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By D. Kaffu. University of Michigan-Ann Arbor. 2018.

Certain drugs help to control this tremor order propecia 1mg visa, but they are different from the drugs that treat the tremor of Parkinson’s buy propecia 1 mg. Patients with benign essential tremor may wish to contact ITF (International Tremor Foundation), a national foundation devoted to their needs. You can reach ITF at the ad- dress of the United Parkinson Foundation (see appendix A). Shy-Drager syndrome is a Parkinson’s look-alike that starts with dizziness on standing, bladder difficulty (ranging from inconti- nence to difficulty voiding), and impotence, which are only later followed by the primary symptoms of Parkinson’s. An unusual look-alike is normal pressure hydrocephalus, in which fluid cavities in the brain become enlarged. The pressure that is exerted on several brain centers causes difficulty in walking, prob- lems of urinary incontinence, and symptoms of senility. However, in this disease, most of the damage is in the striatum, not in the sub- stantia nigra. Patients do not develop tremor, but they do develop rigidity, slowness of movement, and problems with walking and 98 living well with parkinson’s balance. Arteriosclerotic palsy (pseudobulbar palsy), the result of many small strokes in patients with high blood pressure or diabetes, is another look-alike. Patients may be unaware of these small strokes, but the damage caused to the brain affects balance and walking. Progressive supranuclear palsy is a look-alike that causes paralysis of the movements of the eyes, speech problems, rigidity, and symp- toms of senility. Wilson’s disease, which causes copper to accumulate in the liver and the brain, appears in patients under forty years of age. Dystonia is an inherited, progressive disease (that begins in childhood), in which unusual postures develop in the head, the arms, the legs, and the body. Another form of dystonia that affects only the head and the neck begins in adulthood. Today, CAT scans or MRI scans are used to rule out the possibility of a brain tumor. I have included this information about diseases that are sometimes diag- nosed as Parkinson’s disease for people who have doubts about their diagnosis or the efficacy of their medication. If you have been di- agnosed as having Parkinson’s, but your medications, particularly Sinemet, haven’t helped your symptoms, you owe it to yourself to get the opinion of another neurologist or a Parkinson’s specialist. In conclusion, I want to mention that because the information for this chapter (except for anecdotal material) comes from med- ical and scientific literature, you can turn to the list of sources in the appendixes if you wish to know more about any of the topics. CHAPTER 9 Spouses— Special and Otherwise What greater thing is there for two human souls than to feel that they are joined for life. In this chapter, however, I want to concentrate on the role of the spouse as caregiver, for the benefit of both those with Parkinson’s and their spouses as they adapt to the changes they encounter in their lives. When I met Blaine during my college years, we were part of a group that ate together, so we saw each other regularly. At first, I thought that he took life much too seriously to suit my tempera- ment. I learned that he came from a long line of hardworking carpenters known for their honesty, patriotism, and helpfulness to others. I saw that he had learned responsibility early, helping at home, cut- ting timber with his father from the age of twelve, working in a grocery store during high school, and working his way through college. The longer I knew him, the more apparent his many good qualities became and the more things we seemed to have in common. In 1952, we made the lifelong commitment of marriage, and at the same time, we embarked on our careers. After two years in the army, and after graduating from college, Blaine spent several years in school administration. When he decided that he pre- ferred teaching, he taught social studies in the high school and served as the social studies curriculum coordinator. When he retired from education, he returned to carpentry full time, forming a partner- ship—Atwood Builders—with our son, Randy. Recently, he and Randy brought our son-in-law, Keith, into the business as the third partner. He worries for the whole family—I’ve always said that I don’t have to worry because he does it for me. Blaine is very much his own person, just as I am my own person, which is important.

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The original concern with methotrexate Etanercept is the soluble recombinant receptor protein use in RA was with its liver toxicity; that complication for the p75 TNF- protein combined with immunoglob- has proved uncommon with pulse use as just described discount 5mg propecia visa, ulin G cheap propecia 5 mg with amex. This agent is self-injected subcutaneously twice although regular liver testing is recommended. Infliximab is a recombinant humanized antibody sensitivity reactions involving the lungs are uncommon to TNF. If cough or shortness of breath schedule and has been successfully used in the treatment develops in patients receiving methotrexate, drug cessa- of Crohn’s disease and for its complications of fistula tion and complete evaluation of the patient for causation formation. Etanercept has recently been approved for use alone after being studied as the sole Hydroxychloroquine has been used to treat inflammatory disease-modifying agent in early RA. The drug is safe but generally and infliximab work quickly and to date are associated less effective than the other disease-modifying medica- with few side effects. There is concern about retinal toxicity after long- about the patient’s ability to handle bacterial infec- term use, although that is uncommon. Hydroxychloro- The medications should be stopped when infection is quine is most often used early in the course of mild RA present. The dose is 200mg twice daily, often reduced to Leflunomide is a reversible inhibitor of 200mg daily when a good response has been obtained. It provides a novel approach to the with ophthalmologic disorders, but always in consultation treatment of RA and may be as effective as methotrex- with ophthalmologists. It has also been used in combination with methotrex- Sulfasalazine has been used to treat RA since the ate. United States, where it is often used in combination with methotrexate and hydroxychloroquine. Therapeutic response renal stones, and serial blood testing monitoring the bone usually occurs after 6 to 8 weeks of treatment. It appears that the The use of high-dose corticosteroids cytokine TNF plays a central role in chronic inflamma- administered orally or parenterally in RA can be life- tion. Early on after its identification, TNF was thought to saving in elderly patients with serious systemic complica- primarily play a role in defending the body from gram- tions such as vasculitis. Ellman patients seen in a medicine clinic with positive anti- induced autoimmunity refers to induction of ANA, which bodies to nuclear antigens do not have SLE. False positivty increases anecdotal reporting has suggested a possible associa- with age. Recently reported drugs in the latter category and the Smith antigen are almost only found in SLE. Patients treated with the bodies to double-stranded (ds) DNA and to SS-A and recombinant antibody to TNF-alpha, infliximab, have a SS-B do not occur with increased frequency in the normal relatively high incidence of generating ANA and ds elderly population. Some studies have reported a lower DNA, and some of these patients develop clinical SLE. Hypocomplementemia is more common in on metabolic transformation to reactive metabolites that younger patients with SLE. Similar to any chronic disease, matic action of myeloperoxidase in activated neutrophils anemia, and elevation of acute-phase reactants are usual and that the ability of drugs to induce lupus in vivo findings. Further analysis has shown that the generate a positive ANA in 80% of the patients. About association between HLA phenotypes and antibodies to a quarter of this group will manifest clinical symptoms. Ro and La are stronger than HLA correlation with SLE Women are at greater risk of developing procainamide- itself. The male-to-female ratio tions were removed from a group of 113 white SLE of 2:1 in symptomatic procainamide-treated patients patients, the frequencies of HLA-DR2 and -DR3 were is accounted for by the disproportionate use of pro- similar to those in normal Caucasians. Approximately one-fifth of patients common in African-Americans, Latinos, and Asians treated with isoniazid, methyldopa, or chlorpromazine (especially Filipinos and Chinese). The HLA-DR2 hap- develop positive ANA during treatment, but the inci- lotype is significantly increased among Chinese patients dence of a lupus-like syndrome induced by these drugs is with SLE. African-Americans may be a factor in the higher preva- To make a diagnosis of DIL, it is necessary to exclude lence and apparent more aggressive nature of SLE in preexisting SLE. Antinuclear antibodies are invariably present and usually in the homogenous pattern. Following withdrawal of the offending drug, there should be rapid improvement in the clinical symp- In contrast to idiopathic SLE, the incidence of drug- toms and a gradual fall in the antinuclear antibodies. The induced lupus (DIL) increases with age, in part reflecting most common features of DIL include fever, myalgias, the increased usage in the elderly of drugs that can arthralgias, and polyserositis.

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Reading also removes any opportunity for eye contact purchase propecia 1mg with visa, for judging how the presentation is being received buy 5 mg propecia fast delivery, or for spontaneity. They serve partly as an aide memoire and partly as a means of reducing the anxiety of drying up. Check out the venue and equipment Arrive at the venue early enough to check out the room size and layout, the location of light switches and the equipment you are intending to use. If you have opted for a PowerPoint presentation, check that the system is compatible with your computer/floppy. Be sure you know how to operate the equipment – slide projector/OHP controls, laser pointers, lectern layout, video recorders, etc. The audience will be irritated if you are apparently experimenting with your equipment at the start of your presentation. Content Say what you’re going to say; say it; then say what you’ve said All presentations should have a beginning, a middle, and an end. First, you describe the purpose of the talk and the key areas you will be considering. This should cover: • why the work was done • how it was done • what was found • what it means. Put your talk in context It is often erroneously assumed that an audience understands the context of a presentation. Although this example may seem a little unusual, there is much documented evidence in educational research showing that learners are often not able to relate new knowledge to whatever they already know about a certain subject. Having a context through which new information can be related to existing knowledge results in better memory recall. First impressions matter, so do not shuffle, fidget, mumble, or talk to the projector screen. You do not want the audience to be distracted from what you are saying by how you behave. Remember that your non-verbal communication is as important as the words that you use. Grab the attention of your audience right from the start; you can appeal to their curiosity, tell an anecdote, use a powerful and pertinent quote. Catch their eyes and engage them by being enthusiastic, even passionate, about your subject. Decide on your mode of delivery The medium of presentation needs some careful thought. Make your visual aids clear and simple Just as doctors can reinforce the information they give to patients with written materials or simple diagrams or drawings, your visual aids should illuminate or illustrate your words. If you are showing a slide for instance, it is enormously helpful to state what in general it is about as you show it. If your audience needs to read something on your slide or overhead, stay silent for a few seconds. You will be very familiar with your material but do not assume that your audience shares your understanding; for example say what the "x" and "y" axes represent on a graph; explain the key to your histograms. We would probably all like a pound for every slide or overhead that we have been shown in a scientific presentation that is impossible to see or interpret, for which the presenter apologises to the audience. Why not make a new slide which summarises the point that the original was attempting to make? Consider varying the delivery mode Attention span is limited, especially if your audience is sitting through a series of presentations. In a presentation lasting more than 15–20 minutes, it is worth thinking about switching modes of delivery – for instance, to use a video clip to illuminate a particular point which you wish to drive home. Think about the visual impact of being shown an operating technique, for instance, versus a verbal description of it. Or a real patient describing a condition they suffer from, versus your description of what such a patient might say. Don’t go over the top We have all been to presentations that were dazzling – dual projection, fancy animated PowerPoint slides, videoclips, etc.

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It is essential step stool with handrail can make mounting and dis- that good care order propecia 5 mg line, fully informed by current geriatrics mounting the examining table safe propecia 5mg on-line. Drapes for the knowledge, be delivered within a reasonable time alloca- patient should not exceed ankle length so as not to be a tion consistent with contemporary patterns of primary risk for tripping and falling. One hour for a new visit and 30 min for a follow-up are an absolute maximum in most environments. The Acute Hospital or Nursing Home Completing a home visit may also provide valuable The patient room is commonly the site of evaluation for insight into a patient’s environment and daily functional the nursing home resident or hospitalized older adult. How mobility may affect function in a particular Little is different in evaluating older persons in the hos- environment, real insight into nutrition, medication use pital; the patient is usually confined to bed, so that safety and compliance, and social interactions and support can and comfort are dictated by the hospital amenities. In one well- other considerations relevant in the ambulatory setting designed trial, in-home comprehensive geriatric assess- apply. Respect demands either drawing the privacy cur- ment delayed onset of disability and reduced future need 53 tain or, in the nursing home, asking a roommate to leave for skilled placement. In the nursing home, a good strategy, if space priate reimbursement for a home visit with the proper allows, is to do everything except emergency evaluation code (CPT code 99341–99350, depending on the various and treatment in set-aside office space rather than in the conditions). The room is home for the resident; using management by an interdisciplinary team in selected that space for clinical purposes risks implying that the populations may improve overall health outcomes, main- resident has no personal space and that the room and bed tain function, and possibly reduce health care utiliza- 54,55 are part of the medical care environment. The Setting Ambulatory Office Care The History The common occurrence of physical frailty among older Although it is important to discover the patient’s "relia- persons demands particular attention to providing both bility" as soon as possible, one should not simply dismiss a comfortable and safe environment for evaluation. Besdine history taking with questions whose answers will illu- expected in older persons. Medications Regardless of mental status, it is common for older patients to be accompanied by family members. Always The importance of collecting and inquiring about each give the patient the option of being interviewed and and every medication taken by or in the possession of the examined alone; including family members or compan- older patient cannot be overemphasized. Certain older adults may be more comfortable usually acquired from multiple prescribing physicians meeting the physician with others present, but this deci- and over-the-counter sources. Ask patient is essential for the patient to communicate any patients specifically about food and vitamin supplements information he or she regards as confidential for the and the use of any other alternative medications or reme- physician. A national survey of alternative med- is critical to make clear that the patient is to answer all icine use in the United States documented that 42% of questions; the relative should answer only if the physician 2055 adults used alternative therapies during the previ- asks for clarification. In cases of cognitive impairment ous year, mostly for chronic conditions such as back pain, or simply a long and complex history, family mem- anxiety, depression, and headache. In addition, a sizable bers, previous medical records, and other providers can number of people who are taking alternative medicines provide supplementary data. Ascertaining have multiple symptoms and complaints associated with pneumococcal, influenza, and tetanus vaccination status them. Accordingly, trying to structure the history in the can be conveniently done as part of the medication standard format of "chief complaint," "history of present history. More useful is the enumeration ing all drugs that have been prescribed; toxic accumula- of a comprehensive problem list, followed by complaints, tion of one or several agents is common, usually because recent and interval history, and remote information for the patient has not been taking prescribed medica- each of the active problems being considered at a visit. Return to originally history with an open-ended question, such as "What do prescribed schedules produces toxicity. Sedative, antipsychotic, diuretic, antiar- law of parsimony, or Occam’s razor, is not valid—multi- rhythmic, and anti-infective drugs are often continued ple complaints and abnormal findings arise from multi- indefinitely at the nursing home on the incorrect assump- ple diseases; discovering a diagnosis that unifies multiple tion that they are needed. Clinical Approach to the Older Patient 155 Social History 71 dying within 2 years. Accordingly, it is important to include routine questions in the history72; the CAGE (Cut Crucial information for developing a coherent and feasi- down, Annoyed, Guilty feelings, Eye-opener) question- ble care plan at home includes detailed knowledge of any 73 naire has been validated in older persons. In a study change in living arrangements, who is available at home of 120 elderly male veterans, the MAST-G (Michigan or in the local community, and what plans if any exist Alcoholism Screening Test—Geriatric Version) and the for coverage in times of illness or functional decline. CAGE had comparable sensitivity and specificity (70% Although a home visit is the best way to evaluate risks and 81%, respectively, for MAST-G score ≥5, and 63% or limitations, inquiring about stairs, rugs, thresholds, and 82% for CAGE score ≥2). The CAGE is more useful, bathing facilities, heating, and crime can increase the care 74 as it requires only four easily memorized questions. Stable and durable plans for care at home positive response to two of four questions has tradi- both fulfill the patient’s goal to remain at home and the tionally been considered a positive screen. Extent a patient population with high prevalence of drinking of social relationships is a powerful predictor of func- 64 problems, even a score of one should trigger appropriate tional status and mortality for older adults ; accordingly, 75 investigation. In elderly medical outpatients, the CAGE determining the patient’s friendship network and re- 76 may miss half the cases of alcohol abuse or dependence.

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In November 2004 discount propecia 1mg on-line, the British Associ- ation of Sport and Exercise Science (BASES) provided a one-day workshop on physical activity counselling in general and clinical populations discount propecia 1mg without a prescription, and it is hoped that this workshop will be repeated in the future. Exercise consultation is also taught in several undergraduate and postgraduate Sport and Exercise Science degrees in the UK. Future research Many studies have examined the factors influencing uptake of and adherence to supervised CR exercise programmes (Oldridge, et al. However, the factors that contribute to maintenance of physical activity during and between phases of CR progra- mmes have not been fully explored. Understanding these factors is an impor- tant step in the development of interventions to improve maintenance of physical activity and exercise. Sim- ilarly, few studies have examined the effect of interventions to encourage long- term maintenance of physical activity following completion of phases II and III CR exercise programmes. Thus, research is needed to test different forms of intervention aimed at improving long-term compliance to physical activity. Could the exercise consultation be delivered successfully in a group or by post, telephone or World Wide Web? The possibility of delivering this intervention to patients in a group setting at the end of phases II and III is a promising area for further study. First, deliv- ering this intervention to groups of patients as an alternative to one-to-one consultations would be more feasible for CR services in terms of time and staff resources. In addition, conducting an exercise consultation in a group setting would provide patients with the opportunity to discuss issues with each other, such as potential barriers to remaining active, problem solving for these bar- riers and identifying high-risk situations for relapse. Furthermore, group dis- cussion on exercise opportunities in the community, such as phase IV classes, might encourage patients to attend these programmes together. In general, patients routinely receive a discharge interview at the end of phase III that provides cardiac rehabilitation staff with an ideal opportunity to review the patients’ goals for remaining active, devised during the group consultations. Studies using physical activity counselling in the general population and other clinical groups have successfully delivered this type of intervention in a group setting (Dunn, et al. The exercise consultation may be useful between all phases of CR both to improve adherence to supervised exercise programmes and to encourage patients to participate in physical activity outside of the exercise classes. Patients at the start of phase III are likely to be in the contemplation or prepa- ration stages, and the focus of the consultation should be on encouraging these individuals to increase their physical activity. A pilot study found that web- based and one-to-one exercise consultations were equally effective in increas- ing physical activity in a group of patients participating in a phase III supervised exercise programme (McKay, et al. Other strategies could be included in the exercise consultation to increase its efficacy. Recently, physical activity intervention programmes have found the addition of pedometers to be effective in promoting physical activity (Chan, et al. Thus, pedometers, in conjunction with exercise consultation, may be a promising strategy for encouraging par- ticipation in physical activity. SUMMARY Many benefits are associated with participation in exercise-based CR for patients with established coronary heart disease. Sustaining these benefits requires maintenance of regular long-term physical activity. However, many patients find it difficult to maintain exercise participation and an active lifestyle. The exercise consultation is an effective intervention for maintaining Maintaining Physical Activity 215 physical activity and could be applied through all phases of CR. In addition, several randomised controlled trials have shown the exercise consultation to be successful in promoting and maintaining physical activity in the general population and for people with type II diabetes. Exercise consultation is based on established theoretical models of behaviour change, and it uses strategies to increase and maintain physical activity. This intervention is practical and could feasibly be incorporated into all phases of CR programmes to encour- age patients to remain active. With minimal training, any member of the cardiac rehabilitation team could deliver the exercise consultation. However, in order to be trained to deliver the exercise consultation, exercise leaders need to understand the behaviour change theories on which the consultation is based and the counselling skills and strategies required to deliver the inter- vention. Should holders wish to contact the Publisher, we will be happy to come to some arrange- ment with them.

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