Insomnia and the Elderly

One of the most common misconceptions about aging is that the older we get, the less sleep we need. Unlike a newborn baby who requires around 16 hours of sleep throughout a 24-hour cycle, adults need anywhere from seven to nine hours of quality sleep each night. This number does not change for seniors, even though they do experience a shift in their sleep-wake cycles, going to bed earlier and waking up earlier.

However, insomnia in the elderly is also a common occurrence, and it affects around 50 percent of adults age 60 or older. Insomnia is defined as a condition where one has difficulty falling and staying asleep, or feeling like you aren’t getting enough sleep. Normal sleep occurs in several stages, from light, dreamless sleep to periods of active dreaming called rapid eye movement (REM) sleep. As we age, our sleep patterns will change, and the amount of time you spend in each stage of sleep will change. But, if you aren’t getting a good night’s sleep, your health can start to suffer.

What Causes Insomnia in the Elderly?
A variety of things can cause insomnia in the elderly, although many of them can be treated. It can be caused by certain health conditions like cardiovascular disease, COPD or asthma, chronic pain from arthritis or osteoporosis, or sleep apnea. Your environment can also play a role in poor sleep; if your bedroom is noisy, not dark enough or not at a comfortable temperature. Medications can create side effects that disrupt sleep, an irregular sleep schedule, and stress and anxiety can also affect how well you are sleeping.

A few of the most common insomnia symptoms include:

Difficulty falling asleep.
Lower quality sleep.
Awaken at least three times throughout the night.
Day/night confusion.
Changes in circadian rhythm – going to sleep and waking up earlier.
Insomnia Treatment for a Good Night’s Sleep
If you aren’t getting quality sleep on a regular basis, there are a few insomnia treatments you can implement to promote healthy sleeping. For instance, you can:

Create a relaxing bedtime routine. Go to bed around the same time every night. Involve yourself in soothing activities, like reading or taking a hot bath to relax and get sleepy.
Make sure your sleeping environment is comfortable. Your bedroom should be a peaceful environment, free of loud noises and distractions. Make sure your mattress is comfortable and the temperature is set a bit lower overnight to keep you cool.
Eliminate evening exercise. While daily exercise is important, it should be done earlier in the day. Do not exercise within three hours of bedtime.
Nap earlier in the day. If you can avoid taking a daily nap altogether, that’s recommended most. However, if you do nap, do so earlier in the day so you’re sufficiently tired when the evening hours roll around.
Avoid caffeine within three hours of bedtime. Caffeine, other stimulants, and alcohol should not be consumed within three hours of your designated bedtime. Alcohol may make you sleepy initially, but you could wake later in the night.
Clear your mind before going to bed. If possible, try to deal with your worries of the day before getting in bed. Turn off your mind and focus on peaceful thoughts.
If insomnia continues to be a problem for you, schedule a visit with your doctor. There may be medications you can try for a short time to get on regular sleeping patterns, or your doctor may recommend other techniques or possibly a sleep study to allow you to get the best night’s sleep possible.

Multiple Sclerosis Caregiving

When a loved one is diagnosed with MS, you’re bound to worry. What’s in the future? How can you help? Here are some answers.

    1. What is MS? MS is a chronic, often disabling disease that attacks the central nervous system, which is composed of the brain, the spinal cord, and the optic nerves. MS interferes with the transmission of nerve signals.
    1. How serious is it? The majority of people with MS do not become severely disabled and do have normal or near-normal life spans. In some severe cases, however, MS can shorten life.
    1. Are there any typical symptoms? MS affects each person differently, and a wide variety of symptoms is possible. Typical symptoms might include difficulty walking, numbness, visual problems, and bladder and bowel problems. More severe symptoms are difficulty swallowing and paralysis.
    1. Are there any symptoms you can’t see? Yes. Most often people experience “invisible” symptoms: heat sensitivity, changes in cognition such as memory loss, muscle pain, and fatigue. Although you can’t see these symptoms, they can be the ones that are most troublesome for people with MS.
    1. Do the symptoms get worse? The progression of the disease varies from person to person. There are four different diagnoses of MS:
        • Relapsing-remitting MS (RRMS) is the first diagnosis for 85 percent of people with MS. They experience clearly defined attacks followed by partial or complete improvement of symptoms.
        • Secondary progressive MS (SPMS) develops in some people with RRMS. Although periods of remission occur, the symptoms continue to worsen.
        • Primary progressive MS (PPMS) is diagnosed in 15 percent of the MS population. It’s defined by a slow worsening of symptoms.
        • Progressive-relapsing MS is the most rare and is characterized by steadily worsening symptoms with superimposed attacks.
    2. What’s the first course of action? Most relapsing forms of MS respond to disease-modifying medications (DMMs). Doctors recommend treatment as early as possible. In the last few years, the FDA has approved several DMMs that actually halt the progression of the disease in some cases.
    1. Are there any lifestyle changes my loved one should make? Smoking cigarettes has been associated with a worse course in MS, so if your loved one smokes, now is the time to quit. Additional studies have shown that stress may play a role in MS, so it’s important to learn how to manage stress.
    2. Does diet play a role? Studies show that a vitamin D deficiency is associated with increased risk of MS. Many studies have also been done on MS and the role of diet plans, such as the low-fat Swank and McDougall diets. There have been no conclusive findings, but diet does play a role in any overall health strategy — for both the person with MS and for you, the caregiver.
    1. How about exercise? Research has shown that both aerobic and strength-building exercises can be beneficial for people with MS. In addition, stretching exercises, like light yoga, can improve stiffness and improve flexibility and mobility.


  1. Where can I find help? Contact your local chapter of the National MS Society, where you’ll find the latest science on treatments and clinical studies, as well as help with practical matters such as health insurance and legal advice. Most important, chapters usually offer support groups, self-help groups, and even exercise classes at low or no cost.

For caregivers and people with MS, establishing a strong network of people with similar issues is a big help, and the National MS Society can help build that network.

7 Medications That Can Cause Incontinence

When you look in your medicine cabinet, chances are you’re searching for help with incontinence, not worrying about making it worse. But some of the drugs you take every day may be doing just that: triggering incontinence or making a sensitive bladder overactive. Here are seven possible culprits:

1. Blood pressure-lowering drugs

Which ones: Alpha-blockers; brand names Cardura, Minipress, Hytrin; generic names doxazosin mesylate, prazosin hydrochloride, terazosin hydrochloride

Why they may be culprits: Alpha-blockers work to lower blood pressure by relaxing blood vessel walls. The trouble is, they also relax the bladder along with the blood vessels. And alpha-blockers can relax the urethra, the tube leading from the bladder to outside and the muscle at the neck of the bladder. This leaves you prone to stress incontinence, which is leakage when you sneeze, cough, laugh, run, or jump.

What to do: You can start by doing Kegel exercises to increase your ability to control the muscles of the bladder. Good muscle control might be able to overcome the relaxing effects of the alpha-blockers. But if leakage is really a problem, level with your doctor (despite the embarrassment — he or she has heard it all) and ask to switch meds. Luckily, there are many options for controlling blood pressure, so your doctor can try using a calcium channel blocker or another class of medication that doesn’t have this unfortunate effect on your bladder.

2. Hormone therapy

Which ones: Oral estrogen-only or combination estrogen and progesterone pills

Why they may be culprits: This came as a surprise discovery a few years ago, and experts don’t know what exactly is going on. Until recently, hormone therapy was actually thought to help with incontinence, but it’s now known to trigger or worsen both stress and urge incontinence.

What to do: Talk to your doctor about using topical hormones, such as estrogen and progesterone in cream form, or estrogen patches, which seem to have far fewer incidences of this side effect than oral hormone pills. In fact, for some women topical estrogen applied as a cream or patch helps prevent or lessen incontinence. You can also try progesterone-only therapy, either oral or cream, which hasn’t been found to be associated with incontinence. Like so many hormone-related side effects, this one is very individual; it’s important to experiment and see what works for you.

More medications that can cause incontinence

3. Antidepressants and other mental health drugs

Which ones: Drugs with anticholinergic effects, which means drugs that block the neurotransmitter acetylcholine; brand names Norpramin, Cogentin, Haldol, Risperdal; generic names nortriptylene, amitriptyline, desipramine, benztropine, haloperidol, risperidone

Why they may be culprits: These medications affect the elasticity of the bladder, preventing it from contracting all the way, so it doesn’t fully empty. But urine continues to enter the bladder, leading to overflow incontinence, which happens when the bladder overfills and leaks without giving the signal to go.

What to do: If you think your antidepressant or another anticholinergic drug is affecting your bladder, talk to your doctor about switching to an alternative medication. Interestingly, some tricyclic antidepressants have been found to help with incontinence, so you may need to work with your prescribing doctor and try different ones until you find the one that works for you without unwanted side effects.

4. Diuretics

Which ones: Any medication prescribed as a diuretic; brand names Bumex, Lasix, Aldactone; generic names bumetanide, spironolactone, furosemide, theophylline, and all the “thalazides” (such as hydrochlorothiazide), which are among the most common first-line medications for hypertension

Why they may be culprits: Diuretics stimulate the kidneys to flush excess water and salt out of the body, making you have to go to the bathroom more frequently. Because your body’s producing more urine, it puts increased pressure on the bladder.

What to do: If you need a diuretic to prevent hypertension, you’re going to have to find work-around solutions to this problem. Though it’s tempting, don’t quit taking the diuretic, as you’ll lose the protective effect on your heart and cardiac system. Instead, talk to your doctor about experimenting with different diuretics until you find one that doesn’t stress your bladder. It may also help to take your diuretic early in the day, rather than at night when you don’t want to be running to the bathroom.

More medications that can cause incontinence

5. Decongestants and antihistamines

Which ones: Brand names Sudafed, Contac, Benadryl; generic names pseudoephedrine, diphenhydramine

Why they may be culprits: Decongestants that contain pseudoephedrine tighten the urinary sphincter, causing urine retention, which in women is frequently followed by sudden overflow incontinence. However, in men who have leakage after prostate surgery, Sudafed can temporarily clamp down the bladder muscles, preventing leakage. Some antihistamines relax the bladder and also make you sleepy, which can cause incontinence in the elderly especially.

What to do: Try taking a different decongestant, such as loratadine (brand name Claritin), that doesn’t cause bladder-related side effects.

6. Sedatives and sleeping pills

Which ones: Any sedative or sleeping aid that relaxes muscles and makes you sleep deeply; brand names Ativan, Valium, Dalmane, Lunesta, Ambien; generic names diazepam, flurazepam, lorazepam, eszopiclone, zolpidem

Why they may be culprits: Sedatives slow your reflexes, so you don’t recognize the signal that it’s time to go. Sleeping pills compound the problem by putting you into such a deep sleep that you miss the alert from your bladder to get up. Bed-wetting affects about 10 percent of incontinence sufferers, and experts estimate sleeping pills contribute to the problem in many cases.

What to do: Instead of sedatives and sedative-based sleeping pills, try natural remedies for anxiety and sleep. Melatonin taken an hour before bedtime can be an effective sleep remedy, since it’s the natural hormone that tells your brain it’s time to sleep. The herbs valerian and hops are sleep aids that haven’t been associated with incontinence or bed-wetting. The amino acids 5-HTP or tryptophan and L-Theanine are natural sedatives that don’t have muscle-relaxing properties. You might also talk to your doctor about prescription sedatives and sleeping pills that don’t cause muscle relaxation.

7. Narcotic painkillers

Which ones: Any opium-based painkiller; brand names OxyContin, MS-Contin, Oramorph; generic names codeine, morphine, oxycodone

Why they may be culprits: Drugs made from opium interfere with the bladder’s ability to contract fully. This can lead to urine retention and overflow incontinence. Opioid painkillers also lead to constipation, and studies show that constipation desensitizes the bladder and worsens urge incontinence (the kind when you suddenly have to go).

What to do: Avoid opioid painkillers if you can. If you need pain medication after an injury or surgery, ask your doctor to try nonopioid medications first.

What Is Osteoarthritis?

Osteoarthritis, also known as degenerative joint disease, is the most common underlying cause of arthritis symptoms. It’s sometimes referred to as “wear-and-tear” arthritis, because the symptoms are usually the result of joint cartilage wearing down due to age or hard use.

The most commonly involved parts of the body are the hips, knees, hands, neck, and lower spine. However, almost any joint can potentially be affected.

Osteoarthritis is extremely common in older adults and often causes chronic pain and stiffness in the affected joints. The pain and disability can range from mild and occasional to severe daily pain that interferes with mobility or sleep. Although it’s not usually possible to permanently cure osteoarthritis, certain treatments can help control symptoms and maximize movement. It’s also sometimes possible to surgically repair or replace a joint damaged by arthritis.

Because conditions other than osteoarthritis can also cause chronic joint pains, it’s important to see a doctor before concluding that symptoms are caused by osteoarthritis.

Schizophrenia Myths

Schizophrenia is much more common than most people think. According to the World Federation of Mental Health (WFMH), schizophrenia affects one in every 100 people. But schizophrenia remains largely mysterious, because science still can’t explain how brain circuits misfire in those with schizophrenia. And schizophrenia is scary because it typically doesn’t start until adolescence or early adulthood, and it can come on quite suddenly.

“Here we have a disease beginning at this time of life — just as people are graduating from school or reaching for their independence — which, if left untreated, really can derail their lives,” says Dolores Malaspina, MD, a professor of psychiatry at the NYU School of Medicine.

Part of the problem with recognizing schizophrenia is the stigma that’s still attached to serious mental illness; people who have a close relative with the disease are often ashamed to talk about it. Meanwhile, the most extreme cases — the ones involving violence and wild delusions — are the ones that make it into the news headlines. Here are the top 10 misconceptions about schizophrenia and what you really need to know.

Myth: People With Schizophrenia Are Psychotic

In many cases, it takes a psychotic episode to bring schizophrenia to the attention of family and friends. But not all people with schizophrenia are psychotic. And not all psychoses are caused by schizophrenia. What’s the difference? Psychosis is defined as breaking with reality; someone might hear voices, become obsessed with false ideas, see things that aren’t there, or have paranoid delusions. Some people with schizophrenia have these symptoms, but others have a different set of symptoms. Meanwhile, people with bipolar disorder or major depressive disorder can become psychotic, as can those addicted to drugs.

Myth: Young Adults With Schizophrenia Had Earlier Problems

It’s not easy to generalize about the childhoods of people who develop schizophrenia. About half of people with schizophrenia will not have given any sign that something might go wrong; they may even have been athletes or exceptional students. For the other half, it’s possible with hindsight to recognize earlier signs, such as trouble in school, social problems, or extreme shyness. The problem is, these signs aren’t specific to schizophrenia, so they aren’t all that useful except in retrospect.

There is an early phase of schizophrenia known as the “prodrome” that can be recognized by a cluster of symptoms, including feelings of persecution, paranoid thoughts and ideas, social problems, a dramatic decline in school performance, and increasing isolation. If you notice dramatic changes in a teenager’s behavior, involve a psychologist who can distinguish between routine adolescent issues and mental illness.

Myth: Schizophrenia Is Easy to Recognize Because People Act “Crazy”

Some people do have wild, unpredictable behavior, that’s for sure, especially when they’re in the midst of a psychotic episode. But there’s one type of schizophrenia, known as disorganized schizophrenia, that has very different symptoms from what you might expect. Instead of acting out, someone with disorganized schizophrenia may seem to be turning inward, says emergency medicine doctor Mark Morocco, an associate professor at UCLA Emergency Medical Center.

You might notice what experts call a “flat affect,” such as a lack of eye contact and emotional response, or unusual emotional reactions such as laughing inappropriately or lashing out illogically. Withdrawal — to the point of refusing to go out in public — wearing strange clothes, and refusing to bathe or wash are also signs. Often people with disorganized schizophrenia begin speaking in a flat, staccato pattern with little or no inflection, and they say things that don’t make sense.

Disorganized schizophrenia can be very difficult to distinguish from other problems common to teenagers and young adults, such as drug abuse and depression. So you’ll need an experienced psychiatrist to diagnose it.

Myth: Schizophrenia Runs in Families

There is a genetic component to schizophrenia, as there is in many types of mental illnesses. In fact, a study published in Lancet in February 2013 found that the same genetic changes underlie all five of the most common mental illnesses and disorders: schizophrenia, bipolar disease, autism, ADHD, and major depression. This doesn’t mean, however, that you inherit a gene for one of these and that’s it. The researchers believe “hundreds, and perhaps thousands of genes” contribute to the development of these disorders. It’s also clear that these genes contribute just a predisposition; it still takes environmental triggers to “turn on” mental illness. Scientists are still exploring the environmental factors implicated in schizophrenia, but they include exposure to viruses, STDs, and toxins during pregnancy; and child abuse, social stress, and drug use during the teen years.

Myth: People With Schizophrenic Delusions Know Something’s Wrong

Unfortunately, while the behavior of someone with schizophrenia is so unusual that you’d think they’d know something was “off,” that’s rarely the case. In fact, one of the things that makes schizophrenia so difficult to deal with is that the person with the disorder can’t distinguish reality from his delusional thoughts and perceptions. In fact, he believes deeply in his delusions. And because so often the delusional thinking is paranoid, as in “they’re out to get me,” you may end up playing right into the delusion by trying to convince your loved one that his perceptions are wrong. (Think about it: If the government was trying to trick you with a conspiracy, wouldn’t it deny that the conspiracy was real?)

Myth: People With Schizophrenia Get Worse Over Time

It’s easy to fear, when someone you love is in the midst of a psychotic episode, that his disease is progressing and that the worsening of his symptoms will be permanent. In reality, experts now know that schizophrenia tends to be episodic, with periods of recovery interspersed with periods of recurrence. A great deal of current research is focused on identifying the risk factors that trigger recurrence; right now we know that stress is a big one. So is a failure, such as at a job, in school, or in a relationship. Individual personality plays a role, too; people who are vulnerable to anxiety, were poor achievers before the onset of schizophrenia, or have other cognitive issues in addition to schizophrenia seem to be more vulnerable to recurrence. Having a stable routine is extremely important in maintaining schizophrenia treatment, because it’s easier to remember to take medication when you have a routine.

Myth: People With Schizophrenia Are Violent

It would be nice if it were so easy to predict violence, but this idea — although widespread — is simply incorrect. According to those who work with mental illness, people with schizophrenia are much more likely to withdraw into social isolation when their disease asserts itself than they are to lash out. Some people with schizophrenia have violent outbursts, it’s true; but evidence shows that it’s often those who also abuse drugs and alcohol who become violent. Sadly, violence against oneself is common in schizophrenia; as many as 10 percent of those with schizophrenia die by suicide. So it may be more important to be alert for suicidal thoughts than violent ones.

Myth: Schizophrenia Treatment Requires Hospitalization

When someone’s having an acute episode and may pose a danger (to themselves or others) or needs to be kept stable while medications are adjusted, inpatient treatment in a psychiatric hospital is necessary. But this isn’t the case most of the time for most people with schizophrenia. Outpatient treatment is the norm now for the majority of people with schizophrenia, many of whom live independently.

Myth: The Medications That Treat Schizophrenia Stop Working Over Time

This is probably one of the most destructive misconceptions about schizophrenia, because it implies — very discouragingly — that even successful treatment is only temporary. The truth is that using medication to treat psychiatric illness is always a trial-and-error effort, and medications and dosages have to be adjusted frequently to compensate for changes in people’s body chemistry, lifestyle, diet, age, and many other factors.

Happily, there are many different medications used to treat schizophrenia, and more are being identified all the time; 15 new medications are currently in government clinical trials. There are also new delivery methods, such as injections for people who can’t be relied on to stick to a drug regimen.

Myth: People With Schizophrenia Can Never Recover

This was once the conclusion of society, who locked away those who were “crazy” or delusional for the rest of their lives. Today, according to the research on schizophrenia, it’s only one subgroup of patients who don’t recover even with treatment. For the majority, if schizophrenia is diagnosed quickly and treated aggressively, there’s a good prognosis for being able to live comfortably in society. And a 26-year study published in Current Directions in Psychological Science in 2010 found that a significant number of people with schizophrenia do experience full recovery, some of them without treatment.

Depression Triggers

It’s downright scary: More than 20 million Americans can expect to suffer from depression in the coming year. But you don’t have to be one of them if you’re alert to the events and situations that can turn the blues into something more serious.

Here, the 10 most common depression triggers — and what to do to prevent them from dragging you down.

Loss of Job and Depression

Why losing a job may trigger depression: In addition to causing financial stress, losing a job can jeopardize your sense of identity and feelings of self-worth. Unemployment and financial stress also strain marriages and relationships, bringing conflict that compounds stress and unhappiness.

Who’s most vulnerable: Statistics show that the older you are or the higher you were paid, the longer it’s likely to take to find work again. Also, those employed in downsized industries and fields, such as the auto industry, may have to retrain or start over in a new field, which can be frightening and can undermine self-confidence.

What helps: Connect with others in the same situation, whether it’s through a job skills class, training program, or job-search support group. Also, if you can afford it, use a career counselor or coach to help you create a plan, stay accountable, and feel supported. Experts also recommend building a support network by reaching out to friends and colleagues and setting up regular events throughout the week. The more you can structure your time with lunches, walks, and other get-togethers, the better. Try signing up for a morning exercise class or schedule regular morning walks to get you going each day.

If time goes by and it doesn’t look like you’re going to find a replacement job quickly, consider volunteering. It’s not only a way to boost your self-esteem and get out of the house but it’s also great for learning new skills and making new connections.

Sexual Problems and Depression

Why sexual problems may trigger depression: According to sexual health expert Beverly Whipple, professor at Rutgers University and author of The Science of Orgasm (Johns Hopkins University Press, 2006), depression and sexual problems are interrelated in a vicious cycle. Sexual problems and sexual health issues can trigger depression by removing one of the most effective outlets we use to feel good. But many of the most common antidepressant medications, particularly the group of drugs known as SSRIs (brand names Prozac, Zoloft, Celexa) can sabotage your sex drive and make it harder to achieve orgasm.

Who’s most affected: Loss of an active sex life due to age — or health — related issues can trigger depression in both men and women, but men may feel the loss more acutely. That’s because sexuality is more central to a man’s sense of identity, says Whipple: “When a man experiences a loss of libido or sexual dysfunction, his entire sense of self may be affected.”

What helps: In a nutshell, get medical or professional help. While talking about sex and the health of our “equipment” isn’t easy for any of us, it’s essential to breaking the cycle before it leads to depression. If you’re experiencing physical changes that are contributing to a loss of interest in sex or to performance issues, it’s essential to bring them up with your doctor. And if the problem stems from relationship or other emotional issues, make use of a couples counselor or sex therapist.

If you let embarrassment or shame prevent you from speaking up, you’re denying yourself one of the most effective weapons against depression. Recent studies show that having regular orgasms relieves stress, prevents prostate cancer, and releases feel-good brain chemicals that protect against depression. One of Whipple’s many studies even shows that regular sex increases your pain-tolerance threshold, reducing chronic pain.

“Empty Nest” Syndrome and Depression

Why “empty nest” may trigger depression: Two of the hardest things to deal with are loss and change, and when a child leaves home you’re suddenly hit with both, all at once. “Your entire routine changes, from the minute you wake up in the morning to the moment you go to bed at night,” says Celestino Limos, dean of students at Lewis & Clark College in Portland, Oregon. “Parents tend to focus on all the practical details of getting a child ready for college, but they’re unprepared for how much the rhythm of their own lives changes from day to day.”

Who’s most vulnerable: Women seem to suffer more acutely than men, perhaps because their self-identity is more closely associated with being parents, experts say. But men can suffer an acute sense of loss as well, and they may be less prepared for the onslaught of emotions. Those who are divorced or otherwise single are much more likely to be lonely once the kids are gone, but married couples may also find themselves struggling, particularly if the marriage is rocky or they’ve developed a tag-team approach to family life and don’t share many activities and interests. Parents of only children are also more vulnerable.

What helps: Plan in advance. Parenting experts suggest that parents begin exploring independent interests during their child’s last year of high school. Sign up for a class one night a week, or subscribe to a travel magazine and think about trips you might want to take.

When your child leaves home, give yourself a few weeks of quiet time to grieve, but don’t spend too much time alone. Set up regular events you can look forward to. Organize weekly walks with friends, join a book group, or sign up for a yoga, pilates, or dance class. Plan your weekends ahead of time, so you’re not caught off guard with time heavy on your hands. Try something completely new, such as a cooking or language class. When you discover a new interest or passion, having more time available becomes a good thing rather than a liability.

Alcohol and Depression

Why alcohol abuse triggers depression: Recent research backs up what addiction and depression experts have long argued: Alcohol abuse and depression are often linked in what’s called a “dual diagnosis” or, colloquially, “double trouble.” The reason for this complicated interaction is the effect alcohol has on mood. When you stop into your local tavern for a cold one, you might think you’re staving off the blues with some camaraderie and relaxation. But alcohol acts as a depressant in the central nervous system, triggering depression in those who are susceptible.

Who’s most vulnerable: Those already prone to depression or those prone to overusing alcohol are at greatest risk. In either group, the combination of alcohol abuse and depression is dangerous. According to studies, between 30 and 50 percent of alcoholics suffer from major depression. And the relationship works the other way too: Studies have found that alcohol use causes relapse in people with depression, and that when people with depression drink they’re more prone to suicide.

What helps: Cut back on drinking and seek help for alcohol abuse or addiction. “There’s a reason we’ve got the stereotype of the weepy drunk,” says Liliane Desjardins of Pavillion International, a treatment center in Texas. “Alcohol triggers a mood crash.” But people who drink too much rarely attribute their misery to drinking, she adds. Instead they blame it on other people and factors.

There’s only one solution: Cut back and see if, over time, you feel better. If you repeatedly promise yourself or others not to drink and your efforts fail or your drinking brings other negative consequences into your life, you may need help to stop. Alcoholics Anonymous and other 12-step programs are effective for some people. Others need the physical restriction and concentrated services of a residential alcohol rehabilitation facility or the supervised medical detox of an inpatient program. No matter what type of alcohol treatment program works for you, you’ll find it has the additional benefit of preventing depression.

6 Foods That Weaken Bones

To build and maintain strong bones, eating the right foods makes all the difference. By the same token, certain foods can actually sap bone strength by leaching minerals right out of the bone, or they block the bone’s ability to regrow. Surprisingly, some of these are foods we eat lots of every day. Here, the six biggest bone-sappers:

1. Soft drinks

Soft drinks pose a double-whammy danger to bones. The fizziness in carbonated drinks often comes from phosphoric acid, which ups the rate at which calcium is excreted in the urine. Meanwhile, of course, soft drinks fill you up and satisfy your thirst without providing any of the nutrients you might get from milk or juice.

What to do: When you’re tempted to reach for a cola, instead substitute milk, calcium- and vitamin D-fortified orange juice, or a fruit smoothie made with yogurt. Or just drink water when you’re thirsty, and eat a diet high in bone-building nutrients.

2. Salt

Salt saps calcium from the bones, weakening them over time. For every 2,300 milligrams of sodium you take in, you lose about 40 milligrams of calcium, dietitians say. One study compared postmenopausal women who ate a high-salt diet with those who didn’t, and the ones who ate a lot of salt lost more bone minerals. Our American diet is unusually salt-heavy; many of us ingest double the 2,300 milligrams of salt we should get in a day, according to the 2005 federal dietary guidelines.

What to do: The quickest, most efficient way to cut salt intake is to avoid processed foods. Research shows that most Americans get 75 percent of their sodium not from table salt but from processed food. Key foods to avoid include processed and deli meats, frozen meals, canned soup, pizza, fast food such as burgers and fries, and canned vegetables.

3. Caffeine

The numbers for caffeine aren’t as bad as for salt, but caffeine’s action is similar, leaching calcium from bones. For every 100 milligrams of caffeine (the amount in a small to medium-sized cup of coffee), you lose 6 milligrams of calcium. That’s not a lot, but it can become a problem if you tend to substitute caffeine-containing drinks like iced tea and coffee for beverages that are healthy for bones, like milk and fortified juice.

What to do: Limit yourself to one or two cups of coffee in the morning, then switch to other drinks that don’t have caffeine’s bone-sapping action. Adding milk to your coffee helps to offset the problem, of course.

4. Vitamin A

In the case of vitamin A, recent research is proving that you really can get too much of a good thing. Found in eggs, full-fat dairy products, liver, and vitamin-fortified foods, vitamin A is important for vision and the immune system. But the American diet is naturally high in vitamin A, and most multivitamins also contain vitamin A. So it’s possible to get much more than the recommended allotment of 5,000 IUs (international units) a day — which many experts think is too high anyway.

Postmenopausal women, in particular, seem to be susceptible to vitamin A overload. Studies show that women whose intake was higher than 5,000 IUs had more than double the fracture rate of women whose intake was less than 1,600 IUs a day.

What to do: Switch to low-fat or nonfat dairy products only, and eat egg whites rather than whole eggs (all the vitamin A is in the yolk). Also check your multivitamin, and if it’s high in vitamin A, consider switching to one that isn’t.

5. Alcohol

Think of alcohol as a calcium-blocker; it prevents the bone-building minerals you eat from being absorbed. And heavy drinking disrupts the bone remodeling process by preventing osteoblasts, the bone-building cells, from doing their job. So not only do bones become weaker, but when you do suffer a fracture, alcohol can interfere with healing.

What to do: Limit your drinking to one drink a day, whether it’s wine, beer, or hard alcohol.

6. Hydrogenated oils

For a number of years now, we’ve known from studies that the process of hydrogenation, which turns liquid vegetable oil into the solid oils used in commercial baking, destroys the vitamin K naturally found in the oils. Vitamin K is essential for strong bones, and vegetable oils such as canola and olive oil are the second-best dietary source of this key nutrient, after green leafy vegetables. However, the amounts of vitamin K we’re talking about are tiny here — one tablespoon of canola oil has 20 micrograms of K, and one tablespoon of olive oil has 6 micrograms, as compared with 120 micrograms in a serving of spinach.

What to do: If you’re eating your greens, you don’t need to worry about this too much. If you’re a big lover of baked goods like muffins and cookies, bake at home using canola oil when possible, and read labels to avoid hydrogenated oils (which many manufacturers of processed foods have eliminated in recent years).

7 Things Your Teeth Say About Your Health

Some messages coming out of your mouth bypass the vocal chords. Turns out that your teeth, gums, and surrounding tissues also have plenty to say — about your overall health.

“Your mouth is connected to the rest of your body,” says Anthony Iacopino, dean of the University of Manitoba Faculty of Dentistry and a spokesperson for the American Dental Association. “What we see in the mouth can have a significant effect on other organ systems and processes in the body. And the reverse is also true: Things that are going on systemically in the body can manifest in the mouth.”

So stay attuned to the following warning messages, and have worrisome symptoms checked out by a dentist or doctor.

Dental warning #1: Flat, worn teeth plus headache

Sign of: Big-time stress

Many people are surprised to learn they’re tooth-grinders. After all, they do this in their sleep, when they’re not aware of it. And they underestimate the physical toll that stress can place on the body. “Crunching and grinding the teeth at night during sleep is a common sign of emotional or psychological stress,” says Iacopino.

You can sometimes see the flatness on your own teeth, or feel it with the tongue. Or the jaw may ache from the clenching.

What else to look for: Headaches, which are caused by spasms in the muscles doing the grinding. Sometimes the pain can radiate from the mouth and head down to the neck and upper back, Iacopino says. Mouth guards used at night can relieve the symptoms and protect teeth.

Dental warning #2: Cracking, crumbling teeth

Sign of: Gastroesophageal reflux disease (GERD)

Older adults, especially, are vulnerable to teeth that appear to be cracking or crumbling away. The enamel becomes thin and almost translucent. But this erosion isn’t a normal consequence of aging. In fact, it can happen at any age.

Disintegrating teeth are usually caused by acid that’s coming up from the stomach and dissolving them, Iacopino says. The cause: Gastroesophageal reflux disease (GERD, also called acid reflux disease). GERD causes stomach acid to back up into the esophagus — and from there, it’s a short distance to the mouth for some of the damaging acid. GERD is a chronic disorder caused by damage or other changes to the natural barrier between the stomach and the esophagus.

What else to look for: Dry mouth and heartburn are related GERD symptoms. (But in an older adult in someone else’s care — in a nursing home, for example — these complaints may go unreported.) Cracking or chipping teeth in a younger person is also a telltale sign of bulimia, the eating disorder in which the sufferer causes herself (or himself) to vomit before digesting. Same net result: Stomach acid washes up into the mouth, over time disintegrating the tooth enamel.

Dental warning #3: Sores that won’t go away

Sign of: Oral cancer

Many people bite the insides of their mouth as a nervous habit. Others sometimes bite the gum accidentally, creating a sore. But when an open sore in the mouth doesn’t go away within a week or two, it always warrants showing to a dentist or doctor. “We all injure our oral tissues, but if an area persists in being white or red rather than the normal healthy pink, this needs to be evaluated to rule out oral cancer,” says Susan Hyde, an associate professor of clinical dentistry at the University of California, San Francisco, School of Dentistry.

More than 21,000 men and 9,000 women a year are diagnosed with oral cancer, according to the National Cancer Institute. Most are over age 60. Oral cancer has a survival rate of only 35 percent, Iacopino says, but this is mainly because cases are often detected too late. Smokers are six times more likely to develop oral cancer, but one in four oral cancers develop in non-smokers.

What else to look for: Suspicious oral ulcers tend to be raised sores and often have red or white (or red and white) borders. They may lurk underneath the tongue, where they’re hard to see. Bleeding and numbness are other signs, but sometimes the only sign is a sore that doesn’t seem to go away. A biopsy usually follows a visual check.

Dental warning #4: Gums growing over teeth

Sign of: Medication problems

If you notice your gum literally growing over your tooth, and you’re taking a medication for heart disease or seizures or you take drugs to suppress your immune system (such as before a transplant), it’s well worth mentioning this curious development to your prescribing doctor.

“A swelling of the gums to where it grows over the teeth is a sign the dosage or the medication need to be adjusted,” the ADA’s Anthony Iacopino says. Certain drugs can stimulate the growth of gum tissue. This can make it hard to brush and floss, inviting tooth decay and periodontal disease.

What else to look for: The overgrowth can cause an uncomfortable sensation. In extreme cases, the entire tooth can be covered.

Dental warning #5: Dry mouth

Sign of: Sjogren’s syndrome, diabetes

Many things can cause dry mouth, from dehydration and allergies to smoking and new medications. (In fact, hundreds of drugs list dry mouth as a side effect, including those to treat depression and incontinence, muscle relaxants, antianxiety agents, and antihistamines.) But a lack of sufficient saliva is also an early warning of two autoimmune diseases unrelated to medicine use: Sjogren’s syndrome and diabetes.

In Sjogren’s, the white blood cells of the body attack their moisture-producing glands, for unknown reasons. Four million Americans have Sjogren’s, 90 percent of them women. Twenty-four million people in the U.S. have type 1 or type 2 diabetes, a metabolic disease caused by high blood sugar.

What else to look for: Other signs of diabetes include excessive thirst, tingling in the hands and feet, frequent urination, blurred vision, and weight loss. In Sjogren’s, the eyes are dry as well as the mouth, but the entire body is affected by the disorder. Because its symptoms mimic other diseases (such as diabetes), people are often misdiagnosed and go several years before being properly diagnosed.

Dental warning #6: White webbing inside cheeks

Sign of: Lichen planus

The last thing you might expect to discover while brushing your teeth is a skin disease. But it happens. Lichen planus, whose cause is unknown, is a mild disorder that tends to strike both men and women ages 30 to 70. The mucus membranes in the mouth are often a first target.

Oral lichen planus looks like a whitish, lacy pattern on the insides of the cheeks. (The name comes from the same roots as tree lichen, a lichen that has a similar webbed, bumpy appearance.) Seventy percent of lesions appear in the mouth before they strike other parts of the body, says professor Anthony Iacopino.

What else to look for: Another common area where a lichen planus rash may appear is the vagina. Lichen planus often goes away on its own, but sometimes treatment is necessary.

Dental warning #7: Crusting dentures

Sign of: Potential aspiration pneumonia

Most people don’t connect dentures (false teeth) with pneumonia, other than to think they’re both words that often refer to the world of the elderly. And yet the two have a potentially deadly connection. “A leading cause of death in older people is aspiration pneumonia, often from inhaling debris around the teeth and dentures,” Iacopino says.

In aspiration pneumonia, foreign material is breathed into the lungs and airway, causing dangerous (even fatal) inflammation. Too often, the problem stems from people in the care of others — those in nursing homes, for example — who fail to clean dentures properly. Dentures need to be removed daily from the mouth, cleaned with a special brush, and stored in a cleansing solution.

Warfarin: 7 Ways to Keep Blood Levels in a Safe Range

Many Americans take warfarin (brand name Coumadin) every day to make their blood thinner. Some are on the medication for three to nine months, for treatment of a blood clot in the leg veins or the lungs. Others are on the medication indefinitely because of atrial fibrillation, an artificial heart valve, or some other chronic condition linked to a high risk of stroke.

Warfarin is an effective and inexpensive drug, but as anyone who’s been on it can tell you, it’s tricky to use. It requires frequent blood tests to monitor its effect, it interacts with many common foods and medications, and it can cause serious or even life-threatening bleeding. In fact, warfarin regularly shows up on lists of the top-ten medications to cause hospitalization or serious side effects. Studies have also found that most people on warfarin are within the right range (as measured by the INR, or international normalized ratio) only about 60 percent of the time.

Fortunately, it’s possible to greatly reduce one’s chance of warfarin-related problems by following certain precautions to maximize the likelihood of being in the right range. Here’s what to do:

1. Make sure to get dosing instructions in writing, and follow them carefully.

More than almost any other commonly used medication, warfarin requires individualized dosing that may frequently need adjustment. It’s also common for a person to take different doses of warfarin, depending on the day of the week (such as 2 milligrams for five days of the week and 3 mg for two days of the week). Because of this, prescription bottles for warfarin may have vague instructions, such as, “Take as directed.” This allows the clinician to change the directions without ordering a new prescription, but it also means that patients and families must be vigilant about understanding the instructions.

What to do:

  • Make sure any dosage instructions or changes are provided in writing.
  • Don’t skip blood tests or appointments for checking warfarin’s effects.
  • Make sure your doctor provides you with instructions if so-called protime or INR results (the blood tests used to monitor warfarin) are lower or higher than goal. (The goal is usually an INR between 2.0 and 3.0; a higher INR means the blood takes longer to clot.)
  • If you’re a caregiver, make sure your loved one is able to keep up with a complicated dosing regimen, or plan on providing extra help with medications.

2. Pay extra-close attention during the first three months after starting warfarin.

Although everyone on warfarin has an increased chance of bleeding, studies have found that the risk is especially high in the first three months after starting warfarin. This probably occurs because this is when people tend to need more dose adjustments and the most monitoring.

What to do:

  • Make sure to attend all INR checks and warfarin appointments, even if they seem to be frequent. Frequent appointments are usually necessary to keep new patients in range.

3. Avoid big changes in intake of leafy greens and other sources of vitamin K.

Warfarin works by interfering with the liver’s use of vitamin K to make certain clotting factors. Suddenly eating more leafy greens, such as kale, spinach, and collard greens, will decrease the effectiveness of warfarin. Conversely, suddenly reducing intake of leafy greens will make the warfarin have a stronger effect, increasing the chance of bleeding.

What to do:

  • You don’t have to avoid greens; you just need to have a stable weekly intake.
  • Notify your doctor if you decide to go on a spinach salad diet or otherwise make a big dietary change. Extra monitoring of your warfarin will be required.

More ways to keep blood levels in a safe range with warfarin

4. Make sure all doctors know you take warfarin, and ask them to check for interactions when antibiotics or other new medications are prescribed.

Warfarin interacts with a truly mind-boggling array of commonly prescribed medications, including many antibiotics. Some strengthen warfarin’s effect (thus increasing the risk of bleeding), whereas others weaken warfarin’s effect (increasing the risk of blood clots and stroke).

What to do:

  • Bring an up-to-date medication list to every doctor’s visit or, better yet, bring all medication bottles.
  • Whenever a new medication is prescribed, ask the doctor to check for a possible interaction with warfarin. Many doctors have access to computer programs that can check for interactions on demand.
  • If you need to take a medication that will affect warfarin, make sure there’s a plan to adjust your warfarin dose, or at least check on your INR more frequently.
  • Get all prescriptions from the same pharmacy. Pharmacies are often able to check for drug interactions, which can be a helpful backup system.

5. Be extra-careful about regularly using aspirin, acetaminophen, or NSAIDs.

Although occasional use for a headache or sore joint should be fine, these common over-the-counter medications can all increase the risk of bleeding in people on warfarin. Regular use (daily for more than a week) of acetaminophen increases INR; this can be countered by lowering the weekly dose of warfarin. Aspirin and NSAIDs such as ibuprofen don’t affect INR but do cause stomach irritation, which can predispose someone taking warfarin to bleeding.

What to do:

  • Don’t take aspirin, acetaminophen, or NSAIDs on a daily basis without discussing the bleeding risk with the doctor.

6. Avoid herbal remedies and supplements known to affect clotting.

Many herbal medications have been shown to at least theoretically affect certain clotting factors within the blood. Anyone on warfarin should probably avoid these. Otherwise their use should be discussed with the doctor so that extra blood monitoring can be arranged.

What to do:

  • Be careful about supplements containing any of the following: alfalfa, angelica, aniseed, arnica, asafetida, celery, chamomile, clove, fenugreek, feverfew, fucus, garlic, ginger, ginkgo, ginseng, horse chestnut, horseradish, licorice, meadowsweet, poplar, prickly ash, quassia, red clover, willow.
  • Note that dietary doses — doses commonly used in cooking — of garlic and ginger have not been shown to lead to increased bleeding events in people on warfarin.

7. Ask about self-monitoring at home.

Several handheld finger-stick devices now are FDA approved for checking INRs at home. Some people on warfarin do their own monitoring and adjustment, with the support of instructions and backup from a clinician’s office. In 2010, a large study found that rates of bleeding on warfarin were the same whether people were monitored in a special warfarin clinic or they performed self-monitoring. However, the study also found that people reported more satisfaction and slightly better quality of life, on average, with home monitoring.

Parkinson’s Disease and Speech

In a high majority of people with Parkinson’s, the disease also takes a toll on speech. The repercussions can be devastating as patients, unable to communicate clearly, withdraw from social interaction. A form of speech rehabilitation called LSVT compensates by training Parkinson’s patients to talk more loudly.

How to recognize voice and speech problems

Parkinson’s disease can impair muscles of the voice box, throat, mouth, tongue, and lips. Subtle changes may happen early, with the person’s voice becoming softer and flat in tone, making it hard to hear. In advanced stages of Parkinson’s, speech may become unintelligible.

Let the neurologist know if you notice these symptoms:

  • Talking in a monotone, with little inflection in pitch
  • Reduced speech volume
  • Breathy or hoarse voice
  • Mumbled speech, imprecise articulation
  • Difficulties initiating speech
  • Hesitant, sometimes stuttering speech
  • Short, fast rushes of speech

How voice and speech troubles can harm a person’s well-being

Parkinson’s patients experience a sensory processing glitch in the brain that leaves them unable to detect that they’re speaking quietly. Unaware of the problem, they are likely to feel frustrated at being asked to constantly re peat themselves. They may even complain that their spouse needs a hearing aid.

Parkinson’s disease also often causes a loss of facial expressiveness. That change, combined with a soft, monotone voice, can lead family and friends to think the patient is “just depressed, apathetic, bored, disinterested — whereas the person inside feels quite alive,” says Cynthia Fox, a speech-language pathologist and researcher at the National Center for Voice and Speech in Denver.

The upshot is that others stop engaging patients in conversation. They may come to feel ignored, and such patients often give up, says Fox. They drop job responsibilities that require a lot of phone talk, and they avoid dining out because restaurant noise further drowns out their voices. “It’s a real blow to self-confidence,” says Fox.

What are the treatment options?

The standard Parkinson’s drugs don’t always work well for speech impairment. Although some people find that levodopa improves their communication, others don’t. Deep brain-stimulation surgery has also produced inconsistent results for relieving speech difficulties.

The best strategy is drug therapy paired with speech therapy. Traditionally, speech-language experts trained patients to concentrate on multiple, separate aspects of voice and speech, such as breathing properly, articulating well, increasing volume, and slowing down the rate of speech. But even though patients sounded better inside the treatment room, the benefit typically vanished once they walked out the door and reverted to usual habits.

In 1987, however, University of Colorado speech-language researcher Lorraine Olson Ramig devised the Lee Silverman Voice Treatment, the first speech treatment tailored for Parkinson’s disease. (It was named after a Parkinson’s patient whose family funded the research). Small studies have found that LSVT produces lasting improvements.

How LSVT differs from traditional speech treatments:

  • LSVT is much more intensive, requiring four rigorous one-hour sessions a week — and daily voice homework exercises — for one month.
  • It attempts to overcome the sensory processing deficit that affects speech in Parkinson’s. For example, by recording patients’ voices and playing them aloud, the therapist can convince them before treatment that their voices are weak.
  • A patient focuses on a single goal — boosting loudness with maximal ef fort — rather than thinking about several aspects of voice and speech production at once.

How LSVT retrains vocal loudness

When prompted with just one cue of “Speak loudly!” or “Think loud!”, Parkinson’s patients automatically take in a deeper breath, open their mouth more for better resonance and articulation, and increase volume. All aspects of speech production strengthen together, says Fox, who, together with Ramig, cofounded a company called LSVT Global.

LSVT doesn’t train patients to actually yell or scream, although to them it may feeldisconcertingly as though that’s what they’re doing. “A huge piece of the treatment is to teach them that what feels very funny to them, and maybe too loud, is act ually within normal limits,” says Fox.

Each workout session starts with many repetitions of sustained “aaaahhhs” at normal, high, and low pitch, followed by repetitions of 10 everyday phrases or sentences. Over weeks, the therapist trains patients to build a healthy, louder voice to use first with individual words, phrases, and sentences, and then building up to continuous reading and conversational speech.

How long the benefits last:

Studies of LSVT show that in conversation, patients’ voices grow louder by about 5 to 6 decibels, which makes a big difference to a listener’s ability to hear them. A study published in 2001 found that some of the gains from LSVT persist for two years. Ideally, patients keep up voice exercises to maintain benefits. Occasional tune-up therapy visits may be needed.

Where someone with Parkinson’s can go for speech therapy

A neurologist or hospital should be able to refer patients to a speech therapist, where treat ments are usually covered by health insurers. The American Speech-Language-Hearing Association maintains a searchable directory of practitioners at .

To find a certified LSVT therapist in your area, check the directory at the nonprofit LSVT Foundation or its spin-off company LSVT Global . LSVT Global’s eLOUD service offers Internet delivery of the speech treatment via standard webcam technology. The firm is developing a computer program that lets patients do some speech sessions at home.

What you can do to help someone with Parkinson’s communicate better

Encourage them to seek speech therapy early on so that they can remain active at working, socializing, and enjoying life. Fox recommends treatment as soon as problems develop, because once speech impairment starts discouraging someone from conversing, the inactivity may accelerate the speech deterioration.

You can give important positive feedback to Parkinson’s patients the about how much clearer their voice sounds after receiving treatment. These tips can also help when chatting with them:

  • Cut background noise. Turn off the TV, close the windows, and choose quiet restaurants when eating out.
  • Talk face-to-face. Reading their lips will help.
  • Try to be patient. Let them answer questions and finish sentences themselves. Cognitive changes in Parkinson’s disease can slow thinking processes and hinder recall of the words they want to say.
  • Keep encouraging them to speak. Repeat the parts of a sentence that you understood, then ask them to say the full sentence again more slowly. Have them spell words you didn’t catch.

When speech exercises alone aren’t enough

The speech therapist may also recommend a variety of assistive devices, such as a small personal microphone system to amplify a soft voice. For patients who are able to use a computer, communicating via e-mail can be a satisfying way to stay connected with friends and family. For the advanced Parkinson’s patient who can’t speak at all, one option is a computerized device that speaks aloud the phrases the person types in.