Author: braindiseases

I am a qualified neurologist with sub specialization in the fields of epilepsy, clinical neurophysiology, sleep medicine and traumatic brain injury.

Hypothermia and Brain Arrest Protocol

braindiseases2 Comments

Hypothermia and Brain Arrest Protocol

 

Nitin K Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065

 

Recently I attended the American Academy of Neurology (AAN) annual meeting held in Seattle. One of the topics of interest was the use of hypothermia to improve the outcome of patients after cardiac arrest or traumatic brain injury. Since the neurological outcome of patients presenting after a cardiac arrest (whether in hospital or out in the field) is usually dismal, I thought this shall be a good topic for me to discuss here.

The brain needs oxygen to survive and does not do well if deprived of oxygen. Hypoxia (lack of oxygen) occurs after cardiac arrest (the circulation of blood to the brain is interrupted when the heart stops beating as occurs in a cardiac arrest). If the circulatory flow is not rapidly reinstituted (meaning the heart is not restarted) irreversible neuronal death ensures.  The usual scenario is as follows. A patient suffers an out of hospital cardiac arrest. A call goes out to 911. The EMS team is on the scene shortly. The patient is noted to be either in cardiac arrest (we call this asytole) or the heart is beating but ineffectively and there is no palpable pulse (we call this ventricular fibrillation). The heart is revived by either injecting drugs or shocking (with the help of a hand held defibrillator) and there is return of palpable pulse. Alls well you might say but the story is far from over!!!

Even though the heart has been revived the brain has taken a hit. During the time when the heart had stopped, there was a lack of blood flow and oxygen to the brain and irreversible neuronal death has occured. So we have a patient whose heart is now beating but the brain is dead. This patient may never make a meaningful neurological recovery. Some of these pateints end up in persistent vegetative state (PVS) or minimally conscious state (MCS).

By the time, I as a neurologist am called to see the patient, there is precious little I can do. The brain is already dead!!! I can just prognosticate and tell the family that their loved one shall never have a meaningful neurological recovery. In other words, I help them in deciding when to pull the plug!!! Nothing makes me feel more helpless. I did not enter neurology to prognosticate, I entered neurology and medicine to save a life and heal.

So that is why hypothermia for cardiac arrest sounds so promising. Recent studies have shown that if the brain is cooled (there are different ways to cool the brain from using high tech cooling blankets and beds to more primitive but equally effective techniques like bags of ice) to 32-34 degree centigrade for 12-24 hours following cardiac arrest, neuronal death does not occur. Till the heart is revived, the brain remains viable!!!

This research has led to the institution of a Brain Arrest Protocol in some big academic centers. Once a patient who has suffered a cardiac arrest is received, hypothermia protocol is immediately instituted. This has resulted in improved survival rates in these critically ill patients. Patients not only survive but they survive with good neurological outcomes.

If the hypothermia is prolonged or if the temperature is lowered too low it can cause complications and increase the risk for sepsis and cardiac arrhythmia. Hence this protocol is at present still in its infancy but I have a feeling this shall become a standard of care very soon.

 

Is it a seizure or is it syncope? the story continues….

braindiseases179 Comments

                      Is it a seizure or is it syncope? the story continues….

So our story ended with John in the ER. As many of you rightly guessed the first case scenario represents a typical syncopal episode while in the second case John had a generalized convulsion (seizure).

So what are the points in the history which favor syncope and which favor a seizure?

When a patient presents to a neurologist with an episode of loss of consciousness, it is imperative that we try to elucidate the underlying cause. As you can imagine the treatment of both these conditions is very different.

Syncope (fainting) can come either from the heart (we call this cardiogenic syncope) or from the brain (we call this neurogenic syncope or vasodepressor syncope or more commonly as vasovagal syncope). So for example you can faint (have a syncopal episode) if you have a sudden massive heart attack, or a transient arrhythmia of the heart (the heart beat fluctuates). As you can imagine these are potential lethal causes and hence patient’s who present with syncope are frequently evaluated for these cardiac conditions. Tests like ECG, prolonged 24 ECG (electrocardiogram) and sometimes an echocardiogram are ordered. Vasovagal syncope on the other hand is more benign and our patient John likely had a vasovagal syncopal episode in case scenario No 1. Another classical example of vasovagal syncope is when someone faints when he or she sees blood for the first time (frequently reported in medical students when they go into the OR for the first time).

 So what are the points which favor syncope?

1. Feeling light-headed prior to the episode

2. Feeling dizzy as if you are about to faint.

3. Blurring of vision at the onset of the episode ( Doctor I felt light headed, a little woosy, my vision started to go black and then I passed out)

4. Syncope usually occurs in an upright position (patient is usually standing when it occurs). Syncopal patients usually do not shake (that is they do not have convulsive movements. There is an entity called syncopal convulsion where in the episode starts with a syncope but then goes on to become a seizure. I shall not go into the details here as then it shall become confusing).

5. Usually the loss of consciousness is of very short duration. Once they fall to the ground and the blood rushes to their brain (as gravity has been eliminated), they rapidly regain consciousness.

6. They are not confused after the episode. They come around rapidly and know where they are (they are not confused and disoriented after the episode).

7. Syncopal patients usually do not bite their tongue or have loss of bladder control (wet their patients) during an episode.

What are the points which favor a seizure?

1. Patients who have a seizure do not get the type of prodomal symptoms which patients with syncope do. Meaning they do not feel light-headed, dizzy as if they are about to pass out. Seizures frequently occur out of the blue with no warning whatsoever. That said and done, some patients with seizures which come from the temporal lobe may get an aura. Multiple different types of auras have been reported in temporal lobe epilepsy (smell of burning rubber, metallic taste in the mouth, a rising sensation in the tummy among many others).

2. Seizures can occur in any position-standing, sitting, lying in bed and frequently in sleep too.

3. Patients who have a convulsion shake. We call this tonic clonic movements of the arms and legs (first they are noticed to stiffen up, the eyes may roll up or get deviated to one side and later jerking of the arms and legs occur).

4. The tongue may get caught inbetween the teeth as the patient is stiffening up or when they are having a convulsion (shaking). This frequently leads to a tongue bite (usually on the lateral border of the tongue).

5. When the patient stiffens up, the muscles of the urinary bladder go into a spasm and the patient may end having loss of bladder control (wet their pants). This may also occur when the seizure finally ends and the muscles relax.

6. Frequently patients after a seizure are confused and disoriented for a while. We call this the post ictal state.

7. Seizures frequently lead to loss of muscle tone. The patient falls and hits the ground hard. This may lead to cranio-facial injuries and even fractures. Patients with syncope on the other hand do not fall hard, rather thay seem to ease themselves to the ground.

As you can see now syncope and seizures may resemble each other superficially but a good history is usually able to clarify the diagnosis.

Is it a seizure or is it syncope: going over the basics again

braindiseases6 Comments

Is it a seizure or is it syncope: going over the basics again

Nitin K. Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065

 

I have written about this before but thought this would be a good time to go over the basics again. So let us begin with an example. Our main actor (lets call him John) is working in his office. The clock strikes 12 and he decides to step outside to smoke.  It has been a tough day at work for John.  Went out with a couple of friends last night and had one too many Jack Daniels on the rocks (with a slice of lime!!!).  This liberal indulgence in the bubby resulted in John waking up dehydrated and with the worst hangover of his life. That combined with a cold he is still nursing and you can imagine John is a very unhappy camper.

So John  steps out to smoke. Lights up and takes a deep puff. Ahhhhhhhhhhhhhh. And then it happens. He feels light headed, dizzy, his vision starts to grey and before he knows it he is on the floor.  His friend who sees him fall, rushes to help him. By the time he reaches John, John is already coming around. He attempts to get up on his feet and asks his friend what happened. He is alert and oriented and apart from a bruised ego, he feels well.

 

Now lets go to case scenario number 2. John is again our main actor. In this case though John is having a good day. He slept well the night before and steps out to have a smoke. He lights up. Ahhhhhhhhhhh. Life sure feels good. And then it happens. He stiffens up. A cry is heard (we call this the epileptic cry) and then he takes a hard fall to the ground.  After falling to the ground, he is noted to “shake” by his friend who has since rushed to his side ( I saw him shaking–both arms and legs, it was horrible. He was foaming at the mouth and I thought he was going to die is how his friend describes the event to the EMS later on!!!). After a minute, John stops shaking but he does not come around immediately. He remains confused and disoriented till the arrival of the EMS 15 minutes later. John later tells the doctor in the ER that he has bitten his tongue and lost control of his bladder (wet his pants) during the episode.

So after presenting these two case scenarios, my question to you is in which scenario did John have a syncope (fainting episode) and which was a seizure?

In the next post we shall pick up John’s story from the ER. Hopefully we can make him feel better.

 

Epidural hematoma: when a “minor” head injury may prove to be fatal

braindiseases4 Comments

Epidural hematoma: when a “minor” head injury may prove to be fatal

 

Nitin K Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065

 

Many of you must have read about the tragic demise of actress Natasha Richardson from blunt (closed) head trauma she sustained after falling on a ski slope. While exact details about the extent and nature of her injuries are unclear, it drew attention to blunt (closed) head trauma. I shall discuss about the same here.

Broadly speaking head injuries can be of two types: penetrating head injuries and closed head injuries. An example of a penetrating head injury is a gun shot wound to the head or when a person is involved in a motor vehicle accident with significant polytrauma (including fracture of the skull and bleeding into the brain). Penetrating head injuries are usually easily identified by first responders (emergency medical services such as the ambulance crew responding first to the call). Usually there is an obvious scalp laceration and blood is seen oozing from the site of the injury. Later when the patient is transferred to the hospital, the extent of the injury can be better documented. For this usually a CT scan of the brain is done (at times a MRI brain may be carried out). Penetrating head injuries vary depending upon the mechanism of injury (example velocity, trajectory and size of the bullet in the case of gun shot wounds to the head). Patients with penetrating head trauma are critical and require urgent stabilization usually in an intensive care setting.

It is the closed head injuries though which can be a little deceiving and that is where I shall like to steer this discussion. The mechanism of closed head injuries is usually blunt trauma to the head (example a fall, a blow to the head while boxing and so on). One special type of closed head injury is a concussive injury from an improvised explosive device (IED). These IED related injuries have become the signature injury in the battlefields of Iraq and Afghanistan. But moving away from the battlefield, closed head injuries are frequent. Most of them are mild as the ones sustained while playing contact sports like football or boxing or when you get up in the middle of the night to go get a glass of water only to bump your head against a door. One “sees stars” for a while but is none the worse for wear apart from a bruised head and maybe ego (especially if you are like me and love to box). But can seemingly innocuous looking closed head injuries prove to be fatal? Can a “minor” fall or blow to the head kill you?

Well yes and this brings us to epidural hematomas. Let us assume you suffer a “minor” closed head injury. What you may ask exactly is “minor” closed head injury. Well it usually refers to an injury in which there is no prolonged loss of consciousness (example is a concussion after a blow to the head or a fall). As the scalp is not lacerated there is no obvious external bleeding. The patient may suffer a minor black out (loss of consciousness for a few seconds to minutes) but soon is awake and seems alert and able to answer questions.

 Imagine a boxer, who walks into a straight right. BOOM!!! Down he goes. The referee counts him out. It is a KO. The ring side doctor rushes in. The boxer eyes are glazed but he is coming around and slowly is able to get up and walk out of the ring unassisted. Nothing but a bruised ego and a black eye. He shall live to fight another day you may say as a spectator but the next day you read in the papers that the boxer was found dead in his bed. What happened here? Well the answer is simple. Even though the boxer seemed to have a suffered a “minor” closed head injury, a far more sinister injury process started silently in the brain. The blow to the head caused one of the small arteries (usually a branch of the middle meningeal artery) to start leaking blood. This blood starts collecting in the potential space between the brain and the skull (we call this the epidural space and hence a collection of blood in this space is called an epidural hematoma). As the leak is small, the patient seemingly recovers and looks fine. He may answer questions appropriately and hence may decide not to seek further medical attention. This interval where the patient (in our case our boxer) looks fine and seems to have recovered from the head blow is called the LUCID INTERVAL (the patient is lucid, makes sense and looks normal). But things are already starting to go wrong. The small leak from the ruptured blood vessel leads to progressive accumulation of blood in the epidural space. When the epidural hematoma becomes large, it has no place to expand (remember there is a rigid bony skull which prevents the blood from coming out). So the underlying brain starts getting squashed. This leads to a depression in the level of consciousness as the pressure inside the brain increases. If the elevated intracranial pressure is not brought down urgently the patient may die (we call this herniation of brain due to elevated intracranial pressure).

Could our boxer have been saved? Yes by all means. If he had been kept under observation (sometimes we like to observe patients with closed head trauma overnight in the hospital), then the first signs of raised intracranial pressure would have been picked up. Usually this is a change in the level of consciousness (the boxer would have become drowsy or hard to wake up, may have complained of headache). An urgent CT scan would have revealed the epidural collection of blood and neurosurgical evacuation of the blood would have been carried out (the skull is opened and the blood is drained out. The bleeding vessel is identified and cauterized to achieve homeostasis).

So what are the take home points from our boxer’s story?

-some “minor” looking closed head injuries can indeed prove to be fatal.

-patients should be observed after a closed head injury. If the decision is made not to go to the hospital, have a friend or family member check on the patient at multiple points.

-the earliest change in the patient’s level of consciousness warrants a stat transfer to the nearest hospital and further investigations.

I have multiple sclerosis. Do I need to take MS medications? Discussing the pros and cons

braindiseases5 Comments

Nitin K Sethi, MD

 

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065

 

 

The decision of taking MS medications is one which requires consideration of multiple factors by both the patient as well as the treating physician. At times the decision to go on medications is relatively straight forward, at other times it requires consideration of multiple factors before deciding on the best course of action.

Let me try to explain this by using a 29-year-old patient whom we shall refer to as Janet.

YOU CAN READ THE COMPLETE ARTICLE ON THE HEALTH CENTRAL WEBSITE.

http://www.healthcentral.com/multiple-sclerosis/c/73302/62597/make-ms

About pinched nerves and herniated disks—The final saga!!!

braindiseases3 Comments

About pinched nerves and herniated disks—The final saga!!!

Nitin K. Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065

 

The last post ended with our patient officially getting the diagnosis of a pinched nerve due to a herniated disk.  He was in excruciating pain and the doctor had referred him for a MRI scan of the lower back (we call this MRI LS spine (lumbo-sacral spine) or MRI C spine (of the cervical spine) as the case may be).  I want to emphasize that the diagnosis of a herniated disk is usually a clinical one and hence a MRI scan is not warranted in each and every case. I usually refer a patient for a MRI scan only if the clinical presentation is atypical or if there are signs of pressure on the spinal cord itself and lastly if the patient does not respond to treatment.

Well enough of my views, let us get back to our patient, who at this moment finds himself saddled inside a MRI scanner. The magnet starts moving, making a thunderous noise with the patient inside wondering what he has got himself into (many people feel claustophobic inside a MRI machine and for many the scan itself can be quite unnerving!!!).

After seeing the MRI pictures, the doctor decides to treat our patient symptomatically. A few days rest, some pain killers to keep the pain in check and a referral to physical therapy is prescribed. For the majority of patients with herniated disks and pinched nerves, this conservative therapy usually is effective. Traditional pain killers such as Motrin and Advil may not be very effective for neuropathic pain (pain due to the pinched nerves).  Hence medications like gabapentin (Neurontin) and carbamazepine (Tegretol) are at times prescribed. These work well for neuropathic pain though have their own side-effects which patients at times cannot tolerate. 

In patients who do not respond to the above conservative therapy more aggressive and usually invasive treatment options may be pursued. These include epidural steroid injections (these are injections of steroids (anti-inflammatory agents)  and pain-killers administered in the epidural space. The jury is still out whether these injections are truly beneficial. They have their own risks and should be administered only a qualified pain specialist. Relief if any is short lived and I personally do not refer my patients for epidural steroid injections. Surgery to remove the herniated disk (the procedure is called discectomy) is the last option. It is usually reserved for patients who have a large central disk herniation with compression of the spinal cord.

Thankfully our patient responds well to conservative therapy with gradual resolution of pain and discomfort. Soon he is back to his usual state of good health and cheerfully lifting heavy office supplies.  Herniated disks, pinched nerves and other things that make him go ouch and ah are but a distant memory….. A happy ending indeed.

 

 

About pinched nerves and herniated disks—oh how that hurts!!!

braindiseases3 Comments

About pinched nerves and herniated disks—oh how that hurts!!!

 

 

Nitin K. Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065

 

 

Recently I have seen many patients in my office with complaint of pain, numbness and tingling radiating down either the arms or legs. Most of these patients have pinched nerves due to herniated disks. They have ranged from ages of 25 to 65 and all of them have sought a neurological consultation primarily due to discomfort and pain from the pinched nerves.

I have written about pinched nerves before (we refer to this condition as radiculopathy. If the pinched nerve occurs in the neck i.e. the cervical vertebrae are involved it is called cervical radiculopathy and if it occurs in the lower back and involves the lumbar vertebrae it is called lumbar radiculopathy) but thought this might be a good time to again discuss this relatively common but frequently disabling condition. So what does a pinched nerve actually mean?

Well as you know our spinal cord is enclosed and protected by a rigid structure called the spinal column (commonly we refer to this as the spine. The spinal column is made of small bones called vertebra which are stacked one on top of each other and interconnected to one another by ligaments and other soft tissues. It is the tail (spine) of the vertebra which you can feel when you touch someone’s back. Now this bony spinal column encloses and protects the delicate spinal cord (the spinal cord starts from the base of the brain and contains all the nerve tracts which carry signals from the brain to the periphery of the body and vice versa. As it descends down into the neck, it gives off nerves which supply all the muscles of the arms and in the lower back (lumbar area) nerves to the legs come out from the spinal cord).

SO LET’S GO OVER THIS AGAIN. YOU HAVE THE SPINAL CORD; IT IS ENCLOSED BY A STRUCTURE (we are calling this the spinal column) WHICH IS MADE OF SMALL BONES CALLED VERTEBRA STACKED ONE ON TOP OF OTHER. FROM THE SPINAL CORD THE NERVES COMING OUT AND SUPPLY THE MUSCLES OF THE ARMS AND LEGS.

HOLD ON WE FORGOT ABOUT THE DISKS!!! So what is a disk or more correctly called the INTERVERTEBRAL DISK? As the name suggests the disk is a small cartilaginous tissue which lies in-between two vertebrae (think of it as a cushion between two bones which is what it actually is!!!). As compared to the vertebrae which are bones, the disk is a cartilage and fibrous tissue which is prone to degeneration and rupture.

Now imagine a scenario.  You are lifting a heavy weight. You bend down, squat and strain to lift that heavy box of office supplies. You hear a “pop” in the back and feel “something give”. Well what do you think has happened? One of the cartilaginous disks in the lower back (most common is either the one between the 4th and 5th lumbar vertebrae or between the 5th lumbar and 1st sacral vertebrae. In the neck it is between the 5th and 6th or between the 6th and 7th cervical vertebrae) has herniated (POPPED OUT) and is now compressing (PINCHING) the nerve coming out of the spinal cord and going into the leg (may be the arm if it occurs in the neck). What is the end result of this disk herniation?

Well the next day you are in terrible pain and can barely get out of bed. You make an appointment to see your doctor. You have shooting pain (the pain radiates down your leg or in the case of a cervical disk herniation into your arm). You complain of feeling pins and needles and electric shocks radiating into your leg (or the arm as the case may be). Some people have more “negative” symptoms and complain of numb feeling rather than pain. The doctor examines you and orders a MRI of the lumbar spine (or the neck as the case may be). He gives you some pain medications and asks to take it easy!!!.

Voila you now officially have a herniated disk with a pinched nerve. It sure hurts like crazy. Will this story have a happy ending?

The story continues in the next post……….

 

I had a stroke like episode—what do I do?

braindiseases5 Comments

I had a stroke like episode—what do I do?

 

Nitin K Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065

 

 

 

I frequently see patients admitted to the hospital for evaluation of a suspected stroke like episode. Most of these patients are “normal” with no neurological signs and symptoms (the presenting symptom has invariably resolved by the time of their admission to an acute care facility).

So what are these stroke like episodes which scare patients and doctors alike leading to admission to a hospital and invariably a battery of tests including but not limited to MRI scans of the brain? Well some may be as vague as an episode of sudden dizziness, difficulty walking or weakness in the arms and legs, others are more restricted-an episode of difficulty speaking (I could speak but my words did not come out right or my speech was slurred as if I was drunk), loss of vision in an eye and so on.

When patients present to the ER or a doctor’s office with a history of such symptoms, they are frequently advised admission to rule out a possible stroke. When people think of stroke, they usually think of someone with weakness of the arm and leg but stroke signs and symptoms can be more subtle. Many patients have what we refer to as transient ischemic attacks (TIAs) prior to the stroke. As the name suggests, TIAs are transient (short lived) episodes of ischemia to the brain. Let me try to explain a TIA with the aid of an example. Let us assume a clot (entangled platelets and cholesterol crystals) breaks from the heart and goes up to the brain via the carotid artery (the carotid artery is one of the main arteries carrying blood to the brain). As it goes up further and further, it may get lodged in the ophthalmic artery (the ophthalmic artery is a branch of the carotid artery and supplies the retina of the eye). Now if the ophthalmic artery gets blocked by the clot there is no blood supply to the retina with resulting loss of vision in that eye (patients frequently complain of a black curtain descending in front of their eye). If the clot breaks by itself and dissolves the vision comes back (we call this transient monocular blindess—transient blindness in one eye). There you have suffered a transient ischemic episode.

There can be other types of TIAs which can involve different blood vessels in the brain and present with a myriad of signs and symptoms such as dizziness, double vision and difficulty speaking. So what is so important about TIAs?

Well put in simple language a TIA may be a warning sign of a future stroke (and by future, I mean in the NEAR future). It is a sign that all is NOT well with the blood vessels of the brain or the heart (either the vessels are slowing getting narrowed or the heart is not functioning well and throwing up small blood clots into the brain). TIAs thus should be aggressively and thoroughly investigated.

 

What are the stroke risk factors?

How can they be modified?

Does the patient need to be on any blood thinners?

 

As I frequently explain to my patients and their families

 

 

“A TIA IS A CRY OF THE BRAIN, A CRY FOR HELP

IF YOU DO NOT HEED IT IN TIME

YOU RISK HAVING A DEVASTATING STROKE IN THE NEAR FUTURE”

 

 

 

Digitalization of medical records: pearls and perils

braindiseases4 Comments

Digitalization of medical records

 

Nitin K Sethi, MD

 

            No one would argue that digitalization of medical records represents a step in the right direction. The benefits are indeed many to reap. Digital medical records shall ensure rapid communication among caregivers and the current restriction of geography shall be overcome. A resident of Manhattan, who happens to fall ill in San Diego while on a business meeting, can rest assured that the doctor who is taking care of him in the ER shall have access to his medical history and medication list. He would know which drug to avoid based on previous history of drug allergies. Medical errors shall be avoided and costly investigations needed not be repeated. Would it potentially save a life? Yes it would. A comatosed patient brought to the ER after a motor vehicle accident cannot speak and give a history. Doctors waste precious moments trying to ascertain history from family and there are many times when we cannot track any family member to get relevant medical and surgical history. At times this lack of history and delay leads to potentially life saving treatments been denied to the patient. A case in point is the administration of a clot bursting drug to a patient who presents to the ER with an acute stroke. Unless we can document that the patient is not on any blood thinners, this therapy cannot be administered.

            Digital medical records shall also improve physician to physician communication and this shall be of tremendous benefit to patients with chronic disorders such as multiple sclerosis whose care involves multidisciplinary specialties. Care would be more coordinated and I think a win-win situation for all involved and I mean all. Patients would be treated as a whole and not in parts where the right hand does not know what the left hand does. Medical errors shall be avoided; cost of care would decrease benefiting doctors as well as insurance carriers.

            But just like a rose comes with thorns so does the good idea of digital medical records. It cannot succeed unless it is implemented in whole. Every hospital whether state or private run and every doctor clinic would have to be mandated to implement it otherwise like other bright ideas gone sour, we risk having a fractured system with some institutions having digital medical records and others paper records. Digitalization of medical records is not going to be cheap and we rather not add to our already inflated medical budget with a half hearted effort.

 

Behavioral problems in dementia, how common are they and is there any help for it?

braindiseasesLeave a comment

Behavioral problems in dementia, how common are they and is there any help for it?

Nitin K Sethi, MD

 

I recently saw a 75-year-old patient in my office which has prompted me to write this post. His wife brought him in  for memory problems. As I took the history, I realised that it was not memory problems per se that was bothering her, it was his change in behavior. Recently he had become aggressive, at times verbally and physically abusive to her. True he had some memory difficulties which were apparent in the history. He had lost his way once and got confused when he could not recall the names of his grandchildren at a family get together. But as I took his history and asked him questions, I found him to have a good fund of general knowledge. He was aware of recent events like the election of President Obama and the war between Israel and Hamas. He was physically active and liked to cycle around the neighbourhood. But it was his change in behavior which was causing a strain in his relationship with his wife and she was having a difficult time taking care of him and administering all his medications.

The patient above obviously has dementia settling in. One can argue about the type of dementia (is it Alzheimer’s or some other type of dementia such as fronto-temporal dementia? You can read more about the same on my website http://braindiseases.info). But what I wanted to stress in this post was the prevalence of behavioral problems in dementia. Behavioral problems are common in all forms of dementia and are a frequent cause of caregiver stress and burnout.  Patients with dementia may present witha multitude of behavioral issues. They may either become too aggressive and hard to control (verbally and physically abusive they may lash out at loved ones when they attempt to nurse them) or they may become aphathic with loss of motivation and drive. Caregivers may complain that they are listless, just sit in one place thoughout the day and do not attempt any new task on their own.

I want to stress that caregivers need to understand that these behavioral problems are a part and parcel of the dementia complex. Lot of people just associate dementia with memory problems, little realising that the disorder is more pervasive. Thankfully now there are many drugs which can control some of these behavioral issues, thus making life easier for caregivers. These range from antidepressants to antipsychotic drugs apart from cognitive and behavioral therapy.

My advise to my readers is this.  If any of you has a loved one with dementia, learn to recognize behavioral problems early on. Bring them to the attention of the doctor since many of them can be effectively treated.