Author name: Tony Laughton

Alcohol Use Disorder
Cracking Addiction, Global Awareness, Healthcare

Understanding Alcohol Use Disorder

On Cracking Addiction show this week

Alcohol use disorder can sometimes be difficult to define. The DSM defines alcohol use disorder is defined by the following criteria:

  • Spending a lot of time getting, using, or recovering from use of the substance.

  • Cravings and urges to use the substance.

  • Not managing to do what you should at work, home, or school because of substance use.

  • Continuing to use, even when it causes problems in relationships.

  • Giving up important social, occupational, or recreational activities because of substance use.

  • Using substances again and again, even when it puts you in danger.

  • Continuing to use, even when you know you have a physical or psychological problem that could have been caused or made worse by the substance.

  • Needing more of the substance to get the effect you want (tolerance).

  • Development of withdrawal symptoms, which can be relieved by taking more of the substance.

It is important to know how to define alcohol use disorder to determine the severity of the disease with mild disease defined as the presence of 2-3 symptoms, moderate disease the presence of 4-5 symptoms and severe disease the presence of 6 symptoms.

Alcohol use disorder is a chronic relapsing disease that can have a high mortality (both through the effects of being intoxicated but also the secondary health effects with associated cancers, heart disease etc.) but also significant morbidity.

There are simple screening tests that can be done to identify patients at risk of alcohol use disorder including the CAGE questions and the AUDIT-C screening questionnaires that can identify people at risk of alcohol use disorder and with early interventions and appropriate support it is possible to significantly improve and impact the course of a patient’s alcohol use disorder and their life.

This does not necessarily need to be time consuming and indeed brief interventions lasting no more than 10-15 minutes discussing someone’s alcohol use disorder has good evidence to show that it can be effective.

A good framework for a brief intervention is the FRAMES model based on Feedback of personal risks or impairment, Responsibility (the patient’s personal responsibility to implement change), Advice, Menu (of strategies to change the problematic habit or behaviour), Empathy and self-efficacy.

In this episode of Cracking Addiction we define what alcohol use disorder is, the difference between dependence and addiction and the progression of alcohol use disorder.

Home Residential Withdrawal
Cracking Addiction, Global Awareness, Healthcare

Home Residential Withdrawal

On Cracking Addiction show this week

Home based or outpatient alcohol withdrawal management is an area of medicine shrouded in mystery and confusion. It occurs quite often but usually in a haphazard and disorganised manner. The results of poor management of alcohol withdrawal can be dire and lead to complications such as delirum tremens, Wernicke’s encephalopathy and other harms.

Home based or outpatient alcohol withdrawal management is a safe intervention when carried out in the right environment, with the right patient, the right protocols and the right safeguards in place.

Right environment
A safe drug free environment is paramount with a place for safe storage of medications. It is also important that the patient is not geographically isolated and has access to a mobile phone and is able to make and receive calls on this mobile phone.

Right patient
The patient should be over the age of 18 and be judged to only have mild to moderate alcohol dependency. The patient should be able to provide informed consent and be able to adequately follow medical instructions. Alcohol should be the only substance use disorder present and the patient should not be using any other substances as this might complicate withdrawal management and a patient using multiple substances might be better served with a residential withdrawal management admission. The patient should not have serious or significant medical or psychiatric comorbidities and no history of complex withdrawals.

Right protocols
Usually a fixed dose regimen for diazepam is used for home based alcohol withdrawal management. Turning Point’s Alcohol and Drug Withdrawal Guidelines provide a good template upon which to fashion home based withdrawal management. It is important that prior to commencing home based withdrawal management that both doctor and patient are clearly aware of the protocols and medication dosing regimen and the regularity of follow up-this might best be outlined in a written plan. If a complication arises or there are concerns it is important for the doctor to know where to seek help and liaising with your local Addiction Medicine service or specialist may be useful. Safety must be the foremost consideration and daily review and daily pick up of medications in a staggered manner is recommended.

Right safeguards
As mentioned in an earlier section it is important that the patient is not geographically isolated and has access to a working phone. It is important that the patient is linked in with a general practitioner and that they can access this general practitioner daily and contact them freely. It is paramount that the patient not live alone and has a support person with them in the house whilst withdrawal management is occurring.

Disease Prevention
Global Awareness, Healthcare, Lifestyle Matters, MedHeads

Disease Prevention

In this episode of Lifestyle Matters Dr Ferghal and I discuss the benefits of exercise both in primary and secondary prevention of cardiometabolic diseases, heart disease and maintaining a robust immune system.

Some statistics from Diabetes Australia and Australian Institute of Health and Welfare show that:
• In Australia, 1 person develops diabetes every 5 minutes
• An average of 2 people die from heart disease every hour
• 23 Australians die from a stroke every day.

High blood pressure is a well-known risk factor for both, heart disease and stroke. There are studies to show that a modest weight loss of 2kg in a 6-month period can reduce diastolic blood pressure by 2.7mm mercury and systolic by 3.7mm mercury.

This occurs via a variety of mechanisms including the production of free radicals and growth factors that can promote cell signalling and remodelling of our blood vessels. This in turn will reduce the resistance of our blood vessels, thus reducing the risk of high blood pressure.

When we exercise, our heart consumes more oxygen. If exercise is done regularly, one of the changes that occur is the reduction of resistance to blood flow. This is because our blood vessels have adapted to the repeated shearing forces. This in turn improves our cardiorespiratory fitness. For example, the breathlessness a standard sedentary person experiences when walking up 2 flights of stairs at a fast pace would reduce over time if she/he were to engage in regular exercise.

Cardiac rehabilitation (i.e. a tailored exercise program under supervision) after a heart attack can also reduce the rate of recurrence and further hospitalisations. Commencing with aerobic training for a few weeks followed by strength training under guidance is the best way forward in this regard to minimise any risks and enhance one’s cardiorespiratory fitness.

The Diabetes Prevention Program was a study designed to explore if we can reduce the incidence of developing diabetes by way of lifestyle intervention in those diagnosed with Impaired Glucose Tolerance / Pre-Diabetes. All that was required was a 7 % weight loss and 150 min per week of exercise such as brisk walking. The results were astounding – the lifestyle group had a 27% greater reduction in diabetes compared to the cohort that took Metformin (a medication used to treat diabetes)

Some of the ways exercise helps this is by reducing insulin resistance and triglycerides, weight loss and changing our body composition i.e. increasing muscle mass thereby increasing our basal metabolic rate.

Many are worried to exercise after a stroke for a variety of reasons. But really, exercise has been shown to be just as effective as blood thinners in reducing mortality after having a stroke. Starting slow and building up will be the best way forward, with the support of a rehabilitation physiotherapist or exercise physiologist. Cardio workouts are important to improve our heart and lung function and reserve, stretch and flexibility helps reduce spasticity and improve mobility. Tai Chi; for example can improve coordination, balance and cognition and lastly, resistance training can potentially improve muscle strength. Any or all of these exercises can help improve our mood and social connectivity as we would potentially engage with other people and even join a gym.

When it comes to exercise and our immune system, striking the right balance is important. Exercise has an interesting effect on our immune system. Regular moderate intensity help boost our immune function to ward off a plethora of infections by increasing the function of our T cell lymphocytes and natural killer cells amongst others. On the other hand, prolonged intensive exercises (for example; military training) have been thought to depress our immune system. However, there are many other factors such as stress or lack of sleep that could contribute hence this is slightly controversial at this stage. Following the recommended guidelines and not greatly exceeding it; i.e. no more than 420mins / week should keep us safe.

Residential Withdrawal
Cracking Addiction, Global Awareness, Healthcare

Residential Withdrawal

On Cracking Addiction this week

Residential withdrawal management is one of the hallmarks of addiction medicine as a specialty. Residential withdrawal management is for those patients for home a home-based alcohol withdrawal is unsafe or contraindicated doe to significant medical or psychiatric comorbidities.

These patients require closer monitoring and medical and nursing support and this can only be accomplished in a supervised setting. The rationale for the treatment of alcohol withdrawal is to prevent minor withdrawal symptoms to escalating into more severe or complicated withdrawal symptoms which can be distressing for the patient, those around them and in severe case can lead to significant adverse health outcomes or death.

The most severe complications of alcohol withdrawal include alcohol withdrawal seizures, delirium tremens and Wernicke’s encephalitis. The goals in residential withdrawal management is to decrease the chances of severe complications by preventing dehydration and electrolyte imbalance, preventing thiamine deficiency which can lead to Wernicke’s encephalitis and adequate dosing of diazepam (or oxazepam in select cases with significant liver impairment) to decrease the chance of withdrawal seizures or delirium tremens occurring.

Management of alcohol withdrawal in residential setting is usually guided by scales and is protocol driven. The two most commonly used scales to determine alcohol withdrawal are the Alcohol Withdrawal Scale (AWS) and Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) with the goal being to keep the AWS under 5 and CIWA-Ar under 10.

Although as mentioned alcohol withdrawal management is somewhat protocolised it is also important to acknowledge an individual’s particular risk and vulnerabilities. Diazepam loading may be required for some patients whose withdrawal scores are rising despite medication given or those who are at risk of a complicated withdrawal.

Similarly, for those with severe liver disease whose livers may not be able to process diazepam an alternative benzodiazepine oxazepam is used as this does not need to undergo phase 1 metabolism in the liver and thus there is no increased risk of a potential build up to toxic levels within the body. There are a number of such variations to the standard protocol which are utilised to ensure that a patient’s medical and psychiatric conditions as well as individual needs and requirements are catered for.

Residential withdrawal management is about managing potentially high-risk patient who may be at risk of significant complications during their alcohol withdrawal in a safe, humane and holistic manner using evidence-based tools and interventions. In this episode of Cracking Addiction we delve into more detail and practicalities of how to do this.

Medication Safety
Cracking Addiction, Global Awareness, Healthcare

Medication Safety

This week on MedHeads

Maintaining medication safety at home can be daunting as the prescriptions increase.
Medication errors at home can be fatal or leave you in harm’s way.

As complex health conditions can come with increased medications and specific times that they are required or other medications that cannot be taken at the same time, there can be increased stress and fear.

Reminders:
If you are tech savvy, there are apps that can assist in reminding to take medications with notifications. One such app is the Medadvisor app. It links to your local pharmacy, and you can upload prescriptions. Medications can also be delivered. Carer mode is also available – You can manage medications and prescriptions for kids, elderly, and other family members under one Medadvisor account. This is a free app but must be approved by your pharmacist. However, a lot of people either are not tech savvy or don’t want to rely on a reminder, this also may not be appropriate if you have many medications.

Dosette box:

A dosette box is an option for someone who has a few prescriptions. It may also be known to some as the Monday –Sunday pill box. These can be very beneficial for many reasons including travelling. However, the down side is that they also require the unpacking of medications form bottles, an awareness of each pill and an awareness of the time that the pill needs to be taken. Dosette boxes usually don’t facilitate medication dispensing at different times of day, but rather, act as reminders for daily dispensing.
Cost and accessibility: 5-10 dollars

Webster packs:
Webster packs are a useful option for clients who are prescribed multiple medications that need to be dispensed at multiple and specific times during the day. Webster packs are great for those managing complex regimes and can also relieve carer strain/stress and increase peace of mind for all involved in a person’s life.
Webster packs come in a range of options such as the vision impaired version, multilingual version, and the Parkinson’s disease specific version. They can be hung on the fridge and even have photo ID picture placed on the pack.

The generic webster pack has symbols for the time of day and the day of week across and down the side of the pack, the user just sees the time and date needed and pops the medications out of the blister.
Cost and accessibility: 5 dollars per week for pensioners, pending on pharmacy.

Sachet roll: dose aid :
Sachets- up to 5 medications in a pack
DoseAid’s range of medication management solutions are designed to increase medication compliance and reduce the frequency of adverse incidents.

DoseAid’s medicine sachets are a safe and effective way for people to keep track of their daily medicines. To complement its sachets, DoseAid has also partnered with Medido to make a one-of-a-kind compliance device available in Australia.

The medicines are sorted by day, dose, and time into individually labelled sachets with easy tear packaging in chronological date and time order. These sachets are then rolled up.
Each individual sachet can hold up to five different tablets. So, for example, if someone takes seven different tablets in the morning, their morning tablets will be divided between two sachets.

Every sachet is clearly labelled with:
•The patient’s name
•The date and day of the week
•The dose time
•Names and physical descriptions (shape, colour) of the medicines
•The quantity of each tablet.

This information can be easily adapted depending on the specific needs of the individual.
Cost and accessibility: similar to Webster packs under PBS

Where to get help
•Your doctor
•Pharmacist
•NPS Medicines Line call 1300 633 424
•Adverse Medicines Events Line call 1300 134 237

Taking your medication safely
•Your doctor will monitor your prescription medication, but you need to make sure you follow your medication instructions, including:

•Take all medication exactly as instructed by your doctor or pharmacist.

•Do not take medication prescribed for someone else.

•Learn about your medication and know the importance of taking your medicine correctly. Ask your pharmacist for a Consumer Medicine Information (CMI) leaflet, which answers common questions about your medication (or look for it online as many drug companies publish them on the web).

•When buying over-the-counter medication, ask your pharmacist about side effects and interactions with other medication (including vitamins and herbal supplements) you are taking.

•If you are not confident that you will remember the instructions for taking the medication (such as dosage and time of day), write them down, or ask your doctor or pharmacist to write them down.

•If you are taking multiple medications or find you are forgetting if you have taken a dose, talk to your pharmacist about dosage aids (as described above)

•Ask your doctor if making changes to your lifestyle (such as diet and exercise) could reduce your need for medication.

•Ask your doctor if you may benefit from a Home Medicines Review. This is where a pharmacist reviews all the medication you take, and it can be done annually. You may be able to stop taking medication you no longer need.

•Throw out unwanted and out-of-date medication, as the active ingredient may no longer be effective. You can also return it to your pharmacy for safe disposal.

•Do not stop taking a prescribed medication without discussing it with your doctor. If it is not working for you, speak with your doctor about an alternative.

 Watch this weeks show on MedHeads

Unlocking Vitality
Global Awareness, Healthcare, Lifestyle Matters, MedHeads

Unlocking Vitality

This week on Lifestyle Matters I chatted with Saveena about the basics of exercise. This episode is the first of a series of shows in which we plan to explore all aspects of exercise and how it applies to health and wellbeing.

Exercise can be classified as: aerobic, resistance, balance, and flexibility.

Aerobic exercise can be thought of as fitness training, and can include activities such as brisk walking, jogging, cycling, or rowing. These are all types of activity that may you puffed out.

The Australian Government department of health advises the following activity guidelines for adults between 18 and 64.

Adults should be active most days, preferably every day.
Each week, adults should do either:

  • 2.5 to 5 hours of moderate intensity physical activity – such as a brisk walk, golf, mowing the lawn or swimming

  • 1.25 to 2.5 hours of vigorous intensity physical activity – such as jogging, aerobics, fast cycling, soccer, or netball

  • An equivalent combination of moderate and vigorous activities.

In addition, Department of Health guidelines state the following regarding resistance training.

Include muscle-strengthening activities as part of your daily physical activity on at least 2 days each week. This can be:

  • Push-ups

  • Pull-ups

  • Squats or lunges

  • Lifting weights

  • Household tasks that involve lifting, carrying, or digging.

Both balance and stretching activities should performed at least twice a week, especially by older Australians above the age of 65.

Flexibility activities

Activities that focus on your flexibility help you move more easily, and can include:

  • Tai chi

  • Bowls (indoor and outdoor)

  • Mopping or vacuuming

  • Stretching exercises

  • Yoga

  • Dancing

Balancing activities

Activities that help improve your balance can prevent falls and injuries, and can include:

  • Side leg raises

  • Half squats

  • Heel raises.

We also chat about the perils of being sedentary. Sitting increases all-cause mortality and has been found to be, independent of exercise, a risk factor for obesity, metabolic syndrome, cardiovascular disease, and type 2 diabetes mellitus.

Television viewing has been found to increase all-cause mortality even in those getting seven hours of exercise per week. Interrupting sitting with light to moderate intensity walking every 20 mins reduces blood glucose and insulin levels in obese patients.

Transforming a Veteran's Life
Global Awareness, Healthcare, Lifestyle Matters, MedHeads

Transforming a Veteran’s Life

On MedHeads

I chat with DR Andrew Rees about a particularly challenging case of a military veteran in his fifties who ahs been a victim of both a traumatic abusive childhood and combat trauma.

He suffers from chronic pain secondary to degenerative disease of both knees and spine (rather than combat trauma) and is dependent on high dose opioids (oxycontin 40 mg bd) and various benzodiazepines. He also suffers form PTS. In terms of his lifestyle, he is obese, he smokes twenty to thirty cigarettes per day. He lives with a partner and has a child from a previous relationship.

We discussed firstly what his needs might be according to the “SPEW CRAFT” mnemonic.
Sustenance – there do not seem to be any unmet needs in this domain
Protection.
His PTSD may indicate an unmet psychological need for protection.
Engagement with meaningful activities.
He does not engage in any meaningful activities; he has no hobbies or interests and self isolates for most of the time.
Wisdom – He may not know how to seek help, or for that matter that help is available
Creativity – there do not seem to be any unmet needs in this domain
Rest – He does not work, and as mentioned above he does not engage in any meaningful activities, but this does not mean he has rest. He does not have rest from psychological restlessness, and his diurnal rhythms are disturbed.
Freedom – He feels trapped and isolated and is not sure who his tribe is. There is a reluctance to engage with the local RSL for fear of exacerbating his PTSD.
Transcendence or Legacy.
He has no idea of his identity or his personal worth.

Starting from this apparently hopeless situation Dr Rees has been able to engage with this patient and help this patient grow by simply asking the right questions.

What does he hope for in life?
This man’s quest for his purpose in life led him to realize that he wanted to re-establish his relationship with his daughter.
What is he good at, what would his spouse think he is good at, what would his daughter think he is good at?
He identified that his strengths included reliability, conscientiousness, and a sense of duty.

After understanding the answers to these questions then comes the miracle question.
“If all your problems magically disappeared overnight, what would it look like for you, what would it feel like for you and what would be the first sign that someone else would notice?”
In this case the answer was that he would smoke less, take less medication, and do more exercise.

The miracle question has unlocked in this patient the potential for deprescribing and a healthier lifestyle. Finding his purpose in life has shifted his focus from being dependent on medication and has unlocked his desire to be medication free, to enjoy mental clarity and to engage with his family.

Archimedes once said that with a big enough lever he could move the earth. Dr Rees has shown us a similarly profound effect: that with the right question we can unlock a willingness for change and a desire for a drug-free life.

Understanding School Refusal
Global Awareness, Healthcare, Lifestyle Matters, MedHeads

Understanding School Refusal

Maree Eisma is a mental health social worker who has an expertise in dealing with children who are experiencing school refusal.

School refusal usually presents with an escalating school reluctance before frank refusal occurs. Behaviours can include repeated sick bay attendances or multiple but intermittent absences due to various illness presentations.

I like to classify the presentation of school refusal according to primary, secondary or tertiary gain.

Primary gain refers to the intrinsic benefit of the sick role. In the context of school refusal, it suggests that the child who presents with an illness benefits from being sick in terms of care giver attention. This may be an issue of care givers are very busy or otherwise emotionally distant.

Secondary gain refers to a secondary benefit that the sick child enjoys, which in the context of school refusal may indicate a desire to escape from bullying, a test or other academic pressure or sometimes merely the overstimulation that may occur in a busy school yard.

Tertiary gain refers to the benefit that the care giver may derive from a child’s illness behaviour triggering school refusal. Divorce, separation, or other sources of parental disharmony can perpetuate this.

Underlying the phenomenon of primary gain is the concept of somatisation, i.e. the manifestation of medically unexplained symptoms that are not consciously feigned.

It can be challenging from a. medical perspective to distinguish organic pathology from somatisation, but the distinction needs to be made to prevent harm to the patient in terms of unnecessary tests and treatments.

Further to the diagnostic dilemma it is also important to approach the management of the problem from a socio-psycho-biomedical model of care. it is not sufficient simply to advise parents to “Just make their child attend school”.

In a similar vein I remember telling the parents of a young child who was refusing to swallow antibiotics to “just make the child take the medicine”.

Graded exposure can be used to help children re-integrate back into school. This process relies on a patient and gradual exploration of a child’s situational anxiety and providing coping mechanisms to deal with situations as they arise. It is important that both parents and the school be closely consulted and involved in this treatment.

Watch this discussion on MedHeads

Alcohol Physiology
Cracking Addiction, Global Awareness

Alcohol Physiology

On Cracking Addiction show this week

It is estimated that about 5% of the population in Western countries have alcohol dependence with the lifetime exposure to alcohol thought to be up to 88% in the USA. Alcohol dependence progresses without treatment and has a chronic relapsing pattern. And with little interventions 30% achieve stable abstinence, 40% continue to drink heavily and 30% worsen and die within ten years. In a treatment program 45% achieve either longterm abstinence or intermittent relapse but large period of sobriety; 35% have periods of abstinence but large periods of heavy drinking and 20% have progressive downhill course.

With regards to alcohol withdrawal syndrome not all dependent drinkers experience withdrawal symptoms with symptoms ranging from mild to severe. In severe cases symptoms may increase in severity over 48-72 hours from alcohol cessation with anxiety, tremor, sweating, tachycardia, increased temperature and pulse. Mild to moderate withdrawal symptoms typically start around 6-24 hours from the last drink and peaks around 24-48 hours post last drink and lasts 3-7 days.

Withdrawal symptoms can be rated and monitored either through Alcohol Withdrawal Scale (AWS) and Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar).

The most severe alcohol withdrawal syndrome is delirium tremens which is seen in up to 5% of patients in withdrawal. It is a life threatening condition though mortality now less than 1%. The onset of delirium tremens occurs 48-72 hours after last drink and can last between 3-10 days and symptoms include autonomic hyperactivity, severe anxiety, dehydration, electrolyte disturbance, clouding of consciousness, hallucinations, paranoid delusions and cardiovascular collapse may occur.

Wernicke’s encephalopathy is an acute reversible neuropsychiatric condition due to thiamine deficiency and occurs in those who are malnourished or unable to absorb thiamine. It can present during course of alcohol withdrawal or delirium tremens and has a classic triad of symptoms: oculomotor abnormalities (nystagmus, ophthalmoplegia), cerebellar dysfunction (ataxia) and recent onset confusion-not everyone will have all the symptoms.

It can be difficult to differentiate from delirium or confusion and is a medical emergency with a 10-20% mortality. The condition is reversible with parenteral administration of thiamine. The guidelines for treatment include 500mg IV tds for 5 days and if no response to therapy discontinue treatment but if response noted continue with 250-300mg thiamine daily for another five days or longer if needed. Follow up with regular thiamine and multivitamin supplementation thereafter.

It is important to give thiamine before IV glucose or other carbohydrate load as this may potentiate Wernicke’s encephalopathy

The Exercise Pill
Healthcare, Lifestyle Matters, MedHeads

The Exercise Pill

In this episode of Lifestyle Matters I chat with Dr Saveena about the benefits of exercise in terms of mental health, musculoskeletal health, and cancer.

Mental health.
We know that exercise helps improve depression, anxiety, cognitive function, the risk of progression of Alzheimer’s disease and sleep. Exercise causes an endorphin rush causing us to feel good. It also increases the amount of serotonin and melatonin in the brain, improving depression and anxiety and improving sleep. Exercise has been identified as a key intervention in brain health, improving cognitive function and the risk of Alzheimer’s. These benefits are in part derived from improved cerebrovascular health, reductions in blood pressure and improved brain perfusion. Exercise is a good stress reliever and helps us pay off the “adrenaline debt” that the stress of our modern lives imposes on our hypothalamic pituitary adrenal axis.

Musculoskeletal system

Exercise in the form of resistance training can help strengthen muscles which in turn can help reduce the pain of arthritis. Aerobic training can also reduce pain and improve wellbeing not only by the endorphin rush, but also by aiding in weight loss, which in and of itself has been shown to reduce pain. It is important however to engage in boom-and-bust activities, but rather to pace oneself and gradually increase exercise loads. Overexercising as dangerous as not exercising. Weight bearing and load bearing exercises are also known to stimulated bone growth and inhibit bone loss, thereby preventing the progression of osteoporosis, a thinning of the bones that leads to fragility fractures.

Exercise reduces cancer.

We know that exercise reduces the risk of the following cancers: bladder; breast; colon; endometrium; oesophageal; stomach; and lung cancer. For breast and colon cancer exercise has been found to reduce the risk of developing these cancers by as much as 30%. These effects may result from an improved immunosurveillance that occurs in response to the beneficial stimulatory effect that exercise has on natural killer cells and T-cells which are an essential part of our immune system. Secondly exercise improves fitness and improves one’s ability to tolerate cancer treatments including surgery, radiotherapy, and chemotherapy.

Finally, both the American Heart Association and the American Stroke Association have produced a “Presidential Advisory” notice for brain health entitled “Optimizing Brain Health”. It includes physical activity as a key recommendation. The seven metrics for optimal brain health are as follows

Ideal Health Behaviours

  • Non-smoking

  • Physical activity at goal levels

  • Healthy diet consistent with current guideline levels

  • Body mass index <25 kg/m2)

Ideal Health Factors

  • 1. Untreated blood pressure <120/<80 mmHg

  • 2. Untreated total cholesterol <200 mg/dL (5.18 mmol/l)

  • 3. Fasting blood glucose <100 mg/dL (5.55 mmol/l)

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