By A. Pranck. Westminster College, New Wilmington Pennsylvania.

The principles of gardening are obviously just the same whether someone has MS or not discount 20 mg levitra amex impotence prostate, but the tools and methods of working may need consideration trusted levitra 20mg erectile dysfunction causes divorce. It is usually unnecessary to buy a lot of new tools – first consider what tasks you need to carry out, assess your usage of the tools you already have, and consider any adaptations that could be made to make them work to your benefit (such as adding longer handles). LEISURE, SPORT AND HOLIDAYS 177 There are many books on plants that require less maintenance, on making gardening easier, and on accessible garden design. Another organization that promotes horticulture for people with disabilities is Horticulture for All. The Gardens for Disabled Trust raises money to help those who are disabled take an active interest in gardening, and gives advice to those who wish to adapt their gardens (see Appendix 1). Day trips out Managers of theatres, cinemas or concert halls have generally been slow to understand and provide for the needs of people with disabilities. However, the situation is changing rapidly and people are more aware of the importance of disabled customers; negative publicity about access and other problems has helped push this along. Whilst many venues are more prepared for people with disabilities, it is a still a good idea to contact the management before you go, to explain your situation and what you will need. Some seats, or positions for wheelchairs, may be better than others, and notifying the venue in advance should ensure that your needs are better catered for. You may also find that certain performances (for example, matinées) are less crowded than others. Provision for people with disabilities at cinemas has improved enormously in the last few years. There are still some problems for disabled cinema-goers, however, owing to the number of older 1930’s cinemas which have been converted into several screens. The ‘main’ screen is often in the circle of the old cinema and accessed only by several steps. However, a good number of ground-floor screens have wheelchair spaces with flat access, or via a few steps, possibly through a side exit. An increasing number of cinemas are using automatic computerized booking systems via the phone, where you can pay for your ticket by credit card and simply collect it on arrival. Some have an enquiry method for disabled patrons that puts you through to the management to make necessary arrangements. The larger cinemas have facilities available such as seats that provide additional leg room. To find out about the facilities for disabled patrons, contact the cinema showing your choice of film direct and ask for details. As far as theatres go, many of the larger venues now have adapted toilets and facilities. In some theatres, it may be necessary for the occupant of a wheelchair to be able to transfer into an aisle seat, with the wheelchair stowed elsewhere. In other theatres, seats can be 178 MANAGING YOUR MULTIPLE SCLEROSIS removed with advance notice to make way for a wheelchair, while in others there are specific seat-less areas where a wheelchair user will be asked to sit. If you need assistance or a specific seat as an ambulant or visually impaired disabled person, or indeed for any disability, then do ask in advance. Usually the easiest access to seats will be on the same level as any wheelchair spaces, and/or you could ask for a seat at the end of a row if this is helpful.

Comorbidities can also reduce the effect Patient–Treatment Interactions of treatment by producing a bad outcome through mechanisms not affected by the treatment buy 20mg levitra amex erectile dysfunction 30 years old. For example order levitra 10mg otc erectile dysfunction treatment dallas, Older adults experience a variety of age-related changes cataract removal in older adults may not improve vision in pharmacokinetics and pharmacodynamics (see substantially if the patient has underlying macular degen- Chapter 7), resulting in a need to modify drug dosing eration or diabetic retinopathy, which is less likely to regimens from those used in a study. With aging, thermoregulation and exclusion criteria and the relatively small numbers becomes more difficult, the immune system is not as of subjects tested. For example, treatment of atrial responsive, and the maximal heart rate is not as high (see fibrillation with rate control agents such as beta-blockers Chapter 3). This loss of physiologic flexibility and plas- is more likely to result in symptomatic bradycardia 38 ticity means that any intervention might have a more requiring a pacemaker in older adults because it is deranging influence than expected. For example, people more often a manifestation of sick sinus syndrome in with structurally abnormal brains due to either dementia this population. Treatment responsiveness may also vary or stroke are more likely to develop delirium from a with age, as demonstrated by the decreased immune small dose of an anticholinergic drug than age-matched response and efficacy of the influenza vaccine in nursing 31,32 39 people without these conditions. Has the treatment been shown to be superior • Head-to-head trial against current standard treatment showing to other accepted treatments in its effect on Better efficacy outcomes that matter to patients? What is the patient’s likelihood of a bad • Estimation of the patient’s life expectancy22,25–28 outcome if not treated? What is the effectiveness of the treatment Hierarchy of evidence for older adults? Is there • Those identified in the studies (how large were the studies, who was excluded? Geriatric Dosage Handbook: Including Monitoring, Clinical Recommendations, and OBRA Guidelines 2002–2003, 6th ed. How important does the patient view Patient discussion; family and/or caregivers if patient unable to discuss avoiding the disorder’s bad outcome compared to the risk of treatment? An example of this is thrombolysis for acute types of adverse events, such as delirium or falls, which myocardial infarction (MI), where RCTs suggest equal commonly occur in older but not younger adults. This benefit up to the age of 75 but provide no data on persons concern is particularly true for chronically ill or frail older 75 or older. Observational studies concur that 30-day or adults, who may have compromised end organs that hospital survival improves up to age 75; however, these respond differently or in an exaggerated way to "usual" studies found that acute MI patients over this age treated drug levels. Evidence-Based Geriatrics 11 Diagnosis Studies—Diagnostic Tests, the same test appropriate as a screening test for older adults. Differential Diagnosis, Screening, and Differences in the differential diagnosis can affect Clinical Prediction Rules: Applying diagnostic and screening test characteristics such as sen- Results to Older Adults sitivity, likelihood ratio, the accuracy of a clinical predic- tion rule, or the pretest probability of a diagnosis. For Prevalence and competing diagnostic possibilities may example, a clinical prediction rule derived and validated differ between geriatric patients and the original study in middle-aged populations (with 20%–30% ≥60 years population. In a younger population in which a disease old), found that rales, fever, tachycardia, decreased has low prevalence, a test may have a low positive pre- breath sounds, and the absence of asthma were inde- 43 dictive value and not be useful for screening; the positive pendent predictors of pulmonary infiltrates; confusion predictive value, however, can increase in an older pop- and level of consciousness were not. In a similar deriva- ulation where the disease has greater prevalence, making tion study conducted in nursing home residents, however, Table 1. YEA R=POEMs Evidence that Matters) MIAH (Merck Institute on Aging and Health) http://www. Users’ Guides to the Medical Literature: A Manual for Evidence- Guyatt G, Rennie D, Evidence-Based Medicine Working Group, Based Clinical Practice American Medical Association. Users’ guides to the medical alertness were independent predictors, along with all the literature. Randomized trial of acute myocardial infarction may differ for middle-aged estrogen plus progestin for secondary prevention of cor- compared to older adults because of the difference in 45–49 onary heart disease in postmenopausal women.

Prevalence of MI increases with age and is higher in Cardiac Rehabilitation Overview 3 men than in women; estimates show that there are about 838000 men and 394 000 women living in the UK buy discount levitra 20 mg online erectile dysfunction joke, who have had an MI (BHF safe levitra 10mg impotence at 19, 2004). The preva- lence of MI is disproportionately higher in Scotland: 43 per 1000 men, com- pared with 39 in Wales and 34 in England (Wanless, 2001; SIGN, 2002). In addition, there is an increasing number of MI and CHD subjects with chronic heart failure (HF), approximately 662000 in the UK (BHF, 2004). In addition, the BHF (BHF, 2004) estimate 178000 new cases of angina in all men living in the UK and about 159500 in women, totalling 337500. As can be seen from the trends in the increase in morbidity, there is more need for structured secondary prevention. As CR is recognised as the prime vehicle for delivery of secondary prevention (SIGN, 2002), there will be a corresponding increase in comprehensive, patient-centred CR. PATIENT GROUPS IN CARDIAC REHABILITATION Traditionally post-MI and revascularisation patients were referred for CR (SIGN, 2002). In addition, definition of MI has changed with the introduction of tro- ponin blood tests. Acute coronary syndromes Acute coronary syndromes include unstable angina, non-ST-segment eleva- tion MI (NSTE MI) and ST-segment elevation MI (STE MI) (Santiago and Tadros, 2002). It is acknowledged that with revised definition of myocardial infarction, diagnosed by cardiac troponin estimation, there will be a resultant increase in the reporting of myocardial infarction, with increased workloads for the services involved (Dalal, et al. Post-revascularisation Comprehensive CR is recommended for patients who have undergone revas- cularisation that includes coronary artery bypass grafting and percutaneous intervention (angioplasty and stenting) (SIGN, 2002). There can be a miscon- ception by patients that the revascularisation procedure has eradicated the underlying CHD process. It is important that this group of patients continues to address their CHD risk factors. Exercise-based CR has considerable impact on physiological and psychosocial cardiac risk factors post-revascularisation (Ross, et al. One of the first studies to investigate exercise in angina patients was by Todd, et al. They found that habitual exercise had an anti-anginal effect, with the subjects experiencing up to 34% reduction in ischaemia. The authors hypothesised that exercise training enhanced myocardial collateral function. A review of literature by the Scottish Intercollegiate Guide- line Network (SIGN, 2002) examining CR and patients with stable angina found that this patient group should be considered for CR if they have limit- ing symptoms. Angina patients appropriate for exercise-based CR may be those who are not suitable for revascularisation and/or have an anginal thresh- old of 4 METs or more (ACSM, 2000). The aim of exercise is to raise the ischaemic threshold and thus allow patients to exercise more before their angina occurs. In addition, efficent use of anti-anginal medication can help this group to carry out more exercise (Durstine and Moore, 2003). Chronic heart failure There are increasing numbers of patients presenting with heart failure and being referred to CR. Because of the negative effects on quality of life for these patients due to dyspnoea on exertion and fatigue and the generally poor prognosis, the interest in optimising the management of this patient group is increasing. The review of controlled trials of physical training in chronic heart failure by the European Heart Failure Group (1998) concluded that there are positive effects of physical rehabilitation in stable heart failure patients on function and quality of life. These findings are confirmed, with a collaborative meta-analysis, by ExTraMATCH (2004), providing evidence of an overall reduction in mortality for HF groups.

This institu- awake buy levitra 10 mg on line erectile dysfunction effexor xr, limited choice of food cheap 10 mg levitra impotence caused by anxiety, and a general sense of tion can be said to have a mixed heritage, descended from being driven by a therapeutic philosophy does not jibe the almshouse on one side and the hospital on the other. Changes in the sources of payment for nursing home residents age 65 and older from 1985 to 1995. The proportion of coverage from Medicare and Medicaid increased while that from private pay declined. Use of Nursing Home by the Elderly: Preliminary Data from the 1985 National Nursing Home Survey. Hyattsville, MD: Public Health Service; 1987, Table 9; and Georgetown University Institute for Health Care Research and Policy, 1995. For a long time, even though the supply of nursing Physically frail Home care Assisted living homes varied greatly across the country, the demand for Day care nursing home care was perceived to be so strong that Cognitively impaired Home care utilization would rise to meet the supply. For the first time, nursing homes are now facing the Outpatient rehabilitation units potential of empty beds. Nursing home, are increasingly being used for post- Total vegetative state acute care, where the expectation is for a finite stay and discharge to the community. Nursing homes are facing new competition from tions, inherent in the notion of a nursing home, may assisted living. In fact, one might attracted to the idea of being able to live in more com- argue that the very term "nursing home" is a misnomer, modious settings, often at lower costs. People are entering nursing homes later in their about 90 min/day, primarily from nursing aides) nor a medical careers and thus dying sooner, lowering the very homelike atmosphere. The plight of the nursing home has been made more serious by asking it to play multiple roles in the lives of Nursing homes entering the postacute care market very different types of clients. In many instances the may find themselves disadvantaged and unable to pro- nursing home is not the only institution serving this vide the services they wish. Summary less inclined to make comparable nursing home rounds, numbers about the average use of nursing home are mis- certainly not as frequently, nor is Medicare as likely to leading. Ironically, a patient may be covered homes is much higher among those aged 85 and above. Nursing home residents among persons 65 years of age and over by age, sex, and race, 1997. The pro- portion of older persons in nursing home homes increases dramatically with older ages. Concerned doctors may natives that were both more effective and less costly has have to spend considerable effort arguing why they proven frustrating, in part because long-term care is, at should be paid for their work. Some homes have physical therapists on staff, and others The search for alternatives faced many obstacles. Although nurse practitioners have been shown designed to decrease nursing home use could not show to improve primary care in nursing homes for some 3,4 an impressive difference against a low rate in the control time, they have not been widely utilized. In and nurse practitioners have been effectively used to 5,6 one sense, the nursing home is a good buy, as it includes follow nursing home residents. Purchasing room and programs directed specifically at nursing home residents board in the community is an added expense, but one have been created under the belief that aggressive may get much more than in a nursing home, where rooms primary care will prove cost-effective by reducing 7 are not private and little choice of food is offered. On the other hand, much of the care in the community relies on informal The nursing home finds itself squeezed at both ends. Shadow pricing this care the one hand, it must compete with rehabilitation units implies (1) that the care would be given in the same and hospitals that are turning their new excess capacity amount if it were paid for and (2) that the costs would be into long-stay or subacute care units. At the other end, it equivalent to the going wage for an appropriate level of must compete for chronic care business with assisted caregiver. The evidence of benefit may extend beyond reduced All other modalities were considered in terms of alter- hospitalizations or nursing home admissions.