Dear Dr. Roach: Our local newspaper just ran the obituary of a 59-year-old woman who died from Alzheimer's disease. I didn't know her, but I've known at least two other people with that illness. One has passed away; the other is in a memory-care unit. How does Alzheimer's cause or contribute to death?
Dear A.: Alzheimer's disease is a common degenerative disease of the brain. It's, unfortunately, very likely that in the years ahead, you will know many more people diagnosed, as the risk increases with age. Its exact cause is unknown. We often think of Alzheimer's as being a disease of memory; however, personality changes, loss of insight, impaired visual skills and language dysfunction are other cardinal findings of the disease, though any of these may show more clearly as the disease progresses.
Alzheimer's can progress in individuals at very different rates, but the mean survival after diagnosis has been reported as three to eight years. People with Alzheimer's disease usually become debilitated due to poor nutrition and hydration, which leads to increased risk for infection, one of the most common causes of death in Alzheimer's.
I don't mean to suggest that debility is the fault of the caregivers of people with advanced dementia. Caring for a person with Alzheimer's disease is a difficult and demanding task — physically, mentally and emotionally. But no matter how devoted and skillful the care is, there is no preventing the physical decline that happens as the Alzheimer's progresses; we can only slow it down. It has been my experience that in patients with advanced dementia, the caregiver becomes the most important part of the team to get information from and give guidance on care and provide support to.
Dear Dr. Roach: In your recent column regarding a 54-year-old man's sexual difficulties, you neglected to include what could be the most significant cause for erectile dysfunction in older American males: circumcision. Indeed, circumcised males are four to five times more likely to use Viagra than intact males.
Dear R.A.: Circumcision, like any medical procedure, has potential for both benefit and harm. Potential benefits include reduction in lifetime risk of urinary infection (32 percent in uncircumcised versus 9 percent in circumcised), a small decrease in penile and partner's cervical cancer risk and decreased risk of sexually transmitted disease (50 percent to 60 percent reduction in HIV).
Potential harms include surgical complications (0.2 percent for in-hospital circumcisions), possible sexual dysfunction and pain during the procedure. This pain can and, in my opinion, should be prevented by a nerve block or anesthetic cream.
Although one study did show a large increase in the risk for sexual dysfunction for circumcised men, the study had a key flaw: recruiting subjects who already had complaints about circumcision. The preponderance of data on sexual dysfunction does not support circumcision being a large risk factor. In a 2013 review of 2,675 publications, the authors found that the "highest-quality evidence suggest that medical male circumcision has no adverse effect on sexual function, sensitivity, sexual sensation or satisfaction."
Although there may be some health benefits for routine circumcision, I agree with the American Academy of Pediatrics that "parents should weigh the health benefits and risks in light of their own religious, cultural and personal preferences, as the medical benefits alone may not outweigh these other considerations for individual families."
Email questions to ToYourGoodHealth@med.cornell.edu.