Am I Dying Read online

  * * *

  Quick Consult

  * * *

  Sleep Medications

  If your insomnia can’t be improved with lifestyle changes, your doctor might recommend a sleep medication. Note that these medications are not intended for long-term use, but you can try them for a few weeks as you develop better sleep habits. They also have some risks, so please use them under a doctor’s supervision and don’t sneak them from your friend’s medicine cabinet. Older adults should be particularly cautious, as they may experience confusion, balance problems, and falls when using a sleep medication.

  A longer-term, more effective solution that doesn’t have any side effects is cognitive behavioral therapy, or CBT. In this treatment, a psychologist trains your brain to avoid stress, minimize distractions, and relax when the lights go down. Ask your doctor about trying CBT in addition to (or even instead of) sleep medications.

  Benadryl/Tylenol PM/Advil PM/Simply Sleep—These over-the-counter medications all contain the same medication, known as diphenhydramine, which is primarily intended as an allergy medication but also causes drowsiness. Although diphenhydramine’s wide availability makes it a common choice for the sleepless, it isn’t reliably effective and has many side effects, including dry mouth, blurred vision, urinary retention (difficulty peeing), and confusion (especially in older adults). Some research has also linked regular diphenhydramine use to early-onset dementia.

  Melatonin—Melatonin is a chemical produced in the brain to regulate the sleep–wake cycle. In pill form, it might help reset the clock after a time zone change; in such cases, it should be taken a few hours before the new bedtime. In other settings, however, melatonin typically isn’t very helpful. It’s found in the herbal supplements aisle—which means the pills aren’t carefully regulated and contain a highly variable amount of actual melatonin. (In other words, you may be paying for expensive sawdust in pill form.)

  Benzodiazepines (temazepam/Restoril, clonazepam/Klonopin, lorazepam/Ativan)—These medications can help you fall asleep and stay asleep, with some (lorazepam) lasting longer than others (clonazepam). These drugs also help reduce anxiety and stress; for example, we often give them to claustrophobic patients before an MRI. Unfortunately, these medications can be habit-forming. They should be taken for short, predetermined time periods under the supervision of a doctor.

  Nonbenzodiazepine Hypnotics (eszopiclone/Lunesta, zolpidem/Ambien, zaleplon/Sonata)—These medications are also highly effective but, like benzodiazepines, are habit-forming and should be limited to short courses. In addition, patients using these medications have reported hallucinations or engaging in abnormal behaviors while asleep, such as eating, driving, even having sex (try using that excuse). Although these side effects are uncommon, they’re another reason to be cautious.

  * * *

  Get to the E.R.

  You can’t sleep because of shortness of breath or extreme pain. If your body is ringing alarm bells, don’t try to sleep through them. If you can’t fall asleep because you’re unable to breathe in certain positions or have a significant new source of pain, get checked out as soon as possible.

  Dizziness

  Just like youth and good weather, balance is hard to appreciate until it’s gone. If you have a bad case of the spins, simply staying upright may be prohibitively difficult.

  One of the issues with treating dizziness is that the word itself can refer to many different sensations. If you’re feeling woozy, like you’re about to pass out, then it’s more accurate to say you’re lightheaded. This feeling occurs when your brain doesn’t get enough blood—and though that sounds terrifying, it’s not always a sign of a serious problem. The key factors are how often your symptoms occur, and in what circumstances, as described next.

  If instead you feel like the room is spinning, then you probably have vertigo. This sensation usually worsens when you turn your head or close your eyes. Vertigo occurs when the labyrinths, the body’s main organs for sensing head position, go haywire. The labyrinths are located in your inner ears and consist of several fluid-filled rings. When you twist your head or turn upside down, this fluid sloshes around in a recognizable pattern, allowing your brain to determine your head’s position relative to the ground (even with your eyes closed). When the labyrinths send confusing or false signals to your brain, you experience vertigo.

  For example, spin around for a few seconds and then stop. Okay . . . easy there. You probably didn’t feel too dizzy while spinning, but felt terrible after you stopped. That’s because inertia kept the fluid in your labyrinths moving around for a few extra seconds. Your brain got confused because your labyrinths said you were moving, but your eyes said you weren’t. After a few seconds, the fluid stopped, and you felt fine again. The same issue explains why most people feel sick while reading in the car. Your eyes think you’re not moving (since the words are still), but your labyrinths sense every bump and turn in the road.

  So what should you do if you’re stumbling around like you’ve had ten vodka shots, but it’s actually noon and you’re presenting to your boss? Go home, lie down, and hope things get better on their own? Go to your local drug store and snag something from the dizziness section (if they even have one)?

  Take a Chill Pill

  You sometimes feel lightheaded when you get out of bed. When you’re lying down and then stand up, gravity causes blood to pool in your legs. During the few seconds required to get that blood moving again, your brain may experience a slight drop in blood pressure that leaves you feeling lightheaded. This phenomenon is normal as long as it’s brief (less than a few seconds) and doesn’t knock you over.

  If the lightheadedness persists for a few minutes, forces you back down to the bed, or happens every time you stand up, you likely have orthostatic hypotension—basically, a very large and abnormal drop in blood pressure upon standing. This condition can result from significant bleeding or dehydration (since the blood pooling in your legs cuts into an already depleted reserve), medications (like beta blockers and diuretics), and nerve problems (since your nerves help correct blood pressure after standing). If you’ve been bleeding, or you haven’t been able to eat or drink anything for days, go to the emergency room. Otherwise, just make an appointment with your doctor.

  You were recently on a long cruise. Your vacation may be over and the sunburn already fading, but your body still thinks it’s staggering down a long hallway on rough seas. You’re experiencing mal de débarquement syndrome, or disembarkment syndrome. (We guess the French take lots of cruises and got naming rights for this one.) This condition can last for a day or two after returning to solid ground, though in rare cases it continues for weeks. It’s not clear why it happens, but the likely explanation is that your brain adapted to the constant jerking of the rocking boat and is still trying to stabilize your legs. Give it more time.

  You’ve just gotten home from a wild night out. Or just woke up from one. If you’ve ever thrown back a few too many drinks, you probably know the uncomfortable spinning sensation that occurs when your head finally hits the pillow. You’re actually experiencing vertigo because all that alcohol changed your blood’s density, affecting fluid movement in your labyrinths. After an hour or two, your labyrinths adapt to the change in blood density, and the vertigo gets better. By the next morning, however, you may get the spins all over again as your blood alcohol level falls and your blood density changes yet again. You’ll probably also feel lightheaded due to dehydration. Stay in bed if possible, and sip some broths, sports drinks, or rehydration solutions (like Pedialyte) while you make progress on your new favorite show.

  Make an Appointment

  You feel lightheaded during exercise. It’s normal to feel a little lightheaded and winded after a hard workout, but if you’re over fifty and get lightheaded whenever you pick up your pace, you could have a heart problem. For example, you could have aortic stenosis, in which the main valve separating the heart from the body becomes stiff and barely opens. As a result
, your heart can’t pump more blood when your muscles need it most. Your blood pressure drops, and you feel lightheaded. Likewise, you could have severe blockages in the arteries supplying your heart muscle with blood, and your heart may become starved during intense exercise and fail to increase its pumping strength. See your doctor for an ultrasound of your heart and possibly a stress test.

  The room sometimes spins after turning your head. You’re likely experiencing benign paroxysmal positional vertigo, or BPPV. This condition occurs when little rocks form in the labyrinths and slosh around when you turn your head, sending confusing signals to your brain. Your doctor can test for this condition by laying you down on the examination table and suddenly turning your head. If you get vertigo, the diagnosis is confirmed. Your doctor can perform head-positioning maneuvers to relocate the rocks from your labyrinths to other parts of the inner ear where they won’t cause problems.

  Your ears ring and feel full, and you sometimes feel like the room is spinning. You likely have Ménière’s disease. (Again, the French are really into dizziness.) This occurs when the fluid pressure in the labyrinths gets high, for unclear reasons. Additional symptoms include hearing loss and tinnitus (constant buzzing or ringing in the ear). The symptoms often worsen with stress, smoking, and consumption of high-salt foods, MSG, caffeine, and alcohol (most of which should be avoided anyway). The treatment is a low-salt diet and, if that doesn’t work, water pills (diuretics) and antinausea medications. You may need a brain MRI to rule out other rare but dangerous causes of these symptoms. A program known as vestibular rehabilitation can improve your balance and reduce your symptoms.

  You have vertigo and a history of migraines. Migraines can cause vertigo when they involve the brain areas that communicate with the labyrinths. The vertigo usually (but not always) occurs at the same time as the headache. In addition to the usual treatment for migraine attacks, your doctor may prescribe medications for dizziness and nausea.

  You feel unsteady on your feet and constantly need to pee. You could have normal pressure hydrocephalus, or NPH, which occurs when the spaces inside the brain (known as ventricles) become enlarged. People with NPH take short, shuffling steps—as if their feet are stuck to the floor. As the condition gets worse, urinary urgency and incontinence occur, followed by mental slowing and poor concentration. (In medical school, we’re taught the three Ws of NPH: wet, wobbly, and wacky.) Your doctor will perform a brain MRI to assess the size of your ventricles. If they look big, your doctor will perform a spinal tap—basically, inserting a needle into your spine to remove some fluid from the ventricles. If this improves your symptoms, the diagnosis is confirmed. For long-term relief, your doctors may recommend inserting a small tube that drains fluid continuously from the brain to another part of the body (such as the abdomen).

  You get tingling and/or pain in your legs. You may have neuropathy, or irritation of your nerves. This condition is particularly common in people with diabetes, though it can result from many other conditions, including thyroid disease, alcoholism, and vitamin deficiencies. The frayed nerves are unable to keep track of the position of your legs, resulting in instability and the sensation of dizziness.

  Get to the E.R.

  The room is spinning and won’t stop. If you experience more than a few minutes of continuous vertigo, you (1) are probably experiencing a degree of misery you never before imagined possible, and (2) should get urgent help, since the explanation could be a stroke or bleeding into your brain. You may need a brain scan just to be sure. If it looks normal, or the doctors think you’re at low risk for stroke, you may instead have a less dangerous condition called vestibular neuritis, which occurs when a viral infection irritates the nerve connecting the labyrinths to the brain. This condition often improves on its own after a few days.

  Your heart starts racing out of nowhere, and then you feel lightheaded. Your heart may be experiencing an abnormal, rapid rhythm that prevents it from effectively pumping blood. Your blood pressure drops, causing lightheadedness. Lie down and call an ambulance. As you wait, you can try certain maneuvers to break the rapid rhythm; for example, coughing or bearing down (like you’re pooping, though please don’t actually poop in your pants).

  You have been bleeding (for example, from a heavy period) and feel lightheaded, especially when standing up. You’ve probably lost a significant amount of blood and should get urgent help. In fact, you may need a transfusion. As described earlier, orthostatic hypotension (drop in blood pressure upon standing) becomes more severe and frequent in people running low on blood.

  You have fever, chills, and severe lightheadedness. You may have a dreaded condition known as sepsis, which occurs when your body goes totally thermonuclear in response to an infection. (Like actual nuclear war, this often results in both sides dying.) Because of the intense immune system response, your blood pressure drops, causing lightheadedness. The treatment involves immediate intravenous fluids and antibiotics. Call an ambulance, since this condition can rapidly turn fatal.

  Forgetfulness

  Are you mildly concerned that one day the police will find you walking the streets at midnight, wearing only your underwear, swinging a bat at a tree? After all, you couldn’t find your iPhone this morning, and isn’t that the first sign you’re losing your marbles?

  Forgetfulness is very common in old age. But when does it become a real problem and transition from mere forgetfulness to outright dementia? At what point will you find yourself so forgetful that you’re routinely unable to finish what you . . . Where were we?

  In medical circles, the term “dementia” describes a progressive decline in memory that interferes with overall quality of life. Common signs include an inability to recall names or identities, correctly identify your location, or complete multistep tasks. The biggest concern is that dementia will become so severe that living independently is no longer possible.

  Dementia is not itself a disease, but rather a cluster of symptoms that result from an underlying disease. The most common is Alzheimer’s, though dementia also frequently occurs as the cumulative effect of multiple small strokes (blockages in blood flow to the brain, which cause a loss of working brain tissue).

  The main risk factors for dementia are high blood pressure, smoking, high cholesterol levels, and chronic alcohol use. You might be able to delay the onset of dementia by staying physically active and keeping your mind sharp (see the Quick Consult).

  So you’re having trouble remembering names and can’t always recall where you left your keys. Is that normal? Or Alzheimer’s?

  Take a Chill Pill

  You keep pulling all-nighters. During sleep, your brain transfers memories from the day’s events into long-term storage. Inadequate sleep is therefore one of the most common causes of forgetfulness. Other symptoms include poor concentration, irritability, depression, and anxiety. Fortunately, you may have the solution to your sleep problem already in your hands (see the section on insomnia).

  Your head is about to explode with stress. Are you worried about your finances? Work? A recent major change in your life? Stress can drive you to distraction, keeping your brain so preoccupied that it fails to pay proper attention to the outside world. Perhaps, as you were replaying that conversation with your boss for the hundredth time, you walked away from your car without locking the door. One solution is to schedule times to stress out, so your mind can vent all of its pent-up worries. Seriously—mark your calendar for thirty minutes when you can go to town on your deepest fears. Having exorcised those demons, you may find it easier to focus for the rest of the day.

  You keep leaving your credit card at the bar. You may know from personal experience that too many vodka sodas can slur your speech, slow your reaction time, impair your memory, and interfere with your sleep. Even after the alcohol wears off, a few nights of poor sleep can have lingering effects on your memory. Try to limit yourself to one or two servings per day. As an aside, long-term alcoholism can occasionally result in a condition known as Ko
rsakoff syndrome. One major feature is confabulation: the invention of (and sincere belief in) elaborate stories created to fill the gaps left by blackouts and memory loss.

  With age comes . . . something . . . In late middle age and beyond, it’s common to experience a mild loss of short-term memory and difficulty processing new information. (If you don’t believe us, try teaching your great aunt how to use Snapchat.) These changes, however, should not interfere with overall quality of life. Interestingly, long-term memory is spared, so you’ll be able to remember your first phone number . . . but maybe not your current one.

  Make an Appointment

  It’s like you’re always stuck in second gear. The thyroid gland helps regulate your metabolism. If it’s tuned up too high, you get sweats, shakes, diarrhea, and weight loss. If it’s in low-power mode, you get fatigue, constipation, weight gain, and memory loss. A simple and cheap blood test can uncover thyroid problems and is part of the standard dementia workup. (Also, you’re welcome for our putting the Friends theme song in your head.)

  You aspire to be the Marlboro Man. Add memory loss to the long list of injuries that result from smoking. A lifetime of light-ups often causes blockages in the blood vessels that supply oxygen to the brain, causing small strokes that chip away at your memory. Your doctor may perform a brain MRI to look for evidence of previous strokes.

  You never cared much for condoms. A one-night stand can leave behind many unwanted souvenirs. A dirty pair of underwear—not yours—found under the bed. A mystery number in your phone. And, of course, advanced syphilis. Even though you might associate syphilis with prostitutes from World War I, it is still very much out there, and over the course of decades it can spread to the brain and cause problems like memory loss, mood disorders (depression, mania), and tremors. Believe it or not, a syphilis test is part of the standard dementia workup. The treatment for syphilis infection is antibiotics.