Some reported that therapeutic modalities treatment variable generic trecator sc 250 mg free shipping, when combined with other treatments symptoms jet lag purchase 250mg trecator sc fast delivery, may be of some benefit for pain management or other symptoms medicine remix discount 250 mg trecator sc with mastercard. There was no consistent evidence of any beneficial effect when a therapeutic modality was used alone xerostomia medications side effects buy 250 mg trecator sc fast delivery. Seven electronic databases and a manual search resulted in 2 symptoms 5 days before your missed period order trecator sc 250mg overnight delivery,538 unique publications treatment 1st degree burns order trecator sc 250mg otc. Two reviewers independently selected trials for inclusion medications used for adhd cheap trecator sc 250 mg with mastercard, extracted data and assessed the risk of bias according to standard Cochrane methodology symptoms rectal cancer generic 250 mg trecator sc free shipping. They studied different rehabilitation treatments including immobilization using a wrist orthosis, dressings, exercise, controlled cold therapy, ice therapy, multi-modal hand rehabilitation, laser therapy, electrical modalities, scar desensitization, and arnica. Three trials compared a rehabilitation treatment to a placebo comparison; 3 trials compared rehabilitation to a no treatment control; 3 trials compared rehabilitation to standard care; and 14 trials compared various rehabilitation treatments to one another. Eleven trials explicitly reported random sequence generation and, of these, 3 adequately concealed the allocation sequence. Five studies were at high-risk of bias from incompleteness of outcome data at one or more time intervals. The trials were heterogeneous in terms of the treatments provided, the duration of interventions, the nature and timing of outcomes measured and setting. The authors concluded that there is limited and, in general, low-quality evidence for the benefit of the reviewed interventions. It is important for researchers to identify patients who respond to a certain treatment and those who do not, and to undertake high-quality studies that evaluate the severity of iatrogenic symptoms from the surgery, measure function and return-to-work rates, and control for confounding variables. Risk of bias assessment was performed via referring to the Cochrane tool for risk of bias assessment. Thornton et al (2013) stated that shoulder pain is a common musculo-skeletal condition that affects up to 25 % of the general population. Shoulder pain can be caused by any number of underlying conditions including subacromial impingement syndrome, rotator-cuff tendinitis, and biceps tendinitis. Regardless of the specific pathology, pain is generally the number 1 symptom associated with shoulder injuries and can severely affect daily activities and quality of life of patients with these conditions. In addition, these exercise programs have been Proprietary Cold Laser and High-Power Laser Therapies - Medical Clinical Policy Bulletins Aetna Page 22 of 85 supplemented with other interventions including non-steroidal anti-inflammatory drugs, corticosteroid injections, manual therapy, activity modification, and a wide array of therapeutic modalities. These researchers performed an electronic search in PubMed from 2001 to April 2014. The full texts of potentially suitable articles were obtained for final assessment according to the exclusion and inclusion criteria. Following the initial screening of titles and abstracts as well as the final screening of full texts, 22 articles completely fulfilled the inclusion criteria of this study. The authors concluded that low level laser with low-energy density range appears to exert a bio-stimulatory effect on bone tissue, enhance osteoblastic proliferation as well as differentiation on cell lines used in in-vitro studies. These researchers evaluated the scientific evidence about its effectiveness in maxillofacial surgery. They reviewed PubMed from January 2003 to January 2013 using the key phrase "low level laser treatment". The inclusion criterion was intervention studies in humans of more than 10 patients. The authors excluded animal studies and papers in languages other than English, French, and German. Standard fixed or random-effects meta-analysis was used, and inconsistency was evaluated by the I-squared index (I(2)). A total of 4 original research articles met the all required inclusion/exclusion criteria, and were used for this review. They stated that the issues related to the study designs and different sets of laser irradiation parameters of a limited number of available studies with the same treatment outcomes prevented them from making definite conclusions. A systematic literature review identified 22 publications, of which only 2 studies were adopted. Despite the variance in irradiation conditions applied in both studies, very similar wavelengths were adopted. Bone Regeneration / Bone Healing Atasoy and colleagues (2017) evaluated the effectiveness of low-level 940 nm laser therapy with energy intensities of 5, 10 and 20 J/cm2 on bone healing in an animal model. A total of 48 female adult Wistar rats underwent surgery to create bone defects in the right tibias. Low-level laser therapy was applied immediately after surgery and on post-operative days 2, 4, 6, Proprietary Cold Laser and High-Power Laser Therapies - Medical Clinical Policy Bulletins Aetna Page 26 of 85 8, 10 and 12 in 3 study groups with energy intensities of 5 J/cm2, 10 J/cm2 and 20 J/cm2 using a 940 nm GalliumAluminum-Arsenide (Ga-Al-As) laser, while 1 control group underwent only the tibia defect surgery. Fibroblasts, osteoblasts, osteocytes, osteoclasts and newly formed vessels were evaluated by a histological examination. No significant change was observed in the number of osteocytes, osteoblasts, osteoclasts and newly formed vessels at either time period across all laser groups. The authors concluded that these findings showed that low-level 940 nm laser with different energy intensities may not have marked effects on the bone healing process in both phases of bone formation. Electronic search was performed in Medline, Scopus, and Embase databases using appropriate Medical Subject Heading terms, with no time restriction. In human studies, bone density was assessed radiographically (either 2-Dl or 3-D imaging). The studies in animal models measured the formation and maturation of new bone qualitatively or quantitatively. The authors concluded that laser therapy was superior to placebo in terms of improving the grip strength; however, no significant difference was found between both groups in terms of functional status Proprietary Cold Laser and High-Power Laser Therapies - Medical Clinical Policy Bulletins Aetna Page 28 of 85 improvement, pain reduction, or motor electro-diagnostic evaluations. Of the 242 articles examined, 13 were finally included in the critical analysis conducted as a part of the present systematic review; 7 articles showed significant improvement in the study group, whereas 5 showed no significant improvement between the study and control groups. However, due to the limitations of this review, findings must be interpreted with caution. These studies need to be clear in the reporting of allocation, blinding, sequence generation, withdrawals, intention-to-treat analysis, and any other potential source of bias in the study. For intra-group comparisons, the Friedman test was performed, and for inter-group, the Mann-Whitney test. Increased pain sensitivity was found in women with myofascial pain when compared to controls (p<0. I n the placebo group, silent/off laser therapy was carried out during the same period in the same areas. Burning sensation severity and quality of life in the 2 groups after intervention were different significant (p = 0. These researchers stated that further research is needed to validate our findings. Letter to editors, reviews, experimental studies, studies that were not published in English, theses, monographs, and abstracts presented in scientific events were excluded. A total of 10 clinical studies fulfilled the eligibility criteria, 5 of which were randomized clinical trials. In these studies, the laser Proprietary Cold Laser and High-Power Laser Therapies - Medical Clinical Policy Bulletins Aetna Page 31 of 85 wavelengths, power output and duration of irradiation ranged between 630 to 980 nm, 20 to 300 mW, 10 seconds to 15minutes, respectively. A comprehensive search of the literature was conducted in the PubMed/Medline, Scopus, and Cochrane Library databases up to March 8, 2018, using terms such as low-level laser therapy, neuropathic pain, orofacial pain, neuralgia, neuropathy, and all the entities described in section 13 of the International Classification of Headache Disorders, 3rd edition. Moreover, these researchers stated that more quality studies assessing all outcome measures of chronic pain are needed in the medium- and long-terms. Furthermore, Proprietary Cold Laser and High-Power Laser Therapies - Medical Clinical Policy Bulletins Aetna Page 32 of 85 due to the lack of standardization of the application technique, more well-designed studies are needed to confirm the results of this systematic review. Echocardiography was performed 3 days and at the end of the experiment (5 weeks) to evaluate cardiac function. A worsening of cardiac function was confirmed in the hemodynamic analysis as evidenced by the higher left ventricular end-diastolic pressure and lower +dP/dt and -dP/dt with 5 weeks of study. Hair Loss Zarei and colleagues (2016) noted that despite the current treatment options for different types of alopecia, there is a need for more effective management options. From the searches, 21 relevant studies were summarized in this review including 2 in-vitro, 7 animal, and 12 clinical studies. However, only 1 out of 5 studies performed intention-to-treat analysis, and only another study reported the method of randomization and subsequent concealment of allocation clearly; all other studies did not include this very important information in their reports. None of these studies reported the treatment effect of factors such as number needed to treat. In a Cochrane review, van Zuuren and associates (2016) evaluated the safety and effectiveness of the available options for the treatment of female pattern hair loss in women. They also searched 5 trial registries and checked the reference lists of included and excluded studies. Furthermore, there was no difference in effect between the minoxidil 2 % and 5 % with the quality of evidence rated moderate-to-low for most outcomes. They stated that there were inconsistent results in the studies that evaluated laser devices (moderate-to-low quality evidence), but there was an improvement in total hair count measured from baseline. They stated that Proprietary Cold Laser and High-Power Laser Therapies - Medical Clinical Policy Bulletins Aetna Page 36 of 85 moving forward, protocols should be standardized across trials; and it is recommended that future trials include visual evidence and trial duration be expanded to 12 months. These researchers performed a systematic literature review to identify articles on Medline, Google Scholar, and Embase that were published between January 1960 and November 2015. All search hits were screened by 2 reviewers and examined for relevant abstracts and titles. Additionally, hair thickness and tensile strength significantly improved in 2 out of 4 studies. Patient satisfaction was investigated in 5 studies, and was overall positive, though not as profound as the objective outcomes. In the remaining study, improvement in hair counts and hair diameter was recorded, but did not reach statistical significance. Two trials did not include statistical analysis, but showed marked improvement by hair count or by photographic evidence. Clinical trials have indicated efficacy for androgenic alopecia in both men and women. Anecdotal paradoxical hypertrichosis noted during laser epilation has generated interest in the possibility of using laser to stimulate hair growth. They carried out a systematic review on studies identified on Medline, Embase, Cochrane database, and clinicaltrials. These researchers stated that although shown to effectively stimulate hair growth when compared to sham devices, these results must be interpreted with caution. They stated that further studies with larger samples, longer followup, and independent funding sources are needed to determine the clinical effectiveness of this novel therapy. Of the 644 articles, 46 Proprietary Cold Laser and High-Power Laser Therapies - Medical Clinical Policy Bulletins Aetna Page 39 of 85 met inclusion criteria. These researchers analyzed 14 articles, 10 in experimental animals and 4 in humans. In this study, 24 Sprague-Dawley rats were divided into 3 groups: (i) control, (ii) ozone, and (iii) laser groups. All groups received 5-fluorouracil intra-peritoneally and trauma to the mouth pouch with a needle. From 14,525 records, 4 studies were included in the review and 3 studies were included in meta-analysis. Data from 500 patients (mean age Proprietary Cold Laser and High-Power Laser Therapies - Medical Clinical Policy Bulletins Aetna Page 42 of 85 of 53. Meta-analysis showed that laser therapy prevents oral mucositis incidence in 28% and 23% of cases during the third and fourth follow-up week, respectively, in comparison to a placebo-treated control group. There was no statistically significant difference the prevention of pain; dysphagia and quality of life were not analyzed due to missing data. The authors concluded that laser therapy was effective in preventing oral mucositis from the 15th to the 45th days of chemoradiotherapy. However, new primary studies with low risk of bias are needed so a higher scientific evidence can be obtained. Briefly, sites affected by tumors were the following: oral cavity (n = 170), oropharynx (n = 91), throat (n = 42), larynx (n = 32), nasopharynx (n = 11), hypopharynx (n = 9), and in 8 cases, sites were not reported. The outcomes evaluated were the ulcer area, healing rate, and overall healing rate. The risk of bias was evaluated using the tool of the Cochrane Collaboration, and the results were analyzed descriptively. These investigators reviewed the fundamental mechanisms at the cellular and molecular level and the effects on the brain were discussed. The 1st studied pulsed against continuous laser irradiation, finding that 10Hz pulsed was the best. The 2nd compared 4 different wavelengths, discovering only 660 and 810nm to have any effectiveness, whereas 732 and 980nm did not. The 3rd looked at varying regimens of daily laser treatments (1, 3, and 14 days) and found that 14 laser applications was excessive. Because data were clinically heterogeneous, best evidence synthesis was performed. However, they stated that due to the limited numbers of published trials available, there is a clear need for welldesigned high-quality trials in this area. The optimal treatment parameters for clinical application have yet to be elucidated. Photobiomodulation therapy might be a nonpharmacological, non-invasive strategy to improve insulin resistance. Electronic databases (PubMed, Scopus, and Web of Science) were searched from date of inception till and including December 2016, using various combinations of the following keywords: oral lichen planus, laser therapy, low-level laser therapy, and phototherapy. In these studies, the laser wavelengths, power output, and duration of irradiation ranged between 630 to 980 nm, 20 to 300 mW, and 10 s to 15 min, respectively. Laser wavelengths, power, spot size, and duration of laser exposure ranged between 630 and 970 nm, 10 to 3,000 mW, 0. Pemphigus Vulgaris Proprietary Cold Laser and High-Power Laser Therapies - Medical Clinical Policy Bulletins Aetna Page 48 of 85 Yousef and associates (2017) stated that pemphigus vulgaris is a chronic blistering skin disease. In a pilot study, these investigators evaluated the efficacy of low power laser in the healing of pemphigus lesions. Moreover, they stated that since this was a pilot study with a small sample size (n = 10), it is suggested that further research be performed. Multi-disciplinary care for the diabetic foot is common, but treatment results are often unsatisfactory. Low level laser therapy on wound areas as Proprietary Cold Laser and High-Power Laser Therapies - Medical Clinical Policy Bulletins Aetna Page 49 of 85 well as on acupuncture points, as a non-invasive, pain-free method with minor side effects, has been considered as a possible treatment option for the diabetic foot syndrome. These researchers adopted 22 eligible references; 8 of them were cell studies, 6 were animal studies, and 8 were clinical trials. But there are a lot of aspects in these studies limiting final evidence about the actual output of this kind of treatment method. It affects approximately 1/3 of the world population and causes frequent pain and discomfort episodes, as well as social restriction due to its compromise of esthetic features. In addition, the available anti-viral drugs have not been successful in completely eliminating the virus and its recurrence. Currently, different kinds of laser treatment and different protocols have been proposed for the management of recurrent herpes labialis. These investigators reviewed the literature regarding the effects of laser irradiation on recurrent herpes labialis and identified the indications and most successful clinical protocols. The literature was searched with the aim of identifying the effects on healing time, pain relief, duration of viral shedding, viral inactivation, and interval of recurrence. According to the literature, none of the laser treatment modalities is able to completely eliminate the virus and its recurrence. However, laser phototherapy appears to strongly decrease pain and the interval of recurrences without causing any side effects. Photodynamic therapy can be helpful in reducing viral titer in the vesicle phase, and high- Proprietary Cold Laser and High-Power Laser Therapies - Medical Clinical Policy Bulletins Aetna Page 51 of 85 power lasers may be useful to drain vesicles. The main advantages of the laser treatment appear to be the absence of side effects and drug interactions, which are especially helpful for older and immune-compromised patients. The authors concluded that although these results indicated a potential beneficial use for lasers in the management of recurrent herpes labialis, they are based on limited published clinical trials and case reports. They stated that the literature still lacks double-blind, controlled clinical trials verifying these effects and such trials should be the focus of future research. Current therapeutic options have limited efficacy in reducing healing time and recurrence rate of the disease. Due to marked heterogeneity of available data, studies were assessed qualitatively, and no statistical analysis was performed. In view of evidence of no effectiveness, clinicians should not offer structured patient education alone, cervical collar, low-level laser therapy, or traction". In a clinical practice guideline for "Physical therapy assessment and treatment in patients with nonspecific neck pain" (Bier et al, 2018) stated that "The physical therapist is advised not to use dry needling, low-level laser, electrotherapy, ultrasound, traction, and/or a cervical collar". However, there is no evidence to support its effectiveness for improvement of intermediate-term and long-term function and pain. Proprietary Cold Laser and High-Power Laser Therapies - Medical Clinical Policy Bulletins Aetna Page 53 of 85 Breast Implant Capsular Contracture Azimi and colleagues (2018) stated that breast reconstruction with implants can be complicated by symptomatic capsular contracture, especially after radiotherapy. Pain, tightness, arm movement, and appearance were assessed by patient questionnaires. Breast symmetry, shape, naturalness, softness, and grade of contracture were assessed by clinician reports. A total of 42 patients (intervention arm, n = 20; placebo, n = 22) were assessed in the trial; 32 had post-mastectomy radiotherapy. There was no significant difference in the change in any patient-reported outcomes or clinician-reported outcomes of breast symmetry, shape, or naturalness for the 2 groups. There was a significantly greater improvement in clinicianreported breast softness (p < 0. Primary outcome measure was frequency of thyroid nodules, which were subjected to fine-needle aspiration biopsy. The levothyroxine dose needed by group L was significantly lower than that required by group P (p = 0. These researchers stated that future research will be important to corroborate these findings. The vascularization was evaluated by means of a subjective method, with classification of the vascularization into 4 different patterns.
In the later stages medicine 72 hours generic 250mg trecator sc with mastercard, the individual loses physical coordination and is unable to complete everyday tasks medicine 852 purchase trecator sc 250 mg without prescription, including self-care and personal hygiene (Erber & Szuchman medicine 122 cheap trecator sc 250mg without a prescription, 2015) medications kidney patients should avoid buy generic trecator sc 250mg line. Beta-amyloid comes from a larger protein found in the fatty membrane surrounding nerve cells medications causing thrombocytopenia discount 250mg trecator sc with mastercard. When tau malfunctions medicine 74 trecator sc 250 mg cheap, it changes into twisted strands called tangles that disrupt the transport system medications pregnancy cheap trecator sc 250mg amex. Consequently medicine wheel trecator sc 250mg mastercard, nutrients and other supplies cannot move through the cells and they eventually die. For example, the hippocampus is involved in learning and memory, and the brain cells in this region are often the first to be damaged. These findings support other studies that have found that the hippocampus and thalamus are involved in mood disorders. Once tau begins to accumulate in brain tissue, the protein can spread from one brain area to the next along neural connections. The researchers followed a diverse group of 2765 participants for 9 years and focused on five low-risk lifestyle factors: healthy diet, at least 150 minutes/week of moderate to vigorous physical activity, not smoking, light to moderate alcohol intake, and engaging in cognitively stimulating activities. Vascular Neurocognitive Disorder is the second most common neurocognitive disorder affecting 0. Risk factors include smoking, diabetes, heart disease, hypertension, or a history of strokes. Neurocognitive Disorder with Lewy bodies is the third most common form and affects more than 1 million Americans. Lewy bodies can occur in both the cortex and brain stem which results in cognitive as well as motor symptoms (Erber & Szuchman, 2015). Individuals diagnosed with Neurocognitive Disorder with Lewy bodies also experience sleep disturbances, recurrent visual hallucinations, and are at risk for falling. Work, Retirement, and Leisure Work: According to the United States Census Bureau, in 1994, approximately 12% of those employed were 65 and over, and by 2016, the percentage had increased to 18% of those employed (McEntarfer, 2019). Looking more closely at the age ranges, more than 40% of Americans in their 60s are still working, while 14% of people in their 70s and just 4% of those 80 and older are currently employed (Livingston, 2019). Even though they make up a smaller number of workers overall, those 65- to 74-year-old and 75-andolder age groups are projected to have the fastest rates of growth in the next Figure 9. Livingston (2019) reported that, similar to other age groups, those with higher levels of education are more likely to be employed. In contrast, 31% with some college experience and 21% of those with a high school diploma or less are still working at age 60 and beyond. Not only are older persons working more, but they are also earning more than previously, and their growth in earnings is greater compared to workers of other ages (McEntarfer, 2019). Transitioning into Retirement: For most Americans, retirement is a process and not a one-time event (Quinn & Cahill, 2016). Pilots, air traffic controllers, federal law enforcement, national park rangers, and fire fighters continue to have enforced retirement ages. Consequently, for most workers they can continue to work if they choose and are able. For those born before 1938, they can receive full social security benefits at age 65. For those born between 1943 and 1954, they must wait until age 66 for full benefits, and for those born after 1959 they must wait until age 67 (Social Security Administration, 2016). Medicare health insurance is another entitlement that is not available until one is aged 65. Historically, there have been three parts to retirement income; that is, social security, a pension plan, and individual savings (Quinn & Cahill, 2016). When looking at both healthy and unhealthy retirees, a one-year delay in retiring was associated with a decreased risk of death from all causes (Wu, Odden, Fisher, & Stawski, 2016). Retirement Stages: Atchley (1994) identified several phases that individuals ago through when they retire: · · · · · · Remote pre-retirement phase includes fantasizing about what one wants to do in retirement Immediate pre-retirement phase when concrete plans are established Actual retirement Honeymoon phase when retirees travel and participate in activities they could not do while working Disenchantment phase when retirees experience an emotional let-down Reorientation phase when the retirees attempt to adjust to retirement by making less hectic plans and getting into a regular routine Not everyone goes through every stage, but this model demonstrates that retirement is a process. Post-retirement: Those who look most forward to retirement and have plans are those who anticipate adequate income (Erber & Szuchman, 2015). This is especially true for males who have worked consistently and have a pension and/or adequate savings. For some older students who no longer are focus on financial reasons, returning to school is intended to enable them to pursue work that is personally fulfilling. Even if an elder chooses not to attend college for a degree, there are many continuing education programs on topics of Source interest available. In 1975, a nonprofit educational travel organization called Elderhostel began in New Hampshire with five programs for several hundred retired participants (DiGiacomo, 2015). In 2010 the organization changed its name to Road Scholar, and it now serves 100,000 people per year in the U. Academic courses, as well as practical skills such as computer classes, foreign languages, budgeting, and holistic medicines, are among the courses offered. Screen time has increased for those in their 60s, 70s, 80s and beyond, and across genders and education levels. In 2000, 14% of those aged 65 and older used the Internet, and now 73% are users and 53% own smartphones. People with less education spend more of their leisure time on screens and less time reading compared with those with more education. Less educated adults also spend less time exercising: 12 minutes a day for those with a high school diploma or less, compared with 26 minutes for college graduates. These stereotypes are reflected in everyday conversations, the media, and even in greeting cards (Overstreet, 2006). In contrast, older individuals in cultures, such as China, that held more positive views on aging did not demonstrate cognitive deficits. This is known as stereotype threat, and it was originally used to explain race and gender differences in academic achievement (Gatz et al. In terms of physically taking care of themselves, those who believe in negative stereotypes are less likely to engage in preventative health behaviors, less likely to recover from illnesses, and more likely to feel stress and anxiety, which can adversely affect immune functioning and cardiovascular health (Nelson, 2016). Similarly, doctors who believe that illnesses are just natural consequence of aging are less likely to have older adults participate in clinical trials or receive life-sustaining treatment. In contrast, those older adults who possess positive and optimistic views of aging are less likely to have physical or mental health problems and are more likely to live longer. Removing societal stereotypes about aging and helping older adults reject those notions of aging is another way to promote health and life expectancy among the elderly. Unfortunately, racism is a further concern for minority elderly already suffering from ageism. Older adults who are African American, Mexican American, and Asian American experience psychological problems that are often associated with discrimination by the White majority (Youdin, 2016). Older, minority women can face ageism, racism, and sexism, often referred to as triple jeopardy (Hinze, Lin, & Andersson, 2012), which can adversely affect their life in late adulthood. Married couples are less likely to be poor than nonmarried men and women, and poverty is more prevalent among older racial minorities. In 2017, of those 65 years of age and older, approximately 72% of men and 48% of women lived with their spouse or partner (Administration on Aging, 2017). Since 1990 the number of older adults living alone has declined, because of older women more likely to be living with their spouse or children (Stepler, 2016c). Older women are more likely to be unmarried, living with children, with other relatives or non-relatives. In 2016, a record 64 million Americans, or 20% of the population, lived in a house with at least two adult generations. However, ethnic differences are noted in the percentage of multigenerational households with Hispanic (27%), Black (26%), and Asian (29%) families living together in greater numbers than White families (16%). Consequently, the majority of older adults wish to live independently for as long as they are able. According to Erber and Szuchman (2015), the majority of those in late adulthood remain in the same location, and often in the same house, where they lived before retiring. Despite the previous trends, however, the recent housing crisis has kept those in late adulthood in their current suburban locations because they are unable to sell their homes (Erber & Szuchman, 2015). However, as individuals increase in age the percentage of those living in institutions, such as a nursing home, also increases. Specifically: 1% of those 65-74, 3% of those 75-84, and 10% of those 85 years and older lived in an institution in 2015. To meet this higher demand for services, a focus on the least restrictive care alternatives has resulted in a shift toward home and community-based care instead of placement in a nursing home (Gatz et al. This acceptance will lead to integrity, but if elders are unable to achieve this acceptance, they may experience despair. Bitterness and resentments in relationships and life events can lead one to despair at the end of life. Staying Active: Many older adults want to remain active and work toward replacing opportunities lost with new ones. Community, faith-based, and volunteer organizations can all provide those in late adulthood with opportunities to remain active and maintain social networks. Hospitals and environmental groups also provide volunteer opportunities for older adults. Older adults who volunteer experience more social contact, which has been linked to higher rates of life satisfaction, and lower rates of depression and anxiety (Pilkington, Windsor, & Crisp, 2012). However, older adults who volunteer may already be healthier, which is why they can volunteer compared to their less heathy age mates. Both theories indicate that less close relationships will decrease as one ages, while close relationships will persist. The Convoy Model of Social Relations suggests that the social connections that people accumulate differ in levels of closeness and are held together by exchanges in social support (Antonucci, 2001; Kahn & Antonucci, 1980). Therefore, the frequency, type, and reciprocity of the social exchanges with peripheral relationships decrease with age. The Socioemotional Selectivity Theory focuses on changes in motivation for actively seeking social contact with others (Carstensen, 1993; Carstensen, Isaacowitz & Charles, 1999). This theory proposes that with increasing age, our motivational goals change based on how much time one has left to live. Rather than focusing on acquiring information from many diverse social relationships, as noted with adolescents and young adults, older adults focus on the emotional aspects of relationships. To optimize the experience of positive affect, older adults actively restrict their social life to prioritize time spent with emotionally close significant others. In line with this theory, older marriages are found to be characterized by enhanced positive and reduced negative interactions and older partners show more affectionate behavior during conflict discussions than do middle-aged partners (Carstensen, Gottman, & Levenson, 1995). There is more support going from the older parent to the younger adult children than in the other direction (Fingerman & Birditt, 2011). They found that the older parents of adult children who provided emotional support, such as showing tenderness toward their parent, cheering the parent up when he or she was sad, tended to report greater life satisfaction. Lang and Schьtze found that older adults wanted their relationship with their children to be more emotionally meaningful. Being able to talk with friends and rely on others is very important during this stage of life. In contrast, having a family member as a confidante did not provide health protection for those recently widowed. Loneliness or Solitude: Loneliness is the discrepancy between the social contact a person has and the contacts a person wants (Brehm, Miller, Perlman, & Campbell, 2002). Women tend to experience loneliness due to social isolation; men from emotional isolation. In contrast, older adults who take part in social clubs and church groups have a lower risk of death. Opportunities to reside in mixed age housing and continuing to feel like a productive member of society have also been found to decrease feelings of social isolation, and thus loneliness. The Social Source Readjustment Rating Scale, commonly known as the Holmes-Rahe Stress Inventory, rates the death of a spouse as the most significant stressor (Holmes & Rahe, 1967). They must remake their identity after years of seeing themselves as a husband or wife. Loneliness is the biggest challenge for those who have lost their spouse (Kowalski & Bondmass, 2008). Positive support from adult children is also associated with fewer symptoms of depression and better adjustment in the months following widowhood (Ha, 2010). The stress of caring for an ill spouse can result in a mixed blessing when the ill partner dies (Erber & Szchman, 2015). At the same time, this sense of relief may be intermingled with guilt for feeling relief at the passing of their spouse. The widowhood mortality effect refers to the higher risk of death after the death of a spouse (Sullivan & Fenelon, 2014). Subramanian, Elwert, and Christakis (2008) found that widowhood increases the risk of dying from almost all causes. Men show a higher risk of mortality following the death of their spouse if they have higher health problems (Bennett, Hughes, & Smith, 2005). In addition, widowers have a higher risk of suicide than do widows (Ruckenhauser, Yazdani, & Ravaglia, 2007). However, in both America (Lin, 2008) and England (Glaser, Stuchbury, Tomassini, & Askham, 2008) studies have found that the adult children of divorced parents offer more support and care to their Source mothers than their fathers. While divorced, older men may be better off financially and are more likely to find another partner, they may receive less support from their adult children. Dating: Due to changing social norms and shifting cohort demographics, it has become more common for single older adults to be involved in dating and romantic relationships (Alterovitz & Mendelsohn, 2011). An analysis of widows and widowers ages 65 and older found that 18 months after the death of a spouse, 37% of men and 15% of women were interested in dating (Carr, 2004a). Consequently, older adults, much like those younger, are increasing their social networks using technologies, including e-mail, chat rooms, and online dating sites (Fox, 2004; Wright & Query, 2004; Papernow, 2018). Research has previously shown that older women in romantic relationships are not interested in becoming a caregiver or becoming widowed for a second time (Carr, 2004a). Concerns expressed by older women included not 419 wanting to lose their autonomy, care for a potentially ill partner, or merge their finances with someone (Watson & Stelle, 2011). Githens and Abramsohn (2010) found that only 25% of adults 50 and over who were single or had a new sexual partner used a condom the last time they had sex. Remarriage and Cohabitation: Older adults who remarry often find that their remarriages are more stable than those of younger adults. In addition, older adults who have divorced often desire the companionship of intimate relationships without marriage. No longer being interested in raising children, and perhaps wishing to protect family wealth, older adults may see cohabitation as a good alternative to marriage. This trend has been found in several nations and is motivated by: · · · · A strong desire to be independent in day-to-day decisions Maintaining their own home Keeping boundaries around established relationships Maintaining financial stability Besides the desire to be autonomous, there is also a need for companionship, sexual intimacy, and emotional support. By 2025 that number is expected to rise to more than 7 million (National Gay and Lesbian Task Force, 2006). According to the Centers for Disease Control and Prevention (2011), compared to heterosexuals, lesbian and gay adults experience both physical and mental health differences. When compared to heterosexuals, lesbian and gay elders have less support from others as they are twice as likely to live alone and four times less likely to have adult children (Hillman & Hinrichsen, 2014). Ageism, heterocentrism, sexism, and racism can combine cumulatively and impact the older adult beyond the negative impact of each individual form of discrimination (Hillman & Hinrichsen, 2014). David and Knight (2008) found that older gay black men reported higher rates of racism than younger gay black men and higher levels of perceived ageism than older gay white men. They also gather social support from friends and "family members by choice" rather than legal or biological relatives (Hillman & Hinrichsen, 2014). The oldest lesbian and gay adults came of age in the 1950s when there were 421 Figure 9. Consequently, just like all those in late adulthood, understanding that gay and lesbian elders are a heterogeneous population is important when understanding their overall development. Psychological and emotional abuse is considered the most common form, even though it is underreported and may go unrecognized by the elder. Continual emotional mistreatment is very damaging as it becomes internalized and results in late-life emotional problems and impairment. Financial abuse and exploitation is increasing and costs seniors nearly 3 billion dollars per year (Lichtenberg, 2016). Financial abuse is the second most common form after emotional abuse and affects approximately 5% of elders. Abuse of nursing home residents is more often found in facilities that are run down and understaffed Table 9. Additionally, a family history of violence makes older women more vulnerable, especially for physical and sexual abuse (Acierno et al. For example, Dakin and Pearlmutter found that working class White women 422 did not consider verbal abuse as elder abuse, and higher socioeconomic status African American and White women did not consider financial abuse as a form of elder abuse (as cited in Roberto, 2016, p. Perpetrators of elder abuse are typically family members and include spouses/partners and older children (Roberto, 2016). Paid caregivers and professionals trusted to make decisions on behalf of an elder, such as guardians and lawyers, also perpetuate abuse. When elders feel they have social support and are engaged with others, they are less likely to suffer abuse. Substance Abuse and the Elderly Alcohol and drug problems, particularly prescription drug abuse, have become a serious health concern among older adults. Six to eleven percent of elderly hospital admissions, 14 percent of elderly emergency room admissions, and 20 percent of elderly psychiatric hospital admissions are a result of alcohol or drug problems. Older adults are hospitalized as often for alcoholic related problems as for heart attacks. Nearly 17 million prescriptions for tranquilizers are prescribed for older adults each year. Benzodiazepines, a type of tranquilizing drug, are the most commonly misused and abused prescription medications.
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Dry needling is also thought to normalize abnormal motor end plates (the sites that transmit nerve impulses to muscles) symptoms stiff neck cheap trecator sc 250mg amex. Dry needling can produce minor bleeding and some soreness but is a safe procedure when performed by a trained professional medications over the counter purchase 250mg trecator sc with visa. Dry needling is not the same thing as acupuncture medicine 319 pill buy cheap trecator sc 250mg line, a practice based on traditional Chinese medicine and performed by acupuncturists medicine identification generic 250mg trecator sc otc. Trigger Point Injections Trigger point injections are given to individuals with a myofascial pain syndrome medicine lake buy trecator sc 250mg otc, a regional painful muscle condition symptoms brain tumor purchase trecator sc 250mg online. These injections may provide short-term benefit only but are curative for some individuals medications on airline flights 250 mg trecator sc amex. A trigger point is a discrete focal tenderness located in a palpable taut band of skeletal muscle symptoms wheat allergy buy discount trecator sc 250 mg online, which produces a local twitch in response to stimulus to the band. Myofascial pain syndrome is a regional painful muscle condition with a direct relationship between a specific trigger point and its associated pain region. These injections may occasionally be necessary to maintain function in those with myofascial problems when myofascial trigger points are present on examination. Intra-Articular Steroid Injections Invasive therapeutic interventions for osteoarthritis include steroid injections into the joint. Intraarticular steroids are effective for short-term (one to three weeks) pain relief but do not seem to improve function or provide pain relief for longer time periods. Following a steroid injection, the treated joint should be rested (limit its use) for a minimum of 24 hours in order to prolong and to improve effects on function and pain control. Viscosupplementation involves injecting lubricating substances (hyaluronic and hylan derivatives) into the knee joint. Proponents argue that viscosupplementation restores the lubrication of the joint, and as a result, decreases pain and improves mobility. The American College of Rheumatology 2012 Recommendations for the Use of Nonpharmacologic and Pharmacologic Therapies in Osteoarthritis of the Hand, Hip, and Knee regarding the use of intraarticular hyaluronate injections states they are conditionally recommended in patients who had an inadequate response to initial therapy. Obviously, there is some controversy, but some orthopedists feel that viscosupplementation may provide some benefit short-term (weeks to months) for treatment of knee osteoarthritis; but the improvements in pain and function are not long-lasting. American Chronic Pain Association Copyright 2019 46 Implantable Devices: Spinal Cord Stimulation & Implantable Drug Delivery System For selected individuals with chronic pain, the health care provider may suggest an implantable device, such as a neurostimulator (also called a spinal cord stimulator) or a medication pump. The neurostimulator generates mild electrical signals that are delivered to an area near the spine. The impulses travel from the device to this spinal area over thin insulated wires called leads. The purpose of this psychological evaluation is to see if the person has any emotional or other difficulties that may adversely affect the surgery or recovery and to ensure the person has realistic expectations and goals for what can be achieved with the therapy. During the psychological evaluation, the person can expect to be asked questions about how the pain is currently affecting sleep, mood, relationships, work, and household and recreational activities. In both stages, a physician, guided by an x-ray, places a lead into the epidural space located within the bony spinal canal. The first stage is the trial phase, which provides information to predict the success of permanent implantation. During the trial phase, one or two leads are placed via an epidural needle in the appropriate position. It is important that the patient is alert during the insertion and testing of the lead so he or she can inform the health care professional if the lead is in the appropriate position. He or she has an external power source and remote control that allows him or her to control the amount of American Chronic Pain Association Copyright 2019 47 stimulation being received. During the trial, the patient should keep an activity record to determine if the treatment is helpful in relieving pain and improving function. Together, the health care professional and the patient decide whether or not to advance to permanent implantation. In this stage, the lead is again placed and implanted underneath the skin with a power source the size of a pacemaker battery. For the non-rechargeable systems, the battery cannot be recharged and needs replacement every several years with a minor surgical procedure. While it typically lasts longer (up to 9 years) than a conventional system, eventually it will need to be replaced with a minor surgical procedure when it can no longer be recharged in a reasonable period of time. The patient is instructed to limit activity for about 12 weeks to allow for healing. Occasional re-programming will be needed to optimize coverage of the painful area. These devices are invasive and costly, and their use is limited to selected individuals as a treatment alternative for specific conditions after consideration of the risks, after failure of a reasonable trial of less invasive methods and following a successful temporary trial. There is some literature to suggest that in carefully selected patients, despite the initial cost, there may be long-term cost savings after a few years related to a reduction in the use of medications and other medical care services. When utilized, spinal cord stimulation should be part of an overall rehabilitation treatment strategy combining behavioral and physical medicine approaches to pain management. As with most treatments for chronic pain, it is important for the patient and health care provider to have realistic expectations regarding treatment, with the goal being pain reduction and control rather than complete elimination. In general terms, spinal cord stimulation is primarily suited to certain neuropathic and ischemic (loss of oxygenated blood flow) pain states. Potential complications that may occur include lead migration or fracture and infection. Lead migration after implantation may require revision surgery to regain appropriate coverage. An unrecognized and untreated infection around the hardware can progress to more serious complications such as an epidural abscess or meningitis. Intrathecal therapy has been used in long-term pain management for carefully selected patients with failed back surgery syndrome, complex regional pain syndrome, spinal stenosis, osteoporosis with compression fractures, pancreatitis, phantom limb pain syndrome, peripheral neuropathies, and in cancer pain. With Programmable Intrathecal Drug Delivery Therapy: · · · · Pain medication is delivered via a drug pump directly to the fluid around the spinal cord in an area called the intrathecal space. Pain medication is dispensed according to instructions programmed by the physician, which allows noninvasive changes in dose and drug infusion patterns. American Chronic Pain Association Copyright 2019 49 the reader should understand that this discussion of programmable, targeted implanted drug delivery systems is limited to a general overview. These systems are invasive and costly, and their use is limited to select individuals who find oral opioids beneficial but cannot tolerate the side effects and as a treatment alternative for specific conditions after consideration of the risks, after failure of a reasonable trial of less invasive methods and following a successful temporary trial. There is some literature to suggest that in carefully selected patients, despite the initial cost, there may be long-term cost savings after a few years related to a reduction in the use of oral medications and other medical care services. A psychological evaluation of the person being considered for an intrathecal pump is usually recommended as part of the overall evaluation process. The purpose of the evaluation is to see if the person with pain has any emotional or other difficulties that may adversely affect the surgery or recovery and to ensure the person has realistic expectations and goals for what can be achieved with the therapy. During the psychological evaluation, the person with pain will be asked questions about how the pain is currently affecting sleep, mood, relationships, work, and household and recreational activities. The psychologist or psychiatrist should share the results of this evaluation with the person with pain and with the referring physician who will consider all the information to determine if an intrathecal pump is an appropriate option. A decision to proceed with an implanted drug delivery system should include: · · · · · Failure of a reasonable trial of other conservative treatment modalities (medication, surgical, psychological, or physical); Intractable pain secondary to a disease state with objective evidence of pathology; Documentation that further surgical intervention is not indicated; Psychological evaluation has been obtained and evaluation states that the pain is not primarily psychological in origin and that benefit can be anticipated with implantation despite any psychiatric comorbidity; No contraindications to implantation exist such as body size too small to hold the pump; presence of spinal anomalies that may complicate the implantation and fixation of a catheter; the pump cannot be implanted 2. American Chronic Pain Association Copyright 2019 50 Just as when one is taking opioids orally or transdermally, the doses of intraspinal opioids should be limited to the lowest possible dose required to achieve pain relief and increased function, as complications can occur with any dose of opioids regardless of the route of delivery. As with any opioid, constipation, urinary retention, nausea, vomiting, and pruritus (itchiness) are typical early adverse effects of intrathecal morphine and are readily managed symptomatically. Other potential adverse effects include amenorrhea, loss of libido, edema, respiratory depression, and technical issues with the intrathecal system with component failure and need for replacement. Intrathecal Drug Delivery is an invasive treatment and risks of implantation can include infection, bleeding, headache, allergic reaction, spinal fluid leakage and paralysis. High doses of intrathecally-administered morphine or opioid mixtures, including compounded drugs, have uncommonly been linked to the development of a chronic inflammatory or granulomatous mass (an abnormal tissue growth) at the tip of the catheter that can compress the spinal cord or associated nerve roots. Thus, vigilance is important just as is the case when one is taking opioids orally or transdermally. Patients on intraspinal morphine therapy should be monitored carefully by their health care professional for any new neurological symptoms because inflammatory mass can, in some cases, lead to neurological impairment, including paralysis. Even though a direct cause and effect relationship has not been established, the dose of continuouslyadministered intrathecal morphine should be limited to the lowest possible dose to achieve pain relief and increased function, as complications can occur with any dose of opioids regardless of the route of delivery. Apart from morphine, chronic intrathecal infusion of preservative-free, sterile ziconotide solution is approved for the management of severe, chronic pain. Ziconotide (Prialt) is a non-opioid analgesic reserved for patients who are refractory to or who cannot tolerate intrathecal morphine. Typical side effects include dizziness, nausea, vomiting, and states of confusion. Other potential adverse effects include psychosis, convulsions, rhabdomyolysis (muscle breakdown), and problems with the intrathecal infusion system. These side effects can be prevented entirely or may be well managed by raising the dose very slowly to achieve the right level of pain relief with the least amount of drug. Sometimes, a local anesthetic (numbing medicine) may be injected with the steroid. The epidural space is located in the spine just outside of the sac containing the spinal fluid. Epidural steroid injections are often provided to individuals with herniated discs, degenerative disc disease, or spinal stenosis who have associated nerve pain in the arm or leg. The steroids are injected into the epidural space in order to reduce inflammation in and surrounding the spinal nerve roots and adjacent tissues. Epidurals are most useful in patients with acute nerve pain from the above conditions. A majority of individuals (80 to 90 percent) with acute low back pain and associated nerve pain will recover spontaneously within three months, therefore, these injections should be viewed as a way to facilitate earlier pain relief and return to function. These injections have not been demonstrated to provide long-term successful pain relief for people suffering solely from chronic (long-standing) back pain or chronic nerve pain. Epidurals rarely provide long lasting benefit but may be useful in these chronic pain conditions to manage a flare-up. Some people who have residual pain after the first injection may receive a second epidural steroid injection. However, individuals who do not receive any relief from the first injection are unlikely to benefit from a second injection. Furthermore, the number of steroid injections per year should be limited in order to avoid side effects that may occur including osteoporosis (weakening of the bones) and avascular necrosis (bone cell death often seen in the hip). Diabetic patients receiving epidural steroids should monitor their blood sugars closely following the procedure since an elevation can occur. Nerve and facet blocks use a combination of local anesthetic and steroid for diagnostic purposes to identify pain generators. Unfortunately, these procedures do not provide lasting benefit and are best used as part of an overall treatment plan to relieve discomfort temporarily while the patient engages in an active rehabilitation program. Radiofrequency ablation (rhizotomy) or lesioning involves inserting a probe to destroy the nerve that supplies the facet joint. The facet joint, a small joint that connects the back portion of the spine, can become arthritic and cause neck or back pain. These movements can be very painful and may limit daily activities in an individual with facet joint disease. People with lumbar (low back) facet joint syndrome often complain of hip and buttock pain, low back stiffness, and pain that is made worse by prolonged sitting or standing. People with cervical (neck) facet joint syndrome often complain of neck pain, headache, and/or shoulder pain. American Chronic Pain Association Copyright 2019 52 In order to determine if facet joints are responsible for neck or back pain, medial branch blocks are performed. A medial branch block is a block that is performed under fluoroscopy (x-ray), and local anesthetic (numbing medicine) is injected on the nerves that supply the facet joint in the back or neck. Following the procedure, patients are asked to keep a pain diary in order to record any pain relief, the amount of pain relief, and for how long pain relief lasts. Based on the response to this block, it can be determined if the person is a candidate for medial branch radiofrequency ablation (rhizotomy). Following radiofrequency ablation, patients are often asked to resume physical therapy for flexibility and strengthening exercises. Radiofrequency usually blocks the signal for a prolonged period of time (six months to a year). Eventually, the nerve grows back and can allow the pain signal to be transmitted again. This procedure often does not relieve all back pain, but it relieves the pain associated with facet joint arthritis. Denervation of the spinal muscles is possible with rhizotomies, thus repeated rhizotomies can cause atrophy of these muscles and lead to other untoward effects. As with any procedure, there are certain risks involved which should be discussed with a treating physician. In order to achieve optimal results, it is important that these interventions be incorporated into a multidisciplinary treatment plan. Pain medications can be helpful for some patients with chronic pain, but they are not universally effective. It is important to remember that each person may respond in a different manner to any medication. Many people with chronic pain can manage adequately without medications and can function at a near-normal level. Others find that their overall quality of life, in terms of comfort and function, is improved with medications. The use of any treatment, including medications, is judged by efficacy does the benefit exceed the risk/harm? When all is said and done, is the individual better off for having undergone the treatment? For example, a medication may be successful in partially providing pain relief but may have a side-effect such as weight gain or mild loss of mental sharpness Whether the side-effect is worth the benefit is totally individual specific. It is important also to understand that even the most potent medications used for pain rarely completely eliminate pain but rather, may reduce its severity. As such, medications are rarely adequate alone and should be considered as an optional part of a comprehensive approach to pain management and functional improvements. While medications can help relieve symptoms, they also can cause unpleasant side effects that at a minimum can be bothersome and at their worst can cause significant problems including death. These side effects can often be avoided or at least managed with the help of a health care professional. Some substances and drugs may cause serious side effects if they are combined with other medications. American Chronic Pain Association Copyright 2019 54 It is strongly advised that all current medications in the original bottles or boxes or tubes and other items that are active (including non-prescribed medications, vitamins and supplements) be taken to any appointments with the health care professional. It is essential that the health care professional be told about all substances that are being taken (even if they are not legal) or if obtained from someone other than the prescriber. Even medications that may be used only occasionally such as cough and cold medications can have significant medication interactions. People with any medical condition including pain should keep a list of all their medications in their wallet or purse. All opioid medicines and other controlled substances should be locked (in medication safe or other locked compartment) to prevent diversion or unintended intake by children or others. Medications should be mixed with something undesirable, such as used coffee grounds, dirt, or cat litter. This makes the medicine less appealing to children and pets and unrecognizable to someone who might intentionally go through the trash looking for drugs. This mixture should be placed into something you can close (a re-sealable zipper storage bag, empty can, or other container) to prevent the drug from leaking or spilling out before placing in the garbage. Flushing medicines: Because oral and patch formulations of opioid medications could be especially harmful to others, there are specific directions to immediately flush them down the sink American Chronic Pain Association Copyright 2019 55 or toilet when they are no longer needed. Optimal pain relief depends on knowing how much and how often each medication should be taken and whether to take the medication before, with, or after meals or at bedtime. The type of medication and dose may vary depending on the medical condition, body size, age, and any other medications that are taken. It is important to understand the potential side effects of the medications and how these can be prevented or managed effectively. Because of the possibility of interactions between drugs, some medications should not be taken together or should be taken at different times during the day to avoid unwanted reactions. This information can be obtained by reading the labels on the medication containers and/or asking the health care professional or pharmacist. Any concern for drug interactions should be discussed with your pharmacist or health care provider. The label on the medication bottle may show a brand name (for example, Tylenol) or the generic name (for example, acetaminophen) or both. It is often less expensive to buy medications by their generic name rather than by the brand name. The health care professional can be asked to prescribe generic rather than brand-name drugs to hold down the cost of prescription medications. Any noticeable differences in the response to a drug if switching from one drug to another or a brand drug to a generic drug should be discussed with a health care professional. It is essential that the dose and directions written on the medication label be followed. The dose should not be changed without consulting the health care professional and medications that have been prescribed for someone else should never be taken. It is important to periodically evaluate the big picture and ask how life is going overall. Even if months or years have passed, people with pain should tell their health care professionals whether they have regained the ability to engage in and enjoy everyday life activities. A minor tweak may be all that is needed but often bigger changes such as a more comprehensive approach may be required. Symptoms can usually be greatly relieved by learning and strengthening self-care skills.
