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Having a disability also places an elder at a higher risk for abuse (Youdin arthritis diet changes buy indocin with paypal, 2016) arthritis in fingers and elbows indocin 75 mg visa. Definitions of elder abuse typically recognize five types of abuse as shown in Table 9 arthritis in back x ray order genuine indocin. 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 and neglect occurring in a nursing home is estimated to be 25%-30% (Youdin, 2016). 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. Recent research indicated no differences among ethnic groups in abuse prevalence, however, cultural norms regarding what constitutes abuse differ based on ethnicity. 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). Children who are abusive tend to be dependent on their parents for financial, housing, and emotional support. Substance use, mental illness, and chronic unemployment increase dependency on parents, which can then increase the possibility of elder abuse. Prosecuting a family member who has financially abused a parent is very difficult. The victim may be reluctant to press charges and the court dockets are often very full resulting in long waits before a case is heard. According to Tanne, family members abandoning older family members with severe disabilities in emergency rooms is a growing problem as an estimated 100,000 are dumped each year (as cited in Berk, 2007). 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. Although people 65 years of age and older make up only 13% of the population, they account for almost 30% of all medications prescribed in the United States. Benzodiazepines, a type of tranquilizing drug, are the most commonly misused and abused prescription medications. Risk factors for psychoactive substance abuse in older adults include social isolation, which can lead to depression (Youdin, 2016). This can be caused by the death of a spouse/partner, family members and/or friends, retirement, moving, and reduced activity levels. Additionally, medical conditions, chronic pain, anxiety, and stress can all lead to the abuse of substances. For example, compared to adolescents and younger adults, older adults are not looking to get high, but rather become dependent by accident. Additionally, stereotypes of older adults, which include memory deficits, confusion, depression, agitation, motor problems, and hostility, can result in a diagnosis of cognitive impairment instead 423 of a substance use disorder. Further, a diagnosis of a substance use disorder involves impairment in work, school, or home obligations, and because older adults are not typically working, in school or caring for children, these impairments would not be exhibited. Siriwardena, Qureshi, Gibson, Collier, and Lathamn (2006) found that family physicians prescribe benzodiazepines and opioids to older adults to deal with psychosocial and pain problems rather than prescribe alternatives to medication such as therapy. Those in late adulthood are also more sensitive to the effects of alcohol than those younger because of Source an age-related decrease in the ratio between lean body mass and fat (Erber & Szuchman, 2015).


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Children vary considerably in the degree of airflow limitation observed before they complain of dyspnea or use their reliever therapy arthritis low back pain buy generic indocin from india, and marked reduction in lung function is often seen before it is recognized by the parents lifespan arthritis dogs 50mg indocin. Risk factors for poor asthma outcomes Assess risk factors at diagnosis and periodically arthritis physical therapy generic 50 mg indocin amex, particularly for patients experiencing exacerbations. Poor symptom control and exacerbation risk should not be simply combined numerically, as they may have different causes and may need different treatment strategies. Level of activity What sports/hobbies/interests does the child have, at school and in their spare time Persistent 98 bronchodilator reversibility is a risk factor for exacerbations, even if the child has few symptoms. Treatment factors Inhaler technique Ask the child to show how they use their inhaler. Goals/concerns Does the child or their parent/carer have any concerns about their asthma. Other investigations (if needed) 2-week diary If no clear assessment can be made based on the above questions, ask the child or parent/carer to keep a daily diary of asthma symptoms, reliever use and peak expiratory flow (best of three) for 2 weeks (Appendix Chapter 4). Exercise challenge Provides information about airway hyperresponsiveness and fitness (Box 1-2, p. Only (laboratory) undertake a challenge if it is otherwise difficult to assess asthma control. Asthma symptom control and exacerbation risk should not be simply combined numerically, as poor control of symptoms and of exacerbations may have different causes and may need different treatment approaches. Risk factors for exacerbations 60-62 Poor asthma symptom control itself substantially increases the risk of exacerbations. These risk factors (Box 2-2B) include a history of 1 exacerbations in the previous year, poor 115 adherence, incorrect inhaler technique, chronic sinusitis and smoking, all of which can be assessed in primary care. People with asthma may have an accelerated decline in lung function and develop airflow limitation that is not fully reversible. Children with persistent asthma may have reduced growth in lung function, and some 117 are at risk of accelerated decline in lung function in early adult life. Risk factors for medication side-effects Choices with any medication are based on the balance of benefit and risk. The risk of side-effects increases with higher doses of medications, but these are needed in few patients. In some asthma control tools, 69,120 lung function is numerically averaged or added with symptoms, but if the tool includes several symptom items, 121 these can outweigh clinically important differences in lung function. For example, in most adult patients, lung function should be recorded at least every 1-2 years, but more frequently in higher risk patients including those with exacerbations and 2. Lung function should also be recorded more frequently in children based on asthma severity and clinical course (Evidence D). Once the diagnosis of asthma has been confirmed, it is not generally necessary to ask patients to withhold their regular 14 or as-needed medications before visits, but preferably the same conditions should apply at each visit. In children, spirometry cannot be reliably obtained until age 5 years or more, and it is less useful than in adults. Many children with uncontrolled asthma have normal lung function between flare-ups (exacerbations).

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Treatment con weakening of the globe in this region such as perforating sists of systemic antituberculous drugs with local arthritis in neck and hands order indocin overnight, lubricat injuries of the peripheral cornea arthritis relief in toes buy indocin no prescription, marginal corneal ulcer arthritis treatment rheumatoid buy indocin australia, ing eye drops. Suppurative Bacterial Infections Virulent organisms such as Pseudomonas causing an endo phthalmitis may spread to infect the sclera and episcleral tissue, leading to a panophthalmitis including a scleritis. Extension of such infection is clinically diagnosed by the development of painful eye movements due to infamma tion involving the muscle sheaths at the point where they are inserted onto the sclera. Treatment consists of high doses of intravenous broad-spectrum antibiotics and a care ful watch for further spread into the orbit and subsequent cavernous sinus thrombosis. Surgical measures include in travitreal injection of antibiotics, vitrectomy and, fnally, evisceration of the globe if the eye has no light perception and all measures to contain the infection fail. Here the ciliary body is incarcer ated in the region of scleral ectasia and has a bluish colour with a lobulated surface. Developmental glaucoma, end stage primary or secondary glaucoma, scleritis and trauma to the ciliary region of the eye are some of the conditions that lead to a ciliary staphyloma. Equatorial Staphyloma this occurs at the equatorial region of the eye with incarceration of the choroid. The equatorial region is approximately 14 mm behind the limbus and is inher involve the episclera more commonly than the sclera and ently relatively weak owing to the passage of the venae are usually congenital but may increase in size and promi vorticosae. Posterior Staphyloma They are most commonly located at the inferotemporal this affects the posterior pole of the eye and is lined by limbus, are often associated with Goldenhar syndrome the choroid. The ectatic portion is not visible externally excessive astigmatism, encroach on the pupillary area but can be detected by fundoscopy and B-scan ultrasonog or are cosmetically disfiguring. Indirect ophthalmoscopy shows a posterior outward Another variety is episcleral osseous choristomas that curvature of the globe detected as a crescentic shadow in occur in the superotemporal quadrant, are adherent to the the macular region. The retinal vessels are seen to change underlying sclera and are composed of mature compact direction, dipping down into the region. Primary tumours of the sclera are rare, but the sclera can be secondarily involved by tumours, such as retinoblastoma Treatment and malignant melanoma, which extend from within the Infammatory diseases which affect the outer coats of the eyeball. Tumours originating from structures outside the eye such as scleritis, corneal ulcer and keratomalacia from eyeball (such as squamous cell carcinoma and malignant vitamin A defciency or rheumatoid arthritis with preven melanoma from the conjunctiva or lids) and malignant tion of secondary glaucoma should be promptly treated to lacrimal gland tumours may also invade the sclera. Local excision and cally, a thorough local and systemic examination should be repair with a corneal and scleral patch graft can be per done for preauricular and cervical lymph nodes. Large, unsightly blind eyes can be treated with lacrimal gland tumours are usually treated with exentera staphylectomy and keratoplasty, or enucleated and replaced tion of the orbit. A much more pronounced blue coloration is these are benign tumour-like lesions owing to the presence sometimes seen in several members of the same family of normal tissue in an abnormal location. Chapter | 16 Diseases of the Sclera 231 this disease is known as osteogenesis imperfecta and is Summary characterized by frequent bone fractures (fragilitas the sclera is the opaque white outer protective covering of ossium), blue sclera and deafness. Local ocular diseases such as keratoconus syndrome, herpes zoster ophthalmicus, sarcoidosis, gout and gastroenteropathies. Scleritis is classified as posterior and keratoglobus can also have blue sclera as an additional and anterior and the latter may be necrotizing (with or with feature. The this feature is particularly well exemplifed in infam iris is responsible for metabolism of the anterior segment, mation of the iris and ciliary body; iritis never occurs with by diffusion of metabolites through the aqueous. Its vascularity unfortu classifcation of uveitis is based on the anatomical location nately allows the frequent involvement of the uveal tract in and is shown in Table 17. There is a considerable fare and cells in the Uveitis Uveitis Posterior Uveitis Panuveitis anterior chamber. In some cases the aetiology is obvious and several Based on Aetiology infections have distinguishing clinical features; but in most cases with a non-descript clinical picture, a defni Idiopathic, infective, immune-related, neoplastic, traumatic tive diagnosis is diffcult. It seems probable that most of *The International Uveitis Study Group has recommended that the clas these are not due to direct infection but are immunogenic sifcation based on anatomical location be followed. International Uveitis Study Group recommendations for the evaluation of intraocular infammatory disease. The following classifcation may prove useful: clusters of infammatory cells on the pupillary border 1.


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