Greta Pelegrin, PharmD

Alzheimer’s disease (AD) is the most common form of dementia, which involves loss of normal thinking, reasoning, and concentration, and interferes with daily life. According to the National Center for Health Statistics, it is among the top 10 causes of death in the elderly population in the United States. AD also accounts for approximately 60% of dementia in the elderly, and approximately 4 million Americans live with this illness.

	AD destroys memory and makes it difficult to perform even simple daily activities. The symptoms of AD usually affect people at an older age (around the age of 60), although in some cases, it can occur earlier in life. It is not considered part of aging, but the risk increases with age. The symptoms usually begin as confusion and trouble remembering even the most familiar things or individuals.

	In the early stages, AD causes loss of memory and also changes in emotions. In the late stages, however, daily activities become impossible to carry out, and a caregiver eventually is needed. Currently, no cure exists for AD, but treatment is available to at least improve quality of life.

 What Are the Symptoms and/or Warning Signs of AD? 

	Slow memory loss for several years is common in the initial stage of AD. Here are some examples of the signs and symptoms to look for:

		Loss of memory; forgetting how to perform familiar tasks

	Loss of memory, particularly short-term, is the first sign noticed in the beginning. In general, the illness progresses over time. AD involves 3 stages: mild, moderate, and severe.

	The early, mild stage may be difficult for family members and friends to identify, but individuals may get lost in familiar places, withdraw from loved ones, encounter problems taking care of financial tasks, or even experience mood changes such as anxiety or depression.

	As AD progresses from mild to moderate, loss of memory continues, and it is in this stage that further damage happens in the brain, leading to confusion, disorientation, and inability to perform daily tasks. Patients may not be able to learn new things or take care of daily hygiene. At this stage, they may develop feelings of paranoia, frustration, and even anger.

	By the time an individual reaches the severe stage of AD, damage in areas of the brain lead to lack of reasoning and inability to communicate effectively with others. Decisions become difficult and the body essentially begins to shut down. Ultimately, individuals are unable to care for themselves, and may even be bed-ridden or completely dependent on a caregiver.

	It is believed that several factors contribute to AD; however, the actual causes are not well understood. It is known that AD develops over time and that a combination of lifestyle and heredity play a part. Some scientists believe that a special protein—apolipoprotein E&mdash;may be a risk factor, but this has not been confirmed.

	Two types of brain cell lesions are seen in those with AD: “plaques” and “tangles” that accumulate. Plaques essentially keep brain cells from communicating with one another. Tangles are proteins in brain cells that become twisted, causing nerve cells to malfunction and even die. In summary, AD eventually destroys brain cells, causing the decline in everyday functions.

	Currently, no cure is available for AD, but treatment can improve quality of life. Physicians primarily treat their patients by prescribing medications for lack of sleep, agitation, depression, anxiety, and other health problems. The drugs used to treat the actual disease slow the total decline in brain function.

	Certain drugs used for the treatment of AD include donepezil (Aricept), rivastigmine (Exelon), and galantamine (Razadyne). This class of drugs is not effective for everyone and has side effects, such as fatigue, diarrhea, and nausea. Also, these drugs may help ease the symptoms of AD, but they have not been proven to alter the underlying dementing process.

	Memantine (Namenda) was approved in 2003 to treat moderate-to-severe AD. It works by protecting nerve cells from a chemical called glutamate. It can be used alone or together with one of the other previously named drugs.

	Although supplements such as vitamin E and gingko have been studied, no proof exists that these actually work.

	People with AD suffer from confusion, mental disorders, anger, as well as other health issues. Caregivers suffer as well due to the demands placed upon them, ultimately causing poor health and stress. Although no cure for AD exists, research continues in an attempt to benefit those with the disease.

	Undoubtedly, the pressure of caring for someone with AD can end up in “caregiver burnout.” Here are some tips:

		Do not use alcohol or other substances to cope

		Try to control anger and negative feelings

		Try to control stress as much as possible

		Learn about support groups, adult day care programs, home health care services, and other resources

Dr. Pelegrin is a pharmacist for Publix and an associate professor at Mercer University in Georgia.

Articles

In the early stages, AD causes loss of memory and changes in emotions. In the late stages, however, care of patients becomes more complex and help is needed.

Understanding Alzheimer's

The symptoms of ulcerative colitis can cause embarrassment and pain, but pharmacists' expert advice can help ease the discomfort.

	Ulcerative colitis is also known as inflammatory bowel disease because it mainly affects the large intestine, colon, and sometimes the rectum. In this chronic condition, the colon and rectum become inflamed and develop ulcers or sores. As a result, you may experience bleeding and diarrhea, which are characteristic of ulcerative colitis.

	No one knows what causes ulcerative colitis. The immune system is involved, but it is not clear exactly how. Ulcerative colitis affects men and women equally. You can have ulcerative colitis at any age, but it often occurs between the ages of 15 and 30 years, or later in life, from the ages of 50 to 70 years.

	It is more common in Whites and those of Jewish descent. It is important to receive treatment for ulcerative colitis. If left untreated, it can increase the risk of more serious complications in the long run.

	Some complications of ulcerative colitis are:

	• Inflammation in other parts of the body, such as the skin, eyes, and joints

How Do I Know If I Have Ulcerative Colitis? 

	Your doctor will first check for the usual symptoms of ulcerative colitis, mainly bloody diarrhea, abdominal pain, and fever. Following this, several tests can be performed to confirm that it is ulcerative colitis. These include:

	• Colonoscopy or sigmoidoscopy (cameras are used to view inside the intestine, and biopsies can be performed)

	• X-rays (barium enema, computerized tomography scan) • Stool samples to check for bacteria (sign of infection) and white blood cells (sign of inflammation)

	• Sedimentation rate, an indicator of inflammation

	The symptoms of ulcerative colitis can be embarrassing and uncomfortable, and they can have a negative impact on your social life. Certain foods and spices can trigger the symptoms, causing bouts of diarrhea in public places.

	The symptoms will vary depending on how serious your condition is, but they are manageable. Symptoms will occur as flare-ups (worsening of inflammation) that can range from mild, with symptoms coming on gradually, to severe, in which a person can become very ill. Some people may have periods of remission in which symptoms go away for months and even years, but in most, the symptoms will eventually return.

	You may also experience joint pain, mouth sores, nausea and vomiting, skin lumps or ulcers, or anemia.

	The recurrence of symptoms can be reduced by making some dietary and lifestyle changes. Avoiding certain foods that can worsen diarrhea and gas symptoms is a good start. Try the process of elimination to find out which specific foods aggravate your symptoms. The key is to eat a well-balanced diet to prevent the malnourishment that can result from your intestines not being able to absorb nutrients as well. Eliminating dairy products will only help people who are lactose intolerant.

	•Try eating small meals more frequently

	• Experiment with fiber—getting more fiber can sometimes help eliminate diarrhea, but may also aggravate your symptoms

	• Do not choose “gassy” foods, such as beans, cabbage, and broccoli

	• Avoid greasy or fried foods—these can cause more gas and diarrhea because your body might not be able to completely absorb the fat

	• Drink plenty of fluids to prevent dehydration

	• Avoid or limit alcohol and caffeine consumption

	• Consider taking multivitamins to replace lost vitamins and minerals

	When flare-ups occur, medical treatment is necessary to control the inflammation that is triggering your symptoms. In more severe cases, when there is massive bleeding, rupture of the colon, risk of cancer, or your condition is not responding to medical therapy, you might need surgery. About 30% of people with ulcerative colitis will require surgery. This involves removing the colon and rectum, which cures the ulcerative colitis and eliminates the threat of cancer.

	There are 4 types of drugs that are used to treat the inflammation from ulcerative colitis: aminosalicylates, corticosteroids (often referred to as “steroids”), immunomodulators, and biologics.

	Aminosalicylates are aspirin-like medications that are usually tried first in cases of mild to moderate ulcerative colitis. They are moderately effective at treating active inflammation, and better at maintaining remission. They can reduce the long-term risk of colorectal cancer.

	Sulfasalazine is a less expensive aminosalicylate, but not as well tolerated. Nausea, headache, and rash are some of the side effects seen with this medication. Sulfasalazine should be avoided when there is an allergy to sulfur. Enemas and suppositories may be used in combination with oral tablets to better treat the symptoms.

	Corticosteroids are highly effective medications that work quickly to relieve moderate to severe symptoms of inflammation during acute flare-ups. They have predictable side effects when used long term, such as osteoporosis, high blood pressure, and diabetes, so they should only be used for a short amount of time. They are used when aminosalicylates don’t work, or in combination with other treatments. The latest corticosteroid, Entocort HC, offers a safer alternative by causing fewer side effects.

	Immunomodulators and biologic drugs are used as a last resort when other therapies do not work. They work by suppressing the body’s immune system, so there is a potential for serious complications, including an increased risk for infection. Regular monitoring for side effects is required with these medications. They act slowly, and can take from 3 to 6 months to be effective, so they are usually combined with corticosteroids to speed up the response.

	Over-the-counter alternatives can help treat some of the milder symptoms. For diarrhea, Immodium or Metamucil can help, and acetaminophen can alleviate pain. Ibuprofen and naproxen can actually worsen the symptoms of ulcerative colitis, so these should not be taken for pain.

	You might receive antibiotics if you have a fever and your doctor suspects an infection. Iron supplements can be used to prevent anemia. Some herbal supplements that might help include fish oils, probiotics, and Boswellia. Aloe vera has not been proved to be effective for ulcerative colitis. PT 

Dr. Pelegrin is a pharmacist for Publix Pharmacy and Dr. Rouzeau is a pharmacist who has worked in retail and health systems pharmacy.

Irritated About Your Irritable Bowels? Confronting Ulcerative Colitis 

Rosacea's symptoms can cause patients embarrassment, which pharmacists can help relive with important treatment information.

	Rosacea is a chronic, inflammatory disorder of the skin. It affects almost 16 million American adults. It is poorly understood, yet it is spreading worldwide. Rosacea causes inflammation of the nose, cheeks, chin, eyelids, or forehead. It can also cause redness of the face and pus-filled bumps similar to acne. Often it affects the eyes, causing inflammation of the eyelids. It is more common in women, but in men it can result in a more severe disorder. Rosacea causes redness in the face, eventually causing very small red bumps. The disorder usually begins between the ages of 30 and 60 years.

	Because of the redness and acnelike aspect of the disorder, rosacea can cause social and psychological problems if symptoms are not controlled. Often, people with rosacea tend to have a lower self-esteem. They avoid social and professional gatherings, and even contact with friends and family, because of the embarrassment caused by the symptoms.

	• Pre-rosacea—In the beginning, skin flushing is seen. Then redness and the appearance of small visible blood vessels sets in. The redness is due to the dilation of blood vessels in the skin.

	• Vascular Rosacea—At this point, the symptoms start to worsen, and the skin becomes very sensitive. There is inflammation on the nose and checks.

	• Inflammation—The last stage involves bumps or red blisters on the nose, cheek, forehead, or chin.

	Doctors do not really understand what causes rosacea. Researchers think it is probably due to the environment or could run in families. Treatment and lifestyle modifications are aimed at reducing the symptoms and improving the skin.

	You are more likely to develop rosacea if you:

		Are between the ages of 30 and 60 (rosacea is more common during menopause)

	A number of factors can make rosacea worse.

		Certain medications, such as steroids or high blood pressure medicine

	The first step in treating rosacea is avoiding your known triggers, which vary from person to person. A good place to start is to stay away from skin lotions and makeup that can aggravate the problem. Avoid extremes in temperature, spicy foods, alcohol, and stress or emotional problems. You should also limit sun exposure, especially if you are taking medication that makes you more sensitive to the sun, such as certain diuretics and antibiotics.

	Alcohol can aggravate the symptoms, but people who do not drink alcohol can develop rosacea. Without proper treatment, rosacea can worsen and the skin can become disfigured, with more redness, bumps, and thickening of the skin.

	Although there is currently no cure for rosacea, there are ways to control the symptoms (Table). The more unsightly symptoms of rosacea can be minimized with the use of creams and antibiotics. Creams are usually used before antibiotics to avoid unnecessary side effects from antibiotics, such as nausea, vomiting, diarrhea, photosensitivity, allergic reactions, and vaginal yeast infections. Creams have proved to be safer and have fewer side effects. Metronidazole gel works as well as some antibiotics and is the treatment of choice. Some patients will feel stinging and burning of the skin when using metronidazole. Metronidazole is available in both an oral (pill) and topical (cream, gel, lotion) form. Both forms can cause a flushing reaction, so avoid alcohol during treatment.

	Low-dose oral antibiotics, such as doxycyline, may have faster results than the cream alternatives. When symptoms are more severe, or during a flare-up, antibiotics are used first. Your doctor may prescribe a combination of topical and oral antibiotics.

	Retinoids, including topical tretinoin and low-dose oral isotretinoin, are similar to vitamin A. Doctors sometimes prescribe these to treat rosacea when antibiotics fail. Retinoids may help reduce the appearance of pus-filled or red bumps, but sometimes make skin redness and spider veins look worse.

	If you use retinoids, avoid supplements with vitamin A, which can cause serious side effects when taken in excess. Glycolic acid facial peels can also sometimes help control rosacea symptoms. If there is thickening of the skin, laser treatments, although costly, are another option. Electrocautery, in which a device delivers a low-powered electrical current, can also help improve the appearance of thickened skin, as well as destroy visible blood vessels. If rosacea has affected the eyes, artificial tears for the dryness and an antibiotic gel for the eyelids are usually prescribed. In some cases, oral antibiotics are needed to clear up the symptoms.

	Several natural remedies have been studied and have been shown to relieve symptoms to some degree. Many nonprescription products are available as a combination of these. Natural or herbal products and ingredients that may ease rosacea symptoms include:

	Many times patients must work with their doctors to maintain a skin regimen, which should involve good, gentle cleansing with no scrubbing. Patients with rosacea should use mild skin care products and effective sunscreens. A moisturizer with ingredients such as ceramides, glycerin, and hyaluronic acid is preferable.

	Even when medication is needed, one of the most important factors in treatment is keeping triggers in control. Rosacea is a disorder than can be managed, but symptoms must be monitored in the rare severe cases. PT 

Dr. Rouzeau is a pharmacist who has worked in retail and health systems pharmacy, and Dr. Pelegrin is a pharmacist for Publix Pharmacy.