Sunday, January 27, 2019

Knuckle cracking: Annoying and harmful, or just annoying

For most of us, springtime marks the return of life to a dreary landscape, bringing birdsong, trees in bud, and daffodils in bloom. But if you work for the Centers for Disease Control and Prevention (CDC), the coming of spring means the return of nasty diseases spread by ticks and mosquitoes.

The killjoys at CDC celebrated the end of winter with a bummer of a paper showing that infections spread by ticks doubled in the United States from 2004 to 2016. (Tick populations have exploded in recent decades, perhaps due to climate change and loss of biodiversity.)
Lyme disease

The most common infection spread by ticks in the US is Lyme disease. There were 19,804 confirmed cases of Lyme in 2004, compared to 36,429 in 2016. Because of incomplete testing and reporting, these numbers are almost certainly an underestimate. There may be as many as 329,000 cases of Lyme disease in the United States every year. New England, the mid-Atlantic states, and Minnesota and Wisconsin account for 95% of reported cases.

While Lyme disease may lead to fever, rash, meningitis, Bell’s palsy, and arthritis, it rarely kills. More worrisome are surges in deadly diseases spread by ticks, such as Rocky Mountain spotted fever, anaplasmosis, ehrlichiosis, and babesiosis.
Other serious tickborne illnesses

Rocky Mountain spotted fever (RMSF) is a misnomer. Although it occurs throughout much of the United States, including the Rocky Mountains, it is most common in southern Appalachia and the Ozarks; 60% of cases are diagnosed in North Carolina, Tennessee, Arkansas, Missouri, and Oklahoma. Reported cases of RMSF rose from 1,713 in 2004 to 4,269 in 2016. Patients with RMSF have high fever, headache, belly pain, and a rash with pinpoint red dots or red splotches. The rash may not be present early in the disease. Even with treatment, RMSF is fatal in up to 4% of cases.

Anaplasmosis and ehrlichiosis resemble RMSF, except that rash is less prominent (and is rare in anaplasmosis). Anaplasmosis is lethal in 0.5% of cases, while ehrlichiosis kills 1% to 2% of patients. Cases of these two diseases rose from 875 in 2004 to 5,750 in 2016. Anaplasmosis is most common in New York, New Jersey, New England, Minnesota, and Wisconsin, while ehrlichiosis abounds in the southeastern and south central United States.

Babesiosis is a tickborne disease that mimics malaria, leading to hectic fevers, headache, body aches, anemia, and liver and kidney damage. Cases rose from 1,128 in 2011, the first year it was a reportable disease, to 1,910 in 2016. In the US, it is most common in coastal New England and parts of New York, New Jersey, Wisconsin, and Minnesota.

As if that wasn’t enough to worry about, we are still discovering new infections spread by ticks, including Bourbon virus, which killed a man in Bourbon County, Kansas, in 2014, and Heartland virus, first diagnosed in two Missouri farmers in 2009.
Infections spread by mosquitoes

If infections spread by ticks have increased steadily, infections spread by mosquitoes tend to have more of a waxing and waning pattern. West Nile virus, which first came to the United States in 1999, has flared up multiple times in the continental US since then. Other exotic viruses, such as Zika, dengue, and chikungunya, have caused major outbreaks in Puerto Rico, American Samoa, and the US Virgin Islands, with occasional spillover into the continental US. When I was in high school, I mowed my grandmother’s lawn once a week. Yet every time I arrived, she would have already mowed a small part of the back yard. I always told her she didn’t need to do that, but she insisted. At the time I didn’t understand why she felt compelled to do this every week, but now that I’m inching closer and closer to her age then, I get it: it was something she could do to stay active. She knew that to stave off the effects of a sedentary lifestyle, it is important to move more every day.

The older we get, the more likely we are to lapse into a sedentary lifestyle. In fact, an estimated 67% of older adults report sitting for more than eight hours per day, and only 28% to 34% of adults ages 65 to 74 are physically active, according to the Department of Health and Human Services.

Evelyn O’Neill, manager of outpatient exercise programs at the Harvard-affiliated Hebrew Rehabilitation Center, sees the consequences of too much sitting every day. “Sitting is the new smoking in terms of health risks,” she says. “Lack of movement is perhaps more to blame than anything for a host of health problems.”
The dangers of a sedentary lifestyle

A sedentary life can affect your health in ways you may not realize. For example, prolonged sitting, like spending hours watching television, can increase your chance of developing venous thrombosis (potentially fatal blood clots that form in the deep veins of the legs), according to a study of more than 15,000 people. In fact, people who watched television the most had a 70% greater risk of suffering from venous thrombosis compared with those who never or seldom watched TV.

On the flip side, squeezing in extra movement during the day can have a big impact. For instance, simply standing more can help you lose weight and keep it off, according to a review published in the European Journal of Preventive Cardiology.

Everyday activities that incorporate more walking also can build up your leg muscles, which may help you live longer. Researchers have found that loss of leg muscle strength and mass is associated with slower walking speeds among older adults. Slower speeds are linked to a lower 10-year survival rate for people after age 75.
Simple ways to move more every day

One way to combat the health risks of a sedentary lifestyle is to work small bits of exercise into your daily routine. There are many ways to do this, according to O’Neill. “Even if you aren’t sweating or feeling like you’re working hard, you are still moving your arms and legs, stimulating your muscles, and working your joints,” she says.

Focus on adding just 30 minutes of extra activity into your day, three days a week. “You can break it down into smaller segments, too, like 10 minutes in the morning, afternoon, and evening,” says O’Neill. What can you do during that time? Here are some strategies to help you move more every day:

    Walk for five minutes every two hours.
    Get up and walk around or march in place during TV commercials.
    Do a few sets of heel raises, where you stand on your toes. “Try it while you brush your teeth or make breakfast,” says O’Neill.
    Always stand or walk around when you’re on the phone.
    Do a set or two of push-ups against the kitchen counter. “Your body weight is always a good way to strengthen muscles,” says O’Neill.
    Use soup cans as dumbbells and do 10 to 20 reps of biceps curls.
    Perform up to 10 reps of stand-and-sit exercises, where you rise from a chair without using your arms and then sit down again to complete one rep.

“Also, look for opportunities to do extra movement during regular errands and chores,” says O’Neill. For instance, save some dirty dishes for hand washing, which works your hands and fingers. Wash your car instead of using the drive-through car wash, park farther away at the grocery store (or better yet, walk to the store and carry groceries home, if possible), sweep and mop more, and do simple yard work like weeding, planting pots, and raking.

“There’s a lot you can do to be more active,” says O’Neill. “Exercise doesn’t always have to be intense to be effective, and there are many opportunities in your daily life to sneak in extra movement. You just need to do it.” Alzheimer’s disease and other illnesses that cause dementia are devastating, not only for those affected but also for their friends and family. For most forms of dementia, there is no highly effective treatment. For example, available treatments for Alzheimer’s disease may slow the deterioration a bit, but they don’t reverse the condition. In fact, for most people taking medications for dementia, it may be difficult to know if the treatment is working at all.

Experts predict that dementia will become much more common in the coming years. We badly need a better understanding of the cause of these conditions, as this could lead to better treatments and even preventive measures.
New research links certain medications to dementia risk

A new study raises the possibility that certain medications may contribute to the risk of developing dementia.

The focus of this study was on medications with “anticholinergic” effects. These are drugs that block a chemical messenger called acetylcholine, which affects muscle activity in the digestive and urinary tracts, lungs, and elsewhere in the body. It’s also involved in memory and learning.

Many medications have at least some anticholinergic effects, and it’s estimated that up to half of older adults in the US take one or more of these medications. Common examples include:

    amitriptyline, paroxetine, and bupropion (most commonly taken for depression)
    oxybutynin and tolterodine (taken for an overactive bladder)
    diphenhydramine (a common antihistamine, as found in Benadryl).

In this new study, researchers collected detailed information from more than 300,000 adults ages 65 and older, and compared medication use among those diagnosed with dementia with those who were not. Those who had taken any medication with anticholinergic activity were 11% more likely to be eventually diagnosed with dementia; for those drugs with the most anticholinergic effects, the risk of dementia was 30% greater. The largest impact was found for drugs commonly taken for depression, bladder problems, and Parkinson’s disease; for antihistamines, and some other anticholinergic drugs, no increased risk of dementia was observed.
So should you be worried about your medications and dementia?

These findings are intriguing but they aren’t definitive, and they don’t mean you should stop taking a medication because you’re concerned about developing dementia.

First, this study found that use of certain medications was more common in people later diagnosed with dementia. That doesn’t mean these drugs caused dementia. There are other potential explanations for the findings. For example, some people develop depression during the early phases of dementia. Rather than antidepressants causing dementia, the medication might be prescribed for early symptoms of dementia that has already developed. This is called “confounding by indication” and it’s a potential flaw of studies like this one that attempt to link past medication use with future disease.

Another reason to be cautious about these results is that they cannot be used to estimate the impact of medication use on an individual person’s risk of dementia. This type of study looks at the risk in a large group, but individual factors (such as smoking or being sedentary) may have a much bigger impact on dementia risk.

Still, there is reason to be concerned about the possibility that anticholinergic drugs contribute to the risk of dementia. Acetylcholine is involved in memory and learning, and past research has demonstrated lower levels of acetylcholine in the brains of people with Alzheimer’s disease (the most common cause of dementia in the elderly). In addition, animal studies suggest that anticholinergic drugs may contribute to brain inflammation, a potential contributor to dementia.
What’s next?

Additional research will undoubtedly provide more information about the potential impact of medication use on dementia risk. In the meantime, it’s a good idea to review the medications you take with your doctor before making any changes.

And keep in mind that you may be able to reduce your risk of dementia by not smoking, getting regular exercise, and sticking to a healthy diet (that is rich in fiber, fruits, vegetables, and omega-3 fatty acids). Get your blood pressure and lipids checked regularly, and follow your doctor’s advice about ways to keep them in an optimal range.

The use of any medication comes with potential risks and benefits. This recent research linking certain medications with dementia risk reminds us that the risks of some medications are only uncovered years after their use becomes commonplace. At the end of April, two leaders in health research and medicine made national headlines with their New England Journal of Medicine article “Suicide: A Silent Contributor to Opioid-Overdose Deaths.” Dr. Nora Volkow, the head of the National Institute on Drug Abuse, and Dr. Maria Oquendo, a renowned expert in suicide prevention, brought into mainstream discussion a topic that many of us on the frontlines of clinical care have been advocating for years: opioid-related suicide is real, and a preventable part of the nation’s drug overdose epidemic.

The reluctance to address opioid-related suicide has deep roots in stigma and denial that self-injury deaths are preventable, whether substance-related or suicide, or both.

Why do we not talk about suicide as part of the opioid epidemic?

First, suicide is highly stigmatized. In spite of a consistent 20-year increase in the rate of suicide deaths that parallels drug overdose deaths — both of which include alarming increases in premature death of our nation’s youth — our country continues to fear suicide as an “unthinkable” act of despair. Suicide is alternately viewed as “selfish,” “self-serving,” or “just plain crazy.” When Dr. Anne Case and Dr. Angus Deaton, expert economists at Princeton University, drew attention to the devastating social and economic impact of “deaths of despair” in their 2017 report on “Mortality and Morbidity in the 21st Century,” it became much harder to ignore that substance-related deaths and suicides are associated with personal losses: loss of opportunity, employment, security, social connection, and ultimately loss of a sense that one’s life is valuable.

Misuse of opioids and opioid use disorder are similarly stigmatized, but in a different direction: as “irresponsible” behavior by an individual. In actuality, opioid misuse is significantly associated with subjective distress and suicidal ideation, while opioid use disorder is a highly treatable medical illness. The misconception that opioid misusers are simply misbehaving is responsible for a nihilistic (and failing) approach to the epidemic: “Just let them die.” A closer look at both the opioid and suicide epidemics may reflect more alarmingly on society itself, raising questions such as: why are so many jumping into an opioid escape porthole?

Second, hyper-specialization in our health care systems breeds silos of treatment rather than comprehensive care. Pain patients are treated in medicine, suicidal patients in psychiatry, and substance use disorders in specialized addiction treatment centers. This artificial fragmentation of care ignores common co-occurrence of these disorders, as well as common risk factors such as poverty, depression, anxiety, and trauma. What’s worse is that fragmentation affects research funding, public health surveillance, and reporting of data results and trends. The result is that media reports become likewise fragmented, with emphasis on pain, substance use, and suicide considered separately. This feeds back as a bias in health care provision, and public education and expectation regarding health services. Opportunities for prevention and comprehensive care are lost.

Third, and related to the first two points, behavioral health care training is inadequate in all disciplines, reinforcing these silos. By the time a person is an overdose survivor, they are typically in the very advanced stages of a mental health disorder, and many losses must be repaired along with stabilizing their medical and psychological health. Our nation is poorly equipped to meet self-injury epidemics head-on, and the necessary infrastructure for care is lacking. It is easier to disseminate naloxone rescue — the defibrillator equivalent for opioid overdose (intentional or not) — than it is to treat high-risk individuals with multiple social problems influencing recovery.

How can we do better screening for and preventing suicide and substance misuse?

The work of rebuilding family and social support networks, employability, and personal safety is critical to full recovery, but requires robust community social service supports that are not always readily accessible. To get such supports funded requires a broad understanding of suicidality and substance use disorder as treatable, preventable illnesses. We need to focus on prevention efforts that detect mental health problems when they first appear — often in childhood, and especially in communities with generations of suicide and overdose death losses.

Youth rates of anxiety, depression, and suicide are increasing, and substance use has always been companion to these conditions. Universal mental health screening in pediatrics and school-based platforms would improve early detection and intervention, as would family education on these sensitive topics. A lifelong prevention approach of detecting psychological distress and trauma exposure at onset, and providing immediate evidence-based treatment interventions, could provide the nation with a resilience platform for averting epidemics related to stigmatized mental health and substance use disorders.

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