By W. Einar. West Virginia University.

    It is the first thing they think of when they awaken in the morning and the last at night before sleep comes buy silvitra 120mg cheap. A young woman with whom I was working said one day that she was “terrified of the physical pain cheap 120 mg silvitra with mastercard. The Psychology of TMS 53 It has been my experience that the overall severity of the pain syndrome order 120 mg silvitra with visa, including obsessional components, is a good guide to the importance of the underlying emotional state of the patient. By importance I mean how much anger and anxiety there are, and how severe the traumas of early life are that have contributed to that person’s current psychological state. People who were abused as children, emotionally or physically, but especially sexually, tend to have enormous reservoirs of anxiety and anger. This is one of the first things I think of when I see someone who has a particularly severe TMS. The physical symptoms are the means by which they remain out of contact with some terrible, frightening, deeply buried feelings. Those words are not exaggerations—there is great fear and probably enormous rage festering in their minds that they dare not acknowledge. Such patients will tell you that they understand why the pain will not leave, for when they begin to get close to those buried feelings they are panic stricken and can proceed no further. On the other hand, in the great majority of people with TMS, about 95 percent, the anxiety level and the reasons for it are much milder and they experience no emotional reaction when the pain disappears. One has the impression in these cases that the mind has overreacted to the anger and anxiety and the defense wasn’t necessary in the first place. What has been described is universal in our culture; only the degree of repressed emotionality varies. And in our culture, nature has created a mechanism whereby we can avoid being aware of those bad feelings—it gives us physical symptoms. Fortunately there is a way of stopping what is clearly a maladaptive response for most of us. However, my work with TMS has demonstrated that the brain has other attributes and can reverse the process that leads to physical symptoms. Anything that heightens anxiety will increase 54 Healing Back Pain the severity of symptoms. One of my patients reported that she left the doctor’s office in a state of shock after having been told that the lower end of her spine was degenerating. She said she almost fainted in the street and that her pain was much worse after the visit to the doctor. A young man in his twenties, with the physique of a football player, told of how he was the strong one in the family business. One day he decided to accompany his father on a visit to a back practitioner since he had experienced some mild low back pain while brushing his teeth. X rays were taken and he was told that there was a malalignment of the lower end of the spine, whereupon his mild symptoms got worse. When the pain persisted he was advised to see a medical specialist, a CT scan (see “Common Patterns of TMS”) was done that showed a herniated disc, and he was now advised that he had a serious problem and that he must do no more heavy lifting, never play basketball again (one of his great loves) and generally be very careful. Though he had started out with mild low back pain, he now had severe pain every day and was greatly limited in his work and life. He had become disabled, thanks to the structural diagnoses that had been made and all that they implied. He now believed there was something seriously wrong with his spine and that he would never again be able to lift a heavy weight or play sports.

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    For example purchase silvitra 120 mg mastercard, even though a patient older persons: higher than previously reported 120 mg silvitra fast delivery. Prevention of delirium inhospitalized older patient will need to be in a supervised environment rel- patients: risk factors and targeted intervention strategies buy 120 mg silvitra otc. Depression, dementia and reversible disease with a striking memory deficit who has some dementia. A longitudinal study practical method for grading the cognitive state of patients of Alzheimer’s disease: measurement, rate, and predictors for the clinician. London, Ontario: neurocognitive screening battery highly sensitive to University of Western Ontario; 1980. Reference values for Differences between Pick disease and Alzheimer disease the Mini-Mental State Examination (MMSE) in octo- and in clinical appearance and rate of cognitive decline. Genuine memory deficits in demen- with probable Alzheimer’s disease: a clinical perspective tia. A normative study of the neuropsychological lobar degeneration: a consensus on clinical diagnostic cri- battery. This page intentionally left blank 20 Preoperative Assessment and Perioperative Care Peter Pompei The increasing number of older persons undergoing patient. These patient-specific risk factors are only part surgery stems from both our aging population and im- of the required assessment; the type and technical diffi- portant recent advances in surgical and anesthetic tech- culty of the procedure, the skill of the surgeon, and the niques. Currently, about one-third of all operations are anesthetic management all contribute to the risks of performed on persons 65 years of age and older, com- complications. The introduction of neuroleptic anesthesia, sophisticated perioperative monitoring tech- Perioperative Risk Stratification nology, and effective prophylaxis against deep venous thrombosis have contributed to lower surgical mortality Assessing a patient’s risk for postoperative complications 2 for older adults. Endoscopic and other minimal access is an important aspect of preoperative evaluation. This techniques have added to the ease and safety of opera- process allows physicians to focus treatments on modifi- tive therapy and have led to reduced mortality, increased able factors, anticipate specific problems, and provide ambulatory surgery, and shorter-stay hospitalizations. The lowered risk of operative has been modified over the years and now consists of the morbidity and mortality has encouraged physicians and five classes shown in Table 20. The purpose of a preoperative In a large study of complications associated with anes- assessment is to identify factors associated with increased thesia done in France, the rate of complications, although risks of specific complications related to the anticipated rising with advancing age, was largely dependent on the procedure and to recommend a management plan that number of associated diseases per person. The consultant must give tients 75 years of age and older, those with three or more careful attention to the extent and severity of comorbid associated diseases had a complication rate 10 times conditions, the current and anticipated pharmacologic greater than those with no associated diseases. This therapy, and the functional and psychologic state of the observation supports the hypothesis that physiologic 213 214 P. Condition Weight Class I A normal healthy patient for elective operation Myocardial infarction 1 Class II A patient with mild systemic disease Congestive heart failure 1 Class III A patient with severe systemic disease that limits Peripheral vascular disease 1 activity but is not incapacitating Cerebrovascular disease 1 Class IV A patient with incapacitating systemic disease that is a Dementia 1 constant threat to life Chronic pulmonary disease 1 Class V A moribund patient not expected to survive 24 h with Connective tissue disease 1 or Ulcer disease 1 without operation Mild liver disease 1 6 Diabetes 1 Source: New Classification of Physical Status, with permission. Hemiplegia 2 Moderate or severe renal disease 2 reserve and ability to regain homeostasis is affected Diabetes with end-organ damage 2 partly by changes associated with aging but, more impor- Any tumor 2 tantly, by the deleterious consequence of accumulating Leukemia 2 disease among older persons. To determine predictors of Lymphoma 2 30-day mortality among 92 patients undergoing pneu- Moderate or severe liver disease 3 Metastatic solid tumor 4 monectomy, investigators examined the contribution of AIDS 4 the following comorbid conditions: cardiac disease, diabetes, hypertension, respiratory disease, pulmonary Weights are assigned for each of the patient’s conditions; the score is cancer, peripheral vascular disease, liver disease, renal the sum of the weights. The presence of one or more of these conditions was asso- ciated with an increased risk of 30-day mortality. Simi- larly, in a study of about 100 patients undergoing total minemia and severely limited physical activity level. Two knee arthroplasty, comorbidity was quantified by count- reports from a study of more than 200,000 patients ing how many of the following conditions were present: treated at Department of Veterans Affairs Medical hypertension, diabetes mellitus, coronary artery disease, Centers highlight the importance of a low serum albumin atherosclerotic heart disease, peripheral vascular disease, in predicting poor surgical outcomes. These results indicate that a simple count of undergoing proctectomy for rectal cancer, presurgical selected diagnoses can help identify patients at risk for hypoalbuminemia was associated with an increased 30- day mortality rate.

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    If such symptoms are treated successfully purchase silvitra 120 mg on-line, then your sexual drive (often called your libido) may increase generic silvitra 120mg with visa. If the primary cause of your decreasing sexual drive lies in primary neurological damage 120 mg silvitra, then this is harder to deal with directly. You and your partner could consider first sensual activity experiences, without you feeling the immediate pressure for sexual intercourse. Ensure that you make time to enjoy the experiences with each other without feeling hurried or under pressure. As in other relationships where circumstances SEXUAL RELATIONSHIPS 65 change, new, and possibly exciting and stimulating, patterns of mutual exploration may need to be learnt or re-learnt. Problems during intercourse Incontinence If you haven’t had one already, visit your doctor for an assessment of the problems you have with incontinence. Try and ensure that you have no urinary infections, which can make your bladder problems worse if left untreated. The following advice can help reduce the risk of ‘accidents’ during intercourse: • Reduce your intake of fluids for an hour or two beforehand. If the woman has problems with spasticity in her legs, then such a position is likely to reduce the possibility of annoying cramps and rigidity. Sometimes lubrication can be helped by direct stimulation of the genital area; or try to set up an environment which is relaxing and conducive to sexual thoughts and experiences. As far as additional lubrication is concerned, K-Y Jelly or a similar water-soluble substance can be very helpful. Substances like Vaseline are not recommended because they do not dissolve in water, and they are likely to leave residues which could give rise to infections. Spasticity Check with your doctor that the general control of your spasticity is as good as it can be. Try and keep your muscles as well toned as possible through regular exercises (see Chapter 8), and use appropriate drugs such as baclofen as necessary to give additional control. There are also certain positions for sexual activity that appear to make the muscular spasms less likely, although it is important that you explore other possibilities than those mentioned below, for you may find another position that suits you both very well. For a man who may have difficulty with spasms or rigidity in his legs, then sitting in an appropriate chair (without arms) would allow his partner to sit on his penis either facing him or with her back to him. For a woman, lying on her side may help, perhaps with a towel or other material between your legs for more comfort. Another possibility is to lie on your back towards the edge of your bed with the lower part of your legs hanging loosely off the bed. Fatigue As with other symptoms associated with MS, it is important to discuss this with your doctor who will assess the best means of managing it. Although there are one or two drugs which may help (for example amantadine or pemoline) and which – if prescribed for you – might be taken a few minutes before sexual activity, currently the best help is through various appropriate lifestyle changes. The use of various techniques to assist with fatigue is discussed in more detail in Chapter 7. Although this may not necessarily be the time when you feel that you should be having sex – such as in the morning, or during the day, rather than at a more conventional time – you may be less tired and enjoy it more. Rather than thinking of sexual intercourse as the major element, you could agree with your partner to engage in some other less energetic sexual activities – such as gentle stroking or foreplay – that you could participate in more frequently. As with so many other aspects of living with MS, it is a question of finding ways to adapt to the situation through experimentation. When you visit your doctor, particularly your GP, you may find that he or she puts virtually all your symptoms down to MS itself. Whilst statistically it is probably correct that most of your symptoms will be related to the MS, many will not. It is easy for both of you to say ‘Oh, that’s another symptom of MS’ and not realize that, like other people, you can have other everyday problems.

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