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Isoptin

By D. Myxir. Atlantic Union College.

My position is that if I have to put up with Parkinson’s for the rest of my life or until a cure is discovered buy isoptin 240 mg amex sinus arrhythmia, I want the best treat- ment that can be found: excellent doctors and therapists and the best medication available order isoptin 120mg on-line blood pressure ranges too low. The next chapter is devoted to the medications and other remedies that are available for treating Parkinson’s disease. CHAPTER 8 Medications and Therapies Life is short, the art [of medicine] long, timing is exact, experience treacherous, judgement difficult. Most of our knowledge about the treat- ment of Parkinson’s has been gained since the 1970s. It is important for people to understand the different types of medication that are used to treat Parkinson’s disease and the symptoms that each type of medication controls. Viruses are suspected, and so are chemical pollutants that we eat, drink, and breathe (such as insecticides and carbon monoxide). Research with MPTP has led scientists to believe that substances that induce parkinsonism do it by reacting with a chemical in the brain to create other chemicals called free radicals that can destroy brain cells. In any case, something starts destroying the neurons (nerve cells) in a portion of the midbrain called the substantia nigra (pig- mented substance). These are the neurons that produce a chemi- cal called dopamine, a chemical transmitter of messages in the brain, which is sent to another area of the brain called the stria- tum, the area that controls movement, balance, and walking. In the striatum, dopamine counteracts (regulates) another chemical messenger, acetylcholine. In the normal person’s striatum, dopa- mine and acetylcholine are perfectly balanced. In the patient’s striatum, dopamine and acetylcholine are out of balance—acetylcholine is no longer being regulated. This imbalance between dopamine and acetylcholine causes the primary symptoms of Parkinson’s: rigidity of the muscles (stiffness), tremor (shaking) of the hands or sometimes the feet or parts of the face, bradykinesia (slowness of movement), loss of balance and coordination, and loss of "automaticity" (the ability to move auto- matically without having to think about it). Slowness and difficul- ties with balance and automaticity are responsible for the prob- lems of falling, festination (short, shuffling steps), sidestepping, retropulsion (walking backward), inability to stop, and inability to "get started. To control Parkinson’s symptoms, certain drugs can send needed dopamine to the brain; these are the dopaminergic medica- tions that contain levodopa (also called L-dopa). Another group 76 living well with parkinson’s of drugs can counteract acetylcholine in the striatum; these are called the anticholinergic medications. On the way to the striatum and at the striatum, as well as on cells that project down from the cortex of the brain, there are special receptors for dopamine. Med- ications called dopamine agonists can stimulate these receptors to be more efficient. Some dopamine agonists stimulate one type of receptor; others stimulate more than one. It is believed that in Parkinson’s disease, dopamine is also defi- cient in other parts of the brain. The areas in which these other deficiencies occur may determine which of the secondary symptoms a person with Parkinson’s may develop. Deficiencies of certain other chemical neurotransmitters may also be responsible for sec- ondary symptoms. Patients may develop a few (but usually not all) of the secondary symptoms: a stare reminding one of a facial mask, aches and pains, feelings of extreme restlessness, feelings of fatigue, diffi- culty swallowing (which can cause excess saliva to build up in the mouth, leading to drooling), speech difficulties, shallow breath- ing, watery eyes, dry eyes, a hunched or bent posture, or pro- longed feelings of depression. Still other secondary symptoms may include oily skin, constipation, difficulty voiding the bladder, the feeling of unusual hot and cold sensations (usually in an arm or a leg), sudden excessive sweating, forced closure of the eyelids, dizziness on arising from a bed or a chair, swelling of the feet, and impotence. An important secondary symptom is depression, which afflicts about 50 percent of people with Parkinson’s. In the past, parkin- sonian depression was thought to be merely the psychological con- sequence of facing life with a chronic disease. This remains true in some cases; however, scientists now believe there is a chemical medications and therapies 77 component—the depression that is so common in Parkinson’s may be caused by the same chemical problems in the brain that cause the disease. For years, antidepressant medications have been used both to improve the patient’s state of mind and to relieve symp- toms.

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SEXUAL PROBLEMS IN MULTIPLE SCLEROSIS Given the complexity of the sexual response in terms of the neuro- muscular transmissions involved buy isoptin 240 mg without a prescription blood pressure diet chart, it is no surprise that sexual diffi- culties often are encountered in MS purchase isoptin 240mg without a prescription hypertension va compensation. Such difficulties frequently are clearly physical, although a psychological component may be involved in many or most instances of difficulty. More than 90% of all men with MS and more than 70% of all women with MS report some change in their sexual life after the onset of the disease. Men most often report impaired genital sensa- tion, decreased sexual drive, inability or difficulty in achieving and maintaining an erection, and delayed ejaculation or decreased force of ejaculation. Women report impaired genital sensation, dimin- ished orgasmic response, and loss of sexual interest; they also may be bothered by intense itching, diminished vaginal lubrication, weak vaginal muscles, and a reflex pulling together of the legs (adductor spasms). MANAGING SEXUAL DIFFICULTIES The diagnosis of MS may alter one’s self-image, and it is common to feel sexually unattractive when one is concerned about braces, wheelchairs, and catheters. Perhaps the single most helpful approach to managing sexual difficulties is to focus on becoming comfortable with your body, a goal that requires time and commit- ment. It is important to identify your positive personal qualities and to put effort into feeling good about yourself by taking care of your body through exercise, diet, dress, and so forth. Feeling good about 132 CHAPTER 21 • Sexuality yourself will help to defeat the myth that you must have a "perfect" body to be sexually attractive. Communication is critical to achieving a positive, enjoyable sex- ual relationship, and feelings must be dealt with openly and honest- ly. It is important to convey information about what feels pleasurable and what does not and to experiment with different sexual positions and creative, alternative ways to give and receive pleasure. Our soci- ety emphasizes "normal" or proper ways to obtain sexual gratifica- tion, which tends to make sex goal-oriented toward intercourse and orgasm. However, many people find great physical and psychological satisfaction from activities that traditionally have been termed fore- play. One excellent way to decrease or completely eliminate pres- sures and expectations is to become less goal-oriented by renaming such activities sexplay. Sexual expression may be directed to parts of the body other than the genitals, increasing cuddling, caressing, mas- sage, or other forms of touch, and it may involve experimenting with oral sex, masturbation, a vibrator, or other devices. Emotional reactions may be an issue for both the person with MS and his or her partner because anxiety, guilt, anger, depression, and denial are the natural consequences of coping with any chronic ill- ness. Couples should be sensitive to the fact that some painful feelings may not improve or disappear with communication and support. In that case, it may be helpful to seek professional help in response to depression or anxiety that will not go away. To avoid bowel, bladder, and catheter problems during inter- course, fluids should be reduced approximately two hours before sexual activity and the bladder should be emptied before lovemak- ing. Be prepared in case an accident occurs despite these precau- tions, and remember that it is not a catastrophe. If a catheter is used, it may be taped over a man’s penis or to a woman’s abdomen. A vaginal lubricant such as K-Y jelly should be used whether a woman uses a catheter or not. Spasticity or leg spasms may be minimized by timing antispas- ticity medication so that it is maximally effective during sexual 133 PART III • Your Total Health activity. Having intercourse in a side position, with the knees bent or using pillows for support, may make a difference and should be tried. A vibrator may compensate for a loss of deep pressure sense, which is reflected as impaired sensation, numbness, and tingling. A number of different types are available, including hand-held, penis- shaped, and others. A new device called "Eros" has been approved by the FDA for sexual dys- function in the female. It places gentle suction on the clittoral region while applying a gentle vibration. The judicious use of a frozen bag of peas rubbed gently in the vaginal area has been reported to increase sensation and decrease pain for some people.

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Tourette’s disorder mechanical device generic isoptin 240 mg free shipping blood pressure in children, material order 40mg isoptin mastercard arteria pancreatica magna, or equipment attached or adjacent 10. Huntington’s disease to the resident’s body that the individual cannot remove easily 11. Organic mental syndromes (including dementia) with which restricts freedom of movement or access to one’s body associated psychotic and/or agitated features as (includes leg and arm restraints, hand mitts, soft ties or vest, defined by wheelchair safety bars, and gerichairs). There must be a trial of less restrictive measures unless the scratching) documented by the facility which causes physical restraint is necessary to provide lifesaving treatment. The resident or his/her legal representative must consent to the —Present a danger to themselves use of restraints. Residents who are restrained should be released, exercised, —Actually interfere with staff’s ability to provide care toileted, and checked for skin redness every 2 h. Each resident’s drug regimen must be free from unnecessary drugs nausea, vomiting, or pruritus (1) "Unnecessary drugs" are drugs that are given in excessive (b) Antipsychotics should not be used if one or more of the fol- doses, for excessive periods of time, without adequate moni- lowing is/are the only indication toring, or in the absence of a diagnosis or reason for the drug. Impaired memory (2) In deciding whether an unnecessary drug is being used, sur- 7. Uncooperativeness (1) Residents who have not used antipsychotic drugs are not given 15. Any indication for which the order is on an "as needed" these drugs unless antipsychotic drug therapy is necessary to basis treat a specific condition. Summary of new federal regulations relevant to primary physicians and medical directors in nursing homes: 1987 Omnibus Budget Reconciliation Act (OBRA). Code Status this is a "patient order," not necessarily a physician order, in the nursing home. If the physician When physicians enter the nursing home, it is well to is called upon to sign the form as well, it is often merely an remember these two fundamental principles: one, the acknowledgment, almost an afterthought. Many nursing nursing home is run by nurses and patients, and, two, homes simply dispense with the physician signature. The patients’ rights and autonomy rule the day—after all, the MD signature merely confuses the issue as they are not the nursing home is their home. On the other hand, if a code status discomfort with nursing home practice might be traced to decision is reached that the physician feels is not appropri- misunderstanding, and not embracing, these two princi- ate, the onus is on the doctor to work with the family and ples. A sentinel example of this is the typical decision staff to establish goals appropriate to severity of illness making and ordering regarding cardiopulmonary resusci- and prognosis—an "incorrect" code status is often a tation (CPR),or its avoidance [do not resuscitate (DNR)]; good stimulus for such a heart-to-heart discussion. The Geriatrician in the Nursing Home 117 physician can and should discuss code status issues with 6 attention to patient wishes and directives). It is not patients; in the nursing home this is primarily to inform, unusual for patients to request "DNH" (do not hospital- which may or may not influence their decisions. Physician Visits Physician participation in the care of nursing home Patient Population Dynamics in the patients is also regulated. By federal law (and as Modern Nursing Home amended in some states), minimum visitation by the physician to nursing home patients includes the initial Most patients admitted to nursing homes in this day and order and approval for admission in the form of an admit- age are rehabilitated over a period of a month or two and ting history, physical, and orders. After accounted for by long-stayers, patients with slow trajec- admission, monthly visits (every 30 ± 10 days) should tories of improvement or decline, with chronic illnesses ensue for at least one quarter, then every other month such as Alzheimer’s disease or other debilitating neuro- thereafter. These persons can be expected to succumb nated with a physician assistant or nurse practitioner. A substantial Some states continue to require monthly visits indefi- minority of residents, perhaps a quarter to a third, are nitely. So long as medical admitted with a clearly terminal illness, such as advanced necessity can be documented, the physician or nurse carcinoma, amyotrophic lateral sclerosis, or AIDS, and practitioner can round on the patients (and bill for these stay only a few weeks for end-of-life care. Small wonder services) as often as medically necessary, daily, if need that the staffs of most nursing homes are quite proficient be, as occurs in some high-intensity nursing home wings in end-of-life care, with attention to patient and family variously known as rehabilitation or subacute units. Their autonomy and ability to bill easier to arrange (and to attain unanimity of thinking effectively for their services have recently been enhanced among staff and family) in the nursing home than in the by federal legislation. During the physician visit, the doctor must sign all Importantly, most nursing homes cannot necessarily orders (including therapy or telephone orders that have provide the full panoply of hospice care, with expert accumulated between visits) and approve the plan of nursing, social services, clergy, and volunteer support all care, usually by signing monthly orders after review, a directed toward typical hospice goals.

Isoptin
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