow the carpal tunnel, thereby exerting pressure on the median nerve.

Being overweight consistently turns up as a risk factor for CTS and may play a direct causal role on CTS. Greater body mass appears to reduce nerve flow speed into the hand. Obesity is also related to poor physical fitness, which may also increase risk. A 2005 analysis indicated that weight is strongly linked to the onset of CTS in patients under the age of 63 years, but may be a less important factor as they get older.

Hormonal fluctuations in women play a role in CTS. Such fluctuations may cause fluid retention and other changes in the body that cause swelling. Fluid retention is one reason that CTS may develop during pregnancy.

CTS is strongly associated with a family history of the disorder. Many of these cases can be attributed to physical characteristics or medical conditions associated with CTS, which also run in families. However, in one study, 17% of family clusters of CTS were not associated with any such medical conditions, suggesting the genetic factors may be important in some people. Carpal tunnel syndrome that develops in young people is most likely to have a genetic component.

A 2000 study suggested that some patients with CTS may have a genetic defect that produces higher levels of a certain collagen subtype. Collagen is the protein used to build all connective tissue, muscle, bones, and ligament. The collagen found in CTS patients tends to produce stiffness.

Other genetic factors that may contribute to this disorder include abnormalities in certain genes that regulate myelin, a fatty substance that serves as insulation for nerve fibers.

Risk Factors

Evidence suggests that about 3% of women and 2% of men will be diagnosed with carpal tunnel syndrome during their lifetimes, with peak prevalence in women older than 55. Still, determining how many people actually have CTS is very difficult. Many people report CTS symptoms and have normal test results. Other people have no symptoms and abnormal results. Furthermore, some evidence suggests that, after an apparent a decline in cases, the prevalence of CTS is rising.

A large 2005 study of more than 1,000 patients found that the severity of CTS was mild in 42% of patients, moderate in 18%, and severe in 40%. Patients were an average of about 48 years old. More than five times as many women then men participated in the study.

Older people are at higher risk than younger adults. It is very rare in children.

Many studies indicate that women have a significantly higher risk for carpal tunnel syndrome than men do. According to the National Institutes of Health, women are three times more likely than men to experience carpal tunnel syndrome. The explanation for this greater risk is unknown but may be related to the smaller size of women's carpal tunnel.

Hormonal changes appear to play a major role in CTS.

A 2005 study reported that 17% of pregnant women had CTS. Nearly one-quarter of those had it in both wrists. Early studies have presented conflicting reports regarding when CTS is most likely to occur during pregnancy. One found that most cases occurred in the third trimester, and weight gain increased the risk. Another concluded that CTS developed at any point during the pregnancy. New-onset CTS during pregnancy that is severe and persistent enough to require treatment is uncommon. Most cases go away on their own after delivery. However, in one study, 11% of women reported CTS six months after delivery, and 4.3% of them still had the condition a year afterward.

Breastfeeding has also been linked to flare-ups of inflammatory disorders such as CTS. Breastfeeding temporarily lowers the level of natural steroid hormones.

CTS has also been shown to increase during:

The postpartum period
Menopause

Other conditions that are more specific to women than men may increase their risk for carpal tunnel syndrome:

The hand-intensive nature of housework and typing may contribute to a higher incidence of CTS in women.
Women are also at a much higher risk for autoimmune disorders than men are; such disorders are significantly linked to CTS.

People with close relatives who have carpal tunnel syndrome have a higher risk of developing CTS themselves. This risk may be due to family histories of medical conditions associated with CTS, obesity, or genetic factors.

A number of illnesses, skeletal abnormalities, and injuries can predispose individuals to carpal tunnel syndrome, including autoimmune diseases and arthritic conditions.

At high risk are those whose occupations combine force and repetition of the same motion in the fingers and hand for long periods.

Virtually all workers who use their hands and wrists repetitively are at risk for CTS, particularly if they work in cold temperatures and have factors or medical conditions that make them susceptible.

Computer Users and Typists. Repetitive typing and key entry is highly associated with missing work due to CTS. The risk for CTS in this group, however, is still much lower than with occupations involving heavy labor. Although more than 10% of the computer users complain of CTS symptoms, the evidence implicating computer use as a major cause of CTS is weak. One small 2001 study reported that nerve conduction tests on frequent computer users showed the same rate of CTS (3.5%) as in the general population.

A 2003 study found an association between mouse-use (not keyboard use) and CTS. Typing speed may affect risk in some cases, however. For example, the fingers of typists whose speed is 60 words per minute exert up to 25 tons of pressure each day. In one study, typists with CTS struck the keys with greater force than those without the disorder. A large Danish study showed no increased risk of CTS among people who use computers at work. Another study of workers who used computers heavily (up to 7 hours per day) found no increased risk of CTS among them.

Other Very High-Risk Workers. Workers in the meat and fish packing industries and those who assemble airplanes have the highest risk for CTS, according to one study. Meat packers complained of pain and loss of hand function as long ago as the 1860s. Even today, the incidence of carpal tunnel syndrome in the meat, poultry, and fish packing industries may be as high as 15%. A 2005 study of automobile assembly workers found that the estimated annual rate of CTS ranged from 1 - 10%.

Musicians. Musicians are at very high risk for CTS and other problems related to the muscles and nerves in the hands, upper trunk, and neck. In one study, 20% reported CTS or other nerve disorders in the hands and wrists.

Highest to Lowest Numbers of CTS Events by Job. The following is a list of occupations published by the Bureau of Labor Statistics in 2002 rating workers with highest to lowest total numbers of CTS-related events:

Assemblers
Cashiers
Secretaries
General office clerks
Laborers, non-construction
Bookkeepers, accounting, and auditing clerks
Welders and cutters
Data-entry employees
Textile sewing machine operators
Order clerks
Supervisors and proprietors, sales occupations
Machine operators (unspecified)
Truck drivers
Insurance adjusters, examiners, and investigators
Electrical and electronic equipment assemblers
Packaging and filling machine operators
Janitors and cleaners
Bank tellers
Production inspectors, checkers, and examiners

SOURCES: Bureau of Labor Statistics, U.S. Department of Labor, April 2002

At Home and At Play. People who intensively cook, knit, sew, do needlepoint, play computer games, do carpentry, or extensively use power tools are at increased risk for CTS. Long-distance cycling may make symptoms of carpal tunnel syndrome worse.

Square Wrists. Some (but not all) studies have reported a higher risk for CTS in people with square wrists (the thickness and width are about the same) than in those with the more common rectangular wrists.

Palm Shape. In one study, patients with palms that were both shorter and wider than average, and who also had shorter third fingers, were more likely to have CTS than those without these hand characteristics.

Poor Upper Back Strength. Some researchers claim that poor upper back strength makes people more susceptible to poor posture and injuries in the upper extremities, including carpal tunnel syndrome.

Cigarette smoking slows down blood flow, so that smokers have worse symptoms and slower recovery than nonsmokers do. Increased alcohol intake has been associated with CTS in people with other risk factors.

Poor nutrition, previous injuries, and stress can increase one's risk for carpal tunnel syndrome. In addition, high levels of so-called “bad” cholesterol (low-density lipoprotein, or LDL) have also been linked to an increased risk of CTS.

Prognosis

Carpal tunnel syndrome can range from a minor inconvenience to a disabling condition, depending on its cause and persistence and the individual characteristics of the patient. Many cases of CTS are mild, and when symptoms are of short duration, they often resolve (disappear) on their own. Once a woman with pregnancy-associated CTS gives birth, for instance, the swelling in her wrists and other symptoms almost always subside. Proper treatment of other medical conditions that cause CTS can often help reduce wrist swelling.

In severe untreated cases, however, the thenar muscles at the base of the thumb may whither, and loss of sensation may be permanent. CTS can become so crippling that people can no longer do their jobs or even perform simple tasks at home.

Carpal tunnel syndrome exacts a psychological toll. Anyone who cannot use his or her hands is likely to be depressed and suffer from low self-esteem. People may suffer from daily pain. In severe cases, they may be unable to perform ordinary tasks, such as driving a car or carrying groceries. And equally or even more distressing, they may have to give up enjoyable sports and hobbies.

According to a 2005 report from the Bureau of Labor Statistics, among the major disabling diseases and illnesses, carpal tunnel syndrome was associated with the longest average time away from work (28 days).

Employees with CTS who try to work through the disorder often put more stress on the wrists to compensate for the weakness and pain. The end result is to make the condition worse and impair work performance.

Eventually, the worker with CTS may be forced to give up his or her livelihood. In one study, nearly half of all patients with CTS changed jobs within 30 months of an initial diagnosis. And because of the controversy surrounding the issue of carpal tunnel syndrome and workers compensation, it is not always certain that the worker will receive compensation payments.

Prevention

Because multiple factors may cause carpal tunnel syndrome, there is no single mode of prevention. Treating any underlying medical condition is certainly important. Simple common sense may help minimize some risk factors predisposing a person to work-related CTS or other cumulative trauma disorders. A patient can learn how to adjust the work area, handle tools, or perform tasks in ways that put less stress on the hands and wrists. Proper posture and exercise programs to strengthen the fingers, hands, wrists, forearms, shoulders, and neck may help prevent CTS.

Many companies are now taking action to help prevent repetitive stress injuries. In a major survey, 84% reported that they were modifying equipment, tasks, and processes. Nearly 85% were analyzing their workstations and jobs, and 79% were buying new equipment. It should be stressed, however, that there has been no evidence that any of these methods can provide complete protection against CTS. The optimal corporate approach, if possible, is to reallocate workers suffering from repetitive stress injuries to other jobs.

Altering the way a person performs repetitive activities may help prevent inflammation in the hand and wrist from progressing into carpal tunnel syndrome. For example, replacing old tools with ergonomically designed new ones can be very helpful.

Rest Periods and Avoiding Repetition. Anyone who does repetitive tasks should begin with a short warm-up period, take frequent breaks, and avoid overexertion of the hand and finger muscles whenever possible. Employers should be urged to vary tasks and work content.

A 2001 study conducted by the National Institute for Occupational Safety and Health reported that even taking multiple "microbreaks" (about 3 minutes each) reduces strain and discomfort without decreasing productivity. Such breaks may include the following:

Shaking or stretching the limbs
Leaning back in the chair
Squeezing the shoulder blades together.
Taking deep breaths

Good Posture. Good posture is extremely important in preventing carpal tunnel syndrome, particularly for typists and computer users.

The worker should sit with the spine against the back of the chair with the shoulders relaxed.
The elbows should rest along the sides of the body, with wrists straight.
The feet should be firmly on the floor or on a footrest.
Typing materials should be at eye level so that the neck does not bend over the work.
Keeping the neck flexible and head upright maintains circulation and nerve function to the arms and hands. One method for finding the correct head position is the "pigeon" movement. Keeping the chin level, glide the head slowly and gently forward and backward in small movements, avoiding neck discomfort.

Good Office Furniture. Poorly designed office furniture is a major contributor to bad posture. Chairs should be adjustable for height, with a supportive backrest. Custom-designed chairs, made for people who do not fit in standard chairs, can be expensive. However, the costs are often offset by the savings in medical expenses that follow injuries related to bad posture.

Voice Recognition Software. For CTS patients who must use a computer frequently, a variety of voice recognition software packages (ViaVoice, Voice Xpress, Dragon NaturallySpeaking, IListen) are now available, enabling virtually hands-free computer use.

Keyboard and Mouse Tips. Anyone using a keyboard and mouse has some options that may help protect the hands.

The tension of the keys should be adjusted so they can be depressed without excessive force.
The hands and wrists should remain in a relaxed position to avoid excessive force on the keyboard.
A 2003 study suggested that mouse-use poses a higher risk than keyboard use. Replacing the mouse with a trackball device and the standard keyboard with a jointed-type keyboard are helpful substitutions.
Wrist rests, which fit under most keyboards, can help keep the wrists and fingers in a comfortable position.
Some people recommend keeping the computer mouse as close to the keyboard and the user's body as possible, to reduce shoulder muscle movement.
The mouse should be held lightly, with the wrist and forearm relaxed. New mouse supports (ErgoCat) are also available that relieve stress on the hand and support the wrist.
Some people cut their mouse pads in half to reduce movement.

Innovative keyboard designs may reduce hand stress:

Alternative geometry keyboards (Microsoft Natural Keyboard, Apple Adjustable Keyboard) allow the user to adjust and modify hand positions as well as adjust key tension. Most have a split or "slanted" keyboard that places the wrists at an angle. Studies suggest they are useful in promoting a neutral position for the wrist.
The continuous passive motion (CPM) keyboard lifts and declines gently and automatically every three minutes to break tension on the hands and wrist. A report of a clerical worker with CTS who used this device found an overall improvement of 10 words per minute in the typing tests, a decrease in disability score and symptom severity, and an improvement in function.
A keyless keyboard (orbiTouch) is an innovative device that uses two domes. The typist covers the domes with his or her hands and slides them into different positions that represent letters.

The force placed on the fingers, hands, and wrists by a repetitive task is an important contributor to CTS. To alleviate the effect of force on the wrist, tools and tasks should be designed so that the wrist position is the same as it would be if the arms dangled in a relaxed manner at the sides.

No task should require the wrist to deviate from side to side or to remain flexed or highly extended for long periods.
The handles of hand tools such as screwdrivers, scrapers, paint brushes, and buffers should be designed so that the force of the worker's grip is distributed across the muscle between the base of the thumb and the little finger, not just in the center of the palm.
People who need to hold any tools (including pencils and steering wheels) for long periods of time should grip them as loosely as possible.
In order to apply force appropriately, the ability to feel an object is extremely important. Tools with textured handles are helpful.
If possible, people should avoid working at low temperatures, which reduces sensation in hands and fingers.
Power tools and machines should be designed to minimize vibrations.
Wearing thick gloves, when possible, may lessen the shock transmitted to the hands and wrists. One 2001 study found, however, that wearing gel-padded gloves clearly increased comfort but did not actually protect against compression-induced CTS.

Hand and wrist exercises may help reduce the risk of developing carpal tunnel syndrome. Isometric and stretching exercises can strengthen the muscles in the wrists and hands, as well as the neck and shoulders, improving blood flow to these areas. Performing the simple exercises described below for 4 to 5 minutes every hour may be helpful.

Wrists

Exercise 1.

Make a loose right fist, palm up, and use the left hand to press gently down against the clenched hand.
Resist the force with the closed right hand for 5 seconds. Be sure to keep the wrist straight.
Turn the right fist palm down, and press the knuckles against the left open palm for 5 seconds.
Finally, turn the right palm so the thumb-side of the fist is up, and press down again for 5 seconds.
Repeat with the left hand.

Exercise 2.

Hold one hand straight up shoulder-high with fingers together and palm facing outward. (The position looks like a shoulder-high salute.)
With the other hand, bend the hand being exercised backward with the fingers still held together and hold for 5 seconds.
Spread the fingers and thumb open while the hand is still bent back and hold for 5 seconds.
Repeat five times for each hand.

Exercise 3. (Wrist Circle)

Hold the second and third fingers up, and close the others.
Draw five clockwise circles in the air with the two finger tips.
Draw five more counterclockwise circles.
Repeat with the other hand.

Fingers and Hand

Exercise 1.

Clench the fingers of one hand into a fist tightly.
Release, fanning out the fingers.
Do this five times. Repeat with the other hand.

Exercise 2.

To exercise the thumb, bend it against the palm beneath the little finger, and hold for 5 seconds.
Spread the fingers apart, palm up, and hold for 5 seconds.
Repeat five to 10 times with each hand.

Exercise 3.

Gently pull the thumb out and back and hold for 5 seconds.
Repeat five to 10 times with each hand.

Forearms (stretching these muscles will reduce tension in the wrist)

Place the hands together in front of the chest, fingers pointed upward in a prayer-like position.
Keeping the palms flat together, raise the elbows to stretch the forearm muscles.
Stretch for 10 seconds.
Gently shake the hands limp for a few seconds to loosen them.
Repeat frequently when the hands or arms tire from activity.

Neck and Shoulders

Exercise 1.

Sit upright and place the right hand on top of the left shoulder.
Hold that shoulder down, and slowly tip the head down toward the right.
Keep the face pointed forward, or even turned slightly toward the right.
Hold this stretch gently for 5 seconds.
Repeat on the other side.

Exercise 2.

Stand in a relaxed position with the arms at the side.
Shrug the shoulders up, then squeeze the shoulders back, then stretch the shoulders down, and then press them forward.
The entire exercise should take about 7 seconds.

Diagnosis

Carpal tunnel syndrome (CTS) is most accurately diagnosed using the patients' descriptions of symptoms, and electrodiagnostic tests that measure nerve conduction through the hand. If electrodiagnostic testing is not available, then symptom descriptions and a series of physical tests are useful.

Diagnosing CTS, however, is not straightforward. Only a small fraction of patients exhibit all three factors necessary for a clear diagnosis:

Classic CTS symptoms
Specific physical findings
Abnormal electrodiagnostic test results

Many people have abnormal electrodiagnostic test results without classic symptoms or any symptoms at all. Furthermore, about 15% of the population has symptoms consistent with CTS, but most do not show test results indicating the disorder. In fact, in a 2001 study, some patients who had symptoms, but whose nerve and physical tests were normal, still experienced relief after CTS surgery.

Many cases of CTS are a combination of a medical problem exacerbated by repetitive stress factors at work. The patient should give the doctor a detailed history and description of any complaints, in any part of the body. The patient should report in detail any daily activities that require repetitive hand or wrist actions, abnormal postures, or other regular situations that could affect the nerves in the neck, shoulders, and hands. The patient should report whether the symptoms are more likely to appear at night, or after particular tasks.

Questionnaires. The use of specific questionnaires that score results are quite accurate in assessing the severity of the condition.

Hand Diagram. A diagram of the hand and wrist, usually divided into six regions, is a very useful diagnostic tool. Patients are asked to indicate where their symptoms are, including pain, numbness, or tingling, by locating the affected areas on the diagram. They may also be asked to rate the severity of their symptoms. A diagnosis is probable if at least two of fingers 1, 2, or 3 have these symptoms, and if there is pain in or near the wrist. CTS is possible if at least one of these fingers has symptoms. It is unlikely if there are no symptoms in these fingers, the palm, or the wrist.

One of the most important first steps in diagnosing CTS is to rule out any underlying medical disorders that may be contributing to the condition. Experts emphasize the need to fully examine patients presenting with symptoms of CTS. Relying only on CTS symptoms, and personal or work histories may result in the failure to detect (and thus properly treat) underlying medical conditions that could be serious. If the doctor suspects that an underlying medical condition may be exacerbating the symptoms, laboratory tests will be performed. The doctor may take an x-ray, for example, to check for arthritis or fractured bones.

Raynaud's Phenomenon. A diagram of the hand and wrist, usually divided into six regions, is a very useful diagnostic tool. Patients are asked to indicate the location of their symptoms -- including pain, numbness, or tingling -- by locating the affected areas on the diagram. They may also be asked to rate the severity of their symptoms. A diagnosis is probable if at least two of fingers 1, 2, or 3 have these symptoms, and if there is pain in or near the wrist. CTS is possible if at least one of these fingers has symptoms. It is unlikely if there are no symptoms in these fingers, the palm, or the wrist.

Arthritic Conditions. Arthritic conditions, including rheumatoid arthritis, gout, and osteoarthritis, can all cause pain in the hands and fingers that may mimic carpal tunnel disease. The treatment for these conditions, however, is different.

Muscle and Nerve Diseases. Any disease or abnormality that affects the muscles and nerves, including those in the spine, may produce symptoms in the hand that mimic carpal tunnel syndrome.

About 25% of patients with suspected work-related cumulative trauma or repetitive stress disorders have evidence of other conditions that resemble, but are not, carpal tunnel syndrome. A definitive diagnosis is often difficult. Most require treatments similar to those used for CTS: rest, immobilization, steroid injections, and even surgery if conservative management is unsuccessful.


Location	Description
The Median Nerve in Other Locations	Repetitive work can cause pressure on the median nerve in locations other than the wrist and can also affect other nerves in the arm and hand. The branch of the median nerve that runs through the palm of the hand can be damaged directly by repeated pounding or by the use of certain tools requiring a strong grip using the palm, such as needle-nosed pliers. The median nerve can also be pinched in the forearm.
Guyon's Canal Syndrome (Commonly called ulnar tunnel syndrome)	The ulnar nerve can, like the median nerve, can be trapped as a result of repetitive stress. When this nerve is trapped, the condition is sometimes referred to as ulnar tunnel syndrome. It is more correctly known as Guyon's canal syndrome, however, since this is the name of the passage through which the ulnar nerve passes. General symptoms are similar to carpal tunnel syndrome, but patients experience loss of sensation in the ring and little finger and in the outer half of the palm. It can be a separate problem, although it commonly occurs with CTS. In such cases, release surgery for CTS usually also relieves the ulnar nerve entrapment. The ulnar nerve can also be affected at the elbow.
De Quervain's Tenosynovitis	Tenosynovitis is swelling of the slippery covering of the tendons that move the thumb. When it causes pain on the side of the wrist and forearm right below the base of the thumb, it is known as De Quervain's tenosynovitis. (Finklestein's Test may help identify this. Make a fist that encloses the thumb, and bend the wrist sideways and down away from the thumb. If it causes pain, it is likely to be De Quervain's tenosynovitis.) It may be treated with splints or corticosteroid injections. In severe cases release surgery is effective.
Digital Flexor Tenosynovitis (Trigger or Snapping Finger)	Digital flexor tenosynovitis, commonly called trigger or snapping finger, is brought on when a tendon thickens, leaving the finger or thumb in a bent position. This disorder usually occurs when the tendons thicken and form a knot and may arise in those with hypothyroidism, diabetes, gout, rheumatoid arthritis, or connective tissue disorders. It can cause pain and a clicking sound when the trigger finger or thumb is bent and straightened. It can be effectively treated with corticosteroid injections.
Thoracic Outlet Syndrome	Thoracic outlet syndrome is caused by compression of nerves and blood vessels running down the neck into the arm. It can produce symptoms very similar to CTS. Other symptoms may include Raynaud's phenomenon (changes in sensation and temperature in the hand). The compression occurs at the first rib in the front of the shoulder. This may happen after an accident or simply from chronic slouching posture. A doctor may be able to diagnose the condition by detecting diminished blood flow in the arm as the patient raises the affected hand and turns his or her head toward the opposite side. Although the condition is uncommon, a correct diagnosis is important to differentiate it from CTS, since treatments differ. Surgery may be required to relieve pressure on the nerves and blood vessels.

The following findings are helpful in identifying carpal tunnel syndrome:

Less sensitivity to pain where the median nerve runs through to the fingers
Thumb weakness
Inability to tell the difference between one and two sharp points on the fingertips (this is a late sign of carpal tunnel)

Flick Signal. One important and simple test of carpal tunnel is the "flick" signal:

The patient is asked, "What do you do when your symptoms are worse?"
If the patient responds with a motion that resembles shaking a thermometer, then the doctor can strongly suspect carpal tunnel.

Testing for Thumb Weakness. Two questions are useful in determining thumb weakness:

Can the thumb rise up from the plane of the palm?
Can the thumb stretch so that its pad rests on the pad of the little finger pad?

Provocation Tests. Certain tests are conducted to produce symptoms:

Phalen's Test. In Phalen's test, the patient rests the elbows on a table and lets the wrists dangle with fingers pointing down and the backs of the hands pressed together. If symptoms develop within a minute, CTS is indicated. (If the test lasts for more than a minute even patients without CTS may develop symptoms.) This test may be particularly important in determining the severity of CTS and assessing the results of treatment.
Tinel's Sign. In the Tinel's sign test, the doctor taps over the median nerve to produce a tingling or mild shock-sensation.
Pressure Provocation Test. The doctor presses over carpal tunnel for 30 seconds to produce tingling or shock in the median nerve.
Tourniquet Test. This test employs an inflatable cuff that applies pressure over the median nerve to produce tingling or small shocks.
Hand Elevation Test. The patient raises their hand overhead for 2 minutes to produce symptoms of CTS. The test was recently proven to be accurate and may provide useful information when combined with the Tinel's and Phalen's tests.

Electrodiagnostic tests analyze the electric waves of nerves and muscles. These tests can help detect median nerve compression in the carpal tunnel.

Electrodiagnostic tests are the best methods for confirming a diagnosis of CTS at this time. Doctors who perform these tests should be certified by the American Board of Electrodiagnostic Medicine, which uses rigorous standards in qualifying doctors. Specific electrodiagnostic tests, called nerve conduction studies and electromyography, are the most common ones performed:

Nerve Conduction Studies. To perform nerve conduction studies, surface electrodes are first fastened to the hand and wrist. Small electric shocks are then applied to the nerves in the fingers, wrist, and forearm to measure how fast a signal travels through the nerves that control movement and sensation. In suspected cases of CTS, nerve conduction tests can identify over 85% of true carpal tunnel syndrome cases and eliminate 95% of those that are not true CTS. They are less accurate in identifying mild CTS, however. Patients should be sure their practitioners perform tests that compare a number of internal responses -- not just routine testing that records only the responses of muscles located in the palm at the base of the thumb), and those on the second or third fingers.

Nerve conduction tests can also detect causes of symptoms that mimic CTS but should be attributed to other problems, such as pinched nerves in the neck or elbow or thoracic outlet syndrome.

Electromyography. To perform electromyography, a fine, sterile, wire electrode is inserted briefly into a muscle, and the electrical activity is displayed on a viewing screen. Electromyography can be quite painful and is less accurate than nerve conduction. Some experts question, in fact, whether it adds any valuable diagnostic information. They suggest it be limited to unusual cases or when other tests indicate that the condition is aggressive and may increase the risk for rapid, significant injury.
Portable electrodiagnostic testing. Portable electronic devices (such as NC-Stat, Neurosentinel, and the Nervepace digital electroneurometer) are being evaluated for measuring nerve conductivity. They are relatively quick and easy to use on a large scale in an industrial facility. However, the Advancing Association of Neuromuscular and Electrodiagnostic Medicine maintains that these devices are experimental and are not effective substitutes for standard electrodiagnostic studies.

Limitations. Electrodiagnostic studies are not well standardized, and certain conditions can skew the results of either test:

Obesity can slow the speed of electrical conduction.
Anxiety can slow the speed of electrical conduction.
Women and the elderly normally have slower conduction times than younger adult men.
Temperature also affects nerve conduction speed. When undergoing testing, doctors should strictly control room temperature to lessen its impact.

Ruling out other causes is extremely important in order to avoid unnecessary surgery for CTS. Modifications and improvements of these tests are continually being made.

Note: People with abnormal results who have no CTS symptoms are at no higher risk for CTS than those with normal results and no symptoms.

A diagnosis of carpal tunnel syndrome may follow testing the affected hand for numbness, tingling, weakness or pain in specific areas. Muscle and nerve conduction tests may also help affirm or rule out carpal tunnel syndrome.

Ultrasound. Ultrasound imaging, a relatively inexpensive technique that uses sound waves, is showing promise. Studies indicate that it can identify up to 85% of CTS cases, and some suggest it is as effective as electrodiagnostic tests. It may be effective for ruling out other causes of hand pain, such as tendon injuries, tenosynovitis (swelling of the tendon lining), cysts, and blood clots in the median artery (a rare complication that can cause the sudden onset of CTS symptoms). However, results are mixed on its accuracy. Newer color Doppler ultrasound and other technological advances are improving the results achieved with this technique. A 2005 study comparing high-resolution ultrasonography with electromyography found that ultrasonography may be helpful for estimating the symptom severity and problems with nerve conduction.

MRI. Magnetic resonance imaging (MRI), an advanced imaging technique, is being adapted to distinguish weak nerve signals from surrounding tissue, so that eventually it may be able to precisely diagnose CTS. However, studies in 2002 note that it requires special expertise, has limited diagnostic accuracy, and is still too expensive at present for routine use. MRI is accurate in diagnosing carpal tunnel syndrome about 80% of the time, compared to about 85% using electrodiagnostic tests, which remains the preferred method of diagnosis. MRI may be most effective for detecting any internal injuries, tumors, arthritis, or joint damage that might be causing the problem. It may also be valuable in selecting surgical candidates when electrodiagnostic tests produce unusual results or indicate more severe disease than expected. Additionally, an MRI may be useful for evaluating patients if surgery fails to bring relief.

Treatment

It is critical to begin treating early phases of carpal tunnel syndrome before the damage progresses. A conservative approach to CTS, which may include corticosteroid injections and splinting, is the first step in treating this disorder.

Nevertheless, relapse is common, and studies suggest that surgery is a better option for severe CTS. In one study, 89% of patients who had conservative treatments suffered a recurrence of symptoms within a year. Conservative treatments work best in men under 40. They do not work as well in young women. The conservative approach is also most successful in patients with mild carpal tunnel syndrome. Even among these patients, however, one study found that 60% of patients can expect a relapse. Some researchers are reporting better results when specific exercises for carpal tunnel syndrome are added to the program of treatments.

Limiting Movement. If possible, the patient should avoid activities at work or home that may aggravate the syndrome. The affected hand and wrist should be rested for 2 to 6 weeks. This allows the swollen, inflamed tissues to shrink and relieves pressure on the median nerve. If the injury is work related, the worker should ask to see if other jobs are available that will not involve the same actions. Few studies have been conducted on ergonomically designed furniture or equipment, or on frequent rest breaks. However, it is reasonable to ask for these if other work is not available.

Conservative Treatment Approach. In a major analysis, the following conservative approaches were shown to provide symptom relief:

Wrist splints
Corticosteroids (steroids). Injected or short-term oral corticosteroids may be tried if other methods fail.
Yoga. In one study, 8 weeks of regular yoga practice reduced pain significantly more than splinting.
Manual therapy, a type of physical therapy

A major analysis of other conservative approaches found that patients had no significant relief from nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs include common pain relievers such as aspirin and ibuprofen (Advil). The same report also found no benefits from diuretics, magnet therapy, laser acupuncture, vitamin B6, exercise, or chiropractic care. Other approaches being investigated include omega-3 fatty acid supplements and cognitive-behavioral therapy.

Underlying Conditions. It is important to treat any underlying medical condition that might be causing carpal tunnel syndrome. For example, reducing inflammation in rheumatoid arthritis or other forms of inflammatory disorders that directly cause CTS is very helpful.

Hypothyroidism and diabetes are diseases that are associated with an increased risk of CTS. The treatments for such diseases may offer some relief for CTS symptoms. For example, insulin helps nerves heal. A study of patients with CTS and type 2 diabetes found that patients who had an initial steroid injection followed by 7 weekly insulin injections had significantly less pain than those who received sham therapy (placebo). More research is needed on the effects of insulin injections in patients with CTS.

Wrist splints are used to keep the wrist from bending. They are not as beneficial as surgery for patients with moderate to severe CTS, but they appear to be helpful in specific patients. In one study, the best success rates were in patients with mild to moderate nighttime symptoms of less than a year's duration. In selected patients, up to 80% reported fewer symptoms, usually within days of wearing the splint.

Although typically the splint is worn at night or during sports, one 2000 study reported that wearing it full time is most beneficial. (In the study, few patients actually complied with the regimen and wore them full time, but any regular use appeared to improve nerve function and symptoms.) The splint is used for several weeks or months, depending on the severity of the problem, and may be combined with hand and finger exercises. A 2005 study reported that a 6-week course of at-night splinting reduced symptom severity in people with CTS and that the benefits were still evident after 1 year.

Corticosteroid Injections. Corticosteroids (also called steroids) reduce inflammation. If restriction of activities and the use of painkillers are unsuccessful, the doctor may inject a corticosteroid into the carpal tunnel. Some experts recommend them for patients with CTS whose symptoms are intermittent, and there is no evidence of a permanent injury. In CTS, steroid injections (such as cortisone or prednisolone) shrink the swollen tissues and relieve pressure on the nerve. Evidence strongly suggests that they offer relief in more than 75% of CTS patients. It should be noted that the pain may increase for a day or two after the injection, and skin color may change.

A study comparing the benefits of two steroid injections (8 weeks apart) to a single injection in the treatment of CTS found the patients did not significantly benefit from the second shot. One injection is therefore enough to achieve the maximum benefit of this treatment.

Unfortunately, in most cases, steroid injections provide only temporary relief, although studies comparing steroid injection to surgery have produced conflicting results. In a major analysis, after 1 month, injections were no more effective than placebo (sham) injections.

However, a recent analysis compared the effects of local steroid injection versus surgery in patients with new CTS of at least 3 months' duration. Over the short term, local steroid injection was better than surgery for relieving symptoms of CTS. And after 1 year, local steroid injection was as effective as surgery. Another study compared steroid injection with open-release surgery and found that the surgery resulted in better outcomes, but not improved grip strength, in patients with CTS over a 20-week period.

Most doctors limit steroid injections to about three per year, since they can cause complications, such as rupture of tendons, nerve irritation, or more widespread side effects such as hypertension or elevated blood sugar levels.

Low-Dose Oral Corticosteroids. Oral corticosteroids are medicines taken by mouth. Short-term (1 to 2 weeks), low-dose use of corticosteroids may provide long-term relief. People with diabetes should not take oral corticosteroids.

Yoga. Some evidence suggests that yoga practice may be specifically very helpful for carpal tunnel, since yoga postures are designed to stretch, strengthen, and balance upper body joints. In one study, people who practiced yoga for 8 weeks experienced significantly reduced symptoms compared to wrist splints or no treatment at all. Two other small studies also reported improvement in pain relief. Positive effects may take a few weeks of regular practice of at least two sessions a week.

General Exercise Program. Some experts have reported that people who are physically fit, including athletes, joggers, and swimmers, have a lower risk for cumulative trauma disorders. Although there is no evidence that exercise can directly improve CTS, a regular exercise regimen using a combination of aerobic and resistance training techniques strengthens the muscles in the shoulders, arms, and back, helps reduce weight, and improves overall health and well-being. In one 2001 study, CTS patients experienced symptom relief and signs of improved nerve conduction after 10 months of participation in an aerobic exercise program (such improvements appeared to be due to both weight loss and higher oxygen levels in the blood). One study found that most people with CTS felt improvement after two months of physical therapy that included exercises to improve balance and posture. People with any chronic medical condition or with risk factors for heart disease should check with their doctors about an appropriate exercise regimen.

If symptoms subside, the patient may proceed with a supervised program of joint mobilization and hand and wrist strengthening and stretching, usually offered by physical or occupational therapists. Hand and wrist exercises may be most beneficial for patients with mild to moderate disease who are also treated with splints and other conservative measures. Graston Instrument-Assisted Soft-Tissue Mobilization (GISTM) and Soft-Tissue Moblization (STM) techniques have been shown to improve nerve conduction, wrist strength, and wrist motion.

Ultrasound employs high-frequency sound waves directed toward the inflamed area. The sound waves are converted into heat in the deep tissues of the hand, which opens the blood vessels and allows oxygen to be delivered to the injured tissue. A major analysis suggested this approach may be effective when used for seven weeks or more.

Nonsteroidal anti-inflammatory drugs (NSAIDs), which include aspirin and ibuprofen (Advil), are the most common pain relievers used for CTS. They block prostaglandins, the substances that dilate blood vessels and cause inflammation and pain. Unfortunately, as with most other medications used for carpal tunnel syndrome, there are few well-conducted studies to determine their role in CTS. To date, there is no evidence that they offer any significant relief, and regular use can have serious side effects.

NSAIDs Used. Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used to relieve joint pain and inflammation. There are dozens of NSAIDs. The following are the most common:

Over-the-counter NSAIDs include aspirin, ibuprofen (Advil, Nuprin, Motrin IB, Rufen), naproxen (Aleve), and ketoprofen (Actron, Orudis KT).
Prescription NSAIDs include ibuprofen (Motrin), naproxen (Naprosyn, Anaprox), flurbiprofen (Ansaid), diclofenac (Voltaren), tolmetin (Tolectin), ketoprofen (Orudis, Oruvail), dexibuprofen (Seractil), and indomethacin (Indocin).

Regular use of even over-the-counter NSAIDs may be hazardous for anyone. Long-term use can cause stomach problems, such as ulcers and bleeding, and possible heart problems. In April 2005, the Food and Drug Administration (FDA) asked drug manufacturers of NSAIDs to include a warning label on their product that alerts users of an increased risk for cardiovascular events and gastrointestinal bleeding. NSAIDS have been associated with the following side effects:

Ulcers and gastrointestinal bleeding are the major danger with long-term use of NSAIDs.
Increased blood pressure -- most NSAIDs appear to pose this risk, with higher risks observed with piroxicam (Feldene), naproxen (Aleve), and indomethacin (Indocin). Sulindac has the smallest effect; aspirin has no risk. People with hypertension, severe vascular disease, kidney, or liver problems, and those taking diuretics, must be closely monitored if they need to take NSAIDs.
Delay in emptying of the stomach -- this could interfere with the actions of other drugs. The elderly are at special risk.
Kidney abnormalities -- these have been reported in people taking NSAIDs, which resolve when the drugs are withdrawn. Report any sudden weight gain or swelling to a doctor. Anyone with kidney disease should avoid these drugs.

Other side effects include:

Dizziness
Tinnitus (ringing in the ear)
Headache
Skin rash
Depression
Confusion or bizarre sensation (in some higher-potency NSAIDs, notably indomethacin)
Possible higher risk for miscarriage (particularly if the NSAID is taken for more than a week or around the time of conception)
There is a slight risk for liver abnormalities.

COX-2 Inhibitors (Coxibs). COX-2 inhibitors block an inflammation-promoting enzyme called COX-2. This class of drugs was initially believed to work as well as traditional NSAIDs, but with fewer stomach problems. However, numerous reports of heart attacks and stroke have prompted the FDA to re-evaluate the risks and benefits of the COX-2s. Rofecoxib (Vioxx) and valdecoxib (Bextra) have been withdrawn from the U.S. market following reports of heart attacks in patients taking the drugs. At the time of this update, Celecoxib (Celebrex) was still available, but labeled with strong warnings and a recommendation that it be prescribed at the lowest possible dose for the shortest duration possible. Patients should ask their doctor whether the drug is appropriate and safe for them.

Ice and Warmth. Ice may provide benefit for acute pain. Some patients have reported that alternating warm and cold soaks have been beneficial. (If hot applications relieve pain, most likely the problem is not caused by CTS but by another condition producing similar symptoms.)

Anesthetic Injections. In some cases, injections of an anesthetic (such as lidocaine) may be helpful. A recent small study compared a painkilling lidocaine patch with a combination lidocaine-steroid injection. The study found the daily use of a 5% lidocaine patch reduced pain as well as the injections. More patients in the patch group reported satisfaction with their treatment. The lidocaine patch is less painful than injections because it is worn on the skin and doesn't require a shot. Doctors noted improvements in 88% of the patients in the patch group, compared with 74% of the patients in the injections group.

Pheresis. The word "pheresis" means to carry. In the case of carpal tunnel, pheresis is a technique being investigated to deliver (to carry) a corticosteroid cream deep within the wrist. One such technique called iontophoresis uses an electrical current, and another called phonophoresis uses ultrasound. One study recently found steroid injections to be superior to iontophoresis and phonophoresis in the treatment of CTS.

Diuretics. Diuretics such as trichlormethiazide reduce fluid in the body. They are sometimes used to treat CTS. However, studies have not reported any significant benefits with these agents.

Low-Level Laser Therapy. Some investigators are working with low-level laser therapy (LLLT), which generates extremely pure light in a single wavelength. The procedure is painless, but studies are mixed on whether it is any more effective than sham treatment. One major analysis reported that laser therapy was more effective over time than steroid injections (although it does not appear to provide much immediate relief.) A 2004 study comparing LLLT with a sham (inactive) therapy reported no significant differences in outcomes between the two groups.

Muscle Stimulation. Two investigative procedures called automated or electrical twitch obtaining intramuscular stimulation (ATOIMS or ETOIMS) are showing promise. ATOIMS uses an automated mechanical device that vibrates the muscle using a tiny pin. (The sensation is described as similar to a mosquito bite.) ETOIMS uses an extremely mild electrical current. They can also be used together. Both approaches cause the muscles to twitch and then relax until the process is completed. Discomfort is minimal. Small studies are reporting some help in relieving a number of conditions that cause chronic pain, including carpal tunnel syndrome.

Traction. Small studies of a hand traction device showed improvement in some patients. The device, called C-TRAC, significantly improved pain, tingling, and numbness in patients who had failed a minimum of 4 months of therapy with conservative treatments such as NSAIDs, night hand splinting, acupuncture, and hand therapy. Patients used the C-TRAC device for 5 minutes three times daily for four weeks, then as needed to maintain long-term improvement.

Many alternative therapies are offered to sufferers of carpal tunnel syndrome and other repetitive stress disorders. Few, however, have any proven benefit. People should carefully educate themselves about how alternative therapies may interact with other medications or impact other medical conditions, and should check with their doctor before trying any of them.

Vitamin B6. Vitamin B6 (pyridoxine) is often used for carpal tunnel syndrome. Studies have not supported its benefits, however, either in oral or cream form. It should also be noted that excessively high doses of vitamin B6 can be toxic and cause nerve damage.

Acupuncture. Acupuncture may be beneficial. New techniques employing painless laser acupuncture may prove to be particularly effective. The National Institutes of Health issued a Consensus Statement on Acupuncture in 1997, which declared this ancient form of treatment useful as a supplement to standard treatment or even as part of a comprehensive management program for CTS.

Chiropractic Therapies. Chiropractic techniques have been useful for some people whose condition is produced by pinched nerves. In one small study, the technique was as effective as medications or wrist splints for relief of pain, though further research is needed.

Magnets. Magnets are a popular but unproven therapy for pain relief. One small study of patients who wore magnets attached to their wrists showed no benefits over those who wore a nonmagnetic placebo (sham) device, although both groups did experience pain relief, perhaps due to a placebo response.

Botulinum toxin type A. Intracarpal injections of botulinum toxin type A (Botox) have been reported to relieve carpal tunnel syndrome in more than half of the small number of patients tested. The product has been safely used to relieve headaches, myofacial pain, and other neuropathic pains.

Generally, manufacturers of herbal remedies and dietary supplements do not need FDA approval to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been a number of reported cases of serious and even lethal side effects from herbal products. Always check with your doctor before using any herbal remedies or dietary supplements.

Several herbal and homeopathic remedies are sold for pain relief. A small 2002 British study suggested that preparations containing arnica, a popular remedy for swelling and bruising, may ease discomfort following surgery for carpal tunnel, but a 2003 study reported no advantages compared to placebo (an inactive substance).

Research indicates that anxiety, depression, and even pain related to CTS can be relieved to some extent with cognitive behavioral therapy. The focus of this therapeutic approach is to change negative thinking about one's ability to manage pain. Cognitive behavioral therapy is particularly helpful in defining and setting limits. It may be expensive and not covered by insurance, although the therapy is usually of short duration, typically six to 20 one-hour sessions, plus homework, which usually includes attempting a task that the patient has avoided because of negative thinking. Even if people cannot afford this type of therapy, support groups for carpal tunnel syndrome and other sufferers of repetitive stress injuries can be very helpful for exchanging information, specific advice, and solace. Stress management techniques can also be useful in dealing with the psychological and emotional issues accompanying these injuries.

Surgery

Every year more than 200,000 people in the US undergo surgeries for carpal tunnel syndrome. Surgery for CTS is among the most common hand surgeries. In various trials, 70 - 90% of patients who underwent surgery were free of nighttime pain afterward.

Although evidence strongly suggests that surgery is more effective than conservative approaches (at least in patients with moderate to severe CTS), the decision about whether to have surgery to correct CTS, and when to have it, is a troubling one for patients. Electrodiagnostic and other tests used to confirm the presence of CTS are not very useful in determining the best candidates for surgery. For example, results suggesting severe CTS may not relate at all to surgical success or the lack of it.

In general, patients with the following characteristics are less likely to respond to conservative treatment and, therefore, might benefit from surgery:

Older than 50 years of age
Symptoms lasting 10 months or longer
Continual numbness
Muscles in the base of the palm have begun to shrink
Symptoms occur within 30 seconds during a Phalen's test

According to a 2002 study, if none of these factors are present, conservative therapies (splinting and anti-inflammatory agents) are effective in two thirds of patients. However, the conservative approach was ineffective in 60% of patients if only one of these factors were present, in 83% with only two of them, and in virtually all patients who had three or more.

Surgery does not cure all patients, and because it permanently cuts the carpal ligament, some wrist strength is often lost. A number of experts believe that release surgery is performed too often. They recommend aggressive conservative treatment (such as splints, anti-inflammatory agents, and physical therapy) before choosing the more invasive option (surgery). Nevertheless, other experts argue that CTS is often progressive and will worsen over time without surgery. Furthermore, evidence now shows that surgery is better than splints and conservative measures for the relief of pain. Factors that may increase the chances for successful surgery:

Having surgery performed within 3 years of the diagnosis of the disorder
Being in good general health
Having very slow nerve conduction results, but also having some muscle strength before surgery
Symptoms are worse at night than during the day

Factors that may reduce the chances for success:

Being elderly may affect the chances of successful surgery. However, a study found that the majority of patients over age 65 who had surgery were either completely or very satisfied.
Having very severe symptoms before surgery may reduce the chance for successful surgery.
Performing heavy manual labor, particularly working with vibrating tools, may lead to a less successful surgery. Medical evidence has found that only slightly more than half the people who used vibrating hand-held tools were symptom-free 3 years after a CTS operation.
Having very poor nerve conduction results before surgery may reduce the chance for successful surgery. However, some patients with severe symptoms who have normal neurological and physical test results, could still experience significant relief from CTS surgeries.
Patients who are on hemodialysis have good initial success, but approximately half deteriorate in about a year and a half.
Alcohol abuse can negatively affect the results of CTS surgery.
Poor mental health can lead to less successful surgery.
Patients with diabetes and high blood pressure may be more likely to require a second operation.

Factors that make no difference in results:

Patients whose CTS is due to nerve damage from medical conditions, such as diabetes, rheumatoid arthritis, or hypothyroidism. Such patients appear to have the same outcome as those without such conditions, and such disorders should not preclude them from surgery.

Open Release Surgery. Traditionally, surgery for CTS entails an open surgical procedure performed in an outpatient facility. In this procedure, the carpal ligament is cut free (released) from the median nerve. The pressure on the median nerve is therefore relieved. The surgery is straightforward.

In treating carpal tunnel syndrome, surgery may be required to release the compressed median nerve. The open release procedure involves simply cutting the transverse carpal ligament.

The Mini-Open Approach. In recent years, more surgeons have adopted a "mini" open -- also called short-incision -- procedure. This surgery requires only a one-inch incision, but it still allows a direct view of the area (unlike endoscopy, which is viewed on a monitor). The mini-open approach may allow for quicker recovery while avoiding some of the complications of endoscopy, although few studies have investigated its benefits and risks. In a 2005 report, the mini-open approach was directly compared with open release surgery. The recovery time in patients receiving the mini-open approach was shorter than with the open approach, and results were about the same 30 months after the surgery.

Endoscopy. Endoscopy for carpal tunnel syndrome is a less invasive procedure than standard open release.

A surgeon makes one or two 1/2-inch incisions in the wrist and palm, and inserts one or two endoscopes (pencil-thin tubes).
The surgeon then inserts a tiny camera and a knife through the lighted tubes.
While observing the underside of the carpal ligament on a screen, the surgeon cuts the ligament to free the compressed median nerve.

Patients report less pain than those who had the open release procedure, and return to normal activities in about half the time. Nevertheless, at this time the best evidence available does not show any significant long-term advantages of endoscopy over open release in terms of muscle or grip strength or dexterity. The endoscopic approach may even carry a slightly higher risk of pain afterward. This may be due to a more limited view of the hand with endoscopy. (In the open release procedure, the surgeon has a full view of the structures in the hand.) One report indicated a nearly 3-fold increased risk of reversible nerve injury with endoscopic carpal tunnel release, compared with open carpal tunnel release. On the other hand, a recently published review of 486 patients, who had a total of 753 endoscopic release procedures, showed an extremely low number of complications following the procedure. This study calls into the question the widely held belief that endoscopy carries a higher risk of complications. The study also noted that 90% of the patients returned to their original line of work.

Timing for Recovery. Patients should expect the following course:

For some patients, release surgery relieves CTS symptoms of numbness and tingling immediately.

People who have the operation on both hands are completely incapacitated for about two weeks and must have someone to help them at home.
Returning to strenuous work right after surgery may cause the symptoms to return. Patients generally stay out of work for at least a month and often much longer, depending upon the type of surgery and severity of the condition. Recovery time appears to be faster with endoscopy than with open release.
Immediately after surgery patients usually experience a decline in grip strength and dexterity. Studies have reported a wide range of recovery in this area. In one study, grip and pinch strengths reached better levels than before surgery within 6 weeks. In another study, however, grip strength and dexterity did not return to before-surgery levels until 25 weeks after open surgery. The scar may remain tender for up to a year.
Peak improvement (the best level of improvement a patient can reach) may take a long time; in one study, it took an average of almost 10 months.

Physical Therapy. Physical therapy is very important to help rebuild wrist strength. While physical therapy does not reduce the recurrence (return) of symptoms or improve the long-term benefits of surgery, it does accelerate recovery after surgery. Hand exercises can help restore circulation, muscle strength, and joint flexibility in the hand and wrist. Wearing a splint to immobilize the wrist after surgery has no benefits.

Treatment failure and complication rates of CTS surgery vary.

Complications after surgery may include the following:

Nerve damage with tingling and numbness (usually temporary)
Infection
Scarring
Pain
Stiffness. Loss of some wrist strength is a complication that affects between 10% and a third of patients. Endoscopy may have better results than open release. Some patients who have jobs requiring significant strength of the hand and wrist may not be able to perform them after surgery. Such workers may also have problems in other parts of the upper body, including elbows and shoulders. These problems do not go away with surgery and can persist. Studies indicate that between 10 - 15% of patients change jobs after a CTS operation.

If pain and symptoms return, the release procedure may be repeated.

Reasons for procedure failure include:

Incomplete release of the ligament
Extensive scarring
Recurrence of the disorder due to underlying medical conditions

Patients who had open release surgery appear more likely to require repeat operations compared with those who have had endoscopic surgery.

Neurolysis. In severe cases or when scarring is extensive after surgery, surgeons may choose to sever the nerves that are responsible for the pain, using a procedure called external or internal neurolysis. The procedure may extend recovery time substantially, and the need for repeat surgeries may be higher in those who undergo the procedure. One report indicated that neurolysis should be considered if there has not been any recovery within 3 months after surgery, after which improvement is unlikely. It is unclear if this approach offers any benefits over conservative measures to free the nerve from surrounding scar tissue.

Implants. In another procedure for recurrent carpal tunnel syndrome, doctors may take muscle flaps or even fatty tissue from other parts of the body and implant them at the site of the nerve injury. Such flaps enhance the development of new blood vessels, provide padding, and possibly serve as a bed for nerve regrowth. These implants may be used with or without cutting the nerve. Another procedure called vein wrapping uses grafts taken from veins to help protect the scarred nerves.

Resources

www.aanem.org -- Advancing Association of Neuromuscular and Electrodiagnostic Medicine
www.apta.org -- American Physical Therapy Association
www.aoec.org -- The Association of Occupational and Environmental Clinics
www.aaos.org -- American Academy of Orthopaedic Surgeons
www.assh.org -- American Society for Surgery of the Hand
www.ampainsoc.org -- American Pain Society
www.iasp-pain.org -- Association for the Study of Pain
www.aan.com -- American Academy of Neurology
www.nih.gov/niams -- National Institute of Arthritis and Musculoskeletal and Skin Diseases
www.ninds.nih.gov -- National Institute of Neurological Disorders and Stroke
www.nlm.nih.gov/medlineplus/carpaltunnelsyndrome.html -- Information on CTS
www.cdc.gov/niosh/homepage.html -- National Institute for Occupational Safety and Health
www.workerscompensationinsurance.com -- Resources for injured workers
www.keybowl.com -- orbiTouch keyboard
www.ergodevices.com -- Hand and wrist support keyboard

References

Tsai CP, Liu CY, Lin KP, Wang KC. Efficacy of botulinum toxin type a in the relief of carpal tunnel syndrome: A preliminary experience. Clin Drug Investig.2006;26:511-515.

Burke J, Buchberger DJ, Carey-Loughmani MT, et al. A pilot study comparing two manual therapy interventions for carpal tunnel syndrome. J Manipulative Physiol Ther.2007;30:50-61.

Hemminki K, Li X, Sundquist K. Familial risks for nerve, nerve root and plexus disorders in siblings based on hospitalizations in Sweden. J Epidemiol Community Health. 2007;61:80-84.

Porrata H, Porrata A, Sosner J. New carpal ligament traction device for the treatment of carpal tunnel syndrome unreposnive to conservative therapy. J Hand Ther. 2007;20:20-28.

Review Date:
3/14/2007
Reviewed By:
Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

A.D.A.M. Copyright

adam.com

Depression

FitSugar — Wed, 08 Oct 2008 17:34:54 -0700

Overview

Signs and Symptoms
Causes
Risk Factors
Diagnosis
Preventive Care
Treatment Approach
Other Considerations
Supporting Research

HEALTH GUIDE REFERENCE FROM A.D.A.M

Depression is a mood disorder in which feelings of loss, anger, sadness, or frustration interfere with everyday life. Depression affects about 17 million Americans each year. It can be mild, moderate, or severe and occur as a single episode, recurring episodes, or chronic depression (lasting more than 2 years).

The primary types of depression include:

Major depression -- five or more symptoms must be present. An episode must last at least 2 weeks, but tends to continue for 20 weeks. (A mood disorder is classified as minor depression if less than five depressive symptoms are present for at least 2 weeks.)
Dysthymia-- a chronic, generally milder form of depression. Symptoms are similar to major depression but more mild in degree.
Atypical depression-- depression accompanied by unusual symptoms, such as hallucinations, delusions, and physical rigidity

Other common forms of depression include:

Postpartum depression-- experienced by 8 - 20% of women following delivery
Premenstrual dysphoric disorder (PDD)-- experienced by 3 - 8% of women. Depressive symptoms occur 1 week prior to menstruation and disappear following menstruation.
Seasonal affective disorder (SAD)-- experienced by 5% of adults, the majority of whom are women. It occurs during the fall-winter season and disappears during the spring-summer season.

Depression may also occur with mania (known as manic-depression or bipolar disorder). In this condition, moods cycle between mania and depression.

Signs and Symptoms

While it is normal for most people to feel "down in the dumps" on occasion, someone with major depression feels significantly depressed for a prolonged period of time, has difficulty enjoying acts that were once pleasurable, and experiences at least five of the following symptoms for 2 weeks or more:

Sleep disturbances -- at least 90% of people with depression have either insomnia (sleeplessness) or hypersomnia (excessive sleeping).
Significant change in appetite (often resulting in either weight loss or weight gain)
Fatigue and loss of energy
Feelings of worthlessness, self-hate, and inappropriate guilt
Extreme difficulty concentrating
Either agitation, restlessness, and irritability or inactivity and withdrawal
Recurring thoughts of death or suicide
Feelings of hopelessness

Although not generally considered to be defining characteristics of depression, many people with the condition report a lack of sex drive and sudden bursts of anger.

Causes

The causes of depression are complex and involve a combination of biologic, genetic, and environmental factors. People with depression may have abnormal levels of certain brain chemicals, including serotonin, acetylcholine, and catecholamines (such as dopamine). The following may alter the levels of these brain chemicals and contribute to development of depression:

Heredity -- a recently identified gene called SERT that regulates the brain chemical serotonin has been linked to depression.
Chronic stress (such as from loss, abuse, or deprivation in early childhood)
Amount of exposure to light
Sleep disturbances
Social isolation
Nutritional deficiencies
Serious medical conditions, such as heart attack or cancer
Certain medications, including those for high blood pressure, high cholesterol, or irregular heartbeat

Risk Factors

Although depression is a condition that can affect anyone, regardless of age, race, or gender, the following factors may increase your risk for an initial or recurrent episode of depression:

Prior episodes of depression
Family history of depression
Suicide attempt -- a previous attempt of suicide during a major depressive episode increases the likelihood of another episode of depression.
Female gender -- the incidence of depression appears to be greater in women than in men. Some researchers speculate, however, that women may simply report their symptoms more frequently than men, and that men may be more apt to mask their depressive symptoms with alcohol. Therefore, it is still unclear whether women truly have a greater risk for depression.
Young adulthood or middle age -- the highest occurrence of depression is between the ages of 25 - 44. The elderly are also at particular risk due to death of loved ones, physical illness, and loss of independence.
Stressful life events (such as the death of a loved one), particularly if the event occurs at a young age
Postpartum period
Chronic medical or psychological conditions, including autoimmune diseases (such as lupus), cancer, heart disease, chronic headaches, chronic pain, anxiety, obsessive-compulsive disorder, and borderline personality disorder. Medical conditions that cause shifts in hormones, such as thyroid disorders or menopause, may also contribute to depression.
History of abuse (such as mental, physical, or sexual)
Lack of social support system (such as a network of close friends or family)
Current or past alcohol or drug abuse -- 25% of people with addictions have depression.

Diagnosis

If feelings of depression or any of the related symptoms are present, it is important to address them with a doctor or someone who can help direct care appropriately. Unfortunately, many people with depression tend to refrain from disclosing any or all of their symptoms in this setting. Occasionally, even when the symptoms are discussed during an appointment, a doctor may try to treat them individually, rather than recognizing the complete picture of depression. Working together with a primary care doctor is extremely important because they are often the health care providers who make a referral to a psychiatrist who, in turn, makes a definite diagnosis of depression. Proper diagnosis of depression is the first step toward proper treatment.

Only psychiatrists can prescribe medication, but psychologists and social workers, as well as psychiatrists, use psychotherapy as an important mode of treatment. These specialists will often administer a screening test, such as the Beck Depression Inventory or the Hamilton Rating Scale, which consists of about 20 questions that assess an individual's risk for depression. Even before these psychological screening tests, however, several blood tests will be performed to determine whether nutrient deficiencies or underlying medical conditions (such as a thyroid disorder) may be causing or contributing to depression.

Although the vast majority of people with depression are treated as outpatients, hospitalization is necessary for people who intend to, or do, attempt suicide, and may be necessary under other circumstances as well.

Preventive Care

The following steps can help prevent depression or decrease the chances of relapse:

Adequate sleep, regular exercise, and a balanced, healthy diet may help prevent depression and diminish symptoms of this mood disorder.
Mind-body techniques, such as biofeedback, meditation, and tai chi, are effective ways to prevent or reduce symptoms associated with depression.
Psychotherapy directed at coping skills generally helps prevent relapse.
Family therapy may prevent children or teens of depressed parents from becoming depressed later in life.
Compliance with the prescribed treatment regimen decreases the chance of relapse.

Treatment Approach

People with depression have several options for treatment, but a combination of psychotherapy and antidepressant medications is the regimen of choice, particularly for people with major depression. Cognitive-behavioral therapy appears to be the most effective type of psychotherapy, particularly for adolescents and people with atypical or postpartum depression. As many as 90% of people with depression improve from a combination of psychotherapy and antidepressants. However, adverse side effects from certain medications make it difficult for many to take their medications. Some complementary and alternative therapies may be helpful in reducing the side effects from such medications, while other complementary and alternative therapies may actually diminish the symptoms of depression.

Lifestyle

Exercise

Studies have consistently shown that regular exercise (either aerobic or strength and flexibility training) significantly reduces depressive symptoms in people with mild to moderate depression and improves the mood of people with major depression. Some even suggest that exercise may be as effective as psychotherapy for people with mild-to-moderate depression, although additional research is needed. In the meantime, exercise can be used safely in conjunction with medication for those with depression.

Medications

Antidepressant medications are very effective; reports indicate that they are 90% successful in treating depression. In general, medications are taken for at least 4 - 6 months to assure complete and effective treatment. However, antidepressants often cause adverse side effects, making it difficult for some people to comply with taking their medications. Medications must not be stopped before first talking with a physician. Most antidepressants cause withdrawal symptoms if they are not discontinued slowly over time with guidance from a physician.

There are several classes of antidepressant medications, including:

Selective Serotonin Reuptake Inhibitors (SSRIs)

SSRIs increase the activity of a chemical in the brain called serotonin. Most health care providers will prescribe SSRIs before any other antidepressant medication for depression, in part because the side effects associated with SSRIs are generally fewer than for other classes of antidepressants. Typical side effects caused by SSRIs include stomach upset, weight gain or loss, drowsiness, sexual dysfunction (such as impotence, decreased libido, and diminished orgasm), headache, jaw grinding, and apathy. Very unusual side effects from this class of prescription drugs include extreme agitation, impulsivity, tremors, and insomnia. People who discontinue taking SSRIs due to side effects usually attribute their discontent to sexual dysfunction.

Drugs classified as SSRIs include:

Fluoxetine
Sertraline
Paroxetine -- most likely in this class to cause sexual dysfunction
Fluvoxamine
Citalopram -- least likely in this class to cause sexual dysfunction

Another group of antidepressant medications (which are similar to SSRIs, but target other brain chemicals in addition to serotonin) may cause fewer negative sexual side effects. These include:

Bupropion -- should not be used if there is history of or risk for seizure
Nefazodone -- no sexual dysfunction reported. It begins to work very quickly and may cause a decrease in blood pressure when going from lying or sitting to standing.
Venlafaxine -- may impair sexual function and is not recommended in the elderly. It may improve quality of life more effectively than other antidepressants, but can cause irregular heart rhythm. Withdrawal from the medication is difficult.
Mirtazapine -- may be particularly effective if feelings of anxiety are also present. It helps with insomnia but may cause drowsiness, blurred vision, weight gain, and damage to production of cells in the bone marrow (very rare).
Maprotiline -- may cause dry mouth, drowsiness, sensitivity to the sun, and seizures

Tricyclic Antidepressants

Tricyclics increase the activity of the brain chemicals serotonin and norepinephrine. They are as effective as SSRIs, but are usually prescribed only to those who do not respond well to SSRIs because side effects are quite common and are usually less tolerable. Tricyclic antidepressants include:

Amitriptyline
Amoxapine -- increases risk of seizure in those who are prone to have a seizure
Clomipramine -- used for obsessive-compulsive disorder
Desipramine
Doxepin -- may help with insomnia
Imipramine -- may cause a rare lung disorder called idiopathic pulmonary fibrosis
Nortriptyline -- less risk of irregular heart rhythm than others in this class
Protriptyline -- less drowsiness than others in this class and may even cause weight loss and sun sensitivity
Trimipramine -- high risk for irregular heart rhythm

Side effects of tricyclics may include:

Dry mouth
Blurred vision
Constipation
Sexual dysfunction
Weight gain
Dizziness
Drowsiness
Urinary urgency (a sense that one has to urinate even when the bladder is empty)
Drop in blood pressure when going from lying or sitting to standing (causes dizziness and lightheadedness)
Irregular heart rhythm

Monoamine Oxidase Inhibitors (MAOIs)

MAOIs boost levels of norepinephrine, dopamine, and serotonin in the brain. MAOIs are generally prescribed only when other antidepressants have not been effective, which may occur in people with atypical depression. People who take MAOIs may experience a sharp increase in blood pressure after consuming food or drink containing the amino acid tyramine (found in such foods as aged cheeses and red wine). MAOIs also negatively interact with other medications, including Ritalin (used for attention deficit hyperactivity disorder) and pseudoephedrine (decongestant in many over-the-counter and prescription medications), and should not be taken with other classes of antidepressants.

MAOIs include:

Phenelzine -- should be avoided by people with a history of seizures or bipolar disorder (manic-depression)
Isocarboxazid -- side effects include drowsiness, sexual dysfunction, weakness, trembling, and blurred vision.
Tranylcypromine -- should not be used if there is any history of kidney disease or bipolar disorder

Surgery and Other Procedures

Electroconvulsive Therapy (ECT) for depression is usually reserved for when all other therapies have been unsuccessful. In this procedure, a small electrical current induces a seizure lasting approximately 40 seconds. A muscle relaxant and mild sedative are administered prior to the procedure. ECT is generally repeated every 2 - 5 days for a total of six treatments. It may cause temporary confusion, memory impairment, headache, muscle aches, irregular heart rhythm, or nausea.
Magnetic Resonance Imaging (MRI)-Guided Cingulotomy involves the application of an electrical current to a specific part of the brain. The MRI is used as a guide for an exact placement. Long-term improvement has been reported using this technique in over 50% of people with depression who have not responded to other treatment methods.

Nutrition and Dietary Supplements

A comprehensive treatment plan for depression may include a range of complementary and alternative therapies. Preliminary studies suggest that nutritional supplements may reduce the symptoms of some depression. Ask your team of health care providers about the best ways to incorporate these therapies into your overall treatment plan. Always tell your health care provider about the herbs and supplements you are using or considering using.

Following these nutritional tips may help reduce symptoms:

Try to eliminate potential food allergens, including dairy, wheat (gluten), corn, preservatives, and food additives. Your health care provider may want to test for food sensitivities.
Eat antioxidant foods, including fruits (such as blueberries, cherries, and tomatoes), and vegetables (such as squash and bell peppers).
Eat foods high in B-vitamins and calcium, such as almonds, beans, whole grains (if no allergy), dark leafy greens (such as spinach and kale), and sea vegetables such as kelp and dulce.
Avoid refined foods, such as white breads, pastas, and especially sugar.
Eat fewer red meats and more lean meats, cold-water fish, tofu (soy, if no allergy), or beans for protein.
Use healthy oils for cooking, such as olive oil or vegetable oil.
Reduce or eliminate trans-fatty acids, found in commercially baked goods such as cookies, crackers, cakes, French fries, onion rings, donuts, processed foods, and margarine.
Avoid coffee and other stimulants, alcohol, and tobacco.
Drink 6 - 8 glasses of filtered water daily.
Exercise at least 30 minutes daily, 5 days a week.

You my address nutritional deficiencies with the following supplements:

A multivitamin daily, containing the antioxidant vitamins A, C, E, the B-complex vitamins, and trace minerals such as magnesium, calcium, zinc, and selenium.
Omega-3 fatty acids, such as fish oil, one to two capsules or one tablespoonful oil one to three times daily, to help decrease inflammation and help with mental balance.
Vitamin C, 500 - 1000 mg one to three times daily, as an antioxidant and for immune support.
Coenzyme Q10, 100 - 200 mg at bedtime, for antioxidant, immune, and muscular support.
5-hydroxytryptophan (5-HTP), 50 mg two to three times daily, for mood stabilization. Ask your health care provider about potential prescription interactions.
Probiotic supplement (containing Lactobacillus acidophilus and other species), 5 - 10 billion CFUs (colony forming units) a day, for maintenance of gastrointestinal and immune health. You should refrigerate your probiotic supplements for best results.
SAMe (s-adenosyl-L-methionine), 100 - 200 mg before breakfast daily, for mood improvement.
Dihydroepiandosterone (DHEA), start at 5 mg three times a day and work up to 100 mg per day for 7 - 12 months. It is recommended to use DHEA under the supervision of a qualified health care provider. If adverse effects develop, discontinue use.
L-theanine, 200 mg one to three times daily, for nervous system support.
Melatonin, 2 - 5 mg one hour before bedtime, for sleep and immune protection. Ask your health care provider about potential prescription interactions.

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, you should work with your health care provider to get your problem diagnosed before starting any treatment. You may use herbs as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, you should make teas with 1 tsp. herb per cup of hot water. Steep covered 5 - 10 minutes for leaf or flowers, and 10 - 20 minutes for roots. Drink 2 - 4 cups per day. You may use tinctures alone or in combination as noted.

St. John's wort (Hypericum perforatum) standardized extract, 300 mg two to three times per day, for depression. Check with your health care provider if you are taking prescription medications.
Kava kava (Piper methysticum) standardized extract, 100 - 250 mg one to three times daily, as needed for symptoms of stress and anxiety. Talk with your health care provider before taking kava kava if you have an unhealthy liver.
Ginkgo (Ginkgo biloba) standardized extract, 40 - 80 mg three times daily, for blood flow and depression.
Green tea ( Camellia sinensis) standardized extract, 250 - 500 mg daily, for antioxidant and general health effects. Use caffeine-free products. You may also prepare teas from the leaf of this herb.
Rhodiola ( Rhodiola rosea ) standardized extract, 100 - 600 mg daily, for antioxidant and anti-stress activity.

Acupuncture

Two randomized, controlled, clinical trials suggest that electroacupuncture may reduce symptoms of depression as effectively as amitriptyline, a tricyclic antidepressant medication. Electroacupuncture involves the application of a small electrical current through acupuncture needles. Other studies suggest that acupuncture may be effective for people with mild depression and for those with depression related to a chronic medical illness. Further research is warranted in this area.

Homeopathy

Although very few studies have examined the effectiveness of specific homeopathic therapies, professional homeopaths may consider the following remedies to alleviate the symptoms of depression based on their knowledge and experience.

Before prescribing a remedy, homeopaths take into account a person’s constitutional type -- your physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate treatment for each individual. A few homeopathic remedies that may work for depression include:

Ignatia -- for a sudden sense of grief or disappointment following the death of a loved one, the end of a romantic relationship, or an unexpected loss of one's job
Natrum muriaticum -- for grief following the death of a loved one or sadness from the end of a romantic relationship

Massage and Physical Therapy

Studies of formerly depressed adolescent mothers, children hospitalized for depression, and women with eating disorders, suggest that massage decreases stress hormone levels, feelings of anxiety, and symptoms of depression. Giving massage may also be beneficial for people who are depressed. Elderly volunteers with depression showed notable improvement in their symptoms when they massaged infants.

Aromatherapy, or the use of essential oils in massage therapy, may also be of value as a supplemental treatment for depression. Theoretically, the smells of the oils elicit positive emotions through the limbic system (the area of the brain responsible for memories and emotions). However, the benefits of aromatherapy appear to be related to the relaxation effects of the treatment as well as to the recipient's belief that the treatment will be beneficial. Essential oils used during massage for depression are quite varied and include:

Lavender ( Lavandula officinalis)
Basil (Ocimum basilicum)
Orange (Citrus aurantium)
Sandalwood (Santalum album)
Lemon (Citrus limonis)
Jasmine (Jasminum spp.)
Sage (Salvia officinalis)
Chamomile (Chamaemelum nobile)
Peppermint (Mentha piperita)
Rosemary (Rosmarinus officinalis)

Mind-Body Medicine

Mind-body therapies and techniques that may be useful as a part of an overall treatment regimen for depression include:

Psychotherapy

Cognitive-behavioral therapy is a type of psychotherapy in which individuals learn to identify and change distorted perceptions about themselves and adapt new behaviors to better cope with the world around them. This therapy is frequently considered the treatment of choice for people with mild-to-moderate depression, but it may not be recommended for those with severe depression. Studies of people with depression indicate that cognitive-behavioral therapy is at least as effective as tricyclic antidepressants. Compared to those treated with antidepressants, people treated with cognitive-behavioral therapy demonstrated similar, or better, results and lower relapse rates.

Other therapeutic approaches that may be applied by a psychiatrist, psychologist, or social worker include:

Psychodynamic psychotherapy -- based on Freud's theories about unresolved conflicts in childhood and depression as a grief process
Interpersonal therapy -- acknowledges childhood roots of depression, but focuses on current problems contributing to depression and is considered very effective treatment for depression
Supportive psychotherapy -- nonjudgmental advice, attention, and sympathy, and this approach may improve compliance with taking medication

Relaxation

One study suggests that relaxation techniques, such as yoga and tai chi, may improve symptoms of depression in people with mild depression.

Meditation

Some researchers believe that mindfulness meditation may prevent depression from recurring in people who once had the condition.

Other Considerations

Pregnancy

Postpartum depression is experienced by 8 - 20% of women following delivery.
The safety of SSRIs and tricyclic antidepressant medications during pregnancy remains uncertain. The physician will provide guidance regarding use or avoidance of antidepressants during pregnancy. The risks and benefits to the mother and the fetus must be weighed in each individual case in order to determine the most appropriate regimen during pregnancy. MAOIs cause birth defects and should be avoided during pregnancy.
Many of the dietary supplements and herbs mentioned here have not been tested for safety during pregnancy. Talk with your doctor or pharmacist.

Warnings and Precautions

People with Parkinson's disease should avoid SSRIs.
People with coronary artery disease should avoid tricyclic antidepressants.
Several herbal remedies and supplements should not be combined with antidepressant medications. Be sure to inform your health care provider of all herbs and supplements you take to avoid adverse interactions.

Prognosis and Complications

Depression is a serious condition that can have a devastating effect on people's lives. It can directly and indirectly contribute to chronic medical conditions, such as heart disease and stroke, because depressed people with these conditions are less likely to engage in healthy behaviors (such as exercise) and more likely to engage in unhealthy behaviors (such as smoking). Suicide is a significant factor in depression. About 15 % of people with a major depressive disorder commit suicide. Depression also significantly shortens the lifespan of the elderly and is associated with the development of memory impairment and dementia.

When left untreated, depression can last up to 2 years. Rates of recurrence are variable: 50% of people who have had one depressive episode will have a second major depressive disorder, 70% will have a third, and 90% will have a fourth. Symptoms of depression usually disappear after menopause in women with premenstrual dysphoric disorder or seasonal affective disorder. Fortunately, there are several treatment options available for people with depression, and the prognosis improves tremendously for those who seek treatment and comply with their regimen.

Supporting Research

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Beniamini Y, Rubenstein JJ, Zaichkowsky LD, Crim MC. Effects of high-intensity strength training on quality-of-life parameters in cardiac rehabilitation patients. Am J Cardiol. 1997;80(7):841-846.

Benjamin J, Agam G, Levine J, Bersudsky Y, Kofman O, Belmaker RH. Inositol treatment in psychiatry. Psychopharmacol Bull. 1995;31(1):167-175.

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Birdsall TC. 5-Hydroxytryptophan: a clinically-effective serotonin precursor. Altern Med Rev. 1998;3(4):271-280.

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Bottiglieri T, Laundy M, Crellin R, Toone BK, Carney MW, Reynolds EH. Homocysteine, folate, methylation, and monoamine metabolism in depression. J Neurol Neurosurg Psychiatry. 2000;69(2):228-232.

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Review Date:
11/6/2006
Reviewed By:
Ernest B. Hawkins, MS, BSPharm, RPh, Health Education Resources; and Steven D. Ehrlich, N.M.D., private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.

A.D.A.M. Copyright

adam.com

Alzheimer's disease

FitSugar — Wed, 08 Oct 2008 17:35:13 -0700

In This Report

Highlights
Introduction
Causes
Risk Factors
Prevention
Symptoms
Diagnosis
Medications
Stages
Resources
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Alzheimer’s Disease Toll Increasing

More than 5 million Americans now have Alzheimer’s disease, and the number could increase to 16 million by mid-century, according to a 2007 report from the Alzheimer’s Association.

New Drug Indication

In 2006, the FDA expanded the use of donepezil (Aricept) to include treatment of people with severe dementia associated with Alzheimer’s disease. Donepezil was previously approved only for people with mild-to-moderate dementia.

Managing Psychotic and Behavioral Symptoms

Newer antipsychotic drugs are no better than placebo for controlling psychosis, aggression, and agitation in patients with Alzheimer’s disease, indicates an important study in the New England Journal of Medicine. In addition, these drugs can cause severe side effects and have been associated with increased death rate.
Non-drug approaches, such as behavioral techniques and bright light boxes, may be helpful for these patients, suggests an Archives of Internal Medicine study.

Brain Exercises Prevent Mental Decline

Cognitive training exercises that help boost memory, reasoning, and processing speed may help slow mental decline and improve functional abilities in older adults, indicates a Journal of the American Medical Association study.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) Do Not Prevent Alzheimer’s

The NSAIDs naproxen (Aleve) and celecoxib (Celebrex) do not protect against Alzheimer’s disease, indicates a data analysis from a large-scale U.S. National Institutes of Health (NIH) clinical trial.

Docosahexaenoic Acid (DHA) for Alzheimer’s Prevention

DHA, an omega-3 fatty acid found in some types of fish, may lower the risk for dementia and Alzheimer’s disease as well as delay its progression. However, researchers are uncertain whether DHA dietary supplements provide the same benefits as food sources (salmon, mackerel, and other types of fatty fish). In 2007, the NIH announced the launch of a national clinical trial to evaluate whether DHA can slow cognitive and functional decline in people with mild-to-moderate Alzheimer’s disease.

Support for Caregivers

Intensive programs that combine counseling, support groups, and problem-solving techniques can dramatically improve caregivers’ quality of life and may help delay patients’ transfers to nursing homes, several recent studies suggest.

Introduction

Alzheimer's disease (AD) is a degenerative disease of the brain from which there is no recovery. The disease slowly attacks nerve cells in all parts of the cortex of the brain and some surrounding structures, thereby impairing a person's abilities to govern emotions, recognize errors and patterns, coordinate movement, and remember. Ultimately, a person with AD loses all memory and mental functioning.

The major areas of the brain have one or more specific functions.

Causes

Researchers are finding specific biologic factors involved with Alzheimer's disease. Various environmental and genetic players appear to contribute to or trigger the process by which these factors destroy nerve cells leading to this disease.

Imaging techniques in patients with Alzheimer's disease have found significant loss of cells and volume in the regions of the brain devoted to memory and higher mental functioning. Important abnormalities have specifically been observed during biopsies:

Twisted nerve cell fibers, known as neurofibrillary tangles
A sticky protein, beta amyloid

Other factors also play a role.

Click the icon to see an animation about Alzheimer's disease.

The Effects of Neurofibrillary Tangles and Beta Amyloid in Alzheimer's Disease. These biologic factors appear to be involved in the development Alzheimer's disease in the following ways:

Neurofibrillary tangles are the damaged remains of microtubules, the support structure that allows the flow of nutrients through the neurons (nerve cells). A key component in these tangled fibers is an abnormal form of the tau protein, which in its healthy version helps in the assembly of the microtubule structure. The defective tau, however, appears to block the actions of the normal version.
Beta Amyloid (also called A beta) is the second significant finding. This insoluble protein accumulates and forms sticky patches called neuritic plaque, which are found surrounded by the debris of dying nerve cells in the brains of Alzheimer's victims.
Amyloid precursor protein (APP) is a large nerve-protecting protein that is the source of beta amyloid. In Alzheimer's certain enzymes, particularly those called gamma-secretases, snip APP into beta amyloid pieces. This process is controlled by factors called presenilin proteins. (Genetic abnormalities that affect either APP or presenilin proteins occur in some inherited cases of early-onset Alzheimer's.)
High levels of beta amyloid are associated with reduced levels of the neurotransmitter acetylcholine. (Neurotransmitters are chemical messengers in the brain.) Acetylcholine is part of the cholinergic system, which is essential for memory and learning and is progressively destroyed in Alzheimer's disease.
Beta amyloid may also disrupt channels that carry sodium, potassium, and calcium. These elements serve the brain as ions, producing electric charges that must fire regularly in order for signals to pass from one nerve cell to another. If the channels that carry ions are damaged, an imbalance can interfere with nerve function and signal transmission.

Click the icon to see an image of amyloidosis.

Other Proteins. Researchers have now identified other important proteins in the areas of the brain affected by Alzheimer's disease.

ERAB (endoplasmic-reticulum associated binding protein) appears to combine with beta amyloid, which in turn attracts new beta amyloid from outside the cells. High amounts of ERAB may also enhance the nerve-destructive power of beta amyloid.
AMY plaques resemble beta amyloid so closely that researchers were able to detect them only with the use of highly sophisticated techniques.
Elevated levels of a protein called prostate apoptosis response-4 (Par-4) may cause nerve cells to self-destruct.

Researchers are also attempting to discover why beta amyloid is so toxic to nerve cells. Some researchers are focusing on two processes in the body that may be involved with Alzheimer's disease: oxidation and the inflammatory process. There is some evidence that such events can begin decades before Alzheimer's disease actually develops. One scenario for their role in Alzheimer's is as follows:

The Role of Oxidation.

As beta amyloid breaks down it releases unstable chemicals called oxygen-free radicals. Once released, oxygen-free radicals bind to other molecules through a process called oxidation.
Oxidation is the result of many common chemical processes in the body, but when oxidants are overproduced, they can cause severe damage in cells and tissue, including even affecting genetic material in cells (its DNA). Oxidation is known to play a role in many serious diseases, including coronary artery disease and cancers, and experts believe it may also contribute to Alzheimer's.

The Inflammatory Response.

One result of oxidation is the marshaling of immune factors to repair the cellular injuries it produces. Overproduction of some of these factors, however, produces the so-called inflammatory response, in which the immune process itself can actually damage the body's own cells themselves.
Principle immune cells in the brain are called macrophage/microglia (M phi). In the healthy brain, they play an important protective role against invading organisms. However, when they are activated by beta amyloid oxidation, they release toxic molecules called cytokines, which are known to cause harm. For example, significantly high levels of interleukin-6, a specific cytokine, have been detected in people with Alzheimer's.
Other inflammatory factors of specific interest in Alzheimer's research are the enzyme cyclooxygenase (COX) and its products called prostaglandins. Excess amounts of these factors may increase levels of glutamate. Glutamate is an amino acid that excites nerves and, when overproduced, is a powerful nerve-cell killer.
The inflammatory process has also been associated with the release of soluble toxins called amyloid beta-derived diffusible ligands, which some investigators believe may prove to key players in the destructive process.

Major research targets in Alzheimer's disease are the factors responsible for beta amyloid build-up and concentration in certain people and not in others. Genetic factors are believed to play a role in many cases. In 2003, the National Institute on Aging (NIA) launched the ambitious AD Genetics Initiative, a 3-year national project to bank genetic material from families who have at least two members with late-onset Alzheimer's.

The ApoE Gene and Late-Onset Alzheimer's. The major target in genetic research on late-onset Alzheimer's disease (called LOAD) has been apolipoprotein E (ApoE), which plays a role in the movement and distribution of cholesterol for repairing nerve cells during development and after injury.

The gene for ApoE comes in three major types:

ApoE4. Studies have reported the greatest deposits of beta amyloid in people with ApoE4, which is now believed to be a major risk factor for late-onset Alzheimer's. Some evidence suggests that the ApoE protein removes beta amyloid but the ApoE4 variant does so less efficiently than other ApoE types. (ApoE4 has also been studied for years as a risk factor for heart disease.)
ApoE3 and ApoE2. Fewer beta amyloid deposits have been observed in people with the ApoE3, and the fewest deposits have been observed in people with ApoE2, which may actually be protective.

People inherit a copy of one type from each parent, but Alzheimer's disease is not inevitable even in people with two copies of the ApoE4 gene. Reports vary widely in estimating the extent of risk:

People without ApoE4 have an estimated risk of between 9 - 20% for developing Alzheimer's by age 85.
In people with one copy of the gene, the risk is between 25 - 60%.
In people with two copies, the risk ranges from 50 - 90%. (Only 2% of the population carries two copies of the ApoE4 gene.)

Some researchers suspect that some specific variation of the ApoE4 gene or combinations with other genes are critical for the disease, since many people who carry the ApoE4 exhibit no signs of Alzheimer's. For example, evidence suggests that genetic factors play a role in a common subtype of late-onset Alzheimer's disease that also includes psychosis. An important 2002 genetic study has identified certain genetic linkages associated with ApoE4 that appear to play a strong role in this subtype.

Other Genetic Factors in Late-Onset Alzheimer's. Most people with late-onset Alzheimer's disease do not carry the ApoE4 gene. Increasingly, researchers believe that many cases of late-onset Alzheimer's result from a combination of genetic factors that participate in the process of producing or degrading beta amyloid. Some under investigation include:

Researchers are targeting chromosomes 9, 10, and 12 as possible locations for genetic factors involved with Alzheimer's disease. (The ApoE4 gene is on chromosome 19.) In 2005, researchers announced that mutations linked to the ubiquilin 1 (UBQLN1) gene, located on chromosome 9, might be associated with increased risk for late-onset Alzheimer's disease.
Researchers have detected mutations in the proteins amyloid precursor protein (APP) and ubiquitin-B (Ubi-B), which may account for some cases of late- and early-onset Alzheimer's. Such mutations are not inherited, however, but appear to be genetic mistakes that occur during transcription, the coding process in which DNA establishes the pattern for the production of its proteins and other molecules.
In 2007, researchers identified mutations in the SORL1 gene as a possible factor in late-onset Alzheimer’s disease. Researchers think that variations in this gene may contribute to amyloid plaque formation in Alzheimer’s disease.

Genetic Factors for Early-Onset Alzheimer's. Scientists are coming closer to identifying defective genes responsible for early-onset Alzheimer's, an uncommon, but extremely aggressive form of the disease.

Mutations in genes known as presenilin-1 (PS1) and presenilin-2 (PS2) account for most cases of early-onset inherited Alzheimer's disease. The defective genes appear to accelerate beta amyloid plaque formation and apoptosis, a natural process by which cells self-destruct.
Genetic mutations in the genes that control amyloid precursor protein (APP) are also being targeted as causes of early-onset Alzheimer's. The genetic disease Down syndrome, for example, overproduces beta-amyloid precursor protein (APP), the source of beta amyloid, and almost always leads to early Alzheimer's. Other APP mutations are being identified.

Researchers are also investigating environmental factors (infections, metals, industrial and other toxins) that may trigger oxidation, inflammation, and the disease process, particularly in people with a genetic susceptibility to Alzheimer's.

Infectious Organisms. Slow, infectious viruses cause a number of other degenerative neurologic diseases, such as kuru and Creutzfeldt-Jakob disease.

Click the icon to see an image of Creutzfeldt-Jakob disease.

Although no specific virus has been linked to Alzheimer's, some researchers theorize that people with a genetic susceptibility to Alzheimer's may be vulnerable to the actions of certain viruses, particularly under circumstances when the immune system may be weakened.

Metals. Some laboratory studies have reported excessive amounts of metal ions such as zinc, copper in the brain of people with Alzheimer's disease. Such ions may possibly change the chemical architecture of normal beta amyloid, making it more harmful. A mildly acidic environment appears to be important in the process that binds these metals to beta amyloid. Experts observe that such conditions (acidic environment and higher levels of zinc and copper) commonly occur as part of the inflammatory response to local injury.

Electromagnetic Fields. Some studies on people exposed to intense electromagnetic fields (EMF) have reported a higher incidence of Alzheimer's. However, the association between EMF and Alzheimer's is very weak.

Risk Factors

Alzheimer's disease is the seventh leading cause of death in American adults. It affects about 5 million Americans and 8 million more people worldwide. According to the U.S. Alzheimer’s Association, 1 in 8 people age 65 and older, and nearly 1 in 2 people over age 85, have Alzheimer’s disease.

Age is the greatest risk factor for Alzheimer's disease. The number of cases of Alzheimer's disease doubles every 5 years in people over 65. By age 85, almost half of all people are afflicted. People with the disease survive, on average, half as long as similarly aged adults without the disease.

With the increasing numbers of aging adults, unless effective methods for prevention and treatment are developed, Alzheimer's disease will reach epidemic proportions, afflicting about 16 million Americans within 50 years. Evidence points to older age, high blood pressure, cholesterol levels, and a family history of the disease as the most important risk factors for Alzheimer's disease.

Several studies have reported that women have a much higher risk for Alzheimer's disease than men. If there is a gender difference, it is likely to be due estrogen, the primary female hormone, which appears to have properties that protect against the memory loss and lower mental functioning associated with normal aging. Such actions include blocking production of beta amyloid, offering antioxidant protection, and regulating blood sugar (glucose) levels in the brain. The drop in estrogen levels after menopause may explain a higher risk for Alzheimer's disease in older women than in men. (Testosterone, the male hormone, converts to estrogen, which may help protect men.) Studies have been mixed, however, on the association between the decline in natural estrogen levels and mental functioning in older women.

People with a family history of the disease are at higher than average risk for Alzheimer's disease. Researchers are identifying important genetic factors, notably the ApoE4 gene, that may be responsible for late- and early-onset cases.

Dietary and other cultural factors that increase the risk for hypertension and unhealthy cholesterol levels may also play a role. For example, a study of Japanese men showed that their risk increased if they emigrated to America. And the disease is much less common in West Africa than in African-Americans, who share the same or higher risk with Caucasians in America.

High blood pressure and unhealthy cholesterol levels -- the same important risk factors for heart disease and stroke -- may also be risk factors for Alzheimer's disease. In fact, they appear to be more important than ApoE4, the genetic factor most commonly associated with Alzheimer's disease.

Blood pressure is the force applied against the walls of the arteries as the heart pumps blood through the body. The pressure is determined by the force and amount of blood pumped and the size and flexibility of the arteries.

High Blood Pressure. Studies have reported an association between Alzheimer's disease and systolic hypertension (the higher and first number in blood pressure measurement). High blood pressure can cause problems with the vascular system, which is responsible for delivering blood to the brain. Recent research suggests that some types of blood pressure medication may lower Alzheimer's risk.

High Cholesterol Levels. Research indicates an association between high cholesterol levels and Alzheimer's disease in some people. One theory is that cholesterol regulates the processing and accumulation of amyloid beta-protein.

Click the icon to see an image of cholesterol.

Stroke. High blood pressure and heart disease can increase the risk for stroke. For people who have Alzheimer’s disease or mild cognitive impairment, stroke can increase the decline of cognitive function and accelerate dementia.

Diabetes. Patients with diabetes often have high blood pressure, lipid imbalances, and circulatory disorders that affect the heart and vascular system, which in turn increases the risk for Alzheimer’s. In patients who do not have other risk factors for Alzheimer’s, diabetes itself may increase risk. Research also suggests that diabetes can increase the risk for mild cognitive impairment, a condition that often precedes Alzheimer’s disease.

High Homocysteine Levels. Homocysteine is an amino acid that has been identified as a modest risk factor in heart disease. It has also been associated with a higher risk for Alzheimer's disease. High levels are general due to deficiencies of the B vitamins B6, B12, and folate. Such vitamins are also related to nerve protection. Researchers theorize that homocysteine impairs the ability of DNA to repair nerve cells. The weakened cells are then more vulnerable to the harmful effects of oxidized beta amyloid.

Nearly all patients who inherit Down syndrome develop changes in the brain that resemble Alzheimer's if they live into their 40s, although onset varies and can occur as late as age 70. Women under the age of 35, but not older mothers, who give birth to children with Down syndrome are also at much higher risk for Alzheimer's.

Lower Education and Economic Groups. A number of studies have reported either a higher risk for Alzheimer's disease in people with less education or a lower risk for Alzheimer's disease in those who remain mentally active. Some experts speculate that learning itself may stimulate more neurons to grow and thus create a larger reserve in the brain so that it takes longer for brain cells to be destroyed. Some evidence suggests that early malnutrition, which is more likely to occur in lower income and educational groups, has been associated with smaller brains and with Alzheimer's disease in old age. Low-birth weight can cause problems in growth factors that could affect both mental and physical health later on in adulthood.

Small Head Size. The size of the skull is fixed by age 7. Brain size approximates the head size until old age, when it begins to shrink. Some evidence has reported an association between small head size (and therefore less brain volume) and Alzheimer's disease, possibly because people who start with larger brains can sustain more injury over time. For example, a 2002 study indicated that it was reduction in overall brain volume, not specific regions, that contributed to mental impairment in older healthy adults. Another study reported that people who had small heads plus the ApoE4 gene had 14 times the risk for Alzheimer's disease than those without this combination. Nevertheless, other studies have found no association between a small head size and Alzheimer's disease.

Some experts suggest that the relationship observed in other research may simply be due to social and economic factors, such as malnutrition or low birth weight, which have been associated with both Alzheimer's disease and small head size. Small head size independent of other factors, they argue, does not pose a higher risk for either Alzheimer's disease or low intelligence

Depression. There is a significant overlap between depression and dementia in the elderly. In fact depression itself is often an early symptom of Alzheimer's disease. In a 2002 study of Catholic nuns, for each of four depressive symptoms, the risk for developing Alzheimer's disease increased by an additional 19%. For example, for a woman with four depressive symptoms the risk increased by 76%. Some evidence suggests that there may even be common genetic factors in people who have both early depression and Alzheimer's disease.

Head Injury. Some studies have found an association between serious head injuries in early adulthood and the development of Alzheimer's. It is not yet known if such injuries directly cause Alzheimer's or simply accelerate the disease in people who are already susceptible to it.

Prevention

Although there is no strong evidence that any lifestyle change can prevent Alzheimer's disease, studies suggest that certain behaviors may help protect against mental decline. In particular, medications and lifestyle choices that protect the heart may be of specific importance. Various preventive drugs are under investigation, including antioxidant and anti-inflammatory therapies.

In 2004, the National Institutes of Health (NIH) halted a large clinical trial that was investigating the use of anti-inflammatory drugs in preventing Alzheimer's disease. While prior data had confirmed that NSAIDs were not effective in treating AD, research continued to explore these drugs' potential preventive benefits.

The Alzheimer's Disease Anti-Inflammatory Prevention Trial (ADAPT) was launched in 2001 to investigate whether long-term use of naproxen (Aleve) or celecoxib (Celebrex) could decrease the risk of developing AD. The trial was based on the premise that because inflammation is known to be involved in the process of Alzheimer’s disease, anti-inflammatory drugs may help to prevent it. The NIH suspended this trial due to evidence that the NSAID naproxen was associated with increased incidence of cardiovascular and cerebrovascular events among participants. No adverse effects appeared during this trial for the COX-2 inhibitor celecoxib. However, heart safety concerns about this drug had been raised in other trials, and investigators did not believe that celecoxib's potential benefits outweighed its risks.

Since 2004, the ADAPT investigators have continued to monitor the trial’s participants to see if these treatments had any effect in changing their risk for Alzheimer’s. In an update analysis of ADAPT data published in 2007, the researchers announced that neither naproxen nor celecoxib appear to reduce the risk for Alzheimer’s.

The same lifestyle and medical choices that reduce risk factors for heart disease and diabetes are important for reducing the risk for Alzheimer's disease. And, experts believe that treating high blood pressure and diabetes may help slow the progression of Alzheimer’s disease. The following are some heart-protective medications that may also protect the brain.

Blood Pressure Drugs. Because high blood pressure is associated with increased risk of Alzheimer’s, researchers have been studying whether blood pressure medication can reduce this risk. In a 2006 study of patients who took high blood pressure drugs, researchers found that potassium-sparing diuretics reduced the risk of developing Alzheimer’s by 70%. Beta-blockers and certain calcium channel blockers also helped to a lesser extent. ACE inhibitors appeared to offer no protection.

Statins. Statins are common drugs used to lower cholesterol levels. In past years, a number of studies reported a significantly lower risk for Alzheimer's disease in patients who took statins. However, newer studies have failed to prove that statins can help prevent Alzheimer's disease. In these recent studies, large numbers of elderly people had their dementia evaluated at baseline and then monitored over several years. The results indicated that statin use did not predict onset of AD. In the meantime, the NIH is conducting a clinical trial to investigate whether simvastatin can slow the progression of AD.

Hormone Replacement Therapy. Hormone replacement therapy (HRT) has been studied for years for health effects after menopause, including its effect on mental decline. A number of studies, including a major 2003 analysis, have found no differences in mental performance and no protection from Alzheimer's disease in women taking HRT compared to non-users. The 2003 trial, called the Women's Health Initiative Memory Study (WHIMS), enrolled 4,500 women over 65 years of age. The WHIMS study showed that older postmenopausal women who took combination HRT (estrogen plus progestin) had twice the risk of developing dementia than similarly aged women who received placebo pills. In addition to increasing the risk for dementia (including Alzheimer's disease), combination HRT failed to prevent the development of mild cognitive impairment. Based on these results, the researchers from the National Institute on Aging (NIA) recommended against prescribing combination hormone therapy to older women for maintaining or improving cognitive function. The NIA continued to research whether estrogen-only therapy could prevent or delay the onset of Alzheimer's disease. Results released in 2004 indicated that women ages 65 years and older who took estrogen-only HRT had a slightly increased risk of developing dementia.

Testosterone. Some testosterone converts to estrogen, which may be why older men appear to have a lower risk for Alzheimer's disease than older women. Animal studies have suggested that testosterone may help reduce levels of beta amyloid. There is also some evidence that low testosterone levels may be a particular risk factor in men with the ApoE4 gene. Some experts believe that giving testosterone to elderly men, and combinations of testosterone and estrogen to older women, may prove to be protective. Side effects of testosterone in women include increased body hair, acne, fluid retention, anxiety, and depression. Long term benefits or serious adverse effects are unknown.

DHEA. Dehydroepiandrosterone (DHEA) is a male-like hormone in the body that declines with age. Some evidence suggests that it may help reduce mental decline in older women, but not in older men. Studies are under way. The hormone may, however, reduce HDL (the so-called good cholesterol) when taken in higher doses. While its effect on cancer-cell growth is unknown, some evidence indicates that high levels may increase cancer risk. In any case, DHEA is not regulated, and brands vary widely in their content.

Because Alzheimer's disease rates vary among different populations, investigators are researching how diet can help in prevention. Caloric intake itself may play a role in brain health. In one study on animals, restricting calories below normal (but above starvation levels) helped prevent age-related nerve degeneration. However, in patients with existing Alzheimer's, weight loss is a strong indicator of mental decline.

Fats and Oils. Some studies suggest an association between fat and Alzheimer's disease:

In China and Nigeria, where fat intake is low, the risk of developing Alzheimer's is 1% at age of 65 compared to 5% in the U.S.
A study in the Netherlands reported an association between dementia and diets high in total fat, saturated fat, and cholesterol.
A number of studies suggest that a high-fat high-calorie diet in people who carry the ApoE4 gene may confer a particularly high risk. For example, in one study, adults who carried the ApoE4 gene and whose diet consisted of 40% fat calories had 29 times the risk for Alzheimer's compared to non-ApoE4 carriers on the same high-fat diet.

The recommended dietary goal is to limit total fat intake to 25 - 35% of total daily calories. But not all fats are alike. Unhealthy fats include saturated fats (contained in animal products such as meat) and trans-fatty acids (contained in fast foods and commercially baked products). The American Heart Association recommends limiting saturated fat intake to less than 7% of total daily calories and trans-fatty acid intake to less than 1% of total daily calories.

It is best to replace saturated fats and trans-fatty acids with unsaturated fats from plant and fish oils. Omega-3 fatty acids are excellent sources of unsaturated fats. Plant sources of omega-3 fatty acids include canola oil, soybeans, flaxseed, and certain types of nuts such as walnuts. For fish sources, salmon, mackerel, sardines, lake trout, herring, and albacore tuna are especially high in marine omega-3 fatty acids. For heart health, and possibly brain health, experts recommend eating these types of fish at least twice a week.

Two types of omega-3 fatty acids are found in fish oils: Docosahexaenoic acid (DHA) and eicosapentaneoic acid (EPA). Researchers are particularly interested in the role that DHA may play in Alzheimer’s disease prevention. DHA has been linked to many brain cell functions, and appears to have particular importance for aging brains. Studies indicate that people who have higher blood levels of DHA have a much lower risk of developing dementia and Alzheimer’s disease.

Although evidence suggests that consuming DHA-rich foods later in life helps to increase DHA levels in the brain, it is unclear whether dietary supplements can provide similar benefits. A 2007 study indicated that omega-3 fatty acid supplements may help slow cognitive decline in some patients with very mild Alzheimer’s disease, but that the supplements have little effect for advanced stages of the disease. In 2007, the U.S. National Institutes of Health launched a large-scale clinical trial to evaluate whether DHA supplements can slow the progression of cognitive and functional decline in people with mild-to-moderate Alzheimer’s disease.

Mediterranean diet is an eating plan that has specific heart-health benefits. It is rich in fiber and nutrients, including omega-3 fatty acids and antioxidant vitamins. The diet emphasizes fish, fruits, vegetables, and monounsaturated (“good”) fats, particularly olive and canola oils. A 2006 study suggested that the Mediterranean diet may also be good for the brain. In the study, patients who strictly followed the diet had a 40% lower risk of developing Alzheimer’s disease than patients who ate a conventional American diet. Other studies also indicate the Mediterranean diet is associated with a lower risk for Alzheimer’s.

Omega-3 fatty acids, found plentifully in oily fish and flaxseed and canola oils, are beneficial to people afflicted with IBD (inflammatory bowel disease).

Fruits and Vegetables. According to several studies, eating plenty of darkly colored fruits and vegetables may slow brain aging. Blueberries, which are very rich in antioxidants, are of particular interest. A 2006 study of over 3,000 elderly adults found that consumption of vegetables (especially green leafy vegetables) helped reduce the rate of cognitive decline, but fruit intake had no effect.

Alcohol. Some studies have suggested that moderate intake of alcohol (one or two drinks a day) may protect the aging brain, possibly by releasing acetylcholine, the chemical in the brain that is deficient in Alzheimer's disease. Not all studies have been positive. In any case, heavy alcohol consumption offers no protection and is dangerous.

Folate and Vitamin B12. Some studies suggest that deficiencies of vitamins B6, B12, and folate (folic acid) may be a risk factor for Alzheimer' diseases. Deficiencies in these vitamins can increase homocysteine levels, which some research associates with a higher risk for Alzheimer's disease. Foods containing folate include avocados, bananas, oranges, asparagus, green leafy vegetables, and dried beans. In the United States and some other countries, grain and cereal products are fortified with folate. B12 is found only in animal, dairy, and fish products. B6 is found in a variety of foods, including fortified cereals, beans, meat, fish, and some fruits and vegetables.

Click the icon to see an image of vitamin B12 sources.

Click the icon to see an image of folate sources.

Research is still inconclusive and conflicting about whether increased consumption of folate, through food or dietary supplements, can help prevent Alzheimer’s disease or slow its progression. A small 2006 study of healthy older adults, published in the New England Journal of Medicine, found that supplements containing folate, vitamin B12, and vitamin B6 did not help improve cognitive performance. A 2007 Lancet study indicated that folic acid supplements may help slow cognitive decline. People in the Lancet study took 800 mcg of folic acid daily, which is twice the recommended daily allowance of 400 mcg. However, this study was conducted in the Netherlands, where people tend to get less folate in their daily diets than in the United States.

Another 2007 study found that elderly people who consumed folate from both diet and supplement sources had a reduced risk for Alzheimer’s disease. Neither diet alone nor supplements alone affected Alzheimer’s risk; only the combination of the two produced an effect. The study also indicated that vitamins B6 and B12 do not affect Alzheimer’s risk.

Antioxidant Supplements. Much research on Alzheimer's disease has indicated that oxidation (release of damaging unstable particles) may play an important role in the disease process. Some reports, including a large 2002 population study, have suggested that vitamin E intake, from food or supplements, may protect against mental decline. Other studies suggest that vitamin E protects only those who carried the ApoE4 gene. Most of the evidence finding any benefits from other antioxidants comes from using a combination of antioxidant vitamins, such as vitamins C and E, but not from using them separately. However, there is no strong evidence of protection to date from using antioxidant supplements.

Physical Exercise. Studies indicate that exercise may help prevent the development of Alzheimer’s disease and other forms of dementia. A 2006 study found that older adults (65 years and older) who exercised three times a week reduced their risk for Alzheimer’s by about 40%. Exercise in the study included walking, hiking, aerobics, calisthenics, swimming, water aerobics, weight training, and stretching.

Mental Exercise. Cognitive training that includes exercises to stimulate memory, reasoning, and mental processing speed may help improve both mental ability and daily functioning. In an important 2006 study in the Journal of the American Mental Association, older community-dwelling adults who received cognitive training showed reductions in cognitive decline. In addition, they were better able to handle daily living tasks -- such as performing housework, managing money, and preparing meals -- than people who did not receive the training. The benefits of cognitive training lasted for up to 5 years afterwards. Other studies indicate that participating in intellectually engaging activity -- such as doing crossword puzzles or learning a new language -- may help reduce the risk of Alzheimer’s disease.

Social Interaction. Social interaction is also important for maintaining emotional health as well as keeping the mind active and energized. A 2007 study indicated that adults who are lonely have twice the risk of developing Alzheimer’s dementia as those who are not socially isolated.

Symptoms

The early symptoms of Alzheimer's disease (AD) may be overlooked because they resemble signs of natural aging. Older adults who begin to notice a persistent mild memory loss of recent events may have a condition called mild cognitive impairment (MCI). MCI is now believed to be a significant sign of early-stage Alzheimer's in older people. Studies now suggest that older individuals who experience such mild memory abnormalities can later develop Alzheimer's disease.

Early symptoms of Alzheimer's disease may include:

Forgetfulness (particularly of recent events or information)
Loss of concentration (having trouble planning or completing familiar tasks, difficulty with abstract thinking such as simple arithmetic problems)
Language problems (forgetting the names of objects, mixing up words, difficulty completing sentences)
Confusion about time and place (difficulty recognizing familiar neighborhoods or remembering how you arrived at a location, confusion about months or seasons )
Impaired judgment (dressing inappropriately or making poor financial decisions)
Impaired movement and coordination (slowing of movements, halting gait, reduced sense of balance)
Mood and behavior changes (rapid mood swings, emotional outbursts, personality changes, increased fear or suspicion)
Apathy and depression (loss of interest in activities, increased sleeping, sitting in front of the television for long periods of time)

Diagnosis

A definitive test to diagnose Alzheimer's disease, even in patients showing signs of dementia, has not yet been developed. A number of expert groups have developed criteria to help diagnose Alzheimer's disease and rule out other disorders. A diagnosis often involves answering questions about the patient:

Do psychological tests indicate dementia?
Does the patient have deficits in two or more areas of mental functioning (such as language, motor skills, and perceptions)?
Has memory and mental functions gotten progressively worse?
Is consciousness disturbed? (It is not in Alzheimer's disease.)
Is the patient over age 40?
Are other medical or physical conditions present that could account for the same symptoms?
Are daily activity impaired or has the behavior changed?
Is there a family history of Alzheimer's disease?
Are there other symptoms, such as depression, insomnia, incontinence, delusions, hallucinations, dramatic verbal, emotional or physical outbursts, sexual disorders, and weight loss?

Other steps involved in making a decision include laboratory tests (EEG and possibly tests to rule out other diseases) and psychological testing to determine the presence of dementia.

Although some memory impairment occurs in many people as they age, only some of these people develop Alzheimer's disease. Many similar symptoms can occur in healthy older individuals from other conditions associated with aging:

Fatigue
Grief or depression
Illness
Vision or hearing loss
The use of alcohol or certain medications
Simply the burden of too many details to remember at once

The first step in diagnosing Alzheimer's disease is to rule out other conditions that might cause memory loss or dementia. There are a number of causes for dementia in the elderly besides Alzheimer's disease:

Vascular dementia (abnormalities in the vessels that carry blood to the brain)
Lewy bodies variant (LBV), also called dementia with Lewy bodies
Parkinson's disease
Frontotemporal dementia

Experts believe that 60% of cases of dementia are due to Alzheimer's, 15% to vascular injuries, and the rest are a mixture of the two or caused by other factors.

Vascular Dementia. Vascular dementia is primarily caused by either multi-infarct dementia (multiple small strokes) or Binswanger's disease (which affects tiny arteries in the midbrain). One major analysis suggested that patients with vascular dementia have better long-term verbal memory than patients with Alzheimer's disease, but poorer executive function (less ability to integrate and organize).

Lewy Bodies Variant. Lewy bodies are abnormalities found in the brains of patients with both Parkinson's disease and Alzheimer's. They can also be present in the absence of either disease; in such cases, the condition is called Lewy bodies variant (LBV). In all cases, the presence of Lewy bodies is highly associated with dementia. LBV was defined in 1997, and some experts believe it may be responsible for about 20% of people who have been diagnosed with Alzheimer's. They can be difficult to distinguish. Compared to Alzheimer's disease patients, those with LBV may be more likely to have hallucinations and delusions early on, to walk with a stoop (similar to Parkinson's disease), to have more fluctuating attention problems, and to perform better than Alzheimer's disease patients on verbal recall but less well with organizing objects.

Parkinson's Disease. Dementia is about six times more common in the elderly Parkinson patient than in the average older adult. It is most likely to occur in older patients who have had major depression. Unlike in Alzheimer's, language is not usually affected in Parkinson's related dementia. Visual hallucinations occur in about a third of people on long-term medications.

Parkinson's disease is a slowly progressive disorder that affects movement, muscle control, and balance. Part of the disease process develops as cells are destroyed in certain parts of the brain stem, particularly the crescent-shaped cell mass known as the substantia nigra. Nerve cells in the substantia nigra send out fibers to tissue located in both sides of the brain. There the cells release essential neurotransmitters that help control movement and coordination.

Frontotemporal Dementia (FTD). Once considered rare, FTD is now considered to be the second most common cause of early-onset dementia. People who develop this condition tend to be in their mid-fifties although it can develop later on. It results in greater behavioral impairment (apathy, reduced empathy, poor self-care, unrestrained behavior) than with Alzheimer's disease. It may also be marked by speech problems and early incontinence. Brain imaging scans can help diagnose this problem.

Other Conditions that Cause Similar Symptoms. Some elderly people have a condition called mild cognitive impairment, which involves more severe memory loss than normal but no other symptoms of Alzheimer's. A number of conditions, including many medications, can produce symptoms similar to Alzheimer's:

Severe depression
Drug abuse
Thyroid disease
Severe vitamin B12 deficiency
Blood clots
Hydrocephalus (excessive accumulation of spinal fluid in the brain)
Syphilis
Huntington's disease
Creutzfeldt-Jakob disease
Brain tumors

It is important that the doctor recognize any treatable conditions that might be causing symptoms or worsening existing dementia caused by Alzheimer's or vascular abnormalities.

A number of psychological tests are used or being developed to assess difficulties in attention, perception, and memory and problem-solving, social, and language skills. Experts are researching specific tests that may help identify early on people with mild memory impairment who are at high risk for Alzheimer's disease.

Two commonly used tests that are very useful in identifying individuals who may be at risk for Alzheimer's are the Mini-Mental State Exam (MMSE) and the Mattis Dementia Rating Scale. Still, these tests have limitations.
A clock drawing test is also a good test for Alzheimer's disease. The patient is given a piece of paper with a circle on it and is first asked to write the numbers in the face of a clock and then to show "10 minutes after 11." The score is based on spacing between the numbers and the positions of the hands.

Electroencephalography (EEG) traces brain-wave activity; in some patients with Alzheimer's disease this test reveals "slow waves." EEG data helps distinguish a potential patient with Alzheimer's disease from a patient with severe depression, whose brain waves are normal.

Imaging tests include magnetic resonance imaging (MRI), positron-emission tomography (PET), and single photon emission computed tomography (SPECT). These tests are sometimes used to rule out other disorders, such as multi-infarct dementia, stroke, blood clots, and tumors. Research is being conducted to determine if these tests can help to confirm a diagnosis of Alzheimer's disease and improve understanding of disease progression. Researchers hope that imaging tests may also be able to provide diagnoses of Alzheimer’s disease while it is still in its early stages.

In 2006, scientists developed a new imaging molecule called FDDNP that they hope will enable earlier detection of Alzheimer’s disease. Research also continues on Pittsburgh compound B, a tracer molecule used in PET brain scans to highlight beta-amyloid protein deposits. Results from all this research may help to define potential drug targets and aid in the development of new Alzheimer's drugs.

Click the icon to see an image of an MRI of the brain.

In 2005, the National Institute of Aging, in collaboration with industry partners, launched the $60 million Alzheimer's Disease Neuroimaging Initiative (ADNI). This landmark 5-year clinical trial, which will be conducted at 50 sites throughout the United States and Canada, will investigate whether neuroimaging techniques, such as MRI and PET scans, can be combined with biomarkers and neuropsychological tests to measure the progression of AD and mild cognitive impairment. In 2004, the U.S. Medicare system expanded insurance coverage of PET scans for eligible beneficiaries who meet specific diagnostic criteria for both Alzheimer's disease and fronto-temporal dementia. Medicare also covers the costs for patients enrolled in its agency-approved imaging clinical trials.

Blood Tests. Blood tests are currently used to check for anemia and other disorders that can produce dementia symptoms. Investigators are researching serum biomarkers, such as the iron transport protein p97, that might help detect the presence of Alzheimer's disease.

Cerebrospinal Fluid Test. Scientists are developing new nanotechnology screening methods that may eventually be used to identify Alzheimer's disease while it is still in its earliest stages and before plaque deposits accumulate. In 2005, a research team announced it had used a bio-barcode assay to detect tiny amounts of a protein called amyloid-beta-derived diffusable ligand (ADDL) in cerebrospinal fluid. ADDLs may be involved in cognitive decline and are a potential biomarker for early stage Alzheimer's disease. Tests for other proteins are also being developed.

Odor Test. Investigators are also using the impairment of smell in Alzheimer's disease to develop tests that require patients to distinguish between odors.

Once a diagnosis has been made, some experts observe that certain factors at the time of diagnosis indicate a higher risk for a more rapid decline:

Older age
Being male
The presence of high blood pressure
Signs of loss of motor control and coordination
Tremor
Social withdrawal
Loss of appetite and severe weight loss
Accompanying sensory problems, such as hearing loss and a decline in reading ability
General physical debility

Medications

Most drugs used to treat Alzheimer's, and those under investigation, are aimed at slowing progression. There are no cures to date. In addition, the improvements from some of these drugs may be so modest that even the patients and their families are not aware of them. Even in these cases, however, the drugs may delay the need for admission to nursing homes.

There are currently two drug classes that have been approved by the U.S. Food and Drug Administration (FDA) to treat the cognitive symptoms of Alzheimer's disease:

Cholinesterase inhibitors (generally used to treat mild-to-moderate Alzheimer's; donepezil is also approved for treatment of severe dementia )
N-methyl-D-aspartate (NMDA) receptor antagonists (used to treat moderate-to-severe Alzheimer's)

Cholinesterase inhibitors are designed to protect the cholinergic system, which is essential for memory and learning and is progressively destroyed in Alzheimer's. These drugs work by preventing the breakdown of the brain chemical acetylcholine and are recommended for the treatment of mild-to-moderate Alzheimer's. The first cholinesterase inhibitor, tacrine, was approved in 1993 but is rarely prescribed today due to safety concerns. The three most commonly prescribed cholinesterase inhibitors are donepezil (approved in 1996), rivastigmine (approved in 2000), and galantamine (approved in 2001).

Cholinesterase inhibitors may increase the risk for gastrointestinal bleeding or ulcers, and patients should be cautious about using these medicines with NSAIDs (which can also cause gastric irritation). Common side effects of cholinesterase inhibitors, especially when taken at higher doses, may include nausea, vomiting, diarrhea, and upset stomach.

Donepezil. Donepezil (Aricept) is the only Alzheimer’s drug approved for all stages of dementia, from mild to severe. It is taken once a day and has only modest benefits, but it does help slow loss of function and reduce caregiver burden. It works equally in patients with or without the ApoE4 gene. Several trials, including an important 2005 New England Journal of Medicine (NEJM) study, have found that donepezil may have short-term benefits for patients with mild cognitive impairment by delaying progression to AD. In the NEJM study, donepezil slowed progression during the first year of therapy, but demonstrated no benefits by the conclusion of the 3-year trial. Studies also suggest that donepezil may help improve behavior and memory in patients with moderate-to-severe Alzheimer’s when it is given in combination with memantine (Namenda).
Rivastigmine. Rivastigmine (Exelon) targets two enzymes: Acetylcholinesterase and butyrylcholinesterase. It is taken as a pill twice a day. (The FDA approved a skin patch version of the drug in 2007.) Rivastigmine may be particularly helpful for patients with rapidly progressing disease. It has slowed or slightly improved disease status even in patients with advanced disease. Rivastigmine may cause significantly more side effects than donepezil, including nausea, vomiting, and headache.
Galantamine (Razadyne). Galantamine not only protects the cholinergic system but also acts on nicotine receptors, which are also depleted during Alzheimer's. Studies report that it improves daily living, behavior, and mental functioning, including in patients with mild to advanced-moderate Alzheimer's disease and those with a mix of Alzheimer's disease and vascular dementia. Some studies have suggested that the effects of galantamine may persist for a year or longer and even strengthen over time. In 2005, the name of galantamine was changed from Reminyl to Razadyne.
Tacrine. Tacrine (Cognex) was the first cholinergic protective drug. It needs to be taken four times a day, has only modest benefits, and has no benefits for patients who carry the ApoE4 gene. In high doses, it can also injure the liver. In general, newer cholinergic protective drugs that do not pose as great a risk for the liver are now used for Alzheimer's.

About half of patients with mild-to-moderate disease show slight improvement with these drugs. Comparative studies have reported little differences in effectiveness among them. All drugs have gastrointestinal side effects, including nausea. Of note, some of the drugs often used in elderly Alzheimer's disease patients are known as anticholinergics and may offset the effects of the Alzheimer's disease pro-cholinergic drugs. Such drugs include antihistamines, antipsychotic drugs, and some anti-incontinence drugs.

In any case, the benefits of these drugs are far from dramatic. In fact, many experts have reservations about developing any additional drugs that affect the cholinergic system since, at best, they only slow progression and do not appear to affect the basic destructive disease process. When patients go off the drugs, the deterioration continues. In 2005, the United Kingdom’s National Institute for Clinical Excellence (NICE) recommended against the use of donepezil, rivastigmine, galantamine, and memantine for Alzheimer’s disease treatment. The agency contended that the costs of these drugs outweigh their modest benefits.

Memantine (Namenda) is approved for treatment of moderate-to-severe Alzheimer’s disease. (Most cholinesterase inhibitors are used to treat mild-to-moderate stages of the disease.) By blocking NDMA receptors, memantine protects against the overstimulation of glutamate, an amino acid that excites nerves and, in excess, is a powerful nerve-cell killer.

Memantine is prescribed either alone or in combination with donepezil. Studies indicate that memantine may help improve cognitive function and delay the progression of Alzheimer’s disease for up to 1 year. Side effects are generally mild but may include dizziness, drowsiness, or fainting.

In one study of effects on moderate-to-severe Alzheimer's, patients who received memantine showed a small but statistically significant benefit in cognitive function and performance of daily abilities compared with those patients who were given placebo. In a 2004 study, memantine was added to the drug regimen of patients with moderate-to-severe Alzheimer's who had taken donepezil for at least 6 months. In comparison to patients who took only donepezil, patients who received the combination donepezil-memantine therapy showed a greater improvement in measures of cognitive function, activities of daily living, and behavior parameters. A 2006 study indicated that memantine combined with donepezil may help reduce behavior problems -- such as agitation, aggression, and irritability -- and improve disturbances in appetite and eating.

Although cholinesterase inhibitors and memantine are the best available medications for Alzheimer's, their benefits are, unfortunately, quite modest. More effective methods of prevention and treatment are urgently needed.

There has been considerable controversy over whether NSAIDs may help in the treatment of Alzheimer's disease. As inflammation is involved in the destruction of brain cells, it has been suggested that anti-inflammatory drugs might be able to halt this process and thus slow the progression of the disease. In a rigorous 2003 study, patients with mild-to-moderate Alzheimer's were randomized to receive either naproxen (Aleve) or rofecoxib (Vioxx) or placebo. After 12 months of treatment, patients in the anti-inflammatory groups did not show any difference in cognitive improvement compared to those patients who received placebo.

Results from another large study, published in 2004, also failed to demonstrate improvement in cognitive function for patients with mild-to-moderate Alzheimer's who were treated with rofecoxib. Since the completion of these studies, rofecoxib was withdrawn from the market, and the NIH suspended a clinical study assessing naproxen’s preventive benefits (see Nonsteroidal Anti-Inflammatory Drugs as Prevention). As mentioned earlier, patients should be cautious about taking NSAIDs in combination with cholinesterase inhibitors as they may increase the risk of gastrointestinal bleeding.

Nicotine enhances the actions of the cholinergic system (which is depleted in Alzheimer's disease) and is known to improve concentration and memory in the short term. Some studies have suggested that nicotine may protect nerve cells and help prevent the formation of beta amyloid. One study indicated that nicotine might help protect against Alzheimer's disease in carriers, but not noncarriers, of the ApoE4 gene. Another reported improvement in verbal recall and word retrieval in healthy relatives of Alzheimer's disease patients who wore a low-dose nicotine patch. Research to date, however, has found no strong evidence of improvement in Alzheimer's disease patients with nicotine replacement methods. No one should smoke to prevent or treat Alzheimer's disease.

Manufacturers of herbal remedies and dietary supplements do not need FDA approval to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been several reported cases of serious and even lethal side effects from herbal products. Always check with your doctor before using any herbal remedy or dietary supplement.

Ginkgo Biloba. Ginkgo biloba is a common herb that has antioxidant properties and appears to increase blood flow to the brain. A 2002 study of healthy people who took over-the-counter ginkgo for 6 weeks reported no improvements in memory or mental function. Studies are reporting that a ginkgo biloba extract, called Egb 761, may slightly improve the memory of patients with mild to moderate Alzheimer's disease. The herb poses a small increased risk for bleeding, which may be hazardous in combination with other blood-thinning medications, such as warfarin or high-doses of vitamin E.

Turmeric. Studies suggest that circumin, a compound found in the spice turmeric, has properties that may protect against the Alzheimer's disease process.

Melatonin. Melatonin, a natural hormone involved in sleep regulation, is of interest to researchers. It is an antioxidant, may break down beta amyloid, and is able to pass through the blood-brain barrier. Deficiencies have been observed in patients with Alzheimer's disease. A number of studies (but not all) report that melatonin may improve sleep habits in these patients. Some studies reported slower progression of mental impairment.

A number of drugs are being investigated for treatment and prevention of Alzheimer's disease. Intense areas of research are focusing on drugs that prevent beta amyloid build-up, its toxic effects on nerve cells, or other mechanisms of the disease process. Promising research in late-stage clinical trials include.

Tramiprosate (Alzhemed) is an experimental drug designed to prevent beta-amyloid accumulation in the brain.
Flurizan (MPC-7869) may help reduce amyloid plaque development. It is currently being studied in Phase III trials for adults with mild Alzheimer’s disease.
Rosiglitazone XR (Avandia) is an extended-release formulation of a drug used to treat type 2 diabetes. Its anti-inflammatory properties are being studied as a treatment for patients with mild-to-moderate Alzheimer’s who do not carry the APOE-e4 gene. Phase III results have been promising, but this drug has been linked to increased risk for heart attack deaths in patients with diabetes. In 2007, a panel of experts from the Food and Drug Administration (FDA) agreed the drug increases the risk of heart attacks -- but concluded it should remain on the market. The panel did, however, recommend the FDA require rosiglitazone's maker to add warnings to the drug's label. Patients or caregivers of patients who take rosiglitazone, especially those who have heart disease or who are at high risk for heart attack, should discuss their treatment options with their doctors.
Dimebon is an antihistamine, which researchers think may help prevent brain cell death. The drug is currently in Phase II trials.
Antioxidants such as vitamin E and selenium are being investigated for their preventive effects. Antioxidant treatment trials include curcumin (the yellow pigment found in turmeric spice) and a combination trial with fish oil and alpha-lipoic acid.

Depression. Major depression with dementia that occurs in elderly people may be an early sign of Alzheimer's. In such cases, it precedes Alzheimer's by 2 years or less. (It is, in fact, sometimes difficult to differentiate major depression from early-stage Alzheimer's disease.) Antidepressants known as selective serotonin reuptake inhibitors (SSRIs), including fluoxetine (Prozac) and sertraline (Zoloft), may be effective in relieving depression, irritability, and restlessness associated with Alzheimer's in some patients.

Apathy. Depression is often confused with apathy. An apathetic patient lacks emotions, motivation, interest, and enthusiasm while a depressed patient is generally very sad, tearful, and hopeless. According to one study, apathy is more common than depression in patients with Alzheimer's disease. It responds to stimulants, such as methylphenidate (Ritalin), rather than antidepressants.

Psychosis. Antipsychotic drugs are used to treat verbally or physically aggressive behavior and hallucinations. Because older antipsychotic drugs, such as haloperidol (Haldol), have severe side effects, most doctors now prescribe newer atypical antipsychotics, such as risperidone (Risperdal) or olanzapine (Zyprexa).

However, these newer antipsychotic drugs still can cause serious side effects, including confusion, sleepiness, and Parkinsonian-like symptoms. In addition, studies indicate that their safety risks may outweigh any possible benefits. A 2005 study showed that these drugs produce a slightly increased rate of death in patients with Alzheimer’s disease or dementia. In addition, several studies from 2006 and 2007 published in the New England Journal of Medicine suggested that atypical antipsychotics work no better than placebo in controlling psychosis, aggression, and agitation in patients with Alzheimer’s.

Most experts now recommend that doctors delay prescribing antipsychotic medication unless absolutely necessary. They recommend first trying behavioral treatments and controlling changes in the patient’s environment and routine. Anti-seizure drugs, such as carbamazepine (Tegretol) or valproate (Depakote), can also sometimes treat agitation and other psychotic symptoms. Non-drug treatments, such as bright light boxes, are also showing promise for managing psychotic and behavioral symptoms.

Disturbed Sleep. Patients with Alzheimer's disease commonly experience disturbances in their sleep/wake cycles. Moderately short-acting sleeping drugs, such as temazepam (Restoril), zolpidem (Ambien), or zaleplon (Sonata), or sedating antidepressants, such as trazodone (Desyrel, Molipaxin), may be useful in managing insomnia. Some research suggests that exposure to brighter-than-normal artificial light during the day for patients with normal vision may help reset wake/sleep cycles and prevent nighttime wandering and sleeplessness. Trials on melatonin, a natural hormone that helps trigger sleep at night, are in progress.

Stages

The lifespan of patients with Alzheimer's is generally reduced, although a patient may live anywhere from 3 - 20 years after diagnosis. The final phase of the disease may last from a few months to several years, during which time the patient becomes increasingly immobile and dysfunctional. Caregivers should understand the phases of this illness in order to help determine their own capacities for dealing with this painfully sad disease.

Telling the Patient. Often doctors will not tell patients that they have Alzheimer's. If a patient expresses a need to know the truth, it should be disclosed. Both the caregiver and the patient can then begin to address issues that can be controlled, such as access to support groups and drug research.

Mood and Emotional Behavior. Patients display abrupt mood swings, and many become aggressive and angry. Some of this erratic behavior is caused by chemical changes in the brain. But it may also be due to the experience of losing knowledge and understanding of one's surroundings, causing fear and frustration that patients can no longer express verbally.

The following recommendations for caregivers may help soothe patients and avoid agitation:

Keep environmental distractions and noise at a minimum if possible. (Even normal noises, such as people talking outside a room, may seem threatening and trigger agitation or aggression.)
Speak clearly. Most experts recommend speaking slowly to a patient with Alzheimer's disease, but some caregivers report that patients respond better to clear, quickly spoken, short sentences that they can more easily remember.
Use a combination of facial expressions, voice tones, and words for communicating emotions. (One study suggested that patients may have difficulty in recognizing the meaning of facial expressions, particularly those signaling sadness, surprise, and disgust.)
Limit choices (such as clothing selection).
Offer diversions, such as a snack or car ride, if the patient starts shouting or exhibiting other disruptive behavior.
Simply touching and talking may also help.
Maintain as natural an attitude as possible. Patients with Alzheimer's disease can be highly sensitive to the caregiver's underlying emotions and react negatively to patronization or signals of anger and frustration.
Showing movies or videos of family members and events from the patient's past may be comforting.

Although much attention is given to the negative emotions of patients with Alzheimer's disease, some patients become extremely gentle, retaining an ability to laugh at themselves or appreciate simple visual jokes even after their verbal abilities have disappeared. Some patients may seem to be in a drug-like or "mystical" state, focusing on the present experience as their past and future slip away. Encouraging and even enjoying such states may bring some comfort to a caregiver.

There is no single Alzheimer's personality, just as there is no single human personality. All patients must be treated as the individuals they continue to be, even after their social self has vanished.

Appearance and Cleanliness. For the caregiver, grooming the patient may be an alienating experience. For one thing, many patients resist bathing or taking a shower. Some spouses find that showering with their afflicted mate can solve the problem for a while. Often patients with Alzheimer's disease lose their sense of color and design and will put on odd or mismatched clothing. It is important to maintain a sense of humor and perspective and to learn which battles are worth fighting and which ones are best abandoned.

Driving. As soon as Alzheimer's is diagnosed, the patient should be prevented from driving. One study found that more than half of elderly people involved in fatal accidents had some degree of neurologic damage.

Wandering. A potentially dangerous trait is the patient's tendency to wander. At the point the patient develops this tendency, many caregivers feel it is time to seek out nursing homes or other protective institutions for their loved ones. For those who remain at home, the following precautions are recommended:

Locks should be installed outside the door, which the caregiver can open, but the patient cannot.
Alarms may be installed at exits.
A daily exercise program should be implemented, which may help tire the patient. One study showed that walking 30 minutes, three times a day, also improved communication.
The caregiver should contact organizations, such as Alzheimer's Association or Medic Alert, for identification supplies and procedures that help locate patients who wander away from home and become lost.
Some experts are discussing the benefits versus the ethics of electronic tagging, which would emit a radio signal or alarm that allows the patient to be tracked using a detector.

Speech Problems. Some evidence suggests that speech therapy combined with Alzheimer's disease medications may be helpful for maintaining verbal skills patients with mild symptoms.

Sexuality. In many cases, the patient becomes uninhibited sexually. At the same time, the patient's physical deterioration and receding capacity to recognize the spouse as a known and loved individual can make sexual activity unattractive for the caregiving spouse. Other patients may lose interest in sex. If sexual issues are a problem, they should be discussed openly with the doctor. Ways should be found to maintain non-sexual physical affection that can bring comfort to both the patient and the spouse.

Patients with Alzheimer's disease need 24-hour a day attention. Even if the caregiver has the resources to keep the patient at home during later stages of the disease, outside help is still essential. If available, home visits by a health profession can have a favorable impact on survival and delay the need for a nursing home. Medicare now covers many Alzheimer's services, and patients should be able to stay at home longer than previously.

Incontinence. A patient's incontinence is generally devastating to the caregiver and a primary reason why many caregivers decide to seek nursing home placement when the patient reaches this stage. When the patient first shows signs of incontinence, the doctor should make sure that it is not caused by an infection. Urinary incontinence may be controlled for some time by trying to monitor times of liquid intake, feeding, and urinating. Once a schedule has been established, the caregiver may be able to anticipate incontinent episodes and get the patient to the toilet before they occur.

Immobility and Pain. As the disease progresses, patients become immobile, literally forgetting how to move. Eventually, they become almost entirely wheelchair-bound or bedridden. Bedsores can be a major problem. Sheets must be kept clean, dry, and free of food. The patient's skin should be washed frequently, gently blotted thoroughly dry, and moisturizers applied. The patient should be moved every 2 hours and the feet kept raised with pillows or pads. Exercises should be administered to the legs and arms to keep them flexible.

Dehydration. Dehydration can become a problem. It is essential to encourage fluid intake equal to 8 glasses of water daily. Coffee and tea are diuretics and will deplete fluid.

Eating Problems. Weight loss and the gradual inability to swallow are two major related problems in late-stage Alzheimer's and are associated with an increased risk of death. Weight gain, however, is linked to a lower risk of dying. The patient can be fed through a feeding syringe, or the caregiver can encourage chewing action by pushing gently on the bottom of the patient's chin and on the lips. The caregiver should offer the patient foods of different consistency and flavor. Because choking is a danger, the caregiver should learn to administer the Heimlich maneuver, which may be taught by the local Red Cross. In very late stages, some caregivers choose feeding tubes for the patient. They should be aware that feeding tubes have no measurable impact on survival.

About 80% of patients with Alzheimer's disease are cared for by family members, who often lack adequate support, finances, or training for this difficult job. Few diseases disrupt patients and their families so completely or for so long a period of time as Alzheimer's. The patient's family endures two separate losses and grieves twice:

First, they must grieve for the ongoing disappearance of the personality they recognize. Dealing with the patient throughout the course of the disease is like Alice's fall down the rabbit hole into Wonderland. No sooner has the caregiver grappled with one set of problems, when the patient's further deterioration creates new and more intractable ones.
Finally, the caregiver must grieve the actual death of the person.

Often, caregivers themselves begin to show signs of mental disorder or ill health. Depression, empathy, exhaustion, guilt, and anger can play havoc with even a healthy individual faced with the care of a loved one suffering from Alzheimer's.

Fortunately, research shows that intensive support services can greatly improve caretakers’ quality of life and make it easier for them to continue caring for patients in their homes. In a 2006 study, caregivers who received individual and family counseling, telephone counseling, support groups, and stress management and problem-solving techniques reported reduced rates of depression and improved self-confidence compared with those who received only written educational materials. Another 2006 study indicated that improving caregivers’ access to counseling and support services can help delay nursing home placement of patients. National and local Alzheimer's associations can provide important support and other services.

A point comes when the most devoted caregiver will probably need to institutionalize the patient. That point is determined not only by the caregiver's emotional endurance, but also by their physical strength and stamina, as a patient typically takes on the random, undisciplined behavior of a very young child. Financial considerations in finding a nursing home are often paramount, but the kind of care is equally important. Although fully half of all nursing home patients suffer from Alzheimer's, not all nursing homes have programs specifically designed for them. Some institutions may claim that they do, but often they simply group patients together without offering any special programs. If a caregiver manages to find a facility that offers good services, it may be located far from home, making visits difficult. The caregiver must then decide whether superior care at a distant institution is worth seeing the patient less frequently. When the patient's illness becomes terminal, a hospice program may be another option.

1. Although I cannot control the disease process, I need to remember I can control many aspects of how it affects my relative.

2. I need to take care of myself so that I can continue doing the things that are most important.

3. I need to simplify my lifestyle so that my time and energy are available for things that are really important at this time.

4. I need to cultivate the gift of allowing others to help me, because caring for my relative is too big a job to be done by one person.

5. I need to take one day at a time rather than worry about what may or may not happen in the future.

6. I need to structure my day because a consistent schedule makes life easier for me and my relative.

7. I need to have a sense of humor because laughter helps to put things in a more positive perspective.

8. I need to remember that my relative is not being difficult on purpose; rather their behavior and emotions are distorted by the illness.

9. I need to focus on and enjoy what my relative can still do rather than constantly lament over what is gone.

10. I need to increasingly depend upon other relationships for love and support.

11. I need to frequently remind myself that I am doing the best that I can at this very moment.

12. I need to draw upon the Higher Power, which I believe is available to me.

Source: The American Journal of Alzheimer's Care and Related Disorders & Research, Nov/Dec 1989

Resources

www.alzheimers.org -- Alzheimer's Disease Education and Referral Center
www.alz.org -- Alzheimer's Association
www.alzforum.org -- Alzheimer's Research Forum
www.alzfdn.org -- Alzheimer's Foundation of America
www.alz.co.uk -- Alzheimer's Disease International
www.nia.nih.gov -- National Institute on Aging
www.ninds.nih.gov -- National Institute of Neurological Disorders and Stroke
www.aan.com -- American Academy of Neurology
www.medicalert.org -- Medic Alert
www.ahaf.org -- American Health Assistance Foundation
www.clinicaltrials.gov -- Find clinical trials
www.medicare.gov/NHCompare/Home.asp -- Find a nursing home

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Review Date:
7/31/2007
Reviewed By:
Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

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