ADS
My dad, who is 60, has recently become increasingly forgetful and confused. He forgets what he's just said, or boils the kettle then asks: 'Who's boiled it?', and often loses his car keys. He's also having trouble sleeping and mood swings. I've tried to get him to visit his GP, but he is too stubborn to go. He's on pain‑relief fentanyl patches for severe arthritis and also suffers from diabetes, high blood pressure and high cholesterol. Any advice would be appreciated.
A. Huckle, by email.
Left behind: There are multiple possible explanations for your father's symptoms, including cerebrovascular disease, depression, and dementia
What an upsetting time for both you and your father. His reluctance to see his GP may stem from a fear of what he may be told - or it is possible that he may be unaware of his poor memory and confusion.
However, please be assured there are other possible reasons for your father's symptoms aside from dementia.
The first to mention is cerebrovascular disease, where the blood vessels supplying the brain become furred up with fatty deposits. This can impair blood supply to the brain and trigger symptoms such as memory loss.
The combination of high blood pressure, high cholesterol and diabetes significantly increase the risk for this.
The condition must be diagnosed by a specialist. Indeed, some patients are found to have such furred arteries that they have unknowingly suffered mini-strokes which have triggered brain damage and led to the symptoms.
Vigorous treatment is needed to reduce risk factors. Blood pressure and diabetes must be kept under control, smoking (if relevant) must be stopped and cholesterol levels must be pushed as low as possible. This may not only minimise any further damage but could even improve symptoms.
Another possible cause for your father's symptoms is depression.
Many patients with depression have little or no sense of sadness, though they may experience anxiety or irritability.
Impairment of memory and concentration is common, along with fatigue and problems with sleep. This type of depression is often referred to as masked or atypical depression.
Making the diagnosis will require an appointment with your father's GP and, very possibly, a consultant psychiatrist.
The medication your father is taking for his various conditions can also trigger the symptoms you describe.
You tell me he is using the strong painkiller patches, fentanyl. These may impair memory and brain function (though they would not trigger any long-term damage), and symptoms may improve if stopped. But this decision can be made only after consultation with a GP or specialist.
The last possibility is dementia. This triggers impairment of memory and problems handling complex tasks, along with difficulties in reasoning, orientation, or language.
CONTACT DR SCURR
To contact Dr Scurr with a health query, write to him at Good Health Daily Mail, 2 Derry Street, London W8 5TT or email drmartin@dailymail.co.uk — including contact details.
Dr Scurr cannot enter into personal correspondence.
His replies cannot apply to individual cases and should be taken in a general context.
Dr Scurr cannot enter into personal correspondence.
His replies cannot apply to individual cases and should be taken in a general context.
Diagnosis depends upon a patient's medical history, as well as a description of symptoms from family members (the patients are often unable to provide one).
A doctor will use a simple test of cognitive function called an MMSE (mini-mental state examination) which is a widely used test taking several minutes and which checks a broad range of mental functions, such as memory. However, the first step towards a diagnosis is an appointment with a GP.
First, you should see his doctor alone to voice your worries. You can then formulate a plan. Perhaps they can arrange an initial meeting at home with a community psychiatric nurse, who can then help arrange specialist referral in concert with the GP.
Specialist involvement may need to include a psychiatrist, a physician for the elderly, or a neurologist - but this very much depends upon local services.
An important point to consider regarding safety is whether your father is well enough to be driving. The combination of his symptoms and the regular treatment with fentanyl may reduce reaction times.
Though he will not take kindly to losing that independence, I would urge you to consider this and act according to your judgment.
Recently, I have received a number of letters reminding me to go for my cervical smear test. The last one was five years ago and the experience was very painful and upsetting.
The nurse was quite rude and told me it was difficult for her to do as I am not sexually active (I'm in my 60s). I have been unable to find a clinic aimed at older women. Are there any other options for me?
Name withheld, by email.
This occurs when the lining of the vagina switches from being stretchy and elastic to being brittle, leaving it prone to damage and tearing.
This is thought to be due to a drop in levels of the hormone oestrogen after the menopause (when the ovaries, which produce most of the body's oestrogen, shut down).
As a result, carrying out a smear test becomes almost impossible - and the nurse who carried out that brutal and unsympathetic examination was not aware of this detail (too inexperienced).
Women are invited for regular screening tests up to the age of 65.
Although most cases occur in 35 to 39-year-olds, it still affects women in their 50s and 60s.
The best solution is to prepare in advance. This means using an oestrogen cream or pessaries, available from your GP, three to six months before your smear test to boost elasticity of the tissue.
There is nothing in the way of significant side-effects, as only tiny amounts of the hormone are absorbed into your system.
My preference would also be to use a smaller speculum as opposed to the standard size. After your smear test, the oestrogen can be continued if you wish.
To achieve all of this you will need a frank discussion with a GP.
Find out if you can see a female one, and prior to the appointment send a letter detailing what happened with the practice nurse and requesting treatment with oestrogen. The letter should have the effect of crystallising some serious contemplation about patient care, and you will command some respect and attention.
By the way... Cheap clot-buster drugs are a false economy
For decades, the standard medicine for 'thinning' the blood - so making it less likely to form a dangerous clot - has been warfarin.
Most people know this as rat poison, as it was introduced for that purpose in 1948. The name comes from the University of Wisconsin, where it was developed (Wisconsin Alumni Research Foundation or WARF).
Warfarin: Introduced in the late 1940s as rat poison, the blood-thinning drug is effective but finicky
Typically, blood-thinning drugs are given to patients who have recently had a clot in a deep vein in the leg to prevent further unwanted clotting.
The medication is also routinely used for patients with atrial fibrillation, the most common rhythm abnormality of the heart. Here, the atria - the upper two chambers of the heart - no longer contract in a co-ordinated way. This can lead to blood pooling, forming a clot. The risk is that this clot can be pumped out of the heart and into the brain, where it can trigger a stroke.
The problem is that although warfarin is very effective, using it is a high-wire act between giving too much (increasing risk of a dangerous bleed) and giving too little (increasing risk of a clot).
The level of medication that the body needs can change rapidly, and it can interact with various foods such as green vegetables. This means regular blood tests have to be carried out to check patients are taking the right dose.
As a result of this inconvenience, there has long been a quest for an alternative, and in the past year we have seen the arrival of three new tablets - rivaroxaban, dabigatran, and apixaban - all effective and none of which need blood tests to ensure a correct level of activity.
But they are expensive: while warfarin costs a pound or two per month, the new drugs are more than a pound or two per day. However, given the costs of regular blood testing for patients on warfarin, could it be more cost-effective to use the new drugs?
The economic analysis is now being done to work out which is the cheapest option. However, I would be interested to know how the cost-benefit is calculated.
One of my patients has to drive 30 miles to hospital for his blood test - and has to pay £3.50 per hour to use the hospital car park. I wonder if the experts factor that sort of cost into the analysis? I bet not.
ADS
No comments:
Post a Comment