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                                    Sleep   copyright 2010 Timewise Medical

                Sleep. Such a simple concept. Babies do it. Dogs do it. So simple. So easy.

                Until you can’t.

                Sleep is like money. If you have it, you’re not concerned. If you lack it, it’s a problem.

                If you haven’t drifted off to sleep reading this blog yet, perhaps you have insomnia. Insomnia is but one of many sleep disorders, among which are narcolepsy, periodic limb movements, myoclonus, cataplexy, sleep apnea in its many forms, restless legs syndrome, jet lag, sleepwalking, sleep talking, sleep eating,  night terrors, and others. These so-called “parasomnias” are beyond the scope of this essay.

                So what is a person to do if they have simple, ordinary, uncomplicated, garden-variety insomnia?

                First of all, make sure that your lifestyle takes advantage of your natural biological rhythms. By that I mean, if you are out of the blocks at 5:00 a.m and run out of gas in the afternoon,  do not take a 3 PM to 11 PM job. The reverse is also true. If your engine doesn’t get started until noon, but you can work or party ‘til the wee hours, don’t sign up for the 6 AM shift. Find out what your natural rhythms are (it’s not that hard) and adapt your lifestyle to it.    

If your work schedule jibes with your biological rhythms and you still can’t sleep (or can’t sleep well) assess your daytime energy level. If your daytime energy level is average or above, chances are high you are getting enough sleep. There is nothing magic about eight hours. You need as much as you need. Only if you experience chronic and excessive daytime fatigue is insomnia a problem.  

                So. Here you are: a morning person, have a 7 AM to 3 PM job, and have trouble falling asleep, staying asleep, and are awake for two hours before the alarm goes off. What gives?

                Take a closer look at your lifestyle. Too much caffeine? Still smoking? Drink too much? Exercise too little? I don’t mean to preach, but if you don’t sleep well, are tired during the day, put down a six pack of Dew per day, smoke, and vigorously refrain from anything vigorous, what do you expect?

                Connect the dots, people!  Ditch the cigarettes. Alcohol on weekends only (and even then not to excess). Stop caffeine after 1 PM, and for Pete’s sake get in a workout at least five days per week. I would much rather you change your lifestyle than take a pill. In fact, I will insist on it.

                So. Here you are: One cup of coffee with breakfast, two drivetime cigarettes, one glass of wine with Saturday dinner, and a 4 mile walk every day. You still can’t sleep and are still tired. What gives?

                Are your medications timed properly? Decongestants, Wellbutrin, ADD drugs, Provigil, and others are notorious for causing insomnia. Discuss with your doctor your medications, their dose, and timing.

                So. Here you are:  Impeccable lifestyle. No meds. Living on food, water, and fresh air. Still can’t sleep and  still tired. What now?

                Is there any stress in your life? Statistics are difficult to come by, but along with a crummy lifestyle, stress is on the short list of the causes of insomnia. If it is short-term stress, the insomnia is likely limited to the duration of the stress — whatever it may be.

                Long-term stress is an entirely different animal.  If the long-term stress comes with little or no control over the situation, that makes things doubly difficult. It is well known that the less control, the more the anxiety; the more control,  the less the anxiety.

                Thousands of books have been written regarding insomnia, stress management, anxiety, etc. If you find a technique in one of these books, use it. There are dozens of such tricks.

                So. Now we come to sleeping pills.

                Sleeping pills are there for a reason: to help you sleep (DUH!). While it is not a perfect solution, it IS a solution. The sleep quality may not precisely mimic the refreshing REM dream filled sleep, but it is SOME sleep, nonetheless. For short-term use, I have no problems with a few sleeping pills. Among the situations for which I prescribe sleeping pills are: 1. Jet lag 2. Sunday night insomnia (those who get keyed up thinking about another week of work — more common than you may think). 3. Grief reaction (loss of a loved one), and 4. Temporary change of circumstances which are significantly disruptive (change of job, residence, salary, etc.)

                So. Here you are: Healthy lifestyle, stable circumstances, on no meds, no worries, doing everything right, and still have poor quality sleep and daytime fatigue. What do you do now?

                Unfortunately, there are some people who fall into this last category. For these individuals, I will work with them to develop a program of medication which helps. The medication should be effective (DUH!), Free of side effects (another DUH), and cheap (this one may be difficult). There are a lot of choices out there and every patient merits an individualized program.

                Insomnia? It’s nothing to lose sleep over.

Vitamin D.

copyright timewise medical 2010

                Are you vitamin D deficient? If you live in Minnesota, chances are good that you are. How do you know? Unless the deficiency is severe enough to cause rickets (I have seen one case in 30 years) you will notice no symptoms. Vitamin D deficiency is virtually asymptomatic.

                The only way to tell if you are vitamin D deficient or not is to get a blood test. A 25-OH  vitamin D level blood test costs $89. In many ways, it is a more important test than a cholesterol level. Vitamin D. deficiency has been associated with many diseases including cancer and infections.

                Vitamin D is a hormone, not a vitamin. It is intimately associated with metabolism in bones. Yes, bones are living things. They are constantly remodeling. They are not just sticks upon which the muscles hang. Vitamin D helps control absorption and metabolism of calcium and phosphorus and heavily influences parathyroid (another hormone) function as well. Research also shows that vitamin D is important in diabetes, multiple sclerosis and other autoimmune diseases, some cancers, asthma in children, high blood pressure, heart disease, cognitive impairment, chronic fatigue, pain, and depression.

                The present US recommended daily allowance (RDA) of vitamin D is 400 IU. Experts agree that this is far too low. You would need to drink a quart of vitamin D fortified milk in order to get 400 IU. Unless you space it out through the day, a quart of milk can be a nauseating experience. In the winter months, the sun is too low on the horizon to generate much vitamin D in your skin. In the summer months however, you can generate as much as 10,000 IU per day of vitamin D. Looking at recommendations from a variety of sources, there seems to be consensus that about 2000 IU per day of vitamin D is the proper adult dose.

                Production of vitamin D in the skin is reduced by age, sunscreen, natural skin pigment, and changing of the seasons. Certain medications can reduce vitamin D absorption in the gut.

                Some experts say that the level of 50 nmol/L (20ng/L) or higher is adequate. Others recommend the level of 80nmol/L (32ng/L).  Supplementation is straightforward. I routinely put patients on 50,000 IU per week for 12 weeks. This almost always returns the level to the normal range. If you want to supplement at the dose of, say, 4000 IU per day for three months and then check the level, that might save you some money on a second blood test.

                Toxicity is almost unheard of. If it occurs, it is due to vitamin D hypersensitivity syndrome and not due to too much supplementation.

                I’m sure that in the coming months you will hear more and more about the importance of vitamin D in health and disease.

                                                      FATIGUE

                                            James R. Eelkema, MD

                                   Copyright Timewise Medical 2009

                                   “Doctor, I’m tired. Can you help me?”

         I wish I had a nickel for each patient who has asked me that question.

               Fatigue is a normal part of living but it is NOT a normal part of aging.  I see lots of senior citizens, and while some do complain of fatigue, the majority describe their energy level as average or above.

                First of all, let’s define our terms. Normal fatigue is a feeling of weariness or tiredness which, after a period of rest, resolves. Fatigue is different from  sleepiness, dizziness, lack of endurance or stamina, weakness, or lack of motivation. People’s energy levels fluctuate throughout the day. You probably have noticed this yourself. At times, you have plenty of energy and are moving, thinking, talking, and getting things done. There are also spots in your day in which you are mentally dull, physically slow, sluggish, yawning, and less than 100% productive. Let me stress that this variation in energy level throughout the day is normal.

                Just for fun, keep a diary of your “tired and yawning” times. Start when you wake up and end when your head hits the pillow. Write down the time of day and the number of yawns you experience. Do “the yawns”  hit you every 90 minutes? That seems to be a common  pattern.

                Another pattern is the well known circadian rhythm. Humans follow an  (approximately) 24-hour pattern with a hard wired brain circuit for daytime activity and nighttime sleep. Those who disrupt this pattern with evening and late night activities tend to be chronically tired.

               Regarding sleep, there is nothing magic in eight hours, and there are no special rewards for getting all the sleep you need in a single block of time. Some people need more than eight hours, some less. If you need a nap or two during the day to balance  your sleep at night, fine. In terms of how much sleep you need, the short answer is:  You need as much as you need in order to feel well rested.  I happen to think that the people of Spain and Latin America have the right idea when it comes to sleep. They take a siesta every afternoon and will then have the energy to work or play until late evening.

                 I recall one fellow in his 80s whose wife sent him in for excess fatigue. In talking with this gentleman, I learned that  he would get up at 5 AM, go to the club for a two-hour workout, shower, dress, return home, have breakfast, and then take a two-hour nap. After the nap he would go to the office and put in a full day of work. His evenings were free and he would retire about 10 PM. The patient didn’t think there was an issue with the nap. I didn’t think so either,  but I did a physical exam and some basic blood tests in order to reassure his wife that everything was okay.

                For those patients who believe that they have  serious or troubling fatigue, an evaluation is required. This starts with a thorough history and a review of organ systems and their functioning. This is followed by a careful and directed physical exam. Blood tests and imaging studies may be ordered based on the history and physical. In virtually all cases, I can come up with a reason for the patients’ excess fatigue.

                There must be well over 1000 explanations for excess fatigue. Without boring you with a laundry list of clinical diagnoses, most cases fall into a handful of categories:

                Lifestyle: Look at your diet: too much junk food? Not enough fruits and vegetables? Too little iron rich food? Maybe you smoke too much, drink too much, or exercise too little. Just like a car, if you don’t take care of your body, it won’t perform properly.

                Medications:  Are you overmedicated? Did your doctor give you one drug to counteract the side effects of another? Is the dose right? Ask your doctor to review your medications one by one. There should be a reason — a good reason — for every medicine. If it is not the right medicine, at the right dose, by the right route, at the right time, for the right reason, it should be changed or discontinued  by your doctor.  I see many – frankly too many – overmedicated patients.

                Sleep apnea:  Do you snore? Do you stop breathing at night? Are you overweight and have high blood pressure? Excessive daytime sleepiness and fatigue is the hallmark of obstructive sleep apnea syndrome (OSAS). A sleep study can both confirm the diagnosis and indicate the  need for treatment which for most patients is a  CPAP (continuous positive airway pressure) mask. For those patients with OSAS who can get used to the mask, the difference in their energy levels with successful  treatment is dramatic.

                Depression:  Depression  is a real disease whose physiologic basis is a disturbance of brain chemistry. It is not a character flaw and people with depression can’t  just “ snap out of it”. The symptoms are extremely varied, but almost always there is a decline in one’s energy level. Any good evaluation for fatigue must address the issue of depression.

                Illness. Illness, unfortunately, is among the many causes of fatigue. However, it is rare for an illness to present as pure fatigue. Almost always, there are other symptoms such as fever, weight loss, pain, and disturbance of organ function. If you think your fatigue is due to a specific syndrome or disease, let your doctor know so he or she can specifically address your concerns.

                I take pride in my evaluation of a patient with fatigue. Sometimes the answer is obvious based on history and physical alone. Sometimes testing  is necessary. If you are more tired than you think you should be, look at your lifestyle first. If your lifestyle is healthy, you may be a candidate for an evaluation for your excess fatigue.

                                                PUBLIC OPTION

                                      copyright Timewise Medical 2009

                Congress is currently kicking around the so-called public option. What would this look like? Let me take you through a hypothetical public option insurance policy. First of all, someone must write the policy. This would include definitions, eligibility requirements, what is covered and what is not, the drug formulary, claim filing information, and a million other details. The powers that be could certainly compose this de novo, but why reinvent the wheel? There are hundreds, if not thousands, of such health insurance policies already written, having been fine tuned over decades. Congress could simply take a policy, keep what they like, throw out what they don’t like, and tweak and edit the rest. If it looks markedly different from existing policies, people will be reluctant to buy it for fear of the unknown. If it looks substantially the same, what’s the point?

                                Next, Congress must sell the policy to policy holders. How is that to be done? Door-to-door? Direct mailing? Through the Internet? Offered along with other policies at places of business? Any salesperson will tell you that it is extremely difficult to garner market share unless one has a superior product or service. How will the public option standout from all the other background noise of existing policies? It must deliver either superior service, be available at a lower price, or both. If the plan offers more benefits, these benefits must be paid for. If substantially similar benefits are offered at a lower price, someone must pay for the difference. Does anyone doubt that the taxpayer will bear  these burdens?  So much for a level playing field.

                After signing up policy holders, the public option must sign up providers, hospitals, allied health professionals, and drug companies to participate in the plan. Most insurance companies, and Medicare in particular, have already squeezed all they can out of doctors and hospitals. If reimbursement drops much further, doctors and hospitals may drop out of the plan. As providers drop out, this will shift the burden to providers still in the plan. Waiting lines will form. 

                Once these parts of the puzzle are in place, a system for claims processing must be established. Right now, there is a small army of clerks who do nothing but process health insurance reimbursement claims all day long. Does Congress mean to create a new system or to use existing clerks? Again, why reinvent the wheel?

                Even if Congress is able to get all these systems up and running, the logical conclusion is obvious.  Existing policies will be abandoned wholesale. The people will wait until they are sick and then obtained a must issue policy. Premium revenue will be either nonexistent, or fall far short of forecasts. Traditional insurance companies will be forced out of business. The remaining pool of sick people will file claims for services far in excess of any premium revenue obtained. In order for the public option  to “stay in business”, it must either raise premiums,  cut services, or supplement the program with taxpayer dollars.

                Raising premiums will cause howls of protest from the policyholders. Service cuts will engender a similar temper tantrum. The government dare not cut reimbursements to doctors and hospitals, or they will drop out of the program further increasing the burden on those remaining. Supplementing the program with taxpayer dollars will, in effect, cause the public option, by default, to be what is essentially socialized medicine with one universal payor: the government.

                One more word about hospitals and doctors dropping out of the public option: if this were to happen in large numbers, Congress could, in its infinite wisdom, pass a law requiring doctors to abide by the terms of the public option. In other words, they must treat the patient for the price the government decrees. This is involuntary servitude. If you don’t like that word, try slavery. Is this the hope and change we voted for?

                                                         Influenza

                                             copyright  2009 Timewise Medical

                Few topics have generated as many questions or have sparked more controversy than this year’s influenza.  Everyone knows about seasonal influenza, which seems to start in about November, peaks in January, and wanes by April. The H1N1 virus presently circulating is not following that pattern. Both the seasonal virus and the new H1N1 virus are regular flu viruses. They differ only in certain antigens. Both cause the same illness which comes on abruptly, and is characterized by high fever, headache, muscle aches, cough, and debilitating fatigue.. Gastrointestinal symptoms are not a prominent part of this respiratory illness.

                One way to prevent influenza is to not be exposed to the influenza. Unless you are a hermit, this is not practical. Short of living on a desert island, avoid people with the flu, wash your hands frequently, do not fall behind on sleep, and follow a healthy well-balanced diet.

                Another way to avoid the flu is to get a vaccination. Two types are available: the shot, and the nasal spray. The nasal spray is a live vaccine indicated for her targeted populations ages 2 to 49 years. The shots is a killed vaccine and cannot give you the flu.

                For the seasonal flu shot, the targeted populations are: those over 65 years of age, adults with chronic diseases such as diabetes, heart disease, pulmonary disease, kidney failure or liver problems. Other targeted groups are nursing home residents, children ages six months to 18 years on long-term aspirin therapy, and pregnant women in their third trimester.

                The targeted populations for the H1N1 shot are: pregnant women, people who care for children ages six months of age or less, health-care workers, people ages six months to 24 years, and individuals ages 25 to 64 who have a chronic disease. Because of a shortage of this vaccine, not everyone can be vaccinated. Clinics are prioritizing the shot to those in the groups with the highest risk.

                If you are unlucky enough to get the flu, treatment is available. Relenza is an inhaled medicine which can shorten the course by about a day. Tamiflu is a capsule taken twice a day for five days which will also shorten the illness by about a day. Other treatment measures include rest, Tylenol, pushing fluids, and tincture of time. Most cases of influenza resolve in less than a week.

                The nasal spray contains no mercury. The shot contains thimersol, which is a preservative of containing small amounts of mercury. Most experts consider this amount of mercury to be free of any long-term harm. Certainly the disease is harmful in terms of both symptoms and lost productivity. Influenza can also be fatal. Records show approximately 36,000 fatalities each year which can be attributed to the seasonal flu. So far this year, approximately 4000 deaths have been attributed to the H1N1 virus.

                The average person will not be able to get an H1N1 shot unless they are a member of a targeted group, and their clinic has a supply of the vaccine. The regular seasonal flu shot supply a seems plentiful. There is still plenty of time to get a seasonal flu shot and protect yourself from influenza. Good luck.

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