MAYO CLINIC HEALTH LETTER To o l s f o r H e a l t h i e r L i v e s VOLUME 26 NUMBER 5

MAY 2008

Inside this issue HEALTH TIPS . . . . . . . . . . . . . 3 Colonoscopy prep. NEWS AND OUR VIEWS . . . . . 4 Tiny radioactive beads studied as treatment for liver tumors. New advance in allergy immunotherapy. THYROID TROUBLES . . . . . . 4 Subtle symptoms with age. ROUTINE EYE EXAMS . . . . . . . 6 What the doctor sees. EXCESSIVE SWEATING . . . . . 7 Therapies to keep you dry. SECOND OPINION . . . . . . . . 8

Aortic aneurysm When surgery makes sense Your doctor ordered a computerized tomography (CT) scan to see if you have kidney stones. But the CT scan revealed something unexpected in your abdomen — a bulge (aneurysm) in your aorta, the main artery supplying blood to your body. An aortic aneurysm can be a serious and unsettling problem. They often don’t cause any symptoms, but some may burst or tear without warning and cause life-threatening internal bleeding. However, larger aortic aneurysms, which are most prone to rupture, aren’t very common. More common are aneurysms that are small and

slow growing. When detected, these can be closely monitored so that surgical repair can be planned when — or if — it becomes necessary. In addition, certain medications and making heart-healthy decisions may prevent rapid growth.

A weakened artery Your aorta is a cane-shaped blood vessel that exits from the top of the heart and curves downward, passing through the chest and abdomen. It’s about the diameter of a garden hose and is the body’s largest artery. Major arteries branch off from the aorta to supply blood to the brain, arms, internal organs and legs. An aneurysm occurs when the wall of the aorta becomes weak or damaged. Over time, the constant pressure of blood flowing through the weakened area can cause a section of the aorta to slowly enlarge. ➧

Coming in June FUNCTIONAL MRI A window on brain function. CANCER AND WEIGHT A growing problem. HIP BURSITIS Exercise the pain away. DAO YIN SELF-MASSAGE Exploring a Chinese tradition.

Thoracic aortic aneurysm

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Abdominal aortic aneurysm

Dissecting aneurysm

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Aneurysms can occur anywhere on the aorta, but about 75 percent occur in the abdomen and are called abdominal aortic aneurysms. Most of the remainder occur nearer to the heart and are called thoracic aortic aneurysms.

Factors of formation The walls of a healthy aorta are very elastic and can stretch and relax as needed to accommodate pulses of blood from the heart. But with age, the aorta becomes less elastic. That’s one reason why most abdominal aortic aneurysms occur in adults over 60 — but it’s seldom the only reason. The weakening and break-

Dissection of the aorta The walls of your aorta are made of three tissue layers. In some cases, a tear can occur within the aortic wall, causing these layers to dissect (separate). This can hamper blood flow throughout your body and can cause the aorta to weaken and enlarge, putting it at risk of rupture. Surgical repair of a dissecting aorta may be required if blood supply to your organs isn’t adequate — or if the area of dissection is rapidly expanding or located on the part of the aorta nearest the heart. But in many cases, simply lowering your blood pressure is enough to allow the dissection to heal enough so that immediate surgery can be avoided. Careful, lifelong monitoring of the area will be necessary to watch for aneurysm development and growth.

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down of the aorta wall where the aneurysm forms is usually accelerated by other factors, including: ■ Smoking — It’s estimated that about 90 percent of people who develop aneurysms have smoked at some point in their lives. ■ High blood pressure (hypertension) — Over a period of years, excess pressure that hypertension puts on your arteries can cause them to weaken and lose elasticity. ■ Artery clogging and hardening (atherosclerosis) — This is the buildup of cholesterol-containing fatty deposits on artery walls that can damage the artery lining. A number of less common factors may also contribute to aortic aneurysms. In addition, men are more likely to have an aortic aneurysm than are women, and aortic aneurysms can run in families.

will never heal and return to normal. Many aneurysms will eventually need to be repaired surgically — but it’s not always necessary to do so right away. If your abdominal aortic aneurysm is small, appears to be growing slowly and isn’t causing any symptoms, your doctor may recommend a “wait-and-watch” approach, using imaging tests one to two times a year to assess the size and growth rate of your aneurysm. You may be able to minimize aneurysm growth and the risk of rupture — and to maximize the overall health of your arteries — by: ■ Stopping smoking and avoiding secondhand smoke ■ Treating hypertension, which typically involves taking one or more drugs to lower blood pressure, but may also be helped by limiting your sodium intake

Discovering a problem An enlarging abdominal aortic aneurysm may produce some symptoms, such as a pulsing sensation near the navel, tenderness or pain in the abdomen, or back pain. However, it’s more common for aortic aneurysms to occur without symptoms. They are frequently discovered during a routine physical exam, through a CT scan or ultrasound of the abdomen, or on an X-ray of the chest area that’s being done for another purpose. Generally, aortic aneurysms are too rare to warrant widespread screening. However, certain groups for which an ultrasound screening test may be appropriate include: ■ Men who are 65 and older who smoke or who have smoked ■ Men who are 50 and older — and women who are 60 and older — who have a parent or sibling who has had an aortic aneurysm

Preventing rapid growth Once a bulging aneurysm begins to form in your aorta, your aorta May 2008

MAYO CLINIC HEALTH LETTER Managing Editor Aleta Capelle

Medical Editor Robert Sheeler, M.D.

Associate Editors Carol Gunderson Joey Keillor

Associate Medical Editor Amindra Arora, M.D.

Medical Illustration Michael King Customer Service Manager Ann Allen

Editorial Research Deirdre Herman Proofreading Miranda Attlesey Donna Hanson Administrative Assistant Deborah Adler

EDITORIAL BOARD Shreyasee Amin, M.D., Rheumatology; Amindra Arora, M.D., Gastroenterology and Hepatology; Brent Bauer, M.D., Internal Medicine; Tracy Berg, R.Ph., Pharmacy; Julie Bjoraker, M.D., Internal Medicine; Bart Clarke, M.D., Endocrinology and Metabolism; William Cliby, M.D., Gynecologic Surgery; Diane Dahm, M.D., Orthopedics; Mark Davis, M.D., Dermatology; Timothy Hobday, M.D., Oncology; Lois Krahn, M.D., Psychiatry; Michael Mahr, M.D., Ophthalmology; Lance Mynderse, M.D., Urology; Suzanne Norby, M.D., Nephrology; Robert Sheeler, M.D., Family Medicine; Phillip Sheridan, D.D.S., Periodontics; Peter Southorn, M.D., Anesthesiology; Ronald Swee, M.D., Radiology; Farris Timimi, M.D., Cardiology; Aleta Capelle, Health Information. Exofficio: Carol Gunderson, Joey Keillor. Mayo Clinic Health Letter (ISSN 0741-6245) is published monthly by Mayo Foundation for Medical Education and Research, a subsidiary of Mayo Foundation, 200 First St. SW, Rochester, MN 55905. Subscription price is $27 a year, which includes a cumulative index published in December. Periodicals postage paid at Rochester, Minn., and at additional mailing offices. POSTMASTER: Send address changes to Mayo Clinic Health Letter, Subscription Services, P.O. Box 9302, Big Sandy, TX 75755-9302.

At left is open-abdominal surgery using a graft. At right is endovascular surgery with a graft.

Getting regular, moderate exercise, such as walking ■ Avoiding activities that cause prolonged elevation of blood pressure, such as long periods of strenuous activity ■ Improving cholesterol levels, which may be achieved with medication and by eating a diet low in saturated fat and cholesterol and high in fruits, vegetables and other high-fiber foods ■

Surgical options With larger aneurysms, surgery is often considered. Surgery may also be considered if a smaller aneurysm is enlarging rapidly or is

Rupture symptoms A rupture or dissection of your aorta is a sudden event that often feels like a ripping sensation down your back to your groin or between your shoulder blades. The pain can be intense, but it can also be somewhat dull. You may also feel clammy, lightheaded or dizzy. If you know you’re at risk of aortic aneurysm rupture, be aware of these symptoms and seek emergency care if they occur.

leaking. Deciding whether to go ahead with surgery involves numerous factors, one of which is to assess your overall health to determine whether the risk of your aneurysm rupturing is greater than your risk of having surgery to repair it. The two main types of surgery include: ■ Open-abdominal or openchest surgery — This is the standard operation to repair an aortic aneurysm. It involves making an incision in the front or side of the abdomen or chest so that the damaged section of your aorta can be replaced with a synthetic tube. This surgery is generally successful and requires the least amount of followup care. It’s also more durable over the long term. The odds of needing a repeat procedure to repair a problem are less than 2 percent. The major drawback is that it typically requires a four- to sevenday hospital stay and often around four to six weeks for a full recovery. Still, if you’re fairly healthy and under 70, it may be a better choice. ■ Endovascular surgery — This newer procedure may be an option in many situations as a way to avoid major surgery — and may be a better choice only for those who are over 70 or who are at higher risk of complications from open surgery. With the endovascular approach, a synthetic graft is inserted into an artery in the leg and maneuvered to the aorta. Using X-ray guidance, the graft is positioned and expanded into place. Endovascular surgery generally carries fewer risks than does open surgical repair, and you can expect a recovery period of days, rather than weeks. However, follow-up appointments are needed on a more frequent basis and the likelihood of needing a repeat procedure is 10 percent to 20 percent. In addition, it’s not known how well these repairs hold up over the long term. ❒ May 2008

Health tips Colonoscopy prep In the days before a scheduled colonoscopy, prepare for the exam by avoiding red, orange or purple foods and beverages, which can look like blood during the screening. Ask ahead about taking regular medications. For instance, if you take insulin, ask about special instructions to help prevent hypoglycemia. If you regularly take aspirin, ask your colonoscopy doctor if discontinuing aspirin before your test may be worthwhile and if so, for how long. Talk with your primary care provider if you take an anticoagulation drug such as warfarin (Coumadin) or clopidogrel (Plavix), as frequently these must be discontinued or monitored before a colonoscopy. Stop taking oral iron supplements at least five days before the procedure. To help gear up your digestive tract for cleansing: ■ Lighten your diet — Avoid high-fiber foods for two to three days before your preparation day. Reduce portions. ■ Stock up on clear liquids — A clear diet is recommended for 24 hours before a colonoscopy. Good choices include water, clear broth, fruit juices without pulp, and clear, colorless sodas. ■ Serve it cold — You may find the colon prep solution more drinkable if it’s cold. Prepare and refrigerate it according to package directions. It also may help to suck on a lemon slice or hard candy after drinking the solution. ❒

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News and our views Tiny radioactive beads studied as treatment for liver tumors Early results from a Mayo Clinic study show promise for a new way to treat cancer that has spread (metastasized) to the liver. The treatment involves sending radioactive beads (microspheres) into the liver through its blood supply in an effort to halt the growth of multiple tumors in the organ. The small clinical trial involved 20 people, ages 35 to 87, who had cancerous tumors that had spread to the liver. Half of the tumors had spread from rare, slow-growing neuroendocrine tumors, and half originated from other types of cancer, such as colon cancers. Four weeks after treatment, computerized tomography (CT) scans indicated some benefit in 71 percent of participants. Cancer did progress in two people who died within three months of the treatment. However, those who responded to the treatment had no new tumors at the end of a 10-month follow-up period. In addition, researchers say that liver function tests in those who responded became normal or were stabilized. Although the findings are preliminary, Mayo Clinic doctors say the microsphere treatment approach is of interest and further study is under way. They note that depending on the situation, there may be better treatment options — such as chemotherapy — for cancer that’s spread to the liver from a primary cancer elsewhere. ❒

New advance in allergy immunotherapy Allergen immunotherapy is a series of allergy shots given over time to desensitize people to certain allergens. However, it has the potential to cause allergic reactions and it typically involves receiving 100 or more shots over about five years, with many given the first year. A new drug — omalizumab (Xolair) — blocks the type of natural antibody that causes allergic reactions and may be able to make this process safer, more effective and significantly more convenient. But it’s expensive, which is why it’s typically used only to treat very severe allergic asthma, its approved use. Recently, researchers discovered that about two to four injections of omalizumab given prior to allergen immunotherapy make it possible to condense the first year’s worth of immunotherapy into a single day. This reduces by over half the total number of shots and doctor visits needed to complete immunotherapy. Several additional omalizumab shots are typically administered in the weeks after the initial treatment. The major drawback of omalizumab is cost. Each injection costs about $650, and many insurance plans won’t cover it because omalizumab isn’t approved for immunotherapy. In addition, there’s a risk of having an allergic reaction, and the effect of the drug on future reactions to immunotherapy injections is unknown. Still, Mayo Clinic experts say that if your doctor recommends allergen immunotherapy, omalizumab injections may be worth considering. ❒

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Thyroid troubles Subtle symptoms with age You’d never know it by its small size, but your thyroid gland, which is located in your neck just below your Adam’s apple, plays a significant role in your health. Thyroid hormones regulate your metabolism — everything from the rate at which your heart beats to how efficiently you burn calories. As long as your thyroid functions normally, the fine balance of your body’s metabolism runs normally. But if the thyroid gets off kilter, producing too much or too little of its hormones, the balance of chemical reactions in your body is upset. Symptoms may be subtle — especially in older adults — but once a thyroid problem is identified, it generally responds well to treatment.

What’s normal? Hormones made and released by the thyroid — including the allimportant hormone thyroxine — circulate in the blood. These hormones act like chemical messengers. They help control body temperature, heart rate, muscle strength, cholesterol, memory and even your mood. Working in conjunction with the thyroid gland are the hypothalamus and pituitary gland. These two structures in the brain help control the rate of hormone released by the thyroid. This is accomplished with the help of thyroid-stimulating hormone (TSH), which is released by the pituitary and regulates the rate at which the thyroid gland produces hormones. It’s an inverse relationship — for instance, when the blood level of thyroid hormones increases, the pituitary lowers production of TSH and that signals the reduction of thyroid hormone release.

An underactive thyroid gland (hypothyroidism) produces too little thyroxine, thus slowing the body’s metabolism. An overactive thyroid gland (hyperthyroidism) produces too much thyroxine, and so metabolism speeds up.

Pituitary

TSH

Thyroxine

Underactivity is more common The earliest symptoms of an underactive thyroid — such as sluggishness and fatigue — can be vague and even nonspecific. Too often they’re simply mistaken for getting older. As metabolism continues to slow, hypothyroidism may cause: ■ Hands or feet that feel cold all the time ■ Constipation ■ Pale, dry skin ■ Puffy facial appearance ■ Hoarseness ■ Unexplained weight gain, usually limited to 10 to 20 pounds ■ Elevated blood cholesterol level You also may experience muscle aches or weakness, tenderness and stiffness, joint discomfort or swelling, slowed mental function, forgetfulness, and depression. Without treatment, signs and symptoms of an underactive thyroid may become more noticeable and severe. However, if you’re an older adult, you may not notice these changes. Even though thyroid underactivity is fairly common among people over age 60, symptoms in older adults can be nonspecific and more difficult to pin down. Older people with an underactive thyroid may exhibit only one symptom, such as memory loss or decreased mental functioning. As such, it may be easily overlooked as part of aging. In older adults, a lack of other symptoms doesn’t rule out the possibility of an underactive thyroid. Risk of a thyroid problem increases if there’s a family history of the disease, or a history of other diseases such as type 1 diabetes. Other risks

Thyroid Thyroid-stimulating hormone (TSH) is released by the pituitary and regulates the rate at which the thyroid gland produces thyroxine. When the blood level of thyroxine increases, the pituitary lowers production of TSH and that signals a reduction in thyroxine release. If the blood level of thyroxine decreases, the pituitary increases production of TSH, signaling an increase in thyroxine release. Thus, high TSH usually means thyroid function is too low, and low TSH usually means it’s too high.

include previous treatment for an overactive thyroid, a past neck surgery or radiation treatment to the neck. Simple blood tests to check for elevated TSH levels and a low level of thyroxine can identify an underactive thyroid that may warrant treatment. The treatment of choice is the drug levothyroxine, which replaces the missing thyroxine. Periodic blood tests to check TSH levels are done over time to help determine what dose is needed. In older adults, treatment to bring thyroxine levels back to normal may take a slower course to avoid putting stress on the heart and central nervous system. The dose is typically decreased if chest pain (angina), congestive heart failure or mental changes such as confusion occur.

Overactive thyroid Like its counterpart, hyperthyroidism can mimic other health problems. Some of the most serious complications involve the heart and May 2008

include a rapid or irregular heartbeat and congestive heart failure. Other symptoms may include unexplained weight loss, nervousness, anxiety, irritability, increased sensitivity to heat, more frequent bowel movements and an enlarged thyroid. Fatigue, muscle weakness and difficulty sleeping may occur. Again, in older adults the symptoms may be subtle or even unnoticeable. Most typically, you may experience an increased heart rate, heat intolerance, a tendency to tire during ordinary activities and weight loss. Recognizing the problem can be even more challenging if you take beta blockers — such as propranolol (Inderal) and metoprolol (Lopressor) to treat high blood pressure and other conditions — because these can mask many symptoms of an overactive thyroid. If hyperthyroidism is suspected or in question, simple blood tests can create a precise picture of how your thyroid is functioning. Treatment is geared to what’s causing the gland to malfunction. In older adults common causes are the autoimmune disorder Graves’ disease and a lumpy (nodular) goiter. Although oral drugs can be used to reduce the level of thyroid hormones in the blood, the most common treatment involves using radioactive iodine to help throttle back the overactive gland. Taken by mouth, radioactive iodine is absorbed by the thyroid gland, shrinking it within a few months. On occasion, surgical removal of the thyroid (thyroidectomy) may be done. Treating an overactive thyroid with radioactive iodine or surgery commonly results in the thyroid becoming underactive. If that occurs, the regular use of levothyroxine is almost always required at some point to replace normal thyroid hormones on a long-term basis. Blood tests help determine the correct levothyroxine dosage. ❒ www.HealthLetter.MayoClinic.com

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Routine eye exams What the doctor sees Some say the eyes are windows to the soul. But from the standpoint of an eye doctor (ophthalmologist), they are windows to several aspects of health. Some involve vision alone, while others have more farreaching effects on your health. So, just what is the eye doctor looking for when doing a routine eye exam?

For starters Regular eye exams make it possible to track changes in your eyes that may occur as you age. Exams are generally recommended every one to three years for adults 55 to 64 years of age and every one to two years for people 65 and older. Typically, an eye exam includes a check of your visual vital signs, beginning with a check of your vision using an eye chart. A simple hand-held light is used to check how the pupils respond to light, as well as the position and movement of the eyes, eyelids and lashes. The clear covering at the front of the eye (cornea) and the colored part of the eye (iris) are examined for clarity. Muscles controlling eye movement are checked as you move only your eyes to track movement of a simple object. Peripheral vision — which includes everything seen without moving the eyes — is also evaluated in an exam. Another vital check measures pressure inside the eye. Glaucoma is generally associated with abnormally high pressure within the eye (intraocular pressure). If it’s not identified or treated, the condition can eventually damage the optic nerve and irreversibly reduce vision. Similar to high blood pressure, you may

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not know high pressure in the eye is present until it causes damage. At a later point in the exam, your doctor can view the the optic nerve at the back of your eye to see if its color and appearance are healthy. Abnormalities in color or inflammation of the optic nerve may indicate another disease process — such as glaucoma, poor circulation or inflammation — is present.

A closer look Inner workings of your eyes are more easily viewed by putting eyedrops into them to widen (dilate) your pupils. Typically, a specialized light that uses high magnification and a line of light — called a slit lamp — provides a better view of a cross section of structures at the front of the eye. With this light, your doctor can view the eye’s surface (cornea), the color band (iris), and the space between the two (anterior chamber). If any corneal problems are suspected, specialized dye may be used to help illuminate tiny cuts, scrapes, tears, foreign material or infection. In addition, the lens of the eye can be checked by your doctor for any changes associated with cataract development.

On to the retina The inner back wall of the eye is lined with a thin layer of tissue called the retina. At the center of the retina is the macula, which provides your central vision and allows you to see fine detail. Light focused by the cornea and lens to the retina is captured and converted to impulses, which are sent to the brain by the optic nerve and interpreted as visual images. The retina is like a billboard when it comes to eye health. Your ophthalmologist is looking for an even, reddish hue, a yellowish circle at the optic nerve location, and a deep red spot near the center of May 2008

the retina where the macula is located. All are good signs of a healthy, normal eye. Sometimes, the signs can be other than healthy. Your ophthalmologist is also checking for these, including signs of: ■ Macular degeneration — Early signs of dry macular degeneration may show up as mottled pigmentation and yellow dots (drusen) in the macula area. Although the appearance of small drusen is common with age and may mildly interfere with vision, larger drusen may significantly interfere with vision if they involve the macula. Wet macular degeneration is less common. Its hallmark is the appearance of abnormal blood vessel growth under the macula. Fluid leaks from these vessels, forming what looks like blisters or bumps under the macula. ■ Systemic diseases — Conditions that affect blood vessels, such as diabetes, high cholesterol and high blood pressure (hypertension), can leave their mark on the retina. If the eye is affected by these or other vascular conditions, an ophthalmologist may see small outpouchings (aneurysms) on retinal blood vessels or swelling of the retina due to a leaking of fluid. Small, cream-colored deposits of proteins (exudates) may appear around the leaking walls of tiny retinal capillaries. Tissue damage to the retina due to obstructed blood flow (ischemia) in capillaries may show up as white patches (cotton-wool spots) that your doctor can see. Early detection of these disorders, and the appropriate management of the cause of the disorders, can prevent further damage to the eye and visual loss. It’s important to do all that you can to control diabetes or manage high blood pressure (hypertension), to help prevent the damage to your eyes these conditions can cause. ❒

Excessive sweating Therapies to keep you dry Your hands and feet sweat a lot, and you’ve spent much of your life trying to hide it. Many people perspire more heavily than others, when anxious, in hot weather, or when they exercise or eat spicy foods. Some people may suddenly begin to sweat more than usual, which can be a side effect of certain medications or a sign of disease. But some people experience frequent or constant excessive sweating (hyperhidrosis) of their hands, feet or underarms, which can seriously interfere with their social life. People may have trouble working or enjoying recreation with constantly wet hands — or become withdrawn due to self-consciousness about shaking hands with others, having stained shirts or potential body odor. Fortunately, several treatment options are available to minimize excessive sweating. In severe cases, surgical procedures can be very effective at stopping sweat.

Multiple injections of botulinum toxin (Botox) into the underarms can block the nerves that trigger the sweat glands.

body. If it begins suddenly, it typically has an underlying cause, such as being a side effect of a drug, or a sign of a disease or condition such as menopause hot flashes, low blood sugar, overactive thyroid, leukemia, lymphoma, heart attack or possibly an infectious disease. Adjusting your medications or treating an underlying disease often solves this problem. ■ Focal hyperhidrosis — This most commonly involves excessive daytime sweating of your palms and soles, and sometimes the underarms for no apparent reason. The sweating typically stops when sleeping. It usually begins before age 20 and isn’t associated with an underlying condition. It often runs in families.

The science of sweat Sweating is the body’s mechanism to cool itself. In most circumstances, it’s both natural and healthy. Although when, where and how much people sweat varies widely, most people sweat when they exercise or exert themselves, are in a hot environment, or are nervous, anxious or under stress. Hyperhidrosis is the secretion of sweat in amounts greater than needed to cool the body. The problem is divided into two main categories: ■ Generalized hyperhidrosis — This is excessive sweating that often occurs over larger areas of your

Stopping the sweat Focal hyperhidrosis is often treated in steps, starting with: ■ Antiperspirants — Some nonprescription antiperspirants, such as Certain Dri, Secret Clinical Strength, Degree Clinical Protection and 5 Day, often work well for mild to moderate sweating. Prescription antiperspirants containing aluminum chloride (Drysol, Xerac) may work even better. These are often applied to a problem area before bedtime for about a week, then applied less frequently as maintenance therapy. Skin irritation can be a side effect, May 2008

but this often can be avoided by applying the antiperspirant as infrequently as possible and, in the case of underarms, by not shaving the area before application. Keep in mind, deodorants mask odor; antiperspirants inhibit sweating. ■ Iontophoresis — This involves placing your hands or feet in a pan of water through which a batterypowered device delivers a low voltage electrical current. This is thought to temporarily block sweat glands. Treatments last about 15 to 30 minutes and are often performed once a day for a couple of weeks, followed by less frequent maintenance therapy. Iontophoresis is generally safe and can be done at home, but it may not work any better than an antiperspirant. ■ Oral medications — Drugs in the anticholinergic class can help, but they’re used infrequently because they also cause dry eyes and mouth, difficulty urinating and other side effects. Occasionally, when excessive sweating is worsened by stress-induced anxiety, anti-anxiety drugs may be helpful. ■ Botulinum toxin (Botox) injections — Multiple injections of this substance into the palms, soles or underarms can block the nerves that trigger the sweat glands. Although often effective — even with severe hyperhidrosis — the injections can hurt and the results last for only about four to 12 months, after which injections must be repeated. ■ Surgery — This is reserved for severe hyperhidrosis that hasn’t responded to more-conservative therapies. The two basic options involve surgical removal of sweat glands from the underarms, or severing the nerves in the chest area that carry messages to the sweat glands. This primarily treats hand and underarm sweating. Because these are major medical procedures, they’re rarely used. However, if needed, they’re often very effective. ❒ www.HealthLetter.MayoClinic.com

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Second opinion Questions and our answers Q: My wife bought an allergy medicine for me last spring when my allergies flared up. It worked well in reducing nasal symptoms, but it seemed to make urinating even more difficult for me than it usually is. Is there some other medication I can try?

A: Yes, there is. But first, if you have difficulty urinating — such as hesitancy, slow stream or incomplete emptying — at times other than when you’re taking the medication, talk to your doctor. This could be an indication of another problem, such as an enlarged prostate. Apart from that, many nonprescription allergy medications — including those containing diphenhydramine (Benadryl Allergy, others), chlorpheniramine maleate (Actifed, Chlor-Trimeton Allergy, others) and dexbrompheniramine maleate (Drixoral, others) — are within a class of medications that are often referred to as first-generation antihistamines. The most well-known side effect of these drugs is drowsiness. However, additional side effects include drying of the eyes and mouth, and difficulty urinating. These side effects are often more pronounced in older adults, especially in those who already have difficulty urinating. You should be able to lessen most of those side effects by taking an allergy medication that belongs to the so-called “second generation”

class of antihistamines. These include loratadine (Claritin, others) and cetirizine (Zyrtec) — which are available as nonprescription drugs — and fexofenadine (Allegra). In addition, you may want to talk to your doctor about strategies for avoiding allergy triggers and about additional therapies. These may include steroid nasal sprays, which are considered quite safe and are often more effective than using antihistamine drugs for relieving allergy-related nasal irritation. ❒

Q: Is it normal for older people to have sleep difficulties? My sister, who is 76, says it’s normal. I disagree. I sleep very well, and I’m 79. A: The popular belief that sleep difficulties are a natural part of getting old doesn’t explain why nearly half of adults over age 65 don’t complain of sleep problems. Most sleep patterns, including the amount of sleep required, start early in life. Researchers have found changes do occur in sleep patterns between early adulthood and age 60 in healthy adults — sleep becomes lighter, there may be more brief awakenings and total sleep duration may be shorter by up to an hour. Older adults often go to bed earlier and awaken earlier in the day. Researchers also have found that among most healthy adults, sleep patterns don’t change much after the age of 60. There’s growing evidence and awareness that sleep difficulties

experienced by older adults often have more to do with chronic or acute health conditions — including specific sleep disorders, such as sleep apnea — rather than the actual aging process. The simple question of how a person feels during the day — whether generally tired or alert — can be a helpful determinant of whether sleep is impaired. Health issues such as chronic pain, arthritis, urinary problems, stress, emotional problems, depression, restless legs syndrome, dementia, chronic kidney disease and heart failure also can impair the quality of your sleep. Diagnosing and treating these and other health problems may help remove health-related barriers that might otherwise come between an older adult and the ability to get a decent night’s sleep. ❒

Have a question or comment? We appreciate every letter sent to Second Opinion but cannot publish an answer to each question or respond to requests for consultation on individual medical conditions. Editorial comments can be directed to: Managing Editor, Mayo Clinic Health Letter, 200 First St. SW, Rochester, MN 55905, or send e-mail to [email protected] For information about Mayo Clinic services, you may telephone any of our three facilities: Rochester, Minn., 507-284-2511; Jacksonville, Fla., 904-953-2000; Scottsdale, Ariz., 480-301-8000 or visit www.MayoClinic.org

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