By B. Kayor. Wisconsin Lutheran College.
Among those with cognitive impairment or presence of a Charcot joint cheap malegra dxt plus 160mg on-line, orthostatic hypotension order malegra dxt plus 160 mg fast delivery, difﬁculty reporting pain buy malegra dxt plus 160 mg free shipping, other clinicians buy 160 mg malegra dxt plus overnight delivery, family, and impaired gastric emptying, or incontinence may indicate caregivers may be helpful in providing a more accurate autonomic nervous system dysfunction that can imply description. It is important to assess functional status to identify Elders may tend to underreport pain, despite substantial self-care deﬁcits and formulate treatment plans that functional impairment. Functional problems and multiple sources of pain make assessment status can also represent an important outcome measure more difﬁcult. Functional status can be sensory function, and denial and avoidance behaviors evaluated from information taken from the history and may all contribute to underreporting. Pain History and Physical Examination A brief psychologic and social evaluation is also impor- Assessment of pain should begin with a thorough history tant. Depression, anxiety, social isolation, and disengage- and physical examination to help establish a diagnosis of ment are all common in patients with chronic pain. There underlying disease and form a baseline description of is a signiﬁcant association between chronic pain and pain experiences. The history should include questions to depression, even when controlling for overall health and elicit: when the pain started; what events or illnesses coin- functional status. Psychologic evaluation Unidimensional scales consist of a single item that should also include consideration of anxiety and coping usually relates to pain intensity alone. Anxiety is common among patients with acute and usually easy to administer and require little time or train- chronic pain and requires extra time and frequent reas- ing to produce reasonably valid and reliable results. Chronic pain often have found widespread use in many clinical settings to requires effective coping skills for anxiety and other monitor treatment effects and for quality assurance indi- emotional feelings that can be learned. It is important to remember that therapy, biofeedback, or some psychoactive medications unidimensional pain scales often require framing the pain may be necessary for developing and maintaining effec- question appropriately for maximum reliability. Subjects tive coping strategies as well as management of major should be asked about pain in the present tense (here and psychiatric complications. For example, the interviewer should frame the explored for availability and involvement of family and question, "How much pain are you having right now? It has been shown that the family’s and Alternatively, the interviewer can ask, "How much pain informal caregivers’ involvement can have a substantial have you had over the last week? Need for frequent cognitive impairment have shown that pain reports transportation, administration of pain treatments, and requiring recall are inﬂuenced by pain at the moment. Pain Assessment Scales A variety of pain scales are available to help categorize and quantify the magnitude of pain complaints. Results Pain Assessment in Persons with of these scales are also helpful in documenting and com- Cognitive Impairment municating pain experiences. It is helpful to evaluate pain using an appropriate pain scale initially and periodically Cognitive impairment, Alzheimer’s disease, stroke, or to maximize treatment outcomes. Results can be dementia can present substantial challenges to pain recorded in ﬂow chart or graph, making it easy to iden- assessment. Fortunately, it has been shown that pain tify stability or changes in pain over time. Because there reports from those with mild to moderate cognitive are no objective biologic markers or "gold standards," the impairment are no less valid than other patients with validity of pain scales relies largely on face value, corre- normal cognitive function. In general, multidimensional Thus, most elderly patients with mild to moderate cogni- scales with multiple items often provide more stable tive impairment appear to have the capacity to report measurement and evaluation of pain in several domains. The scale tidimensional scales are often long, time consuming, and consists of nine items scored by a trained examiner after can be difﬁcult to score at the bedside, making them dif- observation of a noncommunicative patient. Testing of the scale has demonstrated of these scales speciﬁcally in elderly populations. I n s t r u m e n t D e s c r i p t i o n T a r g e t V a l i d i t y R e l i a b i l i t y A d v a n t a g e s D i s a d v a n t a g e s R e f e r e n c e s M c G i l l P a i n S u b j e c t s a s k e d t o i d e n t i f y w o r d s A l l p a i n G o o d G o o d M u l t i d i m e n s i o n a l , L o n g , d i f ﬁ c u l t t o M e l z a c k 2 4 Q u e s t i o n n a i r e d e s c r i p t i v e o f i n d i v i d u a l p a i n f r o m e x t e n s i v e l y s t u d i e d s c o r e 7 8 w o r d s g r o u p e d i n 2 0 c a t e g o r i e s ; o v e r a l o n g t i m e ; p l u s 4 o t h e r i t e m s ( i n c l u d i n g a 5 - m a y d i s c r i m i n a t e p o i n t w o r d d e s c r i p t i v e s c a l e o f b e t w e e n t y p e s o f p a i n i n t e n s i t y a t t h e m o m e n t [ P P I ] p a i n s c o r e d s e p a r a t e l y ) S h o r t - F o r m 1 5 w o r d s s c o r e d o n L i k e r t s c a l e , A l l p a i n G o o d G o o d S h o r t e r t h a n o r i g i n a l M a y n o t M e l z a c k 2 5 M c G i l l P a i n p l u s a v i s u a l a n a l o g u e a n d P P I s c a l e s M c G i l l ; n o t s t u d i e d a s d i s c r i m i n a t e Q u e s t i o n n a i r e d e e p l y a s o r i g i n a l b e t w e e n p a i n t y p e s W i s c o n s i n B r i e f 1 6 - i t e m s c a l e ; i t e m s s c o r e d C a n c e r G o o d G o o d M u l t i d i m e n s i o n a l S t u d i e d l a r g e l y i n A H C P R C a n c e r P a i n I n v e n t o r y s e p a r a t e l y p a i n c a n c e r p a i n P a i n G u i d e l i n e s 2 6 M e m o r i a l S l o a n – F o u r w o r d d e s c r i p t o r s c a l e s C a n c e r G o o d G o o d M u l t i d i m e n s i o n a l S t u d i e d l a r g e l y i n F i s h m a n e t a l. N e w Y o r k : M c G r a w - H i l l ; 2 0 0 0 : 3 8 9 , w i t h p e r m i s s i o n. Scale Description Validity Reliability Advantages Disadvantages References Visual Analog 100-mm line; Good Fair Continuous scale Requires pencil Clinical Practice vertical or and paper Guidelines5,7,26 horizontal Present Pain 6-point 0–5 scale Good Fair Easy to Usually requires Melzack24 Intensity with word understand, word visual cue descriptors anchors decrease (subscale of clustering toward McGill Pain middle of scale Questionnaire) Graphic pictures Happy faces; Fair Fair Amusing Requires vision Herr et al. It is important to Patients with severe cognitive impairment present sub- remember, however, that family and caregivers are stantial challenges for pain assessment. Patients with "locked-in syndrome" (having intact perception and cognitive func- Table 28. Unfortunately, no Mild pain reliable methods exist to assess pain in these individuals.
The cochlear branch of the vestibulocochlear nerve occupies the antero-inferior quadrant generic 160 mg malegra dxt plus fast delivery. The superior and inferior vestibular branches of the vestibulocochlear nerve are found in the posterior quadrant malegra dxt plus 160 mg overnight delivery. Regarding the facial (seventh) nerve: (a) The intermediate nerve of the facial nerve is the large motor root malegra dxt plus 160mg with mastercard. Regarding the cerebellopontine angle cistern: (a) The ﬂocculus of the cerebellum forms the anterior boundary malegra dxt plus 160 mg. Therefore, this part of the facial nerve is vulnerable to inﬂammatory disease of the middle ear. Coronal CT through the cochlea shows the facial canal twice to produce ‘snake’s eyes’ appearance of the facial nerve above the cochlea. This nerve transmits taste ﬁbres from the anterior two-thirds of the tongue to the lingual nerve and the motor ﬁbres to the submandibular and sublingual gland. Regarding surface anatomy: (a) The nasion overlies the suture between the frontal and ethmoid bones. Regarding the anatomy of the head and neck: (a) The parotid duct can be rolled across the anterior border of the masseter muscle just below the zygomatic bone, with teeth clenched. Concerning vertebral levels: (a) Atlas and dens of axis lie in the horizontal plane of the open mouth in an AP projection. The coronoid process can be identiﬁed by placing a ﬁnger in the angle between the zygomatic arch and the masseter muscle. Also, the vertebral artery usually passes into the foramen transversarium of the cervical vertebra. Regarding the head and neck: (a) The tongue receives innervation from nerves of the ﬁrst, second, third and fourth pharyngeal arches. Regarding the head and neck: (a) The pterygomaxillary ﬁssure opens into the infratemporal fossa through the pterygopalatine fossa. Regarding the mandible and the temporomandibular joint: (a) Each half of the body of the mandible is ﬁxed anteriorly in the midline at the mental symphysis. Therefore, on axial images the lateral and medial pterygoid appear to be at the same level. In the nose: (a) The hiatus semilunaris is situated beneath the ethmoid bulla in the middle meatus. Regarding the salivary glands: (a) The parotid gland lies beneath the ramus of the mandible. The anterior ethmoidal branches of the ophthalmic artery joins the anastomotic network in the nasal septum. Regarding the pharynx: (a) It extends from the base of the tongue to the level of C6. Regarding the fascial layers of the neck: (a) The superﬁcial cervical fascia is subcutaneous and extends into the thorax inferiorly. Therefore, these joints are susceptible to systemic arthropathies such as rheumatoid disease. Regarding the thyroid and parathyroid glands: (a) The pyramidal lobe extends superiorly from the left lobe. Regarding the external carotid artery and its branches: (a) The ascending pharyngeal artery ascends between the internal and external carotid artery on the posterolateral wall of the pharynx. The right lobe is more vascular than the left and tends to enlarge more in diﬀuse disorders. The thyroidea ima is an occasional branch of the brachiocephalic trunk on the aortic arch, which supplies the inferior portion of the right lower lobe. Regarding the maxillary artery and its branches: (a) The maxillary artery passes anteriorly from the parotid gland through the infratemporal fossa. Regarding ultrasonography of the carotid arteries: (a) In a B-mode study, the wall of the normal carotid artery produces two parallel echopoor layers with a hyperechoic strip between them. Regarding venous drainage of the head and neck: (a) The retromandibular vein drains into the external jugular vein. The anterior division is prone to damage in fractures of the skull, giving rise to an extradural haematoma. The anterior deep temporal artery anastomoses with orbital vessels forming another potential external to internal carotid arterial connection.
Interferon beta 1b (Betaseron®) was the first buy discount malegra dxt plus 160 mg online, followed rapidly by interferon beta 1a (Avonex® buy 160mg malegra dxt plus with visa, Rebif®) generic malegra dxt plus 160 mg with amex, glati- ramer acetate (Copaxone®) cheap 160mg malegra dxt plus free shipping, and mitoxanthrone (Novantrone®). If one gets a cold or sore throat, the body makes interferon, which then modulates the immune system. Gamma interferon appears to stimulate the immune system and 16 CHAPTER 2 • Managing the Disease Process makes MS worse. Beta interferon appears to settle it, and it decreas- es the attack rate, decreases the severity of attacks, increases the time between attacks, and decreases the damage to the nervous sys- tem as monitored on magnetic resonance imaging (MRI) scanning. It is a polypeptide—a combination of four amino acids whose structure in some way fools the immune system. It is used as a chemotherapy agent (similar to that used to treat cancer) and affects all aspects of the immune system. All of these medications are expensive and all have side-effects that will be discussed, thus care must be taken in making decisions regarding their use. There is some controversy as to when in the course of the disease these should be introduced. Most MS experts believe that early intervention with an interferon or with glatiramer acetate is appropriate. Some feel that treatment should be initiated when the diagnosis of MS is made or even suspected. They point out that a study done on those with the suspicion of MS resulted in a delay to the actual diagnosis. Unfortunately we do not know exactly what that means for most people with the disease, because the timing of the diagnosis may or may not have anything to do with future disability. Understanding that about 20% of people with MS may not need treatment because they will do well without it also must play a role in the decision making process. Much has been made of the fact that we can see abnormalities on the MRI and that the MRI changes in the course of MS. Clearly the MRI is an excellent tool to be used in making an early diagnosis of MS and helping to confirm the diagnosis. It is fair to assume that if there are many, many abnormalities on the initial scan, problems with func- tion will be forthcoming. Clearly 17 PART I • The Disease and Its Management the scan changes over time, sometimes actually improving. Some feel that routine checking of the MRI will give information about the future course of the disease, but that is not based on reality. Some feel that the brain of those with MS will shrink if treatment is not instituted immediately. Of course, all our brains shrink with age, but it is real- ly impossible to speculate at the front end of the diagnosis how much shrinkage will or will not occur. Thus, many unanswered questions remain that deserve an answer and undoubtedly will be answered in the next decade. In the meantime, there will be some disagreement as to when and which agent should be given and to whom. Clearly, this question must be answered by the physician who knows you and is monitoring your MS. High dose inter- feron (Betaseron®, Rebif®) appears to be stronger than low dose (Avonex®), which is a function of dose rather than the structure of the medication, because Avonex® and Rebif® are structurally identi- cal. Clearly, many people with MS can be successfully treated with a low dose, but many will need a higher dose with time. This is no dif- ferent from other diseases treated with multiple medications (high blood pressure, infections, etc). It appears that glatiramer acetate (Copaxone®) is as effective as the interferons and, in my opinion, falls between the high dose and low dose in terms of "potency. Just which treatment is given and when is a medical decision that should be made by your physician with input about to your lifestyle and desires.
This page intentionally left blank 27 Sources of Suffering in the Elderly Maria Torroella Carney and Diane E buy malegra dxt plus 160mg with visa. Meier The relief of suffering is one of the primary aims of med- chapter attempts to address both physical and psycho- icine buy malegra dxt plus 160 mg on line. The nature of suffering and what physicians can do social sources of distress in elderly patients buy discount malegra dxt plus 160 mg line, as well as to prevent or relieve it is poorly understood order malegra dxt plus 160 mg visa. Suffering is other factors associated with suffering often found in the a global concept that must be distinguished from pain or elderly patient population. Although physicians, patients, and medical literature tend 1 to link pain with suffering, these are distinct phenomena. Personhood includes personality and character, the indi- As symptoms are often interrelated with multiple vidual’s past, the family’s past, associations and relation- concurrent medical problems, management can be chal- ships with family and others, work and social roles, body lenging. As with any illness, the approach to treating image, the unconscious mind, political afﬁliations, the symptoms requires a thorough history, physical examina- secret life, the perceived future, and the transcendent or tion, and laboratory or radiologic investigations appro- spiritual dimension. Suffering with sickness occurs when priate to gain the best understanding of etiology and the illness or its symptoms not only threaten interference underlying pathophysiology. Once the cause and patho- with some aspect of personhood, but when it destroys or physiology are known, intervention ideally includes is perceived to destroy the integrity of the person, as just therapy to relieve the symptoms as well as to treat under- deﬁne. The goals of care may involve weighing the beneﬁts Identiﬁcation of suffering requires a high index of sus- and risks of treatments aimed at relief of suffering versus picion in the presence of serious disease and distressing those aimed at prolongation of life. Ask directly,"Are either cause (or are perceived to cause) a higher risk of you suffering? Intervening analgesics given at doses sufﬁcient to relieve pain to to try to relieve distress or suffering can only be accom- simultaneously lead to respiratory depression. For most patients, physical pain is only one of Nebulized morphine or hydromorphone: several sources of distress. Physical aspects of pain cannot be effectively Plus or minus treated in isolation from the emotional and spiritual com- Albuterol 0. The various components of suffering Dexamethasone 16 mg initial, then must be addressed simultaneously. Many sources of dis- 8 mg bid ¥ 2 days, then 4 mg bid ¥ 2 days, then 2 mg bid tress and suffering are not visible and frequently are not Prednisone pulse spontaneously reported by patients. Formal and regular 40 mg po bid ¥ 5–7 days assessment is therefore critical to identiﬁcation and Oxygen appropriate treatment of diverse symptoms. Physical and psychologic symptoms have been assessed most frequently using simple, validated measures, often in the form of symptom checklists. The Edmonton signs of respiratory function,9 and its management can Symptom Assessment Scale (ESAS) evaluates eight symptoms on visual analogue scales and has been exten- be challenging. It is important to diagnose and treat the sively used in palliative care research. Symptom Assessment Scale (MSAS) is a validated When therapy speciﬁc to the underlying cause is unavail- patient-rated measure that provides multidimensional able or ineffective, several techniques may alleviate information about a diverse group of common breathlessness. Simple techniques include pursed-lip 8 breathing and diaphragmatic breathing, leaning forward symptoms. It characterizes 32 physical and psych- ologic symptoms in terms of intensity, frequency, with arms on a table, cool air ventilation (fan or open 8 window), and nasal oxygen. Other frequently used symptom assessment instruments may be found on the numerous studies to be highly effective in the ameliora- tion of dyspnea. In addition, suffering caused ing cause, steroids and oxygen therapy may be of beneﬁt. Cough is a normal but complex physiologic mechanism that protects the airways and lungs by removing mucus and foreign matter from the larynx, trachea, and bronchi. Management of cough should be determined by the type Dyspnea and the cause of the cough, as well as the patient’s general 9 Dyspnea is a subjective sensation of shortness of breath condition and likely diagnosis. When possible, the aim that is described in 70% of cancer patients during the last should be to reverse or ameliorate the cause, combined 6 weeks of life and in 50% to 70% of patients dying of with appropriate symptomatic measures. It is a common symptom associated with factors should be deﬁned, and simple measures such as pneumonia, congestive heart failure exacerbations, and a change in posture can be very helpful. Breathlessness chronic obstructive pulmonary disease—all illnesses can trigger cough and vice versa.
Increasingly there are more formal evaluations of swallowing problems in order to try and understand exactly where the problems lie purchase malegra dxt plus 160mg with visa. Sometimes this assessment may include what is called ‘videoﬂuoroscopy’ 160mg malegra dxt plus sale, which allows the process of your swallowing to be seen on X-ray following a barium swallow order 160 mg malegra dxt plus overnight delivery. Occasionally it may also include an endoscopic examination – this involves passing a small ﬁbreoptic tube through and past the throat so that additional information can be obtained discount malegra dxt plus 160mg online. Professional help for swallowing difﬁculties centres on teaching exercises to try and: • strengthen your muscles involved in swallowing; • enhance the coordination of your breathing and swallowing (so as to avoid choking); • strengthen the muscles controlling your lips and tongue that help in managing the food in your mouth in preparation for swallowing. Self-help in relation to swallowing It is possible to give general guidelines as to what you can do yourself to help swallowing, although it must be remembered each person has slightly different problems, and thus not every strategy will work for everyone. However, things to try yourself include: • changing the type and preparation of your food – solid foods, particularly those that are only half chewed, are much more difﬁcult to swallow than those which are softer, so you may need to consider chopping or blending food; • changing the ways in which you eat and swallow – eating little and often may help; • exercising to strengthen the relevant muscles as much as possible; • making sure that you do not talk (or laugh) and eat at the same EATING AND SWALLOWING DIFFICULTIES; DIET AND NUTRITION 131 time – problems of swallowing can often be linked to trying to do two things at once! In MS, coordination of the swallowing reﬂex with the amount of saliva you have may become a problem. It is not that you are producing more saliva, but the swallowing of it becomes far more noticeable. In general you have to become more conscious of the process of swallowing, and try and systematically swallow. Indeed swallowing exercises may help you and, paradoxically, by stimulating more regular production of salivation through sucking a sweet (preferably sugar free! A problem often arises when you ‘forget’ to swallow for a period of time and then suddenly notice the saliva. You might try a sequence of events as you eat or drink a little at a time, based on the following: ‘Hold your breath, swallow, clear your throat, then swallow again. Some people still have great difﬁculty but, if food or drink gets into your lungs, which could possibly lead to pneumonia, then more drastic action may be required. The time being taken to eat and drink may also be now so substantial that you run the risk of not getting adequate nutrition or liquids over a period of time. If this happens, then you may ﬁnd yourself losing weight, getting weaker and having further problems. It is an important decision to move from normal feeding by mouth (oral feeding and drinking) to non-oral feeding, where food is directly channelled into the stomach (often avoiding the mouth and swallowing completely), but this step may be necessary if problems with nutrition and/or concern over choking becomes substantial. For example, after certain kinds of surgery in hospital, not associated with MS, people may be fed on a short-term basis through a tube that passes through the nose and then through the throat directly to the stomach (a ‘nasogastric tube’). This particular kind of arrangement has to be temporary because the throat and nose may become irritated after a while. A more long-term arrangement is to have a PEG (‘percutaneous endoscopic gastrostomy’) in which a tube is inserted through the abdominal wall directly into the stomach. As with any surgical openings through the skin, hygiene is particularly important, and great care has to be taken to prevent infections arising. Although it is a particularly difﬁcult step to move to non-oral feeding, for social reasons as well as because of the loss of the pleasures associated with normal eating and drinking, in some cases it may be the best decision, in order to build up your strength if you have been losing a lot of weight, and to prevent fears associated with choking. If you are very careful, it may also be possible to continue to eat or drink a few things orally, at least to retain some of the pleasures of eating normally. You should keep an eye on how your swallowing goes, and always consult with your professional advisors about the possibility of gradually changing the balance between oral and non-oral feeding, so that you can try and resume a greater proportion of oral feeding, with a view to removing the PEG method of feeding if you can. Diet and nutrition There are two broad ways in which diet and nutrition can be considered in relation to MS. The ﬁrst and less contentious relates to your general health: ideas about what is a good diet for general health do, of course, change from time to time. The second deals with the possible beneﬁcial or harmful effects that some diets themselves might have on either symptoms or, more fundamentally, on the underlying cause of the MS. Diet is the most obvious and easy to implement factor that could be changed by people with MS, and many people have focused on this issue. Also, health care professionals are often very interested in diet and its effects on all aspects of general health. Although there has been research on diet and MS, it has not been a core interest of most EATING AND SWALLOWING DIFFICULTIES; DIET AND NUTRITION 133 researchers because Western populations are largely well-nourished – obesity and overeating, on the contrary, are major health concerns. There have been many diets that have been suggested to affect either speciﬁc symptoms or the cause of MS.