Cynthia Bjorlie
Cynthia Bjorlie MD
Executive Director
Cynthia is board certified in internal medicine and was a primary care doctor for many years before starting Adult Foster Care North Shore in 2001.

The Director's Corner

Sharon is a friend who had a stroke. I had not seen her since the stroke when we went to dinner recently. Her conversation was difficult.

"I'll have the haggrop," she said. "I mean haggrop, no hagroop." She knew that she wanted the haddock, but she couldn't get the word out. She has an expressive aphasia.

Aphasia (from the Greek for speechlessness) is a language disorder usually the result of a stroke or brain injury.

Language allows the communications of elaborate thoughts by linking the thoughts to words that we have learned. A person with aphasia can understand the thought but has trouble expressing it. In Sharon's case, she knew that her word was incorrect but was unable to retrieve the word she wanted. She was unable to produce the correct language.

Sharon's intelligence was fine, and her speech was clear, but the language connection in her brain was damaged. She was frustrated and self-concious.

The brain consists of about 20 billion neurons like electrical connections. Aphasia is the result of a short circuit in the brain's language center.

Few people with significant aphasia regain fulll communication levels, but siginificant progress is quite possible. Aphasic people can relearn language. The process can be long.

How can you help an aphasic person cope and make progress? Supportive measures include assuring the aphasic person that intelligence is not the issue and that language can be regained with time. Understand that hearing is usually not affected, so talking louder does not help. Hre are some tips from the Mayo Clinic:

  • Keep conversations one -on-one initially
  • Allow the person time to talk
  • Don't finish sentences (although you may want to reach down and pull out a word)
  • Involve the aphasic person in conversations as much as possible
  • Use papers and pencils for diagrams and shortcuts
  • Check for comprehension or summarize what has been discussed

Other practical coping mechanisms exist. The National Aphasia Association and the American Stroke Association have information. Speech- Language pathologists are trained in aphasia treatment. And aphasia support groups can provide a safe environment in which to vent frustrations and practice language.

Do you have trouble sleeping at night? If so, you are part of a large crowd. For most people, sleep issues are transient and not serious. For others, lack of sleep can lead to big problems such as daytime sleepiness, impaired functioning, depression, and accidents.

The most common symptom of insomnia is difficulty maintaining sleep (i.e. waking and being unable to return to sleep). The issue is more common in women than in men and also in people who work irregular shifts. Insomnia can be a temporary condition related to external events such as illness or loss of a loved one. Most everyone has trouble sleeping sometime, but for others, the condition is chronic and very troublesome. Sleep studies are not needed to diagnose insomnia.

Experts recommend good "sleep hygiene" as a starting point for treating insomnia:

  • Attempt to sleep when sleepy, and get out of bed when awake
  • Use the bed only for sleeping and sexual activity. Do not use the bed as a place to watch TV
  • Limit caffeine and alcohol
  • Keep bedroom dark and quiet
  • Avoid daytime napping
  • Increase exercise (not close to bedtime)

Also keep expectations about sleep time reasonable. As we age, we need less sleep. Sleeping 6 hours per night may be enough.

If the above measures do not work, the next steps would be behavioral therapy (anywhere from 3 to 8 sessions with an experienced sleep therapist). There is also internet-based cognitive behavioral therapy that has shown promising results in studies.

And then, of course, there are sleeping pills, many of which are habit forming and therefore not a first choice for therapy.

Ask your doctor or your AFC team for direction if you want. And sweet dreams.........

Pneumonia

Pneumonia is a respiratory infection that descends into the lung. Pneumonia can be caused by many different bugs including bacteria, viruses, and fungi. Some pneumonias are treatable with antibiotics, and some are treated with supportive measures only such as oxygen and fluids.

Our mouths and noses have common bacteria and viruses that may cause a problem if they are inhaled. The cough is a protective mechanism that helps keep our lungs bug-free. If a person is unable to cough effectively, pneumonia may result. For example, a person at the end stages of a chronic disease may be too weak to cough.

Before the days of anitbiotics and vaccines, they used to call pneumonia "The old man's friend." Pneumonia could mean a quick and relatively painless death.

Our available treatment and preventive measures include the pneumonia vaccine. The vaccine offers protection against the commonest bacterial type of pneumonia. It does not protect against other types. Unlike the flu vaccine, you do not need to get the pneumonia vaccine every year. One vaccination is enough.

The symptoms of pneumonia are fever, cough, and shortness of breath. the lung is made up of millions of tiny air spaces called alveoli. The alveoli are like little balloons that inflate and deflate with each breath. As you breathe in, the oxygen passes through the wall of the balloon into the bloodstream. With pneumonia, some of the alveoli become clogged up with fluid and pus, so the oxygen cannot get into the bloodstream.

In a person with a healthy immune system, the white blood cells rush to the site of inflammation and attack the offending bugs. People with immune systems that are not working correctly (for example, after chemotherapy or with diseases such as Acquired Immunodeficiency Syndrome [AIDS]), the white blood cells are low and less effective. People with weakened immune systems are much more susceptible to any type of infection and would be well advised to get vaccinated for protection.

2015 Q3 Newsletters

September Director's Corner

Suicide

Last month my family experienced a death by suicide. It was not a great surprise as she had attempted a few months before and was on daily monitored medication and regular psychiatric care. It was still a tradegy. Her son had taken a walk with her that day, and nothing had seemed unusual. Should we have seen something? How do you know?

In 2014 in the United States, there were more than 41 thousand reported suicides. Most were men, and many were "at risk." Although women attempted suicide four times more often than men, men are "successful" at it three times more often than women. The highest rate of suicide is men over age 85.

What puts a person at risk for suicide? Mental illness especially depresion, is a major risk factor. Others include death of a loved one, major life trauma (e.g. job loss, marriage break-up, school failure), chronic isolation, sexual identity crisi, family history of suicide, and accessibility to means (such as guns or drugs). Substance abuse (including alcohol) also increases risk. Protective factors are social and family connectedness.

The symptoms of suicidal thoughts may not be obvious. Talking about it ("I wish I were dead" or "I wish I'd never been born") is an indication. Other behaviors that may cause concern are withdrawal from social activity, change in regular routine (e.g. eating or sleeping), giving away belongings or getting affairs in order, and obtaining lethal means such as purchasing a gun or saving up medications.

How do you find out if someone is at risk for suicide? Ask. In the medical profession we are taught to ask non-judgemental, direct questions such as "Are you thinking of harming yourself?" The highest priority in a situation of potential suicide is assuring safety. If a person has thought of self-harm and has a specific plan, that person is considered to be at high risk. In other words, someone who says "I want to kill myself, and I plan to use the pills that I have been saving up" is at high risk. Help should be sought immediately. Hospitalization and treatment are indicated.

Does asking the questions plant the idea? Many studies have shown that the answer is "no." A person will not become suicidal because the idea is discussed.

Treatments are vaired. Medications such as anti-depressants and anti-psychotics are used and may alleviate suicidal thoughts. Behavioral therapy can also be effective. In cases of treatment resistant depression or severe depression with psychotic manifestations, electroconvulsive therapy (ECT)(other wise known as "shock treatments") may be considered. With ECT, a patient receives general anesthesia and then a small electric current is delivered to the brain.

For survivors of a loved one's death, pain is there. In the case of death by suicide there are often feelings of guilt as well. The term "death by suicide" is preferred to "committed suicide" which sounds somehow harsher.

The National Suicide Prevention hotline is 800-273-TALK (800-273-8255). If you have questions or are concerned about someone you know, call and ask for direction.

Dementia

When dementia comes on gradually, there is always a defining moment when loved ones can no longer ignore the problem. One mother had been more and more forgetful, and the family joked about it and worried privately until the day that the mother put a roast on the table uncooked. Another mother put all the groceries away, and the family found the ice cream in a cupboard with the plates.

Dementia is, of course, no laughing matter. It is a progressive, incurable disease, and it affects millions. Median survival after diagnosis ranges from 3 to 12 years. The final stages are often filled with difficult and expensive decisions.

The National Hospice Organization list seven stages of dementia, all the way from forgetfulness and decreased job functioning up to inability to walk, talk and control bodily waste. The last stages are often accompanied by medical issues such as bedsores, infections, and, most commonly, eating problems.

It was interesting to read in last week's New England Journal of Medicine that eating problems are the most common complication of advanced dementia and that of all the things that have been tried, the one that works best is hand feeding. Hand feeding is highly recommended over tube feeding. While tube feeding provides a definite calorie intake and is more efficient, it does not improve survival, nutritional status, or prevention of aspiration. Hand feeding is time consuming, but it allows the patient to enjoy tasting food and to interact with caregivers during meals.

The National Hospice Organization and the New England Journal of Medicine also recommend that decisions about medical care should be guided by the goals of care. Promoting comfort may be more important than prolonging life. The decisions are difficult for loved ones and may be guided by the patients previously stated wishes. Dad may have said, "I never want to be a burden. Just let me go in peace when my time comes," and his wishes should be considered in time of acute clinical deterioration. The final year of life is often a series of worsening medical issues resulting from immobility and inability to control basic functions. In the final stages, an individual with dementia cannot roll over in bed or cough effectively to clear secretions. Hence, bedsores, and pneumonia develop.

I have told my loved ones that when my time comes, please give me morphine (accompanied by laxatives), and let me go. I think they get it. On the other hand, I also said that I wanted someone there holding my hand, and my husband replied that he would try to find someone. He was kidding (I hope).

July Director's Corner

Glaucoma

Glaucoma refers to a group of conditions that affect the eye. The eye consists of the optic nerve that is a bundle of more than 1 million nerve fibers that travel from the brain to the back of the eye. The eyeball itself is full of fluid that is continually bathing the eye tissue and then draining and replenishing. Glaucoma usually occurs when the eye fluid does not drain properly, and the pressure builds up. The fluid presses on the optic nerve causing gradual harm.

Glaucoma has been called "The silent thief of sight." In its most common form, (open angle glaucoma) the condition has no symptoms, and it progresses very gradually. There may be vision loss that occurs so gradually that people do not notice the loss. A rarer form of glaucoma, (angle closure glaucoma) presents with the sudden onset of eye pain and redness, dilated pupil, and vomitting. This rarer form is a medical emergency. There is no "cure" for glaucoma but there is effective treatment that can prevent progression of the vision loss.

Checking for glaucoma is fairly easy and painless. The exam consists of visual testing and a measure of the pressure inside the eye. At my optician's office, the pressure is measured by a computer as I look at a picture in a machine.

Everyone is at risk for glaucoma as we age. African Americans, Hispanics, and people with family history of glaucoma are at higher risk. Glaucoma affects 1 out of 200 people over age 50 and 1 out of 10 people over age 80.

The most common treatment of glaucoma is eye drops that must be used regularly. The drops reduce pressure in the eye. Laser treatments are sometimes done, and rarely a surgical procedure is recommended if more conservative measures do not work.

The American Academy of Ophthalmology recommends regular checks for glaucoma every 3-5 years after age 40 and more often if one is at higher risk.

June Director's Corner

Shingles

Herpes Varicella Zoster is a virus that causes Chicken Pox and can later reactivate as a painful skin rash known as "shingles." Those of us (including me) who had chicken pox as children are at increased risk for shingles as we age. The rash is bad enough, and it can also cause a painful condition "post herpetic neuralgia" that can last for years. Both can be prevented. There is a vaccine.

Herpes Zoster Vaccine ("Zostavax") is a live vaccine that is given once and is recommended for people over age 60. Most insurances cover the cost of the vaccine.

This vaccine is often not stocked in a doctor's office, so you must ask for it. You may be given a prescription to fill and take back to the doctor for the injection.

Chicken Pox used to be a regular childhood infection that we endured. In 1995 children in the United States began to receive a vaccination to prevent Chicken Pox, so it is rarely seen in its accute form any more. Those of us who had the real thing harbor the virus in our central nervous system forever, and, as our immune defenses decline, it may blossom forth as the ugly and painful clusters of blisters, shingles. It may occur anywhere on the body, and it usually looks like a single strip of blisters on either the right or left side without crossing the midline.

If you have had shingles, you know that you don't want it again. If you have had shingles, you may prevent another occurence with the Zostavax vaccine.

The vaccine for adults is safe unless you have a condition that has weakened your immune system (e.g. recent chemotherapy, active AIDS, leukemia). People over age 84 are at 50% risk of getting shingles.