healthmedicinet

By
Martin Scurr

PUBLISHED:

18:43 EST, 31 March 2014

|
UPDATED:

18:43 EST, 31 March 2014

For
the past two years my 71-year-old sister has been slurring her speech.
After some persuasion I finally managed to get her to go to her doctor
who arranged an MRI scan, which he said was clear. There are no other
signs of a stroke. She hasn’t asked for a second opinion or what
could be causing the slurred speech and seems happy to let this be. The
only medication I know that she is on is for blood pressure and
cholesterol. I would very much appreciate your comments.

Valerie Merino, Manchester.

People with dysarthria usually slur their speech but they may also speak very slowly or sound hoarse, or nasal

The
symptoms you describe are characteristic of dysarthria, the loss of the
ability to control the mouth and throat to articulate speech. Those
affected have no problem understanding – their difficulty is solely in
the clear formation of words.

This is very different from aphasia and
dysphasia, an impaired understanding or problems in expressing words,
caused by a problem in the language centres of the brain.

People with
dysarthria usually slur their speech and sound as though they are
drunk, but they may also speak very slowly, or sound hoarse, or nasal.

In
some cases there may be problems in controlling saliva, or difficulty
in chewing or swallowing. The key point is that dysarthria is a symptom,
and diagnosis of the cause is essential.

It may be due to a disorder
of the brain (such as following a stroke) or nerve supply to the
muscles of speech, which involve the face, the tongue, or the muscles of
the throat. There are several types of dysarthria. With cerebellar
dysarthria, the patient speaks deliberately and slowly, with normal flow
being lost.

Diagnosing dysarthria is the job for a neurologist

In pseudobulbar dysarthria, individual syllables are
slurred and consonants are imprecise; there may also be problems in
swallowing, and it is therefore doubtful that your sister has this type.

In bulbar dysarthria, the disorder results from some form of damage
or disease involving the nerve supply to the muscles  of speech, with
slurring of words and  sometimes nasal escape of fluids  when
swallowing.

Diagnosing dysarthria is the job for a neurologist: the
MRI (magnetic resonance imaging) that was organised proved useful in
that it excluded a stroke as the cause, and will almost certainly have
excluded multiple sclerosis.

Nor is your sister’s current medication
– the blood pressure pill and statin to reduce cholesterol –
implicated. What she needs is a detailed clinical examination looking at
all aspects of the nervous system by a specialist in neurology and
possibly further investigations.

It is heartening that despite a
two-year history, the problem does not seem to be getting worse, and
that there aren’t other symptoms.

Hopefully, you will be able to
persuade your sister to press her GP practice to refer her for a further
opinion – although if she is happy to let the problem be, then I do
acknowledge that she should be allowed her autonomy.

Until I was
60, my pulse was 61 beats per minute; but since then it has dropped to
50, and 46 at its lowest – I am now 67. Three years ago, when it dropped
to the low 50s, I saw my GP and was referred to a consultant whose
advice was that I should go back if starting to feel faint and dizzy. This
seems sensible advice, but I can’t get rid of the feeling of being a
clockwork toy that is gradually running down.  Do you have a key? Under
these circumstances, is exercise inadvisable? I am otherwise fit.

Ron Warrington,  Bransgore, Hants.

Be reassured: you have been well advised so far. The reason I can be so confident about this is that you are symptom free.

Most healthy people have a heart rate between 60 and 100 beats per minute

Most
healthy people have a heart rate between 60 and 100 beats per minute;
when the rate is below 60, we refer to it as bradycardia.

This is
not necessarily a sign of poor health, or heart disease – indeed it’s
normal in around 25 per cent of people under the age of 25 when at rest
and in trained athletes (being super fit helps slow down the heart
rate). It can also occur in some older individuals such as yourself.

Bradycardia,
as your experience illustrates, doesn’t usually cause symptoms. And if
and when symptoms do occur, they may be minimal – perhaps nothing other
than fatigue: there may also be sensations such as dizziness, faintness
or lightheadedness.

If you do start feeling unable to exert yourself
or exercise, or experience these other symptoms, you must be further
investigated.

This will involve a careful history supplemented by
ambulant ECG (electrocardiography) monitoring, where you wear a device
that records your heart’s electrical activity for 24 hours, or longer,
so the timing of symptoms can be compared with the recordings.

Should
treatment be recommended, patients have a pacemaker implanted just
below the collar bone. This is designed to monitor the heartbeat and if
it detects a problem, it sends an electrical signal to the heart to
stimulate it.

Powered by an internal battery that has a life of
several years, the pacemaker is about the size of a 50p coin and weighs
an ounce or two, with various types available. It is connected to heart
muscle by flexible wires.

Once it’s installed, the patient doesn’t
notice it and life goes on as normal – it is the most well-refined and
effective technology. But in your current state, no treatment is needed.
Exercise and enjoy life with confidence – you are in no danger.

By the way… Sore throat? You need a swab

Doctors
must take more care about  prescribing antibiotics. So says Professor
Dame Sally Davies, chief medical officer for England, who has accused
GPs of fuelling the spread of resistant bacteria by  prescribing
antibiotics unnecessarily.

Antibiotic resistance means that these
vital drugs are no longer effective against some infections. The problem
is so dire that last year Dame Sally warned that, unless we take
action, we will see a return to a time where infections kill us even
after routine operations.

The nub of the issue is that antibiotics
are being prescribed unnecessarily for everyday respiratory illnesses –
colds, sore throats, coughs – when they are most often caused by
viruses, which do not respond to antibiotics.

What is needed to avoid a tragedy is for patients with throat infections to be given a throat swab

Antibiotics only work
for bacterial infections. The difficulty is: how do we distinguish
between bacterial and  viral conditions?

Last week this issue was
highlighted by Sara Lewis, an assistant coroner, who called for better
guidelines in recognising bacterial throat infections following the
death of Oliver Hiscutt, a two-year-old from Wilmslow, Cheshire.

The
little boy had only been treated with paracetamol for his throat
infection: a terrible bereavement for his  parents who had contacted NHS
Direct for advice, and then taken him to see his GP three days later.
The infection had caused tonsillitis which progressed to a quinsy (an
abscess deep in the tonsils), which led to a fatal haemorrhage.

The assistant coroner called for mandatory paediatric training for GPs and made recommendations to the Department of Health.

Surely,
what is needed to avoid another such tragedy and to help ensure
antibiotics are prescribed with accuracy, is for patients with throat
infections to be given a throat swab.

This is mainstream technology.
GPs carry out microbiology studies in the case of bladder and kidney
infections so that the specific bacteria causing these can be identified
and therefore the correct antibiotics chosen, so where is the problem?

The
difficulty, as I see it, in the case of respiratory illness is that
patients must be seen, the result of the swab must be checked (it is
returned in about 48 hours) and a responsible professional must contact
the patient or parent and advise the necessary action. None of that can
be achieved by NHS Direct or its successor.

It requires quick access to a GP or practice nurse and takes time, trouble, and the cost of a lab test.
Dr
Maureen Baker, president of the Royal College of GPs, has advised that
GP services are at breaking point, but what I am proposing is basic,
routine care, nothing fancy. It needs no guidelines, no new
recommendations, just diligence – and adherence to what we were all
taught at medical school.

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