Alder's NEA Bridge: You can stop 10 by taking four
Dear Doctors:
Our 23-year-old son was diagnosed with bipolar disorder. He's good about taking his medications, but he struggles with the side effects. We recently read that a ketogenic diet may be helpful. We would be grateful for any information you can share about this. A ketogenic diet is one that strictly limits the carbohydrates someone consumes, thereby causing the cells of the body to change their primary source of energy. Plan A is to use glucose for energy, which our bodies make from the carbs that we eat. But when carbohydrates are consistently in short supply, the body will switch to Plan B and use fat for energy. The metabolic process of breaking down fat is known as ketogenesis, or ketosis. It produces compounds known as ketones, or ketone bodies, which become an alternative fuel.
Ketosis is perhaps best-known as the centerpiece of the popular keto diet. However, it has medical applications as well. In the 1920s, before the advent of antiseizure drugs, ketogenic diets were found to be effective in the treatment of epilepsy. More recently, researchers have begun to explore potential benefits in other neurogenerative diseases, such as Parkinson's and Alzheimer's. Now, a new study from researchers at Stanford University suggests the metabolic state of ketosis may be helpful in psychiatric conditions, including bipolar disorder.
For those who aren't familiar, bipolar disorder is a condition in which a person experiences unpredictable and uncontrolled shifts in mood, concentration and energy. Periods of great elation and high energy are followed by episodes of depression that can be quite severe. These extreme shifts can adversely affect judgment and interfere with daily life.
Medications can be effective at leveling out mood swings, but, as your son has experienced, they can also cause unpleasant side effects. These include drowsiness, nausea, dizziness, uncontrolled movement, thirst and headache. The medications can also adversely affect metabolic processes and result in insulin resistance, unhealthful blood lipid levels, high blood pressure and weight gain.
In the Stanford study, 23 people living with either bipolar disorder or schizophrenia changed their diets. They got 60% of their calories from fat and 30% from protein. The remaining 10% was allotted to carbs, with a cap of 20 grams per day. They also continued to take their prescribed medications, which had caused one or more metabolic problems for each of the participants. After four months, lab tests showed that 80% of the people in the study not only saw improvement in the metabolic side effects of the drugs, but they also experienced meaningful psychiatric improvements. In addition, they also lost weight and saw a reduction in visceral adipose tissue, which is the hormonally active body fat that surrounds the organs.
It's important to note this study was both small and brief. It will take larger and longer studies to verify the success rate and see if the positive outcomes are sustained over time. However, the results are intriguing. Although how a ketogenic diet is linked to these improvements remains unclear, this study adds to the growing body of evidence regarding the close and important connection between brain health and diet.
When I was in the waiting room at my doctor's office, I overheard the nurses referring to two of the patients as a "young old" and an "oldest old." Is this office shorthand, or are these actual medical categories? It sounded disrespectful.
Dear Reader: Dear Doctors: Dear Reader:
David Hilbert was a German mathematician who died in 1943. He discovered and developed many fundamental ideas, including Hilbert spaces in functional analysis. He claimed that if one were to bring 10 of the wisest men in the world together and ask them what the most stupid thing was in existence, they would not be able to discover anything as stupid as ... what?
It does not require a particularly wise man to realize that to defeat a four-spade contract, the defenders must take at least four tricks. How would that thought have helped West in this deal? He leads the diamond ace: five, two, four. What should he do next?
South opened three spades to show a respectable seven-card suit and 5-10 high-card points. West made a borderline takeout double. North
Sadly, there is no shortage of stereotypes, prejudice, jokes and even outright cruelty directed at people who have reached older age. It has come to be known as "ageism," a term that was coined in the late 1960s. However, we're happy to say that the language you overheard does not fall into that category. As you suggested, it is part of medical terminology. Rather than signaling disrespect, its use by the nurses at your doctor's office suggests a nuanced awareness of the differing needs of older patients.
One of the factors involved in medical care is the stage of life of the patient. The needs of an infant, a toddler, a young child and an adolescent are obviously all quite different. The same holds true for a young adult in their 20s or 30s and someone who has reached middle age. But as the physical raised, hoping his partner was short in diamonds. (Yes, three no-trump works here but is probably against the odds.)
What does East's diamond two say?
That he does not have a doubleton, when he would have started an echo (high-low). If South has two diamonds, can the second card disappear?
Only in layouts where the contract cannot be defeated. Which four tricks must the defenders get?
One heart, one diamond and two clubs, or one heart, two diamonds and one club.
This means that it must be best to shift to the club eight, high denying an honor.
As you can see, this defeats the contract. But if West cashes the diamond king at trick two, South's second club evaporates on the diamond queen.
Hilbert was talking about astrology. Do you agree? effects of advancing age begin to become evident, such as graying hair, balding, loss of skin elasticity and decrease in muscle mass, older adults can appear to blend into a single, homogenous group. Yet in terms of physical health, disease risk, mental acuity and emotional and social engagement, the distinct stages of life continue. And that's where the language you are asking about comes into play.
The most commonly used terms at this time are "young old," "middle old" and "oldest old." Specific age ranges of these categories haven't been codified, so they tend to vary a bit. In general, the term "young old" refers to the decade after retirement. That is, people between the ages of 65 and 74. People between the ages of 75 and 84 are often known as "middle old." At age 85 and above, they fall into the category of "oldest old." And interestingly, due to the ageist connotations of the word "old," there is now some pushback against its use to describe these life stages.
The differences in these groups lie in the risk and prevalence of disease or illness, the frequency and length of the resulting hospital stays and the likelihood of either cognitive decline or impairment or neurodegenerative disease. Each is likely to increase with advancing age.
For the oldest old, frailty becomes a real risk. This is a clinical diagnosis in which chronic and metabolic diseases such as hypertension, arthritis, heart disease, cancer or diabetes — coupled with age-related changes to the body, including decreases in strength, stamina, muscle mass and stability — put the person at increased risk of frequent or prolonged hospitalization and of death.
Awareness of the stages of older age can be useful in setting health care goals and evaluating treatment options. The hip replacement that makes sense at age 65 might not be wise at age 85. But because we each age differently and at different rates, these categories serve as guidelines and not directives.
Eve Glazier, M.D., MBA, is an internist and associate professor of medicine at UCLA Health. Elizabeth Ko, M.D., is an internist and assistant professor of medicine at UCLA Health.