My father has developed a need to sleep virtually all day as well as at night – he will fall asleep even when having breakfast and then goes and sits in a chair and is sound asleep until at least mid-morning. He’s 93 and had a fall in the garden about eight months ago. We’re waiting for MRI results, but all the other tests are normal. This behaviour started about two months after the fall. It’s been dismissed as ‘being old’ by his doctors, but we’re not convinced.
Jane Johnson, by email.
Your worry over these symptoms is understandable. Daytime sleepiness is common in people of your father’s age.
This may be because older people don’t sleep as well at night as they used to, but it can also be an effect of medications prescribed – sometimes unwisely – for anxiety or sleeping problems, such as tranquillisers or sleeping pills.
It can also be an early sign of dementia – something that has been ruled out in your father’s case.
As his sleepiness is a departure from his previous habits, it warrants investigation. It certainly should not be dismissed as just old age.
It’s possible that a brain injury from his fall is at the root. Sleep disturbances are known to follow traumatic brain injury – commonly excessive daytime sleepiness, but also, at times, insomnia – even though many patients’ scans will look normal.
If the awaited MRI result is normal, then I suspect your father’s doctors will conclude he has a post-traumatic sleep disorder due to brain injury.
The cause of this is still not well understood. There are suspicions about disruptions to a brain chemical called orexin, which is involved in sleep, or minuscule structural brain changes that cannot be seen on scans, but which somehow have an effect on the mechanisms that govern when we feel alert and when we feel sleepy.
I am concerned the MRI scan might show an abnormality: a chronic subdural haematoma, which is a type of blood clot that slowly accumulates between the tough wrapping of the brain and the brain tissue itself.
A haematoma can develop over weeks and months after even minor trauma to the head, especially in the elderly. It may be it was not yet visible at the time of the first scan, which I assume was a CT scan.
A haematoma may cause no symptoms, at least initially, though as blood builds up and impinges on brain tissue there may be headache, unsteadiness and confusion, as well as sleepiness.
Surgery can be performed to drain a subdural haematoma. If one is confirmed on a second MRI scan, your father will come under the care of a neurosurgeon.
However, it is not inevitable that he will need surgery, for sometimes they do resolve on their own.
If there is not a subdural haematoma, the diagnosis must be that he has a sleep-wake disorder due to the head injury. A neurologist or sleep specialist might become involved if this is the case as there is a possibility of treatment with the narcolepsy drug modafinil, which raises levels of brain chemicals such as orexin and histamine – which is also important for sleep regulation.
I recently had an X-ray of my lower spine and it showed ‘significant signs of wear’. I have experienced quite a lot of stiffness and pain because of this and am taking ibuprofen. My doctor tells me I may get some benefit from an osteopath or chiropractor. I would like to know what is the difference between these two professions and which is most likely to be of help in easing my symptoms.
Mrs Sylvia Jones, E. Yorks.
Back pain can be perplexing for the patient and doctor because the extent of the wear and tear – or osteoarthritis – to the bones in the spine as seen on an X-ray does not always correlate with the severity of pain and stiffness that patients experience.
Someone with severe, chronic pain may have few signs of damage, and others may have X-ray evidence of severe osteoarthritis and yet not experience much pain at all.
What is difficult to measure and understand is inflammation of the soft tissues, muscles and ligaments of your back, and of the facet joints between the vertebrae.
It is inflammation that accounts for most of the pain.
Many patients attain a degree of pain relief from prescribed drugs – particularly non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen.
But in view of the potential for side-effects, such as irritation of the stomach lining and kidney damage, this is not ideal as a long-term strategy.
Short courses – a day or two or even a week or two, only when the pain is particularly severe – seem to be the best compromise.
This means that apart from specialist interventions, such as injections of steroids and local anaesthetic into inflamed facet joints, the management of back pain as you are experiencing it must focus on a range of physical interventions.
This includes physiotherapy and, as you have been advised, a complementary approach such as osteopathy or chiropractic.
Osteopathy involves the physical manipulation of muscle tissue and bones.
Chiropractic is similar. However, it also has a commitment to the idea that this can somehow help other health problems elsewhere in the body.
I am not aware of any evidence-backed theory for how these treatments work, but, put simply, people seem to find the experience soothing.
The limited research that is available suggests it sometimes works for lower back pain.
However, given the ever-present dictum ‘first do no harm’ and the knowledge that manipulation treatments have been found to be harmful, it is important not to spend too much time and money on multiple sessions that are not of benefit.
I would instead point you towards other activities, such as tai chi, originally a martial art, pilates or yoga, which have been found to be effective. These activities help to strengthen the muscles of the abdomen and back and improve posture, all of which can help with back pain.
These do take time and should be practised under the supervision of a trained teacher, who can advise you on what moves and positions to do according to your pain levels and limitations.
It may suit you – especially as you say you used to be very active – and, over some months, it could give you considerable ease.
By the way… Closing pharmacies is a dangerous error
There was a time when a familiar face would greet you at your local pharmacy in much the same way you experience when going to your family doctor.
When I entered general practice in 1977, I valued the professional advice and support available in my local pharmacy six days a week.
The same pharmacist was always there to help me research rarely used medicines, seek out information or find urgently needed items of equipment, cylinders of oxygen or other vital emergency supplies.
For many patients today, the local pharmacy is just a High Street shop where you collect the medicine that a GP has prescribed.
But a pharmacist is a highly trained professional who can dispense much-needed, face-to-face, expert advice about health concerns, unexpected symptoms and minor injuries. Indeed, pharmacists are a valuable supplement to the GP service, which, as we know all too well, is under the cosh.
Yet small, local pharmacies seem to be at risk of going the way of local post offices, bakeries and newsagents as, more and more, the big boys take over and worse, the Government is set to ride roughshod over the industry.
Earlier this year, it was revealed that the Department of Health believes there are 3,000 too many pharmacies in England – and admits that many face closure.
All High Street pharmacies receive NHS funding – on average, £220,000 a year, depending on the number of prescriptions they issue and other services they offer, such as providing flu jabs – but the pot is being cut by 6 per cent, which is around £170 million.
The Government is dressing up such cutbacks as ‘efficiencies’ – saying that pharmacy services must be better integrated into primary care.
That might mean more GP surgeries equipped with their own pharmacies, but also, I imagine, prescriptions sent by email to the ‘hub and spoke’ arrangement.
This is where the assembly and labelling of prescriptions is done in a large, centralised hub and then returned to a ‘spoke’, a registered pharmacy or other premises, where a patient can collect it.
This looks efficient, but comes at a cost: the loss of face-to-face contact and support from a pharmacist who knows you – an invaluable safety measure.