Respiratory tract infections are the most common reason for a same-day appointment in most primary care physician offices. What exactly do I mean by a respiratory tract infection? An illness that involves congestion of the nose or sore, scratchy throat or cough or congestion or sneezing or all of these. They are the most common illness normal healthy people experience.
For a video of Fred Ott sneezing, which was one of the first moving pictures ever made:
http://www.youtube.com/watch?v=8PaJ1r0udvQ
Most people catch some type of respiratory illness at least once a year, many of us perhaps twice or three times a year. I personally can count on getting two or three colds a year. I swear I always get them just as I'm leaving on vacation! (That actually did happen just two weeks ago as I was leaving on our spring break trip.)
What are the actual illnesses that make up what we refer to as respiratory infections? I will divide the illnesses into the upper respiratory tract(nose/throat/sinuses/ears) and lower respiratory tract--trachea, bronchial tubes, and lungs.
Upper Respiratory Tract: We call these "URIs" or upper respiratory infections. First and foremost: Colds, which are caused by numerous viruses of the rhinovirus and adenovirus families. Then influenza (also caused by viruses, belonging to two types--influenza A and influenza B). Strep throat, which is, of course, caused by a specific type of bacterium called streptococcus. Then there are ear infections (caused by either viruses or bacterial infections) and sinus infections (also caused by viruses and bacterial infections.
Lower Respiratory Tract: The same viruses that cause colds and influenza can affect the lower respiratory tract, causing coughs, chest congestion, and phlegm or mucus production. "Bronchitis" is a term I consider a "garbage can" diagnosis because it is simply a descriptor--it means the bronchial tubes are inflamed. It can be applied to any illness where a cough is the primary symptom. The most serious of the lower respiratory tract infections would of course be pneumonia, which can be caused by viruses, bacteria, or in rare cases even fungal infections.
Let's take these one at a time:
Colds:
Colds have a pretty predictable pattern in most people. The very first symptoms are usually a sense of discomfort in the back of the throat--often a dryness or scratchiness or just achiness, along with perhaps some unusual fatigue. Usually within 24 hours the cold becomes obvious: a more significant sore throat, deepening voice (from swelling of the vocal cords), increasing nasal congestion, post-nasal drainage (mucus draining down the back of the throat), and a general sense of illness--fatigue, low grade headache, and what we term "malaise"--just not feeling well. Some people note feeling hot and cold, or more sweaty, or more sensitive to environmental temperature. It is fairly unusual for adults to run fevers with the early onset of a typical cold, but it might happen. It is not uncommon at all for a young child to run a fever with the early onset of a cold.
The first three days of a "typical" cold are usually the worst. The sore throat, the occasional coughing, the increasing nasal congestion, runny nose and feeling "blah." Usually by day four, the sore throat is going away and the nasal congestion becomes the most significant symptom. The nasal congestion can drag on for several days, getting slowly better. But usually at this stage energy is returning, and the malaise and feeling grungy are going away. Most people with a cold will be able to tell they are getting better day by day after the first week. It may take them another week or even two to get "back to normal" but at least they can tell they're getting better.
Depending on the strain of virus and the individual make up of the patient, symptoms may descend into the chest. It is NOT uncommon for colds to cause some chest congestion, a moderate cough which is sometimes productive of some mucus, and sometimes a dramatic cough frequency and severity. The cough can sometimes interfere with sleep.
The following is a list of symptoms that typical colds should NOT cause:
--persistent high fevers over 101.5 (more than 1-2 days)
--nausea and vomiting
--severe headaches
--shortness of breath (other than perhaps during a coughing spell)
--persistent unilateral ear pain
--a sore throat so bad it is hard to swallow food or liquids
--persistent (over 3 days) of continuous one-sided severe sinus or facial pressure pain that does not respond to over-the-counter symptom relievers
Management of a cold:
Since a cold is caused by a virus, there is really not much you can do to rid yourself of a cold once it takes hold.
The best recommendations are to stay home for the first two days, rest, stay well hydrated, and treat your symptoms if they bother you a lot.
Zinc and colds: There is some good evidence that taking zinc (typically in the form of zinc lozenges) at the earliest signs of a cold can reduce the severity and duration of a cold. However, the study that came to this conclusion cautioned that more research needs to be done in terms of zinc dosing specifics. Zinc is not without side effects: many people using zinc lozenges in the frequency recommended to shorten colds experience a funky, metallic taste from the zinc, and can experience nausea and headaches.
See the link:
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001364.pub3/abstract;jsessionid=5319A4F7F16131B89882E4A3DBEAAD4C.d03t04
Vitamin C and colds: This has been a moderately debated issue for the past six decades. Recently a meta-analysis of studies of vitamin C and colds concluded that taking vitamin C in high doses (2000 to 3000 mg) a day at the onset of a cold does NOT shorten or lessen the severity of a cold. However, in people who take high doses of vitamin C on a regular, daily basis, there was a slight but statistically significant reduction in the frequency and severity of colds.
Airborne and Colds: Don't even get me started on this one. NO evidence whatsoever exists that Airborne can do anything to prevent or shorten colds. The company was actually fined for making false claims, however, the FDA allowed them to continue to market the product (why is beyond me).
For other symptoms of colds:
--for aches and pains and sore throat: acetaminophen (tylenol) or ibuprofen or naproxen can help. Don't use ibuprofen or naproxen if you have a significant history of stomach ulcers or bleeding, or if you have kidney disease.
--for coughs: dextromethorphan is the most potent over-the-counter cough suppressant. It can be found in products like Robitussin DM or Mucinex DM (the DM is for dextromethorphan). Usually (as in these named products) the dextromethorphan is combined with guaifenesin, which is allegedly a mucus loosener/thinner. Actually lemon and honey is a very good cough remedy. Of course, cough drops or throat lozenges can help reduce the coughs that come from the scratchy throat.
Nighttime coughs that result from an insistently tickly throat are often due to post-nasal drainage. I describe these coughs as though someone is pricking the back of my throat with pins and needles. The best options for these types of coughs are throat lozenges that sort of numb the area, or throat sprays like Chloraseptic, or decongestant nasal sprays like Afrin. There is a particular prescription medication in the form of a nasal spray called ipratropium (Atrovent is the trade name) nasal spray that can dramatically reduce post-nasal drippage and prevent these nighttime coughing spells.
For the nasal congestion, there are three options:
--nasal saline sprays and rinses (like the NeilMed nasal saline rinse kits or "Neti-Pots"). These, of course, are very safe, and can be used as often as needed.
--Nasal spray decongestants such as Afrin. These can work pretty well, but have a "dark side" to them. If used regularly for more than about one week, your nasal linings can get "addicted" to them. Then when you try to stop using them, you nasal mucus membranes get all swollen and congested because they've literally gotten used to having the Afrin there to shrink up the swollen blood vessels. So I always warn my patients that if they use OTC nasal spray decongestants, the MUST stop after one week.
--Oral "pill" form decongestants. There are only two over-the-counter medications that can act as decongestants. Pseudoephedrine (SOO-doh-uh-FED-rin), and phenylephrine (FEN-uhl-EFF-run). Phenylephrine is found in OTC cold preparations and in Sudafed-PE. You can buy these without any limitation. Pseudoephedrine products like Mucinex D and Sudafed have to be signed for at the pharmacy counter. This is because pseudoephedrine is a necessary ingredient in the manufacture of meth. Oral decongestants can cause side effects other than elevated blood pressure: rapid heart rate, palpitations, headache, insomnia, tremors, and irritability.
People with high blood pressure, history of heart attacks, or history of strokes should NEVER use products with pseudoephedrine or phenylephrine, as these medications act like adrenaline and can dramatically elevate blood pressure.
What do I do when I get a cold? I stay home from work for at least the first two days, because that is when I am most infectious. I try to really rest, hydrate, and will use an analgesic of some sort. I might use Mucinex D during the day if I'm really bothered by nasal congestion. At night I usually will use some Afrin (because it won't keep me awake), and later in the cold when I am usually bothered by nighttime post-nasal drainage, I'll use prescription ipratropium nasal spray to reduce the night coughing tendency. I wash my hands even more than I usually do.
Preventing the spread of colds: Cold virus incubation time is about one week. Cold viruses are spread by touch--that is, if someone has a cold, the virus is in the mucus and secretions of the nose and eyes and throat. If they touch those secretions and then touch a surface, and then you come along and touch that same surface and then touch your eyes, nose, or mouth--then you've just transmitted the virus to yourself. Maybe your immune system will take care of it and nothing will happen. But if you are stressed, not sleeping well, not eating well, or otherwise have side-tracked your immune system, then usually within a few days to a week you'll be getting that familiar back-of-the throat feeling that tells you you're catching a cold.
A few myths about colds:
--discolored nasal drainage means you have a bacterial sinus infection. Discolored nasal drainage does not really mean much. We'll discuss the differentiation between sinus infections and colds shortly.
--Being in drafts or cold weather can make you get a cold. Being exposed to cold weather stresses your immune system which can make you less likely to fend off a cold if you are exposed. But drafts or cold air do not, in and of themselves, cause colds.
--Drinking milk or dairy products makes mucus thicker. Now this is an interesting issue. I have NEVER seen any scientific investigation into this claim. I should send this to "Myth Busters." My wife works in the Music Theatre department at a local college and I have known many vocal performance majors and professional singers. They all swear by this. I'll just say I won't necessarily doubt thousands of singers out there, but I would sure like some kind of proof that isn't subject to the placebo effect.
Influenza:
Influenza can be considered a "cold on steroids." When influenza hits, it hits HARD. When someone comes down with the flu, they can run a fever for a couple of days, up to 102 or rarely even 103. They will usually "hurt all over" with muscle aches and pains. They usually don't want to move. Flu symptoms are more "systemic" as opposed to a cold. People feel bad all over their bodies. They may get chills, sweats, and severe fatigue. They will quite frequently have a headache. They might develop some nausea and possibly diarrhea and rarely vomiting.
HOWEVER, when medical people say "the flu" they do NOT mean an illness characterized by nausea, vomiting, diarrhea and abdominal cramping that can last for 1-3 days. I run into this common misperception regularly. Or people will refer to the "stomach flu." I really have no idea why this labeling of a gastrointestinal illness as a "flu" got started. But I digress. . .
Back to influenza: The general systemic sense of illness with influenza can last several days. There is also usually a mildly productive, harsh, sometimes painful cough, and mild to moderate nasal congestion than can last for 2 weeks or longer. Everything with the flu takes longer than with a cold. People are usually making progress after 7-10 days, but it is very slow. The fatigue can go on for 3-5 weeks. The cough can linger for 4-6 weeks.
In short, influenza differs from a cold by the following:
--General whole body misery, aches, pains
--headache
--fever for 1-3 days is not uncommon
--severe fatigue
Prevention of influenza:
The flu vaccine:
Large scale studies of influenza vaccine effectiveness shows that it runs around 60-80% effective in reducing the likelihood of getting the flu for persons over age 2 and under age 65.
Studies show that the vaccine is less effective in kids under 2 and in adults over 65, for various reasons. However, it is still worth considering as side effects or complications of the vaccine are extremely rare, and it can reduce the risk of getting the flu, even if only modestly.
Common flu vaccine myth: Getting a flu shot vaccine can give you the flu. This is absolutely false. The injectable vaccine cannot cause influenza. It is an inactivated, killed virus. The nasal spray FluMist vaccine potentially can cause influenza, as it is a "live, attenuated virus vaccine." But that very rarely happens.
Influenza is spread more by aerosol droplets from people coughing and sneezing as opposed to the contact-type transmission of colds. So having people with the flu stay home from work for the 4-5 days they are most infectious is a great idea. If they are out and about, they should wear masks.
If someone is necessarily exposed to a person with the flu, that someone can be started on a preventive dose of Tamiflu (oseltamavir), which is an anti-viral drug designed to reduce infection from influenza. It is not a guarantee, but it is the only preventive known other than avoidance and the flu vaccine. The preventive dose of Tamiflu is 75 mg once a day for the duration of exposure.
Treatment of Influenza:
Basically the management of influenza is the same as the management of a cold: Symptom relievers. Bed rest, lots of fluids for hydration, analgesics for the body aches and pains as well as fever reduction. Over-the-counter cough medication, throat lozenges, over-the-counter decongestants as needed. Sometimes, prescription cough medications need to be used if the cough is severe and persistently keeping the patient awake. It is hard to recover if you are constantly sleep deprived.
If a patient strongly suspects they have influenza, there is a rapid test that can be done by passing a small swab back into the nose all the way to the back of the throat. It can tell us if the patient has influenza, and if we know we are seeing the patient in the first 48 hours of the process, we can start the patient on Tamiflu 75 mg twice a day for 5 days to try to reduce the duration and frequency of the illness. I don't always feel the necessity of doing the rapid test--there are times when a patient's history and presentation and physical exam suggest influenza, and if everything fits, I'll write a prescription for Tamiflu without a rapid test.
The main thing to remember with influenza is that it can last 2 weeks and then the residual cough, mild congestion, and significant fatigue can drag on for 2-3 weeks more.
Sinus Infections:
Trying to determine who has a bacterial sinus infection versus who just has a bad cold is one of the most common frustrations of primary care. Bacterial sinus infections can rarely occur as a complication of a cold. Bacterial sinus infections almost NEVER occur spontaneously, out-of-the-blue, without some type of initial process that closes off the sinus openings.
The heart of the issue is that several well-designed studies have shown that about 85% of antibiotics used to treat presumed bacterial sinus infections are absolutely unnecessary. Using antibiotics unnecessarily increases the general risk of bacterial resistance to antibiotics, and we have a huge problem with that as it is.
Bacterial sinus infections evolve during a bad cold in the following way: A cold causes inflammation and swelling of the nasal mucus membranes. It also causes an increase in mucus secretions by the mucus membranes. The sinuses are best thought of as sort of "caves" buried in the facial bones on either side of the nose and above the eyebrows, and in the skull bones behind the nose. These are more accurately called the "paranasal" sinuses, because there are many other "sinuses" in the human body.
The sinus caves in the facial bones (maxillary sinuses in the cheekbones, frontal sinuses in the forehead, ethmoid and sphenoid sinuses behind the nose and eyes) are lined with mucus-secreting membranes. They also are lined with small cells which have cilia--microscopic whip-like projections that constantly beat and whip that mucus up and out of the sinus, through a small opening into the nasal passages called an ostium.
During a cold, the mucus membranes of the nasal passages can get so swollen that the openings to the sinuses (the ostia) get blocked. So the mucus secreted inside the sinuses can't get out. Also, with the openings blocked, changes in atmospheric pressure cannot be equalized, and can cause temporary pressure pain in the sinuses. So we have blocked sinus openings, increasing mucus build up, and inadequate pressure equalization. But these are just what can happen with a regular cold.
A bacterial sinus infection develops when the germs/bacteria that live in the nose and throat make their way into the sinuses, and find a nice, secluded, warm, soupy mucousy mess which is a perfect growth medium for them. Since the normal "cleansing" mechanism of the sinuses is not working (the sweeping of the mucus by the cilia out of the sinus ostia), the germs can grab a foothold and start to reproduce. When that happens, white blood cell police get called to the bad-boy germ party now out of control. A pitched battle ensues. White blood cells fight the bacteria, and many of them die in the war. The decaying white blood cells and bacteria cause pus, which adds to the mucus AND adds to the inflammatory reaction in the sinuses, further aggravating swelling and pressure, and perhaps even causing a low-grade fever and malaise and fatigue.
How do we know if you have a sinus infection and not just a cold?
--sinus infections typically come at the tail-end of a cold, often after you have already started getting better. So we look for what is called "double-sickening"--that is, a cold starts, then starts going away, then you get worse again with sinus pressure symptoms, fatigue, and perhaps worsening mucus secretion.
--sinus infections typically are associated with persistent sinus pressure pain, and often even tenderness over them. Some people complain of pain in their upper teeth when the maxillary sinuses are involved.
--sinus infections are often associated with a definite systemic sense of illness. Fatigue, chills, feeling yucky.
We have definite history questions that help us decide the likelihood that a patient has a true sinus infection. The first question I ask is, "How long have you been ill?" If the answer is four days, I am not thinking this patient has a sinus infection. It is incredibly unusual for a bacterial sinus infection to take hold and flourish in only four days. If they say, "Two and a half weeks," then I'm much more suspicious of a true bacterial sinus infection.
The other questions I'll ask relate to the "double-sickening" mentioned above. Then I ask if there is persistent sinus pressure pain for more than just a couple of days.
Signs and symptoms I want to see prior to starting antibiotic treatment for a sinus infection:
--Upper respiratory symptoms that have gone on for over 7-10 days.
--A pattern of initial improvement followed by worsening illness, especially after an initial week of symptoms.
--persistent sinus pressure pain AND tenderness.
--Systemic symptoms of malaise, low grade fever, fatigue.
During the physical exam, I would like to see demonstrable sinus tenderness to pressure from my fingers, puffiness around the eyes, significant nasal mucosal swelling and inflammation, discolored post-nasal drainage down the back of the throat, foul breath (well, I'm not looking forward to that, necessarily), and a particular change in the voice quality of the patient characterized by a loss of facial bone resonance (any professional singer will tell you that open sinuses affect the timbre and resonance of the voice--thus if sinuses are filled or not open, the voice quality changes).
Treatment of Bacterial Sinus Infections:
Mainstays of treatment are:
--antibiotics to cover the most common bacterial causes of sinus infections. Commonly used antibiotics are azithromycin, amoxicillin or amoxicillin-clavulanate, cephalosporins such as cephalexin or cefuroxime, sulfa antibiotics such as Bactrim DS or Septra DS, or sometimes levaquin.
--decongestants: to try to open up the swollen, congested nasal mucus membranes.
--corticosteroids: It is not uncommon that we might use a course of oral prednisone to try to reduce the inflammatory swelling of the nasal mucus membranes. There is no strong evidence data to back up this practice, however.
See the Cochrane Review link:
http://summaries.cochrane.org/CD008115/systemic-corticosteroids-for-acute-sinusitis
Sometimes we might start a patient on a nasal spray corticosteroid such as fluticasone (Flonase), but nasal spray steroids take a good 5-8 days to have any effect at all.
--Nasal saline rinses like NeilMed nasal rinse or a Neti-pot.
--Hydration to help thin out mucus secretions.
--analgesics such as tylenol or ibuprofen or naproxen for pain/pressure relief.
Once treatment has started, it may take 7-10 days to make headway on symptoms. I usually expect to at least see improvement by 4-5 days, and expect the patient to be close to "back to normal" by 2-3 weeks.
If a patient has an excellent history for a true bacterial sinus infection and is not getting better on maximal therapy after 7-10 days, I may change antibiotics to something different, assuming perhaps the germ is resistant to the originally-selected antibiotic.
If the patient STILL is making no progress after a second course of oral antibiotics, then I'm suspicious we are not dealing with a typical bacterial sinus infection. If this occurs, I will set the patient up for a CT scan of their sinuses to see if something is amiss with their anatomy and to confirm if we are really dealing with a true sinusitis. Depending on the outcome of the CT, I may then refer the patient to an Ear/Nose/Throat specialist. (The CT scan below shows the maxillary sinus on the right side of the photo filled with fluid, indicating an acute sinus infection.)
Frustration Note:
It drives me crazy when a patient is seen in another setting by another provider for 4 days of cold symptoms. They get started on antibiotics by a well-meaning but hurried provider for a presumed "sinus infection." (This often happens because it is quicker and simpler to hand someone a prescription than it is to educate them in the differences between viral colds and bacterial sinus infections.) Then in 3-4 days the patient calls me saying their antibiotic is not working and they are still having symptoms. At that point I am in a quandary--are they not better because they just have a cold virus and antibiotics do nothing against viruses? Or do they truly have a bacterial sinus infection that is resistant to the antibiotic chosen, and I need to change antibiotics? If it seems fairly obvious that they were simply treated too early, I'll ask them to wait at least a few more days to see if the symptoms start to subside, as they should with a viral cold.
Strep Throat:
Strep throat is seen more often in children and adolescents than adults, but we still see it in adults frequently enough.
Symptoms of strep throat are a persistent sore throat, maybe even severe. There may be difficulty swallowing. There can be fever (more likely in children). There is often swelling of the lymph nodes at the top of the neck beneath the angle of the jawbone. There can be general fatigue an malaise.
Strep throat typically is NOT associated with:
--significant nasal congestion and drainage
--cough, although an occasional nonproductive cough just from throat irritation may occur.
The physical exam is often very telling in strep throat: the back of the throat tends to be "beefy" red. If tonsils are present they are often very swollen. There may be even some whitish "exudate" on the tonsils or throat. The voice has an odd obstructed quality to it.
We often will do a rapid strep screen throat swab test if we're suspicious. However, if I have a history that sounds pretty typical and typical physical exam findings, I'll just treat the patient directly rather than doing a throat swab test.
The throat swab test is pretty accurate (if done correctly), but does have some degree of a false negative rate. If I'm highly suspicious, but the rapid test comes back negative, I may treat the patient for presumed strep but run a confirmatory "throat culture" in which the actual germs from the throat are grown in an incubator for 2-3 days and then we can determine much more certainly if the patient does or does not have strep.
Strep fortunately continues to be pretty easy to treat. It responds typically in 48 hours to simple antibiotics like amoxicillin. However, strep throat is the one respiratory infection that I warn patients to absolutely complete the full ten day course of antibiotics even if they have felt "back to normal" for several days. Inadequately or incompletely treated strep can in rare cases lead to strep germs making their way into the kidneys or onto the heart valve leaflets, causing serious kidney or heart valve infections.
Still to go: Ear infections, then lower respiratory tract infections such as bronchitis and pneumonia. Work in progress...
High Blood Pressure is an extremely common problem which I see several times every day in my clinical practice. The prevalence of high blood pressure (also called hypertension) goes up with age and weight. However, I have some very young patients in my practice with hypertension also.
Why do we worry about high blood pressure? High blood pressure is associated with a significant increase in the risk of heart attack, stroke, congestive heart failure, kidney disease, and eye retinal damage.
A recent, large, landmark study called the "SPRINT" study showed that keeping blood pressure close to 120/80 reduces heart attack, heart failure, and stroke risk by almost one-third, and overall risk of death by about 25%.
Hypertension is generally defined as having elevated blood pressures (over 140 mm of mercury systolic or top number, or over 90 mm of mercury on the diastolic, or lower number, if you are under age 70), on more than one occasion, at least one to two weeks apart, with no other variables present that could cause high pressures. That is, the patient is not in pain, not severely stressed, not on medication that might elevate blood pressure, not significantly ill.
It is highly likely that with the results of this new SPRINT study, new guidelines for more intensive management of blood pressure will be coming out, probably with goals set depending on other current heart disease risk factors. That is, if you have other risks for heart disease or stroke, such as smoking, obesity, diabetes, hight cholesterol, or a strong family history of early heart disease in your first-degree relatives, your "target blood pressure" may be lower than someone who does not have these risk factors.
Diagnosis of High Blood Pressure:
We check blood pressures with every office visit of every patient (unless small kids). This is because high blood pressure can show up at any time and typically has virtually NO symptoms. SOME patients may occasionally feel some symptoms if their pressures are up--typically a sense of a mild/persistent headache, or pressure around their neck, or pulse-pounding, or mild lightheadedness. If there are symptoms, they are usually very vague.
Blood pressure should normally range from around 110 to 130 on the systolic side, and from 60 to 85 on the diastolic side. It can vary widely over the course of a typical day and under different circumstances.
The SYSTOLIC blood pressure is the pressure of the blood in the arteries (blood vessels leaving the heart) when the heart is in the active pumping phase--the heart is squeezing/forcing blood into the arteries. Therefore this number reflects the pressures created by not only the heart squeezing blood, but the ability of the arteries to accommodate that increased volume of blood coming into the system. Arteries should be rather expansile--flexible, able to open up. In doing so they reduce the pounding effect of the pulse pressure down the blood vessel pipeworks system.
The DIASTOLIC blood pressure is the pressure in the arterial system between heart beats. The heart is relaxed, and is not pushing blood into the system. The diastolic blood pressure reflects the general resistance of the arteries and arterioles (really small arteries). Arteries and arterioles are wrapped with muscles that can constrict them. These muscles are under the control of the autonomic nervous system. They respond to numerous inputs--neurologic and hormonal--resulting in either relaxing the muscle, which widens the artery's opening, or tightening, which narrows the artery's opening.
If the arteries and arterioles are relatively relaxed and "open," then the pressure of the blood within will be lower. If the arteries are under some degree of squeeze effect, then the pressure will rise.
I use the rather simple analogy of a powerful water pump (the heart) pumping water out of a pond, into a big firehose, that is then attached to several garden hoses (arteries) watering, say 15 separate lawns. If those 15 garden hoses are clamped in a vise so that only a trickle is coming through, the pressure in the firehose will climb precipitously. If we unclamp those 15 garden hoses completely, then the pressure in the firehose coming out of the pump diminishes.
The important point of the analogy is, what happens to the water pump if those 15 clamps are kept clamped down for a long time? The water pump starts to get overloaded. In real life, most water pumps have a "pressure relief valve" that will dump water out of the pump if the pressure goes up too high. The heart has no such pressure relief valve. It just has to deal with the elevated pressures. However, over time (years), the heart expands, the valves can leak, the the heart muscle changes and eventually heart failure can occur. Heart failure does not mean the heart stops beating, it just means it can't handle the load and blood starts to back up on the incoming side of the heart pump.
We measure blood pressure with a sphygmomanometer (SFIG-mo-muh-NOM-meter). In 1726, Stephen Hales began measuring the height of the fountain of arterial blood shooting out of a punctured large artery of horses (we'll pretend that those horses' arteries were repaired and that they lived long and happy lives after that). Now, we can buy very accurate battery-operated, electronic home blood pressure machines for around $50-$100.
Here is a typical clinical scenario: I'm seeing John Doe (not his real name) for a general physical. He is 44 years old, a little overweight, and does some occasional exercise. When my medical office assistant checks his blood pressure, it is 148/94. So I go in and we talk and deal with his issues, and after a good 15 minutes or so I'll check it again. It is now 144/92. So it is NOT normal. Does he have high blood pressure? No, not really--since we don't have a series of elevated blood pressure measurements, I can't really say.
So therefore, I would recommend to the patient that we get some home blood pressure readings to determine where his blood pressure likes to "live." I will print out a pre-printed sheet of information about how to monitor home blood pressures. It will say:
Purchase a good quality electronic, battery operated portable home blood pressure machine. Make sure the cuff fits you before you purchase it. Consumer Reports likes Omron brand and Reliant brand machines, though others might be just fine.
Numbers:
Systolic pressures above 140 are considered high.
Diastolic pressures above 90 are considered high.
Current guidelines indicate blood pressures for adults under age 70 should stay under 140/90. For patients over 70, acceptable blood pressures should remain under 150/90.
Start getting home blood pressure readings on a random basis, and write down the readings in a record book with dates and times.
Specific instructions for making readings:
--shoot for 3-4 random readings a week, but more is always better. The concept of random is important here. I want to know if blood pressures vary with different times of day. I don't want to only get blood pressures in the morning when you are relatively dehydrated and haven't been moving much.
--make sure you are always sitting quietly for at least five minutes before making a reading.
--make sure both feet on the floor, no crossed legs.
--make sure no more than one thin layer of clothing maximum between your skin and the blood pressure cuff.
--make sure you are not under unusual duress or in pain when getting the reading.
I am interested in the long term average blood pressure reading over a couple of weeks. That really tells me what I want to know. If the average blood pressure is 150/90, then that is too high, and I am going to want to get that patient started on some type of first line treatment.
I ask my patients to record their blood pressure readings on their smart phones (if they have one). There are many applications ("apps") for smart phones which will store blood pressure readings and even graph them and calculate averages.
(The current iPhone operating system comes with a built-in app called "Health" that will store observations such as blood pressure readings.)
If the average home blood pressure is running 136/87 or so, I would consider that a "borderline" blood pressure range and we would work on non-pharmacologic interventions ("lifestyle interventions--see that post on this blog).
If the average home blood pressure is running 120/84 or so, I would feel comfortable NOT intervening any further (or, if the patient is already on medication, I would not change anything).
The beauty of home blood pressure monitoring is that it gives us highly useful, real-life numbers. It also is incredibly more convenient that having the patient come in to the clinic, pay a $20 co-pay, and have us check their pressure. If the patient is already on blood pressure medication, we can make adjustments in their dose based on home readings, and we don't need office visits every month for "fine tuning."
If my patients are not sure about their home machine being accurate, I ask them to bring their machine in to the clinic and we check out their machine reading with what we get on our "official" clinic sphygmomanometer.
Let's say that it is clear that the blood pressure readings at home or consistently in the office are just running too high. Now what?
There are some basic diagnostic tests that should be considered prior to treating hypertension. Some of these tests are designed to make sure there are other causes of high blood pressure.
Other causes of high blood pressure:
- elevated thyroid function
- kidney disease
- narrowed arteries supplying blood to the kidneys
- epinephrine (adrenaline) secreting tumors (exceedingly rare)
- other hormonal abnormalities
- excessive alcohol consumption (especially during withdrawal)
- medications such as stimulants (such as Ritalin for ADD)
- recreational drugs such as cocaine, speed, meth
- sleep apnea
- elevated pressures within the brain or skull
So when I come across someone with an apparent new diagnosis of hypertension, I will typically set up lab tests and other diagnostic steps to make sure none of these other issues is in play. We will typically run a chemistry panel lab test to make sure that kidney function and electrolyte levels (sodium, potassium) are normal, a thyroid test to make sure we don't have an over-active thyroid, and we'll often run an electrocardiogram to make sure the electrical patterns of the heart are normal (that is, no evidence of heart enlargement or previous heart attack that might have been "silent").
The other issues are primarily derived by the history: snoring with daytime sleepiness as indicators of sleep apnea, a frank alcohol history looking for excessive alcohol use, and other unusual symptoms that might suggest the rare possibility of an epinephrine-secreting tumor.
Some of the tests might be done if we have more trouble than we anticipated in treating the hypertension. If blood pressure is very hard to control, or if I am dealing with a very young person with no family history of hypertension, I'll consider doing an ultrasound of the blood flow through the renal arteries to make sure no blockages are fooling the kidneys into thinking the blood pressure is low.
Treatment of Hypertension:
There is a relatively systematic approach to the treatment of high blood pressure:
Step 1: Lifestyle changes--exercise, diet, and weight loss all have very positive effects on blood pressure control. I'll definitely push this option for most people if they are motivated to work on these interventions and their blood pressures are not excessively elevated.
Sodium restriction is often effective in reducing blood pressure in some populations of people, but not everyone. By sodium restriction, we mean keeping the daily salt intake to under 1500 mg daily. This is actually not easy to do. It takes some careful reading of food nutritional labels to get a feel for how much salt is taken in each day.
Medications:
There are many, many medications available for the treatment of high blood pressure. However, they belong to a relatively limited number of families of medications. Many factors come into play in the decision of which medication to try initially.
Factors I consider:
--Side Effects: I really don't want my patient to have noticeable side effects, given that high blood pressure has usually no symptoms.
--Expense: I want to use the least expensive option, generic if at all possible.
--Safety: I want a medication that has a good safety profile.
--Effectiveness: I want a medication that has been shown to not only reduce blood pressure, but ideally has good evidence that it reduces the effects of high blood pressure, such as heart attack and stroke, heart failure, and kidney damage.
Medication Families:
Diuretics: The two most commonly used medications in this family are hydrochlorothiazide (HYD-ro-KLOR-o-THY-uh-zide) or HCTZ for short, and chlorthalidone (klor-THAL-uh-doan). These are officially "diuretics," in that they cause the kidneys to increase urine production, but they do NOT reduce blood pressure that way. They work directly on reducing the "clench" of the muscles of the arterioles to "loosen them up" so that the overall resistance to blood flow is reduced. Side effects of this group are rare--allergic reactions (especially if someone is already allergic to sulfa), rashes, lightheadedness, sun sensitivity, more frequent urination, potassium depletion, and rare muscle cramping are the usual ones I warn patients about.
Spironolactone is another diuretic-based antihypertensive medication that can work nicely. Spironolactone (spuh-ROW-nuh-LAK-tone) has the added advantage in women of blocking hormone effects that might aggravate acne and excessive facial hair growth (hirsutism). It also preserves potassium levels.
Beta-Blockers: This is a huge family. There are many representatives of the beta-blocker family. These medications work by blocking the effects of "beta-adrenergic" hormones--epinephephrine (adrenaline) being the primary one. Common examples are propranolol (Inderal--which was the first on the market back in the 1980s), atenolol, metoprolol, carvedilol, nadolol, and several others. Most of these are available generically.
Epinephrine works directly on small arteries and arterioles to constrict the muscles surrounding the vessels, thus increasing resistance to blood flow and increasing blood pressure. By blocking the effects of epinephrine, the blood vessels stay "more open," and the blood flow is less restricted. Beta-blockers work quite nicely most of the time. They are largely well tolerated.
However, they should not routinely be used in people who NEED the effects of adrenaline/epinephrine, such as asthmatics or brittle diabetics. An asthma sufferer during an acute asthma attack NEEDS to use adrenaline-like rescue medication to open up their airways urgently, and having a medication on board that blocks the effects of adrenaline could make that rescue medication less effective.
A diabetic patient suffering from a rapidly-falling blood sugar will often notice symptoms of feeling shaky, rapid heart rate, and getting sweaty--symptoms caused by the release of epinephrine by the adrenal glands due to the rapidly falling blood sugar. Blocking that epinephrine release effect could result in the diabetic not realizing their sugar levels are dropping quickly. This does NOT mean we cannot use beta-blockers in diabetic patients; we simply have to keep this issue in mind and explain this to the patient.
Side effects of beta-blockers are related to the blockage of adrenaline/epinephrine: slower heart rate, sometimes feeling lightheaded, sometimes fatigue (from loss of the adrenaline/epinephrine effect), sometimes decreased erectile function in males, and sometimes depression. However, some people who are very anxious might benefit from blocking the excessive adrenaline surges that come with anxiety.
Other benefits of beta-blockers: They can reduce the frequency of migraine headaches.
Calcium Channel Blockers: These have been around for several decades. The most commonly used members of this family are amlodipine, nifedipine, verapamil, and diltiazem. In order for the smooth or involuntary muscle that surrounds the small arteries of the body to constrict, calcium ions have to be moved in and out of the muscle cell. By blocking the "channels" that those calcium ions move through, the involuntary muscle cannot work, thus keeping the blood vessel more "open."
Side effects of calcium channel blockers are relatively rare, but could include faster heart rates, swelling in the feet and ankles, increased heartburn and acid reflux, headache, and lightheadedness.
Other benefits: patients who suffer from Raynaud's Phenomenon--which is a rare "clamping-down" of the arterial blood supply to the fingers and/or toes due to cold temperatures or vibration--can benefit from being on nifedipine. Also, calcium channel blockers are known to help reduce the frequency of migraine headaches.
ACE-Inhibitors: Common members of this family are captopril (the first one that came available in the 1980s), lisinopril, benazapril, enalapril, and ramipril. These medications work actually in the lung. The kidneys make a hormone called renin (REE-nin) that helps regulate blood pressure. If the kidneys think the blood pressure is too low, they make more renin. Renin is converted in the lungs to a new hormone called angiotensin that then causes the smooth muscle of the small arteries and arterioles to squeeze down, increasing resistance and increasing blood pressure. ACE-inhibitors block the transformation of renin to angiotensin, thus reducing the "squeeze" effect of angiotensin.
Side effects of ACE-inhibitors can be headache, nausea, lightheadedness, allergic reactions, sudden facial swelling of a type called "angioedema," and a very odd, persistent, hacky cough. They can rarely increase potassium levels.
Other benefits of ACE-inhibitors: This family of medications has been shown to help reduce the risk of kidney damage in diabetes patients. In fact, most if not all diabetes patients who have normal kidney function should be considered to be on an ACE-inhibitor if they can, to protect their kidneys.
Angiotensin-Receptor Blockers (ARBs): We consider this family a sort of second generation of the ACE-inhibitor family. These, as you can tell by their name, block the receptors for antiotensin on the involuntary muscle of the arterioles, thus keeping angiotensin from constricting the blood vessel. Members of this family include losartan, candesartan, irbesartan, and others. This family is relatively new, so fewer members of this family are available generically.
Side effects of the ARBs include lightheadedness, dizziness, low blood pressure, worsening kidney function (if not monitored carefully), elevated potassium levels, and also, very rarely, the same odd hacky cough that can be seen with ACE-inhibitors.
There are several other less-commonly used groups of anti-hypertensive medications, but I'd estimate that 90% or more of our patients are controlled on the medications in the above five groups.
Strategy: I generally start with one medication at a low dose in one family, as a generic. If that one seems to be well-tolerated, we monitor blood pressures on that medication for a few months. Ideally, the patient is sending us his/her blood pressures from home monitoring periodically. If pressures are not well controlled, then we may move up the dose of the single medication somewhat.
If still the blood pressure is not coming under adequate control, I'll usually recommend adding a low dose of a represtentative of a different family of anti-hypertensives. The goal being to sort of hit the blood pressure from several "sides," and to keep the doses of each medication down to reduce side effects. Many of these medications work together nicely as a "team." Many are available combined together in generic "fixed combinations" such as lisinopril-hydrochlorothiazide in one tablet. This allows the patient to take just one pill, for one price, while getting the benefits of two medications that are synergistic in their effects on blood pressure.
As long as my patient is sending me blood pressure readings fairly faithfully and regularly, we (the patient and I) can "tweak" the medications to reach our common goals of well-controlled blood pressure, minimized (or no) side effects, minimal cost, and maximal safety. If the patient continues to lose weight, exercise, and eat healthily, it is not unheard-of for the patient to be allowed to come off the medications if the blood pressures are running great.
It is said that Americans have the worst sleep habits in the world. Sleep problems are rampant in our society and I see patients with sleep problems of one type or another multiple times each day.
Sleep science and physiology have come along way over the past 20 years. We have learned all kinds of interrelationships between sleep and the rest of the body's functions.
The human brain requires a certain minimum amount of "deep sleep" every night. If it doesn't get it, the brain lets you know about it in a number of various ways. Inadequate deep sleep can cause the obvious problem of excessive daytime sleepiness, but it can also aggravate weight gain, lower pain thresholds, reduce immune function, increase depression and anxiety, worsen chronic back and neck muscle tension, and cause foggy thinking and forgetfulness.
Inadequate deep sleep makes people feel sleepy during the day. So then they crank up their caffeine intake which then continues to erode their nighttime sleep patterns. Daytime sleepiness can get so bad that people can sometimes experience "microsleep:" Tiny, brief episodes of sleep where people just nod off for just seconds. Mostly, though, they just fight to stay awake and feel irritable, and without much mental energy to tackle more challenging tasks.
Inadequate deep sleep contributes to weight gain (or sometimes inability to lose weight) by stimulating the production of cortisol (a weight-promoting stress hormone), decreasing the production of leptin (a hormone that reduces the sense of hunger), increasing the production of ghrelin (a hormone that increases hunger). Also, people who are sleep deprived often just lack the motivation to exercise because they are tired.
I remember as a medical student and resident, when I'd have to work nights at the hospital, the night shift nurses and techs would always keep tons of junk food around--donuts, cake, rolls, cookies--usually high carb, high calorie stuff. They used to claim they had to eat to stay awake.
It has now become the third question I ask when assessing a patient with weight problems: Diet, exercise, and now--sleep adequacy.
Deep sleep deprivation reduces pain thresholds. Why this is so is not known. It has huge implications, though. For people with chronic pain problems, it drives a vicious cycle--these patients don't sleep well due to their pain problems, which reduces deep sleep time, which reduces pain thresholds, increasing the perception of pain, which worsens the sleep situation. Quite often, when I work with someone with chronic pain of any type, one of my primary goals will be to maximize their sleep potential.
Another vicious cycle occurs in the depressed or anxious person. One of the hallmark symptoms of depression or anxiety is awakening in the night being unable to get back to sleep. This, of course, decimates deep sleep time, and dramatically adds to the lack of mental energy, irritability, and fuzzy cognition that accompanies these entities. Sometimes just breaking the sleep deprivation cycle in anxiety or depression can make huge strides in improving how patients feel.
The brain sends nerve impulses continuously to muscles of the body when it is awake. Even in shallower sleep phases, signals are still telling the muscles what to do, especially the "postural muscles" of the neck and back. (We've all seen sleeping dogs make running movements and even small yips and barks.) The ONLY time these nerve signals cease is during deep sleep. Therefore deep sleep is the only time these postural muscles get a "break" from the boss (the brain) and a chance to really loosen up and carry out their essential "metabolic house-keeping" and repairs. So shortening deep sleep time tends to worsen tightness and spasm of the muscles of the back of the neck, the upper back (especially the muscles of the trapezius group between the shoulder blades) and the lower back.
This excessive muscle tension of the back, combined with the reduction in pain thresholds, means that I can practically guarantee that patients with chronic sleep problems are also going to have chronic neck and back muscle tightness, tenderness, and pain.
Okay, so now that we know the effects of inadequate deep sleep, what are the kinds of sleep problems people face?
Inadequate time alotted to sleep: Some people just don't let themselves sleep enough hours. This is what I call "self-inflicted" sleep deprivation. It is especially common among teens and young people in their 20s and 30s. The 20-something guy who is addicted to on-line computer games and stays up until 2 a.m., then gets up at 7 a.m. to get to work by 8 a.m. The over-worked executive who is up working on his business project until the wee hours. The harried mom who just gets her kids to bed at 10 p.m. then stays up until 2 getting the other things done around the house that didn't get done during the day.
These people view sleep as a tradable commodity. And they don't seem to value it very highly--or perhaps more accurately, value other activities much greater. So they short-change their sleep and often play "catch-up" on the weekends. It is true--people do develop a sleep "debt." After three or four days of short sleep time, the effects of sleep deprivation accumulate and can, to some extent, be "repaid" to the sleep bank by sleeping longer hours on the weekends.
An excellent sign of someone who is sleep-deprived (especially deep-sleep deprived) is that they tend to fall asleep "the minute my head hits the pillow." The time it takes to fall asleep is called "sleep latency time." I think the average sleep latency is between 15-25 minutes. If someone is deep-sleep deprived, they'll often fall asleep in just a few minutes.
Sleep initiation disorder: There are some patients who come to me complaining that they just can't fall asleep. They lay in bed, wide awake, tossing and turning and getting frustrated. They'll tell me that once they do get to sleep, they are fine and stay asleep fine. They just can't get to sleep in the first place.
Sleep maintenance disorder: This has got to be the most common presentation. "Doc, I fall asleep fine, no problem. But then I wake up at 2 or 3 a.m. and just can't get back to sleep. My mind is going and I toss and turn and I sometimes just get back to sleep and half an hour later my alarm is going off."
I read a great quote by a famous sleep researcher (and I can't recall the name): She said, "If we all got the right amount of sleep, we would never need an alarm clock."
This is the classic form of insomnia seen with anxiety. People will awaken for any of several reasons, then once they are awake, their minds start working and the adrenaline (epinephrine) levels start rising and they get more and more worked up. Sometimes they'll even start to get warm and sweaty as they lay there thinking about stressful stuff. Then they look at their bedside clock, realize it has been an hour since they awoke, think frustratedly, "I can't believe I'm still awake!" (Sometimes post a quick Facebook note to that effect.) Now their adrenaline is really cranking. I tell patients, "The minute you think 'I have got to get to sleep!' you are pretty well done sleeping."
Interventions for sleep problems:
From my point of view, I need to know what is keeping the person awake.
1. Is there poor sleep hygiene? Sleep hygiene is the term doctors use to describe the basic habits that we develop regarding sleep. A long list will be presented shortly that describes good sleep hygiene habits.
2. Is there a pain issue? Is the person awakening because of pain somewhere? Can we address that issue directly?
3. Is there anxiety or depression? Anxiety is the single largest cause of sleep maintenance problems in our society. Can we address the anxiety with counseling, exercise, stress reduction, or medication?
4. Are there medications causing sleep problems? Many medications can have negative effects on sleep. And I'm not just concerned with prescription medications. Alcohol has an adverse effect on sleep--some people use it to help get relaxed at night, but at about 2 or 3 a.m., brain alcohol levels fall, and can cause a little mini-withdrawal which incites an increase in epinephrine (adrenaline) levels which can wake people up. Caffeine can have effects for up to 12-18 hours in some people.
5. Are there obvious sleep interrupters? Are there young children needing assistance in the night? Patients having to get up to urinate at night (from bladder or prostate problems, perhaps).
Sleep Hygiene Rules:
The following list is what we refer to as basic sleep hygiene points that I want anyone with sleep problems to consider as basic first-line recommendations for improved sleep.
1. Keep regular sleep hours. Try to head off to bed pretty close to the same time every night.
2. Keep your bedroom dark and comfortable. Your brain responds to light by waking up. If you get up at night to use the bathroom, try not to turn on bright lights.
3. Avoid obvious nighttime interruptions. Personal story: our pets, with the exception of our terrier, have been banned from our bedroom because our cats would wake up in the middle of the night and have a party under our bed. If small children are waking you up through the night, address those issues with their doctor. Most children over the age of 1 year should not be requiring you to get up in the night except occasionally. If you have to get up at night to urinate (from prostate problems or bladder problems) these should also be addressed by your physician.
4. Mask unpredictable noises. I recommend sleeping with a noise generator such as a fan or electronic sound device. I actually use an iPhone app connected to my bedroom stereo system that plays sounds of gentle waves breaking on the shore all night long (among other options). I also will sometimes use a fan, especially in the summer. These noise maskers will keep me from hearing street sounds, or cats (out in the hallway) or other intermittent noises.
5. NEVER look at the clock. It instantly sends a jolt of adrenaline through your body and brain, making you anxious and waking you up. You are either thinking, "I can't believe I'm still awake," or, "I've only got 2 more hours before my alarm goes off."
6. Exercise at least 20 minutes every day. Physical exercise burns off excess adrenaline and stress issues. It makes your body physically tired.
7. Avoid eating a large meal within 2-3 hours of bedtime.
8. Avoid caffeine after noon.
9. Avoid alcohol after dinner time.
10. If you find your mind is thinking about all kinds of things, keep a diary or journal at the bedside, and jot notes about what you are worrying about. The idea is to take the worries out of your mind and put them down on paper. Think, "I can stop thinking about these issues--there is nothing I can do about them at 2 a.m. anyway. They are now in the book so I can deal with them in the daytime."
11. Your bed should be for sleep or for sex. It should not be associated with the misery of tossing and turning and not sleeping. If you truly cannot sleep and you've been awake for quite awhile, get out of bed, find a comfortable place where it would be ok to fall asleep, and read a book or magazine that is not too stimulating or exciting. Get your mind off the fact you are not sleeping.
12. Keep the one hour prior to bedtime as a protected "wind-down" period. This period should be free of work, free of stressful interactions, free of worry. Do not balance your checkbook in bed. Don't lay in bed reading your laptop and catching up with Facebook or Twitter. When laying in bed with your spouse, don't get into discussions about the stressful events of the day or family issues or finances. Consider a warm bath in the hour before bed. Consider a gentle stretching regimen before bed.
13. While laying in bed, make sure you (and your muscles) are relaxed. Starting at your toes, clench the muscles moderately for a few seconds and then let them really relax. Use the differentiation between contracting and relaxing to identify what "relaxed" really feels like. Work your way up through your legs (careful if pointing toes at the ankle--can trigger some mean calf cramps if too hard), buttocks, hips, abdomen, lower back, hands, arms, shoulders, upper back, and neck. I try to imaging that my body is gradually weighing several hundred pounds and is literally "sinking" into the bed. (Actually, I imagine I am falling asleep on a large planet where gravity is 2-3 times stronger than Earth--I am a nerd!).
Relax neck muscles as much as possible. See if your head wants to roll a certain direction. Adjust your pillow to prevent your head from rolling too far once muscles relaxed. We often maintain tension in our neck that is unconscious to prevent unwanted head movement.
Check your back teeth. Upper and lower molars should never be in contact. This suggests that you are clenching your teeth unconsciously.
14. Do not watch TV if you can't sleep. Numerous studies have concluded that TV actually increases heart rate and excitement levels and overall stimulates you to be more awake.
15. Do not nap during the day.
Medications for Sleep
Over the Counter: There are several over-the-counter (OTC) medications or supplements for sleep problems. None of the OTC meds are dangerous or habituating. Most of my patients have tried one or several of these prior to seeing me. I don't usually care if my patients try these options as they are across the board safe.
Antihistamines: Benadryl (diphenhydramine) at doses of 25 to 50 mg is the mainstay of the OTC market. Other brand names make use of the fact that antihistamines make people drowsy. Unisom and others use other antihistamines. ZzzQuil similarly uses an antihistamine. Tylenol PM and Advil PM simply add antihistamines to their product to promote drowsiness.
Melatonin: This is a brain hormone that signals to the brain the need to sleep. It is available as a supplement OTC. Doses range from 2-6 mg typically. I suggest people try it--it is safe, and sometimes works well depending on the situation.
DreamWater: this is a relatively new liquid supplement containing GABA, melatonin, and 5-HTP. I found a good review of this:
http://supplement-geek.com/dream-water-review-side-effects/
Prescription Medications for Sleep
I only consider prescription medications if ALL OTHER avenues have been exhausted. There are really only a limited number of medications for sleep. They fall into roughly 3 families.
Tricyclic Antidepressants (TCAs): These are also discussed in my post on anxiety and depression. At low doses, TCAs such as amitriptyline, nortriptyline, doxepin, and a related medication called trazodone improve sleep through an anticholinergic effect much like the antihistamines. They also increase levels of serotonin in the brain somewhat. These medications are relatively safe, not habit-forming, and can be used for years with no adverse effects other than possibly dry mouth, dry eyes, slower bowels, and some morning grogginess that usually goes away with continuing use. Trazodone is probably our most-used version--it seems to have less morning grogginess effect. Typical doses of trazodone are 50 to 100 mg at bedtime.
Ambien and Lunesta: These are relatively new on the sleep medication scene. Ambien is available generically as zolpidem, but Lunesta as of the time of this writing is not generically available. These medications are best used at low doses for intermittent use. They are potentially habituating.
Ambien should be used at as low a dose as possible, typically 2.5 to 5 mg (maximum dose of the regular-release product is 10 mg) at bedtime as needed for significant trouble sleeping. It has a common side effect: amnesia for events that occur in the first few hours after taking it. I tell my patients who start on it--"Do not do anything except go to bed once you've taken it." Patients may not make memories of events that occur within 15-30 minutes of taking the medication. For example, I have had patients take it and then suddenly realize they did not have food for breakfast the next day, so drove to the store to get groceries. In the morning, they come down to find food in the refrigerator and have absolutely no recollection of how it got there. They don't recall driving to the store or anything related to that event. This usually does not extend past the morning, but rarely it can.
There has been some new evidence that especially in women Ambien effects can "accumulate" and cause dizziness, drowsiness or cognitive dysfunction during the day after use. Because of this, the FDA has put out a warning indicating that physicians should use lower doses than previously recommended.
Lunesta works fairly similarly to Ambien. Side effects are similar. I often hear of Lunesta causing an unusual taste side effect. I don't get many patients interested in it as it is more expensive.
Both Lunesta and Ambien are potentially habituating--that is, the longer they are used, the more likely the brain is to become tolerant of the medication, and the desired effect of the medication starts to "wear off." So not uncommonly, after many months or even years on these, patients will return to me and complain that they are only sleeping for 3-4 hours then they cannot remain asleep. If that occurs, we are in trouble, because I won't increase the dose of the product.
Benzodiazepines: These were previously discussed in the post on Anxiety. These are considered medications of "last resort." The usual benzodiazepine medications for sleep include lorazepam (Ativan), clonazepam (Klonapin), and temazepam (Restoril). These have been used for decades, especially for short-term use. In fact, they are really only recommended for short-term use (typically no more than 1-2 weeks). Use beyond two weeks is associated with a significant increase in the risk of habituation. These medications quickly become tolerated by the brain, thus they quickly lose their effectiveness, requiring escalating doses to maintain their effect.
I will use this group (typically clonazepam) only if we are in a complete "bind." That is, nothing else has worked and we are at the end of the line for medication trials. If I get to this point, the medication will be monitored extremely closely. I set a limit on the maximum dose and I will not cross that line. These medications are associated with an increased risk of death from all causes. They can contribute to confusion, fall risk, drug interactions, overdose (accidental/intentional) risk--numerous potential risk issues. These risks get multiplied tremendously in older patients.
Beyond this, someone with intractable sleep problems would need to see either a sleep specialist or a psychiatrist. I have no further medications that I will or can use for sleep problems.
Other Forms of Deep-Sleep Deprivation:
Sleep Apnea: Sleep apnea occurs when a person stops breathing for long periods (several seconds) while sleeping. This causes blood oxygen levels to fall precipitously, which then triggers survival signals in the brain to WAKE UP OR WE ARE GOING TO DIE! The blood pressure can skyrocket, adrenaline levels shoot up, stress hormones crank out. The brain may actually not wake up entirely--it may just move from deep sleep into a shallower stage of sleep that restarts the breathing process, which improves oxygen levels, at least until the brain falls deep enough to sleep to start the cycle over. There are two flavors of sleep apnea: Obstructive sleep apnea and Central Sleep Apnea.
Obstructive sleep apnea (OSA) is the case where someone stops breathing because the muscles of the neck and throat relax in deep sleep (remember?) and allow the patient to block their own airway. This is usually accompanied by significant snoring. OSA has several warning signs and symptoms that we ask about:
--Is the patient observed to have persistent, consistent snoring that is not just positional or with a cold?
--Has the patient had witnessed breath-stoppage by an observer? Often a spouse will describe that while the person is raucously snoring, there will be periods of silence and lack of breathing movements. This will sometimes be followed by that spouse violently kicking and pummeling the snorer so they don't die.
--Does the patient awaken with headaches? This occurs due to the roller-coaster effect of the low oxygen levels (and perhaps the elevated blood pressures) that have occured through the night. If I have a migraine headache patient that is awakening with migraines, I am thinking obstructive sleep apnea until proven otherwise.
--Does the patient awaken in the night with a sense of choking or not being able to breath? This is pretty self-evident.
--Does the patient have a neck circumference greater than 20 inches? A heavy neck aggravates the collapse of the airway which contributes to snoring and airway obstruction.
--Does the patient have significant daytime sleepiness? People with signifant sleep apnea will report difficulty staying awake through the day. There is actually a sleepiness scale--the Epworth Sleepiness Scale--that we can use to quantify this issue:
http://www.stanford.edu/~dement/epworth.html
If my patient reports most or all of these "red-flag" symptoms, then I'll get them set up to see a pulmonary medicine specialist for a consultation for a sleep apnea evaluation, which almost always includes a formal sleep study.
If they have just a few of the symptoms, I might suggest a home "ApneaLink" study. This is a home study using a pulse-oximeter and a breathing monitor that are easy to hook up and fairly nonobtrusive. This home study will measure oxygen levels during the night, and how often the patient stops breathing during the night. From this data we can get some idea of whether or not the patient has dangerous sleep apnea or is just snoring.
Patients with true blue, full-fledged OSA usually are treated with some form of CPAP: Continuous positive airway pressure. This involves some type of mask for the nose (or mouth and nose) that constantly blows air into the airway to keep it from collapsing and blocking airflow. I know, it sounds horrendous, but it works wonders the vast majority of the time. I have sleep apnea patients who sing the praises of their CPAP machines. I frequently hear testimonials like, "I don't know why I didn't do this 5 years ago!" "I sleep better now than I have in years!" "My wife can now sleep in the same bed with me!" " I have energy I never knew I could have." "I won't even go on an overnight trip without my CPAP!"
Other treatments for OSA: Of course, the single largest factor in OSA is weight. Almost all OSA patients are obese. If we can get their weight down substantially, the obstructive process goes away. However, that takes time.
Surgery: There is a surgery that Ear/Nose/Throat surgeons can do which shaves off the back of the soft palate and removes the uvula (the hangy-downy thing at the back of the throat), and also reduces the size of the back of the tongue, and removes the tonsils if still present. Basically, everything that can be done to surgically open the back of the throat to improve air movement. Since this is a surgery that is irreversible, I view it as a "last resort" for OSA, if the person is unable to use CPAP.
Use of an oral apparatus: There are devices which are sold that are purported to keep the tongue properly positioned to avoid snoring, but I have limited experience with these. The problem is really farther down the hypopharynx than these devices can address, so I have my doubts as to their effectiveness. However, if my patient wishes to try one I'll certainly let them, as long as it works and we can prove it works.
Central Sleep Apnea: This is a very rare disorder in which the brain during sleep just shuts off breathing and blood oxygen levels fall. There are different forms and causes: medications, heart failure, brain stem injuries, and others. It is treated by dealing with the underlying cause whenever possible. Sometimes CPAP helps also.
Undiagnosed or untreated sleep apnea can have serious and even life-threatening consequences. Besides the obvious issues of the patient feeling tired all day and usually struggling with weight issues, there is an increased risk of high blood pressure, heart attack and stroke from the barrage of stress hormones released as well as the precipitous drop in blood oxygen levels. There is the significant risk of falling asleep while driving or operating dangerous machinery. We have no idea of the true numbers of traffic fatalities that have occured when a person has fallen asleep at the wheel because of undiagnosed sleep apnea.
Other weird sleep problems: There is a whole family of bizarre sleep disorders called parasomnias. Sleepwalking is the most common, and is usually seen in kids and almost always disappears around puberty. Sleeptalking is similar.
More frightening but very rare is sleep paralysis: The patient may awaken from sleep but still be unable to move or speak, for several minutes. This can sometimes be misconstrued as the person is having a stroke. There are other parasomnias like awake dreaming, where the patient is in sort of a half-awake state but still dreaming. They can have the frightening experience of not knowing if they are awake or asleep and if the dreams are real or just--dreams.
I have some patients who have "active dreaming." They move and act out their dreams by flailing or even making directed body movements, such as pummeling or hitting. I've had some terrified spouses say they were attacked by their husband or wife in their sleep. This could be intentional, I suppose, or it could be this unusual parasomnia. This problem is treatable with medication.
What I find so fascinating about sleep is why we need it. It is still not known completely why we must sleep. The really weird thing about sleep is that if you continue to deprive a person of sleep for long enough, they start to become delirious, have hallucinations, perhaps have seizures, and ultimately, they will die. Don't worry--it takes literally weeks of sleep deprivation to reach that point.
It is also fascinating to me that as we age, we don't sleep as well. My elderly patients almost across the board don't sleep solidly through the night. Increased daytime napping is a major contributor, aggravated by decreased physical activity. However, even beyond simply increased napping, older brains just don't seem to have good, consolidated sleep patterns. It was formerly thought that this was just a "normal" part of aging, and in some sense that is true. But that does not mean it is well-tolerated by the older person. The effects on the body and mind of chronic sleep deprivation are the same, perhaps worse, on an older, more frail population than on younger, more vigorous persons.
Sleep is absolutely essential to our physical, mental, and emotional health. Protecting the quantity and quality of sleep should remain a primary goal of any patient intent on promoting healthy living habits.
