Ambush Grandma Rides Again

Regular readers of my LJ may remember the incident, last winter, in which a berserk church-flyer-wielding grandma knocked on our door, refused to identify herself before the door was opened, and then brightly announced, "It's ME!" and proceeded to proselytize once I actually did open the door. (I'm not exactly the churchgoing type, and at the time, I was afraid that if I said so, I'd find a small army of determined southern baptists camped on my doorstep the next morning, so I temporized and resolved to be verry..... verrrryy.... quiet about my churchgoing deficiencies.)

I still don't know her name. I didn't see her again until yesterday.

In any case, it was a fitting coda to my time here when I ran into her again by the building entrance. She was in a robe and curlers, retrieving her newspaper from the spot by the front door where the paperboy leaves it. In conversation, she said that she was without hot water until Monday.

"Goodness, are you sure you wouldn't like to come take a shower at my apartment?"
"Oh no, I took a bath in some jergens lotion."

There are no words. (Suffice it to say that I'd never thought of that approach to hot waterlessness.) I hope I recovered well from that one, because the conversation continued with her finding out that I was, in fact, moving. She said, very sincerely, that she'd miss me terribly.

I walked out the door, and it took me several minutes to conclude that (a) Ambush Grandma is starting to show some symptoms of dementia and (b) Ambush Grandma lives on the first floor, and probably watches my comings and goings closely, sort of like live TV except with graduate students. I wouldn't have thought I was that interesting to watch, but it would account for the way she seems to know me even though I haven't the slightest idea who she is.

Ah, dementia. Now I'm sort-of interested, because I've met people before who have a little of it, and they do okay. I've also met people (in the geriatric psychiatric ward, or in the locked upper floors of nursing homes) who have a lot of it, and it's not a good time. Hmm, that goes on the pile of Things To Learn More About. (What exactly is dementia? What makes some people stay sharp, and others not? What allows some people who have a little dementia to keep going, and others not?)

Pain: Aspirin, acetaminophen, NSAIDS, and COX-2 Inhibitors

As promised, the entry on pain control.

Acetaminophen: Acetaminophen is considered the "gold standard" for arthritis treatment. Because it reaches peak effectiveness 90 minutes to two hours after you take it, it works best if taken four times a day, not just when it hurts. It works in the central nervous system (ie it stays in the tissues of your brain and spinal cord, and does its work there). That means it has little or no anti-inflammatory effect (since inflammation from an injury stays by the injury, in your foot or knee or wrist or wherever). Last, it has no effect on your blood's ability to clot.

Implications:
If you have a swollen ankle, Acetaminophen is not the choice for you-- it does nothing for inflammation.
If you have arthritis, it is definitely the choice for you, since arthritis typically does not involve inflammation.
If you have a concussion, acetaminophen is definitely the choice for you, since if there is any bleeding in your brain, you want it to clot naturally.



Ibuprofen (an NSAID): NSAID stands for Non Steroidal Anti Inflammatory Drug. It's great for taking down swelling and inflammation, and for pain control. It works in your body's peripheral tissues. It has a small effect on blood clotting. It may cause gastrointestinal bleeding, if you take too much, and if you take 1000 over a lifetime, you double your risk of kidney failure. (In a healthy adult, the risk of kidney failure is very small, though.)

-- All NSAIDs work just a little bit differently. If you try one and it doesn't work, try a different one that may work better with your body chemistry.

-- Prescription NSAIDs are not necessarily better than over-the-counter NSAIDs.

Implications:
If you have a swollen ankle, take an NSAID.
If you have arthritis, it's okay to take an NSAID, but acetaminophen (tylenol) is probably cheaper.
If you have a concussion, do not take NSAIDs for the resulting headache.
If you are looking to reduce your heart attack risk, this will help a little, but aspirin is better.



Aspirin: Back when aspirin was all we had for pain control, it was the standard drug for arthritis treatment, and people took massive doses of it. The doctor knew you had reached your maximum dose when you reported that your ears were ringing. Yikes! These days, aspirin is best for one thing: it permanently decreases your blood's ability to clot, for the life of the platelet it affects (3 months). That means that your blood cannot form clots in your arteries, lungs, or heart either.... which dramatically decreases your risk of stroke or heart attack.



And last, we come to the late and lamented COX-2 Inhibitors. These drugs have been heavily advertised by their manufacturers as being "better than" regular NSAIDs. Well, that's not necessarily true-- don't believe the hype! Studies have shown that when you consider the cost of the drug and the pain relief you get, regular NSAIDS work just as well as COX-2 inhibitors. The only exception to this rule is.... if you are prone to GI bleeds, COX-2 inhibitors, which don't cause that, are a better choice than regular NSAIDs.

Now, about COX-2 inhibitors and heart attack risk: Vioxx and one other COX-2 inhibitor (Celebrex?) were recently found to increase heart attack risk. They do so because, while they reduce platelets' ability to clot in one way, they make it more likely in another way. That increase makes blood clots, and therefore heart attacks and strokes, more likely.

So. If it were me, and I had a patient who needed significant pain relief and had a problem with GI bleeds, I would carefully evaluate that person's heart attack risk before deciding what drug I should recommend. I don't get to prescribe, but I do get to treat patients and see the drugs they take (and how well the drugs are working or not).