What Is High Blood Pressure?

Blood pressure refers to the force of blood pushing against artery walls as it courses through the body. Like air in a tire or water in a hose, blood fills arteries to a certain capacity. Just as too much air pressure can damage a tire or too much water trying to push through a small garden hose can damage the hose, too much blood pressure can threaten healthy arteries and lead to life-threatening conditions such as heart disease and stroke.

High blood pressure, or hypertension, is the most common of all cardiovascular diseases in the industrialized world. It is the leading cause of stroke and a major cause of heart attack. In the U.S. alone, approximately 80 million people over age 6 have high blood pressure. That's one in four Americans and one in three adults. And one-third of people with high blood pressure are unaware that they have it.

A blood pressure reading appears as two numbers. The first and higher of the two is a measure of systolic pressure, or the pressure in the arteries when the heart beats and fills them with blood. The second number measures diastolic pressure, or the pressure in the arteries when the heart rests between beats.

Normal blood pressure rises steadily from about 90/60 at birth to about 120/80 in a healthy adult. If someone were to take your blood pressure immediately after you'd delivered a speech or jogged five miles, the reading would undoubtedly seem high. This is not necessarily cause for alarm: It's natural for blood pressure to rise and fall with changes in activity or emotional state.

It's also normal for blood pressure to vary from person to person, even from one area of your body to another. But when blood pressure remains consistently high, corrective steps should be taken.

People with blood pressure of 140/90 or higher on at least two occasions are said to have high blood pressure. If the levels remain high, the doctor will probably begin treatment. Patients with blood pressure readings of 200/120 or higher need treatment immediately. People with diabetes are treated if their blood pressure rises above 135/80, as this population already has a high risk of heart disease.

Researchers identified people with blood pressures slightly higher than 120/80 as a category at high risk for developing hypertension. This condition is called prehypertension and affects an estimated 50 million men and women in the U.S. It is now known to increase the likelihood of damage to arteries and the heart, brain and kidneys so that many more doctors are recommending early treatment.

Consistently high blood pressure forces the heart to work far beyond its capacity. Besides injuring blood vessels, it can damage the brain, eyes, and kidneys. Even so, many people with high blood pressure do not realize they have the condition. Indeed, hypertension is often called "the silent killer" because it rarely causes symptoms even as it inflicts serious damage on the body. Left untreated, high blood pressure can lead to vision problems, as well as to heart attack, stroke and other potentially fatal conditions, including kidney failure.

Hypertension may also lead to heart failure, a common but disabling condition that can cause breathing problems. Patients who have very high blood pressure are said to have malignant hypertension. The diastolic pressure in such cases usually exceeds 130 or a systolic pressure above 200. Malignant hypertension is a dangerous condition that may develop rapidly, causes organ damage very quickly and requires immediate medical attention.

Fortunately, high blood pressure can be controlled effectively. The first step is discovery, so have your blood pressure checked regularly.

High blood pressure is more likely in people who:

• Have a family history of high blood pressure, heart disease or diabetes.
• Are black.
• Are pregnant or take birth-control pills.
• Are over age 50 (men: after ago 50; women: after menopause).
• Are overweight.
• Are not active.
• Drink excessively.
• Smoke.
• Eat foods high in fat or sodium.

Causes

In as many as 95% of reported high blood pressure cases in the U.S., the underlying cause cannot be determined. This type of high blood pressure is called essential hypertension.

When a direct cause can be identified, the condition is described as secondary hypertension. Among the known causes of secondary hypertension, kidney disease ranks highest. The condition can also be triggered by tumors or other abnormalities that cause the adrenal glands (small glands that sit atop the kidneys) to secrete excess amounts of the hormones that elevate blood pressure. Birth-control pills (specifically those containing estrogen) and pregnancy can boost blood pressure, as can medications that constrict blood vessels.

Though essential hypertension remains somewhat mysterious, it has been linked to certain risk factors. High blood pressure tends to run in families, for example, and it is more likely to affect men than women. Age and race also play a role. In the U.S., blacks are twice as likely as whites to have high blood pressure, although the gap begins to narrow around age 44. After age 65, black women have the highest incidence of high blood pressure.

Essential hypertension is also greatly influenced by diet and lifestyle. The link between salt and high blood pressure is especially compelling. People living on the northern islands of Japan eat more salt per capita than anyone else in the world and exhibit the highest incidence of essential hypertension. By contrast, people who add no salt to their food show virtually no traces of essential hypertension. The majority of all people with high blood pressure are "salt sensitive," meaning that anything more than the minimal bodily need for salt is too much for them and leads to an increase in blood pressure. Other factors that have been associated with essential hypertension include obesity; diabetes; stress; insufficient intake of potassium, calcium and magnesium; lack of physical activity; and chronic alcohol consumption.

Symptoms

In the vast majority of cases, there are no clear warning signs of high blood pressure. This is why high blood pressure is called a "silent" disease and why people often believe it doesn't require treatment.

If symptoms do occur, they may include:

• Headaches, chest pain or tightness, nosebleeds and numbness and tingling; you may have severe hypertension.
• Excessive perspiration, muscle cramps, weakness, palpitations and frequent urination; you may have secondary hypertension, possibly caused by a tumor or an adrenal gland disorder.

Call Your Doctor If:

• While taking antihypertensive drugs you experience worrisome side effects, such as drowsiness, constipation, dizziness or loss of sexual function. Your doctor may need to prescribe a different drug.
• You are pregnant and develop hypertension. Symptoms may include severe headache and sudden swelling of the legs. High blood pressure during pregnancy can affect not only your own health but also that of your unborn child.
• You are experiencing severe headaches, nausea, blurred vision, and confusion or memory loss; you may have malignant hypertension, which can result in stroke or heart attack if left untreated.
• Your diastolic pressure -- the second or bottom number in a blood pressure reading -- suddenly shoots above 130. You may have malignant hypertension, a life-threatening condition.

Detection

Your health-care provider can tell if you have high blood pressure by checking your blood pressure with a blood pressure cuff. It is important to pay attention to both the higher (systolic) and the lower (diastolic) blood pressure readings. While higher diastolic readings were once thought to be the most harmful to the body, it is now known that high systolic reading can be very dangerous also, especially in those adults over age 50.

Treatment

Making lifestyle adjustments is key to maintaining normal blood pressure. In fact, most doctors will suggest lifestyle changes before prescribing drugs. And lifestyle changes are the recommended treatment for prehypertension.

• Quit Smoking. This is perhaps the most important step a person can take to improve health.
• Lose Weight. Losing weight not only decreases blood pressure, but it also can reverse some of the heart damage caused by high blood pressure.
• Eat Right. Studies show that a diet low in salt and fat and high in fruits and vegetables can significantly lower blood pressure. Also, make sure you get enough vitamins and minerals -- some studies show that having the recommended amounts of vitamins C and E, potassium, magnesium and calcium can improve heart health.
• Exercise. Regular aerobic activity such as walking three to four times per week can lower blood pressure. Regularity of exercise is as important as intensity.
• Limit Alcohol. Women should drink no more than one alcoholic drink per day; men should limit intake to two drinks or fewer (one 6-ounce glass of wine, one 12-ounce beer, or a 1-ounce shot glass of liquor).
• Reduce Stress. Emotional factors do play a role in blood pressure. Studies show that relaxation techniques such as meditation, yoga, or even therapy to change reactions to stress may reduce blood pressure.

Women should discuss with their doctor the increased risk of high blood pressure from taking birth control pills (especially if they are over 35 and overweight).

But be sure to consult a doctor for an accurate diagnosis and treatment plan. While essential hypertension cannot be cured, it can be treated effectively, and secondary hypertension can often be cured by addressing the underlying cause.

If you have high blood pressure, you'll probably find out about it during a routine checkup. (You may also have noticed a problem while taking your own blood pressure, but be sure to check with your doctor for a definite diagnosis.) Take the opportunity to learn what you can do to bring your blood pressure under control.

Sometimes hypertension requires drug therapy, either because of severity or because it does not respond to self-help measures. Blood pressure medication usually needs to be taken for life. A number of drugs are used alone or in combination to treat high blood pressure:

• Diuretics, or water pills, rid the body of salt and excess fluids.
• Beta-blockers make the heart beat more slowly and with less force. These are particularly effective in people with heart disease.
• Calcium-channel blockers reduce blood pressure by dilating blood vessels. These drugs remain somewhat controversial.
• Angiotensin-converting enzyme (ACE) inhibitors block factors that cause blood vessels to constrict, making them dilate and thus reducing blood pressure. These drugs can decrease risk of kidney disease, heart disease, and stroke and are especially useful in people with heart disease or diabetes.
• Angiotensin II receptor blockers (ARBs) are a newer type of blood pressure medicine, which work in a similar way to ACE inhibitors.
• Alpha1-adrenergic blockers and centrally acting agents lower blood pressure by relaxing and dilating arteries.

Warning: Do not stop taking prescribed medication until you have consulted your doctor; abrupt cessation can be harmful.

Prevention

You can help keep your blood pressure at a healthy level and reduce your risk of heart disease by making a few changes in your lifestyle.

• Watch what you eat. Stay away from salt and fat, concentrating instead on foods that are high in fiber calcium, and magnesium.
• Get plenty of exercise. Regular aerobic workouts condition the heart and keep blood vessels dilated and working properly.
• If you are overweight, try to trim down. Even a small weight reduction can make a big difference.
• If you smoke or consume alcohol excessively, now is the time to stop.

Medically reviewed by Michael Aronson, MD, July 2005.

SOURCES: "Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressue," (JNC VII), JAMA Express, May 15, 2003. "Hypertension: Journal of the American Heart Association," Summer 2003. Elliot W., "Clinical Features and Management of Selected Hypertensive Emergencies," Journal of Clinical Malignant Phase Hypertension," The West Birmingham Malignant Hypertension Register. Journal of Human Hypertension 2005 Jan; 19(1):69-75. The American Heart Association.

High Cholesterol

Cholesterol Basics

Cholesterol is a waxy, fat-like substance made in the liver and found in certain foods, such as food from animals, like dairy products (whole milk), eggs and meat.

The body needs some cholesterol in order to function properly. Its cell walls, or membranes, need cholesterol in order to produce hormones, vitamin D and the bile acids that help to digest fat. But, the body needs only a small amount of cholesterol to meet its needs. When too much is present health problems such as coronary heart disease may develop.

Coronary Heart Disease

When too much cholesterol is present, plaque (a thick, hard deposit) may form in the body's arteries narrowing the space for blood to flow to the heart. Over time, this buildup causes atherosclerosis (hardening of the arteries) which can lead to heart disease.

When not enough oxygen-carrying blood reaches the heart chest pain -- called angina -- can result. If the blood supply to a portion of the heart is completely cut off by total blockage of a coronary artery, the result is a heart attack. This is usually due to a sudden closure from a blood clot forming on top of a previous narrowing.

Learn more about Heart Disease.

Types of Cholesterol

Cholesterol travels through the blood attached to a protein -- this cholesterol-protein package is called a lipoprotein. Lipoproteins are classified as high density, low density, or very low density, depending on how much protein there is in relation to fat.

• Low density lipoproteins (LDL): LDL, also called "bad" cholesterol, can cause buildup of plaque on the walls of arteries. The more LDL there is in the blood, the greater the risk of heart disease.
• High density lipoproteins (HDL): HDL, also called "good" cholesterol, helps the body get rid of bad cholesterol in the blood. The higher the level of HDL cholesterol, the better. If your levels of HDL are low, your risk of heart disease increases.
• Very low density lipoproteins (VLDL): VLDL is similar to LDL cholesterol in that it contains mostly fat and not much protein.
• Triglycerides: Triglycerides are another type of fat that is carried in the blood by very low density lipoproteins. Excess calories, alcohol or sugar in the body are converted into triglycerides and stored in fat cells throughout the body.

What Factors Affect Cholesterol Levels?

A variety of factors can affect your cholesterol levels. They include:

• Diet. Saturated fat and cholesterol in the food you eat increase cholesterol levels. Try to reduce the amount of saturated fat and cholesterol in your diet.
• Weight. In addition to being a risk factor for heart disease, being overweight can also increase your cholesterol. Losing weight can help lower your LDL and total cholesterol levels, as well as increase HDL cholesterol.
• Exercise. Regular exercise can lower LDL cholesterol and raise HDL cholesterol. You should try to be physically active for 30 minutes on most days.
• Age and Gender. As we get older, cholesterol levels rise. Before menopause, women tend to have lower total cholesterol levels than men of the same age. After menopause, however, women's LDL levels tend to rise.
• Heredity. Your genes partly determine how much cholesterol your body makes. High blood cholesterol can run in families.
• Other causes. Certain medications and medical conditions can cause high cholesterol.

How Much Cholesterol Is Too Much?

Everyone over the age of 20 should get their cholesterol levels measured at least once every 5 years.

When being tested, your doctor may recommend a non-fasting cholesterol test or a fasting cholesterol test. A non-fasting cholesterol test will show your total cholesterol and HDL cholesterol. A fasting cholesterol test, called a lipid profile or a lipoprotein analysis, will measure your LDL, HDL, and total cholesterol. It will also measure triglycerides.

Your doctor may start with a non-fasting cholesterol test and then recommend a lipid profile, based on your results.

Doctors recommend your cholesterol stay below 200. Here is the breakdown:

Your LDL, HDL and triglyceride levels are important as well. Click here for more information on goal levels.

How Can I Lower My Cholesterol and Reduce My Risk of Heart Disease?

A few simple changes can help lower your cholesterol:

• Eat low cholesterol foods. The American Heart Association recommends that you limit your average daily cholesterol intake to less than 300 milligrams. If you have heart disease, limit your daily intake to less than 200 milligrams. People can significantly lower their dietary cholesterol intake by keeping their dietary intake of saturated fats low and by avoiding foods that are high in saturated fat and that contain substantial amounts of dietary cholesterol.
• Quit smoking. Smoking lowers HDL ("good") cholesterol levels. This trend can be reversed if you quit smoking.
• Exercise. Exercise increases HDL cholesterol in some people. Even moderate-intensity activities, if done daily, can help control weight, diabetes, and high blood pressure -- all risk factors for heart disease.
• Take medication as prescribed by your doctor. Sometimes making changes to your diet and increasing exercise is not enough to bring your cholesterol down. You may also need to take a cholesterol lowering drug.

Treatment

The main goal in lowering cholesterol is to lower your LDL and raise your HDL. There are two key ways to lower cholesterol: eat a heart-healthy diet and take cholesterol-lowering medications.

Doctors determine your "goals" for lowering LDL based on the number of risk factors you have for heart disease.

• If you have 0-1 risk factor for heart disease, you are at low-to-moderate risk. Lifestyle changes are recommended to keep the cholesterol in check.
• If you have 2 or more risk factors, you are at moderate risk or next-highest risk, depending on what heart disease risk factors you have. Sometimes your doctor will try lifestyle changes, but most of these people require cholesterol-lowering drugs.
• If you have known heart disease, diabetes or multiple risk factors, you are at high, or very high, risk. These people require a combination of cholesterol-lowering drugs and lifestyle changes to control their cholesterol levels.

What Drugs Are Used to Treat High Cholesterol?

Cholesterol-lowering drugs include:

• Statins
• Niacin
• Bile-acid resins
• Fibric acid derivatives

Cholesterol-lowering medicine is most effective when combined with a low-cholesterol diet.

Reviewed by the doctors in the Department of Preventive Cardiology and Rehabilitation at The Cleveland Clinic Heart Center.

Edited by Cynthia Haines, MD, WebMD, November 2005.

SOURCE: American Heart Association.

Portions of this page © The Cleveland Clinic 2000-2004

Heart Disease

Coronary Artery Disease

Coronary artery disease, also called coronary heart disease, or simply, heart disease, is the No. 1 killer in America, affecting more than 12 million Americans.

What Is Coronary Artery Disease?

Coronary artery disease is atherosclerosis of the coronary arteries. Atherosclerosis is when the arteries become clogged and narrowed, restricting blood flow to the heart. Without adequate blood, the heart becomes starved of oxygen and vital nutrients it needs to work properly.

How Does Coronary Artery Disease Develop?

Your coronary arteries are hollow tubes. Inside, they are smooth and elastic, allowing blood to flow freely.

Before your teen years, fat starts to deposit in the blood vessel walls. As you get older, the fat builds up. This causes injury to your blood vessel walls. In an attempt to heal itself, the cells release chemicals that make the walls sticky.

Then, other substances such as inflammatory cells, proteins and calcium that travel in your bloodstream start sticking to the vessel walls. The fat and other substances combine to form a material called plaque. The plaque builds up and narrows the artery (atherosclerosis).

Many of the plaque deposits are hard on the outside and soft and mushy on the inside. The hard surface can crack or tear, exposing the soft, fatty inside. When this happens, platelets (disc-shaped particles in the blood that aid clotting) come to the area, and blood clots form around the plaque. This causes the artery to narrow even more.

Over time a narrowed coronary artery may develop new blood vessels that go around the blockage to get blood to the heart. However, during times of increased exertion or stress, the new arteries may not be able to supply enough oxygen-rich blood to the heart muscle.

In other cases, the blood clot may totally block the blood supply to the heart muscle, causing what is called an acute coronary syndrome. This is actually a name given to three serious conditions: unstable angina (an impending heart attack) and two types of heart attacks called non-Q-wave myocardial infarction and Q-wave myocardial infarction.

The length of time that blood flow is blocked and the amount of damage that occurs determines the type of acute coronary syndrome. Some people have symptoms that tell them that they may soon develop an acute coronary syndrome, others may have no symptoms until something happens, and still others have no symptoms of the acute coronary syndrome at all.

What Is Ischemia?

When plaque and fatty matter narrow the inside of an artery to a point where it cannot supply enough oxygen-rich blood to meet your organ's needs, cramping of the muscle occurs. This is called ischemia.

Ischemia of the heart can be compared to a cramp in the leg. When someone exercises for a very long time, the muscles in the legs cramp up because they're starved for oxygen and nutrients. Your heart, also a muscle, needs oxygen and nutrients to keep working. If its blood supply is inadequate to meet the heart muscle's needs, ischemia occurs, and you may feel chest pain or other symptoms.

Ischemia is most likely to occur when the heart demands extra oxygen. This is most common during:

• Exertion (activity)
• Eating
• Excitement
• Exposure to cold

When ischemia lasts less than 10 minutes, there is no permanent damage to your heart. You may be told you have "stable coronary artery disease."

Symptoms

The most common symptom is angina or "angina pectoris." Angina can be described as a discomfort, heaviness, pressure, aching, burning, fullness, squeezing or painful feeling. It can be mistaken for indigestion or heartburn. Angina is usually felt in the chest, but may also be felt in the left shoulder, arms, neck, throat, jaw or back.

Other symptoms that can occur with coronary artery disease include:

• Shortness of breath
• Palpitations (irregular heart beats, skipped beats or a "flip-flop" feeling in your chest)
• A faster heartbeat
• Weakness or dizziness
• Nausea
• Sweating

Learn to recognize your symptoms and the situations that cause them. Call your doctor if you begin to have new symptoms or if they become more frequent or severe.

Ischemia, and even a heart attack, can occur without any warning symptoms. This is called silent ischemia. It can occur among all people with heart disease, though it is more common among people with diabetes.

Diagnosis

Your doctor can tell if you have coronary artery disease by:

• Talking to you about your symptoms, medical history, and risk factors.
• Performing a physical exam.
• Performing diagnostic tests, including an electrocardiogram (ECG or EKG), exercise stress tests, cardiac catheterization and others. These tests help your doctor evaluate the extent of your coronary heart disease, its effect on the function of your heart, and the best form of treatment for you.

Treatment

Treatment for coronary artery disease involves reducing your risk factors, taking medications, and possibly undergoing invasive and/or surgical procedures.

• Reduce your risk factors. This involves making lifestyle changes. If you smoke, you should quit. Your diet will likely need modifying to reduce your cholesterol, keep your blood pressure in check, and keep blood sugar in control if you have diabetes. Low fat, low sodium, low cholesterol foods are recommended. You should also get more exercise to help maintain a healthy weight and reduce stress. But, check with your doctor before starting an exercise program.
• Medications. If making lifestyle changes isn't enough to control your heart disease, medications may be needed to help your heart work more efficiently and receive more oxygen-rich blood. The medications you are on depend on you and your specific heart problem.
• Surgery and other procedures. Procedures to treat coronary artery disease include balloon angioplasty (PTCA), stent placement, rotoblation, atherectomy, and coronary artery bypass surgery. All of these procedures increase blood supply to your heart, but they do not cure coronary heart disease. You will still need to decrease your risk factors to prevent future disease.

Doctors are also studying several innovative ways to treat heart disease. Here are a couple of the more promising ones:

• Transmyocardial laser revascularization, or TMR. This procedure improves blood flow to the heart muscle for people with advanced coronary artery disease. Laser beams are used to make channels through the heart muscle to increase blood flow to dying, but not dead, heart tissue. This technique is used for people with intractable angina who are not candidates for traditional open-heart surgery or transplantation.
• Angiogenesis. This involves giving substances through the vein or directly into the heart that trigger the heart to grow new blood vessels to bypass the clogged ones.
• EECP. There are an increasing number of patients who have persistent angina symptoms, who have exhausted the standard treatments without successful results. Enhanced External Counterpulsation (EECP) may stimulate the openings or formation of collaterals (small branches of blood vessels) to create a natural bypass around narrowed or blocked arteries. EECP is a non-invasive treatment for people who have chronic, stable angina; who are not receiving adequate relief from angina by taking nitrate medications; and who do not qualify for an invasive procedure such as bypass surgery, angioplasty or stenting.

Reviewed by the doctors at The Cleveland Clinic Heart Center.

Edited by Charlotte E. Grayson, MD, June 2004, WebMD.

Portions of this page © The Cleveland Clinic 2000-2004

Alzheimers

Overview

What Is Alzheimer's Disease?

Alzheimer's disease or Alzheimer's-type dementia is a progressive degeneration of brain tissue that primarily strikes people over age 65. It is the most common cause of dementia in this age group and is marked by a devastating mental decline. Intellectual functions such as memory, comprehension and speech deteriorate.

Attention tends to stray, simple calculations become impossible and ordinary daily activities grow increasingly difficult, with bewilderment and frustration. These symptoms tend to worsen at night. Dramatic mood swings occur -- outbursts of anger, bouts of fearfulness, and periods of deep apathy. The sufferer, increasingly disoriented, may wander off and become lost. Physical problems, such as an odd gait or a loss of coordination, gradually develop. Eventually, the patient may become physically helpless, incontinent and unable to communicate.

Alzheimer's disease can run its course from insidious onset to death in just a few years, or it may play out over a period of as long as 20 years. More often, however, people suffer with Alzheimer's disease about nine years. By the age of 80, about one person out of three has the disease. Women are more susceptible than men and half of all nursing home residents suffer from Alzheimer's or related disorders.

Causes

Although many people develop Alzheimer's disease as they grow older, the disease is not a natural result of aging. It is an abnormal condition whose causes continue to be investigated.

The gradual loss of brain function that characterizes Alzheimer's disease seems to be due to two main forms of nerve damage:

• Nerve fibers grow tangled (neurofibrillary tangles)
• Protein deposits known as plaques build up in the brain (Figure 2).

Researchers are not yet sure why or how these processes occur, but some of the most promising recent research points to a normally occurring blood protein called ApoE (for apolipoprotein E), which is required for the transport of fatty substances in the body.

As with all proteins, the form of ApoE that each person has in their body is genetically determined, and several different types have been identified -- some of them apparently associated with a higher risk of Alzheimer's. It may be that certain forms of ApoE lead to the nerve damage.

Another possibility is that the protein, perhaps working in combination with other substances, is involved in the formation of the plaques. Whether or not ApoE partly causes Alzheimer's disease, genes almost certainly play a role in the disease and a person with a parent who had Alzheimer's disease is at higher risk.

Other causes have been proposed. One theory suggests that ingesting tiny particles of aluminum -- from cookware, for example -- may lead to Alzheimer's. Another proposes a link between plaque formation and free radicals -- unstable, free-ranging molecules that can produce destructive chemical reactions. Both theories are controversial and unproven. Indeed, many researchers now consider the link between Alzheimer's and aluminum extremely questionable.

Another controversy centers on zinc. But the connection between zinc and Alzheimer's remains unclear. It is thought that at low levels zinc may be protective but at higher doses it may be harmful. For one thing, scientists remain unsure whether plaques cause Alzheimer's or are themselves a result of the disease. If the latter, zinc's ability to form plaques might be unrelated to what causes Alzheimer's disease in the first place.

There is some evidence that people with high blood pressure and high cholesterol have an increased chance of developing Alzheimer's. In a minority of cases, trauma may be a contributing factor. The more severe the head injury, the greater the risk of Alzheimer's dementia later in life

While many of these theories are still being studied, it is clear that the biggest risk factors associated with developing Alzheimer's disease are increasing age and family history.

Symptoms

The Symptoms of Alzheimer's Disease include:

• Mood changes: depression, paranoia, agitation, anxiety, selfishness, childish behavior
• Disorientation, confusion, inattention, loss of memory for recent events, inability to retain new information
• Increased tendency to misplace things.
• Dizziness or impaired equilibrium.

Call Your Doctor If:

A family member or friend exhibits signs of Alzheimer's disease over a period of time. Because the person may not be aware of having these problems, it is often up to others to help.

Diagnosis

Diagnosis by a professional is particularly important because a number of other ailments -- many of which are treatable -- share symptoms associated with Alzheimer's disease. These include respiratory infections, inadequate nutrition, vitamin B-12 deficiency, anemia, hypoglycemia, depression, and cerebral vascular insufficiency (decreased blood flow to the brain due to constricted or obstructed arteries).

An adverse reaction to prescribed medication or a harmful combination of medicines can sometimes cause Alzheimer's-like symptoms. Other diseases and conditions sometimes confused with Alzheimer's disease are Parkinson's disease, stroke, thyroid problems, brain tumors, advanced syphilis and Huntington's chorea -- an inherited degenerative nerve disease.

To check for Alzheimer's disease, the doctor will probably begin with physical and psychological tests designed to eliminate other possible causes of mental impairment. Verbal tests and interviews of the family are the usual next steps, but they will not produce a definitive diagnosis. Today, only an examination of brain tissue after death can yield absolute proof of Alzheimer's disease -- the telltale evidence of nerve tangles, protein plaques, and general brain shrinkage from cell death.

Treatment

Alzheimer's disease is incurable: Nothing can halt or reverse it. However, certain medications seem to slow its general progress to some degree in the early stages and others can help with mood changes and other specific behavioral problems of the disease.

• Cognex. In 1993, Cognex became the first drug approved by the FDA for treatment of Alzheimer's disease. The drug works by slowing the breakdown of acetylcholine, a chemical that helps nerve cells in the brain communicate. Cognex does not cure Alzheimer's disease or keep it from getting worse, but it can help relieve some of the memory impairment associated with the disease. Side effects of the drug include nausea, vomiting, diarrhea, abdominal pain and indigestion. In addition, Cognex can damage the liver, so your doctor will need to perform tests regularly to make sure this isn't happening. Due to its potential effects on the liver and need for frequent blood tests it is rarely used.
• Aricept Exelon and Razadyne(formerly known as Reminyl). These medications work by the same mechanism as Cognex but are better tolerated. They can improve mental functioning in early cases and perhaps delay the need for nursing home care, but do not seem to delay the actual progression of the disease.
• Namenda. This is a newer drug approved in October 2003 that works by blocking a substance called glutamate which may be overactive in someone with Alzheimer's disease. I t improves mental function and may be more effective in moderate to severe symptoms, but is not a cure for Alzheimer's disease.

Other Therapies

Although hormone replacement therapy was initially thought to be beneficial, more recent studies actually show an increased risk in developing Alzheimer's for those taking combination hormone replacement (both estrogen and progesterone) and to a lesser degree estrogen replacement alone.

A number of drugs are prescribed for specific symptoms associated with Alzheimer's disease:

• Antipsychotic drugs such as Haldol, Risperdal, and Zyprexa may be used to treat the paranoia, confusion, hallucinations, and aggressive behavior experienced by Alzheimer's patients.
• Antidepressants such as Prozac, Paxil, Effexor, and Zoloft can be used to treat depression.
• Sleep medications such as Ambien may be used for insomnia, and antianxiety drugs such as Ativan and BuSpar may be used to treat agitation.
• The herbal medication, Ginko Biloba appears to increase blood flow to the brain and may be beneficial in treating the symptoms of Alzheimer's disease, however, there are several reports of serious side effects including coma, bleeding and seizures.

Caring for an Alzheimer's patient is often stressful for family members. Support organizations can help caregivers cope with problems and feelings. Eventually, full-time nursing care will be necessary. Some families are able to provide this full-time care at home, while others turn to professional caregivers.

At-Home Care

• To help an Alzheimer's patient cope with episodes of disorientation and mental lapses, promote a feeling of safety in every way possible: Maintain a stable, familiar living environment; stick to routine; when you must be absent, leave reminder notes and simple directions.
• Wandering and getting lost is a common problem with Alzheimer's patients. Have the patient wear an ID bracelet with a phone number on it.
• To encourage someone with Alzheimer's to talk more, go for a walk. Studies suggest that walking may stimulate areas of the brain linked to speech.

To help an Alzheimer's patient develop a more positive outlook on the present, try to help them remember good times. Often, long-term memories are not initially impaired and pleasant recollections can create feelings of happiness and well-being. This can be effectively done in a group. Good nostalgia-promoting materials include old magazines, photo albums, and favorite family stories. Avoid pressuring the patient to remember. A subtle question or two may provide the key to a memory.

Prevention

No one knows for sure what causes Alzheimer's disease, so any preventive measures are highly speculative at best. But it's important to remember that even if Alzheimer's runs in your family, you will not necessarily develop it yourself.

If you are concerned about the possibility that you might eventually develop Alzheimer's disease, your best strategy is to maintain a healthy lifestyle: Eat right and exercise regularly to keep your entire body -- and especially the nerve cells in your brain -- in good shape. It may be useful to participate regularly in mentally stimulating tasks like reading, crossword puzzles or going to the museum. The concept of what is good for the heart is good for the head also applies. Controlling blood pressure and cholesterol may likely decrease your chances of developing Alzheimer's disease.

In particular, avoid cigarette smoke and air pollution as best you can. This will help you minimize your exposure to free radicals, which some studies have implicated in the formation of nerve plaques.

Although some studies suggest a link between Alzheimer's and zinc, doctors do not recommend that you attempt to limit your daily intake. Zinc is an essential mineral and while you should avoid overdosing on zinc, you would do more harm than good by restricting your intake below the recommended daily allowance (11 mg for men, 8 mg for women).

Medically reviewed by Tracy Shuman, MD, July 2005.

SOURCES: American Association of Family Physicians. Alzheimer's Foundation of America. The Food and Drug Administration. American Federation of Aging Research. American Health Assistance Foundation. Centre for Neuro Skills. Office of Dietary Supplements. Peter Doskoch, "Brain injury and Alzheimer's Disease: What is the Link," Neuropsychiatry review, October 2000.

Arthritis

Arthritis Basics

What Is Arthritis?

Arthritis is a general term for a group of more than 100 diseases. The word "arthritis" means "joint inflammation." Inflammation is one of the body's natural reactions to disease or injury, and includes swelling, pain and stiffness. Inflammation that lasts for a very long time or recurs, as in arthritis, can lead to tissue damage.

A joint is where two or more bones come together, such as the hip or knee.

The bones of a joint are covered with a smooth, spongy material called cartilage, which cushions the bones and allows the joint to move without pain. The joint is enclosed in a fibrous casing called the synovium. The synovium's lining produces a slippery fluid -- called synovial fluid -- that nourishes the joint and helps limit friction within. Strong bands of tissue, called ligaments, connect the bones and help keep the joint stable. Muscles and tendons also support the joints and enable you to move.

With arthritis, an area in or around a joint becomes inflamed, causing pain, stiffness and, sometimes, difficulty moving. Some types of arthritis also affect other parts of the body, such as the skin and internal organs.

Types of Arthritis

There are more than 100 different types of arthritis. Some of the more common types include:

• Osteoarthritis. This is the most common type of arthritis. It occurs when the cartilage covering the end of the bones gradually wears away. Without the protection of the cartilage, the bones begin to rub against each other and the resulting friction leads to pain and swelling. Osteoarthritis can occur in any joint, but most often affects the hands and weight-bearing joints such as the knee, hip and facet joints (in the spine). Osteoarthritis often occurs as the cartilage breaks down, or degenerates, with age. For this reason, osteoarthritis is sometimes called degenerative joint disease.
• Rheumatoid arthritis. Rheumatoid arthritis is a long-lasting disease that can affect joints in any part of the body but most commonly the hands, wrists, and knees. With rheumatoid arthritis, the immune system -- the body's defense system against disease -- mistakenly causes the joint lining to swell. The inflammation then spreads to the surrounding tissues, and can eventually damage cartilage and bone. In more severe cases, rheumatoid arthritis can affect other areas of the body, such as the skin, eyes, and nerves.
• Gout. Gout is a painful condition that occurs when the body cannot eliminate a natural substance called uric acid. The excess uric acid forms needle-like crystals in the joints that cause swelling and severe pain. Gout most often affects the big toe, knee and wrist joints.

Symptoms

Different types of arthritis have different symptoms and the symptoms vary in severity from person to person. Osteoarthritis does not generally cause any symptoms outside the joint. Symptoms of other types of arthritis may include fatigue, fever, a rash and the signs of joint inflammation, including:

• Pain
• Swelling
• Stiffness
• Tenderness
• Redness
• Warmth

Causes

There are many different types of arthritis and the cause of most types is not known. It's likely that there are many different causes. Researchers are examining the role of genetics (heredity) and lifestyle behaviors in the development of arthritis.

Although the exact cause of arthritis may not be known, there are several risk factors for arthritis. (A risk factor is a trait or behavior that increases a person's chance of developing a disease or predisposes a person to a certain condition.) Risk factors for arthritis include:

• Age. The risk of developing arthritis, especially osteoarthritis, increases with age.
• Gender. In general, arthritis occurs more frequently in women than in men.
• Obesity. Being overweight puts extra stress on weight-bearing joints, increasing wear and tear, and increasing the risk of arthritis, especially osteoarthritis.
• Work factors. Some jobs that require repetitive movements or heavy lifting can stress the joints and/or cause an injury, which can lead to arthritis, particularly osteoarthritis.

How Common Is Arthritis?

Arthritis is very common. It has been estimated that as many as 70 million Americans -- or about one in three -- have some form of arthritis or joint inflammation. It is a major cause of lost work time and serious disability for many people. Osteoarthritis, the most common form, affects more than 20 million Americans. Arthritis affects people of all ages, but is more common in older adults.

Diagnosis

Osteoarthritis is typically diagnosed with a complete medical history, including a description of your symptoms, and physical examination. Imaging techniques—such as X-rays or magnetic resonance imaging (MRI)—are sometimes used to show the condition of the joints. If other types of arthritis are suspected, laboratory tests on blood, urine and/or joint fluid may be helpful in determining the type of arthritis. These tests also can help rule out other diseases as the cause of your symptoms.

Treatment

The goal of treatment is to provide pain relief and increase joint mobility and strength. Treatment options include medication, exercise, heat/cold compresses, use of joint protection and surgery. Your treatment plan may involve more than one of these options.

What Is the Outlook for People With Arthritis?

With early diagnosis, most types of arthritis can be managed and the pain and disability minimized. In addition, early diagnosis and treatment may be able to prevent tissue damage caused by arthritis. Early, aggressive treatment is particularly important for rheumatoid arthritis in order to help prevent further damage and disability down the road.

Prevention

Although it may not be possible to prevent arthritis, there are steps to take to reduce your risk of developing the disease and to slow or prevent permanent joint damage. These include:

• Maintaining a healthy weight. Excess weight puts strain on your joints.
• Exercising. Keeping your muscles strong can help protect and support your joints.
• Using joint-protecting devices and techniques at work. Proper lifting and posture can help protect your muscles and joints.
• Eating a healthy diet. A well balanced, nutritious diet can help strengthen your bones and muscles.

Reviewed by the doctors at The Cleveland Clinic Department of Rheumatic and Immunologic Diseases

Edited by Cynthia Haines, MD, WebMD, December 2005.

SOURCE: Food and Drug Administration. The Centers for Disease Control.

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