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From a therapeutic standpoint order forzest 20mg without a prescription erectile dysfunction blue pill, this beneficial buy forzest 20 mg with visa natural erectile dysfunction pills reviews, life-prolonging effects of caloric restriction suggests that efforts to disengage reserves may result occur is precisely that the decreased availability of calo- 34 G. Altered presentation of illness may be Continence another manifestation of homeostenosis. With age, Orientation the precipices may approach homeostasis at dif- fering rates so that modest challenges produce clinically evident events, in this case, new onset of incontinence, and in others, disorientation or Physiologic Reserves confusion. Available Physiologic Reserves Already In Use Increasing Age ries is a low-intensity stress. It is likely harmless stresses, such as caloric restriction or radiation, that most age-related physiologic changes are not linear may be good for us; larger stresses may be harmful. Invoking compensatory mechanisms has the additional In summary, there is an apparent loss of physiologic effect of constraining the complexity of many variables. One should appreciate that striction of heart rate may be due to decreased parasym- this frailty is, in part, present because the older person pathetic tone and possible activation of the sympathetic is continually expending reserves to compensate for nervous system while at rest. The concept of threshold is also useful in understand- Bibliography ing the altered presentations of disease in the elderly. The APACHE III approaches homeostasis may determine whether that prognostic system. New York: Oxford Press; variety of illness in the elderly, a marker of the uneasy 1995. The precarious balance is clearly evident but is not limited to the cholinergic pathways. While it seems References strange that a given older person may have the same presentation (confusion) for a urinary tract infection, gas- 1. Problems of Ageing:Biological and Medical trointestinal bleeding, and a myocardial infarction, this Aspects, 2nd Ed. Estimation of may be exhausted so the distance from homeostasis to severity of illness with APACHE II: age-related implica- tions in cardiac arrest outcomes. Age-dependent changes in For example, the loss in muscle mass approaches 40% as B lymphocyte development in man and mouse. Seeman TE, Singer BH, Rowe JW, Horwitz RI, McEwen tile protein genes in response to pressure overload in the BS. Loss of "complexity" and oviral gene transfer of sarcoplasmic reticulum Ca(2+)- aging. Jay Olshansky The demography of aging involves the investigation of of scientific inquiry in the demographic and actuarial trends in, and characteristics of, fertility, mortality, and sciences. Of particular interest at this time is how high life migration and how these components of population expectancy at birth and at older ages can increase, and change influence, and are influenced by, the physical and how changes in individual aging influence, and are influ- social environments in which people live. It is a relatively enced by, the distribution of diseases and the health status new area of scientific inquiry, principally because aging of the population. Research on the life span potential because they are often used inter- demography of aging is conducted not only by demogra- changeably. As previously noted, life expectancy is a phers and actuaries but also by scientists representing a summary measure of the expected duration of life calcu- range of disciplines spanning the social and biological lated from observed death rates for a population. A central distinction exists between population aging Maximum life span potential (MLSP) has been used in and individual aging. Population aging refers to changes the biologic literature to define the age of the longest- in the age structure of a population or, more specifically, lived member of a species. The underlying premise an increase in the relative proportion of older persons to behind the concept of average life span is the presump- the total population alive at a single moment in time. However, because it is not possible ures include the median age, aged dependency ratio to know the maximum duration of life for any individual, (ratio of the population aged 65+ to those aged 0–64), and by extension it is not possible to know with certainty the the percentage of the total population aged 65 and older. Individual aging refers to the length of life for individ- As individuals in a cohort pass through life from child- uals or an average length of life for population subgroups hood to older ages, the observed probabilities of death or species. Individual aging is measured in chronological take on a characteristic "bathtub" shape (Fig. A summary measure is high mortality at birth, a rapid decline in the risk of of individual aging for a population is most often repre- death to its lowest point at sexual maturity, and an expo- sented by its expectation of life or life expectancy.

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This process is SENSATIONS AND PAIN 77 still expensive and is what doctors would call an ‘aggressive’ treatment for spasticity cheap forzest 20 mg online impotence under hindu marriage act, although it does allow a much finer and more detailed management of the flow of the drug best 20 mg forzest erectile dysfunction treatment side effects. Pain from other MS symptoms Apart from the types of pain that we have already discussed, there are other sorts that can be associated with MS symptoms, such as that from: • urinary retention or infection; • pressure sores (later on in the disease), if not treated as early as they should be; • eye conditions, especially ‘optic neuritis’ (see Chapter 11), when the optic nerve swells. In general, if the source of the problem is treated, the pain will disappear, although the management of the neurological causes of pain is more difficult than management of pain from other sources. This was, in part, because MS was considered then to produce mainly – often only – physical symptoms directly (and obviously) related to the damage occurring in the nervous system. Other symptoms seemed – at the time – to be very difficult to relate to nervous system damage in this way, so fatigue, cognitive problems and, to a substantial degree, depression, were often seen as not related to the disease process itself. There has been a very substantial change over the last decade and now much greater professional attention is being paid to people who have these symptoms. Fatigue Fatigue or tiredness is one of the most debilitating symptoms of MS and one that worries many people. Up to 90% of people with MS experience overwhelming tiredness at least some of the time. Fatigue in MS is often associated with: • heat (or being hot) (see Chapter 6); • activity – using motor skills, or being mobile; • sleep disturbances; • particular mood states (such as depression – see later section); • some cognitive problems that may occur in MS (see later section). Some argue that the best way to manage fatigue is to consider it as a symptom arising from several different sources and thus requiring different techniques to manage it. We could distinguish what we might call: 78 FATIGUE, COGNITIVE PROBLEMS AND DEPRESSION 79 • normal fatigue resulting from everyday exertion etc. Management of fatigue Although it is important that your symptom is recognized as genuine by medical and other healthcare staff (which has been a problem in the past), you will probably have to manage many of the day-to-day aspects of fatigue yourself, for drug therapies (see below) are often only partially successful. Self-help • Identify activities that appear to precede the fatigue and avoid them whenever possible. However, ‘fatigue management strategy’ tends to be a complicated business, taking a lot of energy in itself to think through all the possibilities that might occur. Professional support Specific and carefully planned exercise programmes have been found to reduce feelings of fatigue, but only temporarily. Behavioural therapy can help to alleviate other psychological symptoms that might exacerbate the fatigue, but these non-drug professional approaches have not been successful so far for most people with MS over the medium and longer term. Drugs Some drugs have helped, the two most well known being magnesium pemoline (Cylert), which stimulates the CNS, and amantadine hydro- chloride (amantadine; Symmetrel), an antiviral agent. It has also been suggested that fluoxetine (Prozac) may help in managing MS fatigue. Some antidepressants, particularly those that have a low sedative effect, may help the tiredness even if you are not clinically depressed. Beta-interferon drugs may have some effect on fatigue if, indeed, they help the immune system. Fatigue may be one thing that affects cognition, although it is still not yet clear exactly how this happens. Some people with MS feel fatigued almost simultaneously as they notice problems with their memory or concentration (see below). Self-rated fatigue is linked with certain forms of memory problems, as well as reading comprehension. However, if fatigue is treated with a prescribed drug, it does not appear to influence cognition. In order to try and understand this process, fatigue in people with MS has been compared to that in people with chronic fatigue syndrome (CFS), but it is not clear whether the two are the same; indeed, when fatigue severity is the same between the two groups, people with MS showed more widespread cognitive problems. Cognitive problems Research has identified two broad areas where MS seems to be involved or has effects that are not so much to do with the mind in general, but with what are more neatly and technically considered as cognitive issues on the one hand, and attitudinal and emotional issues on the other. FATIGUE, COGNITIVE PROBLEMS AND DEPRESSION 81 Cognitive issues are those that concern our thinking, memory and other skills, which we use to form and understand language; how we learn and remember things; how we process information; how we plan and carry out tasks; how we recognize objects, and how we calculate. It was thought until recently that memory loss and some other cognitive problems were a rare occurrence. However, more recent research has suggested that a range of cognitive problems varying widely in type and severity may be present in many people with MS. Of course people with MS, just like anyone else of a similar age and sex, can suffer mental illness or dementia but, clinically, people with MS do appear to have more depression (see next section) compared to other people, and perhaps have what might be called mood swings rather more often.

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