FitSugar

Save Your Money: The Chin Gym

FitSugar — Fri, 23 Feb 2007 03:30:00 -0800

I was watching some old Ellen (I know, I am obsessed with her) videos the other day and came across her mom, Betty, trying out "As Seen on TV" fitness contraptions. One product, the Chin Gym, caught my eye as I thought there was no way this product existed but I was wrong, it does exist.

The Chin Gym ($39.95) is basically a really complicated looking contraption that promises to reduce the double chin and define the jaw line by trimming, toning, strengthening and removing wrinkles from chin, neck and jaw line muscles. Here is the deal, the only thing really able to rewind the effects of aging and gravity is plastic surgery if you are willing to go that far. If you're looking to remove excess fat from your facial area, unfortunately there is no real way to spot reduce target areas like your chin or your back. I know I may sound like a broken record, but it is true: Exercise and eating a healthy blanced diet are the only real ways to get rid of fat (without going under the knife) including your chin and back. If, despite my attempts to talk you out of spending your money on this contraption, you still want to try it out, diyhut.com.

Want to laugh at Ellen's mom trying it out? Then, read more

Double Chin Trouble

FitSugar — Tue, 26 Dec 2006 03:17:58 -0800

Are worries over a double chin bringing you down?

I wish more than anything that I could tell you there is a simple work out to tone up your chin but unfortunately fat is fat (no matter where it is). The only way to get rid of fat is with a total-body weight-loss program (eating healthy and working out), which can help you lose some fat in your neck and face.

More than fat, the bigger threats to a firm, youthful chin are gravity, sun exposure, smoking, genetics and the passage of time.

Trust me, if there were such a work out, I'd be spreading the info like wildfire but there's not. I hate to sound like a broken record, but the best way to have a toned chin for now is: Don't smoke, wear sunscreen and try to maintain a healthy weight.

Sleep apnea

FitSugar — Wed, 08 Oct 2008 17:35:30 -0700

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Sleep Apnea and Heart Attack

Obstructive sleep apnea can increase the risk of heart attack by as much as 30% over the course of 5 years, suggests a study presented at the 2007 American Thoracic Society International Conference. Researchers noted that the risk of developing or dying from heart disease rises with increasing sleep apnea severity.

Sleep Apnea and Diabetes

Obstructive sleep apnea may increase the risk of developing type 2 diabetes, indicates research presented at the American Thoracic Society conference. Patients who had severe obstructive sleep apnea had more than 2.5 times the risk of developing diabetes as those who did not suffer from nighttime breathing problems.
Sleep apnea may also increase the risk for women developing diabetes during pregnancy (gestational diabetes). Pregnancy-associated high blood pressure is also linked with sleep apnea.

Sleep Apnea and Depression

As sleep apnea worsens, the odds for developing depression increase, indicates a 2006 study in the Archives of Internal Medicine.

Continuous Positive Airway Pressure (CPAP)

CPAP is the best treatment for severe sleep apnea. However, according to a 2007 study in Sleep, most patients need to use it for a full night’s duration to achieve optimal benefits. The researchers noted that many patients experience some improvement in daytime sleepiness after 4 - 6 nightly hours of CPAP use, but that the best improvements in quality of life occur mostly after 7.5 hours of CPAP use each night.

Risk Factors for Sleep Apnea Surgery

According to a 2006 study in the Archives of Otolaryngology - Head & Neck Surgery, the risks for complications following uvulopalatopharyngoplasty (UPPP) increase with:

Severity of sleep apnea
Being overweight (higher body mass index)
Having other medical conditions in addition to sleep apnea
Undergoing other surgical procedures at the same time as UPPP

Introduction

Sleep apnea is a disorder in which a person stops breathing during the night, perhaps hundreds of times, usually for periods of 10 seconds or longer and sometimes for as long as a minute. These gaps in breathing are called apneas. The word apnea means absence of breath.

Sleep apnea is usually accompanied by snoring. People might not even know they have the condition. It inevitably causes daytime sleepiness.

Sleep apnea is grouped into three categories:

Obstructive
Central
Mixed

There is also another, less severe form of obstructed breathing, called upper airway resistance syndrome (UARS).

Obstructive sleep apnea (OSA) is the most common form of apnea. It occurs when tissues in the upper throat collapse at different times during sleep, thereby blocking the passage of air. In general, OSA occurs as follows:

On its way to the lungs, air passes through the nose, mouth, and throat (the upper airway).
Under normal conditions, the back of the throat is soft and tends to collapse inward as a person breathes.
Dilator (widening) muscles work against this collapse to keep the airway open. Interference or abnormalities in this process cause air turbulence.
If the tissues at the back of the throat collapse and become momentarily blocked, apnea occurs. Breath is temporarily stopped. In most cases the person is unaware of it, although sometimes they awaken and gasp for breath.
In some cases, the interference is incomplete (called obstructive hypopnea) and causes continuous but slow and shallow breathing. In response, the throat vibrates and makes the sound of snoring. Snoring can occur whether a person breathes through the mouth or the nose. (Snoring also occurs without sleep apnea.)
Apnea decreases the amount of oxygen in the blood, and eventually this lack of oxygen triggers the lungs to suck in air.
At this point, the patient may make a gasping or snorting sound but does not usually fully wake up.

Obstructive sleep apnea is defined as five or more episodes of apnea or hypopnea per hour of sleep in individuals who have excessive daytime sleepiness.

Central sleep apnea is much less common. It is caused by some problem in the central nervous system, most likely a failure of the brain to signal the airway muscles to breathe. In such cases, oxygen levels drop abruptly and usually the sleeper wakes with a start. Often people with central sleep apnea recall waking up. They generally experience less sleepiness during the day than people with obstructive sleep apnea. Heart disease, and in particular heart failure, is the most common cause of central sleep apnea.

Mixed apnea is the term used when the two apneas occur together.

Upper airway resistance syndrome (UARS) is a condition in which patients snore, wake frequently during the night, and have excessive daytime sleepiness. However, UARS patients do not have the breathing abnormalities that characterize sleep apnea and they do not show a reduction in blood oxygen levels. Unlike apnea, UARS is more likely to occur in women than in men. Treatments are similar to those of sleep apnea. It is not known if UARS has any serious health complications.

In sleep studies, subjects spend about one-third of their time asleep, suggesting that most people need about 8 hours of sleep each day. Individual adults differ in the amount of sleep they need to feel well rested, however. Infants may sleep up to 16 hours a day.

The daily cycle of sleeping and waking is called the circadian rhythm. It's commonly referred to as the biologic clock. Circadian means "about a day." Hundreds of bodily functions follow biologic clocks, but sleeping and waking comprise the most prominent circadian rhythm. The sleeping and waking cycle is approximately 24 hours. (People who are confined to windowless homes, with no clocks or other time cues, sleep and wake on a slightly longer cycle.) The 24-hour circadian rhythm typically adheres to the following factors:

Humans are designed for daytime activity and nighttime rest.
There is a natural peak in sleepiness at mid-day, the traditional siesta time.

In addition, daily rhythms mix with other factors that may interfere or change individual patterns:

The firing of nerve cells in the brain may be faster or slower in different individuals.
The monthly menstrual cycle in women can shift the pattern.
Light signals coming through the eyes reset the circadian cycles each day, so changes in season or various exposures to light and dark can unsettle the pattern. The importance of sunlight as a cue for circadian rhythms is dramatized by the problems experienced by people who are totally blind. They commonly suffer trouble sleeping and other rhythm disruptions.

The Response in the Brain to Light Signals

The response to light signals in the brain is an important key factor in sleep:

Light signals travel to a tiny cluster of nerves in the hypothalamus in the center of the brain, the body's master clock, which is called the supra chiasmatic nucleus or SCN.
This nerve cluster takes its name from its location. It sits just above (supra) the optic chiasm, a major junction for nerves transmitting information about light from the eyes.
The approach of dusk each day prompts the SCN to signal the nearby pineal gland to produce the hormone melatonin.
Melatonin is thought to act as the body's time-setting hormone. The longer a person is in darkness the longer the duration of melatonin secretion. Secretion can be diminished by staying in bright light. Melatonin also appears to trigger the need to sleep.

Sleep Cycles

Sleep consists of two distinct states that alternate in cycles and reflect differing levels of brain nerve cell activity:

Non-Rapid Eye Movement Sleep (NonREM). NonREM sleep is also termed quiet sleep. NonREM is further subdivided into three stages of progression:

Stage 1 (light sleep)
Stage 2 (so-called true sleep)
Stage 3 to 4 (deep "slow-wave" or delta sleep)

With each descending stage, awakening becomes more difficult. It is not known what governs NonREM sleep in the brain. A balance between certain hormones, particularly growth and stress hormones, may be important for deep sleep.

Rapid Eye-Movement Sleep (REM). REM sleep is termed active sleep. Most vivid dreams occur in REM sleep. REM-sleep brain activity is comparable to that in waking, but the muscles are virtually paralyzed, possibly preventing people from acting out their dreams. In fact, except for vital organs like lungs and heart, the only muscles not paralyzed during REM are the eye muscles. REM sleep may be critical for learning and for day-to-day mood regulation. When people are sleep-deprived, their brains must work harder than when they are well rested.

The REM/NREM Cycle. The cycle between quiet (NonREM) and active (REM) sleep generally follows this pattern:

After about 90 minutes of NonREM sleep, eyes move rapidly behind closed lids, giving rise to REM sleep.
As sleep progresses the NonREM/REM cycle repeats.
With each cycle, NonREM sleep becomes progressively lighter, and REM sleep becomes progressively longer, lasting from a few minutes early in sleep to perhaps an hour at the end of the sleep episode.

Symptoms

People with sleep apnea usually do not remember waking during the night.

Symptoms may include:

Excessive daytime sleepiness
Morning headaches
Irritability and impaired mental or emotional functioning
Snoring (bed partners may report very loud and interrupted snoring)
Heartburn (acid back-up that causes heartburn may be responsible for some cases of sleep apnea)

Sleep apnea occurs in about 2% of children. They may have symptoms that differ from adults, including:

Longer total sleep time than normal in some children, especially obese children or those with severe apnea.
Snoring. (An estimated 3 - 12% of all children snore. However, not all of them have sleep apnea.)
More effort in breathing (flaring nostrils, heaving chests, sweating). The chest may have an inward motion during sleep.
Behavioral difficulties without any obvious cause, such as hyperactivity and inattention. (Some patients may even be misdiagnosed with attention-deficit hyperactivity disorder.)
Irritability
Bed-wetting
Morning headaches
Failure to grow and gain weight

Causes

Any structural abnormality in the face, skull, or airways that causes some obstruction or collapse in the upper airways and reduces air pressure can produce sleep apnea syndrome. Abnormalities in tissues that lie between the back of the mouth and the esophagus (food pipe) are one of the most common structural causes of sleep apnea. Enlarged soft palates (the base of the tongue and surrounding throat walls) are also associated with many cases of sleep apnea.

Researchers have identified several physiologic abnormalities that may play a role in causing sleep apnea or in making it worse. These include an inability to regulate levels of carbon dioxide, impaired brain and nervous system responsiveness to various chemical messengers, and poor reflexes or muscle tone in the upper airways. The underlying reasons for these disturbances and their connection to apnea require further study.

Obesity is strongly associated with sleep apnea and is a cause of it in some cases. Imaging scans have shown fatty cells clogging the throat tissue, which indicates that they narrow the airways. In one study, the more obese a person with sleep apnea was, the higher the pressure on the airway and therefore the greater the obstruction of the airway. (Obstructive sleep apnea may also contribute to obesity itself, however, since a sleepy person tends to be sedentary.)

Snoring. Chronic snoring itself may actually be a cause of sleep apnea. Over time, the vibrations and the increased pressure against the upper airways as snoring people inhale may cause the soft palate to lengthen. This stretched palate is more prone to collapse and obstruction.

It should be stressed that snoring is very common. Snoring occurs in about a third of the population, while apnea, according to one study, occurs in only 6%. Snoring, then, does not always cause apnea, nor is it always a sign of the respiratory disorder. Furthermore, while snoring is also associated with daytime sleepiness regardless of whether apneas are present, snoring alone does not appear to pose any major health risks.

Mouth Breathing. Some evidence suggests that a tendency to breathe through the mouth (rather than the nose) during childhood can actually produce structural changes in the face (longer face, narrow jaw, receding chin). Such facial characteristics may eventually put people at risk for sleep apnea.

Sleep apnea occurs in about 2% of children and can occur even in very young children. The most likely causes are the following:

Facial or skull abnormalities in infants.
Overgrown tonsils, adenoids, or both in small children. (Removal of tonsils or adenoids can free the airways and solve the problem.)
Premature infants also commonly have a form of apnea that may be related to lung or nervous system problems.

Risk Factors

Gender. More men than women appear to have sleep apnea. In the U.S., about 4% of men and 2% of women age 30 - 60 meet the criteria for obstructive sleep apnea. Such people have at lease five episodes of apnea or hypopnea (shallow nighttime breathing) for each hour of sleep plus excessive daytime sleepiness. A much higher percentage has just one of these two conditions.

Sleep apnea actually may be underdiagnosed in women, particularly older women. In general, older women have the same incidence of sleep apnea as men their own age. It is not clear why apnea occurs more often in men than women before menopause and why prevalence equalizes after menopause. Men tend to have larger necks and to weigh more than women and women tend to gain weight and develop larger necks after menopause. However, studies have not found that these physical factors fully explain the differences in risk by gender in young adults or the increase in sleep apnea in postmenopausal women.

Age. Sleep apnea is most common and its symptoms are worse in middle-aged adults age 40 - 60 years old. Nevertheless, it affects people of all ages.

Ethnicity. African-Americans face a higher risk for sleep apnea than any other ethnic group in the United States. Other groups at increased risk include Pacific Islanders and Mexicans.

Obesity, especially having fat around the abdomen (the so-called apple shape), is a particular risk factor for sleep apnea, even in adolescents and children. However, many people with sleep-related breathing disorders, particularly women and small children, are not obese. Also, not all people who are obese have sleep apnea. Specific anatomical and physiological properties in the airways are more likely to be present in obese individuals with apnea.

Having a Larger Neck. Having a large neck is a risk factor for sleep apnea. In fact, larger necks in men may be the primary reason for their higher risk for sleep apnea compared to women. A neck measurement of 17 inches or greater in men or at least 16 inches in women is one indicator that may suggest the condition. Postmenopausal women are more likely than younger women to have sleep apnea, in part because they tend to be heavier and have larger necks.

Specific Facial and Skull Characteristics. Structural abnormalities in the face and skull may be responsible for many cases of sleep apnea. These are likely to be the cause in many non-obese people with early-onset sleep apnea, particularly if they also have a family history of the problem.

Specific physical characteristics that may increase the risk for sleep apnea in both adults and children include:

A long lower part of the face
Brachycephaly, a birth defect in which the head tends to be shorter and wider than average
A narrow upper jaw
A receding chin
An overbite
A larger tongue

Characteristics in the Soft Palate. Some people have specific abnormalities in the soft area (palate) at the back of the mouth and throat that may lead to sleep apnea. These abnormalities include:

The soft palate is stiffer, larger than normal, or both. An enlarged soft palate may be a significant risk factor for sleep apnea.
The soft palate and the walls of the throat around it collapse easily.

Smoking. Smokers are at higher risk for apnea. Those who smoke more than two packs a day have a risk 40 times greater than nonsmokers.

Alcohol. Alcohol use has been associated with apnea, although studies are mixed. A major survey reported that 53% of people who use alcohol to help fall sleep experience symptoms of sleep apnea. Another study found no relationship.

Diabetes. Diabetes is associated with sleep apnea and snoring. It is not clear if there is an independent relationship between the two conditions or whether obesity is the only common factor.

Gastroesophageal Reflux Disease (GERD). GERD is a condition caused by acid backing up into the esophagus. It is a common cause of heartburn. GERD and sleep apnea often coincide. In one study, almost half of apnea patients had symptoms of GERD. Some experts suggest that the backup of stomach acid in GERD may produce spasms in the vocal cords (larynx), thereby blocking the flow of air to the lungs and causing apnea. Or, apnea itself may cause pressure changes that trigger GERD. Some evidence suggests that treating sleep apnea with continuous positive airway pressure (CPAP) may reduce GERD symptoms by nearly 50%. However, obesity is common in both conditions. More research is needed to clarify the association.

Polycystic Ovary Syndrome (PCOS). In a 2000 study, women with PCOS were 30 times more likely than other premenopausal women to have obstructive sleep apnea and excessive daytime sleepiness. Women with PCOS produce high amounts of male hormones, particularly testosterone, which can cause obesity, facial hair, and acne. About half of PCOS patients also have diabetes. Obesity and diabetes are both associated with sleep apnea and may be the common factors.

Chronic Problems in the Upper Airways. A 2001 Swedish study found that people with respiratory tract disorders, including asthma, chronic bronchitis, or seasonal allergies, reported symptoms of sleep apnea more often than those without any of these ailments.

Hypothyroidism. In rare cases, hypothyroidism (low thyroid) has been reported as a possible cause of sleep apnea. In such cases, treating the thyroid condition improves the sleep apnea.

Prognosis

Sleep apnea has a strong association with several diseases, particularly those related to the heart and circulation.

Researchers are intensively investigating why a problem in the upper airways is associated with serious conditions of the heart and circulatory system. Here are some of their findings:

Major known risk factors for hypertension and heart disease (obesity, smoking, and alcohol abuse) are associated with sleep apnea. These factors, however, do not explain all cases of higher heart-related risks in people with sleep apnea. For example, among overweight people, those who have sleep apneas have a greater risk of heart problems than those without them.
When breathing stops during episodes of apnea, carbon dioxide levels in the blood increase and oxygen levels drop. This effect may trigger a cascade of physical and chemical events that can then increase risk for heart problems.
Apnea also causes decreased levels of the gas nitric oxide (NO), a potent substance that causes blood vessels to be elastic and expand. NO plays a crucial role in blood pressure control and heart health.
Apnea may also increase levels of a substance called angiotensin-converting enzyme (ACE), which is known to play a role in high blood pressure and congestive heart failure.
Researchers have reported high levels of certain immune factors called tumor necrosis factor-alpha (TNF-alpha) and interleukin 6 (IL-6) in people with sleep apnea, particularly those who are obese. High levels of TNF-alpha and IL-6 produce a damaging inflammatory response, which can harm cells in the body, including those in the arteries. Elevated TNF-alpha may be associated with fatigue, shortness of breath, and a diminished heart-pumping action.

At this time, however, evidence of a clear causal relationship with any of these health problems is still weak. Some studies have found no significant independent risk for heart disease from obstructive sleep apnea. The following are some discussions on the possible effects of apnea on specific health problems.

High Blood Pressure. A number of studies have found a strong association between sleep apnea and high blood pressure (hypertension). (In the past, the link between sleep apnea and hypertension was thought to be due to obesity, a risk factor for both conditions, but more recent studies contradict that theory.) A 2000 study followed patients for 4 years; the more nightly apnea episodes they had in the first year, the more likely they were to develop hypertension by the fourth year. A weak, but still higher-than-normal, association with high blood pressure has also been observed in those who snore, wake frequently during the night, or have mild sleep apnea.

A 2004 data analysis of over 200,000 patient records revealed that people who took both antidepressants and antihypertensives were 18 times more likely to be diagnosed with obstructive sleep apnea than those who did not take the medications. The probability was highest among adults age 20 - 39 years. These drugs do not cause sleep apnea, but antidepressants may be prescribed to treat hypertensive patients’ complaints of fatigue even if sleep apnea is the real cause. The researchers recommended that patients being treated for high blood pressure, depression, and fatigue should also be evaluated for sleep apnea.

One way that apnea may directly affect blood pressure, regardless of other risk factors:

Blood pressure fluctuates widely and suddenly in response to episodes of apnea and hypopnea (shallow nighttime breathing).
Such fluctuations are possibly due to a sudden surge in the sympathetic nervous system, which controls involuntary muscle responses, importantly those in the blood vessels and heart, and may also play a role in sleep apnea.
These fluctuations lead to transient constriction of blood vessels that, over time, could possibly lead to sustained hypertension and heart damage.
Effective treatment of sleep apnea with continuous positive airway pressure (CPAP) may reduce blood pressure. Sleep apneas must be significantly reduced, however, to have any effect on blood pressure. Even a 50% reduction in apneas has no effect.

Coronary Artery Disease and Heart Attack. Sleep apnea has been associated with heart disease regardless of the presence of high blood pressure or other heart risk factors. In a 2001 study, researchers observed that the more episodes of apnea and hypopnea a patient had, the higher the risk for a heart attack.

Many of the factors associated with stroke and sleep apnea (a risk for blood clots and narrowing of the arteries) may also increase the risk for heart attacks. Research presented at the 2007 American Thoracic Society conference suggested that severe obstructive sleep apnea can increase the risk of dying from a heart attack by as much as 30% over a 4 - 5 year period. Obstructive sleep apnea, however, may have other effects that increase the risk for heart problems:

Some evidence suggests that obstructive apneas cause an increase in stiffness and inflammation in the arteries, which is now proving to be an important aspect of heart disease, particularly in older adults.
A 2002 study reported that the white blood cells of patients with apnea have an increased number of proteins called adhesion molecules on their surface that may bind to the lining of blood vessels and cause inflammation. Increasingly, scientists believe that inflammation plays an important role in the development of coronary artery disease, heart attacks, and many other major ailments.

Stroke. Sleep apnea doubles the risk for stroke. The worse the sleep apnea, the greater the risk; moderate-to-severe obstructive sleep apnea can triple the risk of stroke. Sleep apnea is also associated with high blood pressure, a known risk factor for stroke. However, people who have sleep apnea, but not high blood pressure, are also still at increased risk for stroke. Sleep apnea in stroke patients is also associated with a higher risk for worse symptoms after a stroke, including delirium, depression, poor response to speech, and difficulty conducting daily chores.

A 2000 study observed that blood becomes more viscous (stickier) in the morning in people with obstructive sleep apnea compared to people without the sleep disorder. Such "sticky" blood is more apt to form clots that can lead to strokes. To support this, another 2000 study reported that stroke victims with sleep apnea tended to have higher levels of the blood protein fibrinogen than stroke victims without sleep apnea. Fibrinogen is a factor in blood that causes it to clot. Higher levels of fibrinogen have been linked to both strokes and heart attacks.
A 1998 study reported that the carotid artery, the major artery to the brain, is in far greater danger of becoming sclerotic (hardened and narrower) in people with obstructive sleep apnea than in the average person. People with both diabetes and sleep apnea are at particularly high risk for this effect.

Heart Failure. Studies suggest that 11 - 37% of patients with heart failure also have sleep apnea. Both central and obstructive sleep apnea are linked with heart failure. The evidence for the association between heart failure and sleep apnea includes:

High blood pressure, which is associated with sleep apnea, is a major cause of later heart failure.
Sleep apnea reduces oxygen levels and causes abnormal changes in blood pressure and heart rate that add to the burden of the failing heart.
Obstructive sleep apnea can affect breathing functions that are particularly harmful for patients with existing congestive heart failure.
Sleep apnea is associated with poorer survival in patients with heart failure. Some studies have suggested that treating sleep apnea with CPAP may improve heart function in these patients. However, a 2005 New England Journal of Medicine study found that CPAP did not improve survival in patients with heart failure and central sleep apnea

Atrial Fibrillation. Sleep apnea is more common in people with atrial fibrillation (irregular heartbeat) than in patients with other heart conditions. In a 2005 study published in Circulation, 49% of patients with atrial fibrillation were at risk for developing apnea, compared with 32% of general cardiology patients. An earlier study indicated that patients with untreated obstructive sleep apnea may be at increased risk for recurrence of atrial fibrillation. Patients with atrial fibrillation who received CPAP treatment had a lower risk for recurrence.

Metabolic Syndrome. The metabolic syndrome (also called Syndrome X) is a cluster of abnormalities that cause insulin resistance. Some of these factors, including hypertension and obesity, are also associated with sleep apnea. A 2004 study found that metabolic syndrome was nine times more common among patients with obstructive sleep apnea, independent of obesity.

Diabetes. Severe obstructive sleep apnea may more than double the risk of developing type 2 diabetes. Sleep apnea also increases the risk for diabetes during pregnancy (gestational diabetes).

When it comes to sleep apnea and obesity, it is not always clear which condition is responsible for the other. For example, obesity is often a risk factor and possibly a cause of sleep apnea, but it is also likely that sleep apnea increases the risk for weight gain. Some studies indicate that sleep apnea disrupts rapid eye movement (REM) sleep, which, in turn, increases the risk for obesity. Research indicates that animals deprived of REM sleep tend to eat more. People with apnea may also become too tired to exercise and so put on weight.

Sleep apnea is associated with a higher incidence of many medical conditions, other than heart and circulation. The links between apneas and the conditions are unclear.

Pulmonary hypertension.
Asthma. Sleep apnea may worsen asthma symptoms and interfere with the effectiveness of asthma medications. Treating the apnea may help asthma control.
Kidney failure.
Peripheral nerve damage (tingling, pain, or numbness in the hands and feet).
Liver damage in obese individuals with sleep apnea. Recent research suggests that severe apnea may increase the risk of liver disease regardless of weight.
Seizures, epilepsy, and other nerve disorders. Sleep apnea appears to pose a particularly risk for nocturnal epilepsy, a condition in which seizures occur during sleep.
Headaches. Sleep disorders, including apnea, may be the underlying causes of some chronic headaches. In some patients with both chronic headaches and apnea, treating the sleep disorder has cured the headache, even the very severe and disabling form known as a cluster headache.
High-risk pregnancies. Sleep apnea causes higher rates of pregnancy complications, including gestational diabetes and high blood pressure.
Eye disorders, including glaucoma, conjunctivitis, dry eye, and various other infections and irritations. Findings presented at the 2003 annual meeting of the American Academy of Ophthalmology suggested that patients with sleep apnea may be at increased risk for glaucoma and should be tested for this eye disease. A vision-damaging condition called intracranial hypertension has also been observed in some patients with sleep apnea.

Studies report an association between severe apnea and psychological problems. In one study, 32% of patients had symptoms of depression. According to a 2006 study, the risk for depression rises with increasing severity of sleep apnea. Sleep-related breathing disorders can also worsen nightmares and post-traumatic stress disorder. Certainly, daytime sleepiness interferes with mental alertness and quality of life.

Because sleep apnea so often includes noisy snoring, the condition can also adversely affect the sleep quality of a patient's bed partner. Spouses or partners may also suffer from sleeplessness and fatigue. In some cases, the snoring can disrupt relationships. Diagnosis and treatment of sleep apnea in the patient can help eliminate these problems.

Failure to Thrive. Small children with undiagnosed sleep apnea may "fail to thrive," that is, they do not gain weight or grow at a normal rate and they have low levels of growth hormone. In severe cases, this may affect the heart and central nervous system. Most often, sleep apnea in children is caused by overgrown tonsils or adenoid. Their removal often completely solves all of these problems, including resolution of sleep apnea and restoring weight gain and normal growth hormone levels.

Attention Deficits and Hyperactivity. Problems in attention and hyperactivity are common in children with sleep apnea. There is some evidence that such children may be misdiagnosed with attention-deficit hyperactivity disorder. Snoring, rather than sleepiness, is a stronger risk factor for hyperactivity in many of these children, especially boys under 8 years old. (Even children who snore and do not have sleep apnea may be at higher risk for poor concentration.)

Some researchers believe that sleepiness associated with sleep apnea is the greatest risk factor for car accidents. As many as 200,000 automobile accidents in the U.S. and 1,500 deaths from such accidents are caused by sleepiness. Studies continue to report that drowsy driving is as risky as drunk driving. Several studies have suggested that people with sleep apnea have two to three times as many car accidents, and five to seven times the risk for multiple accidents.

Diagnosis

Not all people with suspected sleep apnea require medical tests. Expensive diagnostic efforts are probably not required for individuals who have no other health risk factors and whose suspected apnea does not affect their quality of life or safety on the road.

Doctors, however, should order diagnostic sleep studies if:

The patient has a serious medical condition that might be worsened or caused by sleep apnea. Such conditions include heart disease, high blood pressure, heart failure, diabetes, chronic headaches, epilepsy, obstructive lung disease, or severe acid reflux (GERD).
A child who shows signs of sleep apnea also has attention deficit problems or fails to thrive.
The sleep apnea is severe enough to impair quality of life, increase the risk for accidents, or both.

In some cases of an uncertain diagnosis, high-risk patients may need to consult a sleep specialist or go to a sleep disorders center. At most centers, patients undergo an in-depth analysis, usually supervised by a multi-disciplinary team of consultants who can provide both physical and psychiatric evaluations. Centers should be accredited by the American Academy of Sleep Medicine.

To help determine the presence of sleep apnea, the doctor will ask the following questions:

Is the patient taking any medications?
How many periods of sleepiness are there each day and when do they occur? (Patients with apnea often do not describe this symptom as feeling "sleepy." They are more apt to describe this feeling as "lack of energy" or "feeling tired all day.")
How restful is sleep?
Do headaches occur regularly in the morning?
Is the patient taking or withdrawing from stimulants, such as coffee or tobacco?
How much alcohol is consumed per day?
Does the patient have any problems with mental or emotional functioning?
Does the patient suffer from heartburn?
What is the normal sleeping position (back, side, or stomach)?
If there is a sleeping partner, does he or she complain about the patient's snoring or gasping for breath? (Many times it is useful to interview the bed partner.)

Keeping a Record of Sleep. To help answer these questions, the patient may need to keep a sleep diary. Every day for 2 weeks, the patient should record all sleep-related information, including responses to questions listed above described on a daily basis. Recording sleep behavior using an extended-play audio or videotape can be very helpful in diagnosing sleep apnea.

To diagnose sleep apnea, the doctor will check for physical indications of sleep apnea, including:

Abnormalities in the soft palate or upper airways, including enlarged tonsils
Upper body obesity
A wide neck measurement

Some evidence suggests that doctors may accurately identify nearly all cases of suspected sleep apnea using physical criteria, including taking measurements of body mass (the indication of obesity), neck circumference, and four areas inside the mouth.

If sleep apnea is not obvious after a physical examination and history, the doctor will need to rule out any other problems. These include sleep disorders, (such as narcolepsy, insomnia, or restless legs disorder), or any medical or psychologic conditions (chronic fatigue syndrome, depression) that may be causing daytime sleepiness.

Polysomnography is the technical term for an overnight sleep study that involves recording brain waves and other sleep-related activity. Polysomnography involves many measurements and is typically performed at a sleep center.

The patient arrives about 2 hours before bedtime without having made any changes in daily habits. Polysomnography electronically monitors the patient as he or she passes, or fails to pass, through the various sleep stages. Polysomnography tracks:

Brain waves
Body movements
Breathing
Heart rate
Eye movements

Changes in breathing and blood oxygen levels are also recorded. In patients with suspected sleep apnea, the sleep expert will track instances of apnea and hypopnea that last longer than 10 seconds. In general, if there are more than five episodes per hour, apnea is significant and if there are more than 15, the condition is serious.

Overnight polysomnography has been the gold standard for diagnosing obstructive sleep apnea in both adults and children. It is very labor-intensive and expensive, however, and also misses snoring-induced arousals. It is not always covered by health insurance, and some centers have waiting lists that are months long.

A number of portable devices are available, or are being developed, so that patients have the convenience of being monitored at home. Experts hope that such monitors eventually will replace the need for overnight sleep clinics or the need for attended monitoring at home. Limited evidence exists, however, on the accuracy of many portable monitors. Patients with serious medical conditions, including heart failure or a history of stroke or respiratory failure, should not use home tests.

The following are descriptions of some home monitoring techniques.

Home Oximetry. Pulse oximetry is a procedure that determines if oxygen levels in the blood are low. This is called hypoxia. Normal levels during the night would generally rule out sleep apnea. With this procedure, a device called a pulse oximeter is attached to the patient's finger. The oximeter transmits red and infrared light through the capillaries in the finger. Hemoglobin, a molecule in the blood that carries oxygen, absorbs part of these light waves. The ratio of the two light beams provides the measurement of oxygen. The test is not always accurate, however. A combination with polysomnography, especially heart rate measurements, may be best for diagnosing sleep apnea.

Home oximetry monitors are available to rule out sleep apnea, but their accuracy is unclear. A 2003 study indicated that home oximetry alone was not very helpful in discriminating between patients with or without sleep apnea. Home oximetry however, may be helpful in identifying patients with unsuspected and seriously low oxygen levels.

Unattended Monitoring with Auto-CPAP. This method is a recent and simple method for detecting impaired breathing. It uses an auto-CPAP machine, which is programmed to apply pressure through the airways via a tube that attaches to a mask that fits the nose. A monitor is attached that digitizes and records on a computer all the information on any apnea episodes during sleep.

Nasal Pressure Recording. One promising technique uses a very simple prong device that attaches to the nostrils. A monitor records the airflow through the mouth and nose.

Peripheral Arterial Tonometry. An investigative technique called peripheral arterial tonometry measures changes in blood flow in the arteries of the fingertips during sleep. Such measurements are proving to be accurate in detecting sleep apnea in 80% of cases.

The Epworth Sleepiness Scale uses a simple questionnaire to measure excessive sleepiness during eight situations.


Situation	Chance of Dozing 0 = no chance of dozing 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing
Sitting and reading.	(Indicate a score of 0 to 3)
Watching TV.	(Indicate a score of 0 to 3)
Sitting inactive in a public place (a theater or a meeting).	(Indicate a score of 0 to 3)
As a passenger in a car for an hour without a break.	(Indicate a score of 0 to 3)
Lying down to rest in the afternoon when circumstances permit.	(Indicate a score of 0 to 3)
Sitting and talking to someone.	(Indicate a score of 0 to 3)
Sitting quietly after a lunch without alcohol.	(Indicate a score of 0 to 3)
In a car, while stopped for a few minutes in traffic.	(Indicate a score of 0 to 3)
Score Results	1-6: Getting enough sleep 4-8: Tends to be sleepy but is average. 9-15: Very sleepy and should seek medical advice. Over 16: Dangerously sleepy

Lifestyle Changes

Sleeping on the back causes sleep apnea in about half of all people with mild sleep apnea. Body position greatly affects the number and severity of episodes of obstructive sleep apnea, with at least twice as many apneas occurring in people who lay on their back as in those who sleep on their side. This may be due to the effects of gravity, which cause the throat to narrow when a person lies on the back. (Indeed, astronauts show a marked reduction in apneas and snoring in the weightlessness of space.) Positional sleep apnea affects people of all ages, including young children.

As a first step in dealing with sleep apnea, the patient should simply try rolling over onto the side. Patients who sleep on their backs and have 50 - 80 apneas per hour can sometimes nearly eliminate them when they shift to one side or the other. (Changing positions is less effective the more overweight a person is, but it still helps.)

Here are some suggestions that might help a person maintain a low-risk sleeping position:

Sew a small pocket to the back of the pajamas and place a tennis ball or other small ball into it.
A special pillow that helps to stretch the neck may reduce snoring and improve sleep for people with mild sleep apnea.
Sleeping in an upright position may improve oxygen levels in overweight people with sleep apnea. Elevating the head of the bed may help.

Over-the-counter nasal strips, such as the Breathe Right strip or other devices that open the nostrils, are inexpensive and useful to prevent snoring. They may significantly improve early-stage sleep in people with sleep disorders associated with nasal obstruction and help reduce morning tiredness. They are not intended as treatments for sleep apnea, however.

All patients with obstructive sleep apnea who are overweight should attempt a weight-reducing program. Weight loss certainly reduces snoring in many people, sometimes stopping it completely. It also improves sleep and significantly reduces daytime sleepiness. A 2000 study suggested that people who lost 10% of body weight experienced an average 26% reduction in risk for developing sleep apnea in the first place. (Gaining 10% of their body weight, on the other hand, increased the odds of sleep apnea 6-fold.)

Smokers should quit, since smoking worsens apnea
Alcohol should be avoided within 4 hours of sleep

Treatment

Treatment for sleep apnea depends on the severity of the problem. Given the data on the long-term complications of sleep apnea, it is important for patients to treat the problem as they would any chronic disease. Simply trying to treat snoring will not treat sleep apnea. Because of its association with heart problems and stroke, sleep apnea that does not respond to lifestyle measures should be treated by a doctor, ideally a sleep disorders specialist.

At this time, the most effective treatments for sleep apnea are devices that deliver slightly pressurized air to keep the throat open during the night. There are a number of such devices available.

The best treatment for severe obstructive and mixed sleep apnea is a system known as continuous positive airflow pressure (CPAP), sometimes referred to as nasal continuous positive airflow pressure (nCPAP). It is safe and effective in sleep apnea patients of all ages, including children. CPAP is not recommended for patients with mild apnea. Patients with apnea but no daytime sleepiness report little or no benefit from this treatment.

CPAP works in the following way:

The device itself is a machine weighing about 5 pounds that fits on a bedside table.
A mask containing a tube connects to the device and fits over just the nose.
The machine supplies a steady stream of air through a tube and applies sufficient air pressure to prevent the tissues from collapsing during sleep.

Effects on Sleep and Wakefulness. A major 2003 analysis confirmed the benefits of CPAP on both objective and subjective measures of sleep. After using CPAP regularly many patients report the following benefits:

Restoration of normal sleep patterns.
Greater alertness and less daytime sleepiness.
Less anxiety and depression and better mood.
Improvements in work productivity.
Better concentration and memory. Some adults with symptoms of attention deficit hyperactivity disorder have improved after CPAP treatments for apnea. In two studies, however, equal improvements were also observed in people on sham CPAP, suggesting that the actual cognitive benefits from CPAP may be modest.
Patients' bed partners also report improvement in their own sleep when their mates use CPAP, even though objective sleep tests showed no real difference in the partners' sleep quality.

If patients do not experience less sleepiness after a period of time and are still complying with the regimen, then the airflow pressure may not be high enough. Patients may require retesting. Many patients report feeling more alert after CPAP treatments even if objective laboratory tests fail to show significant differences in the number of apneas and wake-up periods.

Protection from Accidents. Studies suggest that treatment with CPAP can reduce the risk for accidents. In a 2001 study, untreated patients had a risk for automobile accidents that was three times the risk in the general population. When these patients were treated, their risk fell to normal.

Effects on the Heart and Circulation. Evidence is mixed on whether CPAP treatment may reduce serious heart conditions. Early studies suggested that CPAP could improve heart function, lower blood pressure, and prevent new cardiac events (such as heart attacks) in patients with congestive heart failure and coronary artery disease. However, a 2005 study in the New England Journal of Medicine found that, while CPAP helped improve some heart disease symptoms, it did not affect overall survival in patients with heart failure and central sleep apnea. (Patients with heart failure often have central sleep apnea.)

It is also unclear whether CPAP improves blood pressure. A 2006 study of patients with high blood pressure and sleep apnea indicated that short-term (4 weeks) CPAP treatment has no significant effect on lowering blood pressure. (It is possible that longer-term treatment may be helpful.) Other studies have found blood pressure benefits from short-term CPAP treatment. Treatment for sleep apneas must be very effective, however, to have any benefits on blood pressure. Even a 50% reduction in apneas has no effect.

Effects on Other Medical Conditions. Some studies suggest other benefits with the use of CPAP:

Fewer morning headaches
Reduction in abdominal fat (abdominal fat has been related to a higher risk for diabetes and heart disease)
Lower blood sugar levels in patients with type 2 diabetes
Improved thinking and concentration in people with impaired mental function from sleep apnea
Modest lung improvement in patients with both apnea and chronic obstructive lung disease (such as emphysema)

CPAP works well for both adults and children, but many patients have problems getting used to the device. Unfortunately, CPAP devices are often cumbersome, which can lead to patients becoming discouraged and stopping treatment. All patients should be warned that the first few nights of CPAP therapy are unnerving. The device often produces anxiety, primarily because of the mask. Starting out with low pressure to get used to the mask may help. Patients may actually experience less sleep or sleep of a different quality in the beginning of treatment.

Nearly all patients complain about at least one side effect. Nearly half of complaints are related to the mask. Many of these problems can be reduced with a well-chosen mask that is comfortable and reduces leakage as much as possible. Common complaints include:

Irritation in the nose and throat. The most common complaints are nasal congestion and sore or dry mouth, which are caused by leakage that dries the airway. (This may be severe in elderly people or patients who have had uvulopalatopharyngoplasty, a surgical treatment for sleep apnea. Such patients are more likely to stop using CPAP.) Chin straps, nasal salt water sprays, or humidifiers may prevent these side effects. Heated humidification devices are also now available for CPAP users.
Excessive application of pressure making exhalation difficult.
A feeling of claustrophobia is a major factor in noncompliance. This can be improved by a lightweight and transparent mask or with masks known as nasal pillows, which are used only around the nostrils.
Up to 30% of patients experience irritation and sores over the bridge of the nose. Getting a properly fitted and cushioned mask can help reduce this effect.
Eye irritation or conjunctivitis.
Upper respiratory infections. It is very important to keep the unit clean.
Patients may also experience temporary chest muscle discomfort, which is caused by an increase in lung volume.
Severe side effects are very rare but may include heart rhythm disorders (arrhythmias), severe nose bleeding, and air pockets in the skull.
In addition to initial difficulties with its use, the fixed CPAP needs to be periodically readjusted. Patients can be trained to adjust the CPAP at home, thereby avoiding trips to the sleep professional for machine adjustments and making the process more convenient.

Although studies have reported that long-term compliance with CPAP systems is low, with about one-third of patients giving up the treatment, recent information suggests that it is improving, probably due to better technologies and better education. Patient education and support groups, a dedicated nurse to ensure close follow-up of patients (particularly in the first 2 weeks of therapy), and ready access to doctors to make adjustments as needed have all been shown to greatly improve compliance. (However, sleeping pills do not appear to help patients adapt to the device.) Not surprisingly, patients whose symptoms are noticeably relieved by the procedure early on are more likely to continue the therapy.

Because many patients find CPAP uncomfortable and difficult, they tend not to use it for the duration of the entire night. A 2007 study indicated that while some patients’ daytime sleepiness may improve after 4 - 6 hours of CPAP use each night, maximum benefits in quality of life require at least 7.5 hours of nightly CPAP use. It appears that longer nightly duration of CPAP use is best for achieving normal daytime functioning.

Bilevel Positive Airway Pressure. Bilevel positive airway pressure (BPAP) systems may be particularly helpful for patients with coexisting lung disease and those with excessive levels of carbon dioxide. These devices have a sensing feature that helps determine and vary the appropriate pressure depending on whether a person is breathing in or out. Greater pressure is needed on inhalation and less on exhalation. These machines are more expensive than the CPAP and may not be covered by insurance.

Automatic Titrating (Auto)-CPAP Pressure Devices. Even more sophisticated systems, called auto-CPAP devices, are available. These devices automatically customize air pressure for the individual patient. They usually use one of three methods:

Overall pressure is kept low until a specific problem is detected. At that time the pressure is automatically increased rapidly.
Pressure is low when there are no problems but is raised gradually when they are detected.
Pressure is gradually raised and lowered in response to problems or their absence. In addition, the device can change depending on problems within single breaths.

Brands include AutoAdjust, Virtuoso, and AutoSet. These devices are more expensive than those that provide continuous airflow. A 2003 study indicated that they may improve compliance, particularly in patients who require high CPAP use. They may be especially helpful for patients who require varying levels of pressure due to other conditions, such as seasonal allergies. They may also be useful as home diagnostic tools for sleep apnea. Auto-CPAP devices are not recommended for all patients, particularly those with heart failure or serious lung disease.

In general, drugs have not been very beneficial except for specific situations. Medications that treat accompanying disorders associated with sleep apnea may be helpful. The following may be helpful for certain patients:

Modafinil (Provigil), which is also used to treat narcolepsy, was approved by the FDA in 2004 as the first drug to treat the sleepiness associated with obstructive sleep apnea. However, Provigil is meant to be used in combination with -- not as a substitute for -- standard apnea treatments such as CPAP. Sleep experts stress that patients who take Provigil should adhere to CPAP treatment as the drug treats only the symptom of sleepiness, not the underlying health risks associated with sleep apnea.
Thyroid hormone may help sleep apnea in those with low thyroid (hypothyroidism).
Theophylline, a drug commonly used for asthma management, has shown promise in treating central sleep apnea in patients with heart failure.
Omeprazole (Prilosec), a drug used for patients with severe heartburn, may help patients with both sleep apnea and gastroesophageal reflux disorder (GERD).

Note on Sedatives. Sedatives, narcotics, and anti-anxiety drugs can actually worsen the breathing disturbances and arousal conditions that occur with sleep apnea. These substances cause the soft tissues in the throat to sag and diminish the body's ability to inhale. Apnea sufferers should never use sleeping pills or tranquilizers. Apnea patients undergoing surgery should be sure that their surgeons, anesthesiologists, and other doctors are aware of their sleeping disorder in considering sedatives, anesthetics, and medications taken to relieve pain due to surgery.

Dental Devices

Oral appliances, also called dental appliances or devices, may be an option for patients who cannot tolerate CPAP. The American Academy of Sleep Medicine recommends dental devices for patients with mild-to-moderate obstructive sleep apnea who are not appropriate candidates for CPAP or who have not been helped by it. (CPAP should be used for patients with severe sleep apnea whenever possible.)

Several different dental devices are available. A trained dental professional such as a dentist or orthodontist should fit these devices. Devices include:

Mandibular advancement device (MAD). This is the most widely used dental device for sleep apnea. It is similar in appearance to a sports mouth guard. MAD forces the lower jaw forward and down slightly, which keeps the airway open.
Tongue retraining device (TRD). This is a splint that holds the tongue in place to keep the airway as open as possible.

Patients fitted with one of these devices should have a check-up early on to see if it is working; short-term success usually predicts long-term benefits. It may need to be adjusted or replaced periodically.

MAD and similar devices seem to offer the following benefits:

Significant reduction in apneas for those with mild-to-moderate apnea, particularly if patients sleep either on their backs or stomachs. They do not work as well if patients lie on their side. The devices may also improve airflow for some patients with severe apnea.
Improvement in sleep in many patients.
Improvement and reduction in the frequency of snoring and loudness of snoring in most (but not all) patients.
Higher compliance rates than with CPAP.

According to a 2006 review, dental devices help control sleep apnea in 52% of treated patients. A 2002 report indicated that long-term use of a dental device achieved an 81% success rate in apnea improvement, which was significantly higher than the 53% success rate noted for uvulopalatopharyngoplasty (UPPP), the standard surgical treatment. There were also few complications with the dental device.

Dental devices, including MAD, are not as effective as CPAP therapy. The cost of these devices tends to be high. Side effects associated with dental devices include:

Nighttime pain, dry lips, tooth discomfort, and excessive salivation. In general, these side effects are mild, although over the long term they cause nearly half of patients stop using dental devices. Devices made of softer materials may produce fewer side effects.
Permanent changes in the position of the teeth or jaw have occurred in some cases of long-term use. Patients should have regular visits with a health professional to check the devices and make adjustments.
In a small percentage of patients, the treatment may worsen apnea. Patients should be monitored with polysomnography (sleep lab evaluation) before and after therapy and when apnea symptoms worsen or recur.

An orthodontic treatment called rapid maxillary expansion, in which a screw device is temporarily applied to the upper teeth and tightened regularly, may help patients with sleep apnea and a narrow upper jaw. This nonsurgical procedure helps to reduce nasal pressure and improve breathing.

Surgery

Surgery is sometimes recommended, usually by throat specialists, for severe obstructive sleep apnea. A patient should be sure to seek a second opinion from a specialist in sleep disorders. Few randomized clinical trials, the gold standard of medical research, have been conducted to verify the long-term efficacy of sleep apnea surgery.

The Procedure. Surgery known as uvulopalatopharyngoplasty (UPPP) removes soft tissue on the back of the throat. Such tissue includes all or part of the uvula (the soft flap of tissue that hangs down at the back of the mouth) and parts of the soft palate and the throat tissue behind it. If tonsils and adenoids are present, they are removed. The surgery typically requires a stay in the hospital.

The Goal of Surgery. The goal of UPPP is threefold:

Increase the width of the airway at the throat's opening
Block some of the muscle action in order to improve the ability of the airway to remain open
Improve the movement and closure of the soft palate

Success Rates. Success rates for sleep apnea surgery are rarely higher than 65% and often deteriorate with time, averaging about 50% or less over the long term. Few studies have been conducted on which patients make the best candidates. Some studies suggest that surgery is best suited for patients with abnormalities in the soft palate, which may or may not involve the tonsils. Results are poor if the problems involve other areas or the full palate. In such cases, CPAP is superior. In one study, sleeping on the side (rather than the back) after surgery significantly boosted success rates.

Complications. Uvulopalatopharyngoplasty is among the most painful treatments for sleep apnea, and recovery takes several weeks. It is recommended only for select patients with severe obstructive sleep apnea. The procedure also has a number of potentially serious complications. In fact, in one study, 42% of patients had complaints about the procedure. Some complications include:

Infection. In one study, this complication was so common that 40% of patients needed another operation because of it. Preventive antibiotics administered an hour before surgery can help reduce this risk.
Impaired function in the soft palate and muscles of the throat.
Mucus in the throat.
Changes in voice frequency.
Swallowing problems.
Regurgitation of fluids through the nose or mouth.
Impaired sense of smell.
Failure and recurrence of apnea. In such cases, CPAP is often less effective afterward, although one study found that oral appliances (plastic mouth retainer-like devices) may still help.

Experts estimate that in general about 1.6% of patients experience serious complications. Many of these complications can be avoided with proper technique and experienced surgeons. However, a patient’s health status may also affect outcomes. According to a 2006 study, patients are more likely to experience complications if they have severe sleep apnea, are overweight, have other medical problems, or undergo other surgical procedures at the same time as UPPP.

A variation on UPPP called laser-assisted uvulopalatoplasty (LAUP) is being increasingly performed to reduce snoring. It removes less tissue at the back of the throat than UPPP and can be done in a doctor's office. At this time, however, long-term success rates from LAUP are very modest, particularly for reducing apneas. Some doctors, in fact, are concerned that if LAUP eliminates snoring, they may miss a diagnosis of apnea in patients who have the more serious condition.

More than 50% of patients complain of throat dryness after surgery. Throat narrowing and scarring have also been reported. In a minority of patients, snoring becomes worse afterward.

The pillar palatal implant is a noninvasive surgical treatment for mild-to-moderate sleep apnea and snoring. It helps reduce the vibration and movement of the soft palate. In this procedure, a doctor inserts 3 short pieces of polyester string into the soft palate. The procedure can be performed in a doctor’s office and takes about 10 minutes. Unlike uvulopalatopharyngoplasty (UPPP), the pillar procedure requires only local anesthesia. Studies indicate it works as well as UPPP, with less pain and quicker recovery time.

Tracheostomy used to be the only treatment for sleep apnea. It is quite straightforward:

The surgeon makes an opening through the neck into the windpipe and inserts a tube.
It is almost 100% successful, but it requires a quarter-size opening in the throat. This produces a number of medical and psychological problems associated with recovery.

Today, this operation is performed rarely, usually only if sleep apnea is life-threatening.

A technique called radiofrequency ablation uses radiofrequency energy to shrink tissues in the upper airways:

The radio waves heat, stiffen, and shrink a small amount of tissue at the base of the tongue.
The therapy takes about 20 minutes and can be done in a doctor's office.
It typically requires 10 treatments within five or six sessions. (A newer form requires fewer treatment sessions, and it appears to be effective.)
It is far less invasive than standard surgery and results in far less pain and fewer complications. Discomfort can be controlled with simple pain relievers.

Studies reporting significant improvement in reduced snoring and less daytime sleepiness for some patients although, as with other surgeries, the benefits may be short term in the majority of patients. It may be helpful for mild obstructive sleep apnea.

Other surgical procedures may be appropriate to correct facial abnormalities or obstructions that cause sleep apnea. They may be used alone or combined with each other or with UPPP. They include:

Tongue advancement, in which an opening is cut where the tongue joins the jawbone and the area is pulled forward.
Genioplasty, which is plastic surgery on the chin.
Hyoid surgery, in which the movable bone underneath the chin is moved forward, pulling the tongue muscle along with it.
Maxillary or maxillomandibular advancement (MMA), which moves the upper (maxilla) or lower (mandible) jawbone forward. A survey of patients who had MMA found that the surgery changed their facial appearance, but most people thought it was a change for the better.
Surgery for nasal obstructions (such as a deviated septum) that contribute to snoring and other symptoms.

Adenotonsillectomy, or surgical removal of the tonsils and adenoids, is a first-line treatment for children and adolescents with sleep apnea. It cures the condition in 75 - 100% of cases. Two studies, published in 2005, suggested that adenotonsillectomy can significantly improve quality of life for children with obstructive sleep apnea.

Complications include respiratory illness, which occurs in about 25% of children after the surgery. The highest risk for respiratory complications is associated with:

Age under 3 years old
Severe sleep apnea
Heart complications
Failure to thrive
Obesity
Prematurity
Recent lung infections
Certain facial structures
Neuromuscular disease

The procedure may fail to improve apnea in some patients, such as those with very severe disease. Such children are candidates for continuous positive airway pressure (CPAP) therapy.

Removal of the tonsils and adenoids alone is not an effective treatment for adults with sleep apnea, although the procedure may be effective when combined with UPPP surgery.

Resources

www.sleepapnea.org -- American Sleep Apnea Association
www.nhlbi.nih.gov -- National Heart, Lung, and Blood Institute
www.aasmnet.org -- American Academy of Sleep Medicine
www.sleepfoundation.org -- National Sleep Foundation
www.nhlbi.nih.gov/about/ncsdr -- National Center on Sleep Disorders Research
www.sleepeducation.com -- Sleep Education from the American Academy of Sleep Medicine
www.wfsrs.org -- World Federation of Sleep Research Societies

References

Bradshaw DA, Ruff GA, Murphy DP. An oral hypnotic medication does not improve continuous positive airway pressure compliance in men with obstructive sleep apnea. Chest. 2006 Nov;130(5):1369-76.

Kezirian EJ, Weaver EM, Yueh B, Khuri SF, Daley J, Henderson WG. Risk factors for serious complication after uvulopalatopharyngoplasty. Arch Otolaryngol Head Neck Surg. 2006 Oct;132(10):1091-8.

Peppard PE, Szklo-Coxe M, Hla KM, Young T. Longitudinal association of sleep-related breathing disorder and depression. Arch Intern Med. 2006 Sep 18;166(16):1709-15.

Weaver TE, Maislin G, Dinges DF, Bloxham T, George CF, Greenberg H, et al. Relationship between hours of CPAP use and achieving normal levels of sleepiness and daily functioning. Sleep. 2007 Jun 1;30(6):711-9.

Review Date:
7/18/2007
Reviewed By:
Harvey Simon, MD, 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.

adam.com

Skin wrinkles and blemishes

FitSugar — Wed, 08 Oct 2008 17:34:59 -0700

In This Report

Highlights
Introduction
Blemishes
Risk Factors
Prevention
Treatment
Resurfacing Treatments
Implant Procedures
Plastic Surgery
Resources
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Smoking and Skin Damage

The skin of smokers ages more rapidly than the skin of non-smokers, even in areas of the body not exposed to sunlight, according to a 2007 study. Women in the study who smoked also had much lower levels of vitamin E secretions in their skin. Vitamin E may protect the skin from sun damage.
There may be an association between smoking and higher frequency of a type of acne (noninflammatory acne) in adult women, according to a European study.

Antioxidants and Your Skin

A study in the Journal of Nutrition found that a combination of antioxidants and trace elements supplementation raises the risk of skin cancer in women, but not in men.

Ultraviolet Radiation

Overall, exposure to ultraviolet radiation from sunlight (radiation referred to as UVA or UVB) accounts for about 90% of the symptoms of premature skin aging.
UVB primarily affects the outer skin layers. It is most intense when sunlight is brightest. People receive slightly over 70% of their yearly UVB dose during the summer.
UVA penetrates more deeply and efficiently. The intensity of UVA rays is less dependent on the time of day and season of the year than that of UVB rays.

Vitamin D

A report analyzing studies of vitamin D supplementation found that people who take vitamin D supplements live longer than those who do not. People who avoid sunlight are at risk for vitamin D deficiency.

Introduction

As you age, your skin undergoes progressive changes:

The cells divide more slowly, and the inner layer of skin (the dermis) starts to thin. Fat cells beneath the dermis begin to shrink. In addition, the ability of the skin to repair itself decreases with age, so wounds heal more slowly. The thinning skin becomes vulnerable to injuries and damage.
The deeper layer of the skin, which provides scaffolding for the surface skin layers, loosens and unravels. Skin then loses its elasticity (ability to stretch). When pressed, it no longer springs back to its initial position. Instead, older skin sags and forms furrows.
The sweat- and oil-secreting glands atrophy (waste away), leaving the skin without a protective layer of water and fat. The skin's ability to stay moisturized then decreases, and it becomes dry and scaly.
Frown lines (those between the eyebrows) and crow's feet (lines that spread from the corners of the eyes) appear to develop because of permanent small muscle contractions. Habitual facial expressions also form characteristic lines.
Gravity makes the situation worse, contributing to the formation of jowls and drooping eyelids. Eyebrows, surprisingly, move up as a person ages, possibly pulled up by forehead wrinkles.

Wrinkles can have a profound impact on self-esteem. The stigma attached to looking old is evidenced by the more than $12 billion Americans spend each year on cosmetics to hide the signs of aging. Our society places a premium on youthfulness, and age discrimination in the workplace, although illegal, has stalled many people's careers. Indeed, the emotional consequences of aging explain in large part why the cosmetics industry and plastic surgeons thrive.

The sun is the most important cause of prematurely aging skin (a process called photoaging) and skin cancers. Overall, exposure to ultraviolet radiation from sunlight (radiation referred to as UVA or UVB) accounts for about 90% of the symptoms of premature skin aging. Most of these effects occur by age 20:

Even small amounts of UV radiation trigger the processes leading to skin wrinkles.
Long-term repetitive exposure to sunlight adds up, and likely is responsible for the vast majority of unwanted consequences of aging skin, including basal cell and squamous cell cancers.
Intense exposure to sunlight in early life is an important cause of melanoma, a particularly aggressive type of skin cancer.

Initial Damaging Effects of Sunlight. Ultraviolet radiation penetrates the layers of the skin. Both UVA and UVB rays cause damage leading to wrinkles, lower immunity against infection, aging skin disorders, and cancer. They appear to damage cells in different ways, however.

UVB is the main cause of sunburns, and primarily affects the outer skin layers. UVB is most intense at midday when sunlight is brightest. People receive slightly over 70% of their yearly UVB dose during the summer. We receive only 28% during the remainder of the year. Window glass filters out UVB.
UVA penetrates more deeply and efficiently. The intensity of UVA rays is less dependent on the time of day and season of the year than that of UVB rays. For example, you receive only about half of your yearly UVA dose during the summer months, with the balance spread over the rest of the year. Window glass does NOT filter out UVA.

Both UVA and UVB rays cause damage to the body, including genetic injury, wrinkles, aging skin disorders, and skin cancers. Exactly how they cause this damage is not yet fully understood.

Processes Leading to Wrinkles. Even small amounts of UV radiation trigger the processes that can cause wrinkles:

Sunlight damages collagen fibers (the major protein that gives structure to the skin). Sunlight also causes damage to elastin, a protein in the skin that normally maintains springiness and strength of tissue beneath the skin.
In response to this sun-induced elastin accumulation, the body produces large amounts of enzymes called metalloproteinases. One study indicated that when people with light to moderate skin color are exposed to sunlight for just 5 - 15 minutes, the metalloproteinase levels in their body remain high for about a week.
The normal function of these metalloproteinases is generally positive -- to remodel the sun-injured tissue by producing and repairing collagen. This is an imperfect process, however, and some of metalloproteinases produced by sunlight actually degrade (break down) collagen. The result is an uneven formation (matrix) of disorganized collagen fibers called solar scars. Repetition of this imperfect skin rebuilding causes wrinkles.
An important event in this process is the over-production of oxidants, also called free radicals. These are unstable molecules that are normally produced by chemical processes in the body, a process called oxidation. Environmental damage, however, causes an overproduction of oxidants. Excessive amounts of oxidants damage the body's cells and even alter their genetic material. Oxidation may contribute to wrinkling by activating the specific metalloproteinases that degrade connective tissue.

In addition to sunlight, other factors may hasten the formation of wrinkles:

Cigarette Smoke. Smoking produces oxygen-free radicals, which accelerate wrinkles and aging skin disorders, and increase the risk for non-melanoma skin cancers. Studies also suggest that smoking and subsequent oxidation produce higher levels of metalloproteinases, the enzymes associated with wrinkles.

Air Pollution. Ozone, a common air pollutant, may be a particular problem for the skin. One study reported that it might deplete the amount of vitamin E in the skin. This vitamin is an important antioxidant.

Rapid Weight Loss. If weight loss occurs too rapidly, the volume of fat cells that cushion the face are also decreased before chemicals in the skin can react. This not only makes a person look gaunt, but can cause the skin to sag.

Blemishes

This report covers three types of blemishes: Liver spots, purpura, and seborrheic keratoses (or warts).

Liver spots (known as lentigos, or sun-induced or pigmented lesions) are flat brown spots on the skin. They are almost universal signs of aging. Occurring most noticeably on the hands and face, these blemishes tend to enlarge and darken over time. The extent and severity of the spots are determined by a combination of skin type, sun exposure, and age. These spots are harmless, but should be distinguished from lentigo maligna, which is an early sign of melanoma.

Liver spots or age spots are a type of skin change that are associated with aging. The increased pigmentation may be brought on by exposure to sun, or other forms of ultraviolet light, or other unknown causes.

Treating Liver Spots. Liver spots do not require treatment, although some people are distressed by their appearance. Treatments may include the following:

Trichloroacetic acid (a chemical peel).
Tretinoin (Retin A) alone or in a combination with Mequinol (Solagé). Tretinoin is related to vitamin A, and is also effective in treating wrinkles.
Gentle freezing with liquid nitrogen (cryotherapy).
Laser treatment. Specific lasers, such as the Nd:YAG, are effective in eliminating 80% of liver spots in one treatment. It may be more effective than cryotherapy and have fewer side effects.
Bleaching creams -- these are commonly available but are not as satisfactory as peels, and high concentrations can sometimes cause permanent loss of skin color.

Purpura occurs when tiny capillaries (blood vessels) break and leak blood into the skin. In older people, the condition (called senile or actinic purpura) is usually caused by fragile blood vessels. The capillaries appear as flat purplish patches. These patches are called petechiae when they are smaller than 3 mm (about a tenth of an inch). When they are greater than 3 mm, they are referred to as ecchymoses. Patients typically complain of a rash, which may appear reddish at first but gradually change color, turning brown or purple.

Treatment. Although there is no specific treatment for purpura, patients are advised to avoid trauma, including vigorous rubbing of the skin, which may be sufficient to damage the capillaries. Emollients that soften the skin may be helpful. Some doctors also recommend vitamin C, but its effectiveness is unproven.

Seborrheic keratoses, (also called seborrheic warts), are among the most common skin disorders in older adults. Their cause or causes are unknown. They usually appear on the head, neck, or trunk and can range in size from 0.2 - 3 cm (a little over an inch). They are well defined and appear to be pasted onto the skin, but their appearance can vary widely:

They can be smooth with tiny, round, pearl-like formations embedded in them.
They can be rough and warty.
They can be brown or black.

Seborrheic keratoses sometimes look like melanoma, since they can have an irregular border, but they are always benign. A dermatologist can tell the difference between them, although experts warn that melanomas may "hide" among these benign lesions and go unnoticed without close inspection. In general, seborrheic keratoses have a uniform appearance while melanomas often have a smooth surface that varies in height, color density, and shading. In some cases, keratoses may cause itching or irritation. They can be easily removed with surgery or freezing. Vitamin D3 ointment is also showing promise in clinical trials.

Risk Factors

Exposure to Sun in Childhood. It is estimated that 50 - 80% of skin damage occurs in childhood and adolescence from intermittent, intense sun exposure that causes severe sunburns. In spite of this now well-known effect, many people still believe that a tan in children signifies health. And even though many parents are concerned about sun exposure, they still rely too much on sunscreen and not enough on protective clothing.

The Elderly. Most people over 70 have at least one skin disorder. Many have three or four. Everyone experiences skin changes as they age, but a long life is not the sole determinant of aging skin. Family history, genetics, and behavioral choices all have a profound impact on the onset of aging-skin symptoms.

Of all the risk factors for aging skin, exposure to UV radiation from sunlight is by far the most serious. Indeed, the vast majority of undesirable consequences of aging skin occur in individuals who are repetitively exposed to the sun, including the following:

Outdoor workers, such as farmers, fishermen, construction workers, and lifeguards
Outdoor enthusiasts
Sunbathers
People who regularly attend tanning salons or use tanning beds (One study indicated that regular use significantly increases the risk for non-melanoma skin cancers. Fair-skinned women under age 50 may be at particular risk.)

Experts have devised a classification system for skin phototypes (SPTs) based on the sensitivity to sunlight. It ranges from SPT I (lightest skin plus other factors) to IV (darkest skin). People with skin types I and II are at highest risk for photoaging skin diseases, including cancer. It should be noted, however, that premature aging from sunlight can affect people of all skin shades.


Skin Type	Tanning and Burning History
I	Always burns, never tans, sensitive to sun exposure
II	Burns easily, tans minimally
III	Burns moderately, tans gradually to light brown
IV	Burns minimally, always tans well to moderately brown
V	Rarely burns, tans profusely to dark
VI	Never burns, deeply pigmented, least sensitive

The common belief is that women are at greater risk for wrinkles than men. Some evidence suggests, however, that given the same risk factors, men and women in the same age groups have comparable risks for skin photoaging. In a French study, the evidence of moderate-to-severe photoaging was observed in the following:

Twenty two percent of women and 17% of men ages 45 - 49
Thirty six percent of women and 38% of men by age 54
Nearly half of both men and women by age 60

Some studies report that men are more likely to develop non-melanoma skin cancers.

Heavy smokers are almost five times more likely to have wrinkled facial skin than nonsmokers, according to one study. The skin of smokers in areas of their bodies not exposed to sunlight also seems to age more rapidly, compared to non-smokers in the same age group, according to a 2007 study. In fact, heavy smokers in their 40s often have facial wrinkles more like those of nonsmokers in their 60s.

Studies of identical twins have found smokers to have thinner skin (in some cases by as much as 40%), more severe wrinkles, and more gray hair than their non-smoking twins. Even worse, cigarette smokers are more prone to skin cancers, including squamous cell carcinoma and giant basal cell carcinomas. A European study found an association between smoking and higher frequency of a particular type of acne in adult women. The study also found that women who smoked had much lower levels of vitamin E secretions in their skin. Vitamin E is an antioxidant that may help protect the skin from sun damage. [See In-Depth Report #41: Smoking.]

Prevention

The best long-term prevention for overly wrinkled skin is a healthy lifestyle.

Eat Healthy. A diet with plenty of whole grains, fresh fruits and vegetables, and the use of healthy oils (such as olive oil) may protect against oxidative stress in the skin. One study reported that people over age 70 years had fewer wrinkles if they ate such foods. Diet played a role in improving skin regardless of whether the people in the study smoked or lived in sunny countries. Benefits from these foods may be due to high levels of anti-oxidants found in them.

Exercise. Daily exercise keeps blood flowing, which brings oxygen to the skin. Oxygen is an important ingredient for healthy skin.

Reduce Stress. Reducing stress and tension may have benefits on the skin.

Quit Smoking. Smoking not only increases wrinkles, but smokers have a risk for squamous cell cancers that is 50% higher than nonsmokers' risk. Smokers should quit smoking to prevent many health problems, not just unhealthy skin.

The following are some daily measures for skin protection:

Don't wash your face too often with tap water. (Once a day is enough.) It strips the skin of oil and moisture. In addition, chlorinated water, particularly at high temperatures, poses special risks for wrinkles.
Wash your face with a mild soap that contains moisturizers. Avoid alkaline soaps, especially with deodorant.
Pat the skin dry and immediately apply a water-based moisturizer.
Always apply sunscreen, even if going outdoors for short periods.
Avoid drinking alcohol within 3 hours of bedtime. Alcohol increases the risk for leaks in the capillaries, which allows more water in and causes sagging and puffiness. Capillary leakage increases when one is lying down.
Lie on the back when sleeping. This helps offset the effects of gravity.

One of the most important ways to prevent skin damage is to avoid episodes of excessive sun exposure. The following are some specific guidelines:

Use sunscreens that block out both UVA and UVB radiation. However, do not rely only on sunscreen for sun protection. Wear protective clothing and sunglasses in addition.
Avoid exposure particularly from 10 a.m. to 4 p.m., when sunlight pours down 80% of its daily UV dose.
Avoid reflective surfaces, such as water, sand, concrete, and white-painted areas. Clouds and haze are not protective and in some cases may intensify UVB rays.
Ultraviolet intensity depends on the angle of the sun, not heat or brightness. So the dangers are greater the closer to the summer-start date. For example, in the Northern Hemisphere, UV intensity in April (2 months before summer starts) is equal to that in August (2 months after summer begins).
The higher the altitude the quicker one sunburns. One study suggested, for example, that an average complexion burns in 6 minutes at an altitude of 11,000 feet at noon, compared with 25 minutes at sea level in a temperate climate.
Avoid sun lamps and tanning beds or salons. They provide mostly high-output UVA rays. Some experts believe that 15 - 30 minutes at a tanning salon is as dangerous as a day spent in the sun. People should not be misled by advertising claims of "safe" tanning or promotions offering unlimited tanning.

Sunscreens. The use of sunscreens is complex, and everyone should understand how and when to use them. The bottom line is not that people should avoid sunscreens or sunblocks, but that they should always use them in combination with other sun-protective measures.

Protective Clothing. Wearing sun-protective clothing is extremely important and protects even better than sunscreens. Special clothing is now available for blocking UV rays and is rated using SPF ratings or a system called the UPF (ultraviolet protection factor) index, with 50 UPF being the highest. (According to one study, this is a very reliable indicator of protection.) The clothing is expensive, however. The following are some tips for everyone:

Adults and children should wear hats with wide brims. Even wearing a hat, however, may not be fully protective against skin cancers on the head and neck.
People should look for loosely fitted, unbleached, tightly woven fabrics. The tighter the weave, the more protective the garment.
Washing clothes over and over improves UPF by drawing fabrics together during shrinkage. An easy way to assess protection is simply to hold the garment up to a window or lamp and see how much light comes through. The less the better.
Everyone over age 1 should wear sunglasses that block all UVA and UVB rays.

Chemical Tanners. Some research suggests that melanin and dihydroxyacetone (DHA), the active ingredients in many self-tanning lotions, may help filter out UVA and UVB radiation and are therefore protective against sun damage More research is underway. A preliminary study funded by the National Cancer Institute found that people who received numerous daily injections of melanotan-1 (MT-1) before going in the sun or a tanning bed tanned more quickly and showed fewer signs of sun-related damage. MT-1 is a synthetic version of the hormone melanin, which helps produce the skin's natural pigment (color).

In choosing a sunscreen, look at the ingredients. Preparations that help block UV radiation are sometimes classified as sunscreens or sunblocks, according to the substances they contain. In general, sunscreens contain organic formulas and sunblocks inorganic formulas. However, the term sunblock is used less and less as sunscreens increasingly contain both kinds of ingredients:

Organic formulas contain UV-filtering chemicals such as octocrylene, octyl salicylate, homosalate, and octyl methoxycinnamate (block UVB), avobenzone-Parsol 1789 (blocks UVA), cinoxate, ethylhexyl p-methoxycinnamate (blocks UVB and small amounts of UVA), oxybenzone, benzophenone-3 (blocks UVA/UVB). People should look for a wide-spectrum sunscreen that contains combinations of these ingredients and filter both UVA and UVB. Of note: para-amino benzoic acid (PABA), once a popular ingredient, is now used infrequently. PABA may actually break down in the presence of UV exposure and release harmful oxidants. In addition, many people have an allergic reaction to it. Some products contain PABA derivatives, such as padimate O or octyl dimethyl PABA. It is not known if they have the same effects.
The Food and Drug Administration approved Anthelios SX in July 2006. This new sunscreen prevents sunburn and protects against ultraviolet A and B rays. The product contains ecamsule, an ingredient not previously marketed in the United States.
Inorganic formulas contain the UV-blocking pigments zinc oxide or titanium dioxide. Zinc and titanium oxides lie on top of the skin and are not absorbed. They prevent nearly all UVA and UVB rays from reaching the skin. Older sunblocks are white, pasty, and unattractive, but current products use so-called microfine oxides, either zinc (Z-Cote) or titanium. They are transparent and nearly as protective as the older types. Microfine zinc oxide may be more protective and less pasty-colored than microfine titanium oxide.

Inexpensive products work as well as expensive ones with the same ingredients. Unfortunately, there are still no standards for sunscreens, and even those claiming UVA protection may offer very little. In one study, the average UVA protection from a wide range of brands was only 23%. In fact, the average protection of brands not making the claim was 37%!

Organic formulas and inorganic microfine oxides do not protect against visible light, which is a problem for people who have light-sensitive skin conditions, including actinic prurigo, porphyria, and chronic actinic dermatitis. Inorganic sunscreens that protect against visible light and are still cosmetically acceptable are now available in Europe, but not yet in the US.

Calculating the SPF. The sun protection factor (SPF) on all sunscreen labels is a ratio based on the amount of UVB (not UVA) radiation required to turn sunscreen- or sunblock-treated skin red compared to non-treated skin. For instance, people who sunburn in 5 minutes and who want to stay in the sun for 150 minutes might use an SPF 30. The formula would be: 30 (the SPF number) times 5 (minutes to burn) = 150 minutes in the sun.

Protection offered by sunscreens may be classified as follows:

Minimal: SPF 2 to 11.
Moderate: SPF 12 through 29.
High: 30+. (Although some sunscreens claim SPFs higher than 30, the added protection at such higher levels is insignificant.)

SPF Levels by Age Group. Certain groups should have higher or lower SPFs depending on age and other factors:

Although sunscreens are safe in most toddlers and children, they should not be the first and only lines of defense. In fact, experts are worrying that by relying too much on sunscreen and not providing other protective measures, parents may actually be increasing their children's risk for melanoma. All young children should be well covered with clothing, sunglasses, and hats as the first line of defense against sunburn. Children should be kept out of the sun during peak sunlight periods. Sunscreens should not be used on babies younger than 6 months without consulting a doctor.
Older children and adults (even those with darker skin) benefit from using SPFs of 15 and over. Some experts recommend that most people should use SPF 30 on the face and 15 on the body.
Adults who burn easily instead of tanning and anyone with risk factors for skin cancer should use at least SPF 30.

Timing and Amount of Application. You should apply sunscreen or sunblock liberally as follows:

Adults should include sunscreen with a daily skin regimen, even if going outdoors for only a short time.
Apply a large amount to all exposed areas, including ears and feet. To achieve protection as indicated by the sunscreen's SPF, experts recommend half a teaspoon each for the head, neck, and each arm and a teaspoon each for the chest area, the back, and each leg.
Apply initially 30 minutes before venturing outdoors for best results. (This allows time for the sunscreen to be absorbed. Then reapply every 15 - 30 minutes while being in the sunlight.
Also reapply each time after exercise or swimming. (Choose a waterproof or water-resistant formula even if activities don't include swimming. Waterproof formulas last for about 40 minutes in the water, whereas water-resistant formulas last half as long.)
Insect repellents reduce sunscreen SPFs by up to one-third. Use higher SPFs and very liberal application when applying both.

Possible Hazards of Sunscreens, Sun Avoidance, or Both. When used generously and appropriately, sunscreen products and sun avoidance help reduce the severity of many aging skin disorders, including squamous cell cancers. There are certain concerns, however.

Sunscreen Use May Not Protect Against Basal Cell and Melanoma Cancers and May Even Increase the Risk. Although sunscreens help prevent squamous cell carcinomas and other skin disorders, sunscreens do not appear to provide protection against melanoma and some basal cell cancers. In fact, some studies have reported a higher association with sunscreen use and these skin malignancies, though not all studies report such negative results.

The reasons for this possible increased risk are unclear, though some theories include the following:

Until recently, many sunscreens blocked only or mostly UVB rays and not UVA, the more deeply penetrating rays now known to be especially dangerous. Past studies may not have reflected the effects of the broad-spectrum sunscreens now available, which block both UVA and UVB.
People who apply sunscreens may feel safe and stay out longer during high sun-exposure hours than is safe. Even if a person doesn't sunburn, UVA rays can still penetrate the skin and do harm.
People may not put on enough sunscreen. According to a 2002 study, people generally apply only 20 - 60% of the recommended amount, which can provide significantly less protection than the given SPF. (Of note, a 2003 study reported that when applied at the recommended amount, a broad-screen sunscreen prevents DNA damage from UV exposure. However, omitting it even once resulted in significant cell injury.)

Sunscreen Use May Increase the Risk for Health Problems Related to Sunlight Deficiencies. There is some major concern that underexposure to sunlight, due to the use of sunscreens or sun-avoidance measures, may produce other health problems, such as the following:

Vitamin D Deficiency. Vitamin D is found in only a few foods, such as fortified dairy products and fish, but it is produced in the skin in response to UVB sunlight. A medical literature review published in the journal Nutrition and Cancer reported that UVB rays may outshine dietary supplements for building the body's vitamin D reserves. Without an appropriate mix of diet and supplements, vigorous sun protection measures may increase a person's risk for developing vitamin D deficiency. Vitamin D is important for prevention of rickets, osteoporosis, and some cancers, including melanoma. People who need to avoid sunlight and whose diet is low in foods that contain vitamin D should check with their doctor about taking supplements. People with darker skin are at higher risk for deficiencies from sun protection than those with whiter skin. Note: vitamin D is toxic in high doses. Most doctors recommend 200 IU a day (for young adults) to 600 IU a day (above age 70). Doses up to 2,000 IU a day are considered safe. A report analyzing studies of vitamin D supplementation found that people who take vitamin D supplements live longer than those who do not. The researchers looked at 18 studies. They found that participants who received vitamin D supplements were, on average, 7% less likely to die during the study they were in, compared with those receiving "sugar pills."
Other Cancers. Although sunlight is implicated in skin cancers, it is also associated with lower risks for breast, prostate, ovarian, and colon cancers. Some protection against these cancers may be related to vitamin D production by sunlight.
Depression. Many people suffer from SAD (seasonal affective disorder), a form of depression that generally occurs in winter and is associated with exposure to less sunlight.

The bottom line is that some sunlight is important and even necessary for a healthful and high-quality life. Adults may benefit from daily moderate tanning (20 - 30 maximum minutes of exposure during lower-risk hours) over several days to slowly build up pigment in the skin.

Treatment

An increasing number of dermatology patients are looking for a way to improve the appearance of their skin. As a result, more and more products have become available to treat skin wrinkles and blemishes. From vitamins and supplements to exfoliants and chemical peels -- the options can be overwhelming. In some cases, more than one approach may be needed.

Antioxidants are substances that hunt oxygen-free radicals, the unstable particles that can damage cells. Free radicals may also cause sun damage and even skin cancers. Exposure to sunlight depletes antioxidants in the skin, and therefore they must be replaced.

Antioxidant ointments, creams, and lotions ("topical products") may help reduce the risk of wrinkles and protect against sun damage. Unlike sunscreens, they build up in the skin and are not washed away, so the protection may last. Selenium, coenzyme Q10 (CoQ10), and alpha-lipoic acid are types of antioxidants that come in topical form. Many are proving to be very beneficial for the skin.

Vitamin A. Vitamin A is important for skin health. UV radiation produces vitamin A deficiencies in the skin. Topical products containing natural forms of vitamin A (retinol, retinaldehyde) or vitamin A-related products called retinoids (tretinoin, tazarotene) may help repair skin damage due to sunburn and natural aging.

Tretinoin (Retin-A). Tretinoin (known commercially as Retin-A) is the only topical agent approved for treating photoaging and is available in prescription form (Avita, Renova, Differin). The June 2004 issue of Dermatology Surgery reported that tretinoin (0.25% concentration) was an effective and well-tolerated treatment for photodamaged facial skin. This drug produces a rosy glow and reduces fine and large wrinkles, liver spots, and surface roughness. It also may help prevent more serious effects of ultraviolet radiation. Patients may apply tretinoin to the face, neck, chest, hands, and forearms, and should do so at least twice a week. Noticeable improvement takes 2 - 6 months. Because Retin-A increases a person's sensitivity to the sun, patients should apply just a tiny amount at bedtime, and wear sunblock during the day. Patients should also avoid overexposure to the sun. Almost all patients experience redness, scaling, burning, and itching after 2 or 3 days that can last up to 3 months. In women who experience irritation, a daytime moisturizer or low-dose corticosteroid cream, such as 1% hydrocortisone, may help. There is some concern that overuse of high-dose tretinoin may cause excessive skin thinness over time. Studies now suggest that low concentrations (as low as .02%) of tretinoin can produce significant improvements in wrinkles and skin color, with less irritation than the higher doses.
Retinol. Retinol, a natural form of vitamin A, could not, until recently, be used in skin products because it was unstable and easily broken down by UV radiation. Stable preparations are now sold over the counter. In the right concentrations, retinol may be as effective as tretinoin, and studies indicate that it has fewer side effects. An animal study suggests that adding antioxidant creams (such as those containing vitamins C or E) may offer added protection against degradation of retinol, but not tretinoin. The Food and Drug Administration warns that over-the-counter retinol skin products are unregulated. The amount of active ingredients is unknown, and some preparations, in fact, may contain almost no retinol.
Tazarotene. Tazarotene (Tazorac, Zorac, Avage) is a retinoid used for acne and psoriasis. It has now been approved for treating wrinkles, skin discoloration, and blemishes due to photoaging. One short-term study suggested that it may be as effective as tretinoin and even slightly better at high doses. At such high doses, however, it can cause very severe irritation. Redness and peeling may be reduced by administering tretinoin first to get the skin acclimated. A randomized study of 562 patients with facial photodamage found that a daily application of tazarotene 0.1% cream resulted in a minimum 1 grade improvement in fine and coarse wrinkling, uneven skin color, pore size, skin roughness, and overall photodamage. More research is needed to determine if it produces any long-lasting significant benefits.

Warning: Pregnant women and those who may become pregnant should avoid any vitamin A derivative (a product related to vitamin A). For example, oral tretinoin causes birth defects, and women should avoid even topical Retin-A when pregnant or trying to conceive.

Vitamin C. Vitamin C, or ascorbic acid, is a very potent antioxidant. Most studies on the effects of antioxidants on the skin have used this vitamin. In laboratory studies, large amounts of vitamin C reduced skin swelling and protected immune factors from sunlight. It may even promote collagen production. Vitamin C by itself is unstable, but products that solve the delivery problem are now available (such as Cellex-C, Avon's Anew Formula C Treatment Capsules, Physician Elite, and others). More research is needed.

Antioxidants Under Investigation for Skin Care. Other antioxidants are also being investigated for their value in skin protection. Most available brands, however, contain very low concentrations of these antioxidants. In addition, they are also not well absorbed and have a short-term effect. New delivery techniques, however, may prove to offset some of these problems.

Vitamin E. Studies suggest that topical vitamin E, particularly alpha tocopherol cream (a form of vitamin E), decreased skin roughness, length of facial lines, and wrinkle depth. Studies on mice have also reported reductions in UV-induced skin cancer with its use.
Both green and black tea may provide some protection against skin cancers and photoaging. There is also some evidence that pomegranate and soy extracts may help rejuvenate aging skin.
Aloe, ginger, grape seed extract, and coral extracts contain antioxidants and are promoted as being healthy for the skin, although evidence of their effects on wrinkles is weak.

A small study found that taking vitamin C and E supplements by mouth -- at the same time -- may help reduce sunburn, although it doesn't work as well as sunscreen. Taking the vitamins separately did not have any effect. Vitamin C and E are also antioxidants.

One of the basic methods for improving skin and eliminating small wrinkles is exfoliation (also called resurfacing), which is the removal of the top layer of skin to allow regrowth of new skin. Methods for doing this run from simple scrubs to special creams to intensive peeling treatments, including laser resurfacing. People with darker skin are at particularly higher risk for scarring or discoloration with the more powerful exfoliation methods.

Abrasive Scrubs. Scrub gently with a mildly abrasive material and a soap that contains salicylic acid to remove old skin so that new skin can grow. The motion should be perpendicular to the wrinkles. Use textured material or cleansing grains with microbeads. Organic materials, such as loofahs or sea sponges, may harbor bacteria. Avoid cleansing grains that contain pulverized walnut shells and apricot seeds, which can scratch skin on a microscopic level. Cleansing grains with microbeads don't have sharp edges and remove skin without cutting it. Exfoliation using scrubs, however, can worsen certain conditions, such as acne, sensitive skin, or broken blood vessels.

Topical Alpha Hydroxy Acid and Similar Substances. Alpha hydroxy acids (AHA) ease the shedding of dead skin cells and may even stimulate the production of collagen and elastin. Their natural forms are:

Lactic acid (milk)
Glycolic acid (sugar cane)
Malic acid (found in apples and pears)
Citric acid (oranges and lemons)
Tartaric acids (grapes)

Most alpha hydroxy acid products contain glycolic acid. Skin care products are also made from polyhydroxy acids (PHAs) and beta hydroxy acids (BHAs). Research suggests that PHA products may cause less skin irritation than AHA or BHA products.

Acid concentrations in over-the-counter AHA preparations are 2 - 10%. One clinical study suggested that 8% concentrations showed modest skin improvement Some examples include Avon's Anew Intensive Treatment (8% glycolic), Pond's Age Defying Complex (8%), Elizabeth Arden's Alpha-Ceramid Intensive Skin Treatment (3 - 7.5%), and BioMedic's home product (10%). Prescription strength creams contain at least 12% glycolic acid, and glycolic acid peels of 30 - 70% concentration may be administered in a doctor's office at weekly or monthly intervals.

Response to AHA varies, and the treatment is not without risk, particularly in high-concentration products. Side effects from over-the-counter creams, prescription products, and professional AHA peels can include burns, itching, pain, and possibly scarring. Studies also suggest that AHA may increase susceptibility to sun damage, even at concentrations as low as 4%. Such effects can persist up to a week after a person stops using the product. Experts advise that people purchase products with AHA concentrations of 10% or less. Chemical peels of up to 60% are available without prescription on the Internet. Such concentrations are not recommended, except under a doctor's supervision. If any adverse effects occur, stop using the product immediately. Always avoid sunlight or use proper sun protection when using these products.

Copper Peptides. Certain copper-containing compounds may protect skin and help repair it. Note: copper is a toxic metal. When using products containing copper, buy only those that contain peptides (small protein fragments) that bind to copper. Most studies have been conducted on the copper peptide glycyl-l-histidyl-l-lysine:copper (II) or GHK-Cu. It is currently used in a number of products (such as CP Serum, Neutrogena's Visibly Firm, ProCyte's Neova).

Furfuryladenine. Furfuryladenine (Kinetin, Kinerase) is a naturally occurring growth hormone found in plant and animal DNA. It has antioxidant and anti-aging properties. Some small laboratory studies suggest that furfuryladenine may delay the onset and decrease the effects of aging on skin. However, there are no well-conducted human studies to support this suggestion.

Vitamin K. Microsponge-based vitamin K is said to clear bruises spider veins, and other small blood vessel damage. Vitamin K is important for blood clotting.

Moisturizers help prevent dryness, bruising, and tearing. They have no effect on wrinkles by themselves. Moisturizers should be applied while the skin is still damp. These products retain skin moisture in various ways:

Occlusives, such as petroleum jelly, prevent water from evaporating.
Humectants, including glycerin, act by pulling water up to the surface of the skin from deep tissues. People with oily skin generally should use the humectant type.
More powerful compounds, such as monolaurin (Glylorin), contain mixtures of fatty molecules (lipids), which may help restore the skin's natural barriers against moisture loss and damage.

Most moisturizers contain combinations of these compounds. They usually have other ingredients as well, such as alpha hydroxy acids, sunscreens, collagen, and keratin. Collagen and keratin leave a protein film and temporarily stretch the skin. They range widely in price, and a major consumer organization found little difference in general between the more and less expensive products.

The skin under the eyes is very thin and does not produce as much of the protective oils that keep skin soft and supple. Manufacturers market their under-eye gels as being able to reduce puffiness and dark circles. The creams typically work in one of two ways:

By temporarily constricting blood vessels to prevent the build-up of fluids
By firming the skin with an invisible film

Never rub the creams under the eyes, as this may cause more wrinkles to form. Instead, apply these products with a light tapping motion to stimulate the skin.

Cosmetics, if properly applied, can be surprisingly effective in camouflaging the signs of aging skin, including wrinkles and age spots. Moreover, they offer additional benefits by retarding water loss and providing a physical barrier to UV radiation. However, as women age, less is more.

Here are some suggestions for older women:

Moisturizers. Apply moisturizers before foundation. If reddish discoloration is extensive or the skin is sallow, tinted moisturizers may be helpful and can be worn alone or under foundation.

Foundations. Caking on make-up will cause cracks at the wrinkle lines and only increase the appearance of aging. Try to cover large areas of the face with a moderate-coverage foundation that has a matte or semi-matte finish. Facial powder reflects light and thus minimizes wrinkles, but people with dry skin should avoid it.

Correcting Color. When blemishes are especially prominent, applying color correctors under the foundation can be very effective:

Green neutralizers mask red lesions.
Yellow will camouflage dark circles and bruises.
Mauve (a purplish-pink color) helps neutralize sallow skin or yellowish blemishes.
A white, pearled base helps to minimize wrinkles.

Blushes. Blushes and color washes can help conceal the spidery network of dilated capillaries on the nose and cheeks. Powder blushes are preferred because they blend easily on top of foundation.

Eyes. Powder eye shadows applied on top of a moisturizer are better than cream-based shadows. Light-colored shadow, applied along the upper eyelid crease and above the iris (the colored part of the eye) is best for offsetting the appearance of deep-set eyes. You should then apply a slightly deeper shade of the same color to the lower part of the eyelid, and draw it out to the corner.

Lips. A lip-setting cream or facial foundation should be applied before lipstick to help prevent it from bleeding into surrounding wrinkles. Try using a stiff bristle brush instead of a lip pencil. The brush will help keep the lipstick on and prevent bleeding. (Some women use the pencil itself for the full lip, which gives color but appears natural.) Some make-up artists recommend cream lipsticks instead of matte.

The Food and Drug Administration (FDA) does not regulate herbal remedies and dietary supplements. In other words, the manufacturers and distributors of such products do not need FDA approval to sell their products. In addition, any substance that affects the body's chemistry can, like any drug, produce side effects that may be harmful. There have been numerous reported cases of serious and even deadly side effects from herbal products.

Overexposure to sunlight can damage skin. The following natural remedies may cause extra sensitivity to light (photosensitivity):

St. John's wort (Hypericum perforatum) is a popular herbal remedy for depression. People who are sensitive to light should not use it. A case report suggests that St. John's wort may cause skin reactions in patients who have laser treatment.
Kava (Piper methysticum) is an herb used to calm nerves and reduce stress. In addition to photosensitivity, it can cause liver damage.
Yohimbe (Pausinystalia yohimbe) is used to treat erectile dysfunction. Both the herb and the pharmaceutical drug (yohimbine) can cause sensitivity to light.
Essential oils in many botanical aromatherapy products can trigger photosensitivity. Avoid citrus oils (grapefruit, lemon, lime, and orange) as well as bergamot, cumin, ginger, and angelica root oils.

Resurfacing Treatments

There are many choices for skin resurfacing (also called exfoliation), and the patient must consider several different factors that affect the choice. Resurfacing can achieve the following:

Removal of abnormal tissue and rough skin
Stimulation of new skin growth
Stimulation of collagen and elastin production

In addition to determining the skill of the surgeon and the safety of the procedure, the patient must discuss the desired depth of the resurfacing and the capability of each procedure to reach this depth safely. All resurfacing procedures require a healing period afterward, during which the skin is red and sensitive. The deeper the procedure, the higher the risk for complications, including delayed healing, infection, loss of pigment (skin color), and scarring.

If you make the decision to pursue intensive treatments, consider the following factors, among others, and discuss them with your dermatologist or plastic surgeon:

The ability of the procedure to safely reduce wrinkles
The ease and safety record of the procedure
The skill of the doctor
The length of recovery
Possible complications
How long the benefits will last

A person's age also helps determine the procedure:

For people in their 30s, a simple chemical peel is sufficient.
After age 40, people may benefit from collagen or fat implants.
At age 50 and over, plastic surgeons recommend laser resurfacing and customized treatments for individual needs.

In older individuals, combination procedures may be beneficial. Some examples include the following:

Laser surgery may be used for deep lines (such as those around the mouth) and chemical peels used over the rest of the face.
For enhancing the eye by correcting droopy eyelids, bags, and a "sinking" brow, combinations of eyelift (blepharoplasty), Botox, and laser resurfacing may be used.

Chemical peels, also known as chemosurgery, help restore wrinkled, lightly scarred, or blemished facial skin. Much like chemical paint strippers, chemical peels strip off the top layers of skin, and new, younger-looking skin grows back. The procedure is very effective for the upper lip but cannot be performed around the eyes. Partial peels are often done in conjunction with a face-lift. Combinations of the topical antioxidants, such as tretinoin and vitamin C, along with a chemical peel, may be particularly effective.

The Procedure.

A dermatologist applies chemicals to the skin. They include trichloroacetic acid, high concentrations of alpha hydroxy or beta hydroxy acids, or combinations of all three.
In some cases, tretinoin or alpha hydroxy is applied 4 - 6 weeks before, and starting one day after, the peel. Such treatments can enhance the effects of a peel and reduce the risk of discoloration in people at risk for this complication. Tretinoin is being tested as a chemical peel.
A crust or scab generally forms within 24 hours after surgery. You can remove this scab by gently cleansing with soap and water.
The skin takes 6 - 7 days to heal.
After the scab disappears, the visible skin is deep red but gradually lightens as it regenerates.

Complications. Complications include white heads, cold sores, infection, scarring, numbness, and permanent discoloration, particularly in people with darker skin. Refinement of chemical peel techniques are now permitting doctors to reach deeper skin, improvements which make it easier to apply peels to non-facial skin and to individuals with darker skin.

Dermabrasion affects deeper layers of skin than chemical peels, and may be useful for removing disfiguring marks, such as deep acne scars or deep wrinkles. As with chemical peels, it is effective for wrinkles on the upper lip and chin, and cannot be used around the eyes. Some doctors prefer dermabrasion to lasers for skin surfacing of people with darker skin colors.

Standard Dermabrasion. Standard dermabrasion uses a rotating brush that removes the top layers of a person's skin. As with chemical peels, dermabrasion selectively strips away the upper layers of skin, leaving the underlying skin layers exposed. Similar to chemical peels, after the procedure, the treated skin oozes and forms a scab, a reaction that looks and feels uncomfortable, but only temporary. Postoperative care is similar for both procedures.

Microdermabrasion. A gentler variation called microdermabrasion uses very tiny crystals to polish the skin and a vacuum technique to remove them. It has largely replaced the older dermabrasion, and, in fact, was the fourth most common non-surgical cosmetic procedure performed in 2005, with over a million done. Results are similar to light chemical peels. Patients can have this procedure done on their lunch hour and return to work. Only mild redness occurs after treatment, although for best results five or six repetitive treatments are needed every 1 - 2 weeks. To date, overall patient satisfaction has been very high.

Lasers are currently the most effective exfoliation tools for eliminating wrinkles. Their unique advantages over other resurfacing methods are their ability to tighten the skin. A successful procedure can make patients look 10 - 20 years younger, and the results can last up to 10 years.

The procedure is most beneficial for the following areas:

It is best around the mouth and eyes. Recent evidence suggests CO₂ lasers may be even better than dermabrasion for the upper lip.
It is slightly less beneficial for the area around the nose.

Used alone, current laser therapy does not eliminate crow's feet, broken blood vessels, or dark circles under the eye. The evidence of the effects of lasers on acne scars is incomplete.

Standard laser dermabrasion is too harsh for thinner skin layers, such as on the neck. Newer and gentler laser techniques, however, stimulate collagen without removing skin layers, and may prove to be useful for necklines.

The Laser Resurfacing Procedure. In general the procedure works in the following way:

Laser pulses penetrate the skin quickly, vaporizing water and surface skin without damaging the deeper layers, allowing new top skin to grow.
In addition, the laser delivers enough heat to shorten collagen fibers, restoring some elasticity to the skin.

Choice of Lasers. The lasers used depend on skin type and severity of the condition. Some of the more common laser types are:

The carbon dioxide (CO₂) laser. This is the most powerful laser treatment and is used for deep wrinkles and skin imperfections. People who have had silicone injections should not have CO₂ procedures, which can burn and scar the skin over the implanted area.
The erbium: YAG (Er:YAG). This laser is gentler than the CO₂ laser, and is effective for mild wrinkles and for providing a smooth skin texture. It has a shorter recovery time. Some experts have even found the YAG laser as effective in removing deep wrinkles as CO₂ when used to sufficient depth. A variable pulse YAG laser can shift between pulses that destroy skin tissue to those that heat the skin. This process effectively resurfaces the skin with fewer side effects than CO₂ laser therapy.
Pulsed dye laser. Pulsed dye laser uses yellow light, which is easily absorbed by hemoglobin, the molecule that gives blood its red color. Pulsed dye laser treatments are used to treat skin blemishes that are due to blood vessel abnormalities, such as port-wine stains.

A gentle laser procedure called non-ablative laser resurfacing (NLite), also called photorejuvenation, is now approved for the treatment of all facial wrinkles. The procedure uses light energy to gently stimulate new collagen, and possibly elastin production, without removing the skin tissue itself. Its effects are less pronounced than those of other laser procedures. However, because it does not injure the external layers of skin, it can be used on delicate skin areas, such as the neck and around the eyes. It also causes very little irritation afterward.

Some surgeons are using combination techniques that employ more than one laser technology in one session, to achieve different effects. For example, one combination technique uses CO₂, YAG, pulsed-dye laser, and one other laser technology to both improve wrinkles and clear under-eye dark circles and acne scarring. Pretreatment with botulinum (Botox) injections before laser resurfacing significantly improved the treatment of crow's feet in one study.

Post-Procedure Recovery. The procedure itself is relatively painless, but the redness and irritation that occur during the healing process can be severe. Non-ablative laser resurfacing does not have the same severe after-effects as other laser treatments. For 8 - 9 days, the face looks skinned and swollen, and requires continuous moisturizing. Some doctors suggest that people with very sensitive skin, who cannot tolerate the necessary medications and lubricants, should avoid laser resurfacing. Redness and sensitivity can persist for 1 - 4 months. The patient must stay out of the sun as much as possible during this time, and should always avoid sunbathing and damaging their skin again. Early research suggests that silicone dressings may reduce post-procedure pain and crusting.

Complications. Scarring and infections can occur in about 1% of procedures. The risk of complications depends on the experience of the surgeon. People with a history of herpes simplex may experience flare-ups of fever, facial pain, and flu-like symptoms for 5 or 6 days after the procedure. In addition, people with darker skin may wish to avoid the procedure, because it can cause unpredictable and dramatic lightening of the skin.

A new skin rejuvenation technology, called Plasma Skin Resurfacing, or Portrait Plasma, was introduced in February 2005. The technology uses plasma energy (heat and light energy) to rejuvenate the skin from the deeper layers outwards. While new skin regenerates, the outer layers of the skin act as a natural bandage. When the outer layers peel off in the week after treatment, the new skin emerges. The process prevents or minimizes the raw appearance that follows laser treatments. This system uses radio waves to "excite" nitrogen gas, resulting in the release of energy. According to the manufacturer, skin regeneration using the Portrait Plasma system is rapid, and satisfaction with the procedure appears high. Long-term follow-up studies are not available yet for this new method. In 2006, the Food and Drug Administration approved this method for the treatment of wrinkles on other areas of the body, besides the face.

Cold Ablation. Cold ablation, called coblation for short, delivers saline (salt water) to the skin, through which a cool electric current is passed. A subsequent reaction heats and vaporizes the top shallow layer of skin. The procedure is very specific and appears to minimize any damage to other areas of the skin.

Radiofrequency Resurfacing. A promising technique uses low radiowave energy to resurface the skin. Preliminary research indicates that this procedure may eventually be as effective as laser surgery in reducing severe wrinkles around the eyes and mouth, with minimal pain and a shorter recovery time. In one study, one radiofrequency treatment with only a skin anesthetic resulted in tighter facial skin for 14 out of 15 patients within 12 weeks. All but one patient returned to normal activity immediately afterward. A small clinical trial published in Dermatology Surgery found that a noninvasive radiofrequency technique called NARF safely and effectively improved drooping lower eyelids.

Intense Pulsed Light. Intense pulsed light (IPL) uses filters to deliver different wavelengths of light. Doctors use it to treat a number of photoaging skin problems, and it appears to have long-term effects. Typically, four to six treatments are performed over a four-month period. Each treatment takes 15 - 20 minutes. Unlike laser light, which uses one color wavelength (such as green or red), intense pulsed light starts with a full spectrum of light. It then allows the doctor to selectively block off specific wavelengths, depending on how shallow or deep the procedure should go. IPL machines are less expensive and safer than lasers.

Implant Procedures

Implants, also called injectable fillers, are becoming a common means of erasing wrinkles and folds. Several materials are being used for deep wrinkles, depression under the eyes, lip enhancements, and acne scars.

After being banned from the market in 1992, silicone is making a comeback in research settings as a potential permanent wrinkle eraser. Scientists are looking into a new microdroplet technique (the use of very small drops) combined with purified silicone as a way to eliminate any danger. The past problems with silicone occurred when it was mixed with a foreign substance, like mineral oil, or when it was injected in large doses.

Most implants to date, however, are not completely satisfactory. Collagen implants and biologic fillers from animal, bacterial, or human sources do not provide long-lasting benefits. Synthetic fillers are permanent but may cause an allergic reaction, which can lead to chronic problems. Such reactions are rare, but they can be painful and unattractive.

The U.S. Food and Drug Administration (FDA) approved the Juvéderm product line in June 2006. Juvéderm is an injectable treatment of moderate-to-severe facial wrinkles and folds. Juvéderm products are gels made from hyaluronic acid. They are injected into the face. Doctors report good results after a single treatment with Juvéderm, and the results last for at least 6 months.


Name and Material Used	Procedure	Specific Areas Affected	Benefits	Drawbacks
Collagen implants. Collagen is the protein that forms the structures in the body (such as skin, bones, cartilage). The implant procedure has typically used bovine (cow) collagen. A form of human collagen (CosmoDerm, CosmoPlast) has now been approved.	Injected into target wrinkles with needle and syringe. Several weeks after injection, cow collagen breaks down and is replaced by newly created human collagen.	Wrinkles around the eyes and mouth. It is used to give lips greater fullness.	Very simple with faster recovery than many other implant techniques.	Wrinkles form again, and require repeat treatments 3 - 12 months later. Rarely, severe allergic reactions occur. Should not be used by children, pregnant women, and people with a history of autoimmune disease.
Microlipoinjection. Fat tissue from the patient's own thigh or abdomen.	Injected into target wrinkles with needle and syringe.	Deep wrinkles around the nose and mouth, folds in the forehead, and wrinkles on the hands.	No allergic or immune reaction because substance is patient's own fat.	Body eventually absorbs the fat, resulting in a need for multiple injections. Some studies suggest that 70% of the fat may still be in place after at least a year.
Gore-Tex. Highly porous (full of tiny holes) and inert (not chemically active) synthetic material.	Requires some surgery. Tiny patches are inserted under the skin to fill out wrinkles. Skin cells and blood vessels pass through the porous material easily, reducing the risk of severe irritation.	Deep wrinkles.	Material does not break down.	Possible scarring from surgical procedure. Allergic reactions are rare but can occur even with chemically inactive materials.
Artecoll. Contains PMMA, or polymethylmethacrylate, an inert substance, enclosed in tiny droplets of natural collagen.	Material is injected. Body absorbs collagen. PMMA remains and stimulates new collagen growth.	Deep wrinkles.	Although part of the implant is a natural collagen implant, it does not degrade as quickly as a full collagen implant.	Repeat treatments may still be needed. Possible allergic reaction.
Hyaluronic acid. Natural (non-animal) substance acts like a molecular sponge to absorb water. The FDA approved Restylane in 2003, Captiva, Hylaform-Plus, and Hylaform in 2004, and Juvéderm in 2006.	Gel is injected under the skin.	Moderate-to-severe wrinkles.	Low risk for allergic reaction. May last longer than cow collagen.	Repeat treatments needed.
Poly-L-lactic acid. Synthetic polymer. Approved in US as Sculpta. Approved in other countries as New-Fill.	Material is injected under the skin.	Approved in U.S. only for patients with facial fat loss due to HIV. Approved in other countries for wrinkles.	Low risk of allergies. Treatment effects can last 18 - 24 months.	Doctors require special training.

The popularity of Botox injections has skyrocketed in the United States. Between 2004 and 2005, the number of procedures performed jumped 16 percent. Botox injection was the number one non-surgical cosmetic procedure in 2005, with more than 3.2 million injections. Botulinum, the deadly toxin found in uncooked foods, is also a powerful muscle-relaxant. Tiny amounts of a purified form (Botox) are injected into wrinkles to relax the surrounding muscles. It may benefit forehead and frown lines, crow's feet, lower eyelids, lines on the side of the nose, and the area between the upper lip and the nose. It is also useful for treating involuntary muscle movements that can occur after a face-lift.

The injections need to be repeated every few months, since the effects wear off. The treatment decreases the ability to frown or squint and may cause the corners of the mouth to turn down. When used for areas around eyes, it produces a rounder appearance afterward, which patients should be aware of before they undertake the procedure.

The drug does not cross the blood-brain barrier, and, to date, the only side effects are temporary muscle weakness near the injection site. Although there have been some reports that Botox can reduce migraine and tension headaches, Botox also causes headaches in about 1% of cases. In some cases, the headaches can be very severe and long lasting (from 8 days to a month). Some researchers suggest that either a contaminated batch of Botox or a specific injection technique may be the cause, but additional investigation is needed.

Plastic Surgery

In 2005, there were over 2.1 million cosmetic surgeries, up 1% from the year before. Most of these surgeries were liposuction and breast surgeries. However, over 200,000 each of eyelid and nose surgeries were performed. Facial plastic surgeries range from being fairly minimal, such as a brow lift, to a full face-lift.

Several face-lift procedures (called rhytidectomies) are available. Face-lifts can provide individuals with a more youthful look. The degree of improvement, however, depends on many factors, including age, bone structure, skin type, and personal habits, such as smoking and sunbathing.

The Procedure. When a face-lift is a relatively simple procedure, it can take about 2 hours under local anesthetic in a doctor's office. Complicated face-lifts are done under general anesthesia in a hospital and can take 3 - 6 hours. The face-lift procedure may be one of the following:

Superficial musculoaponeurotic system (SMAS) is the most common face-lift procedure. The surgeon makes an incision at the hairline and separates the skin from the underlying tissue and muscles. The muscles are tightened and excess fat and tissue, such as fat under the chin and neck, are removed.
The endoscopic subperiosteal or subgaleal face-lift is a less invasive surgical technique. The surgeon raises facial structures rather than cutting away flaps of skin. Only a few half-inch incisions are made, and scarring is minimal. Not all individuals are candidates for this procedure, however.

Neither SMAS nor the endoscopic version is effective for the middle part of the face, particularly the deep lines (naso-labial folds) that run down from the nose beside the mouth. Some time after the SMAS face-lift, the upper face begins to age again while the lower area keeps its shape, causing the face to look imbalanced. Researchers are looking at other approaches, such as one called composite face-lift, that lift most muscles in the face.

Recovery Process. Recovery normally lasts from several weeks to several months. Swelling and discoloration are common. Some patients report tingling or numbing sensations after surgery. These sensations generally decrease as damaged nerves regenerate.

Complications. A face-lift is not without risks. A postsurgical hematoma is a collection of blood that can occur after a face-lift. In one study, major hematomas occurred in 2.2% of patients and minor hematomas in 6.65% of patients. They generally develop within 2 weeks of the surgery and require draining. Even minor hematomas need fast treatment to prevent greater complications. Such complications can include infection, changes in skin color, fluid buildup, and prolonged recovery time.

Other less common complications may include the following:

Infection
Excessive bleeding
Imbalanced facial muscles
Delayed healing
Scarring
Permanent injury to the nerves that control facial movements

These complications are rare, particularly with a skilled surgeon, but the more complex the face-lifts, the greater the risk.

Blepharoplasty. Blepharoplasty is the primary surgical procedure for eye lifts. Results usually last 5 -10 years. Although simple, it has potential complications, including permanent difficulty in closing the eyes or making a stern expression. Newer techniques, however, are preventing this complication. Assuming the surgeon is experienced, laser surgery is now preferred to the standard surgical scalpel approach. Laser surgery reduces bleeding and bruising, and both the operation and recovery are faster. Temporary blurred or double vision is common. More serious complications include infection, bleeding, dry eyes, difficulty in closing the eyes, and pulling down of the lower lids. Rare cases of blindness have been reported.

Transconjunctival Upper Blepharoplasty. An innovative procedure called transconjunctival upper blepharoplasty removes fat from the membrane that lines the eyelids (the conjunctiva) and is an effective technique for treating both the upper and lower eyelids. Unlike traditional blepharoplasty, this procedure does not cause scarring in the nasal area. In patients who have scars from previous surgeries, transconjunctival removal of fat can also make existing scars less obvious. Long-term side effects and effectiveness of this procedure have not been studied.

Laser Liposculpture and Platysma Resurfacing. A procedure called laser neck and jowl liposculpture and platysma resurfacing may prove to be an alternative to face-lifts. The procedure requires only a one-inch incision under the chin and removing excess fat. After the fat is removed, the surgeon tightens the platysma, the thin muscular sheet under the skin of the neck, which improves the shape of the neck. Only local anesthetic is needed, and the patient can return to normal activities in 2 days. The patient's skin should be elastic enough to be able to reform without sagging.

Resources

www.aad.org -- American Academy of Dermatology
www.asds.net -- American Society for Dermatologic Surgery
www.plasticsurgery.org -- American Society of Plastic and Reconstructive Surgeons
www.surgery.org -- American Society for Aesthetic Plastic Surgery
www.skincarephysicians.com/agingskinnet -- Aging Skin Net

References

Autier P, Gandini S. Vitamin D Supplementation and Total Mortality : A Meta-analysis of Randomized Controlled Trials. Arch Intern Med. 2007;167:1730-1737.

Cho HS, Lee MH, Lee JW, et al. Anti-wrinkling effects of the mixture of vitamin C, vitamin E, pycnogenol and evening primrose oil, and molecular mechanisms on hairless mouse skin caused by chronic ultraviolet B irradiation. Photodermatol Photoimmunol Photomed. 2007;23(5):155-62.

Edison BL, Green BA, Wildnauer RH, Sigler ML. A polyhydroxy acid skin care regimen provides antiaging effects comparable to an alpha-hydroxyacid regimen. Cutis. 2004;73(2 Suppl):14-17.

Gordon, ML. A conservative approach to the nonsurgical rejuvenation of the face. Dermatol Clin. 2005 Apr;23(2):365-71.

Helfrich YR, Yu L, Ofori A, et al. Effect of smoking on aging of photoprotected skin: evidence gathered using a new photonumeric scale. Arch Dermatol. 2007;143(3):397-402.

Hercberg S, Ezzedine K, Guinot C, et al. Antioxidant supplementation increases the risk of skin cancers in women but not in men. J Nutr. 2007;137(9):2098-105

Kang S. A multicenter, randomized, double-blind trial of tazarotene 0.1% cream in the treatment of photodamage. J Am Acad Dermatol. 2005; 52(2): 268-274.

Mitsuhashi Y, Kawaguchi M, Hozumi Y, Kondo S. Topical vitamin D3 is effective in treating senile warts possibly by inducing apoptosis. Dermatol. 2005;32(6):420-423.

Rubino C, Farace F, Dessy LA, Sanna MP, Mazzarello V. A prospective study of anti-aging topical therapies using a quantitative method of assessment. Plast Reconstr Surg. 2005;115(4):1156-1162.

Samuel M, Brooke RC, Hollis S, Griffiths CE. Interventions for photodamaged skin. Cochrane Database Syst Rev. 2005;(1):CD001782.

Sudel KM, Venzke K, Mielke H, et al. Novel aspects of intrinsic and extrinsic aging of human skin: beneficial effects of soy extract. Photochem Photobiol. 2005;81(3):581-587.

Thornfeldt C. Cosmeceuticals containing herbs: fact, fiction, and future. Dermatol Surg. 2005;31(7 Pt 2):873-880.

Vochelle D. The use of poly-L-lactic acid in the management of soft-tissue augmentation: a five-year experience. Semin Cutan Med Surg. 2004;23(4):223-226.

Yarosh D, Klein J, O'Connor A, Effect of topically applied T4 endonuclease V in liposomes on skin cancer in xeroderma pigmentosum: a randomised study. Xeroderma Pigmentosum Study Group. Lancet. 2001;357(9260):926-9.

Review Date:
10/23/2007
Reviewed By:
Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

A.D.A.M. Copyright

adam.com

Myocardial infarction

FitSugar — Wed, 08 Oct 2008 17:34:55 -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

Myocardial infarction is the technical name for a heart attack. The heart is responsible for pumping blood, which carries oxygen, to every organ in the body – including the heart itself. A heart attack occurs when an artery leading to the heart becomes completely blocked and the heart doesn’t get enough blood or oxygen. Cells in that area of the heart start to die (called an infarct).

A heart attack is a medical emergency. If you or someone you know has any of the symptoms below, call 911 immediately. Waiting even 15 minutes can be fatal. But if you get prompt medical treatment, you can limit damage to your heart. Although heart attack is the leading cause of death in the United States, up to 95% of people who are hospitalized with a heart attack survive.

Most heart attacks are caused by blood clots, which are in turn caused by atherosclerosis (stiffening and narrowing of the arteries). High blood fats (triglycerides) and LDL or “bad” cholesterol form plaque inside arteries, narrowing the passageway and reducing the amount of blood that can flow through. Your lifestyle plays a crucial role in preventing a heart attack or recovering from one. Eating a heart-healthy diet and getting at least 30 minutes of exercise five days a week (or more) can reduce your risk of heart attack.

Signs and Symptoms

Squeezing pain, heaviness, tightness, pressure in center of chest
Pain that spreads to your back, left arm, jaw, neck
Shortness of breath
Dizziness, weakness
Nausea, vomiting
Irregular heartbeat
Sweating
Feeling of doom

Women may experience different symptoms than men. In women, along with chest pain, symptoms can include:

Heartburn or pain in the abdomen
Unusual fatigue
Clammy skin

Causes

Heart attacks happen when an artery supplying your heart with blood becomes blocked. Without blood, the heart doesn’t get enough oxygen and cells in the heart start to die.

The most common cause of blocked arteries is atherosclerosis. No one knows the exact cause of atherosclerosis, but most researchers believe it begins with an injury to the innermost layer of the artery, known as the endothelium. The following factors are thought to contribute to the damage:

High blood pressure
Elevated LDL ("bad") cholesterol
An accumulation of homocysteine (an amino acid produced by the human body, thought to be a risk factor for heart disease, stroke, osteoporosis, diabetes, and dementia)
Smoking
Diabetes
Inflammation

Once the artery is damaged, blood cells called platelets build up there to try and repair the injury. Over time, fats, cholesterol, and other substances also build up at the site, which thickens and hardens the artery wall. The amount of blood that flows through the artery is decreased, and oxygen supply to organs also decreases. Blood clots may also form, blocking the artery.

Rarely, a spasm in a coronary artery (one that supplies blood to the heart) stop blood flow and can cause a heart attack.

Risk Factors

These risk factors increase your chances of developing atherosclerosis:

Smoking
High-fat diet
High LDL “bad” cholesterol and triglycerides (fats in the blood)
Lack of exercise
Being overweight or obese
Family history of heart attack
Diabetes
High blood pressure
Being male, or a female who has gone through menopause
Stress

Also, people who have elevated homocysteine, C-reactive protein (CRP), and fibrinogen levels seem to have an increased risk of heart attack. These are markers of inflammation, but researchers aren’t sure whether they contribute to heart disease or occur when you have heart disease. High homocysteine can be treated with folic acid (see Nutrition and Supplements). More research in these areas is currently underway.

Diagnosis

If you think that you are having a heart attack, don’t wait to be sure – call 911 immediately. Treating a heart attack quickly can save your life, while delay can be fatal. In the emergency room, a doctor will ask you about your symptoms and perform a physical examination. He or she will immediately run tests to determine your heart function. They may include:

Electrocardiogram (ECG) - the first test done to check for a heart attack; you may be hooked up to a monitor even as the doctor is asking you questions. An ECG measures electrical activity of your heart.

Blood tests - Your doctor may look for certain enzymes that are released into your blood when you have a heart attack.

Other tests include:

Chest x-ray
Echocardiogram (uses sound waves to take a picture of your heart)
Coronary catheterization or angiogram (uses a liquid dye inserted through a catheter to see whether your arteries are blocked)
Stress test (involves walking on a treadmill while hooked up to a ECG machine to see how your heart responds to exercise)

Preventive Care

You can reduce your risk of heart attack by:

Stopping smoking.
Getting aerobic exercise (such as walking, biking, or swimming) for at least 30 minutes 5 days per week. If you haven't exercised much in the past, walking is a great way to start.
Reducing stress and learning stress-reduction techniques such as deep breathing and meditation. Yoga and tai chi, two forms of exercise that emphasize stretching, breathing, and meditating, can also help you reduce your stress level.
Eating a diet low in saturated fat and rich in fruits, vegetables, and whole grains.
Losing weight or maintaining a proper weight.

If you have high cholesterol, diabetes, or high blood pressure, follow your doctor’s instructions to keep these risk factors under control. You may need medications in addition to lifestyle changes. If you don't have heart disease yet or have not had a heart attack despite these risk factors, aggressive control can help prevent a heart attack. And, if you already have heart disease, aggressive control of these risk factors can prevent further heart attacks or other problems related to heart disease.

Treatment Approach

The goal when treating a heart attack is to restore blood flow to the affected area of the heart immediately, to preserve as much heart muscle and heart function as possible. If your doctor has prescribed nitroglycerin, take it while you are waiting for emergency medical personnel to arrive. Once at the hospital, your doctor may use drug therapy, angioplasty (using one of several methods to clear the blocked blood vessel, such as inflating a balloon inside it or holding it open with a device called a stent), and surgery.

Once you have been treated for a heart attack, making changes in your lifestyle (especially in your diet and exercise habits) and taking medications as prescribed is very important for avoiding recurrent heart attacks and even death. Although certain herbal remedies as well as relaxation techniques may also be used, they should never be used alone to treat a heart attack. A heart attack always requires emergency medical attention.

Lifestyle

Making lifestyle changes can improve many of your risk factors for heart disease, including high cholesterol, high blood pressure, extra weight, high homocysteine, and elevated C-reactive protein. Cardiac rehabilitation programs generally involve teaching you about diet, physical activity, and relaxation techniques. To keep your risk factors low, you will need to follow the healthy habits taught in cardiac rehab, like exercise and eating properly, for the rest of your life.

Medications

Aspirin - helps stop blood from clotting. You may be given aspirin in the ambulance or as soon as you get to the hospital.

Nitroglycerin - helps dilate (widen) blood vessels. You may be given nitroglycerin in the ambulance or as soon as you get to the hospital.

Pain reliever - Morphine is often given intravenously (IV) to relieve pain.

Thrombolytics - “Clot-busting” drugs may be used, depending on the type of heart attack. They are most effective when taken within 2 hours of the heart attack, and are not given after 12 hours have elapsed. These drugs may be given with other anticoagulants (blood-thinners).

Anticoagulants (blood-thinners) - Make your blood less likely to form clots. Heparin is often given by injection while you are in the hospital.

After you recover, other drugs are used to lower your risk of having another heart attack. They include:

ACE inhibitors - widen blood vessels and make it easier on your heart to pump blood. Side effects can include chronic cough. ACE inhibitors include

Benazepril (Lotensin)
Captopril (Capoten)
Fosinopril (Monopril)
Lisinopril (Zestril)
Enlapril (Vasotec)

Beta-blockers - slows heart rate, thus lowering blood pressure. These drugs include

Acebutolol (Sectral)
Atenolol (Tenormin)
Bisoprolol (Zebeta)
Carteolol (Cartrol)
Metoprolol (Toprol XL)
Nadolol (Corgard)
Propranolol (Inderal)

Statins - help lower cholesterol. People who are pregnant or have liver disease should not take statins. They include

Lovastatin (Mevacor)
Simvastatin (Zocor)
Pravastatin (Pravachol)
Atorvastatin (Lipitor)
Fluvastatin (Lescol)
Rosuvastatin (Crestor)

Niacin (nicotinic acid) - In prescription form, is sometimes used to lower cholesterol. Dietary supplements of niacin should not be used instead of prescription niacin, as it can cause side effects. Only take niacin for high cholesterol with your doctor's supervision.

Bile acid sequestrants - lowers cholesterol; people who have high levels of triglycerides (fats in the blood) should not take bile acid sequestrants. These drugs include

Cholestyramine (Questran)
Colestipol (Colestid)
Colesevelam (Welchol)

Fibric acid derivatives - lower triglycerides and moderately lower LDL cholesterol. They include Gemfibrozil (Lopid).

Anticoagulants (blood thinners) - help keep clots from forming. Your doctor may prescribe aspirin, warfarin (Coumadin), or Clopidogrel (Plavix)

Surgical Treatments

Percutaneous coronary intervention (PCI) – In primary PCI, the doctor performs a coronary angiogram (injecting dye into the arteries) to see where the artery is blocked. The doctor then performs balloon angioplasty (widening an artery with a balloon), often with stent placement, to keep the artery open.

Coronary artery bypass graft (CABG) – This surgery bypasses the blocked arteries by using a graft of another blood vessel (usually from your arm or leg) to restore blood flow to the heart.

Nutrition and Dietary Supplements

Healthy eating habits can help reduce high cholesterol, high blood pressure, and overweight –three of the major risk factors for heart disease. The American Heart Association (AHA) has developed dietary guidelines that help lower fat and cholesterol intake and reduce the risk of heart disease and heart attack. The AHA does not recommend very low-fat diets, because new research shows that unsaturated ("good") fats, such as those found in olive oil, are good for your heart.

Many fad diets are popular, but they may not help you lose weight and keep it off – and in some cases, they may not even be healthy. Any healthy diet will include a variety of foods. If a diet bans an entire food group (such as carbohydrates), it's probably not healthy.

The AHA recommends the following for healthy eating:

Grains: 6 to 8 servings per day (half should be whole grains)
Vegetables: 3 to 5 servings per day
Fruits: 4 to 5 servings per day
Fat-free or low-fat dairy: 2 to 3 servings per day
Lean meat, poultry, seafood: 3 to 6 oz. per day (about the size of a deck of cards)
Fats and oils: 2 to 3 tbsp. per day (use unsaturated fats such as olive oil or canola oil)
Nuts, seeds, legumes: 3 to 5 servings per week
Sweets, sugars: 5 or fewer servings per week (the fewer, the better)

In addition, the AHA also recommends eating 2 servings of fatty fish (such as salmon or lake trout) per week; holding sodium (salt, including salt already added to food) to 2,400 mg per day or less; and limiting alcohol intake to one drink a day for women and two for men.

Diets for People with High Blood Pressure

People with high blood pressure especially need to lower the amount of sodium in their diet. The DASH diet (Dietary Approaches to Stop Hypertension) emphasizes a diet rich in fruits, vegetables, and low-fat or non-fat dairy products that provide high intake of potassium, magnesium, and calcium sources. Sodium intake should be between 1,500 mg to 2,400 mg per day (the lower, the better) . Weight loss, regular exercise, and limiting alcohol are also very important factors for lowering blood pressure.

Mediterranean Diet

The Mediterranean Style Diet concentrates on whole grains, fresh fruits and vegetables, fish, olive oil, and moderate, daily wine consumption. The Mediterranean Style Diet is not low-fat; it is low in saturated fat but high in monounsaturated fat. It appears to be heart-healthy: In a long-term study of 423 patients who had a heart attack, those who followed a Mediterranean Style Diet had a 50% to 70% lower risk of recurrent heart disease compared with people who received no special dietary counseling.

Vitamins and Supplements

Some supplements may help lower your risk factors for heart attacks, such as high blood pressure or high cholesterol. Most do not work as well as prescription medications, but some can be used along with prescription medications in your treatment. If you have had a heart attack or are at high risk of having on, be sure to ask your doctor before taking any supplements.

Folic acid (400 mcg per day), vitamin B6 (25 to 100 mg per day), vitamin B12 (2 to 100 mcg per day) - The B vitamins help the body break down homocysteine, an amino acid that's been linked to increased risk of heart disease and stroke. Researchers believe that homocysteine may also contribute to atherosclerosis by damaging artery walls, making it easier for blood clots to form – but so far they haven't found a definite link. Researchers also don't yet know whether taking B vitamins reduces the risk of atherosclerosis or heart attack, nor do they know how much might have an effect. Talk to your doctor about checking your homocysteine levels and whether your doctor would recommend a B complex vitamin supplement. In the meantime, be sure to get enough B vitamins through your diet by eating fruits and leafy green vegetables every day.
Omega-3 fatty acids (fish oil, 1 to 4 g per day) - There is good evidence that omega-3 fatty acids (known as EPA and DHA) found in fish oil can help treat atherosclerosis by preventing the development of plaque and blood clots. Omega-3s can also help prevent heart disease, lower blood pressure, and reduce the level of triglycerides (fats) in the blood. The AHA recommends that people eat at least two servings of fatty fish (such as salmon) per week. For people who have had a heart attack, several studies show that eating fish or taking fish oil reduces the risk of both fatal and nonfatal heart attacks, as well as lowers your risk of death from any cause. Because fish oil at high doses can increase the risk of bleeding, talk to your doctor before taking a high dose (more than 1 g per day), especially if you already take blood-thinning medication.
Beta-sitosterol (800 mg to 6g per day in divided doses about 30 minutes before meals) - Beta-sitosterol is a plant sterol, a chemical found in plants that can stop cholesterol from being absorbed by the intestines. A number of well-designed scientific studies have shown that beta-sitosterol does lower LDL ("bad") cholesterol levels in the body. Beta-sitosterol may lower the amount of vitamin E and beta-carotene absorbed by the body, so you may want to ask your doctor if you need to take extra E or carotene.
Policosanol (5 to 10 mg two times per day) - Policosanol is a mix of waxy alcohols usually derived from sugar cane and yams. Several studies have indicated it may lower LDL ('bad") cholesterol and possibly even raise HDL ("good") cholesterol. One study found that policosanol was equivalent to fluvastatin (Lescol) and simvastatin (Zocor) in lowering cholesterol levels. It may also help stop blood clots from forming. However, almost all the studies have been conducted in Cuba by a research group that uses a proprietary form of policosanol and is funded by the manufacturer, so it is hard to evaluate the evidence. Policosanol may increase the risk of bleeding, and should not be taken by people who also take blood-thinning medications.
Coenzyme Q10 (CoQ10) - Researchers believe that CoQ10 may help stop blood clots from forming and boost levels of antioxidants. One study found that people who received daily CoQ10 supplements within three days of a heart attack were much less likely to experience another heart attack and chest pain. They were also less likely to die from heart disease than those who did not receive the supplements. Statins, drugs that lower cholesterol, can actually interfere with the body’s natural ability to make CoQ10, so your doctor may recommend taking a CoQ10 supplement. Still, more research is needed to say whether CoQ10 has any role in preventing or treating atherosclerosis.
Psyllium (Plantago psyllium, 10 to 30 g per day in divided doses taken 30 to 60 minutes after meals) - Taking psyllium, a type of fiber, helps lower cholesterol levels as well as blood sugar levels. If you take medicine for diabetes, talk to your doctor before taking psyllium.
L-carnitine (4 to 6 g per day) - Studies suggest that people who take L-carnitine (an amino acid) soon after a heart attack may be less likely to have a subsequent heart attack, die of heart disease, experience chest pain and abnormal heart rhythms, or develop congestive heart failure. (Congestive heart failure occurs when the heart can’t pump blood properly and blood backs up into the lungs and legs.) Studies also suggest that people with heart disease who take carnitine may be better able to exercise. Most studies used a special form of carnitine called propionyl-L-carnitine.

Herbs

Herbs should not be used in place of emergency medical attention for a heart attack, nor should they be used by themselves to lower your risk of heart attack after you’ve had one. However, some can be used along with prescription medications in your treatment. If you have had a heart attack or are at high risk of having on, be sure to ask your doctor before taking any herbs.

Hawthorn (Crataegus monogyna, 160 to 1,800 mg per day in two or three divided doses) - Hawthorn contains the polyphenols rutin and quercetin, and was used traditionally to treat cardiovascular diseases. Animal and laboratory studies show that hawthorn has antioxidant properties that help protect against the formation of plaques and may help lower high cholesterol and high blood pressure. Talk to your doctor before taking hawthorn, as it can interact with other drugs taken for heart disease and high blood pressure.
Garlic (Allium sativum, 900 mg per day of garlic powder, standardized to 0.6% allicin) - Clinical trials have shown that fresh garlic and garlic supplements may lower cholesterol levels, prevent blood clots, and destroy plaque. However, other studies show mixed evidence. In one study, people who had a previous heart attack and then took a garlic oil extract for 3 years had fewer second heart attacks and a 50% reduction in death rate than those who did not take garlic. Garlic can increase the risk of bleeding and should not be taken if you are also taking blood-thinning medication.
Bilberry (Vaccinium myrtillus) and other flavonoids - A close relative of the cranberry, bilberry fruits contain flavonoid compounds called anthocyanidins. Flavonoids are plant pigments that have antioxidant properties, and researchers think they may help prevent a number of illnesses including heart disease and diabetes. Bilberry has been used traditionally to treat heart disease, but only animal and test-tubes studies have been done. Animal studies have found that anthocyanidins and other flavonoids may strengthen blood vessels, improve circulation, and prevent LDL ("bad") cholesterol from being damaged (which may cause blood clots to form in arteries).
Asian ginseng (Panax ginseng) – Ginseng may help reduce risk factors for heart disease, including lowering blood pressure and cholesterol, but more studies are needed to be sure. Ginseng can increase the risk of bleeding and should not be taken if you are also taking blood-thinning medication. Ginseng should not be used if you have high blood pressure unless your doctor recommends it.
Green tea (Camellia sinensis) - Population studies suggest that regularly drinking green tea may reduce the risk of heart attack from atherosclerosis. It also may help you lower your cholesterol and your weight, although more research is needed to know for sure.
Kudzu (Pueraria lobata) - Kudzu has been used traditionally to treat heart disease, including heart attack and congestive heart failure. A few studies suggest it may help relieve angina, but the studies were of poor quality. More research is needed to know whether kudzu has any benefit for heart disease.

Homeopathy

Homeopathy should not be used instead of immediate medical attention for a heart attack. Homeopathy may, however, be used to help reduce your risk of heart disease. Although few studies have examined the effectiveness of specific homeopathic remedies, professional homeopaths would recommend appropriate therapy to lower high blood pressure and cholesterol. Before prescribing a remedy, homeopaths take into account your constitutional type. In homeopathic terms, a person's constitution is his or her physical, emotional, and intellectual makeup. An experienced homeopath would assess all of these factors when determining the most appropriate remedy for you as an individual.

Acupuncture

Acupuncture may be helpful in reducing some risk factors for heart disease. Some studies show that it can help people who want to stop smoking, and it may help some people lose weight and lower their blood pressure.

Massage and Physical Therapy

Although few studies have examined the effectiveness of massage therapy for heart disease, massage has a relaxing effect and can reduce stress-related hormone levels. Lowering stress hormone levels can lower cholesterol and blood pressure, reducing your risk of heart disease. In addition, relaxation techniques may help you make lifestyle changes such as eating healthy, quitting smoking, and exercising. At least one study found that massage can lower blood pressure.

Other Considerations

Prognosis and Complications

After a heart attack, a person’s prognosis depends on how damaged the heart is. If the person is alive 2 hours after an attack, he or she has a good chance for survival, but may experience complications such as:

Irregular heart rhythm, called an arrhythmia
Congestive heart failure
Shock
Infarct extension (extension of the amount of affected heart tissue) or recurrent heart attack(s)
Pericarditis (infection around the lining of the heart)
Pulmonary embolism (blood clot in the lungs)
Complications from treatment (for example, thrombolytic agents increases the risk of bleeding)

The good news, however, is that heart attacks are not always disabling, especially when there are no complications. In fact, a full recovery is possible that allows you to do all the tings you used to do, including sexual activity. Going through cardiac rehabilitation and sticking with lifestyle changes can help lead to a positive recovery.

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Review Date:
12/26/2007
Reviewed By:
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

Acne

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

Overview

Signs and Symptoms
What Causes It?
Risk Factors
What to Expect at Your Provider's Office
Treatment Options
Other Considerations
Supporting Research

HEALTH GUIDE REFERENCE FROM A.D.A.M

Acne is an inflammatory skin condition characterized by clogged pores, blackheads, and pimples. The oil glands, or sebaceous glands, are connected to hair follicles and release a substance known as sebum that lubricates hair and skin. Usually, sebum travels up the hair follicle and out onto your skin. But when the sebaceous glands produce too much oil and combine with dead skin cells, the follicles become blocked and inflamed. The nose, forehead, cheeks, chin, back, and trunk are the areas acne most often affects. Between 17 - 45 million people have acne, making it the most common skin disease in the United States. While it tends to last longer in women, men are more likely to get acne and tend to have more severe cases. Acne is most common in adolescents, and it generally disappears by age 30. Although it is not a serious health threat, severe acne can be painful and may cause permanent scarring, which can be upsetting for people who suffer from the condition.

Signs and Symptoms

There are several types of acne lesions:

Closed comedone (whitehead) -- a clogged follicle. Whiteheads usually appear on the skin as small, round, white bumps.
Open comedone (blackhead) -- a plugged follicle that opens and turns dark at the surface of the skin. Blackheads do not indicate the presence of dirt.
Papules -- inflamed lesions that appear as small, pink bumps on the skin.
Pustules (pimples) -- inflamed pus-filled lesions that are red at the base.
Cysts and nodules -- large, inflamed, pus-filled lesions deep under the skin that can cause pain and scarring.

Lesions can cause scars ranging from small, depressed pits to large elevated blemishes, depending on the severity of the acne and the person's skin type.

What Causes It?

Acne is caused by the combination of too much sebum and a buildup of dead skin cells, but no one knows what trigger the overproduction of sebum. During adolescence, rising hormone levels are thought to be a factor. The increased sebum blocks hair follicles, and small bacteria-filled cysts called comedones form. If these comedones do not rupture, they develop into whiteheads or blackheads. When comedones rupture, the inflammation can spread into the surrounding area. Papules, pustules, cysts, and nodules are types of inflammatory lesions.

Risk Factors

The following may cause or worsen acne:

Family history of acne
Using oily cosmetic or hair products containing vegetable or animal fats
Hormonal changes common during adolescence, pregnancy, or menstruation (acne tends to flare up 2 - 7 days before menstruation begins)
Certain medications such as corticosteroids, androgens, oral contraceptives, lithium, halogens, isoniazid, phenytoin, phenobarbital, and high levels of iodine (such as from kelp)
Sweating and friction on your skin, caused by headbands, back packs, bicycle helmets, or tight collars
Squeezing and picking comedones

What to Expect at Your Provider's Office

Acne is rarely a serious health problem, and general practitioners and internists can treat most people with mild-to-moderate forms of acne. People with more severe cases are often referred to a dermatologist. Your doctor will take a complete medical history that includes questions about skin care, cosmetic use, and diet; factors that trigger flare-ups; medication use; and prior treatment. Your doctor will also examine your face, chest, back, and other areas for blemishes, lesions, and scars.

Treatment Options

Treatments for acne involves lessening sebum production, helping the skin shed dead cells so they don't build up, and preventing bacteria from accumulating. The following self-care techniques may be helpful:

Wash skin once or twice a day with a mild cleanser. Washing more frequently, scrubbing skin, or using facial masks can make acne worse.
Use oil-free skin care products and cosmetics. Look for products that say "water-based" or "non-comedogenic."
Try over-the-counter lotions containing benzoyl peroxide or salicylic acid.
People with mild cases of acne may improve symptoms with herbs, Ayurveda, or homeopathy. Expect to use medications or complementary and alternative remedies for at least 6 - 8 weeks before seeing a noticeable improvement in symptoms.

Drug Therapies

Topical

Your doctor may also prescribe topical medications to treat acne. The most commonly used include:

Retinoids (tretinoin or Retin-A, adapalene or Differin, and tazarotene or Tazorac) -- are medications derived from vitamin A that work by unclogging pores and reducing inflammation. Side effects may include redness, peeling, and photosensitivity (high risk of sunburn). Most retinoids are applied at night and should not be applied at the same time as benzoyl peroxide (with the exception of adapalene). Pregnant women should not use topical retinoids during pregnancy.
Antibiotics -- work by killing bacteria and reducing inflammation. Topical antibiotics such as clindamycin or erythromycin are available in prescription form and may be used to treat mild-to-moderate acne.
Benzoyl peroxide -- Benzoyl peroxide is also available in prescription form.

Your doctor may recommend a combination of topical medications, such as benzoyl peroxide and clindamycin.

Oral

Your doctor may prescribe oral (taken by mouth) antibiotics either alone or in addition to topical medications for moderate-to-severe acne. For those with severe, inflammatory acne that does not improve with other medications, an oral retinoid called isotretinoin may be prescribed.

Antibiotics -- work by killing bacteria and reducing inflammation. Commonly prescribed oral antibiotics include doxycycline, minocycline, and tetracycline. Antibiotics taken by mouth should not be used during pregnancy or by children under 9.
Isotretinoin (Accutane) -- doctors aren't sure exactly how isotretinoin works, although it may reduce the production of sebum. It is usually prescribed for people with severe, inflammatory acne that does not improve with other medications. Isotretinoin is taken twice a day for 20 weeks. It causes severe birth defects and must not be used by pregnant women or those who may become pregnant. In fact, in the U.S. women who take isotretinoin are required to undergo regular pregnancy tests and take some form of prescription birth control.

Some women may be prescribed birth control pills that seem to reduce acne.

Surgery and Other Procedures

Surgery or other procedures can help improve the appearance of skin scarred by acne. Chemical peeling (where a chemical solution is applied to the skin that causes it to blister and eventually peel off) can reduce minor scars, while dermabrasion (a procedure that uses a rapidly rotating brush to remove the top layers of skin) can help more severe scarring. Laser resurfacing uses pulses of light to remove the top layer of skin and reduce scarring.

Complementary and Alternative Therapies

Nutrition

Although some people with acne report that certain drinks and foods (particularly nuts) make their symptoms worse, there is no scientific evidence that any food (even chocolate) affects acne. It is possible that food allergies may play a role in adult acne, and people may want to avoid foods that appear to aggravate their symptoms. Some doctors may suggest a low glycemic diet, which helps keep blood sugar stable and under control.

Zinc (30 mg two times per day for a month, then 30 mg per day) -- Several studies indicate that the mineral zinc may reduce the effects of acne. However, high doses of zinc can cause anemia, vomiting, and immune system suppression. It also interacts with tetracycline, which is often prescribed for acne. For these reasons, talk to your doctor before taking zinc.
Niacinamide (as a 4% topical gel) -- One study found that applying a 4% niacinamide gel to the skin two times per day for two months significantly improved acne symptoms. However, the study lacked a placebo, so it is hard to tell exactly how effective niacinamide might be.
L-carnitine -- Researchers in Greece showed that, among a large group of people, mild side effects from isotretinoin (dry skin, chapped lips, dry eyes, and nosebleeds caused by dry nose) improved when taking L-carnitine compared to those who took a placebo.
Vitamin A -- has many of the same properties as the retinoid drugs, but often with fewer side effects. Few studies have been done on vitamin A and acne, however. Too much vitamin A can be toxic, so talk to your doctor to determine the right dose for you, and only take higher doses of vitamin A under a doctor's supervision. Do not take extra vitamin A if you are pregnant or have liver disease.

Herbs

Tea tree oil (Melaleuca alternafolia, 5% gel) -- Applied topically, tea tree oil may help reduce bacteria on the skin, lessening inflammation and improving symptoms. One study compared the effectiveness of tea tree oil gel with benzoyl peroxide lotion in 119 people with mild-to-moderate acne. People in both groups improved, and the people using tea tree oil reported less side effects (including stinging, itching, burning, and dryness) than those using benzoyl peroxide.

Guggul (Commiphora mukul, dose equivalent to 25 mg guggulsterones or about 500 mg of guggul two times per day) -- In one study, taking guggul orally had the same effect as taking tetracycline. Guggul should not be taken by pregnant or nursing women. Guggul may have estrogen-like effects, and should not be taken by anyone with a history or family history of hormone-related cancers, including prostate cancer and breast or ovarian cancer. In addition, the herb may interact with anticoagulants (blood-thinning medications), tamoxifen, and birth control pills containing estrogen, as well as herbs that have estrogen-like effects (such as black cohosh, licorice, soy, and others). People who take these herbs or drugs should not take guggul.

Ayurvedic medicine -- Ayurvedic medicine may help improve symptoms, although further studies are needed. In one study, a combination of ginger (zingiber officinale), Holarrhena antidysenterica, and Embelia ribes reduced the number of inflammatory and non-inflammatory lesions. In another study, combined oral and topical use of Aloe barbadensis, Azardirachta indica, turmeric (Curcuma longa), Hemidesmus indicus, Terminalia chebula, Terminalia arjuna, and ashwagandha (Withania somnifera ) also reduced the number of lesions.

Homeopathy

There have been few studies examining the effectiveness of specific homeopathic remedies. Professional homeopaths, however, may recommend one or more of the following treatments for acne based on their knowledge and clinical experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type. In homeopathic terms, a person's constitution is his or her physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.

Belladonna -- for people who experience flushes of heat to the face or who have inflamed pustular acne that improves with cold applications
Calendula -- for skin conditions involving pustules or blisters
Hepar sulphur -- for painful, pus-filled acne
Kali bromatum -- for deep acne, especially on the forehead, in persons who are chilled and nervous
Silicea -- for pustules or pit-forming acne

Other Considerations

Pregnancy

Pregnant women should avoid all retinoids (those either taken by mouth or applied to the skin), isotretinoin, and the antibiotics tetracycline, minocycline, and doxycycline because they can be harmful to the fetus. The antibiotic erythromycin (in both forms applied to the skin and taken by mouth) is safe to use during pregnancy.

Prognosis and Complications

Acne is not a serious health threat, but severe acne can be painful, emotionally upsetting, and may cause permanent scarring. Squeezing lesions can rupture comedones and cause inflammation. Infants with acne have an increased risk of developing acne in adolescence. Symptoms generally diminish after adolescence and disappear by age 30. However, the incidence of adult acne, especially in women, seems to be increasing and is not unusual in women in their 30s and 40s.

Supporting Research

Bassett IB, Pannowits DL, Barneston RSC. A comparative study of tea-tree oil versus benzoyl peroxide in the treatment of acne. Med J Aust. 1990;153:455-458.

Brown DJ, Dattner AM. Phytotherapeutic approaches to common dermatologic conditions. Arch Dermtol. 1998;134:1401-1404.

Darmstadt GL. Acne vulgaris. In: Behrman RE, Kliefman RM, and Jenson HB, eds. Nelson Textbook of Pediatrics. 16th ed. Philadelphia, PA: W.B. Saunders Company; 2000: 2047-2051.

Dreno B, Amblard P, Agache P, Sirot S, Litoux P. Low doses of zinc gluconate for inflammatory acne. Acta Derm Venereol. 1989;69:541-543.

Dreno B, Trossaert M, Boiteau HL, Litoux P. Zinc salts effects on granulocyte zinc concentration and chemotaxis in acne patients. Acta Dermatol Venereol. 1992;72:250-252.

Ernst E, Huntley A. Tea tree oil: a systematic review of randomized clinical trials. Forsch Komplementärmed. 2000;7:17-20.

Enshaieh S, Jooya A, Siadat AH, Iraji F. The efficacy of 5% topical tea tree oil gel in mild to moderate acne vulgaris: a randomized, double-blind placebo-controlled study. Indian J Dermatol Venereol Leprol. 2007 Jan-Feb;73(1):22-5.

Georgala S, Schulpis KH, Georgala C, Michas T. L-carnitine supplementation in patients with cystic acne on isotretinoin therapy. J Eur Acad Dermatol Venereol. 1999;13(3):205-209.

Gfesser M, Worret WI. Seasonal variations in the severity of acne vulgaris. Int J Dermatol. 1996;35(2):116-117.

Gold MH. Acne and PDT: new techniques with lasers and light sources. Lasers Med Sci. 2007 Jan 16; (Epub ahead of print).

Jansen T, Plewig G. Advances and perspectives in acne therapy. Eur J Med Res. 1997;2:321-334.

Jonas WB, Jacobs J. Healing with Homeopathy: The Doctors' Guide. New York, NY: Warner Books; 1996: 227-230.

Krowchuk DP. Treating acne. A practical guide. Med Clin North Am. 2000;84(4):811-828.

Kubo I, Muroi H, Kubo A. Naturally occurring antiacne agents. J Nat Prod. 1994;57(1):9-17.

Lucky AW, Biro FM, Simbartl LA, Morrison JA, Sorg NW. Predictors of severity of acne vulgaris in young adolescent girls: results from a five-year longitudinal study. J Pediatr. 1997;13(1):5.

Lucky AW, Cullen SI, Jarratt MT. Comparative efficacy and safety of two 0.025% tretinoin gel: results from a multicenter double-blind, parallel study. J Am Acad Dermatol. 1998; 38(4): S17–23.

Meynadier J. Efficacy and safety study of two zinc gluconate regimens in the treatment of inflammatory acne. Eur J Dermatol. 2000;10:269-273.

Papageorgiou PP, Chu AC. Chloroxylenol and zinc oxide containing cream (Nels cream®) vs. 5% benzoyl peroxide cream in the treatment of acne vulgaris. A double-blind, randomized, controlled trial. Clin and Exp Dermatol. 2000;25:16-20.

Paranjpe P, Kulkarni PH. Comparative efficacy of four Ayurvedic formulations in the treatment of acne vulgaris: a double-blind randomized placebo-controlled clinical evaluation. J Ethnopharm. 1995;49:127-132.

Raman A, Weir U, Bloomfield SF. Antimicrobial effects of tea-tree oil and its major components on Staphylococcus aureus, Staph. epidermidis and Propionibacterium acnes. Letters in Applied Microbiol. 1995;21:242-245.

Swerlick RA, Lawley TJ. Eczema, psoriasis, cutaneous infections, acne, and other common skin disorders. In: Fauci AS, Braunwald E, Isselbacher KJ, et al, eds. Harrison's Principles of Internal Medicine. 14th ed. New York, NY: McGraw-Hill; 1998:303-304.

Thappa DM, Dogra J. Nodulocystic acne: oral gugulipid versus tetracycline. J Dermatol. 1994;21:729-31.

Thiboutot D. New treatments and therapeutic strategies for acne. Arch Fam Med. 2000;9:179-187.

Ullman D. The Consumer's Guide to Homeopathy. New York, NY: Penguin Putnam; 1995: 185-186.

Whang KK, Lee M. The principle of a three-staged operation in the surgery of acne scars. J Am Acad Dermatol. 1999; 40(1): 95–97.

Whitmore, SL. Common problems of the skin. In: Barker LR, Burton JR, Zieve PD. Principals of Ambulatory Medicine. 5th ed. Baltimore, MD: Williams & Wilkins; 1999: 1511.

Review Date:
3/18/2007
Reviewed By:
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

References

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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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Overview

Signs and Symptoms
Causes
Risk Factors
Diagnosis
Prevention
Treatment
Other Considerations
Supporting Research

HEALTH GUIDE REFERENCE FROM A.D.A.M

Asthma is a chronic disease that involves inflammation of the lungs. Airways swell and restrict airflow in and out of the lungs, making it hard to breathe. The word asthma comes from the Greek word for "panting." People with asthma pant and wheeze because of the restricted flow of air.

Normally, when you breathe in an irritant or are subjected to stressful activity such as exercise, your airways relax and open, allowing the lungs to get rid of irritants or take in more air. With asthma, muscles in the airways tighten, and the lining of the air passages swells.

About 20 million Americans have asthma, including 9 million children. In fact, asthma is the most common chronic childhood illness. About half of all cases develop before the age of 10, and many children with asthma also have allergies.

Asthma can either be allergic or non-allergic. In allergic asthma, an allergic reaction to an inhaled irritant -- pet dander, pollen, dust mites -- triggers an attack. The immune system gets involved, but instead of helping, it causes inflammation. This is the most common form of asthma.

Non-allergic asthma does not involve the immune system. Attacks can be triggered by stress, anxiety, cold air, smoke, or a virus. Some people experience symptoms only when they exercise, a condition known as exercise-induced asthma.

While there is no cure for asthma, it can be controlled.

Signs and Symptoms

Most people with asthma may go for periods of time without any symptoms, then experience an asthma attack. Some people experience chronic shortness of breath that gets worse during an attack. Asthma attacks can last minutes to days, and can become dangerous if the airflow becomes severely restricted.

Primary symptoms include:

Shortness of breath
Wheezing -- usually begins suddenly; may be worse at night or early in the morning; can be made worse by exposure to cold air, exercise, and heartburn; is relieved by using bronchodilators (drugs that open the airways; see Medications)
Chest tightness
Cough (dry or with sputum) -- in cough-variant asthma, this may be the only symptom

If you experience any of these symptoms, seek emergency treatment:

Extreme difficulty breathing or cessation of breathing
Bluish color to the lips and face (called cyanosis)
Severe anxiety
Rapid pulse
Profuse sweating
Decreased level of consciousness (such as drowsiness or confusion)

Causes

Asthma is most likely caused by a combination of several factors. Genes play a part; you’re more likely to develop asthma if others in your family have it. Among those who are susceptible, exposure to environmental factors such as allergens (substances that cause an allergic reaction) or infections may increase the likelihood of developing asthma.

Risk Factors

The following factors may increase the risk of developing asthma:

Having allergies
Family history of asthma or allergies
Exposure to secondhand smoke
Having upper respiratory infections as an infant
Living in a large city
Gender -- among younger children, asthma develops twice as often in boys as in girls, but after puberty it may be more common in girls
Obesity
Gastroesophageal reflux (heartburn)

Triggers

Childhood asthma in particular can be triggered by almost all of the same things that trigger allergies, such as:

Sensitivity to allergens such as dust, cockroach waste, pet dander, indoor and outdoor mold, pollen
Air pollutants, such as smoke, aerosols, perfumes, diesel particles, sulfur dioxide, high ozone levels, and fumes from paint, cleaning products, and gas stoves
Changes in the weather, especially in temperature (particularly cold) and humidity

Other triggers include:

Activities that affect breathing (exercising, laughing, crying, yelling)
Stress and anxiety

Diagnosis

The symptoms of asthma can mimic several other conditions, and your doctor will take a thorough history to rule out other diseases. You may also have lung function tests to measure, among other things, how much air your lungs can hold and how much air you exhale. Your doctor may use a spirometer to measure how much air you exhale and how quickly you get air out of your lungs. Other tests may include chest and sinus x-rays, blood tests, or allergy tests.

Asthma is classified as

Mild intermittent: Having mild symptoms up to 2 days a week and 2 nights a month
Mild persistent: Having symptoms more than 2 a week but not more than one time in a single day
Moderate persistent: Having symptoms once a day and more than one night per week
Severe persistent: Having symptoms throughout the day on most days and often at night.

Prevention

Although there is no way you can prevent asthma, you can take several steps to reduce the number and frequency of attacks:

Avoid allergens and irritants as much as possible. For example, to reduce exposure to dust mites, use special mattress and pillow covers that keep allergens out and remove carpets from bedrooms. Clean your house frequently.
Exercise. Even people with exercise-induced asthma can stay active, and exercise will benefit you by strengthening your lungs and helping you maintain a proper weight. Taking precautions when it’s cold outside -- such as wearing a face mask to warm the air that you’re breathing -- can help you avoid asthma symptoms. Talk to your doctor before starting an exercise regimen.
Pay attention to your breathing. Watch for signs of an oncoming attack, such as wheezing. Your doctor may give you a machine called a peak flow meter that can detect slight differences in your breathing before you even notice them and allow you to take medication immediately to ward off an attack.
Treat attacks quickly. The sooner you treat an attack, the less severe it will be, and the less medication you’ll need.

If you have allergies, a process known as allergy desensitization may decrease the number of asthma attacks and their intensity, and lower the amount of medication you need. Desensitization includes regular injections of the allergen (substance causing the allergic reaction), with each shot containing a slightly higher amount. Gradually your immune system becomes used to the allergen and no longer attacks it. Talk to your doctor about whether desensitization is right for you.

Treatment

Avoiding asthma attacks, reducing inflammation, and preventing lung damage are the primary goals of treatment. The more you know about your condition, the more you can work closely with your doctor to develop a treatment plan. Preventing exposure to allergens or irritants and taking medication as prescribed are important for the successful control of asthma. You may need emergency medications during an asthma attack, but monitoring your breathing taking your medications every day will help you control asthma over the long term.

Severe attacks may require hospitalization for oxygen and medications that are given intravenously (IV).

Lifestyle

If you smoke, quit.
Lose weight if you are overweight; excess weight may put pressure on the lungs and trigger an inflammatory response.
Monitor your condition every day using a peak flow meter (a portable device that helps measure how your lungs are working). Keep a diary of readings to show your doctor; together, you will establish your "personal best" reading. You should call your doctor if your peak flow reading falls below 80% of your personal best and go to the hospital if it falls below 50%.
Keep a journal that logs changes or attacks -- it may help determine triggers

Medications

Medications for asthma are prescribed for two different purposes: to stop an immediate attack, and to control inflammation and reduce lung damage over the long term.

Quick relief medications -- These drugs are called bronchodilators and help open the airways when you have an attack.

Short-acting beta-adrenergic agonists start working immediately. These drugs include:

Albuterol (Proventil)
Isoproterenol (Isuprel)
Metaproterenol (Aluprent)
Pirbuterol (Maxair)
Terbutaline (Brethine)
Levalbuterol (Xopenex)

Another drug that might be prescribed to help open your airway is ipratropium (Atrovent).

Sometimes, steroids are needed for an acute asthma attack. They can take longer to work (from a couple of hours to a few days) and include:

Prednisone
Prednisolone
Methylprednisolone
Hydrocortisone

Long-term control -- These drugs are usually taken every day.

Inhaled corticosteroids reduce inflammation have fewer side effects than oral corticosteroids. They include

Beclamethasone (Qvar)
Budesonide (Pulmicort)
Flunisolide (Aerobid)
Fluticasone (Flovent)
Triamcinolone (Azmacort)

A class of drugs called leukotreine modifiers help reduce the production of inflammatory chemicals called leukotreines that cause your airways to swell. They include:

Montelukast (Singulair)
Zafirlukast (Accolate)

Cromolyn (Intal), Nedocromil (Tilade) -- These medications, which are inhaled, can help prevent mild to moderate attacks and are used to treat exercise-induced asthma.

Theophylline (TheoDur) -- This medication helps open airways and prevent asthma symptoms, especially at night. Too much can cause serious side effects, so your doctor will monitor levels in your blood.

Nutrition and Dietary Supplements

Although asthma cannot be cured by any nutritional supplement, people who have a chronic illness such as asthma should eat well-balanced meals that include plenty of fruits and vegetables. Some studies have shown that people with asthma tend to have low levels of certain nutrients, but there is no evidence that taking supplements has any benefit. Rather, an overall healthy diet will ensure you get the nutrients you need and help your body deal with a long-term condition such as asthma.

Choline (3 g per day) -- Choline, a B vitamin, may help reduce the severity and frequency of asthma attacks, and allow people with asthma to use bronchodilators less often. Some evidence indicates that higher doses (3 g per day) may be most effective. More research is needed to say for sure whether choline helps.
Magnesium -- The suggestion of taking magnesium to treat asthma comes from the fact that people who have asthma often have low levels of magnesium, and from some (but not all) studies showing that intravenous (IV) magnesium can be effective as an emergency treatment for an asthma attack. However, studies that have looked at whether taking magnesium orally was beneficial have shown mixed results. More research is needed.
Omega-3 fatty acids -- The evidence for using omega-3 fatty acids (fish oil) to treat asthma is mixed. At least a few studies have found that fish oil supplements may improve inflammation and symptoms in children and adults with asthma. But the studies have only included a small number of people, and one study found that fish oil might make aspirin-induced asthma worse. Talk to your doctor about whether a high quality fish oil supplement makes sense for you.
Quercetin -- Quercetin, a kind of antioxidant called a flavonoid, inhibits the production and release of histamine and other allergic/inflammatory chemicals in the body. Histamine contributes to allergy symptoms such as a runny nose, watery eyes, and hives. Because of that, quercetin has been proposed as a treatment for asthma, but no human studies have examined whether it works or not.
Selenium -- Studies suggest that people with asthma tend to have low levels of selenium. In addition, a population-based study suggested that eating selenium-rich foods may reduce the risk of asthma. And in one small study of 24 people with asthma, those who received selenium supplements for 14 weeks had fewer symptoms than those who received placebo. However, a recent study indicated that people who took 200 mcg of selenium per day for about eight years were more likely to develop type 2 diabetes. Talk to your doctor before taking selenium supplements.
Vitamin C (1 g per day) -- One preliminary study suggested that children with asthma experienced significantly less wheezing when the ate a diet that was rich in fruits with vitamin C. Vitamin C does have anti-inflammatory and antioxidant properties, which may help you maintain good health overall. Other studies have indicated that taking a vitamin C supplement (1 g per day) may help keep airways open, but other studies have found no benefit.
Other -- Other supplements that may have benefit for asthma include:
- Coenzyme Q 10 (CoQ10) -- if you have asthma, you may have low levels of this antioxidant in your blood. It is not known, however, whether taking CoQ10 supplements will make any difference in your symptoms.
- Lycopene and beta-carotene -- preliminary data suggests that these two antioxidants, found in many fruits and vegetables, may help prevent exercise-induced asthma.
- Vitamin B6 -- may be needed if you are taking theophylline because this medication can lower blood levels of this nutrient.
- Potassium -- levels in the body also may be lowered if you take theophylline.

Herbs

The use of herbs is a time-honored approach to strengthening the body and treating disease. Herbs, however, can trigger side effects and interact with other herbs, supplements, or medications. For these reasons, herbs should be taken with care, under the supervision of a health care practitioner.

Boswellia (Boswellia serrata, 3 mg three times per day) -- Boswellia (also known as Salai guggal), an herb commonly used in Ayurvedic medicine (a traditional Indian system of health care), has shown promise in treating asthma. In one double-blind, placebo-controlled study, people who took boswellia had fewer attacks and improved lung function. Boswellia may help leukotreine modifiers work better. However, more research is needed. People who take medication to lower their cholesterol, or people who take nonsteroidal anti-inflammatory drugs (NSAIDs) should talk to their doctor before taking boswellia.
Coleus forskohlii -- Coleus forskohlii is another herb used in Ayurvedic medicine to treat asthma. A few preliminary studies that used inhaled coleus powder seemed to relieve symptoms, but more research is needed to know for sure. People who have diabetes or thyroid conditions should not take coleus. If you take an anticoagulant (blood thinner), taking coleus may increase your risk of bleeding. Pregnant women should not take coleus.
Tylophora (Tylophora indica, 250 mg one to three times per day) -- Tylophora has also been used historically to treat asthma. Some modern scientific studies show that it can help reduce symptoms, but the studies were not the best quality. More research is needed. Tylophora may cause serious side effects at high doses, so talk to your doctor before taking it. Do not take tylophora if you are pregnant, have diabetes, high blood pressure, or congestive heart failure.
Pycnogenol (Pinus pinaster, 1 mg per pound of body weight, up to 200 mg) -- A 2002 review of studies on a standardized extract from French maritime pine bark, called pycnogenol, suggests that it may reduce symptoms and improve lung function in people with asthma. Do not use pycnogenol if you have diabetes or take medication for high blood pressure. Taking pycnogenol with an anticoagulant (blood thinner) -- including aspirin -- can increase your risk of bleeding; talk to your doctor first.
Saiboku-to -- A traditional Japanese herbal mixture called Saiboku-to has helped reduce symptoms and allowed study participants to reduce doses of corticosteroids in three preliminary trials. In test tubes, Saiboku-to has shown anti-inflammatory effects. Saiboku-to contains several herbs, including Asian ginseng (Panax ginseng), Chinese skullcap (Baikal scutellaria), licorice (Glycyrrhiza glabra), and ginger (Zingiber officinale). Talk to your healthcare provider before taking Saiboku-to as the herbs it contains can interact with other herbs and medications.

Acupuncture

Some preliminary studies indicate that acupuncture may help reduce symptoms for some people with asthma, but not all studies agree. It is important to note that acupuncture should be used in addition to, not as a replacement for, conventional medicine when treating asthma.

Homeopathy

Although very few studies have examined the effectiveness of specific homeopathic therapies, professional homeopaths may consider the following remedies for the treatment of asthma based on their knowledge and experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type-- your physical, emotional, and psychological makeup. An experienced homeopath assesses all of these factors when determining the most appropriate treatment for each individual.

Arsenicum album -- for asthma that generally worsens between midnight and 2 am and is accompanied by restlessness, anxiety, chills, and thirst.
Ipecacuanha -- for those with asthma, particularly children, who have significant tightness in the chest, a chronic cough with lots of phlegm that may lead to vomiting, and worsening of symptoms in hot, humid weather.
Pulsatilla -- for asthma with yellow or greenish phlegm that gets worse in the evening, in warm, stuffy rooms, or after consuming rich, fatty foods; this remedy is most appropriate for adults or children who are tearful and clingy or sweet and affectionate.
Sambucus -- for asthma that awakens a person at night with a sensation of suffocation; symptoms worsen when the person is lying down .

Mind-Body Medicine

Because stress and anxiety can make asthma worse, incorporating stress management techniques into daily life may help reduce symptoms. These techniques do not directly treat asthma, however.

Hypnosis -- may be especially useful for children, who can readily learn the technique.
Yoga -- in addition to general relaxation and reduction of stress, several studies of people with asthma have suggested that lung function improve with the regular practice. Any benefits in breathing appear to be slight, however.
Journaling -- A study published in the New England Journal of Medicine documented the positive effect of daily journaling on people with asthma. Some theorize that journaling allows for the release of pent-up emotions and leads to overall stress reduction.

Other Considerations

Warnings and Precautions

Long-term treatment with theophylline for asthma may reduce blood levels of vitamin B6.

Prognosis and Complications

People with asthma can live normal, active lives. Because asthma is a chronic illness, it requires self-care and monitoring over the long term, as well as close contact with your doctor. Most people with asthma have occasional attacks separated by symptom-free periods. Paying attention to your mood, lowering the stress in your life, and having a good emotional support system will help you take good care of yourself.

Supporting Research

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Review Date:
9/23/2007
Reviewed By:
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

Diarrhea

FitSugar — Wed, 08 Oct 2008 17:35:25 -0700

Overview

Signs and Symptoms
What Causes It?
What to Expect at Your Provider's Office
Treatment Options
Following Up
Special Considerations
Supporting Research

HEALTH GUIDE REFERENCE FROM A.D.A.M

Diarrhea is an increase in the wateriness, volume, or frequency of bowel movements. Although uncomfortable, most diarrhea is not serious and will go away in a few days without treatment. See a health care provider, however, if the feces contain blood, if the diarrhea is particularly severe, or if the diarrhea lasts more than a few days. Children and elderly people should see a health care provider sooner because they are at more risk of dehydration.

Signs and Symptoms

Diarrhea is a symptom of another ailment. Symptoms you might experience with diarrhea are as follows:

Frequent need to defecate
Abdominal pain, cramping
Fever, chills, general sick feeling
Thirst
Weight loss

What Causes It?

Most diarrhea is caused by an infection (viral, bacterial, or parasitic), often from food or water. Diarrhea produces watery stools and lasts only a few days. Eating local food and drinking local water during foreign travel can result in "traveler's diarrhea." Diarrhea can also be caused by reactions to medications (including some vitamins, minerals and herbs) and ingestion of milk or dairy products by people who are lactose-intolerant. A different type of diarrhea that results in blood in the stool, accompanied by fever or abdominal pain, could be caused by intestinal disorders such as inflammatory bowel disease or Crohn's disease, and requires a doctor's care.

What to Expect at Your Provider's Office

Your health care provider will question you about your symptoms. Your provider will also check if you are dehydrated and may feel your abdomen to see if it is tender, listen to your abdomen with a stethoscope, and give you a rectal exam.

Treatment Options

Drug Therapies

In many cases, diarrhea will disappear on its own. However, many drugs can treat symptoms of diarrhea. Your health care provider may suggest the following drugs for your diarrhea:

Opioid derivatives: diphenoxylate with atropine sulfate, and loperamide
Adsorbents: Bismuth salt (for traveler's diarrhea) and attapulgite
Bulk-forming medications: psyllium husk

Over the Counter

Since diarrhea is your body's way of getting rid of toxins, it's best to let it run its course. However, you may use over-the-counter anti-diarrheal remedies for convenience, including loperamide (Imodium), bismuth sub-salicylate (Pepto-Bismol), and attapulgite (Kaopectate). You should not take bismuth sub-salicylate with the herbs meadowsweet (Spirea ulmaria), white willow (Salix alba), or wintergreen (Gaultheria procumbens ).

Complementary and Alternative Therapies

Work with your health care provider to find remedies that are right for you.

Nutrition and Supplements

Drink plenty of liquids, and avoid solid foods, coffee, chocolate, dairy products, and strong spices. Introduce clear soup, crackers, white bread, rice, potatoes, applesauce, and bananas as diarrhea gets better.
Rice or barley water, fresh vegetable juices (especially carrot and celery), miso broth, or other clear broths help restore proper fluid and electrolyte balance. Make rice and barley water using 1 cup of raw grain to 1 quart of boiling water. Let steep for 20 minutes. Strain and drink throughout the day.
Lactobacillus acidophilus and/or bifidobacteria taken as powder or in capsules helps normalize bowel flora and may help cure your diarrhea. Take as directed. Active culture yogurt containing these probiotics may help prevent diarrhea.
A live yeast, Saccharomyces boulardii, is often used in Europe to prevent diarrheas associated with antibiotic use. Take 1 - 3 capsules per day (3 - 9 billion colony forming units). May be taken with other probiotics. Rare but serious cases of infection in seriously ill patients have been reported, so do not takeSaccraromyces boulardii without a doctor's supervision.
Bovine colostrum, the pre-milk fluid secreted by a cow's mammary glands just after giving birth, may help treat some kinds of infectious diarrhea (1,000 - 4,000 mg per day)
Glutamine (3,000 mg three times per day) is helpful in treating diarrhea that is caused by irritation of the intestinal lining.
If lactose intolerance is the cause of the diarrhea, use over-the-counter lactase enzyme supplements before consuming dairy products.

Herbs

Do not use herbs to treat diarrhea without talking to your health care provider first. If your diarrhea is caused by certain types of infections, herbal treatments could make it worse. The most common herbal remedies for diarrhea are described below. They can be used as teas unless otherwise noted. 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.

Astringent herbs:

Astringent herbs, such as blackberry leaf (Rubus fruticosus) or raspberry leaf (Rubus idaeus), help "dry up" the mucous membranes in the intestine. Make a tea with 1 heaping tsp. per cup. Drink a ½ cup per hour. These teas are safe for children.
Carob powder (Ceratonia siliqua), which is rich in fiber, may be taken at the rate of 1.5 g per 2.2 pounds or 1 kg of body weight.Dissolve powder into a hydrating solution such as Pedialyte.
Extract of bilberry (Vaccinum myrtillus) also has astringent properties (4 g, spread over several doses). Do not take bilberry if you take blood-thinning medication.
Agrimony (Agrimonia eupatorium) is a traditional remedy for diarrhea. Usual dosage is 3 g (about 1/2 tsp.) per day.

Inflammation reducers:

Quercetin (250 - 500 mg two to four times per day)
Chamomile (Matricaria recutita) is usually taken as a tea. Dissolve 3 - 4 g powder (about 3 tsp.) in 1 cup hot water, strain and cool. Drink three times per day.
Marshmallow root (Althea officinalis) as cold-water tea. Soak 2 tbs. root in 1 quart of water overnight. Strain.Drink throughout the day.
Slippery elm powder (Ulmus fulva) or marshmallow root powder (Althaea officinalis). Use 1 oz. powder to 1 quart of water. Make a paste with the powder and a small amount of water. Gradually add in the rest of the water and then simmer down to 1 pint. Take 1 tsp. every 30 - 60 minutes.

Infection fighters:

Plants containing berberine can be used for infectious diarrhea. These include barberry (Berberis vulgaris) 250 - 500 mg three times per day; goldenseal (Hydrastis canadensis) 250 - 500 mg three times per day; and Oregon grape (Berberis aquifolium ), 250 - 500 mg three times per day.

Homeopathy

Some evidence suggests that homeopathic treatment may help diarrhea. In one study, children with acute diarrhea who received an individualized homeopathic treatment for 5 days had diarrhea for significantly less time than children who had placebo. 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 remedy for a particular individual. Some of the most effective homeopathic remedies are as follows:

Arsenicum album -- for foul-smelling diarrhea from food poisoning or traveler's diarrhea with burning sensation in the abdomen and around the anus. This remedy is most appropriate for individuals who feel exhausted yet restless and whose symptoms tend to worsen in the cold and improve with warmth. Vomiting may also occur.; Arsenicum may also be used to prevent diarrhea when traveling.
Chamomilla -- for greenish, frothy stool that smells like rotten eggs. Used primarily for children, especially those who are irritable, argumentative, and difficult to console. Chamomilla is commonly recommended for colicky or teething infants.
Calcarea carbonica -- for children who fear being in the dark or alone and who perspire heavily while sleeping. Stools may have a sour odor.
Mercurius -- for foul-smelling diarrhea that may have streaks of blood accompanied by a sensation of incomplete emptying. This remedy is most appropriate for people who tend to feel exhausted following bowel movements, experience extreme changes in body temperatures, perspire heavily, and have a thirst for cold fluids.
Podophyllum -- for explosive, gushing, painless diarrhea that becomes worse after eating or drinking. Exhaustion often follows bowel movements and the individual for whom this remedy is appropriate may experience painful cramps in lower extremities.; Podophyllum is often used in infants for diarrhea experienced from teething.
Sulphur -- for irritable and weepy children. They may have a red ring around the anus and diarrhea with the odor of rotten eggs.
Veratrum album -- for profuse, watery diarrhea accompanied by stomach cramps, bloated abdomen, vomiting, exhaustion, and chills. The diarrhea is worsened by fruit, and the individual craves cold liquids.

Acupuncture

Although several studies in traditional Chinese medicine journals have reported success in treating childhood diarrhea, acupuncturists in the United States do not generally treat this condition in children. However, acupuncture may be used when conventional treatment has failed. In this case, acupuncturists would examine both the nutritional value and the "energetic" qualities of food that might be affecting digestion.

Acupuncture is also combined with conventional medicine in treating diarrhea in adults.

Acupuncturists treat people with diarrhea based on an individualized assessment of the excesses and deficiencies of qi located in various meridians. In the case of diarrhea, a qi deficiency is usually detected in the spleen meridian. As a result, acupuncture treatments often focus on strengthening this meridian. Moxibustion (a technique in which the herb mugwort is burned over specific acupuncture points) is frequently used in the treatment of diarrhea because its effect is thought to reach deeper into the body than needling alone.

Following Up

If your diarrhea does not stop in 3 - 5 days, contact your health care provider.

Special Considerations

If you are pregnant, tell your doctor. Dehydration can cause you to go into labor early. Also, the diarrhea-related spasms may cause you to have contractions. Do not take goldenseal (Hydrastis canadensis), barberry (Berberis vulgaris), or high doses of vitamin A if you are pregnant.

Diarrhea can be serious, even fatal, for infants and elderly people because of dehydration and the loss of electrolytes.

Supporting Research

Andreoli TE, Bennett JC, Carpenter CCJ. Cecil Essentials of Medicine. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1993:271-277.

Bartram T. Encyclopedia of Herbal Medicine. Dorset, England: Grace Publishers; 1995:147.

Bensky D, Gamble A. Chinese Herbal Medicine. Seattle, Wash: Eastland Press; 1986:47-49.

Blumenthal M, ed. The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Boston, Mass: Integrative Medicine Communications; 1998:425, 464.

Berkow R. The Merck Manual of Medical Information. Whitehouse Station, NJ: Merck Research Laboratories; 1997:523-525.

Carr AC, Frei B. Toward a new recommended dietary allowance for vitamin C based on antioxidant and health effects in humans. Am J Clin Nutr. 1999;69(6):1086-1107.

Dambro MR. Griffith's 5 Minute Clinical Consult. Baltimore, Md: Lippincott Williams & Wilkins; 1999:316-319.

Gruenwald J, Brendler T, Jaenicke C, et al., eds. PDR for Herbal Medicines. Montvale, NJ: Medical Economics Co; 1998:617-618, 621-622, 763-766, 1047-1050, 1061-1063, 1078-1079, 1103-1104, 1201-1202, 1226-1227.

Johnston CS. Recommendations for vitamin C intake. JAMA. 1999;282(22):2118-2119.

Jacobs J, Jiménez M, Malthouse S, Chapman E, Crothers D, Masuk M, Jonas WB. Homeopathic treatment of acute childhood diarrhea: results from a clinical trial in Nepal. J Altern Complement Med. 2000;6(2):131-139.

Jonas WB, Jacobs J. Healing with Homeopathy: The Doctors' Guide. New York, NY: Warner Books; 1996: 218-220.

Khin-Maung-U, Myo-Khin, Nyunt-Nyunt-Wai, et al. Clinical trial of berberine in acute watery diarrhoea. Br Med J 1985;291:1601-5.

Kollaritsch H, Holst H, Grobara P, Widermann G. Prevention of traveler's diarrhea with Saccharomyces boulardii. Results of a placebo controlled double-blind study. Fortschr Med 1993;111:152-6.

Lin Y, Zhou Z, Shen W et al. Clinical and experimental studies on shallow needling technique for treating childhood diarrhea. J Tradit Chin Med. 1993;13(2):107-114.

Loeb H, Vandenplas Y, Wursch P, Guesry P. Tannin-rich carob pod for the treatment of acute-onset diarrhea. J Pediatr Gastroenterol Nutr. 1989 May;8(4):480-5.

Murray MT. Encyclopedia of Nutritional Supplements. Rocklin, Calif: Prima Publishing; 1996:431-439.

Patel AV, Rojas-Vera J, Dacke CG. Therapeutic constiuents and actions of Rubus species. Curr Med Chem. 2004 Jun;11(11):1501-12.

Saavedra J. Probiotics and infectious diarrhea. Am J Gastroenterol. 2000;95:S16-18.

Saaker SA, Casswall TH, Mahalanabis D, et al. Successful treatment of rotavirus diarrhea in children with immunoglobulin from immunized bovine colostrum. Pediatr Infect Dis J 1998;17:1149-54.

Spanier JA, Howden CW, Jones MP. A systematic review of alternative therapies in the irritable bowel syndrome. Arch Intern Med. 2003;163(3):265-74.

Stein JK, ed. Internal Medicine. 4th ed. St. Louis, Mo: Mosby-Year Book; 1994:436-440.

Stoller JK, Ahmad M, Longworth DL, eds. The Cleveland Clinic Intensive Review of Internal Medicine. Baltimore, Md: Williams & Wilkins; 1998:638-643.

Su Z. Acupuncture treatment of infantile diarrhea: a report of 1050 cases. J Tradit Chin Med. 1992;12(2):120-121.

Ullman D. Homeopathic Medicine for Children and Infants. New York, NY: Penguin Putnam; 1992: 75-77.

Ullman D. The Consumer's Guide to Homeopathy. New York, NY: Penguin Putnam; 1995: 243-245.

Walker LP, Brown EH. The Alternative Pharmacy. Paramus, NJ: Prentice Hall Press; 1998:147-150.

Review Date:
6/27/2006
Reviewed By:
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

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Autism

FitSugar — Wed, 08 Oct 2008 17:35:11 -0700

Overview

Signs and Symptoms
Causes
Risk Factors
Diagnosis

HEALTH GUIDE REFERENCE FROM A.D.A.M

Autism is a complex developmental disorder that appears in the first 3 years of life, although it is sometimes diagnosed much later. It affects the brain’s normal development of social and communication skills. Autism encompasses a wide range of behavior. The common features include impaired social interactions, impaired verbal and nonverbal communication, and restricted and repetitive patterns of behavior.

Signs and Symptoms

The symptoms may vary from moderate to severe. A combination of the following areas may be affected.

Communication:

Is unable to start or sustain a social conversation
Develops language slowly or not at all
Repeats words or memorized passages, like commercials
Doesn’t refer to self correctly (for example, says "you want water" when the child means "I want water")
Uses nonsense rhyming
Communicates with gestures instead of words

Social interaction:

Shows a lack of empathy
Does not make friends
Is withdrawn
Prefers to spend time alone, rather than with others
May not respond to eye contact or smiles
May actually avoid eye contact
May treat others as if they are objects
Does not play interactive games

Response to sensory information:

Has heightened or low senses of sight, hearing, touch, smell, or taste
Seems to have a heightened or low response to pain
May withdraw from physical contact because it is over-stimulating or overwhelming
Does not startle at loud noises
May find normal noises painful and hold hands over ears
Rubs surfaces, mouths or licks objects

Play:

Shows little pretend or imaginative play
Doesn’t imitate the actions of others
Prefers solitary or ritualistic play

Behaviors:

Has a short attention span
Uses repetitive body movements
Shows a strong need for sameness
"Acts up" with intense tantrums
Has very narrow interests
Demonstrates perseveration (gets stuck on a single topic or task)
Shows aggression to others or self
Is overactive or very passive

Causes

Autism is a physical condition linked to abnormal biology and chemistry in the brain. The exact causes of these abnormalities remain unknown, but this is a very active area of research. There are probably a combination of factors that lead to autism. Genetic factors seem to be important.

A number of other possible causes have been suspected, but not proven. They involve digestive tract changes, diet, mercury poisoning, vaccine sensitivity, and the body’s inefficient use of vitamins and minerals. Research suggests that heredity and early fetal development may play a causal role in autism, however studies show no association between risk of autism and parental factors such as age and socioeconomic status.

Some parents have heard that the Measles, Mumps, and Rubella (MMR) vaccine that children receive may cause autism. Although many clinicians still believe there is a link, several major studies have found no connection between the vaccine and autism. The American Academy of Pediatrics and the Centers for Disease Control and Prevention report that there is no proven link between autism and the MMR vaccine.

Some doctors attribute the increased incidence in autism to newer definitions of autism. The term “autism” now includes a wider spectrum of children.

Risk Factors

Autism affects males four times more often than females, and it may be inherited. In fact, about 50% of all boys with autism have a parent with the disease.

Autism occurs more frequently in children with rare genetic disorders and other medical conditions, such as tuberous sclerosis, phenylketonuria, neurofibromatosis, and epilepsy.

Diagnosis

All children should have routine developmental exams by their pediatrician. Further testing may be needed if there is concern on the part of the clinician or the parents. This is particularly true when a child fails to meet any of the following language milestones:

Babbling by 12 months
Gesturing (pointing, waving bye-bye) by 12 months
Single words by 16 months
Two-word spontaneous phrases by 24 months (not just echoing)
Loss of any language or social skills at any age

An evaluation of autism will often include a complete physical and neurologic examination. It may also include a specific diagnostic screening tool, such as:

Autism Diagnostic Interview - Revised (ADI-R)
Autism Diagnostic Observation Schedule (ADOS)
Childhood Autism Rating Scale (CARS)
Gilliam Autism Rating Scale
Pervasive Developmental Disorders Screening Test-Stage 3

Children with known or suspected autism will often have genetic testing (looking for chromosome abnormalities) and perhaps metabolic testing.

Treatment Approach

An early, intensive, appropriate treatment program will greatly improve the outlook for most young children with autism. An experienced specialist or team should design the individualized program. A variety of effective therapies are available. The best treatment plan may use a combination of techniques.

Teaching Programs

There are many types of teaching programs for children with autism. Some use a one-on-one teaching approach that relies on reinforced practice of various skills to get the child close to typical developmental functioning. Others use picture schedules and other visual cues to help the child work independently and to organize and structure their environments.

Medicine

Medicines are often used to treat behavior or emotional problems that people with autism may have. These include hyperactivity, impulsiveness, attention problems, irritability, mood swings, outbursts, tantrums, aggression, extreme compulsions that the child finds it impossible to suppress, sleep difficulty, and anxiety.

Treatment Options

Diet

Some children with autism appear to respond to a gluten-free or a casein-free diet. Gluten is found in foods containing wheat, rye, and barley. Casein is found in milk, cheese, and other dairy products. Not all experts agree that dietary changes will make a difference, and not all reports studying this method have shown positive results.

Some clinical studies show that children who have autism benefit from antioxidants like vitamin C. Parents and physicians have reported improvement in symptoms in children with autism who have been given certain supplements, including vitamin B, magnesium, cod liver oil and vitamin C.

If you are considering these or other dietary changes, seek guidance from both a gastroenterologist (doctor who specializes in the digestive system) and a registered dietitian. You want to be sure that the child is still receiving adequate calories, nutrients, and a balanced diet.

Touch Therapy and Massage

Research shows that some children with autism exhibit a reduction in symptoms after several weeks of touch therapy. In one clinical study, after 16 weeks of massage intervention parents reported feeling physically and emotionally closer to their children and children expressed a range of cues to initiate massage at home.

Several clinical studies have found that children who had Qigong massage (a type of massage that focuses on energy) showed a decrease in autistic behaviors and an increase in language development, as well as improvement in motor skills, sensory function, and general health.

Art, Music, and Pet Therapy

Art therapy, music therapy, animal therapy, and sensory integration therapy provide opportunities for children who have autism to develop social and communication skills.

Art therapy offers a child a nonverbal way to express his or her feelings.
Music therapy involving singing helps develop the child’s speech and language skills. In fact, research shows that any music intervention effectively reduces symptoms for children and adolescents with autism.
Animal therapy may include therapeutic riding programs on horses and swimming with dolphins. These types of therapies can help improve the child’s motor skills, while also building self-confidence. In fact, some studies show that children who interact with dolphins learn faster and retain more information than children who learned in a classroom setting.
Sensory integration focuses on normalizing extreme reactions to sensory input. It tries to help children reorganize and integrate their sensory information so they can better understand the outside world.

While there is little scientific evidence supporting these therapies, many parents and therapists report noticeable improvement in a child’s behavior and communication skills as well as a sense of enjoyment.

Prognosis/Possible Complications

Autism remains a challenging condition for individuals and their families, but the outlook is much better than it was a generation ago. Today, with appropriate therapy, clinicians can help reduce many of the symptoms of autism, though most people will be affected on some level throughout their lives.

Autism can be associated with other disorders that affect the brain, such as mental retardation or fragile X syndrome. Some people with autism will develop seizures.

Other Considerations

Viral infection during the first three months of pregnancy -- particularly with rubella -- is a suspected cause of autism.

Supporting Research

Angley M, Semple S, Hewton C, Paterson F. Children and autism - management with complementary medicines and dietary interventions. Aust Fam Physician. 2007 Oct;36(10):827-30.

Cullen L, Barlow J. Kiss, cuddle, squeeze: the experiences and meaning of touch among parents of children with autism attending a Touch Therapy Programme. J Child Health Care. 2002;6(3):171-181.

Smeeth L, Cook C, Fombonne E, et al. MMR vaccination and pervasive developmental disorders: a case-control study. Lancet. 2004;364: 963–969.

Cullen-Powell LA, Barlow JH, Cushway D. Exploring a massage intervention for parents and their children with autism: the implications for bonding and attachment. J Child Health Care. 2005;9(4):245-55.

Cullen LA, Barlow JH, Cushway D. Positive touch, the implications for parents and their children with autism: an exploratory study. Complement Ther Clin Pract. 2005;11(3):182-9.

Elder JH, Shankar M, Shuster J, Theriaque D, Burns S, Sherrill L. The gluten-free, casein-free diet in autism: results of a preliminary double blind clinical trial. J Autism Dev Disord. 2006 Apr;36(3):413-20.

Gillberg C, Cederlund M. Asperger syndrome: familiar and pre- and perinatal factors. J Autism Dev Disord. 2005;35(2):159-166.

Larsson HJ, Eaton WW, Madsen, KM, Vestergaard M, Olsen AV, Agerbo E, Schendel D, Thorsen P, Mortensen PB. Risk factors for autism: perinatal factors, parental psychiatric history and socioeconomic status. Am. J Epidemiol. 2005;161(10):916-925.

Malone RP, Gratz SS, Delaney MA, Hyman SB. Advances in drug treatments for children and adolescents with autism and other pervasive developmental disorders. CNS Drugs. 2005;19(11):923-34.

McGinnis WR. Oxidative stress in autism. Altern Ther Health Med. 2004;10(6):22-36.

Myers SM. The status of pharmacotherapy for autism spectrum disorders. Expert Opin Pharmacother. 2007 Aug;8(11):1579-603.

Nye C, Brice A, Nye C. Combined vitamin B6-magnesium treatment in autism spectrum disorder. Cochrane Database Syst Rev. 2005;(4):CD003497.

Potts M, Bellows B. Autism and diet. J Epidemiol Community Health. 2006 May;60(5):375.

Silva LM, Cignolini A. A medical qigong methodology for early intervention in autism spectrum disorder: a case series. Am J Chin Med. 2005;33(2):315-27.

Silva LM, Cignolini A, Warren R, Budden S, Skowron-Gooch A. Improvement in sensory impairment and social interaction in young children with autism following treatment with an original Qigong massage methodology. Am J Chin Med. 2007;35(3):393-406.

Volkmar FR, Wiesner LA, Westphal A. Healthcare issues for children on the autism spectrum. Curr Opin Psychiatry. 2006 Jul;19(4):361-6.

Wills S, Cabanlit M, Bennett J, Ashwood P, Amaral D, Van de Water J. Autoantibodies in autism spectrum disorders (ASD). Ann N Y Acad Sci. 2007 Jun;1107:79-91.

Whipple J. Music intervention for children and adolescents with autism: a meta-analysis. J Music Ther. 2004;41(2):90-106.

Review Date:
11/9/2007
Reviewed By:
Ernest B. Hawkins, MS, BSPharm, RPh, Health Education Resources; and Steven D. Ehrlich, NMD, private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.

A.D.A.M. Copyright

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