Brain & Nervous System Autonomic neuropathy

Subject: Brain & Nervous System Autonomic neuropathy Sun Jan 02, 2011 8:59 pm

Autonomic neuropathy is a
nerve disorder that affects involuntary body functions, including heart
rate, blood pressure, perspiration and digestion.

It isn't a specific disease, instead autonomic neuropathy refers to
damage to the autonomic nerves. This damage disrupts signals between the
brain and portions of the autonomic nervous system, such as the heart,
blood vessels and sweat glands, resulting in decreased or abnormal
performance of one or more involuntary body functions.

Autonomic neuropathy can be a complication of a number of diseases and
conditions. And some medications can cause autonomic neuropathy as a
side effect. Signs, symptoms and treatment of autonomic neuropathy vary
depending on the cause, and on which nerves are affected.

Symptoms

Signs and symptoms of autonomic neuropathy vary, depending on which
parts of your autonomic nervous system are affected. They may include:

* Dizziness and fainting upon standing (orthostatic, or postural, hypotension), caused by a drop in blood pressure
* Urinary problems, including difficulty starting urination,
overflow incontinence and inability to empty your bladder completely,
which can lead to urinary tract infections
* Sexual difficulties, including erectile dysfunction or ejaculation
problems in men, and vaginal dryness and difficulties with arousal and
orgasm in women
* Difficulty digesting food, due to abnormal digestive function and
slow emptying of the stomach (gastroparesis), which can cause a feeling
of fullness after eating little, loss of appetite, diarrhea,
constipation, abdominal bloating, nausea, vomiting and heartburn
* Sweating abnormalities, such as excessive or decreased sweating, which affects the ability to regulate body temperature
* Sluggish pupil reaction, making it difficult to adjust from light to dark and causing problems with driving at night
* Exercise intolerance, which may occur if your heart rate remains
unchanged instead of appropriately increasing and decreasing in response
to your activity level

When to see a doctor
Seek medical care promptly if you begin experiencing any of the signs
and symptoms of autonomic neuropathy. If you have diabetes, a
compromised immune system or another chronic medical condition, see your
doctor regularly to be checked for nerve damage.

The American Diabetes Association (ADA) recommends that people with type
2 diabetes be screened every year for autonomic neuropathy starting as
soon as they receive their diabetes diagnosis. For people with type 1
diabetes, the ADA advises annual screening beginning five years after
being diagnosed with diabetes.

Causes

Autonomic neuropathy can be caused by a large number of diseases and
conditions or as a side effect of treatment for diseases unrelated to
the nervous system. Some common causes of autonomic neuropathy include:

* Alcoholism, a chronic, progressive disease that can lead to nerve damage.
* Abnormal protein buildup in organs (amyloidosis), which affects the organs and the nervous system.
* Autoimmune diseases, in which your immune system attacks and
damages parts of your body, including your nerves. Examples include
Sjogren's syndrome, systemic lupus erythematosus and rheumatoid
arthritis. Autonomic neuropathy may also be caused by an abnormal attack
by the immune system that occurs as a result of some cancers
(paraneoplastic syndrome).
* Diabetes, which is the most common cause of autonomic neuropathy, can gradually cause nerve damage throughout the body.
* Multiple system atrophy, a degenerative disorder that leads to
loss and malfunction of some portions of the central nervous system.
* Injury to nerves caused by surgery or trauma.
* Treatment with certain medications, including some drugs used in
cancer chemotherapy and anticholinergic drugs, sometimes used to treat
irritable bowel syndrome and overactive bladder.
* Other chronic illnesses, such as Parkinson's disease and HIV/AIDS.

Risk factors

Factors that may increase your risk of autonomic neuropathy include:

* Diabetes. Diabetes, especially poorly controlled diabetes,
increases your risk of developing nerve damage, including autonomic
neuropathy. The risk is greatest for people who've had the disease for
more than 25 years and have difficulty controlling their blood sugar.
Additionally, people with diabetes who are overweight or have high blood
pressure or high cholesterol have a higher risk of autonomic
neuropathy.
* Alcoholism. People who abuse alcohol have a higher risk of nerve damage.
* Other diseases. A number of other diseases also increase your risk
of autonomic neuropathy, including amyloidosis, cancer, systemic lupus
erythematosus and other autoimmune diseases, HIV/AIDS, Parkinson's
disease, and botulism.

Preparing for your appointment

You're likely to start by seeing your primary care physician. However,
you may then be referred to a doctor who specializes in disorders of the
nerves (neurologist). In addition, depending on the part of your body
that's affected by autonomic neuropathy, you may need to see other
specialists, such as a cardiologist for problems with your blood
pressure or heart rate, or a gastroenterologist for digestive
difficulties.

Because appointments can be brief, and there's often a lot of ground to
cover, it's a good idea to arrive well prepared. Here's some information
to help you get ready for your appointment, and what to expect from
your doctor.

What you can do

* Be aware of any pre-appointment restrictions. At the time you make
the appointment, be sure to ask if there's anything you need to do in
advance, such as restrict your diet for certain tests.
* Write down any symptoms you're experiencing, including any that
may seem unrelated to the reason for which you scheduled the
appointment.
* Make a list of all medications, as well as any vitamins or supplements, that you're taking.
* Ask a family member or friend to come with you, if possible.
Sometimes it can be difficult to remember all of the information
provided to you during an appointment. Someone who accompanies you may
remember details that you missed or forgot. Additionally, family members
may need education about your illness. For example, if you don't know
when your blood sugar levels are dropping rapidly (hypoglycemia
unawareness), you may pass out from low blood sugar levels. Your family
members will need to know what action to take.
* Write down questions to ask your doctor.

Your time with your doctor is limited, so preparing a list of questions
can help you make the most of your time together. List your questions
from most important to least important in case time runs out. For
autonomic neuropathy, some basic questions to ask your doctor include:

* Why did I develop autonomic neuropathy?
* Are there any other possible causes for my symptoms?
* What kinds of tests do I need? Do these tests require any special preparation?
* Is autonomic neuropathy temporary or long lasting?
* What treatments are available, and which do you recommend?
* What types of side effects can I expect from treatment?
* Are there any alternatives to the primary approach that you're suggesting?
* Is there anything I can do on my own that will help?
* I have other health conditions. How can I best manage these conditions together?
* Are there any activity or diet restrictions that I need to follow?
* Are there any brochures or other printed material that I can take home with me? What Web sites do you recommend?

In addition to the questions that you've prepared to ask your doctor,
don't hesitate to ask questions during your appointment at any time that
you don't understand something.

What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to
answer them may reserve time to go over any points you want to spend
more time on. Your doctor may ask:

* When did you first begin experiencing symptoms?
* Have your symptoms been continuous or occasional?
* How severe are your symptoms?
* Does anything seem to improve your symptoms?
* What, if anything, appears to worsen your symptoms?

Tests and diagnosis

Autonomic neuropathy is a possible complication of a number of diseases,
and the tests you'll need often depend on whether or not you have known
risk factors for autonomic neuropathy.

When you have known risk factors for autonomic neuropathy
If you have conditions that increase your risk of autonomic neuropathy,
such as diabetes, your doctor can often make the diagnosis based on your
signs and symptoms. Similarly, if you have cancer and it's being
treated with a drug known to cause nerve damage, your doctor will be on
the lookout for signs of neuropathy.

When you don't have risk factors for autonomic neuropathy
If your symptoms point to autonomic neuropathy and you're unaware of an
underlying cause, the diagnosis is more difficult. Your doctor is likely
to review your medical history, ask for a thorough description of your
symptoms and do a physical exam. Tests that your doctor may use to help
with diagnosis will evaluate the reaction of several body functions
controlled by the autonomic nervous system. These may include:

* Breathing tests. These tests measure how your heart rate and blood
pressure respond to breathing exercises such as the Valsalva maneuver,
in which you exhale forcibly.
* Tilt-table test. This test monitors how your blood pressure and
heart rate respond to changes in posture and position, simulating what
occurs when you stand up after lying down. You lie flat on a table,
which is then tilted to raise the upper part of your body. Normally,
your body compensates for the drop in blood pressure that occurs when
you stand up by narrowing your blood vessels and increasing your heart
rate. This response may be slowed or abnormal if you have autonomic
neuropathy.
* Gastrointestinal tests. Gastric-emptying tests are the most common
tests to check for slowed movement of food through your system, delayed
emptying of the stomach and other abnormalities. The testing can take
various forms. One test may measure the rate at which food leaves your
stomach, while another checks how well your stomach muscles relax after
you eat. These tests are usually done by a doctor who specializes in
digestive disorders (gastroenterologist).
* Quantitative sudomotor axon reflex test (QSART). This test
evaluates how the nerves that regulate your sweat glands respond to
stimulation. A small electrical current passes through four capsules
placed on your forearm, foot and leg, while a computer analyzes how your
nerves and sweat glands react. You may feel warmth or a tingling
sensation during the test.
* Thermoregulatory sweat test. During this test, you're coated with a
powder that changes color when you sweat. You then enter a chamber with
slowly increasing temperature, which will eventually make you perspire.
Digital photos document the results. Your sweat pattern may help
confirm a diagnosis of autonomic neuropathy or other causes for
decreased or increased sweating.
* Urinalysis and bladder function (urodynamic) tests. If you have
bladder or urinary symptoms, a series of urine tests can evaluate
bladder function.
* Ultrasound. If you have bladder symptoms, your doctor may do an
ultrasound, in which high-frequency sound waves create an image of the
bladder and other parts of the urinary tract.

Treatments and drugs

Treatment of autonomic neuropathy includes:

* Treating the underlying disease. The first goal of treating
autonomic neuropathy is to manage the disease or condition damaging your
nerves. For example, if the underlying cause is diabetes, you'll need
to control your blood sugar to keep it as close to normal as possible.
In some cases, treating the underlying disease stops autonomic
neuropathy from progressing, and the damaged nerves can even repair
themselves or regenerate.
* Managing specific symptoms Beyond managing the underlying disease,
other treatments can relieve the symptoms of autonomic neuropathy.
Treatment is based on which organ system is most affected by nerve
damage.

Gastrointestinal symptoms
Your doctor may recommend:

* Modifying your diet. This could include increasing the amount of
fiber you eat and fluids you drink. Supplements containing fiber, such
as Metamucil or Citrucel, also may help. Be sure to increase the fiber
in your diet slowly to avoid gas and bloating.
* Metoclopramide (Reglan). This prescription drug helps your stomach
empty more rapidly by increasing the contractions of the digestive
tract. This medication may cause drowsiness, and its effectiveness wears
off over time.
* Medications to ease constipation. Over-the-counter laxatives may
help ease constipation. In addition, increasing the amount of fiber in
your diet may help relieve constipation.
* Antidepressants. Tricyclic antidepressants, such as imipramine
(Tofranil) or nortriptyline (Pamelor), can help treat diarrhea and
abdominal pain. Dry mouth and urine retention are possible side effects
of these medications.

Urinary symptoms
Your doctor may suggest:

* Retraining your bladder. Following a schedule of when to drink
fluids and when to urinate can help increase your bladder's capacity and
retrain your bladder to empty completely at the appropriate times.
* Bethanechol (Urecholine). This medication helps facilitate
complete emptying of the bladder. Potential side effects include
headache, abdominal cramping, bloating, nausea and flushing.
* Intermittent urinary catheterization. During this procedure, a
tube is threaded through your urethra to empty your bladder.
* Medications that decrease overactive bladder. These include
tolterodine (Detrol) or oxybutynin (Ditropan). Possible side effects
include dry mouth, headache, fatigue, constipation and abdominal pain.

Sexual dysfunction
For men with erectile dysfunction, your doctor may recommend:

* Medications that enable erections. Drugs such as sildenafil
(Viagra), vardenafil (Levitra) or tadalafil (Cialis) can help you
achieve and maintain an erection. Possible side effects include mild
headache, flushing, upset stomach and altered color vision. Men with a
history of heart disease, stroke or high blood pressure need to use
these medications with caution and medical supervision. Seek immediate
medical assistance if you have an erection that lasts longer than four
hours.
* An external vacuum pump. This device helps pull blood into the
penis using a hand pump. A tension ring helps keep the blood in place,
maintaining the erection for up to 30 minutes.

For women with sexual symptoms, your doctor may recommend:

* Vaginal lubricants. If vaginal dryness is a problem, vaginal
lubricants may make sexual intercourse more comfortable and enjoyable.

Heart rhythm and blood pressure symptoms
Autonomic neuropathy can cause a number of heart rate and blood pressure problems. Your doctor may prescribe:

* Fludrocortisone acetate (Florinef). If you get dizzy or feel faint
when you stand up, this medication helps your body retain salt.
* Midodrine (ProAmatine) or pyridostigmine (Mestinon). This drug can
raise your blood pressure if you get dizzy or feel faint when you stand
up. High blood pressure when lying down is a possible side effect of
midodrine.
* Beta blockers. This class of medications helps to regulate your
heart rate if your heart rate doesn't respond normally to changes in
activity level.
* A high-salt, high-fluid diet. If your blood pressure drops when
you stand up, a high-salt, high fluid diet may help maintain your blood
pressure.

Sweating
If you experience excessive sweating, your doctor may prescribe:

* A medication that decreases perspiration. The drug glycopyrrolate
(Robinul, Robinul Forte) can decrease sweating. Side effects may include
dry mouth, urinary retention, blurred vision, changes in heart rate,
loss of taste and drowsiness.

There is no medication to increase sweating if you have lost the ability to sweat.

Lifestyle and home remedies

*

Posture changes. To decrease dizziness when standing, try standing
slowly, in stages. It may also help to flex your feet and grip your
hands for a few seconds before standing up, to increase blood flow.
After you stand up, try tensing your leg muscles while crossing one leg
over the other a few times to increase blood pressure.

It also may help to raise the head of your bed by about one foot
(30 centimeters) and sit with your legs dangling over the side of the
bed for a few minutes before getting out of bed.
* Digestion. If you have gastrointestinal symptoms, try eating
small, frequent meals. Increase the amount of fluid you drink, and
choose foods that are low in fat and high in fiber, which typically
improves digestion.
* Diabetes management. Try to keep your blood sugar as close to
normal as possible if you have diabetes. Not only will tight blood sugar
control lessen symptoms, but also it may prevent or delay new problems
from developing.

Alternative medicine

Several alternative medicine treatments may help people with autonomic
neuropathy. However, because autonomic neuropathy is a serious
condition, discuss any new treatments with your doctor to ensure that
they won't interfere with treatments you're already receiving or cause
you any harm.

Alpha-lipoic acid
Preliminary research suggests this antioxidant may be helpful in slowing
or even reversing neuropathy that's causing blood pressure or heart
rate problems. However, more study is needed.

Acupuncture
This therapy, which uses numerous thin needles placed on specific points
in the body, was found to help treat slow stomach emptying. More
studies are needed to confirm these findings.

Coping and support

Living with a chronic condition presents daily challenges. Some of these suggestions may make it easier for you to cope:

* Set priorities. Decide which tasks you need to do on a given day,
such as paying bills or shopping for groceries, and which can wait until
another time. Stay active, but don't overdo.
* Seek and accept help from friends and family. Having a support
system and a positive attitude can help you cope with the challenges you
face. Ask for or accept help when you need it. Don't shut yourself off
from family and friends.
* Talk to a counselor or therapist. Depression and impotence are
possible complications of autonomic neuropathy. If you experience
either, you may find it helpful to talk to a counselor or therapist in
addition to your primary care doctor. There are treatments that can
help.
* Consider joining a support group. Ask your doctor about support
groups in your area. If there isn't a specific group for people with
neuropathies, you may find that there's a support group for your
underlying condition, such as diabetes. Some people find it helpful to
talk to other people who truly understand what they're going through. In
addition to offering camaraderie, support group members may also have
tips or tricks to make living with autonomic neuropathy easier.

Prevention

While certain inherited diseases that put you at risk of developing
autonomic neuropathy can't be prevented, you can slow the onset or
progression of symptoms by taking good care of your health in general
and managing your medical conditions. Follow your doctor's advice on
healthy living to control diseases and conditions, which may include
these recommendations:

* Control your blood sugar if you have diabetes.
* Seek treatment for alcoholism.
* Get appropriate treatment for any autoimmune disease.
* Take steps to prevent or control high blood pressure.
* Achieve and maintain a healthy weight.
* Stop smoking.
* Exercise regularly.

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