Category: POWER

So many physical abilities decline with normal aging, including strength, swiftness, and stamina. In addition to these muscle-related declines, there are also changes that occur in coordinating the movements of the body. Together, these changes mean that as you age, you may not be able to perform activities such as running to catch a bus, walking around the garden, carrying groceries into the house, keeping your balance on a slippery surface, or playing catch with your grandchildren as well as you used to. But do these activities have to deteriorate? Let’s look at why these declines happen — and what you can do to actually improve your strength and coordination.

Changes in strength

Changes in strength, swiftness, and stamina with age are all associated with decreasing muscle mass. Although there is not much decline in your muscles between ages 20 and 40, after age 40 there can be a decline of 1% to 2% per year in lean body mass and 1.5% to 5% per year in strength.

The loss of muscle mass is related to both a reduced number of muscle fibers and a reduction in fiber size. If the fibers become too small, they die. Fast-twitch muscle fibers shrink and die more rapidly than others, leading to a loss of muscle speed. In addition, the capacity for muscles to undergo repair also diminishes with age. One cause of these changes is decline in muscle-building hormones and growth factors including testosterone, estrogen, dehydroepiandrosterone (better known as DHEA), growth hormone, and insulin-like growth factor.

Changes in coordination

Changes in coordination are less related to muscles and more related to the brain and nervous system. Multiple brain centers need to be, well, coordinated to allow you to do everything from hitting a golf ball to keeping a coffee cup steady as you walk across a room. This means that the wiring of the brain, the so-called white matter that connects the different brain regions, is crucial.

Unfortunately, most people in our society over age 60 who eat a western diet and don’t get enough exercise have some tiny "ministrokes" (also called microvascular or small vessel disease) in their white matter. Although the strokes are so small that they are not noticeable when they occur, they can disrupt the connections between important brain coordination centers such as the frontal lobe (which directs movements) and the cerebellum (which provides on-the-fly corrections to those movements as needed).

In addition, losing dopamine-producing cells is common as you get older, which can slow down your movements and reduce your coordination, so even if you don’t develop Parkinson’s disease, many people develop some of the abnormalities in movement seen in Parkinson's.

Lastly, changes in vision — the "eye" side of hand-eye coordination — are also important. Eye diseases are much more common in older adults, including cataracts, glaucoma, and macular degeneration. In addition, mild difficulty seeing can be the first sign of cognitive disorders of aging, including Lewy body disease and Alzheimer’s.

How to improve your strength and coordination

It turns out that one of the most important causes of reduced strength and coordination with aging is simply reduced levels of physical activity. There is a myth in our society that it is fine to do progressively less exercise the older you get. The truth is just the opposite! As you age, it becomes more important to exercise regularly — perhaps even increasing the amount of time you spend exercising to compensate for bodily changes in hormones and other factors that you cannot control. The good news is that participating in exercises to improve strength and coordination can help people of any age. (Note, however, that you may need to be more careful with your exercise activities as you age to prevent injuries. If you’re not sure what the best types of exercises are for you, ask your doctor or a physical therapist.)

Here are some things you can do to improve your strength and coordination, whether you are 18 or 88 years old:

• Participate in aerobic exercise such as brisk walking, jogging, biking, swimming, or aerobic classes at least 30 minutes per day, five days per week.
• Participate in exercise that helps with strength, balance, and flexibility at least two hours per week, such as yoga, tai chi, Pilates, and isometric weightlifting.
• Practice sports that you want to improve at, such as golf, tennis, and basketball.
• Take advantage of lessons from teachers and advice from coaches and trainers to improve your exercise skills.
• Work with your doctor to treat diseases that can interfere with your ability to exercise, including orthopedic injuries, cataracts and other eye problems, and Parkinson’s and other movement disorders.
• Fuel your brain and muscles with a Mediterranean menu of foods including fish, olive oil, avocados, fruits, vegetables, nuts, beans, whole grains, and poultry. Eat other foods sparingly.
• Sleep well — you can actually improve your skills overnight while you are sleeping.

About the Author

Andrew E. Budson, MD, Contributor

Dr. Andrew E. Budson is chief of cognitive & behavioral neurology at the Veterans Affairs Boston Healthcare System, lecturer in neurology at Harvard Medical School, and chair of the Science of Learning Innovation Group at the Harvard Medical School Academy. Graduating cum laude from Harvard Medical School in 1993, he has given over 650 local, national, and international grand rounds and other talks; published over 100 scientific papers, reviews, and book chapters; and co-authored or edited seven books. His book Seven Steps to Managing Your Memory: What’s Normal, What’s Not, and What to Do About It explains how individuals can distinguish changes in memory due to Alzheimer’s versus normal aging; what medications, vitamins, diets, and exercise regimes can help; and the best habits, strategies, and memory aids to use; it is being translated into Chinese and Korean. His book Memory Loss, Alzheimer’s Disease, and Dementia: A Practical Guide for Clinicians has been translated into Spanish, Portuguese, and Japanese. His latest book, Six Steps to Managing Alzheimer’s Disease and Dementia: A Guide for Families teaches caregivers how they can manage all the problems that come with dementia—and still take care of themselves. Website: Andrew Budson, MD Facebook: Andrew Budson, MD Twitter: @abudson View all posts by Andrew E. Budson, MD

When you think about progressive brain disorders that cause dementia, you usually think of memory problems. But sometimes language problems — also known as aphasia — are the first symptom.

What’s aphasia?

Aphasia is a disorder of language because of injury to the brain. Strokes (when a blood clot blocks off an artery and a part of the brain dies) are the most common cause, although aphasia may also be caused by traumatic brain injuries, brain tumors, encephalitis, and almost anything else that damages the brain, including neurodegenerative diseases.

How neurodegenerative diseases cause aphasia

Neurodegenerative diseases are disorders that slowly and relentlessly damage the brain. After ruling out a brain tumor with an MRI scan, you can usually tell when aphasia is from a neurodegenerative disease, rather than a stroke or other cause, by its time course: Strokes happen within seconds to minutes. Encephalitis presents over hours to days. Neurodegenerative diseases cause symptoms over months to years.

Alzheimer’s disease is the most common neurodegenerative disease, but there are other types as well, such as frontotemporal lobar degeneration. Different neurodegenerative diseases damage different parts of the brain and cause different symptoms. When a neurodegenerative disease causes problems with language first and foremost, it is called primary progressive aphasia.

How is primary progressive aphasia diagnosed?

Primary progressive aphasia is generally diagnosed by a cognitive behavioral neurologist and/or a neuropsychologist who specializes in late-life disorders. The evaluation should include a careful history of any language and other problems that are present; a neurological examination; pencil-and-paper testing of thinking, memory, and language; blood tests to rule out vitamin deficiencies, thyroid disorders, infections, and other medical problems; and an MRI scan to look for strokes, tumors, and other abnormalities that can affect the brain’s structure.

The general criteria for primary progressive aphasia include:

• difficulty with language is the most prominent clinical feature at the onset and initial phases of the neurodegenerative disease
• these language problems are severe enough to cause impaired day-to-day functioning
• other disorders that could cause the language problems have been looked for and are not present.

There are three major variants of primary progressive aphasia

Primary progressive aphasia is divided into different variants based on which aspect of language is disrupted.

Logopenic variant primary progressive aphasia causes word-finding difficulties. Individuals with this variant have trouble finding common, everyday words such as table, chair, blue, knee, celery, and honesty. They know what these words mean, however.

Semantic variant primary progressive aphasia causes difficulty in understanding what words mean. When given the word, individuals with this variant may not understand what a table or chair is, which color is blue, where to find their knee, what celery is good for, and what honesty means.

Nonfluent/agrammatic variant primary progressive aphasia causes effortful, halting speech in which individuals know what they want to say but cannot get the words out. When they can get words out, their sentences often have incorrect grammar. Although they know what the individual words mean, they may have trouble understanding a sentence with complex grammar, such as, “The lion was eaten by the tiger.”

Different primary progressive aphasia variants are caused by different diseases

These primary progressive aphasia variants are not diseases themselves. They are symptoms of brain problems. Not sure what I mean? Consider three other symptoms: fever, headache, and chest pain. As you know, each of these symptoms may be caused by different underlying diseases.

The logopenic variant of primary progressive aphasia is usually caused by Alzheimer’s disease. Does that surprise you? What this means is that although Alzheimer’s disease typically begins with memory loss, in some individuals it can start with trouble finding words. Memory problems typically begin a few years later. (Why do we call it Alzheimer’s disease if it doesn’t start with memory problems? Because Alzheimer’s disease is defined by the pathology that we see under the microscope when we examine the brain tissue, not by its symptoms.)

The semantic variant of primary progressive aphasia is usually caused by frontotemporal lobar degeneration, and specifically by accumulation of TDP-43. TDP-43 is an abnormal protein that accumulates in — and ultimately kills — brain cells.

The nonfluent/agrammatic variant of primary progressive is also usually caused by frontotemporal lobar degeneration, but this time it is most often due to tau pathology. Tau accumulation leads to tangles inside cells that damage and then destroy them.

Can primary progressive aphasia be treated?

The treatments available for primary progressive aphasia are generally strategies and systems to help individuals with these disorders communicate better.

• Thinking of information related to the word they are looking for can sometimes help individuals with logopenic variant primary progressive aphasia. For example, if they are searching for the word lion, thinking of yellow, Africa, big cat, mane, and similar words may help.
• Using your tone of voice, facial expression, and body language can be helpful to communicate with individuals with semantic variant primary progressive aphasia, as can pantomiming the message you are trying to convey.
• Using pictures, either on paper or in a tablet-based application, can be helpful to individuals with all variants of primary progressive aphasia.

Unfortunately, there are no cures for primary progressive aphasia, and no medications that have been shown to be effective. Most patients with primary progressive aphasia develop other cognitive problems over time, leading to a more general dementia.

If you suspect that you (or your loved one) may have primary progressive aphasia, start by meeting with your doctor. If your doctor is concerned, they will send you (or your loved one) to the right specialist.

About the Author

Andrew E. Budson, MD, Contributor

Dr. Andrew E. Budson is chief of cognitive & behavioral neurology at the Veterans Affairs Boston Healthcare System, lecturer in neurology at Harvard Medical School, and chair of the Science of Learning Innovation Group at the Harvard Medical School Academy. Graduating cum laude from Harvard Medical School in 1993, he has given over 650 local, national, and international grand rounds and other talks; published over 100 scientific papers, reviews, and book chapters; and co-authored or edited seven books. His book Seven Steps to Managing Your Memory: What’s Normal, What’s Not, and What to Do About It explains how individuals can distinguish changes in memory due to Alzheimer’s versus normal aging; what medications, vitamins, diets, and exercise regimes can help; and the best habits, strategies, and memory aids to use; it is being translated into Chinese and Korean. His book Memory Loss, Alzheimer’s Disease, and Dementia: A Practical Guide for Clinicians has been translated into Spanish, Portuguese, and Japanese. His latest book, Six Steps to Managing Alzheimer’s Disease and Dementia: A Guide for Families teaches caregivers how they can manage all the problems that come with dementia—and still take care of themselves. Website: Andrew Budson, MD Facebook: Andrew Budson, MD Twitter: @abudson View all posts by Andrew E. Budson, MD

It is estimated that worldwide there are more than 55 million people living with Alzheimer’s disease and other causes of dementia, and this number is estimated to rise to 78 million by 2030 and 139 million by 2050. There are simply not enough neurologists, psychiatrists, geriatricians, neuropsychologists, and other specialists to diagnose these individuals with cognitive decline and dementia. Primary care providers will need take the lead.

Although this may sound like the obvious and simple solution, my friends who are primary care providers remind me that they barely have time to do the basics — like blood pressure and diabetes management — and that they have no time to administer fancy cognitive tests. Even a simple test like the Mini-Cog (clock drawing and three words to remember) is too long for them. So how are we going to diagnose the increasing numbers of individuals with Alzheimer’s and other dementias in the next few decades?

A self-administered test can screen for memory loss

In 2010, clinicians at the division of cognitive neurology in The Ohio State University Wexner Medical Center developed a cognitive test to screen for memory loss that individuals can self-administer. This concept of a self-administered cognitive test can solve the problem of the time-crunched primary care provider. Individuals can take this test in the privacy of their own home and bring the results with them to the office. The results can then be used to determine whether additional work up and/or referral to a specialist is indicated.

The test, the Self-Administered Gerocognitive Examination (SAGE), has compared favorably to clinician-administered tests such as the Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA), as well as to standard neuropsychological testing. What was not known, however, is how well SAGE would be able to predict who would develop Alzheimer’s disease or another cause of dementia.

Predicting the future

To answer this question, the authors performed a retrospective chart review on 655 individuals seen in their memory disorders clinic, with a follow-up of up to 8.8 years. They compared their SAGE test to the MMSE.

Based on both initial and follow-up clinic visits, they divided their clinic population into four groups. Before I describe the groups, let me explain a few terms:

• Dementia is when cognitive impairment leads to impaired function.
• Mild cognitive impairment (MCI) is when there is cognitive impairment, but function is normal.
• Subjective cognitive decline is when individuals are concerned about their thinking and memory, but both cognition and function are normal.

The four groups they compared were individuals with

• Alzheimer’s disease dementia
• MCI who converted to Alzheimer’s disease dementia
• MCI who converted to another type of dementia
• subjective cognitive decline.

They found a surprisingly high correlation between the SAGE test and the MMSE in being able to predict how each of these groups did over time. Moreover, they found that the SAGE test could predict the conversion of an individual with MCI who would develop dementia six months earlier than the MMSE.

What is needed to bring this test into current practice

Even a self-administered test that individuals can do at home will still require training for primary care providers, to understand how the test should be used and how to interpret the results. There is no question, however, that such training will be worthwhile. Once the training is complete, the knowledge gained should be able to save literally thousands of hours of clinician time, in addition to missed — or improper — diagnoses.

Another question is how individuals will react when they are told that they need to perform a 10-to-15-minute cognitive test at home and bring the results to their doctor. Will they do it? Or will the ones who need the test the most avoid doing it — or cheat on it? My suspicion is that people who are concerned will do the test, as will people who generally follow their doctor’s instructions. Some individuals who would benefit from the information that the test provides may not do it, but many of those individuals wouldn’t do the “regular” pencil-and-paper testing with the doctor or clinic staff either.

A new model of cognitive screening

Previously, there were two types of screening instruments to help determine if someone is developing cognitive impairment that could lead to dementia: clinician-administered cognitive tests and family/caregiver questionnaires. Now there is a third type of screening instrument: a self-administered test. Use of these self-administered tests will be key in detecting the increasing numbers of individuals with Alzheimer’s disease and other causes of dementia who will be with us in the next several decades.

Want to test yourself?

You can download the SAGE test here. As it says on the website, please take the answer sheet to your doctor so they can score it and speak with you about the results.

About the Author

Andrew E. Budson, MD, Contributor

Dr. Andrew E. Budson is chief of cognitive & behavioral neurology at the Veterans Affairs Boston Healthcare System, lecturer in neurology at Harvard Medical School, and chair of the Science of Learning Innovation Group at the Harvard Medical School Academy. Graduating cum laude from Harvard Medical School in 1993, he has given over 650 local, national, and international grand rounds and other talks; published over 100 scientific papers, reviews, and book chapters; and co-authored or edited seven books. His book Seven Steps to Managing Your Memory: What’s Normal, What’s Not, and What to Do About It explains how individuals can distinguish changes in memory due to Alzheimer’s versus normal aging; what medications, vitamins, diets, and exercise regimes can help; and the best habits, strategies, and memory aids to use; it is being translated into Chinese and Korean. His book Memory Loss, Alzheimer’s Disease, and Dementia: A Practical Guide for Clinicians has been translated into Spanish, Portuguese, and Japanese. His latest book, Six Steps to Managing Alzheimer’s Disease and Dementia: A Guide for Families teaches caregivers how they can manage all the problems that come with dementia—and still take care of themselves. Website: Andrew Budson, MD Facebook: Andrew Budson, MD Twitter: @abudson View all posts by Andrew E. Budson, MD

For many of us, a trip to the doctor’s office produces anxiety: What do my blood results mean? Will my doctor think this bump is cancer? The physical exam can make us feel vulnerable and may involve mild discomfort, so we may shower, shave, and put on better-than-average clothes before heading out for our physical in an attempt to minimize this discomfort.

However, it’s the intimate discussions — whether a crushing depression, escalating alcohol use, or sexual problems — when our palms really start to sweat. These difficult discussions can be more comfortable and productive when we know what to expect.

Sex

Most people do not volunteer their sexual history, so be prepared for your doctor to ask you a few questions directly as part of your comprehensive exam. Doctors ask all patients about their sexual history, regardless of age, gender, and marital status. (This blog post has some tips for talking about sex with your doctor if you are in the LGBTQ+ community.)

As a psychiatrist, I routinely discuss sexual activity with my patients, as changes in mood, substances, and many medications can affect sexual functioning. For example, the most commonly prescribed class of antidepressants, the selective serotonin reuptake inhibitors (SSRIs), are more likely to lower libido than to treat depression. (They achieve remission in approximately 30% of patients — but they cause sexual dysfunction in 60% to 70%.)

What your doctor may ask: The five Ps: partners (number and gender), practices (what kind of sexual contact), protection (method of contraception), past history of sexually transmitted infections (STIs), and pregnancy. Your doctor may also ask about medications or supplements that can affect libido.

What your doctor needs to know: Your doctor needs to understand your risk of getting an STI, including any risky behaviors or substance use. In addition, your doctor needs to hear about any changes in libido, problems achieving orgasm, difficulties maintaining an erection, or a delay in ejaculation. This information helps your doctor think through contributing causes, including your hormone levels, medical conditions, and medications.

Substance use

This is another tricky topic, as almost everyone minimizes their substance use. Most people understand that smoking or excessive alcohol is not good for them — it’s not a matter of education. In fact, patients may avoid revealing their use because they don’t want their doctors to “educate” them.

People using substances often experience shame, one of the strongest negative emotions we can feel, and something people go to great lengths to avoid. It’s helpful to remember the role of your doctor: it’s not to judge, and certainly not to reprimand. Assuming you trust your doctor, it can help to think of your doctor as an ally. Together you can brainstorm ways to decrease use (harm reduction) or to discontinue use altogether, when you are ready.

What your doctor may ask: It is standard practice to ask about tobacco, alcohol, and illicit drug use. If you drink alcohol, smoke, or use substances, be prepared for your doctor to ask detailed questions about the quantity, frequency, attempts to cut down, and cravings.

What your doctor needs to know: The truth! Try to think about the past week and count the total drinks/cigarettes/pills consumed. Also let your doctor know whether you are interested in cutting down or discontinuing use altogether. Your doctor can work with you to optimize your treatment, whether it’s medications to reduce your cravings or connecting you to support groups.

Mental health

Most primary care clinics routinely screen all patients for depression, and some may screen for anxiety disorders as well. If you screen positive, your doctor will almost certainly ask you more questions about your mood, whether you are experiencing anxiety, and even whether you have experienced hallucinations or paranoia. This is not because your doctor thinks you’re crazy; rather, these symptoms may accompany severe illness and could affect treatment decisions.

What your doctor may ask: To assess for depression, your doctor will ask about your sleep, appetite, interest in activities, feelings of guilt, and any changes in concentration or energy level. Your doctor will also ask whether you have experienced thoughts about ending your life. These questions can feel probing and intimate — especially if you came to the doctor’s office for an unrelated complaint, such as heartburn. However, your doctor is asking these questions to develop a better understanding about the length and severity of your symptoms in order to make the correct diagnosis. Here too, it’s helpful to think about your doctor as an ally. If you’re worried about this information going into your medical record, you can request this information to be marked as sensitive. No one is allowed to see your medical records without your permission, unless they are caring for you.

What your doctor needs to know: Sometimes depressed mood and anxiety can be related to an underlying medical illness such as heart, lung, or thyroid problems. Mention any physical symptoms you have noticed, even if they seem unrelated. If this is your first episode of feeling anxious or depressed, think about any life events that could be contributing (such as a recent break-up, job loss, or move), as this may help your doctor in differentiating between an adjustment disorder and a major depressive episode. Talk about your coffee habits and alcohol use, which can affect sleep and anxiety.

The bottom line

Sharing the most intimate details of your life with your doctor is understandably nerve-racking. Rest assured your doctor will keep this information confidential, unless there is a risk you could seriously harm yourself or others. It helps to realize that doctors talk about sex, substances, and mental health with almost all of their patients, and they will meet you where you are. Try to relax, take a deep breath, and remember: the doctor is on your side.

About the Author

Stephanie Collier, MD, MPH, Contributor

Dr. Stephanie Collier is the director of education in the division of geriatric psychiatry at McLean Hospital; consulting psychiatrist for the population health management team at Newton-Wellesley Hospital; and instructor in psychiatry at Harvard Medical School. Her professional interests include the interface of medicine and psychiatry, the treatment of mental illnesses in the primary care setting, and the optimization of training and supervision of non-specialist clinicians to deliver mental health interventions in resource-limited settings. View all posts by Stephanie Collier, MD, MPH

Weight loss once was considered a simple calculation: eat less and move more to create a calorie deficit. Now, basic differences between people — in genetics, health conditions, body type, and more — are also thought to play a role in how challenging it is to lose weight. Yet research suggests that some factors may help set the stage for success.

Sleep more to eat less? New research boosts this premise, suggesting that adults who are better rested consume significantly fewer calories than those who are chronically sleep-deprived.

This short-term study of 80 overweight people drives home just how integral slumber — or lack of it — is to our propensity to put on excess pounds, says Dr. Beth Frates, director of lifestyle medicine and wellness in the department of surgery at Massachusetts General Hospital.

“Working to find ways to clean up sleep hygiene may help people to extend sleep time to the recommended seven to nine hours per night,” Dr. Frates says. “This could, in turn, lead to consuming fewer calories and even weight loss in people who are in the overweight category by BMI.”

Sleep shortfall linked to chronic diseases

The new study, published in JAMA Internal Medicine, reinforces earlier findings indicating that people who sleep less consume more calories — and even crave higher-calorie foods — compared with those who sleep for longer periods.

About one-third of Americans don’t sleep the recommended seven to nine hours each night, Dr. Frates notes, and this shortfall is linked to many chronic diseases, including high blood pressure, heart disease, diabetes, and obesity. Sleep, she says, is one of the six pillars of lifestyle medicine — a list that also includes exercise, nutritious eating, stress reduction, social connection, and avoiding risky substances.

“Most people focus on exercise and diet when it comes to weight management and a healthy heart, but few focus on sleep,” she says.

Tracking sleep cycles, calories, and weight

The study participants were adults ages 21 to 40 with a BMI between 25.0 and 29.9, which is considered overweight. All of them routinely slept less than 6.5 hours each night. For the first two weeks, all maintained normal sleep patterns.

For the second two weeks, participants were randomly split into two equal groups. With the aim of lengthening sleep times to 8.5 hours, one group received individualized counseling pointing out ways to alter sleep-busting factors relating to bed partner, children, and pets.

“The advice wasn’t generalized,” Dr. Frates notes. “It was specific to the person, and then there was a follow-up visit with more counseling.” The second group of participants continued their typical sleep habits.

All were told to keep up daily routines without changing diet or exercise habits. Each wore a wrist device that tracked their sleep cycles, and they weighed themselves each morning. Sophisticated lab tests teased out the difference between the number of calories each participant consumed and expended each day.

Balancing appetite-regulating hormones

Researchers found participants who received sleep hygiene counseling slept for more than an hour longer each night than those continuing their prior sleep habits. Extended-sleep participants also consumed an average of 270 fewer calories each day and lost about a pound compared to control group participants, who gained just under a pound on average.

The findings are exciting, because they reveal the power of education and counseling on behavior change — in this case sleep, Dr. Frates says. Significant extra slumber time can help people feel like they’re thriving rather than just surviving, she adds.

But why might extra sleep matter? Sleep duration has long been linked to the body’s production of appetite-regulating hormones. Insufficient sleep is associated with higher levels of the hormone ghrelin, which increases appetite, and lower levels of the hormone leptin, which leads to feeling less full. This sets people up to gain weight. By contrast, sleeping more could alter these hormones and bring them back to balance.

“People might also feel more alert, energized, and happier with more sleep,” Dr. Frates adds. “This could lead to more activity, even if it isn’t exercise. It may lead to less sitting and more socializing.”

It’s worth noting that the study didn’t reveal whether the extended sleep pattern was maintained after the two-week intervention period, or what types of food participants ate and when.

The study had other limitations, too. “Were the people in the sleep extension intervention making healthier choices?” Dr. Frates asks. “Calories are important, but what makes up those calories is equally important. Measuring hunger levels, cravings, and stress levels would also provide important information.”

Takeaway tactics to improve your sleep

A few key tactics from the study could help you improve how long you sleep — and possibly help you take in fewer calories:

• Keep a sleep log
• Monitor sleep times with wrist actigraphy devices such as smartwatches
• Evaluate bedtime routines to tweak factors influencing sleep duration
• Limit use of electronic devices at least an hour before bed.

About the Author

Maureen Salamon, Executive Editor, Harvard Women’s Health Watch

Maureen Salamon is executive editor of Harvard Women’s Health Watch. She began her career as a newspaper reporter and later covered health and medicine for a wide variety of websites, magazines, and hospitals. Her work has appeared in The New York Times, The Atlantic, CNN.com, WebMD, Medscape and HealthDay, among other major outlets. Maureen earned a BA in print journalism from Penn State University. View all posts by Maureen Salamon

You were recently started on antibiotics for an infection and you are now doing well. But slowly your skin begins to itch, and the telltale signs of a rash are already popping up — first on your torso, and now spreading to your arms and legs. What do you do? Should you worry? Should you see a medical professional?

Rashes are a common and pesky side effect of many medications. It can be so disheartening to be getting better from one ailment only to discover that you have another issue to address. While these itchy eruptions can be annoying, they usually run their course over a week or two and can be treated with topical medications.

But not all drug rashes are created equal — and some can even be deadly. Luckily the scary ones are pretty rare, but it’s still a good idea to know how to spot them. How can you tell the serious rashes from ones that are just a nuisance, but will get better with time and treatment?

Types of drug rashes

There are two main allergic rashes that may happen after taking a drug. The most immediate type of reaction happens within hours. Hives appear and move around the skin. Since this process is related to the release of histamine, antihistamines (available over the counter at a drugstore) are the typical treatment.

There is also a delayed type of drug rash that comes up four to 14 days after you start taking a medication. Pink and red bumps appear on your chest and back, and spread to the arms and legs over the course of days. Unlike hives, these bumps don’t move around, and after a few days things may start to get better, but you may have peeling skin much like a healing sunburn.

This delayed type of rash doesn’t respond as well to antihistamines, but an over-the-counter topical cortisone cream (or one of its stronger prescription-strength versions) can help speed the healing process along.

When is a drug rash cause for concern and a visit to the ER?

With hives, the main concern is that you’re experiencing a whole-body reaction that goes beyond the skin, one that can make breathing difficult or dangerously drops your blood pressure. If you experience either of these symptoms, it’s very important to get to the ED.

These immediate, life-threatening reactions can be treated with steroids, epinephrine, and higher-dose antihistamines than you can find at the drug store. While they are scary, these types of allergic reactions to a drug are not hard to identify, and many doctors are skilled at spotting dramatic changes in your breathing or blood pressure. It’s important to tell the doctor you see what medications you have taken and how long ago you took them.

Know the signs of severe cutaneous adverse reactions (SCARs)

In the more delayed type of rash, symptoms can be more difficult to diagnose. The most common triggers for these types of rashes include antibiotics, antiseizure medications, antigout medications like allopurinol, and even over-the-counter medications like NSAIDs. (This isn’t a complete list, and any new medication should be regarded with caution.)

As for the rash, when it’s just itching things are usually fine, but still a nuisance. When the skin starts to hurt, or turns a deeper purple color, doctors worry about something more serious. If your skin starts to blister up or you see pustules, or if you notice sores in your mouth, eyes, or your genitalia, these are red flags and you should get to an urgent care clinic or the ER and ask for a dermatology consultation. Sores in the mouth can be so severe that drooling becomes a common symptom, because patients avoid swallowing due to the pain.

If you start to feel ill, like you have the flu, or if you’re getting puffy from swelling, especially in the face, this could mean it’s a severe drug hypersensitivity syndrome. Sometimes people develop a fever, a drop in their blood pressure, or their liver, kidneys, and heart can all be affected by drug hypersensitivity syndromes. These are so severe that most patients need to be admitted to the hospital, and sometimes even to the burn or intensive care unit.

While there are different names for different types of severe drug reactions, including Stevens-Johnson syndrome (SJS), drug rash with eosinophilia and systemic symptoms (DRESS), and acute generalized exanthematous pustulosis (AGEP), they are often grouped together as severe cutaneous adverse reactions (SCARs).

What happens if you develop a SCAR from a medication?

The first step is getting evaluated by a specialist, either in a dermatological clinic or the hospital. Finding someone who has expertise in managing these types of reactions is critical. A doctor (usually a dermatologist) may biopsy your skin, and they may have to start systemic medications that suppress your immune system. Sometimes, patients with SCARs also require a stay in a hospital.

The most important thing you can do is to keep an eye on your skin and its symptoms if you’re taking a new medication, or even if you’ve increased the dose of an old medication. If you suspect that you may be dealing with one of these SCARs, be sure to seek help from an expert, like a board-certified dermatologist, so that you can rest assured that you’re getting the care you need. Patients who are treated appropriately generally do well. Your doctors should also report these reactions to the FDA.

Once you’re on the mend, things can start to get back to normal, but it’s important to follow up with your doctors because there are some long-term issues that are important to pay attention to. Ultimately your doctors and healthcare team will advise you on what exactly is safe in the future. Remember that if you’re worried about one of these reactions, it’s important to stop the medication as soon as possible, but with the input of your doctors.

About the Author

Stephen Chen, MD, MPH, Contributor

Dr. Steven Chen is a board-certified internist and dermatologist. He is an assistant professor at Harvard Medical School. Dr. Chen earned his MD and an MPH from Johns Hopkins University. He then pursued residency training at Harvard, where he completed an internal medicine residency at Beth Israel Deaconess Medical Center, and a dermatology residency in the Harvard dermatology program. Dr. Chen attends on both the dermatology and internal medicine services with a clinical and research interest in oncodermatology. He co-directs the comprehensive cutaneous lymphoma program at Massachusetts General Hospital, and serves as an associate program director for the Harvard dermatology residency program. View all posts by Stephen Chen, MD, MPH

Let’s face it: inflammation has a bad reputation. Much of it is well-deserved. After all, long-term inflammation contributes to chronic illnesses and deaths. If you just relied on headlines for health information, you might think that stamping out inflammation would eliminate cardiovascular disease, cancer, dementia, and perhaps aging itself. Unfortunately, that’s not true.

Still, our understanding of how chronic inflammation can impair health has expanded dramatically in recent years. And with this understanding come three common questions: Could I have inflammation without knowing it? How can I find out if I do? Are there tests for inflammation? Indeed, there are.

Testing for inflammation

A number of well-established tests to detect inflammation are commonly used in medical care. But it’s important to note these tests can’t distinguish between acute inflammation, which might develop with a cold, pneumonia, or an injury, and the more damaging chronic inflammation that may accompany diabetes, obesity, or an autoimmune disease, among other conditions. Understanding the difference between acute and chronic inflammation is important.

These are four of the most common tests for inflammation:

• Erythrocyte sedimentation rate (sed rate or ESR). This test measures how fast red blood cells settle to the bottom of a vertical tube of blood. When inflammation is present the red blood cells fall faster, as higher amounts of proteins in the blood make those cells clump together. While ranges vary by lab, a normal result is typically 20 mm/hr or less, while a value over 100 mm/hr is quite high.
• C-reactive protein (CRP). This protein made in the liver tends to rise when inflammation is present. A normal value is less than 3 mg/L. A value over 3 mg/L is often used to identify an increased risk of cardiovascular disease, but bodywide inflammation can make CRP rise to 100 mg/L or more.
• Ferritin. This is a blood protein that reflects the amount of iron stored in the body. It’s most often ordered to evaluate whether an anemic person is iron-deficient, in which case ferritin levels are low. Or, if there is too much iron in the body, ferritin levels may be high. But ferritin levels also rise when inflammation is present. Normal results vary by lab and tend to be a bit higher in men, but a typical normal range is 20 to 200 mcg/L.
• Fibrinogen. While this protein is most commonly measured to evaluate the status of the blood clotting system, its levels tend to rise when inflammation is present. A normal fibrinogen level is 200 to 400 mg/dL.

Are tests for inflammation useful?

In certain situations, tests to measure inflammation can be quite helpful.

• Diagnosing an inflammatory condition. One example of this is a rare condition called giant cell arteritis, in which the ESR is nearly always elevated. If symptoms such as new, severe headache and jaw pain suggest that a person may have this disease, an elevated ESR can increase the suspicion that the disease is present, while a normal ESR argues against this diagnosis.
• Monitoring an inflammatory condition. When someone has rheumatoid arthritis, for example, ESR or CRP (or both tests) help determine how active the disease is and how well treatment is working.

None of these tests is perfect. Sometimes false negative results occur when inflammation actually is present. False positive results may occur when abnormal test results suggest inflammation even when none is present.

Should you be routinely tested for inflammation?

Currently, tests of inflammation are not a part of routine medical care for all adults, and expert guidelines do not recommend them.

CRP testing to assess cardiac risk is encouraged to help decide whether preventive treatment is appropriate for some people (such as those with a risk of a heart attack that is intermediate — that is, neither high nor low). However, evidence suggests that CRP testing adds relatively little to assessment using standard risk factors, such as a history of hypertension, diabetes, smoking, high cholesterol, and positive family history of heart disease.

So far, only one group I know of recommends routine testing for inflammation for all without a specific reason: companies selling inflammation tests directly to consumers.

Inflammation may be silent — so why not test?

It’s true that chronic inflammation may not cause specific symptoms. But looking for evidence of inflammation through a blood test without any sense of why it might be there is much less helpful than having routine healthcare that screens for common causes of silent inflammation, including

• excess weight
• diabetes
• cardiovascular disease (including heart attacks and stroke)
• hepatitis C and other chronic infections
• autoimmune disease.

Standard medical evaluation for most of these conditions does not require testing for inflammation. And your medical team can recommend the right treatments if you do have one of these conditions.

The bottom line

Testing for inflammation has its place in medical evaluation and in monitoring certain health conditions, such as rheumatoid arthritis. But it’s not clearly helpful as a routine test for everyone. A better approach is to adopt healthy habits and get routine medical care that can identify and treat the conditions that contribute to harmful inflammation.

About the Author

Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. As a practicing rheumatologist for over 30 years, Dr. Shmerling engaged in a mix of patient care, teaching, and research. His research interests center on diagnostic studies in patients with musculoskeletal symptoms, and rheumatic and autoimmune diseases. He has published research regarding infectious arthritis, medical ethics, and diagnostic test performance in rheumatic disease. Having retired from patient care in 2019, Dr. Shmerling now works as a senior faculty editor for Harvard Health Publishing. View all posts by Robert H. Shmerling, MD

In late March, the FDA approved a new therapy for advanced prostate cancer that is metastasizing, or spreading, in the body. Called Pluvicto (and also lutetium-177-PSMA-617), and delivered by intravenous infusion, the treatment can seek out and destroy tumors that are still too small to see with conventional types of medical imaging.

Pluvicto is approved specifically for men who have already been treated with other anticancer therapies, including chemotherapy and hormonal therapies that block the tumor-promoting hormone testosterone. The drug contains two parts: one that binds to a protein on prostate cancer cell surfaces called PSMA, and a radioactive particle that kills the cancer cells. Most normal cells do not contain PSMA, or do only at very low levels. This allows Pluvicto to attack tumors while sparing healthy tissues.

To confirm whether a man is eligible for the drug, doctors first inject a radioactive tracer that travels the bloodstream looking for and then sticking to PSMA proteins. Cancer cells flagged by the tracer will show up on a specialized scanning technology called positron-emission tomography. About 80% of prostate cancer patients have PSMA-positive tumors; for those who do not, the treatment is ineffective.

During the clinical trial leading to Pluvicto's approval, 831 men were randomly allocated to two groups. One group of men got Pluvicto plus standard-of-care treatments, while men in the control group got standard-of-care only. All the men had metastatic, castration-resistant prostate cancer, meaning that their tumors were spreading and no longer responding to hormonal therapy.

Results and considerations

Results after 21 months showed that Pluvicto was more effective at delaying cancer progression. Among men who got the drug, it took 8.7 months on average for their tumors to start growing again, compared to 3.4 months among men who got standard of care. Pluvicto was also associated with better overall survival: 15.3 months versus 11.3 months. The drug was generally well tolerated, but it also had side effects including fatigue, nausea, kidney problems, and bone marrow suppression.

Dr. David Einstein, a medical oncologist at Beth Israel Deaconess Medical Center in Boston and an assistant professor at Harvard Medical School, describes Pluvicto as a new and exciting tool. Yet he cautioned that while the drug provides a welcome incremental advance for men with advanced prostate cancer, it is not a cure. "Some patients may get the message that Pluvicto replaces all the other available therapies, and this is definitely not the case," he says.

Meanwhile, additional questions remain over who might be able to get the drug. "What about men with metastatic prostate cancer who were never treated with chemotherapy?" Dr. Einstein asks. "If you go strictly by the label, then prior chemotherapy is required. But some men are too sick for chemotherapy, or they may refuse it over potential side effects." Researchers are now conducting studies to determine if Pluvicto is beneficial during earlier stages of prostate cancer, or if combining it with other therapies that might enhance its effects.

"The availability of this new treatment is important for several reasons," said Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, editor of Harvard Health Publishing's Annual Report on Prostate Diseases, and editor in chief of HarvardProstateKnowledge.org. "First, it extends survival among men who have been heavily treated already and have few therapeutic options remaining. Second, it represents a new approach to using radioactive substances that adds benefit to traditional medicine. And finally, it relies on a diagnostic scan that specifically identifies which men are most likely to benefit from the treatment."

About the Author

Charlie Schmidt, Editor, Harvard Medical School Annual Report on Prostate Diseases

Charlie Schmidt is an award-winning freelance science writer based in Portland, Maine. In addition to writing for Harvard Health Publishing, Charlie has written for Science magazine, the Journal of the National Cancer Institute, Environmental Health Perspectives, Nature Biotechnology, and The Washington Post. View all posts by Charlie Schmidt

In parts of the United States and Canada, warming temperatures driven by climate change may be contributing to a rise in tick-borne illnesses. Ticks are now thriving in a wider geographic range, and appearing earlier and sticking around later in the shoulder seasons of spring and fall. That means we need to stay vigilant about protecting ourselves against ticks that cause Lyme disease and other illnesses— even during winter months in many warmer states and provinces.

Here's a timely reminder about why preventing Lyme disease is important, and a refresher on steps you can take to avoid tick bites.

What are the symptoms of Lyme disease?

Lyme disease is best known for its classic symptom, a bull’s-eye red rash that appears after a bite from an infected tick (scroll down to see photos of classic and non-classic rashes). However, 20% to 30% of people do not develop a rash. And a rash can be easy to miss because ticks tend to bite in dark body folds such as the groin, armpit, behind the ears, or on the scalp. Some people have flulike symptoms such as a headache, fever, chills, fatigue, and aching joints. So if you notice a rash or have these symptoms, call your doctor for advice. At this stage, prompt antibiotic treatment can wipe out the bacterial infection.

When people don’t receive treatment because they didn’t see the rash or didn't have other early symptoms, the bacteria can spread to different parts of the body. Not only can the bacteria itself cause problems, but the body’s immune system can over-respond to the infection. Either process, or sometimes both, may harm joints, the heart, and/or the nervous system. And some people treated for any stage of Lyme disease develop post-Lyme disease syndrome, which can cause a range of debilitating symptoms that include fatigue, brain fog, and depression.

How to avoid getting Lyme disease

Preventing tick bites is the best way to avoid Lyme disease and other tick-borne illnesses. Blacklegged ticks (also called deer ticks) may be infected with the bacteria that causes Lyme disease. If you live in one of the areas where the incidence of Lyme disease is high, these steps can help.

Know where ticks are likely lurking. Ticks usually crawl up from leaves or blades of grass on the ground to the legs. So be extra careful when walking through fields or meadows and on hikes where you may brush up against bushes, leaves, or trees. Try to walk on well-cleared paths.

Wear protective clothing. Long pants tucked into socks is the best way to keep ticks from crawling up under the pant leg. Lighter-colored clothing can make ticks easier to see.

Use repellents. You can buy clothing that’s pretreated with the insecticide permethrin (which repels ticks). Or you can spray your own clothes and shoes; just be sure to follow the directions carefully. On all exposed skin, use a product that contains DEET, picaridin, oil of lemon eucalyptus (OLE), IR3535, para-menthane-diol (PMD), or 2-undecanone. This search tool from the EPA can help you find a product best suited for your needs. Pay attention to the concentration of active ingredients: for example, at least 20% but not more than 50% with DEET; between 5% to 20% with picaridin; and 10% to 30% with oil of lemon eucalyptus. Many products come in pump spray bottles or as sticks or wipes, which may make them easier to apply where needed.

Get a tick check. After spending time in tick-infested areas, ask a partner to check you for ticks in areas on your body that you can’t see very well. The common bite areas are the back of the knee, the groin, under the arms, under the breasts in women, behind the ears, and at the back of the neck. The tick species that transmits Lyme disease is about the size of a sesame seed. Note that a tick has to be attached to your skin for 24 to 36 hours for it to transmit enough bacteria to give you the disease.

About the Author

Julie Corliss, Executive Editor, Harvard Heart Letter

Julie Corliss is executive editor of the Harvard Heart Letter. Before working at Harvard, she was a medical writer and editor at HealthNews, a consumer newsletter affiliated with The New England Journal of Medicine. She is co-author of Break Through Your Set Point: How to Finally Lose the Weight You Want and Keep it Off. Julie earned a BA in biology from Oberlin College and a master’s certificate in science communication from the University of California at Santa Cruz. View all posts by Julie Corliss

We all experience moments of indulgence that lead to overeating. If it happens once in a while, it’s nothing to worry about. If it happens frequently, you may wonder if you have an overeating problem or “food addiction.” Before you worry, know that neither of those is considered an official medical diagnosis. In fact, the existence of food addiction is hotly debated.

“If it exists, food addiction would be caused by an actual physiological process, and you’d experience withdrawal symptoms if you didn’t have certain foods, such as those with sugar. But that’s a lot different than saying you love sugar and it’s hard not to eat it,” notes Helen Burton Murray, a psychologist and director of the Gastrointestinal Behavioral Health Program in the Center for Neurointestinal Health at Harvard-affiliated Massachusetts General Hospital.

Many people unconsciously overeat and don’t realize it until after they finish a meal. That’s where mindfulness exercises can help you stick to reasonable portion sizes.

But she urges you to seek professional help if your thoughts about eating are interfering with your ability to function each day. Your primary care doctor is a good place to start.

What is mindful eating?

Mindfulness is the practice of being present in the moment, and observing the inputs flooding your senses. At meal time: “Think about how the food looks, how it tastes and smells. What’s the texture? What memories does it bring up? How does it make you feel?” Burton Murray asks.

By being mindful at meals, you’ll slow the eating process, pay more attention to your body’s hunger and fullness cues, and perhaps avoid overeating.

“It makes you take a step back and make decisions about what you’re eating, rather than just going through the automatic process of see food, take food, eat food,” Burton Murray says.

Set yourself up for success in being mindful when you eat by:

• Removing distractions. Turn off phones, TVs, and computers. Eat in a peaceful, uncluttered space.
• Pacing yourself for a 20-minute meal. Chew your food slowly and put your fork down between bites.

More mindfulness exercises to try

Practicing mindfulness when you’re not eating sharpens your mindfulness “muscles.” Here are exercises to do that.

• Focused breathing. “Breathe in and breathe out slowly. With each in breath, allow your belly to go out. With each out breath, allow your belly to go in,” Burton Murray explains. “This engages the diaphragm, which is connected to the nerves between the brain and gut and promotes relaxation.”
• Progressive muscle relaxation. In this exercise, you tighten and release one major muscle group at a time for 20 seconds. As you release a contraction, notice how it feels for the muscles to relax.
• Take a mindful walk, even if it’s just for five minutes. “Use your senses to take in your surroundings,” Burton Murray suggests. “What colors are the leaves on trees? Are there cracks on the ground, and where are they? What does the air smell like? Do you feel a breeze on your skin?”
• Practice yoga or tai chi. Both of these ancient martial arts practices include deep breathing and a focus on body sensations.
• Keep a journal. Write down the details of your day. Try to include what your senses took in — the sights, sounds, and smells you experienced, and the textures you touched.

Don’t worry about trying to be mindful all day long. Start with a moment here and there and build gradually. The more mindful you become throughout your day, the more mindful you’ll become when you eat. And you may find that you’re better able to make decisions about the food you consume.

About the Author

Heidi Godman, Executive Editor, Harvard Health Letter

Heidi Godman is the executive editor of the Harvard Health Letter. Before coming to the Health Letter, she was an award-winning television news anchor and medical reporter for 25 years. Heidi was named a journalism fellow of the American Academy of Neurology, and has been honored by the Associated Press, the American Heart Association, the Wellness Community, and other organizations for outstanding medical reporting. Heidi holds a bachelor of science degree in journalism from West Virginia University. View all posts by Heidi Godman