Insomnia!!!

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teddy-is-sleeping-vector-583552Hi, it’s Dr. Louella again. Would you imagine that after that talk about the basics of health I haven’t yet gotten enough sleep? While people looked forward to this, another long weekend in Trinidad, I didn’t. I knew that preparing for the Indian dance on Friday would take all day. Today I’m opening my office and then am part of a community-based clinic. I must attend a wake tonight then church tomorrow and event planning after. Breathe doc!

But there was a time, not so very long ago, that I wanted this very sleep but could not get it. I experienced insomnia for the first time in my life the end of 2013 into 2014. Now I know this is common among patients, but when you yourself suffer with something you sit up.

And my doc tried everything. He was a psychiatrist so I trusted his judgment and tried very much not to practice self-medicating. But I knew the medical options were limited.

First he thought the air-conditioning in my bedroom was too cold. If you research it you will see that environmental factors have a lot to do with sleep. You need a dark room. They advise you turn off your TV, computer, cell phone, anything with a lighted screen, about an hour before going to bed.

They repeatedly say the bed is only for sleep and sex. But we are all guilty of lazing around, reading, talking, using the computer, watching TV etc. on our beds.

Then what about the noise factor? Our bedrooms should be quiet except for some soothing or isochronic music (did not work for me though; isochronic tones got me tense).

Now these things never mattered to me before. I used my computer, watched TV and chat on my bed. Then next moment I was asleep. It is when you begin to have problems that you need to start examining your environment.

Is your partner’s snoring affecting you. Let him visit an ENT doctor or research solutions on the net. Maybe it’s frequent awakenings from a crying child. Can no one babysit for a couple of nights for you to get back your rhythm? At the other extreme we have the elderly who may need mild sedation at night to prevent them from disturbing the household.

I turned off my air condition and used the fan and still couldn’t sleep on my own. Then I admitted to my doctor my frequent trips to the bathroom. That obviously disturbed my sleep. He wanted me to do less water guzzling (or as they say abstain from fluids for an hour or two before bedtime). When I said it was small amounts of urine he said I needed to learn to hold it, to retrain my bladder.

Good advice. But it didn’t work. I still awoke frequently and couldn’t get back to sleep. This is when I started doing my own research as to what else was out there. I had been using melatonin, which is supposed to be a natural sleep aid, but it just wasn’t kicking in.

I focused on trying to get myself to relax prior to bed. Against my will I had a warm cup of milk, I did not exercise too close to bedtime, I tried mild meditation, and progressive relaxation. As I said, the isochronic tones were not for me but my radio chimed love music throughout the night.

I tried to have a routine time to go to bed and to wake up. I saw where it was said that you ought to limit daytime naps to 30 min and then not after 3 pm. Now, mind you, I have no qualms in telling this to my patients. Because that’s what ‘they say’. But to me it was a bunch of hogwash since I have been taking afternoon naps for years and sleeping perfectly.

In this present scenario, when I missed a nap I slept no better at night. At least if I could get an hour or two under my belt during the day I would feel better.

Of course I know someone who sleeps a lot during the day may having difficulty sleeping at night. I didn’t sleep all day. And the elderly with little physical activity or who sleep all day, may be also unable to sleep at night.

Another rule that I broke is where they say if you haven’t fallen asleep after half hour, get out the bed. Go do something. When you’re sleepy again come back. Sounds good. But when I’m battling with my bed to sleep I’m down for the long-haul. (Maybe that’s why I usually lost the battle).

I feel for my patients a lot more in this area of insomnia after having been through this myself. It was terrible!!! You “awake” on mornings totally unrested, eyes heavy and burning, head groggy. And of course you have to go to work that day.

I only got a good night’s rest when I used the benzodiazepines (e.g. Valium, Ativan) my doctor prescribed. He kept trying to reset my clock with them and started and stopped them. He was particularly concerned about not aggravating another condition I have, that is triggered by lack of sleep.

But we all know benzodiazepines are addictive. You simply cannot take them for long. By now I thought I had figured out what caused my insomnia…anxiety. I never realized anxiety could cause such horrible insomnia. I was getting insights for my patients all the time. But I couldn’t shake the anxiety.

I had always thought that patients often had trouble sleeping because of their thoughts at night. But I had no self-defeating thoughts at night (except “I can’t sleep; I’m gonna die”). I learnt that it was also the daytime thoughts, fears, worries, ruminations that play on our subconscious and prevent us from sleeping at night.

My doctor next prescribed antipsychotics. I went along with it because things were not improving. Within three days I had horrible side effects so I stopped. I realized I had reached the end of the line. This anxiety thing had to stop. I willed my mind to be calm and trust in the Lord I believe in.

In two days, I was sleeping naturally again. It had to happen. I came from a history of beautiful sleep and I was not now going to be condemned to a life of insomnia.

I’ve been sleeping well since, making it two and a half months. I’m still working on the anxiety and have insights to share on this.

I know that a lot, a lot of people have problems to sleep. Please try some of these methods I mentioned above, I can always clarify, and above all, be anxious for nothing (KJV).

Dr. Louella. Over and out!

The Very Basic Rules of Health

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474657739Hi folks. Dr. Louella here. Did you miss me? I wasn’t feeling too well these past couple days. Took two days off work. When I was younger, people, usually the younger ones, would say, “You’re a doctor and you’re sick!” and look in amazement. I would simply explain to them that we are human beings like everyone else and the same imperfect medicine we apply to them applies to us too.

But it’s worse when you’re a doctor. I recently read an article from the UK which expressed the same things I experience. You’re both doctor and patient, there’s no one to turn to, you’re not objective when it comes to yourself, you shun any unpleasant treatment.

So why was I not well? It comes from breaking the basic rules of health, as I am going to discuss with you, and indeed I have discussed with many of my patients. Let’s put aside all the fancy medicine for a moment, all the gadgets and the tests, the antibiotics, the vitamins and the painkillers.

The basic rules of health are to eat well, drink plenty water, sleep well, be active, exercise and don’t be stressed.

So which one did I break? … not enough rest. I am frequently guilty of that. Caused me to faint at a bank. Also think I strained my abdominal muscles lifting some very heavy books. I’m still in pain.

Now, do not take these basic rules lightly. Many people come to me run down saying they think they need some vitamins. Now, vitamins are still controversial but there’s no harm in taking them because we do have deficiencies in our diet that we are not aware about. But vitamins ain’t food! We can last a lifetime on food alone but certainly not on vitamins alone.

Are you having three square meals a day? Basic. No, you miss breakfast because you can’t eat that early in the morning or more likely because there is no time. Well have a juice or a fruit or a cup of milk, something. Pack up breakfast and take it with you to the office. You miss lunch because you’re too busy or dinner because you’re trying to lose weight or it isn’t convenient. No wonder so many of us have stomach problems or experience lack of energy.

I’m sure I explained already that to lose weight you eat small amounts more frequently. You don’t miss meals. Our meals also need to be balanced with sufficient veges, peas and beans and fibre and less of the rice, flour, meat and sweets.

Do you drink sufficient water? Many people don’t. 6-8 glasses a day is a rough estimate. You may require more but not much less. Many people do not like to or do not make the time to drink enough water but our bodies are made up mainly of water and all systems need it to function efficiently.

What about sleep? That’s my Achilles’ heel. I literally started to feel that there weren’t enough hours in the day to get a proper rest, 7-9 hours, and do everything I wanted to do.

But that’s the quickest way for your body to be run down, for you to be less alert, less focused. You make more mistakes without a good night’s sleep, have more memory lapses and are more irritable. It also feeds both anxiety and depression. We need to plan our days so that we get the essential sleep.

You don’t need a doctor to tell you to eat right and sleep right. You need to know the importance for yourself. There is no medication that can replace these things. As I say, basic.

Being active. Many of us lead sedentary lifestyles. A family doctor may sit at a desk for hours with little breaks in between. The office worker, the computer geek, often does the same. The little old lady will sit on the comfy chair all day. The housewife may whip up her chores early in the morning then relax all day. These are common but unfortunately unhealthy scenarios. We must keep moving throughout the day. Obesity is so rampant because we do not do this.

Exercise is something you need to add to that active lifestyle. It increases your heart rate, breathing and the energy you expend. But we don’t like to exercise!!! It takes up our time, and certainly takes effort. It even hurts sometimes. The exercise buff is the exception rather than the rule. But we all know we need to exercise. It’s no secret. Exercise has a long lists of benefits. You lack energy? …Well exercise.

Lastly, let’s talk about stress baby. It is a relatively new buzz term isn’t it? But it’s so real. It incorporates worry, anxieties, fears, depression, all sorts of negative emotions we allow to play on our minds and disturb our psyche. Stress is not the situation or person that is affecting you, but your response to them. Two persons can have completely different responses in identical situations. If we are stressed we cannot function properly.

We often blame others for our problems. But if we do that, we can never solve them because we cannot change the other person. We need to change our attitude to acceptance and move on.

We cannot be dwelling on our past. Those monsters can only hurt us if we bring them into the present. And worrying about the future does not help either. I tell that to clients who insist on worrying about their children and grandchildren as a duty.

We often find inadequacies in ourselves. But we should not dwell on these. Sure, we all have faults, but there are so many wonderful things in each of us that we can be grateful for and focus on instead.

I ask my patients, when last did you have a vacation, or a break? Do you have any me time, especially those wives and mothers. I’ve come across miserable housewives caring for husbands, children, parents and/or in-laws with no time for themselves and feeling unappreciated by those they care for.

For me, I know, I need a time everyday to feel like I am me. Not a doctor, daughter, sister, friend, just me. Just to exist for a few moments. Nothing to rush and do next.

So, please people. These tips I am giving here are worth thousands. Take care of yourself. Do what is necessary. Avoid unnecessary doctor visits. He cannot do for you what you ought to do for yourself. Eat right, sleep well, a little exercise wouldn’t kill, in fact it prolongs lives. And deal with the stressors.

And if you do break these rules know that you will suffer and who will put humpty dumpty back together again? …  Take care. Dr. Louella.

Hypertension 10 – Summary

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Hi folks! It’s Dr. Louella and we’ve reached the grand finale of our discussions on hypertension. Yeeaaah!!!!

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This one you should definitely keep for your records because I’ll be reiterating and reminding you of all the important points, having already explained the mechanics of this disorder in detail.

Firstly blood pressure is derived from the pumping action of the heart as it forces blood into large blood vessels. This causes the blood to circulate around our bodies. The force with which  the blood flows is called the blood pressure.

Just as we are unable to feel the blood circulating around our bodies, we are unable to feel our blood pressure. It is a common myth in Trinidad and Tobago that high blood pressure causes neck pain.

95% of high blood pressure cases are caused by the kidneys by an unknown mechanism. The other 5% have an identifiable cause, usually in younger individuals.

Certain emotional states, such as anger, pain and anxiety, as well as increased physical activity, can cause a temporary rise in blood pressure. This is not hypertension, which is a chronic condition. For this reason, not just one, but a few blood pressure readings need to be taken before a person is diagnosed as hypertensive.

Factors which predispose to the disease include a family history of hypertension, increasing age and certain ethnicities such as Afro-American or Afro-Caribbean.

Dietary associations of hypertension include a high sodium intake (salt, not fresh seasonings), low potassium intake, heavy consumption of alcohol and obesity. Increased oats and fruits in the diet help to reduce blood pressure. Physical inactivity is also associated with a higher blood pressure.

General guidelines for hypertension are that a reading of 120/80 or less is normal and ideal; a target of less than 140/90 is used for those on treatment; less than 150/90 is now used for those over 60 and 130/80 or less for those with certain diseases such as diabetes and heart disease.

Complications of hypertension are the dreaded stroke, heart failure, heart attack, kidney failure, aortic aneurysm and eye disease. Hypertension damages the inner lining of blood vessels allowing cholesterol to enter the wall and form a plaque that partially blocks blood flow.

If it a blood clot forms at the site it seals up the blockage long enough for no blood to flow and permanently damage brain or heart cells. The person then gets a stroke or heart attack.

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The DASH diet has been shown to help lower blood pressure. It includes less salt, alcohol, red meat, fat and sweets including sweetened drinks.

But it also includes more fruits, vegetables and high fibre foods (whole grain products such as whole wheat/meal bread, bran, oats, as well as more peas, beans and nuts).

Weight loss for the overweight and obese is important in controlling hypertension. This can be achieved by a combination of dietary control and exercise. To lose weight you need to eat less and have a lower calorie intake but frequent little meals, and not starvation, is the key.

Exercise is beneficial in lowering blood pressure on its own, even in those of normal weight. Aerobic exercise can take many forms including running, skipping and dancing.

Some people can have their hypertension controlled through diet and exercise alone but most will still need the assistance of medication. Medication is varied but it must be stressed that it needs to be taken everyday, as prescribed by the doctor, unless the person is experiencing ill effects, which he must inform his doctor about.

So there! We’re done. That’s the end of hypertension. I’ve taught you almost everything I know. Feel free if you have questions or comments. See you next week. Dr. Louella is out!!!

Hypertension 9 – Treatment and Compliance

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Hi everyone! I’m on time today. This is Dr. Louella checking in from the office. This ought to be our final post on hypertension but I feel the need to give a summary afterwards to draw all the essential points together. Let us finish up on treatment.

So, let’s say diet and exercise (as we discussed previously), fail. You ask what I mean by fail… well you just don’t do them or you make a half-hearted attempt to do so. Then they will fail. Or, better yet, say you do try, and get some results but not sufficient for your blood pressure to be called normal, what do we do?

It is obvious we turn to medication at this point. Antihypertensive medication is used to control but not to cure hypertension or high blood pressure. Some people’s blood pressures are so high that we have to put them on medication from the start, but this should be done in conjunction with diet and exercise.

Now I don’t need to go too much into the actual medications. There are many classes of antihypertensive drugs and several drugs in each class. One may work a bit better in an individual than another but none is clearly superior.

I do have a lot to say on “The Patient and the Taking of Antihypertensives” though. Oh my goodness! I have only dealt with patients from Trinidad but I am sure there are patients all over who behave similarly.

Many patients aren’t convinced of the diagnosis of hypertension. They say “so they say” but don’t own it for themselves. They are in denial. Others treat it like a minor irritation or joke. But I am usually quickly able to convince them of the diagnosis by giving them the normal range and showing where a number of their blood pressures, as recorded in the patient notes, are beyond that. Remember, if they were diagnosed based on one reading, they have a right to be skeptical.

I show them that antihypertensives work on everyone. If they do not have hypertension their blood pressures would run low if they took medication. Are their blood pressures running low? Or are they being maintained just normal, high normal or even too high? If your blood pressure is normal whilst on an antihypertensive, you need to continue on that treatment, or else it will go high.

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It is difficult to get hypertensive patients to take their medication because they don’t feel sick. This often leads them to rush to take a pill when they do feel something like a headache or neck pain. Recall that hypertension has no symptoms. I tell them if you are waiting to feel something, that’s when complications have already set in, and it will be too late.

A lot of our patient population think a water pill is to help them pass water and improve functioning of their kidneys, so they don’t take it because they pass water just fine. They are oblivious to the fact that it is a pill for treating hypertension, so I make this clear to them.

Many of them have their own regimen for taking medicines: once a day instead of twice, every other day, twice or three times a week, whenever they remember or whenever the blood pressure is high. No wonder the pills don’t work!!! I always ask why? What is your reasoning for this?

I will admit, years ago when I first discovered this deviant behavior I was shocked. I found out that we doctors increased the dosages of patient medication when needed but the patients themselves didn’t. So the notes may be saying as many as four tablets a day when the patient still routinely took one. My most gruesome discovery was bags and bags half-filled with medication at the homes of the elderly we visited in Cedros. I was upset and thought I was fighting a losing battle.

But I’m older and wiser now. I understand many of the reasons they don’t take their medicines as prescribed. I ask them point blank about it and spend some time on the topic. But even after explaining there is no guarantee they will follow comply. Most of our patients are unaware of the names of their medication and this makes it more difficult.

I explain to those that take their meds only when blood pressure is high is that they are doing more damage by allowing their pressures to go high and then taking a pill, as opposed to having it controlled at all times. If your blood pressure is good today it may be the pill you took yesterday. If you miss the pill today it will be high tomorrow or the next day. To decrease risk of complications blood pressure needs to be controlled at all times

Many patients are afraid of side effects. I try to explain that these side effects are only potential and nothing happens to most people. There is no automatic damage by the medication. And furthermore, the damage they will get from hypertension is more sure and worse than what the tabs will do.

For those who have decreased the dosages due to convenience, I explain to them that the drug only is effective in their system for a certain length of time and they need to take it as prescribed for it to work properly. It comes as though you’re wasting your time because the drug can’t work like that.

A few of them cannot read so I emphasise to them that I am changing the dose and ask them to refer to a relative or neighbor to read it for them. Sometimes for the elderly or mentally challenged I ask for them to bring a relative. I explain to that person and charge them with the responsibility.

That’s it folks!!! We just completed the series on hypertension. Only the summary is left. Thereafter I’ll be starting a new topic. Now if I left out anything or you don’t understand something, feel free to comment before we move on. I enjoyed this because it was like a refresher for me and as you can tell, I love to share my patient experiences. Enjoy the rest of the weekend and the incoming week!

 

Hypertension 8 – Prevention/Treatment 2

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Hi. This is Dr Louella saying sorry for the late post. It was a hectic weekend! But we need to continue our discussion on prevention and treatment of hypertension. Previously we talked about how your diet can help lower blood pressure so now we go on to weight loss and exercise.

Yes, I know you’ve heard a lot on these topics before, but not like this…

Now weight loss and exercise are not the same thing.There are so many health benefits to exercise that everybody needs to exercise (including  the skinny, the fat and the in-between; toddlers and grandmas) but not everyone needs to lose weight. I have frequently heard the retort, “What you have to lose?” when people hear that I exercise.

But I love to provoke my elderly patients by asking them if they’re exercising because they should be. It would help unstiffen those joints, reduce their pains, strengthen their bodies and lift their depression among other things.

Now if there is one thing you need to know about exercise is that it makes you live longer. Exercise increases your longevity! Did you know that? It’s been proven!.

It has been also been found to lower blood pressure about 1 to 3 months after engaging in it, as long as the person continues to exercise. It strengthens heart muscle reducing the force needed to pump the blood around the body.

Exercise is recommended for everyone for the prevention and/or control of hypertension. 30 min of moderate exercise, 5 days a week is the basic requirement for health or, if its vigorous exercise, 15 min for 5 days will do.

Now don’t get scared. It isn’t as hard as you think. Get yourself a pair of sneakers and pants, as well as a safe environment, and you’re almost there. I tell my patients these things because I am saddened to find out that many of them don’t exercise even though they know better.

I was a gym freak once, but not anymore. I’m well aware that not everyone can toil away for hours at the gym… timing, cost, distance, shyness, whatever, prohibits that. But that does not rule you out.

Remember, anything aerobic will do – brisk walking, jumping, jogging, dancing, aerobics, active sports, swimming, cycling, skipping, climbing etc. You can use a video, gym instructor, exercise equipment, a friend or do it by yourself. You can be in the house, around the house, on the street, in the park, in the gym.

Weight training is not as good for blood pressure as it may increase it. But your housework (scrubbing, mowing the lawn etc) may count, once it increases your heart rate and breathing. It has been found that physically strenuous jobs are associated with lower life expectancy because of the stress associated with them.

If you’re new to exercise 5 min may be enough and you gradually work your way up. Don’t try to overdo it. The body has to get accustomed. If you injure yourself you’ll never want to go back. Warm up first before you stretch. Never stretch a cold body but always stretch those muscles after use. Please drink sufficient water. Hydration is important.

Now, I’m going to burst some people’s bubble here. I’m going to make it clear that exercise alone  is not enough. You cannot lead a sedentary lifestyle, sit for most of the day, and think that 30 min of exercise is going to be sufficient to counteract that.

There is something called non-exercise physical activity that we must also engage in. This simply means being active throughout the day, doing the little stuff. Excessive sitting is unhealthy. If you reduce it to less than 3 hours a day it can help extend your lifespan by 2 years.

A generally active daily life is associated with cardiovascular health and longevity in older adults. So get the old people moving and get yourself active: stairs instead of elevator, walk instead of drive, manual tools instead of automatic, do it yourself instead of outsourcing, walk the dog, do the dishes, wash on hand and so on… They all add up.

Our populations are getting fatter so hypertension is rising. Remember obesity is linked to hypertension. So many of us need to lose the weight, for this and other reasons (helps lower cholesterol, blood sugar etc).

No one said it would be easy but it will be worth it. You know the drill. Weight loss entails diet and exercise. Even when you take weight loss pills you need some kind of diet.

You don’t need to get down to your ideal weight, a BMI of 18.5 to 24.9. That would be lovely, but for some it is extremely difficult. It is said that losing as little as 5% of your weight may make a difference to your blood pressure, 10% is better and more even better, if you are obese.

What I discussed previously with regards hypertension was a healthy diet but not a weight loss diet. I will mention the main features of this.

You should know by now that you must eat less (or take in less calories) in order to lose weight. Watch the content of the food: less sugar, flour and fatty/oily items. Decrease your portion size, but I stress, gradually. You don’t want to feel hungry. Use more protein, especially beans and peas, and your veggies. Increase your number of meals to 4-6 a day. You use calories more efficiently this way.

Make your dietary changes healthy and palatable and never entertain long periods without meals. In this way the diet will be easier for you to incorporate into your lifestyle and not be just a passing fad. You would not continue to lose weight indefinitely but eventually settle.

While the majority of weight loss would be achieved through the diet, exercise is also very important as it increases your calorie output, increases the efficiency with which you lose the weight, tones the body, etc. I normally explain to my patients that 30 min of exercise, 5 days a week is the basic requirement for health so if you’re looking to lose weight you may need to go beyond that.

So I have told you about exercise and the weight reducing diet, why they are needed and how to achieve them to prevent/control hypertension.  But it’s been another long day. I’m tired. But I really enjoy doing these blogs so come back for more when we talk a bit about drug treatment of hypertension. Later! Dr. Louella is out.