October 2008

Volume 20 Issue 8
THE

JohnsHopkinsHealthAlerts.com

JOHNS HOPKINS MEDICAL LETTER

HealthAfter50

Taking Control of: Arthritis...Heart Health...Memory...Vision...Diabetes...Cancer...Hypertension...Depression...Nutrition...Osteoporosis...Prostate Health...

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L O N G E V I T Y FA C T S
1Depression coupled with hostility

can be a dangerous combination.

Researchers measured inflammatory proteins associated with cardiovascular disease in 316 people
ages 5070 and found that blood
levels were higher in participants
who showed signs of both hostility
and depression.
Psychosomatic Medicine, vol. 70, p. 197.

1Researchers from Finland and

Canada examined 300 sets of male
twins who reported divergent risk
factors for back pain (e.g., one
brother had a sedentary job while
the others work required heavy
lifting). Despite differences in risk,
many brothers both had back pain.
Shared back pain was greatest
between identical twinswhose
DNA is the samesuggesting back
pain may be due in part to genetic
factors.
Pain, vol. 131, p. 272.

1A recent study links strong social

ties to a healthier recovery after

injury. Among 674 hip fracture
patients, those whod seen or
phoned a friend once a day during
the two weeks before their injury
were less likely to die within the
next two years than patients without such frequent personal contact.
Journal of the American Geriatric Society,
vol. 56, p. 1069.

1Combined data from 7 studies

that followed participants for up to

36 years found that obesity and
being underweight (a body mass
index of 18.5 or less) were associated with an increased risk of
dementia. Other illnesses, like
hypertension, type 2 diabetes, and
cardiovascular disease, may have
contributed to the elevated risk.
Obesity Reviews, vol. 9, p.204.

Intense Diabetes Treatment & CVD

Cardiovascular disease (CVD) continues to be the leading cause of death
among people with type 2 diabetes.
Two major clinical trials set out to test
whether lowering glucose levels even
further than recommended levels could
help protect patients against heart attack
and stroke. The results were alarming,
and one study was stopped early when
investigators found that trying to reach
very low glucose levels increased the
risk of death.
TARGET LEVELS AND THE TRIALS
Glycosylated hemoglobin (A1c or
HbA1c) is a measure of the bodys
average glucose level over several
months. Most doctors and the American Diabetes Association recommend
that people with diabetes aim for A1c
levels of 7% or less. Normal A1c levels for people without diabetes are less
than 6%.
The ACCORD and ADVANCE
trials each enrolled over 10,000 participants with or at very high risk for
CVD. Participants received either
intensive treatment with multiple medications, including insulin, to try to
achieve A1c levels of 66.5% or less
aggressive therapy to reach A1c levels
of 77.9%. Participants were also
treated for high cholesterol and high
blood pressure.
The ACCORD trial was stopped
early when it became clear that participants in the intensive-therapy group
who had CVD were more likely to die
than similar patients who were treated
less aggressively. A total of 257 people
died in the intensive-treatment group,

compared with 203 deaths in the standard-treatment group. This is a significant, 22% higher death rate. About
half the deaths were caused by CVD.
There was no increased incidence
of death in the ADVANCE intensivetreatment group, but intensive treatment did not reduce the risk of heart
attack or stroke any better than trying
to achieve standard levels. And the
greatest benefit of intensive treatment
in ADVANCEless kidney diseasewas compromised by more
instances of severe hypoglycemia (dangerously low blood sugar).
The ACCORD investigators dont
know why the risk of death was greater
in the intensive-treatment group. Thus
far, it doesnt look like any particular
medication played a role in the
increased death rate. The average A1c
levels were 7.5% in the standard-treatment group and 6.4% in the intensivetreatment group. Severe hypoglycemia
was significantly more common in the
latter group, and hypoglycemia may
have been responsible for their higher
death rate. Preliminary, unpublished
findings from a study done by the U.S.
Department of Veterans Affairs suggest that hypoglycemia raises the risk
continued on next page

CONTENTS
Proscar and prostate cancer
Easing an aching neck
Facts about swallowing disorders
Medications to avoid
Artificial disk replacement
DHEA supplements
Treating allergies after 65

3
4
6
7

HEALTH AFTER 50

Johns Hopkins Medicine

Baltimore, Maryland
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Barbara de Lateur, M.D. Distinguished Service Professor,
Physical Medicine & Rehabilitation
John A. Flynn, M.B.A., M.D. Professor, Medicine; Director,
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Arlene A. Forastiere, M.D. Professor, Medicine &
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Professor of Surgery; Chief, Division of Vascular Surgery;
Director, Vascular Noninvasive Laboratory
Peter Rabins, M.P.H., M.D. Professor, Psychiatry &
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continued from previous page

of heart attack and stroke. Its unclear
why participants from the ADVANCE
trial didnt show the same increased
incidence of death.
Notably, in the ACCORD trial,
there were fewer heart attacks and
strokes among people in the intensivetreatment group who did not have
CVD when the trial started than in the
standard-treatment group, suggesting
that very low A1c levels may be safe
for people who have type 2 diabetes
but no evidence of CVD. But given the
high number of deaths, more research
must be conducted to identify the types
of patients who might benefit from
aggressive therapy.
Researchers will continue to analyze the data from both trials in an
effort to determine whether particular
medication combinations or other medical conditions may have played a role
in the surprising outcomes.
WHAT THIS MEANS FOR PATIENTS
The complications that we know are
reduced by lowering A1c to recommended levelskidney disease, vision
loss, and nerve damageare diseases
of the microvascular (small blood vessel) system. CVD is a macrovascular
condition, which involves large blood
vessels, and the results of these studies
demonstrate that very tight control of
blood glucose levels will not reduce
CVD complications.
Simeon Margolis, M.D., Ph.D.,
Professor of Medicine and Biological
Chemistry at Johns Hopkins and Medical Editor of Health After 50, explains,
It is very important to control blood

glucose to prevent acute symptoms,

like excessive thirst and urination, as
well as some late complications like
kidney and eye disease. But even excellent control does not seem to help in
preventing cardiovascular complications and may increase the risk of
dying, perhaps because of the greater
likelihood of severe hypoglycemia.
To prevent cardiovascular complications, patients must focus instead
on smoking cessation, eating well, and
exercising, in addition to taking the necessary medications to control blood
pressure and cholesterol levels. Reductions in both blood pressure and cholesterol have been proven to reduce
events and deaths from CVD in people with diabetes.
Most people with type 2 diabetes
should still aim for A1c levels of around
7%. But patients who have been diagnosed with CVD should not try to get
their glucose levels below 7%.
The ACCORD and ADVANCE
findings do not apply to people with
type 1 diabetes. Long-term studies have
shown less CVD among people with
type 1 diabetes who maintained A1c
levels of 66.5%.
Finally, negative findings like these
are just as important to medical research
as more encouraging discoveries.
Together, the ACCORD and the
ADVANCE trials better our understanding of the connection between
heart disease and diabetes and they
challenge the medical community to
identify new treatment strategies that
address the spectrum of health problems that can develop when people have
type 2 diabetes.
d

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October 2008

Our popular Johns Hopkins Health Alerts website provides information on

prostate health, memory, COPD, osteoarthritis, colon cancer, diabetes, weight
loss, and much moreall from the experts at Johns Hopkins.
Recently, Johns Hopkins Hospital earned the top spot in U.S. News & World
Reports annual rankings of American hospitals for the 18th consecutive year!
So you know that everything you read on the Health Alerts website is reliable.

The Johns Hopkins Medical Letter

Does Proscar Prevent Prostate Cancer?

In 2003, researchers from the landmark
Prostate Cancer Prevention Trial
(PCPT) reported that men who took
the drug finasteride (Proscar) were
approximately 25% less likely to be
diagnosed with prostate cancer than
men who took a placebobut men in
the finasteride group who did develop
cancer were 68% more likely to
develop high-grade disease, so the drug
was rejected as a cancer prevention tool.
Now, in a complete about-face,
researchers have reanalyzed the original PCPT data and come out in
favor of the drug for the prevention
of cancer. But Patrick Walsh, M.D.,
a pioneer in prostate cancer treatment and the former, long-time
Director of the Brady Urologic
Institute at Johns Hopkins, says that
continued caution is in order.

than in the finasteride group, suggesting that this study error contributed to
the higher rate of high-grade tumors in
the finasteride group.
The researchers suspect also that
the risk of high-grade cancer in the
finasteride group resulted from more
exact biopsiesthe drug had shrunk
the prostate, making biopsy tests more
sensitive to cancer cells. Thus, finasteride wasnt to blame for the high-risk

Determining Your True PSA Level

While Taking Finasteride
Men taking finasteride for BPH or hair loss
should adhere to the following guidelines for
PSA testing:

For a truer PSA reading, your test levels

should be multiplied by 2 for the first 2
years on finasteride

After 2 years on the drug, your PSA level

should be multiplied by 2.3 for up to 7 years

After 7 years on finasteride, your PSA level

FINASTERIDE BASICS
should be multiplied by 2.5
Finasteride is currently used to treat
If your PSA level ever rises, get a biopsy
age-associated enlargement of the
prostate or benign prostatic hypercancers that were found; the cancer was
plasia (BPH). The drug works by supjust easier to find.
pressing dihydrotestosterone (a
In fact, when PCPT data was reanstronger cousin of testosterone) that
alyzed with this in mind, finasteride
contributes to BPH.
reduced the risk of developing aggresBPH does not increase your risk
sive prostate cancer by 27%.
of developing prostate cancer; however, testosterone and dihydrotestosCAVEATS
terone also encourage the growth of
prostate cancer cells; thus, the question
Dr. Walsh raises a third possibility:
about whether finasteride can help preBecause finasteride dramatically
vent prostate cancer. (Dihydrotestosreduces prostate specific antigen (PSA)
terone also blocks hair follicles from
levels, fewer participants taking the
growing in the scalp; Propecia, a meddrug underwent biopsies, reducing the
ication used to treat hair loss, is lownumber of cancers that were detected
dose finasteride.)
rather than reducing the number of
cancers that developed. Therefore, the
PCPT REVISITED
drug just prevents men from having a
biopsyit doesnt prevent them from
Investigators published their revised
developing prostate cancer. In fact,
analyses of the PCPT study data in
15% fewer men who took finasteride
Cancer Prevention Research. One reunderwent a biopsy than men who
examination indicated that more hightook a placebo.
grade cancers had been misclassified as
Some experts point out that conlow grade in the original placebo group

ducting fewer biopsies may be a good

thing, because that could reduce the
overtreatment of prostate cancer. Widespread PSA testing has resulted in more
frequent biopsies and better cancer
detection, but doctors cant be certain
which cancers will become dangerous.
Thus, many men are cautious and opt
for prostatectomy (removal of the
entire prostate gland) or radiation; both
can have devastating side effects, including impotence and incontinence.
Dr. Walshs major concern,
though, is that finasteride may have
kept some men who really needed
a biopsy from getting one.
And, looking only at the participants in the PCPT study who
did have biopsies, it seems unlikely
that finasteride prevents cancer. Dr.
Walsh points out, Finasteride did
not significantly reduce the risk of
prostate cancer in men who underwent a biopsy because of elevated
PSA levels or an abnormal digital
rectal examthe group of patients
who, ideally, would be given finasteride
for cancer prevention.
WHAT NOW?
Some doctors remain hopeful that additional research will prove finasteride
helps prevent prostate cancer. But
because finasteride artificially lowers
PSA levels and because available evidence suggests that the medication does
not work in the very population it was
supposed to help, Dr. Walsh says that
men should not take finasteride for
prostate cancer prevention.
Finasteride is safe for treating
BPHjust make sure that you have
your PSA monitored more carefully.
If you are taking finasteride and your
PSA goes up at all, you should
promptly have a biopsy, advises Dr.
Walsh. The slightest rise is proportionally greater than similar changes in
men who are not taking finasteride. d
October 2008

HEALTH AFTER 50

How To Nip Neck Pain in the Bud

Neck pain is a common health complaint. Cortisone injections, prescription pain relievers, or over-the-counter
pain medications like nonsteroidal antiinflammatory drugs (NSAIDs) can help
but offer only temporary relief. Experts
agree that you have to exercise to really
get rid of a pain in the neck.
ROOTS OF NECK PAIN
There are many potential causes of neck
pain. Arthritis, like degenerative disk
disease (the gradual deterioration of
spinal disks that cushion adjacent vertebrae), and herniated disks (disks that
push into adjacent nerves) are all potential sources of pain. Acute muscle
strains and injuries like whiplash, which
stretch the neck muscles beyond their
natural capacity, also may cause severe
pain.
Imaging tests, including x-rays,
computed tomography (CT) scans, and
magnetic resonance imaging (MRI)
scans, help diagnose neck pain caused
by arthritic changes or herniated disks.
Since degenerative spine conditions and
cervical disk problems in the neck can
lead to neurological symptoms, like tingling, numbness, and weakness in one
or both arms, imaging also helps to rule
out more serious conditions with similar symptoms, like neck tumors.
Often, neck pain is nonspecific,
which means it lacks a discernable
cause. Sources of nonspecific neck pain
might include poor posture, teeth
grinding, or seemingly innocuous activities like driving or reading upright in
bed every night. Psychological factors,
like anxiety and stress, also may be at
work: Many people seem to hold
their tension in the neck muscles.
Unlike neck pain from arthritis or
injury, nonspecific pain may not be
focused in one particular spot, and
patients might find it difficult to link
their pain to any one activity. This
doesnt mean the pain cant be treated.
4

October 2008

SUPERIOR STRENGTH
Whether the root of neck pain is arthritis or nonspecific, exercise is essential.
Strong muscles reduce pain by taking
pressure off arthritic joints and disks.
The stronger your muscles are, the
more support they will provide and the
less likely they will be to get achy and
fatigued.
A 2003 study published in the
Journal of the American Medical Association assigned 180 women who had
desk jobs and nonspecific neck pain to
participate in one of three year-long
exercise programs: (1) a strength-training group that used elastic exercise
bands and weights to perform resistance exercises targeting the neck, (2)
an endurance-training group that performed neck exercises without resistance, or (3) an aerobic exercise only
group. All three groups were given the
same stretching exercises, and all were
advised to complete 30 minutes of aerobic exercise daily (e.g., peddling a stationary bike or brisk walking). The
strength-training and endurance groups
also strengthened their arms and shoulders with weights.
At the studys end, the aerobics
group had less neck pain and disability, but their gains were small compared
with the endurance and strength-training groups. And on measures of neck
rotation, strength, and flexibility, the
strength-training group scored 47%,
82%, and 53% better, respectively, than
the endurance group.
Another study, published in the
journal Arthritis Care & Research,
recruited 48 women with chronic pain
in the trapezius muscle, which runs
from the shoulder to the neck. Some
women did strength-training exercises
with dumbbells to target neck and supporting shoulder muscles. A second
group of women performed fitness
training that consisted of riding a stationary bike without holding the han-

dlebars. Both groups worked out 20

minutes a day, three times a week, for
10 weeks. A third group received only
health counseling.
The group that did strength training reported 75% less pain both immediately following the workouts and
several weeks after the study ended.
Despite the well-known cardiovascular benefits of fitness training, the fitness group felt less pain and stiffness
only immediately after working out,
perhaps because endorphins released
during cardiovascular exercise acted as
a temporary analgesic. The counseling
group showed no improvement.
GETTING STARTED
The next page contains neck exercises
commonly recommended by physical
therapists. Dumbbells can be purchased
at most any store that sells sports
equipment.
Start with light dumbbells (28 lbs)
and then work up to heavier weights
as your strength increases. Try out
weights at the store before buying
them. A good test is 12 repetitions of
one of these recommended exercises.
If youre not struggling on the last repetition, the dumbbell is too light; if
youre struggling early on in the set,
its too heavy.
Once youve started exercising,
keep to a regular schedule, like three
days a week for about 20 minutes per
session. Try completing at least three
of the suggested exercises each session
and rotate the order of the exercises
each time you work out.
Strength training can be fairly
intense if youre not used to weight lifting. Talk to your doctor before
embarking on a strength-training program and progress slowly, being careful not to strain your neck. Stop if you
feel pain and take a few days off to let
your muscles recover. If the pain persists, see your doctor.
d

The Johns Hopkins Medical Letter

Suggested Strengthening Exercises To Ease Your Pain

Cervical Flexion
Lie on the floor with your head supported by a
pillow
Lift your head, bringing your chin to your chest without lifting your shoulders
Once your chin touches your chest, lower head and
relax for 5 seconds
Perform 3 sets of 10 repetitions once a day, resting 1
minute between sets

Dumbbell Shrug

Stand straight with your feet shoulder-width apart and

your knees slightly bent

Hold a weight in each hand with your arms at your

sides

Shrug your shoulders up, contracting the trapezius

muscle for 1 second

Work up to performing 3 sets of 812 repetitions, resting 1 minute between sets

Lateral Rise With Weights

Stand straight with your feet shoulder-width apart

and your knees slightly bent

Hold a weight in each hand with your arms at your

sides

Raise both arms to shoulder level and then lower

your arms slowly

Work up to performing 3 sets of 812 repetitions, resting 1 minute between sets

Upright Row With Weights

Stand straight with your feet shoulder-width apart and
your knees slightly bent
Hold a weight in each hand with your palms facing
the front of your thighs
Raise the weights to your chest (hands should be
shoulder level and elbows parallel to the floor) and
then lower your arms slowly
Work up to performing 3 sets of 812 repetitions, resting 1 minute between sets

October 2008

HEALTH AFTER 50

Dysphagia: When Its Hard To Swallow

Swallowing is an elaborate process. As
you chew, your tongue helps to break
down food by mixing it with salivary
enzymes. Then your tongue moves the
food into the pharynx (a small canal
that connects the mouth with the
esophagus), which triggers the swallowing reflex. The epiglottis valve,
located at the opening of the trachea
(windpipe), closes to prevent food from
getting into the lungs, and food moves
down the esophagus and into the stomach by peristalsis, the involuntary contraction of esophageal muscles.
A problem anywhere along this
pathway can cause dysphagia (trouble
swallowing)which has potentially
serious consequences. Aside from
choking, people with dysphagia may
also not eat or drink enough and can
become malnourished or dehydrated.
The biggest worry is pulmonary aspiration, which happens when small
amounts of food, saliva, and the bacteria they contain seep into the trachea
and lungs. Patients with pulmonary
aspiration are at high risk for developing pneumonia, which can be fatal for
older people, particularly those who
are already in a weakened state because
of other chronic conditions.
Although dysphagia cant always
be cured, 80% of people can improve
their dysphagia symptoms through targeted exercises and eating and swallowing strategies.
DEFINING DYSPHAGIA
There are many different causes of dysphagia. Some medications that depress
the nervous system, such as diazepam
(Valium), antipsychotics, corticosteroids, and anticholinergerics (including medications for bladder spasms,
trihexyphenidyl [Artane], and diphenhydramine [Benadryl]), can cause dysphagia, as can thyroid conditions,
esophageal tumors, and herpes infections of the mouth.
6

October 2008

Swallowing Up Close
As food enters the pharynx, the epiglottis closes to prevent food from entering
the lungs. The food then moves into the esophagus, where peristalsis (involuntary contractions) push it toward the stomach.

tongue

food in pharynx
epiglottis

larynx

esophagus
(to the stomach)

trachea
(to the lungs)

Most often, dysphagia is due to

structural problems within the esophagus. For instance, the lower esophageal
sphincter above the stomach may not
close properly, which can allow stomach contents to regurgitate back up into
the esophagus, often creating a choking sensation. Acid reflux, or gastroesophageal reflux disease (GERD), also
can damage the lining of the esophagus, which can lead to regurgitation or
encourage the formation of scar tissue
called strictures. These strictures narrow the esophagus and make swallowing painful and difficult, since
muscles must work overtime to push
food through. Pouches (diverticula)
also can form in the esophagus, trapping food and obstructing other food
from passing through.
An endoscopy or barium x-ray
(drinking a barium solution enhances
images on x-rays as you swallow) can
detect strictures and diverticula. Both
can be removed through laparoscopic,
minimally invasive surgery.
A muscle contraction test that measures swallowing pressure also may be
performed. If the esophageal sphincter
muscle is weak or not functioning

properly, it can be tightened through

surgery. Or if dysphagia is related to
GERD, dietary changes, H2 blockers,
or proton pump inhibitors may reduce
the production of stomach acid and
ease swallowing.
Loss of control of swallowing muscles in the mouth and throat is another
common source of dysphagia. This can
happen after a stroke or as a result of
neurological disorders such as multiple sclerosis or Parkinsons disease.
Hospitalized patients getting critical
care with breathing tubes also may
develop dysphagia. The muscles of the
mouth and throat also may weaken or
deteriorate as you agethough dysphagia is not considered a natural part
of the aging process.
TRAINING AND ADAPTING
Plasticity, the theory that the brain can
adapt and relearn through repetitive
motion after a stroke or neurological
illness, has been applied to swallowing
disorders. For instance, researchers have
found that loading (gradually increasing weight load to increase strength)
can be applied to eating: Increasing bite
size over time may ease dysphagia.

The Johns Hopkins Medical Letter

Patients can also learn postural

maneuvers that strengthen swallowing
muscles and/or open the esophagus to
ease swallowing. One maneuver is the
effortful swallow, in which patients
squeeze all of their head and neck muscles while swallowing. For the Shaker
exercise (also called the Shaker head
lift), patients lie down and slowly lift
the head to look at the feet and then
slowly lower the head back down;
patients may do a few lifts, holding the
head up for 60 seconds each time. Postural compensationtilting or turning
the head so that food favors the unobstructed or stronger side of the esophagusmay help patients swallow, as
can altering the thickness and amount
of food and liquid.
Applying external electrodes to

stimulate the muscles involved in swallowing also has been tested, but so far,
results are mixed.
THE BOTTOM LINE
If youre having trouble swallowing,
get help. Otolaryngologists specialize
in disorders of the ear, nose, and throat.
Other experts, including Physical Medicine and Rehabilitation (PMR) physicians or physiatrists (physicians who
specialize in rehabilitation medicine),
also are specially trained to help people with dysphagia.
Because the causes of dysphagia are
so varied and because the condition
often results from other medical disorders, treatment should be very individualized. In order to help the most
patients, many hospitals have created

multidisciplinary swallowing centers,

which employ specialists who can diagnose and treat the gamut of disorders
linked to dysphagia.
d
FOR

MORE INFORMATION

Dysphagia Resource Center

http://dysphagia.com
Johns Hopkins Department of
Physical Rehabilitation
Swallowing Disorders Program
(410) 532-4700
(888) JHU-REHAB
www.hopkinsmedicine.org/Rehab/
services/swallowing_disorders.html
National Institute on Deafness &
Other Communication Disorders
(800) 677-1116
www.nidcd.nih.gov/health/voice/
dysph.asp

Do You Know What's in Your Medicine Cabinet?

Listed below are 33 medications with side effects that are
more dangerous to people over 65, like memory impairment, dizziness, drowsiness, and blurred vision. These
drugs should be avoided unless no other options exist.
Unfortunately, a 2007 review by the Agency for Healthcare
Research and Quality (AHRQ) found that older adults are
still using these risky medications. According to the AHRQ,
13% of adults over 65 used always inappropriate drugs.
This percentage was higher (25%) among older adults with
disabilities.

More recently, researchers from the University of North Carolina (UNC) at Chapel Hill compiled a second list of dangerous drugs. This new list includes drugs that increase the risk
of falls in people over 65 who take more than four medications. Patients shouldnt avoid the drugs on the UNCChapel
Hill list, but if theyre taking one of the UNCChapel Hill
drugs, they should talk to their doctors about reducing their
risk of falling. To view the UNCChapel Hill list, go to: uncnews.unc.edu/images/stories/news/
health/2008/drugslist.pdf

33 Drugs To Avoid if Youre Over 65

Always Inappropriate

Barbiturates (amobarbital, butabarbital, pentobarbital, phenobarbital,

secobarbital)

Flurazepam (Dalmane, Somnol,

Novo-Flupam, Apo-Flurazepam)

Meprobamate (Equanil, Meprospan

200, Meprospan 400, Probate, ApoMeprobamate)

Chlorpropamide (Diabinese, NovoPropamide, Apo-Chlorpropamide)

Meperidine (Demerol)
Pentazocine (Talwin, Talwin Nx)
Trimethobenzamide (Benzacot,
Stemetic, Tebamide, Tigan, Tribenzagan, Trimazide)

Dicyclomine (Bentyl, Bentylol, Spasmoban, Formulex)

Hyoscyamine (Anaspaz, A-Spas-S/L,

Cystospaz, Levbid, Levsin, Levsinex
Timecaps, Symax SL)

Propantheline (Pro-Banthine)
Belladonna alkaloids/phenobarbital
(Barbidonna, Donnatal)
Rarely Appropriate

Chlordiazepoxide (Librium)
Diazepam (Valium)
Propoxyphene (Darvon, Darvon-N)
Carisoprodol (Soma)
Chlorzoxazone (Remular-S, Paraflex,
Parafon Forte DSC)

Cyclobenzaprine (Flexeril)
Metaxalone (Skelaxin)
Methocarbamol (Robaxin)

Sometimes Appropriate

Amitriptyline (Elavil)
Doxepin (Sinequan)
Indomethacin (Indocin)
Dipyridamole (Persantine)
Ticlopidine (Ticlid)
Methyldopa (Aldomet)
Reserpine (Serpasil, Serpalan,
Novoreserpine)

Disopyramide (Norpace, Norpace CR)

Oxybutynin (Ditropan, Ditropan XL)
Chlorpheniramine (Aller-Chlor, Chlorate, Chlo-Amine, Chlor-Trimeton)

Cyproheptadine (Periactin)
Diphenhydramine (Benadryl)
Hydroxyzine (Atarax, Rezine, Vistaril)
Promethazine (Phenergan)

Journal of the American Medical Association, vol. 286, p. 2823.

October 2008

HEALTH AFTER 50

HOU S E CALLS

Q I have degenerative disk disease.

Will Medicare cover the cost of an
artificial disk replacement?
A Not yet. In 2004 the U.S. Food and
Drug Administration (FDA) approved
the first artificial lumbar disk, Charit,
and in 2006 it approved the Prodisc-L.
Both can replace worn disks in a particular area of the lower spine (between
the L4 and S1 vertebrae) in patients
with no history of osteoporosis, scoliosis, or a potential allergy to the artificial material. Patients must also have
demonstrated no improvement after six
months of conservative treatment with
physical therapy, heat, ice, and antiinflammatory medicines.
Research suggests that artificial disk
replacement effectively restores movement and eliminates pain. But clinical
trials have included only people ages
60 and younger; therefore, Medicare
has determined not to provide coverage for its beneficiaries until additional
studies show the disks work in the
over-60 age group.
Generally, surgery is a last resort
for treating degenerative disk disease.
If you havent done so already, talk to
your doctor about conservative treatments, such as pain relievers and exerciseover time, they tend to work for
most patients.
Q Can taking DHEA supplements
improve my memory?
A Probably not. Between ages 20 and
30, dehydroepiandrosterone (DHEA)
hormone levels peak and then fall gradually with age. Some research has associated declining DHEA levels with
age-related problems like memory loss.
DHEA supplements that contain a

plant-based version of this hormone

are sold over the counter at many pharmacies and health-food stores as a cure
for age-associated memory loss, but as
is the case with many dietary supplements, evidence supporting DHEAs
efficacy is scant at best.
The first long-term, controlled
study of DHEA supplements was published in the Journal of the American
Geriatrics Society. Researchers enrolled
225 participants ages 5585 who
received either a DHEA supplement
or a placebo each day. After a year,
researchers found no improvements in
memory among those taking DHEA
compared with participants who took
the placebo.
Moreover, because dietary supplements are not regulated by the FDA,
supplements can be dangerous as well
as ineffective.
Instead of taking DHEA supplements to improve your memory, stay
socially active, get plenty of physical
activity, and try stimulating your brain
with music, reading, or puzzles.
Q Im 75, and Ive always taken
Benadryl for my allergies. My doctor
advised me to switch to a prescription allergy medication. Why?
A Believe it or not, the antihistamine
Benadryl (diphenhydramine) is a drug
that people over 65 should avoid unless
they have no other options. (See page
7 for a complete list of medications to
avoid.) Benadryl (like many drugs on
this list) can cause drowsiness and
dizziness, which are particularly dangerous for people over 65.
Several prescription and over-the
counter antihistamines, like Allegra
(fexofenadine HCl), Zyrtec (cetirizine),
and Claritin (loratadine), dont cause
such intense drowsiness.

g
REMEDIES
1People who bring a companion

to doctors visits are more satisfied

with their care and have an easier
time communicating with their
physicians, according to a recent
study of Medicare recipients.
Spouses, children, neighbors, and
friends accompanied patients and
helped by writing down instructions, asking questions, and providing moral support.
Archives of Internal Medicine, vol. 168,
p.1409.

1If you are undergoing joint

replacement, talk to your doctor
about what medications you'll
need after surgery. According to a
study of over 10,000 participants,
fewer than 1 in 5 patients were discharged with medications such as
warfarin (Coumadin) to prevent
potentially deadly blood clots that
may develop after surgery. Anticoagulant drugs should be taken for
at least 10 days after knee surgery
and for 10 to 35 days after hipreplacement surgery.
Canadian Medical Association Journal,
vol. 178, p.1545.

1Gout is typically treated with

nonsteroidal anti-inflammatory
drugs (NSAIDs), but these can be
dangerous for people at risk for
gastrointestinal bleeding. Steroids,
the next line of defense, are very
effective, but long-term use can
lead to health problems. The good
news: A study comparing the
NSAID naproxen with the steroid
prednisone among 121 participants found that only 4 days of
prednisone was enough to relieve
gout symptoms.
Lancet, vol. 37, p.1854.

IN FUTURE ISSUES
New osteoporosis guidelines
Kidney transplants for the elderly
Light therapy for Alzheimers
patients

HOUSE CALL QUESTIONS:

Health After 50, Johns Hopkins, 901 South Bond Street, Suite 550, Baltimore, MD 21231.
We regret that we cannot answer letters personally.
SUBSCRIPTION INQUIRIES: Health After 50, P.O. Box 420179, Palm Coast, FL 32142-0179, or phone 1-800-829-0422.
BULK SUBSCRIPTION INQUIRIES: Health After 50, 6 Trowbridge Drive, Bethel, CT 06801.

October 2008

Published with Johns Hopkins Medicine