MANUAL on Geriatric Health Care

Comments

Transcription

MANUAL on Geriatric Health Care
MANUAL
on
Geriatric Health Care
Focusing on strength of Ayurveda
Faculty of Ayurveda
Institute of Medical Sciences
Banaras Hindu University
Varanasi
www.imsbhu.nic.in
Department of AYUSH
Ministry of Health & Family Welfare
Government of India
New Delhi
www.indianmedicine.nic.in
1
© 2009
Department of AYUSH, Ministry of Health and Family
Welfare, Govt. of India, New Delhi, India
And
Faculty of Ayurveda, Banaras Hindu University, Varanasi,
India
2
FOREWORD
BY
SECRETARY
Department of AYUSH
Ministry of Health & Family Welfare
Govt. of India
New Delhi
3
PREFACE
ckY;ao`f)'NfoesZ/kk Rod~n`f"V'kqØfoØekSA
cqf)% desZfUæ;a psrksftfora n'krks gzlsr~AA
'kk0l0 II. 6. 20
The recent years have shown significant increase in the number of
elderly in the population world over due to the declining birth rate and reduced
rate of death in elderly age groups. The developed countries like US, Europe
and Japan have registered high rate of population-aging for last few decades
with significant negative impact on socio-economic and health-care planning of
the present day society. The developing counties like China and India have
now started exhibiting similar trends. Most demographers all over the world
believe that population-aging is going to remain the most significant
demographic trend of the 21st century, which will influence a wide range of
public issues of our times warranting newer strategies of socioeconomic and
health care management.
This trend of population aging specially demands development of newer
health care strategies for the growing section of the elderly population. It can
not be over emphasized that the coming decades will encounter larger number
of victims of the age related diseases like degenerative neuropathies, locomotor
disabilities, geriatric urinary disorders, cardiovascular diseases, diabetes
mellitus and cancers. Hence there is a need of launching geriatric health care
services at all levels, both in rural and urban sectors.
It is understood that Ayurveda has strength in this aspect of health care.
Ayurveda being essentially the science of life and longevity, puts special
emphasis on geriatric care and devotes one of its eight specialty branches,
named Rasayana Tantra entirely to longevity specially its nutritional,
immunological and neuro- protective aspects. Considering the obvious strength
of Ayurveda in this area and its safe, pronature, cost- effective potential, the
Govt. of India has recently launched a campaign to promote integrative
geriatric healthcare through Ayurveda at national level. This campaign was
4
inaugurated on Jan.23, 2008 by Union State Health Minister in New Delhi,
before a gathering of the public and professionals from all over the country.
The Govt. has also set up a task force for follow up action and the campaign is
already in action.
Geriatrics is still not a very well organized discipline in India, hence it
was rightly thought to organize short term training and reorientation programs
for practitioners firstly at institutional level and later also at district and PHC
levels. The Department of AYUSH appointed a working group under the
chairmanship of the undersigned to develop a training module and a manual on
geriatric health care focusing on Ayurveda, wide its letter F.no.v27020/43/2007-Ay Dated April, 4, 2008.
After several rounds of meetings and intensive discussions the working
group has developed a 22-point training module for this purpose, which is
already published and is being used in ongoing training program. The module
covers a comprehensive range of topics, both promotive and curative to expose
the doctors to the basics of geriatric health care and management of diseases of
the old age. Making this program participation-friendly it was decided to limit
this training / orientation program to six intensive days in two phases with a
total of 72 hours. The specific topics identified essential for the purpose of
training have been casted in a brief bi-phasic module shape which have been
now published for use as a guideline for national training program. In order to
facilitate the training program, it was envisaged to publish an extended manual
on the subject, which has now been compiled by the same working group who
drafted the module. The draft manual was submitted to a set of experts across
the country for review and comments. The suggestions received from the
reviewers have been incorporated in the final draft wherever considered
necessary by the working group.
The Department of AYUSH has identified certain regional geriatric
training centers in the country preferably in good Ayurvedic colleges specially
where facilities and expertise of modern medicine are also available, as their
own constituent component or as available for ready collaboration. It can not
5
be over emphasized that this training program will have to be conducted on
integrated pattern with emphasis on practical work without undue theoretical
and conceptual learning-load on the trainees.
It is hoped that this manual will prove to be an useful aid for the trainees
opting for training in Geriatric health care. The undersigned acknowledges the
excellent cooperation and help of the Dept. of AYUSH, Govt. of India and
Advisor, Dr.S K Sharma on one hand and of the members of the working group
on
the
other.
The
valuable
help
received
from
Dr.A.C.Kar,
Dr.
K.H.H.V.S.S.Narasimha Murthy and Dr.J.S.Tripathi in editorial work is
specially acknowledged.
31.07. 2008
Prof. Ram Harsh Singh
Professor Emeritus, Ayurveda
Banaras Hindu University
Chairman, Working Group
6
THE WORKING
GROUP
Prof. R.H.Singh
Dr. S.K.Sharma
Chairman
Coordinator
Prof. P.V.Tewari
Prof. G.P.Dubey
Prof.I.S.Gambhir
Prof. V.K.Joshi
Prof. M. Sahu
Dr.A.C. Kar
Dr.J.S.Tripathi
Dr. A.K. Tripathi
Dr.O.P.Singh
Dr. K. Narasimha Murthy
Dr.Ajai Pandey
Dr.A.K.Dwivedi
Dr.Shrikant
Member
Member
Member
Member
Member
Member
Member
Member
Member
Member
Member
Member
Member
7
CONTRIBUTORS TO THIS VOLUME
Sl. Name
No.
1.
Prof. Ram
Singh
Chapters
contributed
1,4,8,14
2.
22
3.
4.
5.
Designation, affiliation
and E mail
Harsh Professor Emeritus, Dept. of
Kayachikitsa, Institute of Medical
sciences,
Banaras
Hindu
University, Varanasi.
Formerly
Professor-Head
Kayachikitsa and Dean, Faculty
of Ayurveda, BHU and Vice
Chancellor, Rajasthan Ayurveda
University, Jodhpur
[email protected]
Prof. P V Tewari
Additional
Medical
Superintendent, Mata Anand
Mayee Hospital, Varanasi.
Formerly Professor-Head Prasuti
Tantra and Dean, Faculty of
Ayurveda,
Banaras
Hindu
University, Varanasi.
[email protected]
Prof. G. P.Dubey
Formerly Professor-Head Basic
Principles and Dean, Faculty of
Ayurveda,
Banaras
Hindu
University, Varanasi.
Nandigram, Lanka, Varanasi-5.
[email protected]
Prof. I S Gambhir
Professor,
Department
of
Medicine, Institute of Medical
Sciences,
Banaras
Hindu
University, Varanasi.
[email protected]
Prof. V. K. Joshi
Dean, Faculty of Ayurveda,
Banaras
Hindu
University,
Varanasi.
19
2
3,15
[email protected]
6.
Prof. M. Sahu
Professor, Department of Shalya 17,18,19,20
Tantra, Faculty of Ayurveda,
Banaras
Hindu
University,
Varanasi.
[email protected]
8
7.
Dr.J. S.Tripathi
Reader, Section of Manasa Roga, 6,10,22
Department of Kayachikitsa,
Faculty of Ayurveda, Banaras
Hindu University, Varanasi.
[email protected]
8.
9.
10.
Dr.B.Mukhopadhyay Reader, Department of Shalakya 21
Tantra, Faculty of Ayurveda,
Banaras
Hindu
University,
Varanasi.
[email protected]
Dr.A.C.Kar
Reader and Head Department of 16
Vikriti Vigyan, Faculty of
Ayurveda,
Banaras
Hindu
University, Varanasi.
Formerly, Assistant Director,
CCRAS, New Delhi
[email protected]
Dr.A.K.tripathi
Dy. Medical Superintendent 11
(Indian Medicine), S.S.Hospital,
Banaras
Hindu
University,
Varanasi.
[email protected]
11.
Dr.O.P.Singh
12.
Dr.K.H.H.V.S.S.N.
Murthy
13.
Dr.Ajai Pandey
Sr. Lecturer, Department of 5
Kayachikitsa,
Faculty
of
Ayurveda,
Banaras
Hindu
University, Varanasi.
[email protected]
Lecturer, Section of Manasa 7
Roga,
Department
of
Kayachikitsa,
Faculty
of
Ayurveda,
Banaras
Hindu
University, Varanasi.
[email protected]
Lecturer,
Department
of 8,12,13,14
Kayachikitsa,
Faculty
of
Ayurveda,
Banaras
Hindu
University, Varanasi.
[email protected]
14.
Dr.A.K.Dwivedi
Medical Officer (Radiodiagnosis), 17,18,19,20
(Co-author
with Indian
Medicine
Wing,
Prof. M. Sahu)
S.S.Hospital, Banaras Hindu
University, Varanasi.
[email protected]
9
CONTENTS
Chapter
Subject
Page No.
Part – I Perspectives, Promotive and Preventive Care
1.
Basic tenets of Ayurveda and Ayurvedic
geriatrics — R H Singh
13
2.
Current issues in geriatric health care —
I S Gambhir
26
3.
JarÁvasthÁ poÒaÆa (Geriatric Nutrition) —
V K Joshi
37
4.
RasÁyana
R H Singh
5.
Pancakarma
O P Singh
rejuvenation
—
45
health
—
57
6.
Mental health care in the elderly (MÁnasa
svÁsthya) — J S Tripathi
67
7.
Geriatric counseling and social support —
K Narsimha Murthy
85
8.
Referral Requirement and Clinical Judgment in
Geriatric Practice — R H Singh & A K Pandey
therapy
in
and
geriatric
care
111
Part – II Therapeutic Care of Elderly
9.
Neurodegenrative disorders — G P Dubey
125
10.
Neuropsychiatric disorders (JarÁ Janya Mano
VikÁra) — J S Tripathi
138
11.
Cardiovascular disorders in the elderly —
A K Tripathi
156
12.
Endocrine & Metabolic disorders in the elderly
— A K Pandey
183
13.
Diabetes mellitus vis-a-vis Madhumeha in the
elderly — A K Pandey
204
10
14.
Respiratory diseases of the elderly — R H Singh
& A K Pandey
225
15.
Agni Evam MahÁsrotasa VikÁra in JarÁvasthÁ
(Gastro-Intestinal Diseases of the old age and
their care) — V K Joshi
249
16
Musculoskeletal & Joint diseases in elderly —
A C Kar
256
17.
Urinary diseases and other surgical problems of
the elderly — M Sahu & A K Dwivedi
282
18.
Ano-Rectal Disorders of Elderly — M Sahu
& A K Dwivedi
287
19.
Wound management in the Elderly — M Sahu
& A K Dwivedi
299
20.
Adjuvant therapy for Cancer — M Sahu
& A K Dwivedi
304
21.
Pancendriya VikÁra (Sense organ diseases of
the old age), Eyes, Ears and Skin —
B Mukhopadhyay
312
22.
Geriatric women health care — P V Tiwari
& J S Tripathi
331
11
Part – I
Perspectives, Promotive and Preventive
Care
12
Chapter- 1
Basic Tenets of Ayurveda and Ayurvedic Geriatrics
Ayurveda is the most ancient science of life and a system of health care in the
world, its antiquity going back to the Vedas in India. It has been in an unbroken
tradition of professional practice for thousands of years and is flourishing even
today in India and several other South East Asian Countries. In recent years it
has been drawing the attention of seekers all over the world because of its
unique holistic pronature approach and its safe and cost effective green
pharmacy. Currently Ayurveda is one of the official systems of Medicine and is
being revived and developed through extended efforts for professional
education, research and good practices. Ayurveda essentially being the science
of life and longevity, geriatric health care is its prime concern which reflects
well in its RasÁyana Tantra which is one of the eight branches of Astanga
Ayurveda.
Historicity and Primary Source Literature
Ancient Ayurveda has survived to the present times down the ages through
following two sets of its classic texts, all written originally in Samskrit, now
translated in many contemporary languages including English. They are :
Text
Brihattrayi
1. Caraka SaÞhitÁ
2. SuÐruta SaÞhitÁ
3.SamhitÁs of
Vagbhata (AÒÔÁnga
Hridaya/Samgraha)
Laghuttrayi
1. MÁdhava NidanÁ
2.ÏÁrangdhara
SamhitÁ
3. BhÁva PrakaÐa
Historicity Subject
Authority
700 BC
AgniveÐa/Caraka
SuÐruta/Nagarjuna 600 BC
Medicine & Philosophy
Surgery & anatomy
Vagbhata (1 & 2)
300 AD
Therapeutics
MÁdhava Kara
ÏÁrangdhara
900 AD
1300 AD
Diagnostics
Therapeutics
BhÁva Misra
1600 AD
Drugs & Mat. Med.
AÒÔÁnga Ayurveda :
AÒÔÁnga
Specialty
AÒÔÁnga
Specialty
1. KÁyacikitsÁ
Internal Medicine
5.
Agad Tantra
Toxicology
2. Ïalya Tantra
Surgery
6.
BhÚta VidyÁ
Psychiatry
3. ÏÁlÁkya
Tantra
Ophthalmology & ENT 7.
RasÁyana
Geriatrics
4. KaumÁra
Bhritya
Paediatrics, Obstetrics 8.
& Gynaecology
BÁjikaraÆa
Sexology
13
The Basic Principles
Ayurveda adopts its basic philosophy from SÁmkhya and modifies the same to
suit the working frame of a biological science. The SÁmkhya scheme of
evolution of the universe stands moulded into Ayurvedic biology as is evident
form the concepts of the ÑaÕdhÁtwÁtmaka CikitÒya PuruÒa and the doctrine of
Loka PurÒa SÁmya operating through the principle of SÁmÁnya and ViÐeÒa i.e.
Homology vs Heterology. Ayurveda adds to the physics of Panca MahÁbhÚta
the theory of certain biological constructs like TridoÒa, Sapta DhÁtus, Ojas,
Agni, Àma, Srotas etc. The following aspects deserve special consideration :
• Evolution of the universe – Sendriya/Nirindriya.
• The concept of ÑaÕdhÁtvÁtmaka CikitÒya PuruÒa.
• Theory of Loka-PuruÒa SÁmya (Macrocosm – Microcosm continuum).
• The doctrine of SwabhÁoparamavÁda (self cessation of the cause of
illness and spontaneous healing).
• The TanmÁtras, their subtle nature.
• Panca-PancikaraÆa.
• Panca MahÁbhÚtas .
• The TriguÆas.
• Theory of TridoÒa & DwidoÒa. Deha & MÁnas Prakritis.
• The Sapta DhÁtu i.e. primary tissues of the body.
• Agni, the biofire system and Agni Bala
• Àma, the morbid byproduct of faulty biofire.
• Ojas, the vital essense, Ojabala and Oja DoÒa.
Loka PuruÒa SÁmya and SwabhÁoparamavÁda
The CikitÒya PuruÒa i.e. individual living-being is the miniature replica or
1
microcosm of the Loka i.e. the universe/macrocosm . The microcosmmacrocosm continuum is the essential requirement for sustenance of life. The
two maintain the continuum and state of universal balance with the help of the
law of SÁmÁnya and ViÐeÒa i.e. Homology vs Heterology meaning that similar
(SÁmÁnya) increases the similar while dis-similar (viÐeÒa) depletes the same
which is the law of Nature2.
1
folxkZnkufo{ksiS% lkselw;kZfuyk ;FkkA
/kkj;fUr txísga dQfiÙkkfuykLrFkkAA lq0lw0 21:8
VisargÁdÁnaviksepai SomasÚryÁnilÁ YathÁ,
DhÁrayanti Jagaddeham VatapittÁnilÁstathÁ — SS. Su. 21:8
2
loZnk loZHkkokuka lkekU;a o`f)dkj.ke~A
gzklgsrqfoZ'ks"k'p izo`fÙkZmHk;L; rqAA p0lw0 1:44
SarvadÁ SarvabhÁvÁnam SÁmÁnyam VriddhikÁraÆam;
HrÁsheturviÐeÒaÐca, Pravrittirubhayasya tu. — CS. Su. 1: 44
14
The same face of Nature allows spontaneous cessation of the cause of disease and self
healing as autocorrection of the errors occuring in the biological system. This is the
3
theory of SwabhÁoparamavÁda.
Diagram showing the Tri-triangular Ecogenetic Model of Holism in Ayurveda, the
round circle depicting the inherent power of harmony in the nature.
TridoÒa Theory
The three DoÒas – VÁta, Pitta & Kapha are the biological derivatives of Panca
MahÁbhÚta i.e. the five basic elements of matter. The DoÒas are PrÁÆic in
nature and are responsible for all physiological and pathological events taking
place in the body-mind system. They exist in our body in a genetically predetermined proportion which is responsible to constitute our prakriti
characterised by the sum total of our physique, physiology and psychology.
There are seven types of DoÒa Prakritis marked by clear dominance of any one
of the these DoÒas, dominance of any two or balance of all the three viz.
1- VÁtaja Prakriti
3
tk;Urs gsrqoS"kE;kf}"kek nsg/kkro%A
gsrqlkE;kr~ lekLrs"kka LoHkkoksije% lnkAA p0lw0
16:27-30
JÁyante HetuvaiÒamyÁdviÒamÁ DehadhÁtavaí,
HetusÁmyÁt SamastesÁm SwabhÁoparamaí SadÁ. — CS. Su. 16: 16-27-30
15
2 – Pittaja Prakriti
3 – Kaphaja Prakriti
4 – 6 Dwandwaja Prakritis
7 – Sama Prakriti
NB : There can be other possible combinations too.
The SubdoÒas
Each of the three DoÒas are subcategorsied into Five types in view of their
specific sites and functions in the body as mentioned below.
VÁta — PrÁna, UdÁna, SamÁna, VyÁna, ApÁna
Pitta – SÁdhaka, Àlocaka, BhrÁjaka, PÁcaka, Ranjaka
Kapha – Avalambaka, Bodhaka, Kledaka, Tarpaka, ÏleÒaka
Five-Elemental Connections of DoÒas and GuÆas
TridoÒa
VÁta
Panca MahÁbhÚta
TriguÆa
ÀkaÐa
Sattva
VÁyu
Pitta
Teja
Rajas
Jala
Kapha
Prithvi
Tamas
NB : The subtle forms of five elements are called TanmÁtra which exist as
qualities and do not exist as real physical matter. Hence the TanmÁtras are
energetic entities and cannot be the object of senses. The TanmÁtras are five,
one each corresponding to the respective MahÁbhÚta.
Five-Elemental basis of Articles of Food & their TridoÒika
Attributes:
Tastes
Elements
Qualities
Balances
Aggravates
Madhura
(Sweet)
Earth,Water
Heavy, wet, cool
VÁta, Pitta
Kapha
Amla (Sour)
Earth, Fire
Warm, moist, heavy
VÁta
Pitta, Kapha
LavaÆa (Salty)
Water, Fire
Heavy, moist, warm
VÁta
Pitta, Kapha
KaÔu
(Pungent)
Fire, Air
Dry, light, warm
Kapha
Pitta, VÁta
Tikta (Bitter)
Air, Ether
Cold, light, dry
Kapha
Pitta
VÁta
16
Air, Earth
KaÒÁya
(Astringent)
Cold, heavy, dry
Pitta
Kapha
VÁta
Physical Properties of Three DoÒas
TridoÒa
VÁta
Major
Locations
Lower part of Middle part of Upper part of the body, head,
body throat and chest
the body – pelvis the
specially the
and limbs
grahaÆi
Broad
Functions
Activity,
movement,
locomotion
Digestion,
metabolism,
brightness,
light, heat
Solid substratum of the body,
provides shape and form to the
body, responsible for strength
and reproduction.
Physical
properties
& body
type
qualities
Dry
Cold
Light
Mobile
Erratic
Rough
Bitter
Astringent
Pungent
Hot
Oleus
Light
Intense
Fluid
Fetid
Sour
Pungent
Salty
Oily
Cool
Heavy
Stable
Dense
Smooth
Sweet
Sour
Salty
Pitta
Kapha
Seven Primary DhÁtus or Body Tissues
1. Rasa
2. Rakta
3. Mámsa
- Plasma
- Blood cells
- Muscles
4. Meda
5. Asthi
6. MajjÁ
7. Ïukra
- Adipose
- Bone
- Marrow
- Reproductive tissues
These Seven DhÁtus are formed in the same order deriving nurishment from
ÀhÁra I. e. food which is digested and metobolised with help of 13 Agnis. The
dhÁtu poÒaÆa takes place through three mechanisms which are complementary
to each other namely 1. KedÁri kulya nyÁya( micro circulation and tissue
perfusion), 2. Khale kapota nyÁya (selective uptake) and 3. KÒira Dadhi nyÁya
(Assimilation and Transformation).
Ojas, Ojabala & Bala DoÒa
• Ojas is the vital essence of all DhÁtus and is responsible for our
biostrength or Bala.4
4
r= jlknhuka 'kqØkUrka /kkrwuka ;r~ ija rst% rr~ [kyq vkst% rnso oye~A lq0lw0
15:9
Tatra RasÁdinÁm ÏukrÁntÁnÁm Yat Param Tejaí tat Khalvojaí Tadeva Balam. - SS.Su. 15:9
17
• Ojas is of two types –
1. Para Ojas (8 drops) located in the heart and sustains life.
2. Apara ojas (½ Anjali) located all over the body and sustains the
biostrength and Immunity.
• Trividha Ojabala (Immune strength)
1. Sahaja Bala or Natural immunity/biostrength
2. KÁlaja Bala or Acquired immunity gained by the impact of time
factor viz. age, season, climate etc.,
3. Yukti Krita Bala or artificially induced immunity and biostrength by
suitably planned action, life style, food etc5.
• Trividha Bala DoÒa6 (Immune Disorder)
1. Oja VyÁpat – Labile immune disorders.
2. Oja Visransa – Dislodged immunity such as in autoimmune
disorders.
3. Oja KÒaya – Immunodeficiency
• Restoration of Oja Bala
1. Identify the Bala DoÒa and rectify the same by SrotoprasÁdana and
SamÐodhana (biopurificaiton) and RasÁyana therapy of all range.
2. Regular healthy life-style i.e. Sadvritta, Swasthavritta and positive
nutrition.
3. RasÁyana — ÀcÁra RasÁyana, Àjasrika RasÁyana, KÁmya RasÁyana
and Naimittika RasÁyana as per need.
Agni and Agni-Bala7
Agni refers to the biological fire system operating in our body which is
responsible for the entire range of digestive and metabolic functions. There are
13 categories of Agni viz.
• One JaÔharÁgni or digestive fire located in the digestive system.
• Seven DhÁtwagnis for tissue metabolism located one in each of the
seven DhÁtus.
• Five BhÚtÁgnis responsible for elemental metabolism at the level of five
BhÚtas.
• Vagbhatta also describes seven PÁcakÁmÐas which produced in the gut
but function in Dhatus
5
6
7
f=fo/ka cya&lgta dkyta ;qfäÑre~ pA pjd0lw0
11:36
Trividhaï Balaï — Sahajaï KÁlajaï Yuktikritaï Ca.
- CS. Su. 11:36
=;ksnks"kk oyL;ksäk O;kir~ foL=alu {k;k%A lq0lw0 15:25
Trayo DoÒa BalasyoktÁ VyÁpat Visramsana KÒayÁí. — SS. Su. 15:25
pjd fp0 15:38
18
The strength of Agni at all the above mentioned levels may vary in
physiological and pathological range which can be clinically identified for Agni
management in clinical settings viz.8
• SamÁgni
Balanced state
• ViÒamÁgni
-
Imbalanced state
• TikÒÆÁgni
-
Hyper functioning
• MandÁgni Hypo functioning
The hypofunctioning of Agni leads to ÀjrÆa of varying range leading
further to the formation of morbid byproduct, Àma which is toxic and antigenic
in nature and causes different diseases due to blockade of channels (SrotÁmsi)
of the body and auto immune disorders.
Life, Health and Disease
• Àyu or life is a four-dimensional entity comprising of physical body,
senses, mind and spirit – Ïarirendriya SattvÁtma Samyogo Dharijivitam9
CS. Su. 1:42. The term 'Ayu' means life entity and also refers to life span
while the term 'Vaya' refers to age (the part of life span already spent)
• Àyu may be in the state of 1. SukhÁyu i.e. normal and comfortable, 2.
DuíkhÁyu i.e. ill & ailing, 3. HitÁyu i.e. conducive to all i.e. social wellbeing and 4. AhitÁyu i.e. nonconductive to others i.e. unsocial. Àyu is
also categorised as Niyata or destined and Aniyata or predestined.10
• Health is a state of SwÁsthya i.e. being stabilised in oneself in complete
normalcy. Àrogya or health is the MÚla of PuruÒÁrtha CatuÒÔaya—
Dharma-Artha- KÁma-MokÒa.11
• The SwÁstha or healthy person is only one who is in a state of total
biological balance in terms of DoÒas, DhÁtÚs, Malas in the body and is
in the state of blissful wellbing (sensorially, mentally and spiritually).12
Amazingly this definition of SwÁsthya as given by Susruta (SS.Su.
15:41) is in complete conformity with the four-dimensional concept of
Àyu and strikingly resembles the latest modern definition of Health
recently approved by WHO – "Health is a state of complete physical,
mental, social and spiritual wellbeing.
8
9
10
pjd fp0 15:50-51 / Caraka Ci. 15: 50-51
'kjhjsfUnz; lÙokRe la;ksxks /kkfjthfore~A pjd lw0
1:42
Sarirendriya sattvvÁtma Samyogo Dhari jivitam CS. Su 1: 42
fgrfgra lq[kanq%[ka vk;q% rL; fgrkfgre~A pjd lw0 1:41
HitÁhitam sukham Dukham Àyu tasya HitÁhitam CS. Su 1: 41
11
/kekZFkZdkreks{kk.kekjksX;a ewyeqÙkee~A ¼p0lw0½
12
lenks"k% lekfXu'p le/kkrqeyfØ;% izlUukReksfUæ; euk% LoLFk bR;kfHk|h;rsA ¼lq0lw0 [email protected]½
DharmÁrthakÁmamokÒÆÁ Àrogyam mulamuttamam CS. Su 1
SamadoÒa½ SamÁgnisca Samadhatu malakriya½ ;
PrasannÁtmendriya Mana½ Swastha ityabhidhiyate SS. Su 15: 40
19
• While health is a state of SÁmya/biobalance, the disease is a state of
VaiÒamya/inbalance. The aim of health care and cure is to preserve the
state of balance and to restore it to normalcy whenever it falls to
imbalance due to a disease.
• There are two fundamental causes of diseases No. 1. Karmaja i.e.
morbid actions of the past life resulting into intractable Karmaja and
Sahaja Vyadhis which fall into the realm of DaivavyapÁsraya CikitsÁ;
No.2. Acquired diseases occurring due to disruption of the law of Loka
PuruÒa SÁmya i.e. disconnection of the man from the Nature and the
environment. In principles Loka-PuruÒa VaiÒamya precipitates due to
Ayoga-Atiyoga-MithyÁ yoga of KÁla, Buddhi and IndriyÁrtha popularly
termed as KÁla-PariÆÁma, PrajnÁparÁdha and AsÁtmyendriyÁrtha
Samyoga which are considered the three basic causes of all diseases in
Ayurveda. Rest all other causes of ill-health are secondary to the above
mentioned three fundamental causes.
Aging is the SwabhÁva
The life is a time-bound phenomenon. The man is born, grows to adulthood,
passes to senility and ultimately dies. Still a long healthy life is the most
cherished wish of man for which Vedas too pray "Jivema Ïaradaí Ïatam,
PaÐyema Ïaradaí Ïatam" and so on. The standard human life span as
contemplated in scriptures is of 100 years, after which the body becomes senile
and decayed to cease; although the JÍiva (barring physical body) is immortal
and transmigrates from one body to another. This is the process of Aging or
JarÁ which is the SwabhÁva or the very nature of the living body. Beside the
'SwabhÁva Factor' of aging there can be a range of environmental factors which
accelerate aging process such as nutritional deficits, stress, climatic factors,
free radical injury, immune disorder and endocrinal factors etc. The aging or
JarÁ is a continued process of involution overwhelming the evolutionary
processes which initially set-in to allow the growth and development of the
body-mind system. This involution is marked with a range of biological
changes which can be identified in relation to DoÒas, DhÁtus, Ojas, Agni etc.
The Three Phases of Life in Ayurveda
Age/Phases of Life
DoÒas
DhatÚs
Agni
Ojas
Young Age:
Kapha dominant
Kapha ↑↑
VÁta
Optimum
Pitta
+++
++
+++
Adult Age:
Pitta dominant
Pitta ↑↑
VÁta
Optimum
Kapha
++
+++
++
20
Old Age:
VÁta dominant
+
VÁta ↑↑
Kapha ↓
Depleted
Pitta ↓
+
+
Vagbhata and ÏÁrangdhara described the 10-Phasic sequential biolosses
occurring during 1st to 10th decades of life which may be restored by age
specific RasÁyanas. Further details of aging process, its preventions and
management in Ayurveda will be discussed in chapter 4 on RasÁyanas and
Rejuvenation.
Sl.No.
Inherent Biolosses
Sl.No.
1
2
3
Aging
Decades
0-10
11-20
21-30
BÁlya – Corpulence
Vriddhi – Growth
Chhabi – Lusture
6
7
8
Aging
Decades
51-60
61-70
71-80
4
5
31-40
41-50
MedhÁ – Intellect
Twaka – Skin quality
9
10
81-90
91-100
Inherent Biolosses
DriÒÔi – Vision
Ïukra – Virility
Vikrama – Physical
strength
Buddhi – Thinking
Karmendriya –
Locomotion
ckY;ao`f)'NfoesZ/kk Rod~n`f"V'kqØfoØekSA
cqf)% desZfUæ;a psrksftfora n'krks glsr~AA & 'kk0 l0 II : 2: 20
Ayurvedic Diagnostics
Patient-oriented holistic approach in ayurvedic diagnosis.
Intense doctor-patient rapport.
Two-fold clinical methodology – RogiparikÒÁ, RogaparikÒÁ.
Emphasis to evaluate the genetic make-up and nature of the person and
the status of remainder health of the patient i.e. evaluation of the health
of the diseased.
• Tools of examination comprise of ÑaÕvidha ParikÒÁ viz. PraÐna ParikÒÁ
(Interrogation) and Pancendriya ParikÒÁ (Physical examination)
simulating the conventional methodology.
• The Roga ParikÒÁ comprises of DaÐavidha ParikÒÁ schedule described
by Caraka viz. Prakriti, Vikriti, SÁra, Samhanana, Sattava, SÁtmya,
PramÁÆa, ÀhÁra Ïakti, VyÁyÁma Ïakti and Vaya.
•
•
•
•
• The Roga ParikÒÁ comprises of 1. AÒÔavidha general examination for
NÁÕi, Mutra, Mala, JihwÁ, Ïabda, SparÐa, Drik, Àkriti and 2. ÑaÕanga
Srotasa ParikÒÁ of the 13 major channels/systems of body described in
Ayurveda.
• Final diagnosis is done by constructing the SamprÁpti of the disease
without insisting to identify the diseases by name, because Ayurvedic
21
treatment is to be done for SamprÁpti VighaÔana i.e. resolution of the
disease process and its morbid components i.e. the pathophysiology.
Grriatric Svasthavétta and Sadvétta
Ayurvedic texts describe in great details the codes of healthy living, i.e.
Svasthavétta and Sadvétta denoting personal hygiene and mental hygiene
respectively. The Svasthavétta CatuÒka chapters of Caraka Samhita present a
classic account on this aspect of the subject (CS. Su. 5-8).
DinacaryÁ or daily routine of right living is designed as means of promotive
and preventive health care. The prescribed time to wake up in the morning is
BrÁhma MuhÚrta approximately between 4-5 AM. This should be followed by
cleaning the teeth, toung and mouth with suitable fresh herbal tooth brushes
using Khadira, Karañja, Neem and Babbula which are bitter and astringent in
taste with antiseptic property. This should be followed by drinking water,
bowel evacuation, oil massage and healthy bath, VyÁyÁma and ÀhÁra as per
prescribed rules (see chapter 3).
ètucaryÁ or seasonal regimen is another important component of Svasthavétta
prescribed in terms planning diet, life style and seasonal SaïÐodhana
(biopurification) in consideration of TridoÒika rhythms of Dosas - VÁta, Pitta,
Kapha and their Sancaya, Prakopa and PraÐama.
1. ÏiÐira
2. Basanta
3. GriÒma
4. VarÒÁ
5. Ïarada
6. Hemanta
Sancaya
Jan-Feb
March-April
May-June
July-August
Sept-Oct
Nov-Dec
Prakopa
-Kapha
-VÁta
Pitta
--
Prescribed SaïÐodhana
-Vamana
-Vasti
Virecana
--
Sadvétta, ÀcÁra, Vega VidhÁraÆa:
Ayurvedic texts give equal emphasis on psychosocial factors of good living
and describe in detail the ethics and code of conduct conducive to good mental
and social health.
Sadvétta, AcÁra (CS. Ci 1) and Vega Niyamana give a comprehension
psychosocial and spiritual code of conduct which can be suitably tailored and
updated to suit the present generation as a social and mental health promotion
regimen. Such practices render the life stress free promote health, longevity
and immune strength.
22
Principles of Treatment
1. NidÁna Parivarjana – Identify the cause of disease and eliminate the
same, self healing may follow spontaneously.
2. SamprÁpti VighaÔana i.e. Reversal of the pathogenesis of the disease by
applying SamÐodhana and SamÐamana measures.
3. SamÐodhana or biopurification of the body performed through Panca
Karma therapy restores the integrity of the channels or SrotÁmsi of the
body which augments the inner transport system with improved
nutrition, bioavailability of medications and clearance of excretables,
toxins and metabolites affording improved physiological pattern and
occurrence of self-healing.
4. SamÐamana or palliative therapy is designed for balancing of DoÒas and
DhÁtus through appropriate use of 1. Planned diet, 2. Drugs and
therapeuticals and 3. Life-style management.
5. Adjuncts- Exercise, rest, recreation, relaxation, yoga, meditation,
nutrition, physical rehabilitation, occupation, counseling and supportive
therapy and RasÁyana, Daiva VyapÁÐraya treatment for Sahaja and
Karmaja diseases.
6. Referrals – Patients suffering from surgical diseases should be referred
to surgical care units as advocated by Caraka. "Tatra
DhÁnvantariyÁÆÁma adhikÁraí" which warrants clinical skill and
clinical jundgement in time.
7. The geriatric subjects should be subjected to soft care, geriatric
Pancakarma and RasÁyana therapy besides nutritional care, yoga and
social support as well as appropriate treatment of the associated diseases
of old age by specialised referrals.
Ayurvedic Materia Medica and Pharmacy
Ayurveda has not only its own comprehensive classical literature and its own
unique fundamental principles; it has also its own unique and comprehensive
materia-medica comprising of a wide range of herbs, minerals, metals and
biological products used singly and in combinations, fresh or processed
through a sophisticated pharmacy system. However, the Green Pharmacy and
herbal resource is the hall mark.
The medicaments are used for therapeutic applications in consideration of their
Five–elemental composition and TridoÒika attributes. The Ayurvedic materiamedica works through an uniquely conceived holistic pharmacodynamics in
terms of:
1. Rasa or Taste.
2. GuÆa or physical property.
3. Virya or bio-potency.
4. VipÁka or metabolite effect.
23
5. PrabhÁva or specific pharmacologic activity.
Actions through Rasa, GuÆa, Virya, VipÁka are suggestive of nutraceutical
effect, while the PrabhÁva action probably signifies real pharmacological
action irrespective of Rasa, GuÆa, Virya, VipÁka and hence could be
considered to be caused by the presence of a specific active principle in the
drug.
Ayurveda prescribes five primary methods of preparation of dosage forms of
fresh medicaments for daily use. These primary dosage forms are:
1. Swarasa or expressed juice
2. Kalka or fresh paste
3. ChurÆa or powder
4. PhÁnÔa or light infusion
5. KwÁtha or decoction
In addition to the five basic primary dosage forms, Ayurveda also uses a wide
range of other preparation such as:
1. Vati/Guti or Tablet/Pill
2. PÁnak or Syrup
3. Avaleha
4. Khanda/Modaka-confectionery like medicine
5. Taila- Medicated oil
6. Ghrita- Mediated ghee
7. Àsava-AriÒÔa (Fermented formulations)
8. ÀÐcyotana (Eye drops)
9. Malahara (Ointments)
Besides, the Ayurvedic Pharmacy practices elaborate pharmaceutical methods
to process minerals, metals, toxic herbs, biological products etc. for their
purification and detoxification, ashing and transforming them into stable
products. The methods of preparations of BhaÒmas of metals and organometals are a very subtle science of alchemy and chemotherapy which does not
come under the purview of the present write-up. The readers are advised to
refer to standard texts on Rasa Shastra. However, certain recent studies have
indicated that the Ayurvedic pharmaceutical methods have certain hither to
unknown mechanisms to transform the metals into safe and therapeutically
effective forms warranting further research and application of Nanotechnology.
Conclusion
Ayurveda is the most ancient science of life, health and cure practised in India
for thousands of years based on its own unique fundamental principles,
materia-medica and pharmacy. Promotion of health, prevention of disease and
promotion of longevity are its main concerns. Because of its pronature holistic
approach and its safe cost-effective Green Pharmacy and rejuvenative
24
measures like Panca Karma and RasÁyana therapy Ayurveda is becoming
more and more popular in present times.
Recommended Further Reading
1. Caraka SaÞhitÁ English Translation by Sharma, P.V., Vol. I-IV,
Choukhamba Publication, Varanasi.
2. SuÐruta SamhitÁ English Translation by Singhal G.D. & Associates Vol
I-III, Choukhamba Surbharati, New Delhi, 2008.
3. Ayurvedic Biology by Valiathan, M.S., INSA, New Delhi, 2007.
4. The Holistic Principles of Ayurvedic Medicine by Singh, R.H.,
Choukhamba Surbharati, New Delhi, 2001
5. Ayurveda in India Today by Singh, R.H., in Proc. Symposium on
Traditional Medicine, WHO Kobe Centre, Japan, 2001
6. Advances in Ayurvdic Medicine Vol. I-V, by Singh, R.H. & Associates,
Choukhamba Vishwabharati, Varanasi, 2005.
7. Legacy of Susruta by Valiathan, M.S., Orient Longman, Chennai, 2007.
8. Fundamental Principles of Ayurveda by Dwarakanath, C. Popular
Books, Bombay.
9. Science and Philosophy of Indian Medicine by Udupa, K.N. & Singh,
R.H., Sri Baidyanath Ayurveda Bhavan, Nagpur, 1975.
10. KÁyacikitsÁ Vol. I, II by Singh, R.H., Choukhamba Surbharati
Publication, Varanasi, 2007.
11. AÒÔÁnga Hridaya Ed. KV. Atrideo, Choukhamba Sanskrit Series,
Varanasi, 1962.
12. Swasthavritta VijnÁna by Singh, R.H., Choukhamba Surbharati,
Varanaasi, 2006.
13. Pancakarma Therapy by Singh, R.H., Choukhamba Sanskrit Series,
Varanasi, 2006.
14. Strength of Ayurveda in Geriatric health care, Keynote lecture by
Singh, R.H. Launching National Campaign on geriatric health care,
Department of AYUSH, Ministry of Health Govt. of India, 2008.
15. History of Medicine in India Ed. Sharma, P.V. INSA, New Delhi, 1992.
25
Chapter- 2
Current Issues in Geriatric Health Care
1.
Definition of Elderly
a.
b.
Definition of elderly:
Old age a stage of life cycle characterized by constellation of decline
following maturity.
Chronological age as cut off for defining elderly varies widely from 55
years to 65 years.
United Nation & Consensus Criteria- 60 yrs or above
Biological markers lack specificity- No biological scale either
Biology of Aging:
Cellular and Molecular Basis: Normal human cells except germ line
cells undergo a definite number of cell divisions before entering a non
replicative state known as senescence, which is followed by cell death.
The number of divisions varies between 40 and 90 depending upon cell
type, and is known as Hay flick number. Cells that continue to divide
are cancerous cells.
Telomeres are highly conserved sequence of DNA that are present at the
ends of chromosomes (consist of repeats of the nucleotide sequence
TTA GGG), to form a protective cap around genomic DNA, preventing
chromosomal loss and aberrant fusion during mitotic cycles. With aging
of cells, there is progressive shortening of telomere DNA and when it is
completely sloughed off, chromosomal degradation ensues, leading to
cell death. The progressive erosion of telomere DNA is proposed as
molecular mechanism of cell aging.
In progeria, a rare disorder of accelerated aging, telomeres are
drastically shortened when compared to age matched cohorts.
Telomerase, an enzyme which rebuilds telomeres, is normally found in
germ line cells as well as cancer cells but is absent in somatic cells.
Genetic Changes in Ageing: The integrity of genetic information
reposited in the genome, is essential for normal functioning and survival
of organism. The genomic DNA is subject to variety of defects and
damage due to action of several exogenous and endogenous agents such
as free radicals, UV radiations, Chemical agents both exogenous and
metabolic products. Consequently there occurs related increase in DNA
cross links, decentric chromosomes, aneuploidy, polyploidy, loss of
centromeric tandem repeats. Base damages, point mutations & various
deletions of mitochondrial DNA also increase in senescent tissues.
26
These DNA damaging processes are countered by repair processes,
which become inadequate with ageing leading to instability of the
genome.
As the normal functioning of the cell organism depends upon the
capacity of its cells to maintain their genetic information and transfer it
accurately from DNA to RNA to protein. This storage & flow of genetic
information depends upon genomic structure stability & flexibility,
which is compromised with ageing leading to incorporation of errors at
the level of DNA replication, transcription and translation. The RNA
transportation from nuclei to cytoplasm reduces and there are defects in
translation with ageing. With ageing expression of various genes alter,
there are changes in transcription factors but comprehensive effect of
genetic changes with ageing is still not elucidated.
Where as life span is genetically determined the likelihood of reaching
that is determined by environmental and life style factors.
Theories of Aging: Madvedev reviewed a large number of molecular
and cellular theories & concluded that no theory is universally
acceptable as they suggest a single major cause; it appears that ageing is
a multi-component process which occurs due to eventual break down of
maintenance.
Network Theory: Stresses that a biological system is sustained by a
network of maintenance processes which control cellular homeostasis. It
integrates the contribution of defective mitochondria, aberrant proteins
and free radicals to the aging process; which also includes the protective
effects of antioxidants, enzymes and proteolytic scavengers.
A mathematical model to test the plausibility of network hypothesis has shown
that imbalances between oxidants and antioxidants result in free radical damage
to cells; this also destabilizes an otherwise stable cellular translation system
leading to protein error.
c.
Demography of Aging
Population changes:
Global Scenario: As projected by UNO by 2050 20% of
world
population will be elderly 2/3rd of elderly will be residing in India or
China
Table 1. Global Scenario of Aged, 1995-2150
Year
1995
2000
Population in
billions
5.687
6.091
% of aged 60+
% of aged 65+
% of aged 80+
9.5
9.9
6.5
6.8
1.1
1.1
27
2025
2050
2075
2100
2125
2150
8.039
9.367
10.066
10.414
10.614
10.806
14.6
20.7
24.8
27.7
29.2
30.5
10.8
15.1
19.1
22.0
23.6
24.9
1.7
3.4
5.3
7.1
8.6
9.8
Indian Scenario: At present elderly (60 yrs or above) constitute 8% of
population; by 2051 this is likely to go up to 17%.
Table 2. Projected Number of Older Persons.
Their Percentage in Population and Old Age Dependency in India: 2001-2051
Population in millions and (%)
Year
60+
70+
80+
Dependency
2001
2011
2021
2031
2041
2051
70.78
(7.1)
27.07
(2.7)
5.37
(0.5)
11.9
96.30
(8.2)
35.90
(3.1)
7.88
(0.7)
13.4
133.2
(9.9)
50.55
(3.8)
10.75
(0.8)
16.0
178.59
(11.9)
73.13
(4.8)
15.69
(1.0)
19.0
236.01
(14.5)
97.90
(6.0)
23.17
(1.4)
23.2
300.96
(17.3)
133.31
(7.6)
31.98
(1.8)
28.2
Table 3. Expectation of Life for Older Indians at 60 and 70:
Projected Figure for 2001, 2011,2021
Year
1991
2001
2011
2021
2.
Male 60+
15.01
15.74
16.29
16.75
Male 70+
9.27
9.70
10.03
10.32
Female 60+
16.23
17.05
17.75
18.18
Female 70+
9.97
10.45
10.87
11.14
Pattern of Age changes & their health implications
I. Non homogeneous changes: Elderly differs in their health status and
this difference gets more marked with aging ie., as people grow old they
become more heterogeneous. Hence, no standard health solutions may
be applicable and problem solving has to be individualized
II. Aging prejudices/myths:
Low expectations of health and resources by elderly
Mostly neglected by family – least sharing of household resources
Old age perceived as preparation for final take off
Common health problems taken as part of normal aging.
28
III.
3.
Social/Psychological changes: Traditionally Indian society views
elderly to disengage from life and follow a spiritual path- Vanprastha
Elderly most of the time disengage from socioeconomic activities
and are lonely, neglected and depressed.
Due to industrialization; children often move to far away places
leaving parents home or uprooting them to new environment, both
causing psychological distress.
Successful aging refers to modifications of behavioral process to
achieve (1) low probability of aging (2) high cognitive and physical
function capacity (3) active engagement with life. Elderly who
maintain control of their lives are most likely to age successfully.
Having close relationship and involvement with the family and
society increases likelihood of high quality of life for elderly.
Why elderly differs from adults:
Anatomical changes: Significant anatomical changes are:
Table 4. Selected Anatomical Changes with Aging
System affected
Height
Weight
Total body water
Muscle mass
Bone mineral content
Taste buds
Change
↓ (avg. 2″)
Peaks : 50s (M); 60s (W)
↓ : 60-54% (M); 54-46% (W)
↓ 30%
↓ : 10-15% (M); 25-30% (W)
↓ 70%
Physiological changes: Clinically relevant changes are:
Table 5. Selected Physiological Changes with Aging
System affected
Cardiac reserve
Lung vital capacity
Renal perfusion
Cerebral blood flow
Change
↓ 20%
↓ 17%
↓ 50%
↓ 20%
Pharmacology in elderly: with physiological changes with ageing; there are
changes in pharmacokinetics (i.e., absorption, distribution, metabolism and
elimination of drugs) and pharmacodynamics (receptor affinity & effect) of
drugs; the knowledge about these becomes essential for rational prescription.
Pharmacokinetics: Changes in absorption of drugs are not clinically
significant, in elderly.
29
Distribution of drugs: In elderly there is decrease in body water and increase
in body fat, this affects volume of distribution (Vd) of drugs. Thus, water
soluble drugs like digoxin will have increased concentration. Lipid soluble
drugs like diazepam, chlordiazepoxide, thiopentone sodium will have a greater
volume of distribution and longer half life (t1/2). The decrease in plasma
albumin with age or diseases means increased free fraction of albumin bound
drugs like digoxin, phenytoin, warfrain.
Renal clearance: It is decreased and this may affect drugs eliminated primarily
by kidneys for e.g., aminoglycosides, atenolol, lithium, digoxin. However, this
decline in renal clearance with aging is variable.
Hepatic clearance
Decreased first pass effect results in increased serum levels of
propranolol, metoprolol, verapamil, nitrates, acetaminophen, tricyclic
antidepressants (TCA).
Decreased hepatic microsomal enzyme activity means prolonged
duration of action of benzodiazezepines, warfarin and phenytoin.
Increased volume of distribution (Vd) and/or decreased renal or hepatic
clearance (Cl) results in increased half life (t1/2) for a number of drugs
like diazepam, propranolol, aminoglycosides.
Pharmacodynamics: Older patients are generally more sensitive to the doses
or plasma levels of a number of medications considered appropriate for
younger patients; such as sedatives, psychotropic drugs, narcotic analgesics
(opiates), digoxin , theophylline, phenytoin. For some drugs like β-adrenergic
blockers and β-agonists there is decreased receptor sensitivity (Table 2).
Changes in homeostasis: Adverse pharmacodynamic effects are commoner
and greater in elderly due to physiological decline and co-morbidities. A mildly
nephrotoxic drug like NSAIDs may have disastrous consequences in an elderly
with impaired renal function at baseline.
Orthostatic hypotension: Due to blunting of baroreceptor reflex; postural
hypotension in elderly is aggravated by antihypertensive as well as by
neuroleptics, TCA, benzodiazepines and antiparkinsonian drugs.
CNS: Postural control is poorer in elderly with increase in sway. Drugs with
sedative actions further accentuate it, leading to increased falls and injuries.
Neurotransmitters in CNS decrease with age, drug related confusion increases
in elderly with theophyllines, β-blockers, anticholinergics and hypnotics.
Temperature control: Thermoregulation is blunted with aging. Alcohol,
barbiturate, neuroleptics and TCA potentiates hypothermia and anticholinergics
aggravate
30
Hyperthermia in elderly.Though, any drug can cause adverse drug reaction
(ADR), usually commonly used drugs are most often implicated in ADRs.
Analgesics, sedatives, antipsychotic drugs account for nearly 50% of ADRs in
hospitalized elderly. Other common groups of drugs with ADRs are
antihypertensive, bronchodilator, digitalis, oral hypoglycemic, antiparkinsonian
drugs, anticoagulants, antiarrhythmics. Some ADRs with commonly used
group of drugs is given in Table 3.
4.
Disease/Illness Profile in elderly
NSSO data (1995) underlines that at any time almost 50% of elderly are ill, and
75% of them have more than two diseases. Multiple diseases co-exist together
in elderly, in a study in elderly population between 65-74 years suffered from
an average 4-6 chronic diseases, for those over 75 years the mean number was
5.8 and only 10% reported absence of any problem.
Special hazards of illness in elderly:
Functional decline: In elderly due to poor physiological reserve diseases
manifests early but are reported late due to socio economic factors, dementia or
marking of symptoms by co-morbidities. Hence, elderly usually presents with
advanced disease and as disease in one organ may trigger failure of other
systems, multi system manifestations are common. Certain diseases like
ischemic heart diseases, strokes, osteoarthritis are commoner in elderly, while
others like Parkinson’s disease, Multisystem atrophy of CNS, Alzheimer’s
disease, Polymyalgia rheumatica is seen only in elderly. Co-existence of
multiple diseases may mask or exacerbate symptoms for e.g., dementia of
Alzheimer’s disease may be exacerbated by concurrent presence of hearing
loss. Certain pattern of presentation of diseases are particular to old people i.e.,
immobility, instability (falls), incontinence and intellectual impairment. These
four is having been designated as giants of geriatrics.
Diseases in an elderly invariably presents with a decline in functional
capacity.
Rule of thirds: These functional declines usually have a rule of thirds
i.e., only a third is due to disease, another one third is due attributable to
disuse and the remaining is due to normal ageing.
Functional status- 1/3rd Normal ageing+1/3rd disuse+1/3rd disease Functional
decline due to disease and disuse parts can be managed and reversed to a large
extent; but normal ageing process is irreversible.
Geriatric functional assessment is crucial to problem detection, planning,
prevention and monitoring in old people. Use of screening instruments
helps to assure comprehensive assessment.
5.
Altered Presentation in elderly:
Factors for nonspecific and atypical presentation in elderly are in table-1, 2. A
number of illnesses in the elderly have typical altered presentation-Table. 3.
31
6.
Management of diseases in elderly:
Diagnostic problems:
Clinical presentations of diseases differ markedly in elderly; clinical
features may be mutifactorial and nonspecific; co-morbidities may
mask, mimic or aggravate clinical features. Clinical features of diseases
has to be differentiated from those due to normal ageing or disuse
phenomenon clinical features of an organ system disease may manifest
in multiple organ system; camouflaging the main problem. Adverse drug
reactions or drug interactions may change the clinical presentations.
Certain conditions may be present without signifying disease like
asymptomatic bacteriuria or benign aortic sclerosis. Similarly, due to
decreased muscle mass, creatinine clearance is not good enough for
assessing renal impairment; it has to be corrected by following formula.
[Creatinine clearance = age in years * wt. in kg/ 72 * Screatinine
(mg/dl)] to be multiplied by a factor of 0.85 in case of females.
Treatment Goals:
As elderly will have multiple problems, lot of which are amenable to
treatment the care plan must address all the problems detected.
As a clinical problem may be multi-factorial; addressing all factors will
have an additive effect on overall improvement for e.g., anemia in
elderly may be caused by combination of iron, Vit. B12 deficiency and
warm infestation which all shall be tackled for good results.
Treatment goals have to be individualized. In most of the circumstance
the first goal is to control the disease and make patient functionally
independent. Treatment priorities shall be based upon life expectancy of
the patient, effectiveness of therapeutic intervention; co-morbidities,
goals of care set by patient and attendants. For e.g., tight glycemic
controls may be abandoned if it means placement of elderly with life
expectancy of less than 5 years, in a nursing home.
Treatment problems:
Due to poor physiological reserve and multiple diseases adverse drug
reactions (ADRs) are commoner for e.g., antihistamines (e.g.,
diphenhydramine) may cause confusion, loop diuretics may precipitate
incontinence and digoxin may induce arrhythmia even at normal serum
levels.
Due to polypharmacy, drug interactions, poor compliance and dosage
errors are quite common.
Under treatment in elderly is quite common due to fear of side effects,
for e.g., chronic atrial fibrillation in elderly is usually not treated with
anticoagulants due to fear of intracranial bleed, though studies have
clearly proven that anticoagulant treatment has favorable risk benefit
ratio and should be given.
32
7.
Geriatric physician often grapple with ethical dilemmas, older patients
are particularly vulnerable and family members may have to be involved
in decision making like surgery or nursing home placement. The
physician must be knowledgeable about the complexities of medical
care in elderly.
Geriatrics is inherently interdisciplinary. A well functioning,
interdisciplinary team is critical for comprehensive care of elderly. At
the same time geriatric care needs involvement of family or care giver to
ensure compliance with the treatment. Attention should also be given to
the needs and health of care giver to ensure long term care of elderly
patient.
Rehabilitation:
Impairment is the alteration of physical or physiologic function at the organ
level. Rehabilitation is the process of helping a person reach the optimal
functional potential consistent with his/her physiologic or anatomic
impairment, environmental limitations, and desired life plans.
Rehabilitation is the process of helping a person reach his/her optimal
functional potential
Rehabilitation can be provided at different sites and is not limited to inpatient rehabilitation units.
A systematic approach to assessing the cause of disability leads to
development of a care plan that facilitates the rehabilitation process.
Different disabilities require different rehabilitation plans.
Rehabilitation interventions should be comprehensive and should
include early recognition of potential disability and prevention
There are several ways in which geriatric rehabilitation can be utilized.
The Process of Rehabilitation
Stabilization of the primary problem. Maintenance of function must be
part of the management of the acute illness.
Prevent secondary complications. Common complications and hazards
of hospitalization include delirium, de-conditioning, depression,
malnutrition, pressure sores, and incontinence.
Restore lost function. Even in the face of irreversible medical
conditions, attempts can be made to restore function to optimum.
Adaptation of person to new disability.
Adaptation of the living facility.
Working with the family.
33
8.
Prevention of diseases in elderly
Table 6. Primary Prevention in Elderly.
Condition
1.
Prevention Strategy
Immunization Yearly
Infections
Once at 65 yrs
(a) Influenza
(b)Pneumococcal
(c) Tetanus/
Diphtheria
Every 10 years
2.Cigarette/Tobaccouse/
Alcoholism
3.Nutrition
4.Sedentary life habits
Counseling by health
physicians/health
workers/
education by mass media
Counseling/health
education for balanced
diet high in fruits and
vegetables
Counseling/health
education for exercises
especially flexibility
exercises aimed to
improve balance
Comments
− may be given in
vulnerable group
− repeated 6 yearly
in vulnerable
group like
asplenic patients,
patients on
dialysis, COPD,
CHF
− possible in all
elderly (already
existing national
programme for
children)
mass media involvement
to create mass
awareness
mass media involvement
to create awareness,
change habits
mass media
programmes to create
awareness about
benefits of exercise
Table 7. Secondary Prevention in Elderly.
Condition
Screening
Frequency Definitive test Corrective step
method
Opthalomologic Cataract removal
Visual impairment Visual acuity 1-2 yrs.
(Snellen's chart
al examination or other measures
Jaegar's chart)
Hearing
impairment
Hypertension
Hearing tests
1-2 yrs.
Blood pressure 1-2 yrs.
measurement
34
Audiometery
Hearing aid, other
measures
Nonpharmacologi
cal/
Pharmacological
measures
Breast cancer
Breast
1 yr.
examination
Mammography
Biopsy
Definitive
treatment
Cervical cancer
Pap smear in
1-3 yrs.
women not
screened earlier
in life
B.M.I. (Height 1 yr.
and weight)
Biopsy
Definitive
treatment
Nutritional
assessment
Diet counseling/
Nutritional
supplements
Malnutrition/
obesity
Primary & Secondary Prevention
Primary prevention of falls, accidental injuries, and primary
chemoprophylaxis with aspirin has lacked the cost benefit evidence and
are not widely accepted.
Secondary
prevention: cholesterol measurement, digital rectal
examination, prostate specific antigen test, thyroid function tests,
Blood/Urine sugar tests have been controversial.
In well elders extensive history, cognitive assessment tests, incontinence
tests, depression tests, complete physical examination, screening blood
tests, cancer screening of lung, ovary, uterus has been found to be of
little value
Secondary Prevention
Screening for secondary prevention (Table 5) of visual and hearing
impairments, hypertension, breast cancer, cervical cancer, smoking
tobacco/ alcohol abuse, orodental examination, malnutrition is widely
accepted.
The association between elevated cholesterol and cardiovascular disease
is weaker in the elderly; though tertiary prevention through lipid
lowering is appropriate for persons with known coronary artery disease.
Cancer Screening
Incidence of breast cancer increases with age up to 75 years.
Manual Breast examination every year by clinician is highly
recommended screening measure to detect breast malignancy.
Mammography every 2 years; though effective is not widely available
and hence cannot be a mass screening tool in India.
Cervical cancer is often viewed as a problem of young women but 25%
of new cervical cancers and 40% of total cervical cancer deaths occur in
elderly.
In prostate cancer mass screening is not justified.75% of the colorectal
cancers occur in 65% population Mass screening with sigmoidoscopy is
not recommended
Oral cancers are quiet common in tobacco chewing population and may
be detected at an early stage by oral examination, with effective
treatment.
Mass screening may not be useful in all cases, a geriatrician should
evaluate elder patient for Immobility and risk factors for falls, accidents,
35
incontinence, dementia, depression, social support, adverse drug
reactions and suggest preventive measures. He should also enquire into
tobacco/alcohol abuse and consul for stoppage of these substances as
well as diet and exercise to prevent diseases.
Tertiary Prevention
In patients with chronic diseases like CAD, hypertension, diabetes
preventive measures to modify risk factors like obesity, smoking etc.
constitute tertiary prevention.
9.
Summary:
10.
Elderly population is a rapidly growing segment of population with high
morbidity and multiple illnesses.
Ageing or senescence is the result of continuous interaction between
genetic structure and environment and results in marked heterogeneity,
seen in elderly.
Physiological aging or homeotension is marked by changes at
anatomical, physiological and pharmacological aspects of body resulting
in changes in clinical presentation of diseases, treatment modalities.
Clinical features of disease become no organ specific & multifactorial,
co-morbidities, socio-economic factors; physiological aging and drugs
are important factors in atypical clinical presentations. Some morbidity
patterns are age specific.
Treatment goals differ in elderly drug choice and dosages are directed
by altered pharmacokinetics and pharmacodynamics. Adverse drug
reactions and drug interactions are quite common due to altered
pharmacology, co-morbidities and polypharmacy.
Rehabilitation is an important component of treatment of elderly to
restore the functionality. It should be started during acute illness and
rigorously pursued to attain maximum benefits.
Prevention of diseases and promotion of health is the key for healthy
ageing of geriatric population. It will not only improve quality of life of
elderly but also will be the most sensible health service.
Recommended Further Reading
1.
2.
3.
Brocklehurst JC, Tallis Raymond and Fillit. Textbook of Geriatric
medicine and Gerontology (5th ed.) Edited by Churchill Livingstone
(Pub.), 2002.
Primer on Geriatric care- A clinical approach to older patient- Editors:
Rosenblatt and US Natrajan 2002, Printers castle, Cochin.
Journal of Internal Medicine of India- Geriatric issue. 1999, 2(3).
36
Chapter- 3
JarÁvasthÁ PoÒaÆa (Geriatric Nutrition)
Introduction
Aging is the natural phenomenon for every living being on the earth so also for
human beings. According to Sushruta, VÁrdhakya is natural disorder
(SvabhÁva) and this can be restrained to some extent with the use of RasÁyana
remedies (See Chapter – 4). RasÁyana essentially denotes improved nutrition
and nourishment by practicing ÀcÁra RasÁyana i.e healthy life style, Àjasrika
RasÁyana or rejuvenative dietetics and RasÁyana drugs as and when needed.
Every living being has to pass through three phases in his life span with
predominance of VÁta, Pitta and Kapha doÒa in Véddha, YuvÁ and BÁlya
avasthÁ respectively. This is of great significance in health and disease state
because their maintenance is possible only by proper use of dietary substances
in consideration of the TridoÒika Principles. Thus the Ayurvedic dietetics and
nutrition are largely governed by the doctrine of PancamahÁbhÚta and TridoÒa
Features of Senility
DhÁtu KÒaya - Rasa-rakta-mÁïsa-meda-asthi-majjÁ and Ðukra dhÁtukÒaya
causes following disorders:
• HétpiÕÁ (cardiac pain), Kampa (tremer), TéÒÆÁ (thirst), SirÁ Ðaithilya
(venous changes), DhamaniÐaithilya (arterial changes).
• Sandhi saumyatÁ, AsthikÒaya (decay of bone), AsthiÐÚla (pain in bone),
AlparaktatÁ (loss of haemoglobin), Maithune asakti (loss of sexual act).
• MandaceÒÔatÁ (diminished activity), RÚkÒatÁ (body dryness),
NiÒprabhatÁ (lack of lusture), MandoÒmÁ (diminished body heat),
MandÁgni (loss of appetite), ViÒamÁgni (irregular appetite), AnidrÁ
(insomnia).
Visible mental changes:
PrajÁgaraÆa (vigil), AtipralÁpa (talkative), Adhairya (intolerance), Bhaya
(fear), ViÒÁda (sorrow), Ïoka (grief).
Status of Agni in JarÁvasthÁ
Concept of Agni in Ayurveda - JÁÔharÁgni-one; DhÁtvÁgni-seven, BhÚtÁgnifive, Different kinds of Agni and their location in body are important in this
context.
JÁÔharÁgni and its four kinds- Sama (balanced); ViÒama (imbalance); TÍkÒÆa
(hyper); Manda (low). Sapta-dhÁtvÁgni-Rasa-rakta- mÁïsa -meda-asthi-majjÁ
37
and Ðukra and their importance to maintain healthy state of life and JarÁavasthÁ. Panca bhÚtÁgni and Pancavidha vipÁka and their significance in
Health and JarÁ-avasthÁ.
Influence of CintÁ (anxiety), Ïoka (grief), Bhaya (fear), Krodha (anger), Dukha
(sorrow), AnidrÁ (insomnia) on JaÔharÁgni. Inter-relation of JaÔharÁgniDhÁtvÁgni and BhÚtÁgni in health and disorders of JarÁ-avasthÁ.
Upacaya (dehapuÒÔi) and Apacaya (dhÁtukÒaya) in health and JarÁ-avasthÁ
respectively. Action of PancabhautikÁgni, Sapta-dhÁtvÁgni and one JÁÔharÁgni
in the maintenance of health and alleviation of disorders particularly in
VÁrdhakya.
Impact of Emotional Factors
•
CintÁ (anxiety) and its influence on JatharÁgni and RasadhÁtu.
• Ïoka (grief) and its influence on JaÔharÁgni, Rasa and
RaktadhÁtu.
• Bhaya (fear) and its influence on JaÔharÁgni, Rasa, Rakta
and mÁïsa dhÁtu.
• Krodha (anger) and its influence on JaÔharÁgni, Rasa,
Rakta and mÁïsa dhÁtu.
• Du½kha (sorrow) and its influence on JaÔharÁgni &
DhÁtvÁgni.
• Anidra (insomnia) and its influence on JaÔharÁgni,
DhÁtvÁgni and Pancabhutagni.
• Influence of CintÁ, Ïoka, Bhaya, Krodha, Du½kha and
AnidrÁ on VÁta, Pitta and Kapha causing early aging
DhÁtupoÒaÆa and maintenance of Health in JarÁ-AvasthÁ
• Concept of SaptadhÁtu - Rasa-rakta-mÁmsa-meda-asthi-majjÁ and
Ðukra and their co-relation with body tissues according to conventional
system of medicine.
• Physiological parameters to assess the Sapta DhÁtus - i.e. blood plasma,
white blood cells, red blood cells, haemoglobin, packed cell volume,
bleeding time, coagulation time, muscular strength, measurement of
body surface area having excessive fat deposition, study of bone density,
bone marrow sperm count etc.
• DhÁtupoÒaÆa in Ayurveda through Svayonivardhana dravya prayoga• Rasa dhÁtu poÒaÆa - Madhura, Snigdha, ÏÍta dravya.
• Rakta dhÁtu poÒaÆa - Amla, Guru, Snigdha, UÒÆa dravya.
• MÁïsa dhÁtu poÒaÆa - Amla, LavaÆa, UÒÆa dravya.
38
• Meda dhÁtu poÒaÆa - Madhura, Guru, ÏÍta, Snigdha dravya.
• Asthi dhÁtu poÒaÆa - Sthira, ViÒada dravya.
• MajjÁ dhÁtu poÒaÆa - Snigdha, Pichhila, ÏÍta dravya.
• Ïukra dhÁtu poÒaÆa - Snigdha, Pichhila, Sthira, VéÒya Karma
dravya.
• DhÁtupoÒana in JarÁ-avasthÁ • Dravyas having following properties are best in JarÁ-avasthÁ Laghu, Snigdha, Pichhila, ÏlakÒÆa, Médu.
SaptadhÁtusÁra, Ojas, and Bala in JarÁ-AvasthÁ
Concept of ojas in Ayurveda - Ojas is a substance of white or red,
slightly yellowish in colour, which resides in the heart. A person dies if
it para oja is destroyed in the body of the living being. The ojas is
produced first. This has the colour of ghéta, taste of honey and smell of
fried paddy. From the heart as root, ten great vessels carrying ojas
pulsate all over the body.
The final essence or most precious part of all the seven dhÁtus, from
Rasa to Ïukra, is called ojas and that is also known as bala (SuÐruta)
PrÁkéta guÆa of ojas are- SomÁtmaka, Snigdha, Ïukla, ÏÍta, Sthira,
Sara,
Vivikta,
Médu,
Métsnam
and
Uttama.
Ojas
is
sarvadhÁtusÁra/SnehÁïsa (utkéÒÔÁïÐa) like Ghéta in milk found in each
of the seven dhÁtus.
Ojas is Bala (strength). Ojas is KÁraÆa (cause) and Bala is its kÁrya
(effect). Because of its affect in the body in the form of strength ojas is
known as Bala. (Ojastadeva balam - SuÐruta). Ojas is the seat of prÁÆa
and diminution of ojas causes decay of the body. Thus the existence of
body is dependent upon ojas. It is of two kinds para and apara which is
aÒÔabindu pramÁÆa and Ardha añjali pramÁÆa respectively.
According to Caraka when ojas is diminished the person is bhÍta
(fearful), durbala (weak) dhyÁyati (always worried), byathita indriya
(having disorder in sense organs) duÐchhÁyÁ (deranged lusture),
durmanÁ (mentally disturbed), rÚkÒa (rough) and kéÐa (emaciated).
Excessive VyÁyÁma (exercise), anaÐana (fasting), cintÁ (anxiety), rukÒa
(rough), alpapramitÁÐana (little and measured diet), vÁtÁtapau
(exposure to wind and sun), bhaya (fear), Ðoka (grief), rukÒapÁna
(unctuous drinks), prajÁgarana (vigil), excessive loss of kapha, ÐoÆita
(blood), Ïukra, mala (excreta), kÁla (ageing), bhÚtopaghÁta (injury by
invisible organism), are known for loss of ojas.
RasÁyana Drug substances and DhÁtupoÒaÆa
RasÁyana has been one of the important branches of AÒÔÁnga Ayurveda
since very beginning as found in Caraka SamhitÁ and SuÐruta SamhitÁ.
39
The very object of RasÁyana is to live long life without any disorders.
According to Caraka, the means by which one gets the excellent rasÁdi
saptadhÁtu - rasa-rakta-mÁïsa-meda-asthi-majjÁ and Ðukra, is called
RasÁyana.
Benefits of RasÁyana - according to Caraka people who undergo
RasÁyana therapy obtain longevity and freedom from disease.
Drug Substance of Plant Origin Used as DhÁtupoÒaÆa (Nutritive)
AindrÍ (Bacopa monnieri), Kapikacchu (Mucuna pruriens), AtirasÁ
(Asparagus racemosus), PayasyÁ (Holostemma rheedei), KÒiravidÁri
(Ipomoea digitata), AÐvagandhÁ (Withania somnifera), BalÁ (Sida
cordifolia), AtibalÁ (Abutilon indicum), AmétÁ (Tinospora cordifolia),
AbhayÁ (Terminalia chebula), DhÁtrÍ (Emblica officinalis), JivantÍ
(Leptadenia reticulata), ManÕÚkaparÆÍ (Centella asiatica), SthirÁ
(Desmodium gengaticum), PunarnavÁ (Boerhaavia diffusa).
Drug Substances of Mineral Origin used as DhÁtupoÒaÆa (Nutritive)
SvarÆa (gold), Rajata (silver), TÁmra (copper), YaÐada (zinc), Vanga
(tin), Loha (iron), Abhraka (mica).
Mineral origin drugs are mostly used in the form of Bhasma. Before using
them one must ensure that they are made in accordance with the classical
methods for best efficacy, least adverse effect and of standard quality.
Dietary substances Administered as DhÁtupoÒaÆa(Nutritive)
DhÁtupoÒaÆa: Substances, which have ultimate effect to nourish the
seven bodily dhÁtus, are either vegetable/plant or animal origin.
• Vegetable origin- JivantÍ-ÐÁka (leave of Lepadienia reticulata),
PunarnavÁ ÐÁka (leave of Boerhaaira diffusa and Boerhaavia
verticilata), ÏatÁvarÍ ankura (young shoots Asparagua racemosus),
BalÁpatra (leaves of Sida cordifolia) ÏéngÁÔaka fruit (endosperm of
Trapa-bispinosa), VÁrÁhÍkanda (bulb of Dioscorea bulbifera), KharjÚra
(fruit of Phoenix dactylifera), AkÒoÔa (endosperm of Juglans regia),
VÁtÁda (endosperm Prunus amygdalus), MédvikÁ (dried fruit Vitis
unifera).
• Animal origin: MÁïsa of AjÁ (goat), Àvika (lamb), VÁrÁha (pig),
Cataka (sparrow), KukkuÔa (male chicken), AÆÕÁ (egg), Matsya (fish).
The commonly used dietary supplements as DhÁtupoÒaÆa (nutritive)
are: CyavanaprÁÐa, AmétaprÁÐa, BrÁhmarasÁyana, ÀmalakÁvaleha,
BhallÁtaka KÒira etc.
Cow ghee with milk administration of other traditional preparations like
- MethÍ ke laÕÕÚ, Harira, Gonda kÍ paÔÔÍ/ laÕÕÚ etc.
40
Rules of Dietary Conduct
The principles of AÒÔa ÀhÁra vidhi viÐeÒÁyatana i.e. eight rules of dietary
processing described by Caraka and DvÁdaÐa Àsana vicÁra (12 – rules of
consuming food) should be popularized among the masses to improve the
dietary habit of the people. Similarly the concept of viruddhÁhÁra (dietary
incompatibility) and its 18 – fold approach need to be observed in dietary care
and the idea should be brought to the awareness of the masses; if possible such
information should form a part of elementary education in schools, in families
and in old age homes alike. It will be advisable to identify common food
articles in terms of their TridoÒik attribute to help planning balanced diet on
principles of Ayurveda.
Planning Balanced Diet for the elderly:
The balanced diet of elderly people should be planned individually in
consideration of the following principles ensuring appropriate nutrition for
body-mind system and suitable for digestion of food.
1. Vaya (Age) and its range.
2. Prakéti- Psychosomatic constitution.
3. Season and weather
4. Quantum of mobility and physical activity
5. Current nutritional status
6. Associated diseases if any
7. Status of digestive power and Agni Bala.
8. Preference should be given to light easily digestible diet comprising
of SÁttvika articles such as milk, fruits, green vegetables avoiding
excess of sugar and salt.
9. Vegetarian diet should be preferred. Non vegetarian diet to be
avoided.
10. Dietary supplements with RasÁyana and appropriate nutraceuticals
should be added.
Dietary guideline for certain diseases of old age
The planning of diet for an ailing old person largely depends on the individual
vision of a treating physician in consideration of the age as well as the
associated disease and a range of environmental factors. However, some
guidelines are being given here under.
1. Habitual constipation
• Predominantly liquid and semisolid diet.
• Rich fibre diet considering Agni Bala.
• Adequate water, preferably lukewarm.
• Fruits and green vegetables.
• A spoon of ghee in every meal.
• Appropriate dietary supplements, vitamins, minerals and a RasÁyana
recipe viz. AbhayÁriÒÔa, TriphalÁ, or fried HarÍtakÍ cÚrÆa at bed time.
41
2. Chronic Diarrhoea
• Reduce fat and protein content.
• Maintain fluid intake.
• Replace milk by Takra one cup 2-3 times a day.
• Add fruits like Bilva, Banana, DÁÕima.
• All foods should be warm, soft spices.
• KéÐarÁ of rice, Munga DÁla.
• Dietary supplements, vitamins, minerals and RasÁyana recipes like
Bilva cÚrÆa, KuÔaja-Bilva PÁnaka, TakrÁriÒÔa etc.
3. Arthritis and Rheumatism
• Avoid nonvegetarian food.
• Promote low protein diet.
• Avoid cold, stored raw foods
• Promote warm soft spicy food.
• Avoid all Kaphakara foods
• Lukewarm water medicated with TrÍkaÔu may be used for drinking.
• PaÉcakola phÁnta half cup twice daily after major meals.
• Dietary supplements- Minerals, Vitamins and RasÁyana recipes like
GuÕÁrdraka, DrÁkÒÁriÒÔa, AÐvagandhÁ RasÁyana, Améta BhallÁtaka etc.
4.
•
•
•
•
•
•
•
•
•
5.
•
•
•
•
•
•
Diabetes Mellitus
Low fat, low carbohydrate diet.
Reduce Kaphaj articles of diet like sweet and oleus substances viz.
sugars and sugar containing items- potatoes, raw rice and sweet fruits.
Promote edible spices viz. ÏuÆÔhÍ, PippalÍ, Marica, Rasona, PalÁÆdu,
Tejapatra.
Warm food and drink.
Lukewarm water medicated with TrÍkaÔu for drinking.
Sprouted MethÍkÁ seeds for chewing and swallowing as part of
breakfast.
Bitter leafy vegetables like PÁlaka, BÁstuka, KarelÁ, PaÔola etc.
Fruits- JambÚ, Bilva, Kapittha etc.
Dietary supplements and RasÁyana recipes viz. ÏilÁjatu, AÐvagandhÁ,
AmétÁ, ÀmalakÍ RasÁyana, JambÚ beeja.
Hypertension and IHD
Reduce sugar and fat in food.
Reduce salt intake as per clinical condition.
Add soft spices to promote taste and to promote Agni.
Promote bitter leafy vegetables and citrus fruits.
Butter free milk and Takra.
Avoid alcohol and coffee. Prefer green tea.
42
• Dietary supplements and RasÁyana recipes viz. Arjuna twak cÚrÆa,
AÐvagandhÁ.
6.
•
•
•
•
•
•
7.
•
•
•
•
•
•
8.
Respiratory diseases
Adequate calories and warm food.
Avoid cold and raw uncooked food and other Kaphaja substances.
Promote lukewarm spiced water for drinking.
Avoid buttermilk, ice creams, too much of sweets and fatty meals.
Bitter leafy vegetables.
Dietary supplements and RasÁyana recipes viz. GudÁrdraka,
CyavanaprÁsa, HaridrÁkhaÆÕa, ÏirÍsÁdi Avaleha, KaÉÔakÁryÁvaleha
etc.
•
•
•
•
•
•
•
Hepatobiliary conditions
Low fat, rich carbohydrate diet.
Monitored salt and water intake.
Bitter leafy vegetables and citrus fruits.
Butter reduced milk and Takra
Stop alcohol and coffee.
Promote green tea.
Dietary supplements and RasÁyana recipes viz ÀmalakÍ RasÁyana,
Àrogya VardhinÍ VaÔÍ, Phala TrikÁdi PhÁÆÔa.
•
•
•
•
•
•
•
Infections and Malignancies
Ensure adequate calories and protein supplements.
Regulated salt water intake as per clinical condition.
Ensure adequate mineral and vitamin supplement.
Prefer warm and soft spicy food.
Warm spiced water for drinking.
Bitter leafy vegetables and citrus fruits.
Dietary supplements and RasÁyana recipes viz Améta BhallÁtaka,
Àmalaki RasÁyana, BhÚmyÁmalaki cÚrÆa.
9.
10.
Urinary diseases
Low protein diet with adequate calories.
Monitored salt water intake as per clinical condition.
Fruits- citrus fruits
Avoid spicy food.
Avoid constipating food.
Dietary supplements and RasÁyana recipes viz. ÏilÁjatu, VaruÆa, Ïigru,
CandanÁsava.
AgnimÁndya and AjÍrÆa
• Langhana, DÍpana, PÁcana.
43
•
•
•
•
•
•
Relatively semisolid/liquid diet.
Warm spicy food.
Lukewarm spiced water for drinking.
Spiced vegetable soups.
Replace milk by Takra.
Appropriate dietary supplements and Agni bala vardhaka RasÁyanas
Viz. LavaÆÁrdraka, PippalyÁsava, TakrÁriÒÔa.
Recommended Further Reading
1. Relevant Chapters of Caraka Samhita
2. Biogenic Secrets of diet by Gupta, L. P. Chaukhamba Publication,
Varanasi
3. Kayachikitsa vol. I Chapter 12 on Ahara and Pathyapathy by Singh, R.
H. Chaukhambha Surabharati Varanasi
4. Swasthavritta vijnÁna Chapter 7 on AhÁra and AhÁravidhi by Singh,
R. H. Chaukhambha Surabharati Varanasi
5. Bhava Prakasa Relevent Chapters.
44
Chapter- 4
RasÁyana Therapy and Rejuvenation
Ayurveda, the science of life and longevity has been practiced in India since
inception in an AÒÔÁngic form through its Eight specialty branches. One of the
Eight branches is specially devoted to the uplift of nutrition, immunoenhancing and longevity. It is called RasÁyana Tantra. As this manual is
designed to assist geriatric health care training RasÁyana Tantra is its central
focus. The present chapter will discuss in detail the definition and scope of
RasÁyana, mode of action of RasÁyana measures, their classification and range
of application, methodology of RasÁyana Karma and its indications, contraindications and complementary uses besides observations on future potential
development of RasÁyana therapy in newer areas in contemporary times.
The Classical Textual References
• Caraka SamhitÁ CikitsÁ SthÁna Chapter 1, PÁda 1-4
1. AbhayÁmalakiya RasÁyana
2. PrÁÆa KÁmiya RasÁyana
3. Karapracitiya RasÁyana
4. Ayurveda SamutthÁniya RasÁyana
• SuÐruta SamhitÁ CikitsÁ SthanÁ Chapter 27-30
27. SarvopaghÁta Ïamaniya RasÁyana
28. MedhÁyuÒkÁmiya RasÁyana
29. SwabhÁwa VyÁdhi PratiÒedhaniya RasÁyana
30. Nivritta SantÁpiya RasÁyana
• AstÁnga Hridaya Uttar Tantra Chapter 39
39. RasÁyana Vidhi AdhyÁya
Definition and Scope
The term RasÁyana (Rasa + Ayana) refers to the procurement of nourishment
for formation of the best qualities of DhÁtus or body tissues which leads in turn
to improved physiological state, immunity, bio strength, mental competence
and longevity– “LÁbhopÁyo hi ÐastÁnÁm rasÁdinÁm RasÁyanam. (Caraka);
YajjarÁvyÁdhi nÁÐanam tad RasÁyanam (ÏÁrangdhara)”. Thus RasÁyana karma
has comprehensive scope to positive nutrition, immuno-enhancing, longevity
and sustenance of mental and sensorial competence. Besides promotion of
mental and physical health and rejuvenation potential, RasÁyana karma affords
a preventive role against all range of diseases through improved immunity and
biostrength. Thus RasÁyana is the central consideration in Ayurvedic
Geriatrics.
45
Mode of Action
All RasÁyana measures and remedies produce their effect in the mind-body
system through one or all of the following three modes1:
1. At the level of Rasa by directly acting as a nutrient in itself enriching the
nutrient value of PoÒaka Rasa in the plasma. The examples are a range
of nutrient RasÁyanas like ÏatÁvari, ÏarkarÁ, Ghrita, PravÁla, MuktÁ
etc.
2. At the level of Agni by promoting the biofire system of the body with
positive digestive and metabolic functions in turn promoting nutrition
such as Pippali, ÏunÔhi, Citraka etc.
3. At the level of Srotas i.e. microcirculation by inducing SrotoprasÁdana
effect improving the competense of inner transport system,
microcirculation and tissue perfusion such as Guggulu RasÁyana.
By acting through the above modes the RasÁyana Karma establishes a
positive nutritional status in the body, helps in healthier tissue formation,
stronger immune status, improved mental power and long life. All this put
together amounts to rejuvenation or KÁyÁkalpa, of course in a limited meaning.
Classification
As envisaged in Ayurveda RasÁyana is not a mere remedy or a recipe. It is a
rejuvenative regimen and is an approach to positive health. It encompasses
elements of positive life-style and conduct, healthy dietetics and rejuvenative
herbs and minerals. RasÁyana is practiced as a routine open life-style form or
as an intensive indoor regimen depending upon the need and the feasibility for
a client. The RasÁyana therapy can be categorised in the following manner.
A. As per method of use:
1. VÁtÁtapika RasÁyana or outdoor practice.
2. KuÔiprÁveÐika RasÁyana or intensive indoor regimen (inclusive of
Pancakarma) using a specially designed Trigarbha RasÁyana KuÔi
or therapy chamber.
B. As per scope of application :
1. KÁmya RasÁyana – For promotion of health of the healthy, further
sub-categorised as :
a. Sri KÁmya – To promote lusture and beauty.
b. PrÁÆa KÁmya – To promote longevity.
c. MedhÁ KÁmya – To promote mental competense
2. Naimittika RasÁyana – To impart biostrength in a diseased person to
fight better with his existing diseases.
1
ykHkksik;ks fg 'kLrkuka jlknhuka jlk;ue~A p0 fp0 1
LÁbhopÁyo hi ÏastÁnÁÞ RasÁdinÁÞ RasÁyanaÞ. CS. Ci. 1
46
C. Adjunct RasÁyana – Non-recipe rejuvenative regimen to be practiced
alone or as an adjunct for all forms of RasÁyana therapy, remedies and
recipes viz.
1. ÀcÁra RasÁyana – Healthy rejuvenative life style and conduct.
2. Àjasrika RasÁyana – Daily dietary RasÁyana approach consuming
SÁttvika, nourishing elements of diet viz. ghee, milk, milk products,
fruits and vegetables etc.
Planning Age Specific RasÁyana
Aging is the SwabhÁwa or the nature of a living-being. The physical bodymind system has been designed to stay for a time–bound tenure approximately
100 years. During the life span the body undergoes progressive involution and
decay leading ultimately to decadence and death. Ayurveda deliberates on the
process of aging and sequential senile changes in different ways in different
contexts such as BÁlyÁwasthÁ, Madhya AwasthÁ and BriddhÁwasthÁ hallmarked by Kapha, Pitta and VÁta activities respectively. VÁta is the drying and
decaying force and is the master DoÒa in the aging process.
Vagbhatta and Ïarangdhara describe an unique scheme of biological aging in a
ten-decade frame speculating the specific sequential loss of certain bio-values
specific to respective decades of life. This information opens the possibility of
developing specific RasÁyanas to restore the likely losses of the particular
decade. If RasÁyana therapy is planned in relation to age there is a possibility
of retarding the aging process. The following table describes the pattern of agerelated biolosses and proposes certain RasÁyanas for the purpose2. .
S.No.
Decades of Natural Biolosses
Life Span
1.
0 –10
BÁlya – Corpulence
Suggested RasÁyana for
restoration
GambhÁri, KÒira, Ghrita
2.
11 – 20
Vriddhi – Growth
BalÁ, Àmalaki
3.
21 – 30
Chhabi – Lusture
Àmalaki, HaridrÁ
4.
31 – 40
MedhÁ – Intellect
BrÁhmi,ÏankhapuspÍ
5.
41 – 50
Twaka – Skin quality
BhringrÁja, HaridrÁ
6.
51 – 60
DriÒÔi – Vision
TriphalÁ, Jyotismati
7.
61 – 70
Ïukra – Virility
AÐvagandha, Kapikacchu,
2.
ckY;ao`f)'NfoesZ/kk Rod~n`f"V'kqØfoØekSA
cqf)% desZfUæ;a psrksftfora n'krks glsr~AA & 'kk0 l0 II : 2: 20
BÁlyam vriddhiÐcchabirmedhÁ Twak dristi Ïukravikramou,
Buddhií Karmendriyam Ceto Jivitam DaÐato Hraseta. SS II.6.20
47
ÏatÁvari, PippalÍ
8.
71 – 80
Vikrama – Physical strength
Àmalaki, BalÁ
9.
81 – 90
Buddhi – Thinking
BrÁhmi, ÏankhapuÒpÍ
10.
91 – 100
Karmendriya – Locomotion
BalÁ, Sahacara
Tissue and Organ Specific RasÁyana
Although RasÁyana in general is a holistic restorative and rejuvenative
modality, one can visualise some RasÁyana remedies and recipes for specific
promotion and protection of certain specific tissues and organs. Such
RasÁyanas can be prescribed in need-based manner for promotive or even for
curative purposes for organ protection. Some examples are proposed in the
following table.
S.No. RasÁyana quality
Purpose
Suggested remedies
1.
Medhya RasÁyana
ÏankhapuspÍ,
Promotion of Brain and BrÁhmi,
Mandukaparni
cognitive functions
2.
Hªdya RasÁyana
Cardioprotective
Arjuna, PuÒkarmÚla
3.
MÚtra Janana
Nephroprotective
PunarnavÁ, GokÒuru
4.
Twacya RasÁyana
Skin Health
HaridrÁ, SomarÁji
5.
CakÒuÒya RasÁyana Eye Health
TriphalÁ, JyotiÒmatÍ
6.
KanÆÔhya RasÁyana Throat and speech
VacÁ, YaÒÔimadhu
7.
Vrisaya RasÁyana
For virility
AÐvagandhÁ, Kapikacchu
8.
Stanya RasÁyana
To promote Lactation
ÏatÁvarÍ
9.
SrotoprasÁdana
To promote inner
transport
Guggulu
10.
Nasya RasÁyana
To help nose and sinuses
Katphala, ApÁmarga
Disease Specific/Naimittika RasÁyana
Although RasÁyana therapy is primarily a promotive and preventive health care
modality a concept of disease-specific RasÁyana therapy has been projected by
Susruta and his commentator Dalhana under the term Naimittika RasÁyana i.e.
VyÁdhi-Nimitta RasÁyana. Susruta gives only two examples for Naimittika
RasÁyana namely ÏilÁjatu and TubÁraka RasÁyana for Prameha (Diabetes)
and KuÒÔha (Leprosy) respectively. However, in the contemporary contexts one
can visualise using a range of other RasÁyanas for different diseases. The
Nimittika RasÁyana is really not a specific treatment of a disease entity, rather
is a RasÁyana for promoting the strength and immunity of a patient to fight
48
with his existing disease in RasÁyana way. A few Naimittaka RasÁyanas are
suggested in the following table.
Selected Diseases
Suggested Naimittika RasÁyana
Diabetes melltius
ÏilÁjatu, HaridrÁ
Leprosy & Dermatoses
TubÁraka, HaridrÁ, SomarÁji
Bronchial Asthma
HaridrÁ, ÏiriÒa
Hypertension & IHD
SarpagandhÁ, PuÒkaramula, Arjuna
Urinary Disorders
PunarnavÁ, GokÒuru
Arthritis
BhallÁtaka, Eran±a, Guggulu
Neurodegenerative Diseases
BrÁhmi, AÐvagandhÁ
Dementia
BrÁhmi, ÏankhapuspÍ
Immunodeficiency
ÀmalakÍ, Gu±uci
Cancers
BhallÁtaka, ÀmalakÍ
Àcara and Àjasrika RasÁyana
Àcara RasÁyana is an unique concept in Ayurveda which implies that a moral,
ethical and benevolent conduct viz truth, nonviolence, personal and public
cleanliness, mental and personal hygiene, devotion, compassion and yogic life
bring about rejuvenative state in the body-mind system. A person who adopts
such a life-style and conduct gains all benefits of RasÁyana therapy without
physically consuming any material RasÁyana remedy and RasÁyana recipe. All
forms of Sadvritta, Àcara and practice and Yoga and spirituality produce such
a quantum RasÁyana effect in a non-pharmacological way. This can be
practiced alone or in a combination with material substance RasÁyana therapy.
The term Àjasrika RasÁyana refers to daily rejuvenative dietetics with adequate
quantity of nourishing SÁtvika elements of diet viz ghee, milk, fruits,
vegetables. Àjasrika RasÁyana is used alone or along with material RasÁyana
remedies.
Divya (Soumya) RasÁyana
Ayurvedic classics as well as the Vedic texts present an unique concept of
Divya RasÁyana which is claimed to possess devine power to bring about
devine transformation in an individual. Caraka, Susruta and Vagbhatta describe
a number of Divya RasÁyana MahouÒadhis with paranormal attributes. They
are supposed to grow in Soumya Himalayana range and are rarely found. This
class of RasÁyanas, which are of plant origin, display a kind of spiritual
pharmacology and their actions are due to their Divya PrabhÁva. Caraka
Samhita Ckikitsa Sthana Chapter – 1, Pada-4 (Ayurveda SamutthÁniya
RasÁyana), Susruta Samhita Chikitsa Sthana Chapter-30 (Nivritta SantÁpiya
RasÁyana) and AÒÔÁnga Hridaya Chapter 39 mention a range of Divya AuÒadhis
49
such as Brahma SubarchalÁ, SomÁ, PadmÁ, VÁrÁhi, Golomi, AjagarÍ etc. The
identify of these drugs is presently unknown and this entire context warrants
serious research.
SamÐodhana for RasÁyana Therapy
Besides Àcara and Àjasrika components another important requirement for use
of material RasÁyana therapy is SamÐodhana through appropriate Panca
Karma procedures. Ayurveda emphasises that a RasÁyana remedy yields its
full effect only when the body has been therapeutically purified by Langhana,
Deepana, PÁcana, Snehana, Swadana, Vamana, Virecana, Vasti, Ïirovirecana
etc. If the SrotÁmsi i.e. micro-channels of the body are clean and competent
with their physiological integrity at the time of administration of the RasÁyana
remedy, it is fully utilized by the system and its bioavailability is ensured.
Hence SamÐodhna Karma should be planned accordingly. The most
appropriate choice of age for use of RasÁyana therapy is Purva Vaya or
Madhya Vaya i.e. young or adult age, not the actual old age when irreversible
senile changes might have already occured.3.
Guidelines to Select a RasÁyana
In all procedures of RasÁyana therapy a physician is expected to take due
consideration of many individual and environmental factors while selecting a
RasÁyana remedy for a particular client. Few of the factors to be considered are
mentioned below :
1. Vaya i.e. age group of the individual.
2. Prakriti or constitution of the individual.
3. Agni Bala i.e. digestive and metabolic status.
4. DhÁtu Status i.e. consideration of the status of Sapta DhÁtus (Seven
Primary body tissues and their nutritional status).
5. Oja Bala and Oja DoÒa i.e. vitality and immune status as well as
immune disorders if any.
6. Srotas Status i.e. status of functioning of the inner transport system and
microcirculation.
3.
iwosZ o;fl e/;s ok euq";L; jlk;ue~ A
iz;qathr fHk"kdizkK% fLuX/k'kq)ruks% lnk aAA
ukfo'kq)'kjhjL; ;qDrks jlk;uks fof/k% A
u Hkfr oklfl fDy"Vs j³~x;ksx bofgr% AA lq- fp- 27% 3 4
Purvevayasi madhye wÁ ManuÒyasya RÁyanam;
Prayunjita BhiÒak prÁjnaí snigdhsuddha tanoh sadÁ.
NaviÐuddhaÐarirasya yukto RasÁyana vidhihi ;
Na BhÁti vÁsasi klisÔe Rangayoga ivahitaí SS. Ci 27:3-4
rLekRiqjk 'ks/keso dk;Zacykuqjwia ufg o`";;ksxk% A
fl/;fUr nsgs efyuks iz;qRdk% fDy"Vs ;Fkk oklfl jkx;ksxk% AA p-fp- [email protected] % 51
TasmÁtpurÁ Ðodhnameva kÁryam BalÁnurupam NahivéÒyayoga½ ;
Sidhyanti Deha Maline PrayuktÁ½ kliÒÔe yathÁ vÁsasi rÁgayoga½ . CS. Ci.2/1 : 51
50
7. DeÐa SÁtmya i.e. climatic variations viz. SÁdhÁraÆa DeÐa, JÁngala
DeÐa, Ànupa DeÐa etc.
8. Ritu SÁtmya or season i.e. consideration of the six Ritus as well as
ÀdÁna and Visarga KÁla of the year.
9. VyÁdhi and VyÁdhi Bala i.e. disease state if any.
10. Manobala or mental stamina.
Persons with different categories and features of the above mentioned factors
would need different RasÁyanas in consideration of their biological features to
yeild best results. Some decades of life are associated with different specific
biological losses due to aging and hence their is a need to compensate these
losses with specific RasÁyana remedies as mentioned earlier in this chapter
using Ïarangdhara's scheme of aging as a guideline.
Suggested RasÁyanas for Different Prakritis, KÁla & Agni Bala
●
Vata Prakriti
:
AÐvagandhÁ, BalÁ, GÁmbhÁri, Rasona, AmritÁ,
Ïankhapuspi, CyavanaprÁÐa, BrÁhma RasÁyana.
●
Pitta Prakriti
:
Àmalaki, Candana, BrÁhmi, MuktÁ, PravÁlapiÒÔi, Àmalaka
RasÁyana.
●
Kapha Prakriti
:
Pippali, Àrdraka, ÏilÁjatu, Bibhitaka, BhallÁtaka
RasÁyana.
●
RÁjasa Prakriti
:
BrÁhmi, Man±Úkaparni, ÏankhapuÒpÍ, MuktÁ.
●
TÁmas Prakriti
:
Pippali, Àmalaki, Citraka, BhallÁtaka etc.
●
Àdana KÁla
:
AÐwagandhÁ, Àmalaki, BrÁhmi, Candana, Khasa.
●
Visarga KÁla
:
Pippali, ÏilÁjatu, BhallÁtaka, Kasturi,Ïringa.
●
VishamÁgni
:
AÐwagandhÁ, Rasona.
●
TiksnÁgni
:
ApÁmÁrga, Ïankha, PravÁla, KumÁri, BrÁhmi.
●
MandÁgni
:
Pippali, Sunthi, Ghrita, Citraka, LavaÆa.
A physician should select a suitable RasÁyana in consideration of different
individual and environmental factors taking into account the principle of
SÁmÁnya and ViseÒa (Homology vs Heterology).
Enlisting Singles, Groups and Compound RasÁyanas
A range of single drugs, group and compound RasÁyanas have been described
in Ayurvedic classics in different contexts. Some are enlisted below:
Popular Single RasÁyanas – Àmalaki, Haritaki, Pippali, AÐwagandhÁ,
BrÁhmi, ÏankhapuÒpÍ, GudÚci, MadhuyaÒÔi, ManÕukparÆi, BalÁ, ÏatÁvri,
BhallÁtaka, PunarnavÁ, Lauha, SwarÆa, ÏilÁjatu etc.
51
Àmalaki: Emblica officinalis
Haritaki: Terminalia chebula
AÐvagandhÁ: W. somnifera
BrÁhmi: Bacopa Monnieri
MaÉdÚkaparÆÍ: C. asiatica
ÏankhapuÒpÍ: C. prostratus
GuÕÚci : Tinospora cordifolia
PunarnavÁ: Boerhaavia diffusa
MadhuyaÒÔhi: G. glabra
ÏatÁvarÍ : Asparagus racemosus
52
Kapikacchu: Mucuna. pruriens
PippalÍ: Piper longum
Classical RasÁyana Groups:
• JÍvaniya MahÁkaÒÁya Varga (Caraka Su. 4.9.) : 1. Jivaka, 2.
RiÒabhaka, 3. MedÁ, 4. MahÁmedÁ, 5. KÁkoli, 6. KÒirakÁkoli, 7.
MudgaparÆi, 8. MÁÒaparÆi, 9. JivantÍ, 10. Madhuka.
• BrimhaÆiya MahÁkaÒÁya (Caraka Su. 4.9) : 1. KÒirini, 2.
RÁjaksavaka, 3. VatyÁyani (Ïweta BalÁ), 4. Bhadraudani (Pita BalÁ), 5.
AÐwavandhÁ, 6. KÁkoli, 7. KÒirakÁkoli, 8. BhÁradwÁji (VanakaprÁsi), 9.
PayasyÁ (VidÁrikanda), 10. RiÒyagandhÁ.
• Balya Varga (Caraka Su. 4:10) : 1. AindrÍ, 2. RiÒabhi, 3. AtirasÁ
(ÏatÁwari or Ridddhi), 4. RiÒya, 5. Prokta (MÁÒaparÆi), 6. PayasyÁ
(KÒÍra VidÁri or KÁkoli), 7. AÐwagandhÁ, 8. SthirÁ, 9. RohiÆi, 10. BalÁ,
AtibalÁ.
• VarÆya Varga (Caraka Su. 4:10) : 1. Candan, 2. Tunga (PunnÁga),
3. Padmaka, 4. UÐira, 5. Madhuka, 6. ManjiÒÔhÁ, 7. SÁrivÁ, 8. PayasyÁ,
9. ÏitÁ (Ïveta DÚrvÁ), 10. LatÁ (ÏyÁma DÚrvÁ).
• Kanthya Varga (Caraka. Su. 4 : 10) : 1. SÁrivÁ (AnantamÚla), 2.
IkÒumÚla, 3. Madhuka, 4. Pippali, 5. DrÁkÒÁ, 6. VidÁri, 7. Kaitarya
(KaÔphala), 8. Hansa PÁdi, 9. Brihati, 10. KanÔakÁri.
• Stanya Janana (Caraka Su. 4 : 12) : 1. Virana, 2. ÏÁli, 3. ÑaÒÔika,
4. IkÒu BÁlikÁ, 5. Darbha, 6. KuÐa, 7. KÁsa, 8. Gundra (Gulunca), 9.
Itkata, 10. TriÆamula.
• Ïukra Janana (Caraka Su. 4 : 12) : 1. Jivaka, 2. Risabhaka, 3. KÁkoli,
4. KÒirakÁkoli, 5. MudgaparÆi, 6. MÁÒaparÆi, 7. MedÁ, 8. VriddharuhÁ
(ÏatÁwari), 9. JaÔilÁ, 10, Kulinga.
• PrajÁsthÁpana (Caraka Su. 4 : 18) : 1. AindrÍ, 2. BrÁhmi, 3. Ïatavirya,
4. Sahastra ViryÁ, 5. AmoghÁ (PÁtalÁ), 6. AvyathÁ, 7. ÏivÁ, 8. AriÒÔÁ
(KaÔu RohiÆi), 9. VatyapuÒpi, 10. VisvaksenakÁnta (Priyangu).
• VayaísthÁpana (Caraka Su. 4 : 18) : 1. AmritÁ, 2. AbhayÁ, 3. DhÁtrÍ,
4. MukhÁ (RÁsnÁ), 5. ÏwetÁ (RÁsnÁ Bheda), 6. JiwantÍ, 7. AtirasÁ
(ÏatÁwarÍ), 8. ManÕukparÆi, 9. SthirÁ, 10. PunarnavÁ.
• Carakokta Divya RasÁyana (Caraka Ci. 1/4: 7) : 1. Brahma
SuvarcalÁ, 2. ÀdityaparÆi, 3. NÁri, 4. KasthagodhÁ, 5. SarpÁ, 6. Soma,
7. PadmÁ, 8. AjÁ, 9. NilÁ.
• Susrutokta Divya (Soumya) RasÁyana (Su.Ci. 30 : 5) : 1. AjagarÍ, 2.
ÏwetakapotÍ, 3. KriÒÆa KapotÍ, 4. GonasÍ, 5. VÁrÁhÍ, 6. KanyÁ, 7.
ChhatrÁ, 8. AtchhatrÁ, 9. KareÆu, 10. AjÁ, 11. ChakrakÁ, 12.
ÀdityaparÆi, 13. Brahma SuvarcalÁ, 14. ÏrÁwaÆi, 15. MÁha ÏrÁwaÆi,
16. GolomÍ, 17. AjalomÍ, 18. MahÁvegawatÍ.
53
Popular formulations and Kalpa RasÁyanas:
CyavanaprÁÐa, BrÁhma RasÁyana, Àmalaka RasÁyana, Améta BhallÁtaka,
BhallÁtaka KÒirapÁka, HaridrÁ KhanÕa, BalÁ RasÁyana, AmétÁ RasÁyana,
PunarnavÁ RasÁyana, LouhÁdi RasÁyana, Aindra RasÁyana, TriphalÁ
RasÁyana, ÏilÁjatu RasÁyana, ètu HarÍtakÍ Kalpa, PippalÍ VardhamÁna Kalpa,
BhallÁtaka Kalpa, PancÁméta ParpaÔÍ Kalpa etc.
Classical Compound RasÁyanas :
Caraka SamhitÁ Cikitsa Sthana Chapter 1/1 – 4 and AÒÔÁnga Hridaya Uttara
Tantra Chapter 39 describe several classical RasÁyana formulations which are
listed below:
1. Caraka CikitsÁ SthÁna Chapter 1, PÁda-1 :
1.
2.
3.
4.
Brahma RasÁyana (1 & 2)
CyavanaapraÐa
Àmalaka RasÁyana
HaritakyÁdi Yoga (1 & 2)
2. Caraka CikitsÁ SthÁna Chapter, PÁda-2 :
1. ÏatapÁka Àmalaka Ghrita
3. SahasrapÁka Àmalaka Ghrita
5. Àmalakawaleha (1 & 2)
7. Àmalaka Curna RasÁyana
9. VidangÁwaleha
11. NÁgabalÁ RasÁyana
13. BalÁ RasÁyana
15. Asana RasÁyana
17. AmritÁ RasÁyana
19. Abhaya RasÁyana
21. DhÁtri RasÁyana
23. MuktÁ RasÁyana
25. ÏwetÁparÁjitÁ RasÁyana
27. Jiwanti RasÁyana
29. AtirasÁ RasÁyana
31. ManÕÚkaparÆÍ RasÁyana
33. SthirÁ RasÁyana
2. AtibalÁ RasÁyana
4. Chandana RasÁyana
6. Aguru RasÁyana
8. Dhava RasÁyana
10. Tinisha RasÁyana
12. Khadira RasÁyana
14. Shinshapa RasÁyana
16. PunarnavÁ RasÁyana
18. BhallÁtaka KÒira
20. BhallÁtaka GuÕa
22. BhallÁtaka YuÒa
24. BhallÁtaka Sarpi
26. BhallÁtaka Taila
28. BhallÁtaka Palala
30. BhallÁtaka Saktu
32. BhallÁtaka LavaÆa
34. BhallÁtaka TarpaÆa
3. Caraka CikitsÁ SthÁna Chapter 1, PÁda-3 :
1. ÀmalakÁyasa Brahma RasÁyana
2. KewalÁmalaka RasÁyana
3. LauhÁdi RasÁyana
4. Aindra RasÁyana
5. ManÕukparÆÍ Medhya RasÁyana
6. YaÒÔumadhu Medhya RasÁyana
7. GuÕÚchi Swarasa Medhya RasÁyana
54
8. ÏankapuÒpÍ Kalka Medhya RasÁyana
9. Pippali RasÁyana (1 & 2)
10. Pippali VardhamÁna RasÁyana
11. TriphalÁ RasÁyana (1, 2, 3, 4th)
4. Caraka CikitsÁ SthÁna Chapter 1, PÁda –4 :
1. Indrokta RasÁyana (1 & 2)
2. Droni PrÁvesika RasÁyana
5. AÒÔanga Hridaya Uttara Tantra Chapter 39 :
BrÁhma RasÁyana
BhallÁtaka Swarasa Yoga
HaritakyÁdi RasÁyana
Amrita BhallÁtÁka PÁka
ÀmalakÍ RasÁyana
Kustha NÁsaka BhallÁtaka Taila
CayavanaprÁÐa
Tubaraka RasÁyana
TriphalÁ RasÁyana
Pippali RasÁyana
MedhÁ vriddhikara RasÁyana
VardhamÁna Pippali Yoga
Pancarvinda RasÁyana
ÏunthyÁdi Yoga
BrahmyÁdi RasÁyana
BÁkuci RasÁyana
NÁgabalÁ RasÁyana
Lasuna Prayoga
Varahikanda RasÁyana
ÏilÁjita RasÁyana
Lauha ÏilÁjitu
JarÁhara LohÁdi Prayoga
Ïitodaka
PurnarnavÁ Kalpa
Haritaki Sewana
BhrinigarÁja Kalpa
Conclusion
The context of RasÁyana therapy and its Àjasrika, Àcara and Divya AuÒadhi
components are largely unexplored part of ancient wisdom. However, the
prevalent RasÁyana procedures and recipes are of great current value in
promotive, preventive and therapeutic aspects of geriatric health care. There is
a great need to acquaint the professionals as well as the public about the use of
RasÁyana remedies and recipes besides the pro-RasÁyana dietetic and life-style
regimen described in Ayurvedic texts. There is also a need to undertake
appropriate research strategies in the field for developing an evidence-based
Ayurvedic Geriatrics and its mainstreaming.
Recommended Further Reading
1. Caraka SamhitÁ, Ed. Sharma P.V., Cikitsa SthÁna, Chapter 1, Pada 1-4.
2. Susruta SamhitÁ, Ed. Singhal G.D., Cikitsa SthÁna, Chapters 27-30.
3. AÒÔÁnga Hridaya Uttara Tantra, Chapter 39
55
4. The Holistic Principles of Ayurvedic Medicine by Singh, R.H., Chapter 8,
Choukhambha Surbharati, New Delhi.
5. Kayachikitsa Vol. I Chapter 13 on RasÁyana by Singh R.H., Choukhambha
Surbharati, Varanasi.
6. Science and Philosophy of Indian Medicine by Udupa, KN and Singh R.H,
Sri Baidyanath Ayurveda Bhawan, Nagpur.
7. Sarangdhara Samhita Khand II, Chapter 6, Choukhmbha Prakasana,
Varanasi.
8. Strength of Ayurveda in Geriatric health care. Key Note Lecture by Singh
R.H., Launching National Campaign on Geriatric Health Care, Deptt. of
AYUSH, Ministry of Health, Govt. of India, 2008.
9. Panca Karma Therapy by Singh R.H., Pub. Choukhambha Sanskrit Series,
Varanasi.
10. Advances in Ayurvedic Medicine Vol. 1-5 by Singh, R.H. and Associates,
Choukhamba Vishwabharati Publication, Varanasi.
56
Chapter-5
PANCAKARAMA IN GERIATRIC HEATH CARE
Introduction
Pancakarma therapy is the therapeutic technology of Ïamsodhana karma
which forms the most fundamental component of Ayurvedic treatment.
Ïamsodhana denotes biopurification of the body and milieu interior. Ayurvedic
texts propound that the living body is comprised of innumerable channels i.e.
Srotas, which function as inner transport system. The purity and integrity of
these channels (SrotÁïsi) is essential for proper functioning of the body-mind
system specially the nourishments of body tissues and transport of biological
fluids containing life factors, nutrients and medicaments administered in a
particular person. The SrotÁïsi are prone to loose their integrity due to
stagnation of unwanted by produdcts of physiology warranting periodical
cleansing or Ïamsodhana for which the technology of Pancakarma was
developed in Ayurveda, which is considered as the most unique contribution of
Ayurveda.
Ordinarily, major Pancakarma procedures are contraindicated in children, the
elderly and in pregnant women. But several intermediary palliative measures
like Abhyanga, Sveda, PiÆda Sveda, KÁya Seka, Ïirovasti and ÏirodhÁrÁ are
very useful in elderly persons too for imparting physical fitness and
rehabilitative effect. The present chapter will present a brief account of
Geriatric Pancakarma. For details, the readers are advised to refer to
independent books and monographs on the subject such as “Pancakarma
Therapy” by R H Singh and “Pancakarma VijnÁna” by H S Kasture.
Senile Body constitution and Panchakarma:
Cardiovascular system: Characteristics of the normal ageing process in CVS
are changes in the renal, hormonal and thirst regulatory systems involved in the
control of sodium and water balance. In the presence of disease or drug use, the
ageing changes put the elderly person at increased risk of either sodium
retention or loss and of water retention or loss. Clinically, these alterations in
water and sodium balance are commonly expressed as either hyponatraemia or
hypernatraemia with central nervous system dysfunction as the symptomatic
expression. Thus, the impaired homeostasis of many systems affecting fluid
balance in the elderly is readily influenced by many of the disease states and
medications which are often present in the elderly with resultant adverse
clinical consequences. Awareness of these age-associated circumstances can
allow the physician to anticipate the impact of illnesses and drugs and to
implement a rational approach to therapeutic intervention and management.
Such changes are of great importance while administering Pancakarma therapy
measures in the elderly.
57
Respiratory system: The tendency of the lung to assume a larger resting
volume and the limitations imposed by a stiffer chest wall plus a decrease in
motor power result in a change in the components of the total lung capacity.
Vital capacity declines progressively with age. As a rough rule of thumb, there
is a linear loss of 5 to 20 percent of functional ability per decade, which may be
helpful in comparing an elderly patient's current capacity against normal
values. A Pancakarma therapist has to keep a close watch on the respiratory
status of his elderly patients before subjecting him or her to major karmas like
vamana or Ðirovirecana.
Gastrointestinal system: Age-related changes of esophageal function, so
called presbyesophagus, are due primarily to disturbances of esophageal
motility. The esophagus in an older person may have a decreased peristaltic
response, an increased nonperistaltic response,a delayed transit time or a
decreased relaxation of the lower sphincter on swallowing.The decrease in
peristalsis and delay in transit time may lead to dysphagia with a voluntary
curtailment of caloric consumption. Vamana and Nasya are directly related to
such changes or because of such changes; vamana and Nasya are usually
avoided in such subjects.
The incidence of atrophic gastritis increases significantly with age. Severe
atrophic gastritis results in achlorhydria, deficient intrinsic factor secretion,
decreased pepsinogen production and, in type A, hypergastrinemia due to lack
of acid inhibition of gastrin cell secretion. Atrophic gastritis appears to be an
autoimmune disease, whereas may be due to local environmental factors such
as chronic enterogastric bile reflux. Degree of such senile changes needs to be
evaluated in all prospective clients of samÐodhana.
A decrease in intestinal motility occurs with age. The colon becomes
hypotonic, which leads to increased storage capacity, longer stool transit time
and greater stool dehydration. These are all etiologic factors in the chronic
constipation that plagues the aged. Laxative abuse therefore results and is the
most common cause of diarrhea in the elderly besides loss of control of the
internal and external anal sphincters in the elderly. Such situations warrant
care while planning Virecana and Vasti karma in the elderly.
The liver decreases in weight by as much as 20 percent after the age of 50 but
perhaps because of its large reserve capacity this attrition is not reflected by a
decrease in the usual liver function tests. Although tests of liver function show
little or no change with age. Probably Pitta Virecana procedures could be of
benefit in such situations.
Nervous system: Corticotropin-releasing factor (CRF) plays a major role in
coordinating the endocrine, autonomic, behavioral and immune responses to
stress through actions in the brain and the periphery. CRF receptors identified
in brain, pituitary and spleen have comparable kinetic and pharmacological
58
characteristics, guanine nucleotide sensitivity and adenylate cyclasestimulating activity. Differences were observed in the molecular mass of the
CRF receptor complex between the brain (58,000 Da) and the pituitary and
spleen (75,000 Da), which appeared to be due to differential glycosylation of
the receptor proteins. Pancakarma therapy interventions like ÐirodhÁrÁ and
Ðirovasti are seen to help such persons to compensate the senile involution in
brain.
Locomotor system: This strategy can be powerful in understanding the
complex effects of aging resulting from pathologies in central nervous system,
peripheral nervous system, muscles, cuticle and other skeletal elements. While
behaviors such as horizontal walking may clearly emphasize some locomotor
difficulties, others will be subtle. By examining a full range of locomotor
behaviors, these subtle effects will be clearly brought forward. PiÉÕa Sveda,
KÁya Seka, Anna Lepa and different kinds of Abhyangas are known for helping
these deficits in the elderly. Most of the practices of Keraliya pancakarma are
of special value in geriatric practice than classical pancakarma.
Urogenital systems: Urogenital problems in the elderly female population are
experienced by one third of women from the age 50 years and
onward.Symptoms from the lower urinary tract includes incontinence,
urethritis, and recurrent urinary tract infections. Atrophic changes within the
bladder neck and urethra could be corrected by a range of medications. Control
of micturition is a complex process of which estrogen deficiency is only one of
several factors. The aging process with subsequent changes in membrane
permeability, neuromuscular function, and collagen synthesis contribute to the
local problems of control of micturition. In addition, the central control may
also be affected by degenerative changes of the nervous system. Vaginal
symptoms comprise dryness of vagina, dyspareunia, and recurrent vaginitis
often followed by a fowl odor and discharge. All such senile changes can be
treated with selective Uttara Vasti, Picu DhÁraÆa and Vaginal irrigation. The
males have often the problem of senile enlargement of prostate leading to
AÒÔhÍlÁ syndrome and UdÁvarta which are treatable by Vasti Karma.
Immunological status: Immune function declines with age, leading to
increased infection and cancer rates in aged individuals. In fact, recent progress
in the study of immune ageing has introduced the idea that rather than a general
decline in the functions of the immune system with age, immune ageing is
mainly characterized by a progressive appearance of immune dysregulation
throughout life. Changes appear earlier in life for cell-mediated immunity than
for humoral immunity. All such factors deserve high consideration while
planning Geriatric pancakarma and RasÁyana therapy.
59
Status of Prakéti, Agni, DoÒa, DhÁtu, Mala and Ojas with reference to
Pancakarma for geriatric care
As regards the status of doÒas, the VÁta doÒa is elevated while pitta and kapha
are reduced in elderly persons. All the seven dhÁtus are reduced in aged people
while due to increased VÁta the aged persons suffer from viÒamÁgni leading to
genesis of many disorders like grahaÆÍ, arÐa, udara roga etc. Reduction in
pitta leads to ajÍrÆa, amlapitta, agnimÁndya etc. Reduced quanity of kapha
leads to dhÁtukÒaya, reduced immunity, reduced strength etc. In elderly people
reduction in mala, mÚtra and sveda leads to genesis of vivandha, mÚtrasÁda
and kuÒÔha respectively. Due to deficiency of apara oja the immunity of body,
strength and the luster is reduced while any reduction of para oja causes loss of
vitality and instantaneous death. A pancakarma therapist should always keep a
watch on these biovalues while planning Geriatric pancakarma or RasÁyana
therapy.
Diseases specific to the elderly treatable by Pancakarma
Ischemic heart disease, hypertension, peripheral vascular insufficiency, COPD,
Pulmonary Tubsulosis, habitual constipation, anorexia, senile diarrhoea,
GrahaÆÍ Roga, diabetes, dementia, Parkinson's disease, sleepdistrubences,
motor neuron disease, dysfunction of sensory organs, peripherial neuropathies,
oestoporosis and oesteoarthritis, certain forms of myopathies, spondylosis,
sexual dysfuncations, benign prostatic enlargement and neurogenic bladder are
the common aliments of old age warranting special care. In all such cases some
selective pancakarma procedures such as Snehana, Svedana, PiÆÕasveda,
Annalepa, KÁyaseka, Ïirovasti, Kativasti, ÏirodhÁra are beneficial.
Available treatment modalities in Pancakarma:
Snehana:
This is the main peparative procedure for
pancakarma. It is used internally as well as
externally. The dose of sneha for internal use is
increased adjusted as per need. The maximum dose
should be as per individual requirement and tolerance
in graded schedule. The duration of administration is
3-7days as per requirement of an individual. External
Abhyanga
Snehana is done using a suitable medicated oil
Source: www.tucsonayurveda.com
and Abhaynga massage preceding Svedana.
60
Svedana:
Svedana is the procedure which relieves stiffness,
heaviness, and cold and also induces sweating. Besides
being principal pÚrvakarma procedure it is also used in
the specific treatment for a number of disorders
specifically vata pradhÁna diseases like sandhigata
vÁta, katiÐÚla, ardita, pakÒavadha. Svedana is of two
types sÁgni (13 types) niragni (10 types). SÁgni sweda Vaspasvedana
is done with the help of heating device and niragni
Source: www.sparsa.co.in
sveda is done without help of heating device. If svedana has to be done as a
preparatory procedure of samÐodhana, it should follow proper snehana or if it
is to be done as samÐamana measure it should be done as per need of the
patient in view of his disease.
Vamana:
Vamana is the main pradhÁna karma procedure of pancakarma therapy.
Literally vamana means to expel out the vitiated doÒas through the oral route. It
is a specific therapy for kapha doÒa. Vamana karma is indicated for elimination
of doÒas not only in disease states but also in healthy persons during Kapha
Prakopa KÁla. Vamana karma is contraindicated in old age. However it can be
considered if the patient is in good health.
The patients after registration should be given sneha in the dose of 30, 60, 90,
120, 150, 180, 210 ml per-oral from day 1 to day 7
respectively. Once the proper snigdha lakÒaÆas appear as
assessed by passage of ghee in the stool and the feeling of
greasy (oily) skin by the patients, the oleation is stopped.
Then SarvÁnga svedana (medicated steam bath) is given
along with external application of sneha for two days i.e.
day 8th and day 9th. Kaphavardhaka diet in the form of Vamana
Source: www.indianetzone.com
sweets, oily rich foods, milk, curd and meat in the case of non-vegetarians
should be advised during the above two days. Then on the 9th day in the
kaphaja kÁla i.e. at 9 am vamana process should be started. After vamana
khadirÁdi vaÔÍ should be given for chewing followed by dhÚmapÁna to pacify
the aggravated kapha. The above process is terminated by advising the patient
to follow samsarjana krama according to features of proper emesis. Vamana
is not indicated in old age. However, it can be considered in otherwise healthy
clients.
Virecana
Virecana is the next major pradhÁna karma included under pancakarma.
Virecana means to expel out the doÒas through anal passage. Virecana is a
specific therapy for pitta doÒa. Virecana is an easiest and the least complicated
61
procedure in pancakarma therapy. The degree of elimination of doÒa by
purgation therapy have been described e.g. maximum, moderate and minimum.
Passing of 30 motions or expulsion of 2.6 kg. of fecal matter is considered as
maximum. 20 motions in number or 1.3 kg of fecal matter are medium and 10
motions or 650gm of fecal matter is considered as the minimum elimination.
The calculation of number of motions or the quantity, mentioned above should
not include the two or three stools. The limit uptil which purgation should be
allowed to take place is the appearance of kapha (mucus) in the stool.
Nasya
Nasya is a term applied generally for medicines or
medicated oils administered through the nasal passage.
Nasya is considered as t he best and most specific
procedure for diseases of head (urdhvajatrugata roga).
Nasya karma is done after preparing the patient by
snehana and svedana. The patient is asked to lie down
at his ease or in the sitting position with his head tilting
down backwards lightly so that the medicine reaches Nasya
the desired site. The physician with his thumb raises
Source: karmakerala.com
the tip of the patient’s nose and with the right hand drops the medicine into
both nostrils to induce nasal oleation, nasal medication and Ïodhana through
sneezing and nasal purging.
Vasti
Vasti is the most important procedure among the samÐodhana karmas. The
term vasti is derived from fact that the vasti yantra or apparatus which used to
be used in early times for introducing the medicated materials into anus is
made up of vasti or urinary bladder of animals. Vasti is the specific treatment
for vÁta doÒa. It is beneficial for old as well as for young and there are no
notable hazards in this therapy. Vasti is broadely of two kinds:
AnuvÁsana vasti – A medication containing fat when administered through
enema and retained in the body for some time (3 yamas) to give desired
therapeutic effect is known as anuvÁsana vasti. AnuvÁsana vasti is
administered after meal.
The vasti can also be catagorised as karma, kÁla and yoga according to the
number of vasti. Karma vasti consists of 30 vastis (18 anuvÁsana + 12
ÁsthÁpana), kÁla vasti includes 16 vasti (10 anuvÁsana + 6 ÁsthÁpana) and
yoga vasti includes 8 vasti (5 anuvÁsana + 3 ÁsthÁpana vasti). In principles
AnuvÁsana and ÀsthÁpana vasti are given alternatively to avoid aggravation of
Kapha and VÁta to excess of a particular type of Vasti.
62
RaktavisrÁvaÆa
Most of the texts do not include the raktavisrÁvaÆa in pancakarma schedule.
Inclusion of raktavisrÁvaÆa in pancakarma schedule has been principally
considered by Sushruta. RaktavisáavaÆa considered for elimination of vitiated
rakta or blood. Various methods are described for raktavisrÁvaÆa like Ïénga,
jalaukÁ, alÁbu, ghati yantra, prachhÁna and sirÁvedha. JalaukÁ is the most
populor method of raktavisrÁvaÆa and is very useful in a range of intractable
diseases and has been extensively studied in recent years for its mode of action
scientifically.
KeralÍya pancakarma
Besides above mentioned classical pancakarma
procedures a number of Keraliya traditional prcatices such
as dhÁrÁkrama, PiÆÕa Sveda, KÁya Seka, Anna Lepa, Ïiro
Lepa or Ïirovasti are very useful in geriatric care. The
KeralÍya practices are very popular in view of their
ÏirodhÁrÁ
efficiency and safety because of being non-invasive.
Source: www.herbalmassage.biz
Complication profile of Pancakarma Therapy:
Patient related – Due to age related changes in body organ system proper
absorption, assimilation, distribution and biological effect of drugs do not
occur. Impaired immune system of senile body may also cause adverse effects
of drugs during pancakarma.
Drugs and procedure related - Senile changes in general body constitution
and organ system restrict the use of drugs in required dose and sometimes
required procedures also can not be performed, which limits the scope of
pancakarma therapy in old age or if performed without care may lead to
harmful effects.
Therapeutic Limits:
Metabolic- Metabolic disorders in elderly age are very common with various
impairments of body organ system- like Diabetes with impairment of Renal
and Cardiac functions which limit the use of medications in required dose
along with limitations of use of certain procedures of pancakarma therapy.
Degenerative- Degenerative changes in body and organ system cause
restriction of use of drugs and procedures e.g. cerebral and other neurological
degenerative changes causing limitations of drugs and procedures.
Therapeutic- Due to metabolic, degenerative, hormonal and immunological
changes in the body many of the drugs and procedures needed in pancakarma
may not be used in proper dose and at desired time and hence desired benefits
can not be achieved.
63
Pancakarma procedures to be adopted for Geriatric care
:
The classical pancakarma procedures viz. Vamana, Virecana, Vasti, Nasya and
RaktamokÒaÆa will have to be planned with due care in the elderly. Vamana is
ordinarily not suitable for old age because of its invasive nature and also
bacause old age is the age of VÁta doÒa not of Kapha which is the target DoÒa
for Vamana. Virecana and Vasti are good to use. In addition the noninvasive
practices of KeralÍya pancakarma can be used with advantage in elderly
persons.
Use and limitations in elderly people:
Vamana in old age should be administered with great precaution and after
careful monitoring of the general health and accompanying disease. Vamana
should not be administered in an elderly person if he is suffering from
hypertension, ischemic heart disease, peptic ulcer, cirrhosis of liver, pulmonary
tuberculosis, or any major lung disease, intra cranial tumour and glaucoma etc.
Indications/contraindications of Panchakarma in geriatric care:
Name of organ system
Cardiovascular system
Urogenital system
Respiratory system
Nervous system
Elderly ailments
Hyper cholesteraemia
BPH, Atonic bladder,
oligospermia
Bronchial asthma, Tropial
pulmonary eosinophilia,
Respiratory allergies etc.
Neurodegenerative diseases
Skin
Wrinkling, Pigmentation,
Dryness of skin
Locomotor system
ÀmavÁta, Sandhigata vÁta,
Osteoarthritis, Cervical and
lumber spondylosis, Gout
etc.
ENT Diseases
PratiÐyÁya, KarnakÒveÕa,
Headache, KarnanÁda,
Deafness, Sinusitis etc.
Gulma, YakétvikÁra,
PlÍhavikÁra, Digestive
disorders, Costipation etc.
Gastrointestinal system
64
Procedures
Lekhana vasti
Vasti- AnuvÁsana,
Niruha
Vamana, Virecana
Vasti, Ïirovasti,
ÏirodhÁrÁ,
KÁyaseka, Pinda
sveda
Snehana, svedana,
Vamana, Virecana,
RaktavisrÁvaÆa
Snehana, Svedana,
Patra PiÆÕa Sveda,
PiÆÕa Sveda,
Vasti,
RaktavisrÁvaÆa
Nasya,
KarnapuraÆa,
ÏirodhÁrÁ, Vasti
Vamana, Virecana,
Vasti
Precautions, Complications and limitation of procedures
Certain procedures of classical pancakarma such as vamana are drastic in
nature therefore ordinarily they are contraindicated in elderly person. However
many procedures may be suitably tailored and modified to be administered in
elderly persons to achieve desired results. The dose of sneha in internal
snehana should be minimized in elderly. As stated earlier, Vamana in old age
should be administered with great precaution and after careful monitoring of
the general health and accompanying disease. Vamana should not be
administered in an elderly person if he is suffering from hypertension, ischemic
heart disease, peptic ulcer, cirrhosis of liver, pulmonary tuberculosis, or any
major lung disease, intracranial tumour and glaucoma etc. Virecana specially
of médu variety is best suited to the elderly persons.
Preparatory Procedures like Snehana or Svedana:
Snehana means to administer a preparation containing fat i.e. oil or ghee to a
patient for a limited period to get desired clinical effect. Fat cures abnormal
vÁta, and renders the body soft and clears the accumulated wastes which have
obstructed the body channels. Further the regular use of fats has been
considered beneficial for the proper digestion, cleansing of the bowel, the
promotion of body strength and integrity of senses and prevention of aging
besides several other effects.
Svedana is the therapy by which a person is made to sweat. Generally the
sweating therapy should be undertaken after fat therapy.It is considered that the
sweating therapy melts the waste products of metabolism, stagnated in the
subtle channels of circulation which have been disintegrated by the fat therapy.
As a rule the svedana should be given in a closed chamber not exposed to
direct air, after ensuring that the food consumed by the patient earlier is fully
digested.The patient should be fully explained and assured about the procedure.
The Major Procedures
As stated earlier Vamana is the major pradhÁna karma procedure of
pancakarma therapy. Literally Vamana means to expel out the vitiated doÒa
through the oral rout. It is a specific therapy for kapha doÒa. Vamana karma is
indicated for elimination of doÒas not only in disease states but also in healthy
person. Vamana karma is contraindicated in old age. Virecana is a next major
pradhÁna karma included under pancakarma. Virecana means to expel out the
doÒas through anal passage. Virecana is a specific therapy for pitta doÒas. It is
a pro physiological procedure and is safe. It is indicated also in old age. As
stated earlier Vasti karma is specific for vÁta doÒa and is also indicated in old
age specially in neurological diseases. Nasya refers to the use of medicines or
medicated oils administered through the nasal passage. Nasya is considered as
65
the best and most specific procedure for diseases of head (urdhvajatrugata
roga).
ÏirodhÁrÁkrama is useful in mental diseases like psychosis and epilepsy,
neurosis, insomnia, fainting, confusion, fatigue, alcoholism, premature greying
and hair loss etc. This procedure is also called as MÚrdhÁ seka, ÏirodhÁrÁ, and
Ïiroseka. It is indicated in old age and has no known contraindications.
Ïirovasti is useful in all types of headaches like chronic daily headache, tension
induced headache, insomnia, psychosis, bells palsy and speech disorders. It is
specially indicated in degenerative brain diseases and is quite safe. KaÔivasti is
very useful in kaÔiÐÚla. KaÔiÐÚla is most common problem in elderly women.
Elderly men are also affected by the kaÔiÐÚla with lesser extent. KaÔivasti is
considered as an important component of geriatric pancakarma.
Recommended Further Reading
1.
2.
3.
4.
5.
Charaka Samhita- Sutrasthana chapters-13,14,15,16
Charak Samhita- Sidhisthana and Kalpasthana
Susruta Samhita relevant chapters
Astanga Hridaya relevant chapters
Panchakarma Therapy by Prof. R. H. Singh, Chowkhambha Sanskrit
Pratisthana, Varanasi.
6. Ayurvediya Pancakarma Vigyana by Prof. H S Kasture, Baidyanath
publications, Nagpur.
7. Swasthavritta vigyna by Prof. R. H. Singh chapter No. 3 on panckarma;
Chowkhambha Surabharati, Varanasi.
8. Kayachikitsa by Singh R.H, Vol. I Chapter 10 and 11, Choukhambha
Surbharati, Varanasi.
9. Guidelines of good practices in Panchakarma, Panchakarma Therapy by
Prof. R. H. Singh, Chowkhambha Sanskrit Pratisthana, Varanasi.
10. Keraliya Panchakarma by Prof. T. L. Devaraj, Chaukhambha
Publication, Varanasi.
66
Chapter-6
Mental Health Care in the Elderly
(JarÁ MÁnasa SvÁsthya)
The Central Council of Health Programme in its meeting (18-20 August, 1982)
held at New Delhi for implementation of alma-ata declaration (Anthicad J. et
al., 2001) recommended that (a)
Mental health must form an integral part of total health programme of
India.
(b)
In all training courses for medical professionals, mental health education
will be an integral part.
The programme will have three components treatment, rehabilitation
and promotion of positive mental health. The present chapter deals with the
third component with focus on elderly individuals.
Mental health: Key to perfect health
Mental Health in an integral part of the complete health and is regarded
as one of the basic factors that contributes to the effective physical health and
social wellbeing. W.H.O. defines health as a state of complete physical, mental,
social and spiritual well being not merely an absence of disease or infirmity, in
conformity with age old definition given by Ayurveda.
Susruta has defined health (SvÁsthya) as inclusive of mental and spiritual
wellbeing alongwith equilibrium of doÒas, dhÁtus, aganis and malas. Recently
western medicine has also started emphasizing these aspects of health.13
13
SamadoÒah samÁgniÐca samadhÁtu malakriya
PrasannÁtmendriya manÁh swasthaityabhidhÍyate
(Su.Su. 15/41)
67
Thus, health includes sound and efficient mind with controlled
emotions. It means both body and mind should work efficiently and
harmoniously.
Mental health
Mental health is the ability to balance feelings, desire, ambition and
ideals in one’s daily life. It means the ability to face and accept the realities of
life. Thu, it is a process of adjustment, which involves compromise and
adaptation, growth and continuity or it is the ability of the individual to make
personal and social adjustments.
Renowned psychologist K.A. Meninger defines “mental health as the
adjustment of human being to the world and to each other with a maximum of
effectiveness and happiness. It is the ability to maintain an even temper, an
alert intelligence, a socially considerate behaviour and a happy disposition”.
Thus, the greater the degree of successful adjustment the greater will be the
mental health of individual. Lesser mental health will lead to lesser adjustments
and greater conflict.
Adjustment
If one can establish a satisfactory relationship with other people, or if
one can meet the demands of a situation, he can be said to have achieved
adjustment. Adjustment results in happiness because emotional conflicts and
tensions are resolved and relieved.
Models of mental health
Medical model: Normal mental health is conceptualized as the absence of
psychiatric disorder/disease or psychopathology.
Statistical model: Statistically normal mental health falls with in two standard
deviations (SDs) of the normal distribution curve.
Utopean model: In this model, the focus is on defining normality as optimal
functioning.
68
Subjective model: According to this model, normality is viewed as an absence
of distress, disability or help seeking behaviour resulting thereof.
Social model: A normal person, according to this model is expected to behave
in a socially acceptable way.
Process model: This model views normality as a dynamic and changing
process, rather than as a static concept. This model can be combined with any
of the above mentioned models.
Continuum model: Normality and mental disorders are considered by this
model as falling at the two ends of a continuum, rather than being disparate
entities. According to this model, it is the severity that determines whether a
particular person's experience constitutes a symptom of a disorder or falls on
healthy side of the continuum.
Factors affecting mental health:
Hereditary factors: They give the raw material as the potentialities of the
individual. What the individual inherits from his forefathers affects his growth,
intelligence, appearance, mental stamina (Satvabala) and health. The
development and utilization of these potentialities are determined mainly by the
environmental opportunities.
Physical factors: People with greater strength, better looks and health enjoy a
social advantage in the development of personality characteristics.
Physical health improves mental vitality, motivation and drive.
Continued hunger, overwork or sleeplessness produce fatigue affecting mental
health.
Social factors: Every individual is born in the society which is responsible for
his upbringing and formation of his behaviour through social norms, customs,
tradition culture and taboos of the social factors which affect mental health, the
most important are home, school and community.
69
A good home provides love, security, shelter, attention and basic needs
of the elderly members, this in turn promotes their mental health; on the other
hand, the home full of conflicts, economic problems and insecurity has adverse
effect on the elderly. The old person in the family should be respected as a
person, not neglected and should be given full freedom of expression. School is
relevant in case of children and adolescents.
The
community
provides
healthy
atmosphere,
competition,
accommodation facilities and securities. This reduces the mental illness and
promotes mental health. The society also keeps continuous check over
individual's bahaviour.
Satisfaction of basic needs: Mental health is also determined by the way our
basic needs are satisfied. These need include physiological needs, safety and
security needs, belongingness, love and esteem needs.
Mental health Vs. Mental Illness:
The two terms are closely related to one another and are relative terms.
It we consider healthy and unhealthy behaviour as part of a continuum or scale,
mental health / healthy behaviour is at one end of scale and mental illness or
very definite unhealthy behaviour at the other end of scale. Borderline
behaviour is in the middle of the scale.
Mental
Borderline
Health
Behaviour
Mental disorder/
disease
Unhealthy behaviour is identified, when it becomes extreme for
prolonged periods of time and prevents adjustment in society. Anxiety before
an interview is healthy behaviour but euphoria is unhealthy.
Two aspects of mental health:
Individual:
Person's internal adjustment ability, frustration, conflicts and tension.
70
Social :
Every society has certain value system, customs, tradition and heritage,
through which the behaviours of an individual are controlled or in other words
he has to make internal adjustment according to them.
CHARACTERISTICS OF A MENTALLY HEALTHY INDIVIDUAL
Self evaluation: (AtmÁnam AbhisamÍkÒya/SameekÒhya KÁrÍ)
•
A mentally healthy individual evaluating himself is aware of his
limitations, easily accepts his faults and makes effort to get rid
himself of them.
•
He introspects, so that he may analyze his problems, prejudices,
difficulties etc. and reduce them to minimum.
Adjustability (Sama½):
Special characteristics of mentally healthy individual are the adjustment
to new situation with least delay and disturbance.
•
Does not try to think of old age when he is young and think of his
youth state when a senile crank.
•
Makes fullest possible use of existing opportunities.
•
Deals coolly and patently with every novel circumstance, without
any fear, anxiety etc. and is aware of the fact that change is the
principle of life.
Maturity (ViÐadÁ ca Buddhi):
Mature mind is constantly engaged in increasing his fund of knowledge,
behaves responsibly.
•
Expresses his though to and feelings with clarity.
•
Is prepared to sympathise with anothers feeling and view points.
•
Behaves like a balanced, cultured and senible adult in all matters.
Regular life (CaryÁ PÁlana):
Forming proper habits in matters of food, clothing, the normal routine of
daily life → systemic and regular life → economises energy and time.
71
Absence of extremism (Madhyam MÁrgÍ):
Ayurveda believes that the ideal man lacks excess in any and every
direction, and the principle that excess of anything is bad is a golden rule for
mental health. Extremism should be avoided all cost.
Satisfactory social adjustment (viÒayeÒvasaktam):
Mentally healthy individual maintains good adjustment with social
situations, and is engaged in some or other project intended to benefit society.
Social relationships are a part of life. The greater the balance of these
social relationships, the greater their simplicity, the better will be the mental
health.
Satisfaction from the occupation / Profession (Karma SukhÁnubandhÍ):
It is absolutely essential for mental health that one should find
satisfaction from his occupation. If work interests an individual, a proper
utilization of time will bring an increase in his pleasure and happiness.
Expression of emotion in desirable and controlled manner (KÒamÁvÁn).
The description does not exhaust all the components, but it is
sufficiently suggestive picture of mental health.
Components of mental health in elderly •
Reality orientation
•
Self awareness and self knowledge.
•
Self esteem and self acceptance.
•
Ability to exercise voluntary control over behaviour.
•
Ability to form affectionate relationship
•
Pursuance of productive and goal directed activity.
Mental Hygiene:
Mental Hygiene is the science which creates the kind of personality in
every individual in a society, which
(a)
Makes for good adjustment with environment,
72
(b)
Attains a proper synthesis between the intellectual, emotional and
physical aspects,
(c)
That is satisfied optimistic and
(d)
That experiences a minimum of tension and conflict in its
conduct with other individuals in society.
Mental hygiene and mental health:
Mental hygiene is a way of life in which the individual’s adjustment to
this environment in maintained. Mental hygiene is the means or tool which
maker the adjustment possible while mental health is that ability by means of
which we established our adjustment with the difficult situations of life.
Thus, mental hygine is the means to mental health. It is that since which
studies the laws and means of achieving mental health, of maintaining it and
preventing mental illnesses. Mental health is the ended mental hygiene is the
means.
OBJECTIVES OF MENTAL HYGIENE
Safeguard of mental health:
Mental hygiene consistently stresses the
development of such qualities in the individual as optimism, confidence,
cooperation, emotional adjustment and maturity, pointing out the means of
improving adaptability and efficiency of individuals.
Development of balanced personality: Removal of abnormalities of the
personality is another important objective, since only in the absence of such
aberration that the individual can be balanced.
Prevention of personality complications: Mental hygiene attempts to present
all kinds of personality disorders, since all kinds of mental disease originate in
them.
Treatment and remedying of mental defects: Mental hygiene or science of
mental health is concerned with the prevention of inadequate adjustment or
with those processes or methods which adjust the maladjusted individual.
73
(Lowrence F. Shaffer). This function of mental hygiene is the curing of mental
ailments, defects and imbalances.
NECESSITY AND IMPORTANCE OF MENTAL HEALTH CARE IN
ELDERLY
In old age when man has passed prime of his energy, his children or
busy in affairs of their own families, there are very few ways in which the
elderly can pass his time. He may have plans or desire to do things but his
growing age makes him physically unfit to move or carry out his plans.
↓
When retired from job, the source of income is blocked, accompanied
by loss of social status and much of social work the mental health is challenged
at the most. The loss of contemporaries due to death, illness and migration
bring not only psychological deprivation but also a void which remains
unfilled. The loss of friends is frequently associated with restricted mobility,
which leads to further social isolation.
↓
In such state, if the elderly happen to loose his/her life partner, it
becomes most disastrous and mentally shocking. With advanced age, he
develops poor memory, eyesight, hearing etc. old age health problems like
hypertension, heart disease, diabetes, arthritis an other chronic problems which
also affect mental health.
↓
Because of above many related factors, mental health care of old aged
persons is of paramount importance and is needed very greatly.
SPECIFIC TECHNIQUES FOR PROMOTION OF MENTAL HEALTH
IN ELDERLY
Ayurvedic approach
I.
Methods of Right conduct (Sadvétta)
74
According to Ayurveda, the life must be based upon the rules of right
conduct (Sadvétta) or the dharma for us to achieve anything real or lasting.
These are the natural law or rules, which should be followed to maintain
appropriate social and personal relationships. There is a large list of the
conducts and behaviours, which provides a guideline for what is appropriate for
us as an individual, our role in the society. According to stage of life
(elderly/young). Dharma includes our social responsibilities as well as
individual responsibilities.
They promote adjustment with our environment and help in attaining a
proper synthesis between the intellectual, emotional and physical aspects,
thereby promoting the mental health in a larger way.
II.
Methods of Behavioural rejuvenation (Acara RasÁyan)
Ayurveda has mentioned hundreds of single and compound medications
for retardation of ageing and modification of the physical and psychological
consequences of ageing and also for rejuvenation of the old body and mind
under the RasÁyana Tantra. In the end of the description, Ayurveda says that
all these rasÁyana are for ordinary people but for the really wise persons, the
rasÁyana is to follow truthfulness, never get angry, known your ownself, be at
peace, do only noble things, abstain from alcohol and excess coitus, be
generous in giving, consider every body equal, do service to the great
personalities etc.14
14
“Satyavadinamakrodhaï nivéttam madyamaithuúat
AhimsakamanÁyÁsam prasantam priyavadinam
Japa Ðaucha param dhÍram dÁnanityam tapasvinam
Deva go brÁhmaÆÁcÁrya guru véddhÁrcane ratam”
75
This kind of conducts and behaviour not only promote the positive
mental health of the individual but goes a long way in rejuvenation of body and
kind of an elderly individual.
III.
Medhya RasÁyana (Nootropics / Cognitive enhancers)
These are a separate class of RasÁyana medication which are extremely
effective in promotion of mental health and enhancement of higher mental
functions like memory, intelligence etc. Recent researches have also
substantiated their adaptogenic and nootropic effect, BrÁhmÍ (B. monnieri),
AÐhwagandhÁ, Mandookparni, GudÚchÍ, ÏankhapuÒpÍ, YaÒÔimadhu, VacÁ etc.
belong to this group of RasÁyana.15
IV.
VyÁyÁm (Physical exercise):
Psychological benefits of physical exercises are of immense importance.
Increased social contact may be achieved by group exercise programmes and
improved self esteem may lead to other health promoting activities. Such social
contact and activates help the old people to feel a part of society. Such
activities reduce the tension, anxiety, depression etc and promote the mental
health. These psychological benefits may be due to alteration in the level of
various chemical substances in the brain.
V.
Practice of yogic techniques (TatparatÁ ca yoge):
Classical yoga described eight steps to achieve its ultimate aim of
reintegration. These steps follow a certain sequence and each one has its
specific role in mental health promotion, though all of them are not equally
important.
15
MandÚkaparnyÁ½ swarasa½ prayojya½ kÒeeren yaÒÔÍmadhukasya cÚrÆam
RasoguÕÚcyÁstu samÚlapuÒpyÁ, kalkah prayojyah khalu ÐankhapuÒpyÁ
MedhyÁni caitÁni RasÁyanÁni MedhyÁ ViÐeÒeÆa ca ÐankhapuÒpÍ
76
The first two steps, yama and niyama, describe the rules of social
conduct and personal conduct respectively and together constitute the ethical
foundation of human life.16
I.
Yoga in this sense requires a high sense of social responsibility
and ethical behaviour defined by five yamas or rules of social
conduct nonviolence (AhimsÁ), Truthfulness (SatyÁ), control of
sexual energy (BrahmacÁrya), non stealing (Asteya) ad non
possessiveness (aparigraha).17
•
Nonviolence is the most important attitude for bringing
about right relationship with world and preveting negative
energies from entering into us.
•
Truthfulness keeps us in harmony with forces of truth in
the world around us and removes us from influences of
falsehood and illusion. It gives mental place and equipoise
and allows us to discover what is real.
•
Control of sexual energy builds up the internal power
necessary to bring the mind at a higher level of awareness.
16
Yogena cittasya padena vÁcÁ malam ÐarÍrasya tu vaidyakena
Yopakaroti tam pravaram muneenÁm pÁtanjalim prÁnjali mÁnatosmi
Àtmendriya manorthanÁm sannikarÒÁt pravartate
Sukha dukha manarambhadatmasthe Manasi sthire
Nivartate tadubhayam vaÐitvam copajÁyate
SaÐarÍrasya yogajñastam yogaméÒayo vidu½
17
AhimsÁ satyÁsteyabrahmacarya parigrahÁ yamah
(Pa. Yo. SÚ. 2/30)
77
Uncontrolled/misdirected sexual energy distorts our
physical and mental functions.
•
Non stealing is not just a simple matter of avoiding theft, it
requires honesty about what we are and what we have
done and not taking anything that is not rightfully ours. It
establishes right relationship with persons in society.
•
Non possessiveness stands for material simplicity and not
craving for material comforts, as having too many things
many generates worries, hampering mental health.
Right social conduct is an important tool for treating the disease and
promoting mental health.18
II.
Rules of personal conduct included under second step of yogaNiyama, refers to our daily lifestyle practices. The fives
niyamas19 are - Ðauca (Purity), santoÒa (contentment), SwÁdhyÁya
(study of spritiual teachings), tapas (self discipline) and iÐvara
pranidhÁna (surrender to God).
•
Purity (Ðauca) refers to purity and cleanliness of the body
and mind by adopting appropriate measures. Lack of
psychological cleanliness causes many mental problems
and disturbs mental health.
•
Contentment (santoÒa) refers to finding happiness inside
ourselves rather than in outer involvement, As longer we
are discontented we will not have peace of mind.
•
Study of spiritual teachings helps us understand who we
are and the nature of the universe in which we like.
18
Ïauca santoÒa tapasswÁdhyÁyeÐwara praÆidhÁnÁni niyamÁ½
(Pa.Yo.Su.2/31)
78
•
Self discipline (tapas) makes on learn to cordinate and
direct one's action in a meaningful manner towards a
higher goal or ideal. It is necessary to control the mind.
•
Surrendering inwardly to the God (IÐwar PranidhÁn) is for
the sake of honouring the great powers of the universe and
acknowledging his contribution in life.
III.
Physical postures (Àsanas) consist of the performance of such
postures which release physical stress and tension. The practice
of postures described in yogic texts increase the vital force and
calms the mind, which is stressed by improper postures. It aids in
releasing psychological stress through releasing the physical and
pranik blocks sustaining it. ÏirÒÁÒana, SarvÁgÁsana, MayÚrÁsana
and other such strenuous postures should not be done by elderly
individuals.
IV.
Control of the breath (PrÁÆÁyÁmÁ) calms down the disturbed
patterns of breathing which agitates mind and senses. It aims at
development and expansion of the energy of the life force beyond
its ordinary limitation. It provides the needed energy for both
body and mind for promoting healing at all levels.
There are various types of PrÁÆÁyÁmÁ, most of which consist of
deepening and extending the breath until it leads to a condition of energized
relaxation. NÁ±i Ðodhan PrÁÆÁyÁmÁ and BrÁmarÍ PrÁÆÁyÁmÁ are specially
useful for elderly individuals.
V.
Control of senses (PratyÁhÁra) refers to keeping our mind away
from the senses and in control of their inputs. It is, not
suppression of the senses but their right application, which is as
instruments of perception rather than as judges of what we
perceive.
79
The technique of PratyÁhÁra is primarily of two types-shutting off the
senses like closing the eyes or ear or using the senses with attention rather than
distraction. Closing the sensory openings is a practice like fasting for the body.
PratyÁhÁra is the main method for strengthening the mental immune system.
VI.
Control of attention (DhÁraÆÁ)20 consist of different methods to
make the mind one pointed, including concentration on particular
objects. It differs from PratyÁhÁra in that the in DhÁraÆÁ the
goal is positive, to became focussed on a particular object,
whereas in the former the goal is negative, to withdraw sensory
distraction, which the nature of object itself is not important.
VII.
Right reflection (DhyÁna)21 is meditation in the true sense, which
is the ability to sustain long term attention on the object of our
examination. DhÁraÆÁ sets our attention on a particular object,
DhyÁna holds it there. Sustained DhÁraÆÁ in time becomes
DhyÁna. Medication can be passive or active. Passive meditation
involves the mind reflecting on an object, form or idea. It creates
a witnessing consciousness in which we can choicelessly observe
all the movements of mind.
Much of what is called meditation today is more properly PratyÁhÁra
(Visualization) or DhÁraÆÁ (concentration technique). Such meditation is
useful for calming the mind in psychological derangement. The stress reliving
effect of meditation has been researched and validated in recent years.
20
DeÐabandhaÐcittasya dhÁraÆÁ
(Pa. Y. Su. 3/1)
21
Tatra pratyayaikata natÁ dhyÁnam
(Pa. Y. Su. 3/2)
80
VIII. Right union (SamÁdhi) is the last and highest step of yoga.
SamÁdhi is the capacity of consciousness to become one with its
object of perception, through which the nature of ultimate reality
is known. Hence, SamÁdhi helps to understand how the mind
works and how to change it.
VI.
Spiritual therapy and sattvÁvajaya:
According to Ayurvedic concepts, the psyche is rooted in the spirit (self)
and the spirituality is the essence of Ayurvedic psychology, which otherwise
remains superficial and limited, spirituality is the endeavor to unite oneself
with God or higher self. It includes ordinary religious activity based on faith,
ritual and prayer, but only as initial part of an inner quest for self realization
through meditation. The important spiritual practices which are extremely
useful for elderly individuals and are also utilized in the psychotherapeutic
practice of Àyurveda called sattvÁvajaya are •
Devotion: God in the manifest aspect of the Godhead or absolute
(BrahmaÆa) which rules the time space creation. In the Vedic
view, God is an inner reality, our own inner guide. Contacting
him is the key to contracting our inner self and source of
wellbeing and happiness. Attuning one self to his will lifts one to
the summit of the natural world.
Lack of devotion is the root of many psychological problems. A person
who has devotion can not have psychological problems of a significant nature
because the divine is never apart from them. It is the very sap that vitalizes the
mind.
•
Surrender to the will of God is the quickest way to go beyond the
all problems. It wins all things, we may have to surrender to the
devine through the medicine of friend, a teacher or a form of
God.
81
•
Compassion22 is the quality of feeling together or having a
common feeling, regarding the other as oneself. It is not merely
trying to help others, but recognizing that the sufferings and joys
to others are also our own. Compassion is a recognition of the
devine presence in all beings.
•
Rituals are major healing practices in themselves and part of the
spiritual therapy of Àyurveda. They put us in proper frame of
mind to receive the energies of our consciousness. Rituals also
serve to provide positive impressions to nourish and heal the
mind. Home or fire ritual in an important example.
•
Prayers are supplication to the deity for help, love or guidance,
one should learn to communicate with God and can pray to
devine and ask for help in dealying with his problems.
•
The name is the most important factor in devotional worship.
One should result to repeating devine name whenever his mind
becomes upset.
•
Mantras23 are specially energized sounds or words, which are the
most direct method to strengthen and heal the mind. They are
repeated in regular manner in order to empower them and turn
them into the tools of physical and psychological transformation.
The mantra means "The instruments of the mind" or "what
protects the mind". The physical effect of the mantras has
recently been validated in different diseases including S.L.E.
22
Maitri KaruÆÁ muditopekÒatam sukha – Dukha punyÁ puÆya
ViÒayÁÆÁm bhÁvanÁt cittaprasÁdanam
(Pa.Yo. Su. 2/33)
(Pa. Y. Su. 3/2)
23
MananÁt trÁyate iti mantra½
82
different type of cancers where a reduction in the size of tumour
has been noted following mantra therapy in experimental studies.
•
Self knowledge refers to understanding the full extent of our
being meaning thereby not only the knowledge of physical and
the mental self but the individual soul which persists from birth
to birth self knowledge. Self knowledge requires calm and
balanced (sÁttvika) mind and it is the only way to ultimately go
beyond all sufferings, which comes from not knowing who we
really are.
General advice to elderly for mental health:
•
Accept your personal feelings - It is healthier to recognize them and find
the ways of the releasing the tensions caused by them.
•
Old age should be accepted gracefully and retired life should be planned
in such a way as organizing or participating in such activities which
keep them engaged partially such as sports, social club, walking
exercising with other elderly persons, social welfare programmes etc.
•
Know your weaknesses - Know your fears, what upsets you or hurts you
under stress and protect yourself from these situations. Avoid people or
situations which hurt you. Work out ways of dealing with them, in case
it is unavoidable.
•
Share yourself with other persons.
•
Recognize unhealthy behaviour in yourself
•
Know use sources of professional help.
Recommended Further Reading
1. Abadanand Swamy Yoga Psychology 3rd Edi. 1983. Ram Krishana Vedanta
Math, Kolkata.
2. Ahuja N.: A short text book of psychiatry 6 ed. (2006) Japee Brothers Medical
Publishers New Delhi.
3. Openheimer: Psychiatry and Ole age in Essential Psychiatry, Nicolas D.B.
Rose (editor) II ed. 1994 black well scientific publication, London.
4. Frawley David: Ayurveda and the mind, MLBD Publishers reprint 2004, New
Delhi.
83
5. Hogstel MO, Zembrushkey CD gerontology: Nursing care for older adults
Alany, N.Y. Delmer 2001.
6. Jacob Anthicad: Psychology for nurses (IInd ed.), Jaypee Brothers medical
Publishers (P.) Ltd., New Delhi. 2001.
7. James D. Page : Abnormal psychology 2002 ed. Tata M.C. Graw hill ed. New
Delhi.
8. Report on Physical activities and health: JAMA 1996, 276 : 522.
9. Singh R.H. : Ayurvediya Nidan Chikitsa Ke Siddhantha vol-I & II, 1985,
Chaukhabha Amarbharti Prakashan, Varanasi.
10. Singh R.H.: Ayurvediya Manas Vigyana 1st ed. 1986, Chaukhabha Amarbharti
Prakashan, Varanasi.
11. Singh R.H.: Foundation of contemporary yoga 1st Ed. 1991, Chaukhabha
Sanskrit Pratisthan New Delhi.
12. Singh, R.H. Singh: Kayachikitsa Vol-I & II, 2005, Chaukhambha Surbharati
Prakashana, Varanasi.
13. Udupa, K.N. and Singh R.H. : Science and Philosophy of Indian Medicine. Sri
Baidyanath Ayurveda Bhavan, Nagpur.
14. Vatsyayan: Applied Psychology Kedarnath and Ramnath Publisher and Meet.
15. Wilber Ken: The spectrum of consciousness, 2002, 1st ind. Ed. MLBD
Publishers New Delhi.
16. Winner J.M. and Breslin Nancy A: The behavioural Sciences in Psychiatry,
N.M.S. Series, B.I. Beverly P. Ltd., New Delhi, 1st Ed. 1995.
84
Chapter-7
Geriatric Counseling and Social Support
I. Introduction
Life styles, values and practices of Humans in present society are changed due
to rapid industrialization and technological advancement. Average life span of
Humans has increased due to modern medical advancements. The number of old aged
persons in our society is increasing day by day. This ultimately effecting the Human
relationships especially with senior citizens to the other family members. This
ultimately reflects in inter personal contacts and adjustment of the old people. To over
come these situations one has to cope up with the rapid changes of society and adjust
to live with happiness & joy. In this regard geriatric counseling and social support
will help a lot.
A.
B.
C.
D.
E.
F.
Historical aspects: Crisis is common in every person’s life. This can be handled
with proper care support. ÏrimadbhagavadgÍtÁ gives the best example. Lord
ÏrikéshÆa counseled and guided Arjuna when he was in crisis. Ayurveda
acharyas Caraka, SuÐruta and Vagbhata have mentioned about different
contexts of management of psychiatric and psychosomatic conditions. In
modern times many Researchers, Psychologists, Psychiatrists and Social
scientists have contributed and developed present days counseling.
The word ‘counseling’ was coined by J. B. Miner and established
the first counseling centre in the field of education career. Carl Jung, Clifford
Beers, Rev. Elwood Worcester, Samuel Frank Parsons, Eli weaver, Wheatly,
Boyden, John Dewey, Mrs. Adolph Myer, E.L. Thorndike and Roberk Yerkes
were important personalities in the field of counseling and guidance.
Issues related to counseling: - Moral issues, Economic and Social changes are
related to counseling. With the development of society, scientific innovations,
industrialization and urbanization some of the traditional conventions and values
are now challenged. In present modern world new occupations and new avenues
are emerging and some old ones are dying out. These major changes in the
society and system are leading to conflict and need counseling.
Philosophical concerns of counseling: - counseling depends upon certain
concepts; values and purpose together make its philosophy. The core philosophy
of counseling is based on faith in humanity, concern for persons, and belief in
the potentiality of human beings for realizing their selfhood and developing
responsibility for themselves; groups and institutions which embody and
implement the values to which they subscribe.
Potentials of Man: - Counseling believes in humanity and counseling doesn’t
believe in turning a helping relationship into dependency. The major potentials
of man are freedom, affection, cognition and conation, sovereignty, values.
Understanding of the trends in counseling: - counseling is a fast growing
dynamic subject. Counseling has rapidly progressed from its modest beginnings
in the early part of the present century to its current dynamic status.
Role of government and university, educational institutes in the field of
counseling through starting courses, national programmes, counseling centers,
service organizations.
85
G.
H.
Status of counseling : 1) ancient Indian context, e.g. counseling from the time of
MahÁbhÁrata i.e. ÏrimadbhagavadgÍtÁ
2) modern times
3) global scenario
Concept of Transactional Analysis (TA): – Man is a social animal and indulges
always in social interactions. In these reactions people show noticeable changes
in posture, view point, voice, vocabulary and other aspects of behaviour often
accompanied by shifts in feeling. This coherent behaviour pattern is called egostate. There are three ‘ego-states’ viz. Parent, Adult and Child.
The Parent ego-state is considered as Externalpsychic i.e. ego-state
that resembles those parental figures. The Adult ego-state is Neopsychic which
means the ego-state that is autonomously directed toward objective appraisal of
reality. Child ego-state is Archaeopsychic i.e. which represents archaic relies,
still active ego-state which were fixated in early childhood.
Our parent is that part of our behaviour that we have incorporated
from our own parents or from other parental models that we have inadvertently
learned to emulate. Our child is that part of us which carry over from our
childhood feelings. A child response to the first command might be simply to
break down and cry-behaviour that might be appropriate for real child, but not
for a mature adult. The adult in each of us is that part of us which processes
information rationally and appropriately for the present unique set of
circumstances.
In transaction analysis, the counselor analyses the interactions among
group members, and helps the individuals to understand the ego-states in which
they are communicating with each other. Usually the conflict develops when
one party decides to stop playing child to parent (ego-states).
1) Transactions: Generally, at a given time one person recognizes the
other with a smile, a nod, a frown, a verbal getting, etc., this
recognition is called a stroke, in T. A. Two or more strokes make a
transaction. All transactions can be classified in to Complimentary,
Crossed or Ulterior transactions.
2)
Complimentary transactions: This type of transaction occurs when a
message sent from a specific ego-state, gets the predicted response
from a specific ego-state in the other person.
A complementary transaction can occur between any two ego-states.
In complementary transactions communication is open because the
responses given were expected responses and were appropriate to the
stimulus.
3)
Crossed Transactions: A crossed transaction occurs when an
unexpected response is made to the stimulus. Crossed transactions
are a frequent source pain between people.
86
4)
I.
J.
Ulterior transactions: In healthy relationships people transact
directly, straight forwardly and on occasion intensely. These
transactions are complementary and free from ulterior motives.
Ulterior transactions are always involve more than two ego states.
When an ulterior message is sent, it is disguised under a socially
acceptable transaction.
Psychological positions: The psychological positions taken about oneself and
about others fit into four basic patterns. The first is the winner's position, but
even winner may occasionally have feelings that resemble the other three.
1)
I am O K you are O K: This is the first position. It is potentially a
mentally healthy position. Their expectations are likely to be valid.
They accept the significance of people.
2)
I am O K you are not O K: This is second position. Also called
projected position. It is the position of persons who feel victimized or
persecuted, so victimize and persecute others. They blame others for
their miseries.
3)
I am not O K you are O K: This is third position. Also called
introjective position. It is a common position of persons who feel
power less when they compare themselves to others. This position
leads them to withdraw, to experience depression, and, in some cases
to become suicidal.
4)
I am not O K you are not O K: This is fourth position. Also called
futility position. It is the position of those who lose interest in living,
who exhibit schizoid behaviour, and who, in extreme cases, commit
suicide or homicide.
K.
Human relation training: It is also called sensitivity training. In this, generally
the person learns things about himself and his relations with other people; about
how he behaves, how his behaviour affects others, how others see him and how
he is affected by other people.
L.
Crisis intervention: The word ‘crisis’ really means a point of a time for deciding
something: the turning point, ‘the decisive moment’ we use this word when we
are faced with an urgent stressful situation which feels overwhelming. Crises
happen to individuals, families, organizations and nations.
The key features of crises are as follows.
A triggering stress event or long-term stress
Individual’s experience of distress
Loss, danger, or humiliation
A sense of uncontrollability
The occurrence of unexpected events
Disruption of routine
Uncertainty about the future
The distress continuing over time.
87
Crisis may strike anyone at any time. At times of tragedy and major difficulty,
there is always demand for people who understand crisis and crisis responses.
‘Post traumatic stress disorder’ has now been recognized as a distinct syndrome
by DSM-IV-TR.
People respond very differently to major life changes. Anxiety arises in essence
from a subjective appraisal by the person concerned that there is a threat to the
physical or psychologica1 self. There are some events which most people
perceive as deeply distressing and which are inevitably accompanied by
profound anxiety. It is now known that there are four ways through which the
crisis mediates response, and which interact with each other.
1. The physiological response via the autonomous nervous system:
Adrenalin secretion increases heart rate and muscle tension, and overall
vigilance and arousa1. This results in inappropriate or impossible physical
activity.
2. The emotional response via the person's private emotional experience;
He/she may experience intense fear to the point of terror or panic. In panic,
the essential feature is a compelling desire to avoid the feared situation, but
in a crisis the object of fear cannot be avoided, the event has already
happened.
3. The cognitive response via the person's thoughts and self statements;
Often the person is unable to comprehend what has happened, this may last
for several days or more. Later the person's capacity to concentrate or plan
may be impaired and he or she may experience flashbacks or nightmares as
the mind attempts to integrate with the previous experience.
4. The behavioural response via the person's observable behaviours:
Often he or she is extremely restless and hyper-vigilant to further threats.
Sleep is disturbed and sleepless nights may be one of the most distressing
parts of the crisis experience.
Generally crisis intervention done by experienced professional workers who
provide support and they should act to mobilize the person's own coping
resources, and should avoid encouraging dependency.
The distinctive qualities of effective counselors are
a) They have an internal map of the psychology of crisis;
b) They understand how help from professiona1 can complement the person's
own resources;
c) They have great sympathy with the person’s situation.
There are two main dimensions upon which people in crisis have to adjust:
1) Coping with feelings
2) Coping with the situation
88
II. Counseling
People in crisis hopefully can find support in their families or immediate social
circle, but this is not always the case. More and more people are turning to
counselors in the hope of finding help for their difficulties.
1. What is counseling?
In general counseling is consultation, mutual interchange of options
deliberating together. Counseling is a process involving an interaction
between counselor and client, in a professional setting, which is intended
and maintained to facilitate changes in the Behaviour of a Client.
2. Meaning of counseling :
• Counseling is face to face meeting of the counselor and the counselee
in which the counselor offers suggestion, opinions and advice to one
who seeks his advice.
• It is consultation and a mutual interchange and deliberation together,
which encourages the counselee to learn to solve his educational,
vocational, personal and all other types of problems.
• The motivation provided by the counselor brings about a change in
attitude, in development of skill and a choice of adequate environment.
3. How counseling works:1. There is a relationship of warmth and trust in which the counselor
attempts to understand the person and to convey this understanding
respect for the person.
2. The person is offered support by the counselor. This may be support
in coping with a crisis: support in terms of acceptance and respect as
an individual; or support in facing past events or trauma.
3. The person experiences a release of tension or reduction in anxiety
which allows him or her to face or talk about a particular problem or
problems.
4. The adaptive responses of the person are reinforced. In learning to
understand more about themselves and any self-defeating patterns of
thought or behaviour, the person is given an opportunity of solving
particular problems, improving relationships, etc. The counselor
shares any skill or knowledge which may be appropriate.
4. Objectives of Counseling :
The thrust area of counseling lies on the healthy adjustment of the
individual with himself / herself as well as others, in variegated life
situations. Counseling is specific for each client since each individual
has unique problems and expectations. Thus Individuals with varying
competencies and varying problem have different expectations from
the counseling. The major objective of counseling is obviously to help
the client. These are as follows
A. Resolution of problems: - Life presents a never-ending succession of
problems to be solved and decisions to be made. There are many
situations, however, that require a fresh approach in our work, in our
relationship with other people, in our role as citizen. It is often
necessary to carefully analyze the problems we encounter and work out
the best solution.
89
B.
C.
D.
E.
Improving personal effectiveness: - Blocher (1966) defines an effective
person as one who is able to commit himself into, projects, investing
time and energy and willing to take appropriate economic,
psychological and physical risks. He is seen having the competence to
reorganize, define and solve problems. He is seen as reasonably
consistent outside and with in his typical role situation. He is seen as
being able to think in the different and original, that is, creative ways.
Finally he is able to control impulses and produce appropriate
responses to frustration, hostility and ambiguity.
Decision making as a goal: - When faced with a problem, careful and
systematic analysis of a problem does not automatically indicate the
action we should take often we must choose between two or more
solutions which seem to be about equal in term of risks they involve
the satisfactions, the promise and the amount of time and effort they
demand.
Some times our choice is not even between two good
alternatives, but between the lesser, of two evils. Because we can not
control a1l relevant variables or anticipate chance factors we can never
be entirely sure but a decision will work out as we think it will. In spite
of the difficulties inherent in making decisions, however, we must
continually choose how to act or else be acted upon. Reorganizing that
occasiona1 failures are inevitable, we can substantially improve our
odds for success by following the principles of counseling.
Modification of behaviour as a goal: - Behaviorally oriented counselor
stresses the need for modification of behaviour for example removal of
undesirable behaviour or action, or reduction of an irritating symptom
such that the individual attains satisfaction and effectiveness.
Promoting Mental Health:Everyone experiences anxiety, but there is a continuum between
ordinary anxiety, uncomfortable but, common, and panic which is
totally disabling but rare.
The term abnormal is used when all four of the following criteria are
present: 1. Deviation from a statistical norm, 2. Marked departure from
social norms, 3. Maladaptive ness of the behaviour, 4. Personal distress
Certain factors seem to make people vulnerable to mental-health
difficulties. Those who experience multiple stressors are most at risk.
The risk is not for a specific disorder but for a spectrum of disorders.
Counseling may help in these situations.
5. Types of counseling: - The different type of counseling includes Advising,
Guidance, Therapy, Hygiology, Helping relationship, Solution to human
problem. Depending on individual’s nature, personality, circumstances,
situations the type of counseling may be selected.
6. Approaches of counseling: - Different approaches to counseling are based
on the varying conceptions of human personality structure and dynamics,
and are subject to the limitations to which personality theories. The term
‘approach’ is used in preference to theory as no single theory has yet been
able to encompass all the aspects of counseling.
Counseling therapies could broadly be divided into two major categories:
i. supportive therapies, ii. insight therapies.
90
1.
Supportive therapies believe in restoring the individuals,
adaptive capacities by teaching him / her new ways to maintain and
control by strengthening the existing defenses against anxiety.
Behaviour, modification and learning theory approaches can be placed
under this type of supportive therapy.
2.
Insight therapies try to release the self-actuating tendency in the
individual. They are, broadly of two kinds:
(1) Re-educative approaches directed toward producing more
harmonious self-structure (Client-centered approach),
(2) Reconstructive approaches aim at gaining of insight in to an
individual's unconscious conflicts, thereby bringing about
extensive alteration in the individual's character structure and the
release of energies for the development of new adaptive capacities.
Psychoanalytic approaches are reconstructive.
7. Counseling approaches (details)
A. The directive or authoritarian or Psychoanalytic approach :
This is developed by Sigmund Freud. Psychoanalytical therapy
emphasizes three basic ideas.
First is the important role of irrational and unconscious process – such as
repressed memories, motives, and conflicts-in self defeating and
maladaptive behaviour.
Refer to those Second is that such processes and adjustive difficulties
which originate in early childhood experiences and in the conflict
between social prohibitions and basic instinctual drives such as sex and
hostility.
Third is the importance of bringing these unconscious and irrational,
processes to consciousness so that the individual does not need to
squander his or her energies on repression and other ego-defense
mechanisms but becomes open to experience thus paving the way for
better personality integration and more effective behaviour
Psychoanalytic therapy is a complex and long-term procedure.
1) Basic nature of people: - The psychoanalytic model is a complex
one, but its outlines can be sketched as follows
2) Concept of ID, EGO and SUPER EGO: - The model is based on the
concept that behaviour results from the interaction of three key
subsystems within the personality: the id, the ego, the superego.
The id contains our primitive instinctual drives such as hunger, thirst,
aggression and sex. These instinctual drives are seen as being of two
types: 1. Constructive drives primarily of a sexual nature which
provides the basic energy of life, called libido; and (2) destructive
and aggressive drives, which are more obscure but tend toward selfdestruction and death. In essence, life Instincts are opposed by death
instincts. It may be pointed out here that Freud used the term ‘sex’ to
refer practically anything of a pleasurable nature, from eating to
bathing.
The Id operates upon the pleasure principle and is concerned only
with immediate gratification. It is completely selfish and
unconcerned with reality or moral considerations. Although the id
can generate images and wishes related to need gratification - such as
day dreams about several relations but it cannot undertake direct
91
action toward meeting its needs. These images and wishes are
referred to as the primary process.
A second key subsystem - the ego - develops to mediate between the
demands of the id and the realities of the external world. Although
the Primary purpose of the ego is that of meeting Id demands, it must
do so in such a way that will ensure the individual’s survival. This
requires the use of reason and other intellectual resources referred to
as the secondary process in dealing with the realities of the external
world as well as in exercising control over id demands. Hence the
ego is the central control or decider system of the personality and is
said to operate in terms of the reality principle.
However, the id-ego relationship is merely one of expediency and
makes allowance for moral values. Hence Freud introduces third key
subsystem-the superego - which is the out growth of learning the
taboos and moral values of society. It is the conscience and is
concerned with the good and the bad, the right and the wrong. It is an
additional inner control coming into operation to cope with the
uninhibited desires of the id. However, the superego, as well as the Id
operates through the ego system.
Freud has also identified two basic urges of the human personality,
namely – ‘EROS’ – the urge to live – the life instinct and
‘THANATOS’ the urge to die – the death instinct. The Eros is the
creative force and the Thanatos is the destructive force. The ego has
to deftly balance these two instinctual urges and personality
development is the result of this process.
When the id derives gratification of its ‘urge’, its energy libido is
drawn and used by the ego. But the id demands are not always
manageable.
The ego turns them down. This process is known as inhibition. Often
the libidinal urges may come in to direct conflict with the injunctions
of the superego. The result is repression, where, the idea on wish is
relegated to the depths of the unconscious or id but does not become
extinct. A repressed wish or idea is dynamic and even active and
wants to thrust itself into the region of the conscious which is a
threatening situation. Inhibition and repression are among the egodefense mechanisms which are irrational protective measures of the
ego.
3) Goals therapy: - The goal of analytic therapy is to reform the
individuals character structure by making the unconscious conscious
in the client. Past experiences are reconstructed, discussed, analyzed,
and interpreted with the aim of personality reconstruction. Insight
and intellectual understanding are important. But the feelings and
memories associated with this self-understanding are crucial.
4) Basic techniques used are free association, dream interpretation,
analysis resistance, analysis transference.
i. Free association: - This ‘basic rule’ of psychoanalytic therapy
requires that the client tells the therapist whatever comes in to his
or her mind regardless of how personal, painful, or seemingly
irrelevant it may be.
92
ii. Dream interpretation: Presumably when an individual is asleep,
repressive defenses are lowered and forbidden drives and feelings
may find an outlet in his or her dreams. As the client relates his
or her dreams the therapist interprets their symbolism to the
client.
iii. Analysis resistance: - During free association on narrating of
his dreams the client may be unwilling or unable to talk about
certain thoughts. Since resistance prevents painful irrational
material from entering consciousness, it must be dealt with if
the individual is to face conflicts and deal with them in realistic
way.
iv. Analysis transference: - During the course of psychoanalysis,
clients usually ‘transfer’ their feelings about some significant
individual from the past to their therapists. An important part of
therapy is helping clients work through this irrationa1
transference and see part relationships as well as their present
life situations in more realistic light.
5) Role of therapist: - In this approach (psychoanalysis) the therapist
remains anonymous and there is very little sharing of his or her own
feelings and experiences so that the client projects on to the therapist.
This projection is the material of therapy and is integrated and
analyzed. The therapist must first establish a working relationship
with the patient and then do a lot of listening and interpreting. One of
the central functions is to teach the client the meaning of these
therapeutic processes so that the client is able to achieve insight into
his or her problems, increase his or her awareness of ways to change
and thus gain more rational control over his or her life.
6) Relevance of psychoanalysis to counseling: - The empirical
data upon which Freud based his theories consisted principally of the
verbalizations and expressive behaviour of patients undergoing
psychological treatment. His theories germinated as he listened to the
facts and fantasies verbalized by troubled personalities. However the
most significant contribution of Freud and his psycho-analytic
technique cannot be under estimated. The works of Freud and his
followers influence to a great extent the thinking of counselors like
Darley, Williamson, Rogers and others.
B. Humanistic Approach: - The humanistic model is characterized
more by its positive view of the basic nature of human beings and
potential for self-direction and growth. The humanistic model
assumes that human behaviour cannot be understood in terms of
external stimulus conditions alone. Internal psychological
structures and processes also have a causal influence on thought,
feeling and action. People are viewed as having some measure of
freedom for self-direction. Great importance is given to the
uniqueness of the individual. Not only is the human species unique,
but each of us, by virtue of our particular learning and experience,
is unique. This uniqueness makes it our duty to gain a clear sense
of our own identity. We are self-aware, evaluative, future-oriented
and capable of resisting environmental influences as well as
93
modifying the environment. Only in this way we can fully develop
our potential as self-directing human beings.
1) Roger’s self theory: - The psychologist, Carl Rogers has played
a major role in delineating the self-concept in the humanistic
model. His views are as follows:
a. Each of us exists in a private world of experience in which I,
me, or myself is the center.
b. Our most basic striving is toward the maintenance,
enhancement, and actualization of the self.
c. We react to situations in terms of our unique perception of
ourselves and our world. We react to, ‘reality’ as we perceive it
and in ways consistent with our self-concept.
d. A perceived threat to self is followed by defense, including the
narrowing and rigidification of perception and coping
behaviour arid the introduction of self-defense mechanisms
such as rationalization.
e. Our inner tendencies are toward health and wholeness. Under
normal conditions, we behave in rational and constructive ways
and choose pathways toward personal growth and selfactualization or fulfillment.
i. Concept of self: - Roger’s theory is basically
phenomenological that is, he places a strong emphasis on the
experiences, feelings and values of a person, as summed up
by the ‘inner life’. Two constructs central to his theory are the
organism and the self. The organism is the locus of all
experience i.e., everything potentially available to awareness
that is going on within the organism at any given moment.
This totality of experience constitutes the phenomenal field
and is the individual’s frame of reference that can only be
known to the person. The individuals’ behaviour is
determined by the phenomenal field (subjective reality) and
not upon the stimulating condition (external reality). A
position of the phenomenal field gradually becomes
differentiated. This is the self. The self is the organised,
consistent conceptual gestalt composed of perceptions of the
characteristics of the ‘I’ or ‘me’ and the perceptions of the
relationships of the ‘I’ or ‘me’ to others and to various
aspects of life, together with the values attached to these
perceptions.
ii.
Development of self concept: - Roger focuses upon the
ways in which evaluations of an individual by others,
particularly during childhood tend to favour distancing
between experiences of the organisms and experiences of the
self. If an individual experienced only ‘unconditional positive
regard’, then no ‘conditions of worth’ would develop, selfregard would be unconditional, the needs for positive regard
and self-regard would never be at variance with organismic
evaluation, and the ‘individual would continue to be
psychologically adjusted, and would be fully functioning’.
But because parental evaluations of the child’s behaviour are
94
sometimes positive and sometimes negative, the child learns
to differentiate between actions and feelings that are worthy
(approved) and those that are unworthy (disapproved).
Unworthy experiences, though organismically valid, get
excluded from the self-concept and the self becomes out-ofline with organismic experience. This incongruence grows
with age and consequently, an organismic experience that is
at variance with this distorted self-concept is felt as a threat
and evokes anxiety. To protect the integrity of the selfconcept these threatening experiences are denied
symbolization or are given a distorted symbolization. In
client-centered therapy the person finds him or she in a nonthreatening situation because the counselor is completely
accepting of everything the client says.
2) Client centered therapy approach: - When the client
becomes more accepting of experiences that have been
denied symbolization, he becomes more understanding
and accepting of other people. The client also replaces
the present value ‘system’ with a continuing valuing
process which is important for wholesome adjustment.
i. Counseling goals: - The basic goal of the process is to
provide a climate conducive to helping the individual
become a fully functioning person. To reach this ultimate
goal, the essential stages are achieving openness to
experience, getting to trust one organism, having an
internal locus of evaluation and accepting the concept of
self as a process, rather than a product.
ii. Role of counselor: - The role of the counselor is rooted
in his or her ways of being and attitudes. The attitudes of
the counselor rather than his or her knowledge, theories or
techniques, initiate personality change in the client. The
counselor has to establish a non-threatening therapeutic
climate that facilitates the client growth along a process
continuum. Although it is easy to say that clients have to
find their own way, it takes considerable respect for
clients and courage on the therapist’s part to encourage
clients to listen to themselves and follow their own
directions particularly when clients make choices that
might not be the choices the therapist would hope for.
3) Experiencing of responsibility: - Once the client discovers
that he is responsible for himself and his experiences,
various feelings may result varying from unpleasant to
pleasant. These experiences should not be rejected or
distorted. The counselor should create an environment
which the client freely explores his feelings and attitudes.
As the process progresses, negative attitudes are
experienced and perceived as freely as are the Positive
attitudes. Anxiety about his perceptions is overcome. The
client thus reaches a stage where he can reorganize
himself.
95
4) Essential conditions for Personality change : - According
to Roger the following six conditions are necessary and
sufficient for personality changes to occur:
1. Two persons - the client and the counselor are in
psychological contact.
2. The client is in a state of incongruence being
vulnerable or anxious.
3. The counselor is concurrent or integrated in the
relationship.
4. The counselor experiences unconditional positive
regard for the client.
5. The counselor experiences an empathic understanding
of the clients, internal frame of reference and endeavours to
communicate this experience to the client.
6. The communication to the client of the therapist’s
empathic understanding and unconditional positive regard is
to a minimal degree achieved.
If the sixth condition exists over some period of time then
constructive personality change will occur. The conditions do
not vary according to client type.
5) Stages in personality change process includes Stage I to VII
Stage I: - 1. There is an unwillingness to communicate about the
self: communication, if any is only about externals, such as
experiences which have no deep significance for himself. 2.
Feelings and meaningful personal experiences are neither
recognized nor accepted. 3. Clients personal constructs are
extremely rigid. 4. Close and communicative relationships are
often viewed as dangerous and interpreted likewise. 5. The client
does not recognize or perceive any problems. 6. Owing to blockage
of internal communication, (non-perception of inconguerence)
there is no desire to change the experiential field. 7. Individua1s at
this stage do not recognize the need for counseling and do not
come voluntarly for help.
Stage II: - 1. In this stage the client begins to express his feelings
about non-self objects. The client may speak about other things
which are remote in relation to his self. 2. Problems, if perceived
are looked upon as external to the self. 3. There is no sense of
personal responsibility in problems. 4. Feelings may be exhibited
or expressed as unrelated to himself and are not owned. 5. ways of
experiencing generally follow past tendencies as distorted by the
self-structure acquired in the past. 6. Client’s personal constructs
are rigid. Feelings may be shown but are not recognized or owned.
There is little differentiation of personal meanings and recognition
of contradictions. Clients may begin therapy at this stage
Stage III: - 1. The client feels free to express his feelings. The
process started in the previous stage continues more freely.
Another significant improvement is that the client talks about the
self as an objective. Past feelings and personal feelings which are
usually negative are expressed. However, the client does not accept
them. For most part the feelings are revealed as something
96
shameful, bad or abnormal or unacceptable in other ways. Certain
experiences are described as in the past or as somewhat from the
self. 2. Personal constructs though rigid are recognized. 3.
Differentiation of feelings and meanings is better and less general.
There is some recognition of contradictions in experience. 4. The
client is able to see his personal choices as ineffective but not in
their proper perspective.
Stage IV: - 1. The client describes more intense feelings
experienced in the past and does not refer to the feelings in the
present. 2. The client is able to overcome his defenses occasionally
and expresses his feelings as experienced in the present. 3. The
tendency towards experiencing feelings in the immediate present is
dominant but there is distrust and feel of experiencing. 4. The
client does not show open acceptance of feeling though
occasionally this is exhibited. 5. The client is able to express his
experience as experienced in the present and is less bound by the
past self-structure and is less remote. 6. Acceptance and
understanding and empathy enable the client to move smoothly in
the direction of therapy. 7. There is a realization about
contradictions and incongruence between the experience and self.
8. The client shows feelings of self-responsibility in problems but
there is a tendency to vacillate. 9. The client is still wary about
close relationships.
Stage V: - 1. Feelings are expressed freely in the present. 2.
Feelings are very close to being fully experienced though fear,
distrust and lack of clarity are still present. 3. Self-feelings are
increasingly owned and accepted. 4. Responsibility for problem is
accepted. 5. The client is increasingly able to accept contradictions
and to incongruence in experience. 6. There is an increase in free
dialogue with in the self and improvement in reducing blockage of
internal communication.
Stage VI: - 1. The client is able co experience a previously
inhibited feeling with more immediacy and without any difficulty.
2. Feelings are freely experienced and expressed. The immediacy
of experiencing and the feeling which constitutes its content are
accepted and not denied, fear or struggled. Negatives give place to
positives. 3. Self as an object tends to disappear. 4. The
incongruence between experience and awareness is vividly
experienced and it disappears into congruence. There are no longer
external or internal problems. Physiological Concomitants of
loosening relaxing nature – tears, sighs, muscular relaxation,
improved circulation, etc. are present.
Stage VII: - New feelings are experienced with immediacy and
richness of detail. Changing feelings are accepted and owned.
There is generalized feeling of trust. All the elements of his
experience are now available to awareness and that is experiencing
of real and effective choice in new ways of being. The counselor
becomes a fully functioning person.
97
C. Behaviouristic approach : Behaviour therapy has come to mean the application of a diversity of
techniques and procedures that are rooted in a variety of theories of
learning.
1) Basic assumptions of Human nature : Behaviorism is a scientific view of human behaviour. The individual
is seen as having an equa1 potential for positive and negative
tendencies. The individuality of clients is a hallmark in the
behavioural approach. All clients should not experience the same
technique. The counseling technique should not necessarily be
employed in helping an individual client to resolve a variety of
concern. There is no standard counseling technique for all clients.
The method of assessment, counseling goals and techniques are
tailored on an individual client basis.
2) Learning and behaviour change : Since most observable behaviour is learned, behaviourists have
concentrated on the question of how learning comes about. Much of
our learning, particularly during infancy and childhood is based on
classical conditioning. This learning can be adaptive or maladaptive.
Another important concept is operant conditioning. The conceptreinforcement refers to the strengthening of a new response by its
repeated association with some stimulus presumably, any response
that the individual is capable of making, can be produced,
maintained, or eliminated by the appropriate scheduling of
reinforcement or lack of it - if the environment can be controlled.
3) Therapeutic goals: - The goals of counseling in the behavioural
framework are dependent upon the clients concern. The goals are
individualized for each client. Goals are mutually established by
the counselor and the client. These are specified in terms of what
the client will do where the actions will occur and how well the
actions will be performed.
4) Role of therapist: - The behaviour therapist must assume an
active, directive role in treatment. He typically functions as a
teacher, director and expert in diagnosing maladaptive behaviour
and in prescribing curative procedures that lead to new and
improved behaviour.
5) Technique used ‘Reciprocal inhibition technique’:-This technique
has been introduced by J. Wolpe. It is based on the assumptions
that all behaviour conforms to caused laws. Changes in the
behaviour of any organism are caused by (1) growth
(maturation), (2) lesions (damage, Injury and disease) and (3)
learning. This technique deals with changes in behaviour caused
by learning and is based on the theories of learning viz. classical
conditioning, Operant conditioning and observational learning.
The actual components of the learning processes, i.e.
reinforcement,
punishment,
extinction,
generalization,
discrimination, etc., are vital to counselors who are behaviouristic
in their orientation.
98
Wolpe has used the reciprocal inhibition technique with a
variety of anxiety-related behaviours, fears, and phobic reactions.
The procedure consists of these steps: 1.Systematic relaxation, 2.
Systematic desensitization and 3. Assertive training.
1. Systematic relaxation: Clients are trained to relax. This is the
most widely used approach, helps clients to perform deep
muscle relaxation. The methods of relaxation can be taught by
counselor or through the use of audiotapes or written materials.
Other relaxation methods have been used with equal success.
The important point is for clients to be trained to perform, at a
high level, a behaviour that is incompatible with anxiety.
2. Systematic desensitization: Clients construct a hierarchy of
stimulus situations in which they experience the anxiety. The
counselor helps the client to identify and arrange the situations
in a graduated order from lowest to highest anxiety
experienced. Ten to Twenty such items should be identified and
ordered. The ordering should be accomplished so that the
spacing, in terms of anxiety experienced, is equal between the
events listed. It is important that the various items on the
hierarchy be significant enough so that the client can imagine
the event vividly. The events listed must also be sufficiently
potent so that the client can identify them as anxiety producing
situations.
Pairing of the hierarchically items with the response that
is incompatible with anxiety is completed during the third step.
In the case of using relaxation as the incompatible response, the
counselor would help the client to move up the hierarchy of
events, while the client is performing the relaxation skill, from
the event identified as least anxiety producing to the items
listed in succession as being more anxiety-producing. The
hierarchy items are experienced one at a time in imagination by
the client. The images which are induced by the client
counselor must be vivid and should be held for a minimum of
25 seconds. Clients who are unable to move up the anxiety
items on the list without anxiety are asked to go back to the
next lower item and attempt again to achieve vivid imagery of
that item while remaining relaxed. If after three attempts an
item cannot be imagined without anxiety, the listing should be
checked for proper spacing.
3. Assertive training: This involves learning to make assertive
responses. These responses enable to overcome anxieties
arising out of inter-personal relationship. Assertiveness refers
to the ability to express one’s emotional feelings without
hurting other’s feelings. It is also concerned with standing up
for one’s rights without impinging upon other's rights.
Responsible assertion does not provoke unwanted feelings or
aggression on the part of the listeners.
Researchers have identified and indicated specific verbal
behaviour that differentiates between assertive and nonassertive persons. Assertive individuals speak more loudly and
99
make more requests from others than do non-assertive
individuals (Eisler, Miller and Hersen, 1973). Assertive persons
also use fewer words to get their message across (Galassi et al,.
1975), and take less time to deliver a message than do nonassertive persons. Similarly, assertive people are more likely to
maintain eye-contact during conversation, to stand erect with
their heads up, and to match their expressions with what they
are saying than are non-assertive people (Williams and Long,
1979). There is spontaneity, politeness and firmness in the
speech of assertive individuals.
Assertiveness training is helpful to improve the well-being of
individuals who are passive, lacking in self-confidence, unable
to make decisions and excessively inhibited. It can be helpful
for individuals who experience anxiety in a variety of social
situations. Assertiveness training has helped people to control
their anger, (Rimm. Hil1, Brown & Stuart, 1974), reduce their
anxiety (Percell. Berwick & Beigai. 1974) and to decrease
marriage problems between distressed couples (Fenesterheim,
1972). It provides emotional freedom and relationships.
6) Behaviour modification technique: - Behavioural Modification
is a technique or group of techniques that employ the principles
of learning theory. As far as behavioura1 counselors are
concerned, behaviour results from the interaction of heredity
and environment. Behavioural counselors are usually
concerned with observable behaviour. Implicit behaviour is as
much a result of the interaction of heredity and environment.
They stress five tenets.
1. Most, if not all, human behaviour is learnt (excluding
maturation). Hence it is changeable or modifiable; 2. Changes in
the environment can alter behaviour. Counseling therapists seek to
bring about relevant changes in client behaviours by altering the
environment suitably; 3. Social reinforcement, modeling, labeling,
etc. effect behavioural change; 4. The counseling effectiveness can
be assessed in terms of actual outcomes in behavioural change; 5.
The counseling technique or procedure cannot be a predetermined
fixed process. It has to be designed to suit each client’s specific
needs.
The central principle in behavioural counseling is reinforcement. A
positive reinforcement (something valued by the individual)
increases the occurrence of behaviour so does the ‘removal’ of a
negative reinforcement (an aversive event or stimulus) immediately
after the response occurs. Presumably any response that the
individual is capable of making can be produced, maintained or
eliminated by the appropriate scheduling of reinforcement or lack
of it - if the environment can be controlled.
In addition to reciprocal inhibition technique, there are a good
number of techniques used for behaviour modification, Systematic
100
desensitization; Flooding technique and Aversive therapy are some
of the more popular techniques.
D. Existential approach: The existential approach had its origins in philosophy and literature
rather than science. Existentialists are very much concerned about the
social predicament of the individual in the twentieth century. They
emphasize the breakdown of traditional faith, the depersonalization of
the individual in a standardized mass culture, and the loss of meaning
in human existence. In such a situation, it becomes the task of each of
us to stand on our own, to shape our identity and to make our existence
meaningful, to make our life count for something, not on the basis of
philosophical and scientific abstractions, but through our personal
experience of being.
1) Basic assumptions of Human nature: - Like the humanistic model
the existential model emphasizes the uniqueness of the
individual, the quest for values and meaning and our freedom for
self-direction and self-fulfillment. However, the existential model
represents a somewhat less optimistic view of human nature.
There is more emphasis on irrational trends and the difficulties
inherent in self-fulfillment. They also place considerably less
faith in modern science for dealing with our deepest problems
and more faith in the inner experiencing of the individual.
2)
Learning and behaviour change: - Human beings are capable of
self-awareness, the more awareness, and the more possibilities
for freedom. With freedom to choose and act comes a
responsibility. The awareness freedom and responsibility give
rise to existential anxiety which is a basic human attribute.
Existential guilt, also a part of the human condition is the result
of failing to fully become what one is able to become.
Humans are unique in that they strive toward discovering a
purpose in life and creating values that will give substance to
living. Although every human being to essentially alone in this
world one has a need to relate to others in a meaningful way, for
humans are rational beings.
Failure to create meaningful relationships resu1ts in conditions
such as isolation, depersonalization, alienation, estrangement and
loneliness. The human being strives for self-actualization- that is
the fulfillment of human potential. To the degree that one does
not actualize oneself one becomes “sick”. Pathology is viewed as
a failure to use freedom to actualize one’s potentials.
3)
Therapeutic goals: - Existential therapy aims at having clients
experience their existence as authentic by becoming aware of
their own existence and potential and by becoming aware of how
they can open up and act on their potentials. There are three
characteristics of authentic existence: (1) being fully aware of the
101
present moment, (2) choosing how to live in the moment; and (3)
taking responsibility for the choice. The neurotic client is one
who has lost the sense of being and the goal is to help him or her
recaptures or discover his or her lost humanity.
Basically, the goal of existential therapy is to expand selfawareness and thus increase choice potentials- that to become
free and to be responsible for the direction of one’s life.
4)
Role of therapist: - The therapist’s main task is to attempt to
understand the Client as a being and as a being-in-the world.
Technique follows rather than precedes understanding. Because
of the emphasis on experiencing a particular client in the present
moment, existential therapists show wide latitude in the methods
they use and their procedures might vary not only from client to
client but also with the same client at different phases of therapy.
5)
Application of existential approach: - Unlike most other
therapeutic approaches this model does not have well-defined
techniques. The therapeutic procedures can be borrowed from
several other approaches. Methods derived from the Gestalt and
from Transactional Analysis are particularly appropriate and
some of the principles and procedures of psychoanalysis can be
integrated
into
the
existential-humanistic
approach.
Existentialism developed as a reaction to the menacing growth of
materialism.
E.
Minnesota (University) point of view or Trait – factor
approach: - Basic assumptions: - The trait-factor approach is based
upon several assumptions that are taken from the tradition of
differential psychology.
(a) To some extent, individuals differ from one another in every
behavioural respect, and individual differences are all-pervasive; (b)
Within broad limits that are imposed genetically behaviour is
modifiable, and can be modified within limits that are a function of the
organism and of the environment; (c) Enough consistency of behaviour
characterizes individuals to allow for generalization in describing
behaviour over Time.
(d) The individual’s behaviour is a product of current status,
experiences, and present physical and social setting: (e) Human
behaviour can be conceptualized conveniently in terms of ability,
general personality and temperament and motivation; (f) Social and
interpersonal conflicts are inevitable, necessary and can be
constructive or destructive.
F. Eclectic approach : “Psychological case handling” is a broader term than psychotherapy
and more comprehensive than the latter. It is based on an individual
appraisal of each case. The plan includes suitable measures for
beginning the relationship and unearthing and identifying the problem
102
for dealing with the psychopathological symptoms and related
etiological factors.
Taking the clientele of any counselor one may come across wide
personality differences. No single theory of personality can justifiably
encompass all phenomena. Therefore eclecticism is the most
practicable and apt approach to counseling.
The matter of choosing what is best from each system is left to the
counselor to decide under the given circumstances and this can lead to
much avoidable controversy. It is explained that the choices of
principles are never made in advance but are made as and when they
are found to be expedient in working with the counselees. It is
therefore not practicable to predict what an eclectist will do in a given
situation. This suggests that the position of every eclectic counselor
will naturally differ from every other eclectician making the position
impossible to define or describe.
8. Counseling process – characteristics: - It consists
A. Counseling is person to person relationship. It involves two people
(counselor and counselee) in interaction which is highly
confidential and unobserved by others.
B. Mutual participation through verbal communication. The mode of
interaction is usually verbal communication.
C. Main emphasis in counseling is on Self direction and Self
acceptance.
D. Counseling is a process in which counselee freely and frankly
expresses and explores himself the issues which are of concern to
him.
E. Counseling process structured around the felt needs of Counselee
F. Counseling process continuous till the behaviour of the counselee
is modified to enable him to handle his problems independently
G. Counseling process usually takes long time as the change in
behaviour is gradual process
9. Steps of counseling process: in the counseling process the following steps
are involved. They are Initial appointment, a pre-counseling session,
Devolvement of facilitative relation ship, Goal specification, Identification
and consideration of factors related to the achievement solution,
Development and implementation of a programme to wards goal
achievement, Evaluation of results, Termination of relationship, Followup.
10. Characteristics of client (counselee): a counselee should have Self –
image, Social – image, Needs, Motivation, Problem of adjustment,
Frustration, Threat and Conflict, Failures of adjustment, Abnormal or
disturbed general physical appearance, Abnormal or disturbed emotional
expression, Abnormal or disturbed verbal expression, Abnormal or
disturbed social communications, Awareness of the problem, Seeking
professional help, Growth towards maturity.
103
11. Characteristics of the Counselor: The American Psychological Association has put forward certain criteria
for the selection of clinical psychologists. They can serve as guiding principles
for the selection of Indian counselors for they are not culture-bound. They
as follows
1. Superior intellectual ability and judgment
2. Originality resourcefulness and versatility
3. Fresh and Insatiable curiosity; self-learner
4. Interest in persons as individuals, rather than as material for
manipulation - a regard for the integrity of other persons.
5. Insight- into one's own personality characteristics: sense of humour
6. Sensitivity to complexities of motivation
7: Tolerance: ‘Unarrogance’
8. Ability to adopt a therapeutic attitude: ability to establish warm and
effective relationships with others.
9. Industry: methodical work habit; ability to tolerate pressure.
10. Acceptance of responsibility
11. Tact and cooperativeness
12. Integrity self-control and stability
13. Discriminating sense of ethical values
14. Breadth of cultural background.
12. Limitations of counseling (REFERAL STATE IN COUNSELING)
The Counselors limitations: - The counselor should be aware of his own
limitations and should not go beyond his area of competence in counseling
clients and if necessary should refer such cases to the competent agency.
There are atleast two kinds of limitations:
a) Limitations arising from lack of rapport and
b) Limitations arising from inability to help
13. Professional Ethics in counseling: - Professional ethics here refers to a
systematized body of moral principles that guide or determine the
counselor’s behaviour in his relationships to the client, to the client's
relatives, to his referring agency and to society in general.
A. The Counselor’s relationship to the /client –
a) The counselor must respect the values of the client. The
counselor should always try to understand another man’s point of
view.
b) Test results must be interpreted to the client in a manner likely
to be constructive in his efforts to solve his problems and
misinterpretation to be avoided.
C) The most important area of ethical concern in counseling is
confidentiality. The information about the client should be kept strictly
confidential. It is not disclosed even, to the client’s relatives without
prior permission from the client. Sometimes, it may be necessary to
take the close relatives into confidence even though the client may not
permit it; the counselor should be aware of this line of demarcation
depending upon the seriousness of the problem at hand.
B. The Counselor’s relationship to the profession –
104
a) The counselor must maintain high standard of work, not aiming
at temporary success. It is unethical for a counselor to offer services
outside his area of training.
b) When a counselor becomes aware of malpractice of other
counselors, he should exert what influence he can to rectify the
situation.
c) A counselor should not normally accept for counseling a person
who is receiving psychological assistance from another professional
worker except by agreement or after termination of the client’s
relationship with the other professional worker.
C. The Counselor’s relationship to referring bodies - It is courtesy to
inform the referring person or agency that the client kept the
appointment and is continuing counseling or has been referred to
another agency. No confidential information about the client is to
be imparted to the agency.
D. The Counselor’s relationship to himself / herself –
The Counselor has a right to his private life and to relaxation.
He should leave the problems of clients in the office, and not allow
them to interfere with his happiness at home.
The counselor should not encourage dependency in the client; not
allow unreasonable demands on his time, activities etc,
The counselor should not entertain too high an expectation in his
counseling practice as there are always limitations in helping the other
individual.
E. The Counselor’s relationship to the society –
His responsibility to the society should allow him to contribute to
the welfare of the society whenever it is possible.
14. Legal considerations
A. Proper certificate from recognized institution / university
B. License to practice from a authorized authority (if presents)
C. Appropriate diagnosis of client’s condition and its certification
D. Should not issue improper certificates under pressure / obligations
15. Adjustment and Mal- adjustment traits in personality
Adjustment is the process by which a living organism maintains a
balance between its needs and circumstances that influence the
satisfaction of these needs
Personality is the dynamic organization within the individual of
those psychophysical systems that determine his unique adjustments to
his environment.
A person with an integrated personality will have relatively stable
patterns of behaviour. Personality integration is obtained as a result of
intermaturity, balance, stability and harmony between the various
characteristics of the Individual. This kind of integration is observed in
all normal individuals but the levels of integration differ from person
to person. There are also differences in the degree of integration. In the
development of personality, atleast three levels of integration can be
observed.
105
It may be necessary for the counselor to have higher degree of
organization of the personality in comparison with that of the client.
Otherwise, the helping relationship may lead to a failure.
A. Problem of adjustment: - Stable forms of adjustment can be
regarded as traits of personality. Problems of adjustment are
universal in that all people must face difficult and troubled
circumstances of living: but the styles of coping may vary and
G.W. Allport refers to uniqueness in the individual adjustment
pattern. There are a variety of physical and social demands and a
growing individual learns adjustive reactions to deal with the
environment. There are also biological aspects related to these
adjustive reactions. The environment also serves the individual as a
resource for adjustive reactions. But whenever there are stressful
demands, the adjustment becomes difficult. Stress occurs when
there are demands on the person which tax or exceed his adjustive
resources. Stress may originate in the environment but actually it is
the individual who feels the stress and hence it is considered to be
psychological.
Individual differences in reaction to the same situation may be
observed. Even in severe disasters in which many are killed or left
homeless and in which the whole structure of the community is
disrupted or destroyed, there are still some individuals who appear
comparatively capable of acting in an et1ective fashion. In contrast,
others become disorganize, dazed and panicky showing the signs of
severe emotional disturbance. All these have stimulated research on
stress management.
B. Frustration, Threat and Conflict: - Frustration
is an important
component of psychological stress when an individual experiences
thwarting or delaying of some goal gratification. When a person
loses a loved one through illness or death, it may become a major
source of frustration.
Threat may be defined as the anticipation of harm which may
produce great stress; the individual anticipates future harm and shows
stress - reactions.
Conflict occurs in the presence of two incompatible action
tendencies or goals and produce psychological stress till the conflict is
resolved.
C. Failures of adjustment: - The client or the counselee may face
failures to adjustment either due to severe stressful condition where
normal coping patterns fail or due to generally ineffective coping
patterns of adjustment.
Aggressive behaviour, apathy
or depression psychosomatic
Symptoms, anxiety, anger or guilt – these are a few of the various
symptoms one can observe in the client. There are individuals who
show disturbance in memory, perception and thought.
106
D. The thin line between normal and abnormal behaviour /
adjustment: - When an individual lands up in the counselor’s office
seeking assistance to his problem, it is necessary for the counselor
to know whether this client is amenable to simple counseling or
whether he needs a psychiatric help. Who are the individuals who
can be helped through counseling?
Psychopathology is the study of deviant behaviour which is
referred to as behaviour pathology, behaviour disorder or
abnormal behaviour. All these terms carry implications of a
departure from normality. At one time or another, everyone
experiences headaches brought on by nervousness, an
overwhelming anxiety in the midst of crisis, or uncertainty
about his or her own identity and goals in life. On the
behavioural side the line between normal and abnormal is a thin
one.
Counseling is much more useful to the normal people with
emotional and adjustmental problems experienced at some
point of their life. Many of these people require a change in
their attitude, development in interpersonal skills and
enhancement in self-concept. Problems of suicidal tendencies
can also be averted through counseling.
16. Analysis of adjustment and mal-adjustment traits in personality
A. Concept of Stress and it’s effect on personality : Life would be simple indeed if our needs were automatically
gratified. But, as we know, many obstacles, both personal and
environmental, prevent this. Such obstacles place adjustive demands
on us and can lead to the experience of stress. The term, stress has typically been used to refer both to the adjustive demands placed on an
organism and to the organism's internal biological responses to such
demands.
All situations, positive and negative, that require adjustment are
stressful. Thus, according to Canadian physiologist Hans Selye (1976),
the notion of stress can be broken down further into positive stress,
eustress, and negative stress, distress. Both types of stress tax the
individual’s resources and adjustment, though distress typically has the
potential to do more damage.
Stress is a fact of life, and our reactions to stress can give us
competencies we need and would not develop without being challenged to do so. Stress can be damaging, severe stress can exact a high
cost in terms of lowered efficiency, depletion of adaptive resources,
wear and tear on the system, and, in extreme cases, severe personality
and physical deterioration, and even death.
On a psychological level, perception of threat brings a narrowing
of the perceptual field and increased rigidity of cognitive processes so
that it becomes difficult or impossible for the individual to see the
situation objectively or to perceive the range of alternatives actually
available. This process often appears to be operating in suicidal
behavior.
107
Our adaptive efficiency may also be impaired by the intense
emotions that commonly accompany severe stress. Acute stage fright
may disrupt our performance of a public speech; examination jitters
may lead us to blow it despite adequate preparation. In fact, high levels
of fear, anger, or anxiety may lead not only to impaired performance,
but to disorganization of behavior.
B. Reaction to stress
When stressors are over loaded, they induce a number of effects. These
effects are of two types. 1. Immediate effects 2. Long-term effects. The
immediate effects are changes in Behavior (over eating, excessive
alcohol consumption) Physiological (increased blood pressure, rapid
heart rate, heightened mussel tension), Emotional (heightened anxiety,
depression, anger) and Cognitive (decreased concentration, increased
distractibility). If these stressors continued for long period they, leads
to various responses called as long-term effects of stress. These longterm effects are leading to Behavior disorders (obesity, alcoholism),
Medical (physiological) disorders (hypertension, heart disease, and
headaches), Emotional disorders (chronic anxiety, depression, phobias,
personality changes, mental illness) and Cognitive disorders (memory
problems, obsessive thoughts, sleep disorders).
1) Psychological reactions are of two types viz. emergency
responses, General Adaptation Syndrome (GAS) includes Stage
of alarm reaction; Stage of resistance; Stage of exhaustion.
C. Measurement of stress: - usually stress can measured by using
different stress measuring scales like life events scale, adjustment
scale etc,
17. Counseling as solution for Adjustment and Mal- adjustment traits in
personality : - the mal-adjustment traits can be corrected by using the
different counseling techniques such as Resolution of problems, Improving
personal effectiveness, Decision making, Modification of behaviour and
by Promotion of mental health.
18. Counseling as Hygiology: - Hygiology is the study of the problems of
normal people and the prevention of the incidence of serious emotional
difficulties the counselor is almost always concerned with normal
individuals who experiences conflicts of different degrees of complexity,
experience anxiety, are unable to decide and are subject to stress. The
Importance of counseling in modem times cannot be overemphasized. It
can become almost indispensable owing to rapid
industrialization,
ecological Imbalances, excessive competition and other factors
contributing to the increase in occurrence of mental disorders and
maladaptive behaviour.
III. Social Support and Social Adjustment
1. Social support: - Social support is the physical and emotional comfort
given to us by our family, friends, co-workers and others. Social support is
that we are part of a community of people who love and care for us, and
value and think well of us. Social support is a way of categorizing the
rewards of communication in a particular circumstance. An important
aspect of support is that a message or communicative experience does not
constitute support unless the receiver views it as such.
108
2. Social adjustment: - Social adjustment is Kind of relationship which
involves the accommodation of an individual to circumstances in his / her
social environment for the satisfaction of his / her needs or motives.
3. Why social support required for old age people?
• Many studies have demonstrated that social support acts as a
moderating factor in the development of psychological and/or
physical disease (such as clinical depression or hypertension) as a
result of stressful life events
• There is growing evidence to suggest that social support affects
humans differently throughout life, suggesting that the need to
receive and provide social support shifts across development.
• Social support can also increase one’s sense of belonging, purpose
and self-worth, promoting positive mental health.
4. Why social adjustment required for old age people? Because the old age
people suffers from anxiety (severe anxiety, panic anxiety), helplessness
and guilt & shame, anger, ambivalence.
5. Family support for elderly
6. Utilization of services of elderly people for family
7. Social support for elderly
8. Utilization of services of elderly people for society
9. Scope of utilization of services of elderly people for society
10. Methods of social utilization of elderly people: - the recommended
strategies for the social utilization of elderly people are they may be given
Re-employment, appointed as Advisors, Consulting Subject experts and as
well as Counselors.
11. Recreation of elderly people
12. Occupational supports for elderly people
13. Familial support for elderly women
14. Social support for elderly women
RECOMMENDEDE FURTHER READING
1. Advances in Ayurvedic Medicine Vol IV – Mental State Examination K.
Narasimha Murthy and R. H. Singh (2005) Chauhamba Visvabharati,
Varanasi ;
2. Assertiveness Skills Training Sue Bishop [1999] Visuthamby Publishers Pvt.
Ltd
3. Ayurveda and the Mind: An Overview (An article) Dr. David Frawley
Published:
Tuesday
10
October,
2006
available
at
http://www.vedicsociety.org/ayurveda-and-the-mind-an-overview-a-208.html
4. Ayurveda and the Mind: The Healing of Consciousness
David Frawley (2005) Motilal Banarsidass Publishers Pvt, Ltd. Delhi
5. Ayurvede
sattvavajayachiitsÁyah
sameekshaatmakam
adhyayanam
K.H.H.V.S.S. Narasimha Murthy, R. H. Singh and G. S. Tomar (2007) Ph.D
Thesis, Department of Kayachikitsa, Faculty of Ayurveda, Sampoornanand
Sansrit University, Varanasi
6. Ayurvediya Manas Vijnan R. H. Singh (1986)Chauhamba Amarabharati
prakashan, Varanasi
109
7. Behaviour modification Handbook of Assessment, Intervention & Evaluation
Gambrill (1979) Joneybon publishers.
8. Clinical methods in Psychology Weiner, Irving (1976) New York, Wiley
9. Counseling and Guidance S. Narayana Rao (2nd edition) (24th Reprint 2006)
Tata Mc Graw-Hill Publishing Company limited , New Delhi
10. Counseling Current Status of Yoga Therapy Edited by R. G. Singh and K. N.
Murthy (2006) Indian Academy of Yoga, B. H. U, Varanasi
11. Experiences with Ayurvedic Psychotherapy “Satvavajaya” in Europe ; Karel
Nespor and R. H. Singh (January 1986) Ancient Science of Life, Vol. V, No.
3,
12. Handbook of Counselling Psychology Ray Wolfe & Windy Dryden (1996)
Sage Publications Ltd.
13. The Counselling Process Lewis E. Patterson and Elizabeth Reynolds Welfel
(2000), V edition, Wasworth Brooks/Cole Thomson Learning
14. The Holistic Principles of Ayurvedic Medicine R. H. Singh (1998) Chauhamba
Sansrit Pratishthan, Delhi
15. The Mind in Ayurveda and other Indian Traditions A. R. V. Murthy (2004)
Chaukhamba Sanskrit Pratishatan, Delhi
110
Chapter-8
Referral Requirement and Clinical Judgment in Geriatric Practice
1. Introduction:
Scientific study, research and care of elderly persons have gained tremendous
priority and importance during the past couple of decades. Rapid advances in
medical science and better care of the elderly, improvement in nutrition, mass
immunization against diseases, decreasing infant mortality rate, late marriage and
later child bearing and more people now practicing family planning, the absolute
number of the elderly over 65 years is increasing very fast. Today 60% of the
world’s older persons live in Asian continent and by 2025 it will be increases up to
75%. Modernization, urbanization, breaking of joint family system and consumerism
have aggravated the problems of the elderly. In most of the Asian countries, the
order of precedence had been mother, father, teacher and God but the fast changing
culture and the impact of western civilization has diluted the precedence, family ties
and mutual regards. Aging is no longer a minor issue and soon in many countries,
elderly will be greater in number than the young. Baby bonus schemes have been
taken up in Australia, Scandinavia, France, Spain and Singapore, etc to increase the
birth rate. Recent surveys have indicated that 50% of the people above 50 have one
or more diseases and significant disability.
It is generally found that the physical and mental health of a person gradually
declines with advancing age. On the physical side, both ailments and diseases coexist with elderlies. Age and ailments therefore some times are described as
concomitant. It is also mentioned that multiplicity of ailments increases with the
advancement of age as a natural process. In terms of minor diseases both in males
and females the common problems are arthritis, digestive disorders, cough and cold,
insomnia, general debility, vertigo, swelling of limbs and hypertension, arthritis,
asthma, tuberculosis, cancer of lung and cancer of cervix in females, cardiac
problems, peptic ulcer, IBD, IBS, diabetes mellitus, thyroid disorders, genitourinary
problems, dementia and other neurodegenerative disorders are the main major
disorders found in old age group. Primarily the geriatric disorders should have to be
registered in geriatric service centers for total care and assessment.
At this juncture geriatric assessment is crucial to evaluate the uncovered
multiple problems of elder persons, because some of the elderly patients will need
referral for specialized medical and surgical care for their associated major disorders.
This requires a team work of multiple services. The goals of geriatric assessments
are:
i. To improve diagnostic accuracy.
ii. To guide the selection of therapeutic intervention to restore or preserve health.
iii. To recommend an optimal environment for care.
iv. To predict outcomes.
v. To monitor clinical and therapeutic changes over time to time.
vi. To improve over all health of the elderly.
111
2. Availability of referral services:
In geriatric practice availability of referral services is utmost important. This
in depth requires the participation of a number of other professionals to make sure
that their patient gets exactly the right kind of help. Today’s doctor- patient
relationships are more collaborative than ever. Seniors need to find someone who
truly listens to them. It may include a team of nurse practitioners, surgical specialists,
geriatric psychiatrists, medical specialists, oncologists, endocrinologists,
cardiologists, pulmologists, nephrologists, urologists, osteopath experts,
ophthalmologists, pharmacists, physical and occupational therapists, nutritionists,
speech therapists, and audiologists etc for over all health care of the elderly.
3. Referral need, Timely Clinical Judgment and Mutual referral
Arrangement:
The geriatrician will not only keep close watch on degree and progression of
associated major disorders in his elderly client but will also watch on overall quality
of life. A geriatrician will truly assess the spectrum problems of the seniors such as:
Cognitive and functional strength and limitation.
Home safety evaluation and fall risk assessment.
Speech and oral expression skills.
Pain assessment.
Assessment of severity of disease.
Assessment of emotional, cognitive, behavioral, social and spiritual status.
Activities of daily living.
Instrumental activities of daily living.
Depression screening and mini mental status examination.
Caregivers burden assessment
Medication review
Physical examination.
Lastly geriatrician may assess the major geriatric problems and severity of
associated disease.
At this juncture clinical judgment for referral services in other specialized units is
crucial for investigative, diagnostic and therapeutic purposes. There is also a need of
mutual referral understanding and arrangement for the benefit to the elderly patients
in a right way.
•
•
•
•
•
•
•
•
•
•
•
•
•
4. Therapeutic nutrition:
In general, nutrition is considered as one of the most important factors in
promotion of health in the process of aging. In elderly patients nutrition is greatly
hampered due to many reasons such as depression, poor dentition, functional
impairment, and cognitive impairment, lack of appetite, chronic co- morbid diseases,
lack of caregivers and resources. Nutritional assessment of elderly patients is
difficult due to limited availability of reference standard for this population. In
addition, many physiological changes that occur in the normal process of aging
result in alteration of biochemical values and clinical presentation of common
ailments and diseases. These features are indistinguishable from selected nutrients
deficiency disorders. A comprehensive evaluation of the nutritional status and
nutritional needs of an individual is based upon anthropometric, biochemical,
clinical and dietary information. By using this information a practical nutritional care
112
plan for elderly patients can be formulated by a nutritionist and dietician. Hence for
specialized opinion and planning referral may be required in few elderly patients in
view of their associated major illness, like• Provision of sufficient amount of energy, protein and micronutrients.
• Maintenance or improvement of nutritional status.
• Improvement of function, activity and capacity for rehabilitation.
• Improvement of quality of life.
• Planning of dietary regimen for a particular disease.
• Reduction in morbidity and mortality.
5. Trauma and Orthopedic Care:
Trauma is an important morbidity factor in old age group, which may lead to
fall, fracture and other orthopedic problems. Degenerative changes of joints and
bones are most common in the elderly leading to a variety of clinical conditions of
which osteoarthritis of various joints; cervical spondylosis, lumber-thoracic spine
degeneration and osteoporosis are important ones. Though rheumatoid arthritis is a
disease of young age, but due to its chronicity, it becomes a major factor contributing
disability in elderly. Certain bone and joint disorders like bone and joint TB,
avascular necrosis of bones and joints, bone cancer, joint destruction, traumatic and
pathological fractures etc need special care. Fracture of neck of the femur is the
commonest condition in old age. It draws attention of geriatrician, to assess the
condition thoroughly and refer it timely to the specialist for better assessment, care
and management. The indications of referral in elderly patients of traumatic and
orthopedic disorders are given below.
A. Clinical conditions to be referred in presence of diagnostic uncertainty
and
therapeutic intervention:
•
•
•
•
•
•
•
•
•
•
•
•
History of recent and past trauma.
Shortening of limb in case of fracture
Onset of diseases- acute, sub- acute and chronic.
Past/ recent history of malignancies other than bone.
Past/ recent history of malignancies of bone and joint.
History of chronic fever and weight loss.
Past history of chronic diseases associated with problems of joints and bones.
Tenderness of bones and joints in TB and other inflammatory disorders.
Gross irregular bony outgrowth.
Immobility of joint and affected part.
Displacement of joint.
Markedly reduced nutritional status of the patient.
113
Common traumatic fracture in elder age group
Preoperative
Radiography, displaying
bilateral fracture of the
femoral neck
Source: www.scielo.brscielo.phppid
Source: www.santarosastrength.com
B. Referred for investigative purpose:
• Serological estimation of Hormones i.e. Thyroid, Parathyroid and Calciferol,
• Serum Calcium and Phosphate.
• Serum IgG and IgM for Tuberculosis of joint and bones.
• Blood sugar, Lipid profile, RA, CRP, ESR.
• Bone biopsy for detection of carcinoma.
• Bone density measurement.
• X-rays and MRI of affected joint and bone.
6. Endocrine and metabolic disorders:
A significant alteration in hormone production, metabolism and action are
found during the process of aging. In aged people associated disease, smoking,
sedentary life style and adverse consequences of drugs may lead to reduce
physiological reserve and make them more vulnerable to environmental,
pharmacological and pathological challenges. In old age the equilibrium
concentration of principal hormones are not necessarily altered but there is a change
in endocrine regulatory process and signal transduction process at the target level.
This may lead to endocrine and related problems e.g. diabetes mellitus, thyroid
disorder, parathyroid disorder, osteoporosis etc.
A. The indications of referral and clinical judgments in endocrine and metabolic
disorders in
geriatric practice are given below.
- Presence of acute complications- hyperglycemia, hypoglycemia, thyroid crisis,
hypocalcaemia etc.
114
Source: www.hughston.com
- Presence of chronic complications- osteoporosis, pathological hip fracture
neuropathy, nephropathy, retinopathy, cardiopathy etc.
- Those that are not responding to therapeutic measures.
- Those that have adverse consequences of therapeutic measures.
- In cases of target organ damage.
- In case of adverse consequences of disease itself.
- At least once a year for a detail assessment of the target organ involvement.
- Patients with severe infection, marked weight loss & breathlessness.
- In dose titration for ongoing 3-4 drugs regimen.
- No response to the emergency treatment.
- In cognitive impairment.
B. Referred for investigative purpose:
•
Full blood count, ESR, Platelet count.
•
Blood sugar fasting and post prandial.
•
Lipid profile.
•
Glycosylated Hb%.
•
Urine for-Routine and microscopic examination, culture and sensitivity test.
•
Blood urea and serum creatinine.
•
Serum Calcium and serum Phosphate.
•
Hormonal estimation i.e. - thyroid, parathyroid, insulin, calciferol.
•
Immunological investigations.
7. Neurological, neuromuscular and neurosurgical disorders:
With the advancement of age neuro-degenerative and neuromuscular
impairment become common. Because of such changes an elderly person becomes
unable to perform his routine activity. These consequences and other triggering
factors such as sedentary life style, smoking, alcohol along with other associated
diseases such as hypertension, obesity, diabetes mellitus etc lead to develop a variety
of neurological, neuromuscular and neurosurgical disorders. In advanced stage and
115
in acute onset of these disorders the patient should be referred timely to specialized
care centers for therapeutic strategies and special investigations.
Clinical conditions to be referred for therapeutic strategies include Treatment failure at geriatric clinic.
Deranged function of consciousness.
Convulsive disorders.
Chronic persistent headaches.
Disorders of neuropathy.
Severe dementia with or without Parkinson’s and Alzheimer’s disease.
Acute onset diseases such as meningitis, encephalitis, and other
encephalopathies
Uncontrolled cases of vertigo.
Exacerbation of transient ischemic attack.
Acute onset of CVA and Hemiplegia.
Neoplastic disease of brain.
Cases of brain concussion, contusion, laceration, edema and hemorrhage.
Referred for special investigations:
• Testing of higher cortical, motor and sensory functions.
• Examination of reflexes.
• Testing of cranial nerves.
• Testing of speech, gait and coordination.
• Full blood count, ESR, Blood sugar and urea, Lipid profile, Serum
electrolyte etc.
• Spinal tap and CSF examination.
• Electroencephalography- EEG.
• Electromyography- EMG: electrical activity of resting muscle and muscle in
action.
• X-rays skull and CT scan of cranium and skull.
• MRI- It is useful in diagnosis of arterial and cerebral lesions which are not
seen on CT scan.
8. Psychiatric disorders:
According to the national institute of mental health the most common
psychiatric disorders in old age are depression, melancholia, phobia, cognitive
impairment due to dementing disorders, alcohol and drug dependence. Depressive
disorder is of significant concern in the elderly. It is characterized by reduced energy
and concentration, sleep disturbance, reduced appetite, weight loss somatic
complaints and suicidal risk with age. Melancholia is a type of depressional
syndrome, unique to elderly and is characterized by depression, hypochondriasis,
and low self esteem, feeling of worthlessness, self accusatory trends with paranoid
and suicidal ideation. These psychiatric illnesses need referral to a neuropsychiatrist
and geropsychiatrist for diagnostic purpose, planning of therapeutic strategies and
joint follow ups.
A. Clinical conditions to be referred for planning of therapeutic strategies
include:
1. Disorder of thought – obsessions, hypochondrial belief, phobia.
116
2.
3.
4.
5.
Disorder of emotion- depression, anxiety, agitation, panic labile effect etc.
Disorder of motor behavior- negativism, catalepsy, compulsion etc.
Disorder of perception- hallucination, illusion.
Organic mental disorder- dementia, delirium, epilepsy, psychotic condition,
personality and behavioral changes.
B. Referred for special diagnostic tests and investigations:
• Intelligence test
• Personality test
• Projective test
• Test for organic brain damage
• Electrophysiological investigation- EEG.
• Imaging technique- CT scan, PET, MRI: useful in organic psychiatric
conditions.
• Neuroendocrinal test- Dexamethasone suppression test is useful in major
depressive disorder.
• Urine test for substances- alcohol, barbiturate, benzodiazepine, heroin,
cannabis, cocaine etc can be detected in patients’ urine.
9. Cardiovascular disorders:
The age associated cardiovascular problems are hypertension, unstable
angina, MI, hyperlipidemia, and congestive heart failure. The features of
hyperlipidemia are feeling of heaviness in the body, lethargyness, greasiness over
the body and deposition of fats that may lead to fatty liver, atherosclerosis of blood
vessels and obesity. Atherosclerosis is an important factor in hypertension and
ischemic heart disease. Serious cases of cardiovascular disorders are to be referred to
the specialist timely for assessment of risk factor, coronary care, and therapeutic
guidelines and for special investigations.
A. Cardiovascular disorders to be referred include:
• Hypertensive emergency.
• Hypertension associated with CVD, CHD, CHF.
• In case of treatment failure.
• Cases of major angina and MI.
• Cardiac problems associated with hyperlipidemia.
• Cardiac problems associated with diabetes mellitus.
• Endocrine disorder with cardiac manifestation.
• Valvular heart disease.
• Coronary artery disease and cardiovascular complications.
B. Referred for special diagnostic tests to evaluate cardiovascular disorders:
• Full blood count, platelet count, BT, CT, PT.
• Blood urea and sugar, Serum electrolyte and creatinine, lipid profile.
• Serum enzyme- SGOT, CPK, CPK- MB, LDH, Troponin T and I.
• Urine for routine and microscopic examination.
• X-rays chest PA view.
• ECG and TMT test.
• Echocardiography.
117
•
Cardiac catheterization and angiography.
10. Chest and tuberculosis:
The common changes which are seen in the physiology of lungs and bronchi
in the elderly include gradual reduction in lung volume, fall in elastic recoil of lung,
increased FRC, reduced ventilatory response, decreased lung defense, progressive
impairment in cough reflex, reduced mucociliary clearance etc. These changes
results various respiratory disorders. In uncontrolled, undiagnosed and treatment
failure cases there is a need of immediate referral to a specialized chest care centre
for investigative purpose and for planning of management strategies.
A. Clinical conditions to be referred to the specialist include:
• Acute onset of asthma and COPD.
• Treatment failure cases of asthma and COPD at geriatric clinic.
• Complications of respiratory disorder- hemothorax, pneumothorax, carpulmonale etc.
• Cases of lung cancer - for radiation, chemotherapeutic and surgical
intervention.
• Drug resistance in case of Pulmonary Tuberculosis and MDR Tuberculosis.
• Patients that need ventilatory support.
• Undiagnosed cases of respiratory disorder.
B. Referred for investigative purpose:
Complete blood count, ESR, HB%, Platelet count.
Sputum examination- Routine & Microscopic examination
Sputum for AFB and for Histopathological tests.
Serological test- for diagnosis of fungal disease.
Skin test
- Immediate- allergic rhinitis, allergic asthma.
- Delayed - tuberculin test – for TB.
- Kveim test - for Sarcoidosis.
Serum IgG and IgM for tuberculosis.
FNAC and Lung biopsy- for detection of lung cancer.
X-ray chest PA, USG and CT scan of lung.
Thoracocentesis and pleural fluid examination.
Pulmonary function test.
Test for pulmonary gas exchange.
•
Gastrointestinal disorders:
The most important disorders of gastrointestinal system in the elderly are
peptic ulcer disease; IBD, IBS, and Cancer colon. Ulcerative colitis is also common
in this age group. There is no liver disease characteristic of elderly nor there is a
tendency for increased incidence with aging except for hepato-cellular carcinoma.
However, presentation of liver disorders and their course vary a little because of age
related changes in the liver. The GI disorders under geriatric care frequently need
referral to the gastro-entro services not only for diagnostic and therapeutic purpose
but also for surgical intervention in certain cases.
A. Clinical problems to be referred to the specialist include:
118
•
•
•
•
•
•
•
•
•
•
•
Acute gastrointestinal hemorrhage.
Acute pain in abdomen.
Distension of abdomen.
Chronic GI bleeding.
GI perforation.
Patients that are not responding therapeutic measures at geriatric clinic.
Cases of hepato-cellular carcinoma.
GI disorder associated with complications.
Presence of cachexia, markedly reduced appetite and weight loss.
Indication of blood transfusion.
Indication of surgical intervention.
B. Referred for investigative purpose:
• Full blood count, platelet count, BT, CT, PT, Hb%.
• Blood urea and sugar, Serum electrolyte and creatinine, liver function
test.
• Stool for ova and cyst and also for occult blood.
• X-rays abdomen – erect posture.
• USG abdomen- to identify organomegaly, abscess and free fluid in
peritoneum.
• Upper GI endoscopy, rigid sigmoidoscopy.
• Colonoscopy.
• Ileal and rectal biopsy.
• CT scan and MRI abdomen- for evaluation of the activity and
complications of GI disorder.
12. Urological/ Nephrological disorders:
The common urological and nephrological problems found in the elderly are
BPH, UTI, Cancer prostate and bladder, prostatism, acute and chronic renal failure.
In females non specific cysto-urethritis, urethral syndrome comprising of symptoms
like dysurea, frequency and urgency, stress incontinence etc are important ones.
These disorders under geriatric care frequently need referral to the Uro and nephro
services for therapeutic, diagnostic as well as for the purpose of planning of renal
transplant. Carcinoma of prostate is most common cancer in elderly age male; their
pictorial presentation is given below.
119
Staging of Prostate carcinoma in old age
Source :www.wiki.strivewell.com
A. Clinical problems to be referred include:
• Haematuria- associated with hypertension, proteinuria, and renal function
impairment.
• Difficulty in micturition with dribbling and incontinence.
• Patients of carcinoma of prostate.
• Nephritic syndrome with presence of haematuria, edema and
hypertension.
• Nephrotic syndrome with presence of generalized edema all over the
body.
• Massive proteinuria.
• Acute renal failure.
• Chronic renal failure.
• Urinary tract infection
• Abnormal renal structure.
• Recurrent stone disease.
• Symptoms and signs of vasculitis associated with haematuria, proteinuria,
and renal failure.
• Patients who need dialysis and kidney transplant.
120
B. Referred for investigative purpose:
The following investigations are usually required in urological and nephrological
disorders in the elderly.
Urine microscopy, culture and sensitivity and dipstick.
Full blood count, ESR, BT,CT, PT, platelet count.
Blood sugar fasting and PP.
Plasma biochemistry- albumin, urea, creatinine, calcium, phosphate, uric acid,
electrolyte etc.
Renal ultrasound to assess the architecture of kidney, ureter, bladder and
prostate.
Quantitation of proteinuria:
-Urine albumin: creatinine ratio.
- 24 hours urine protein or albumin.
-Creatinine clearance.
Serum IgG and IgM for renal tuberculosis.
FNAC and biopsy in case of cancer of prostate.
13. Other surgical ailments:
A number of the elderly registered for geriatric care may have associated surgical
diseases or having occurred de novo. Such types of problems in the elderly as given
below will need urgent referral to a specialist for surgical intervention and other
therapeutic measures.
• Diabetes mellitus with gangrene/ ulceration.
• Diabetes mellitus with CAD/ CVA.
• Gastrointestinal perforation.
• Acute GI bleeding.
• Obstructive uropathy.
• Gastrointestinal obstruction.
• Accidental trauma and fracture.
It is estimated that in the year 2000 world wide there were 10 million new
cases, 6 million deaths and 22 million people living with cancer. In terms of
incidence the most common cancers were lung, breast, colorectal, stomach, and liver.
The most common cause of death due to cancer was due to cancer of lung followed
by cancer of stomach and liver. It is estimated that 15 million new cases and 10
million new deaths are expected in 2020 from cancer even if the current rates remain
unchanged. A recent survey reveals that about 2/3 of all cancers occur over the age
of 65 and it is the 2nd commonest cause of death after heart disease in old age. The
survival of cancer patients has improved in the last two decades. In India cancer of
lung, head, neck region are common in males and cancer of cervix and breast are
common in females.
Evaluation of metastatic tumor:
Primary site of cancer
Secondary site to be considered
Squamous cell carcinoma in Neck nodes;
Head, neck and lung
Adenocarcinoma in Neck nodes;
Breast in female, lung and GI. in both
Malignant ascites in women
Ovary
121
Bone metastasis
Breast in female,
prostate in male and lung in both
Inguinal metastasis
Anal carcinoma
Adeno-carcinoma
Penile carcinoma in male
Cancer of vulva and vagina. in female
Retroperitoneal lymph-adenopathy
Lymphoma in both and testicular germ
cell tumor in male
Carcinoma of prostrate, bladder, stomach, lung etc will need most frequent referral
to the oncology surgery specialist for the assessment of staging of cancer and their
management strategies. Most of the geriatric patients referred to the specialists will
have to be followed-up jointly by a geriatrician and the respective referral specialist.
14. Conclusion:
The advancing technology and management skill in different professional
spheres has resulted into the compulsion of professional interdependence. Hence a
general practitioner and geriatrician is required to keep a close watch on his clients
for the referral needs for specialized services to higher centers in matters of
investigation and specialized treatment. The overall outcome of care system largely
depends on timely judgment for referrals. The spirit that no single specialty is the
sole custodian of health care and care is to be sincerely followed. The referrals need
collaborative understanding and arrangement for joint follow-ups.
Recommended Further Reading
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Kalache A: Aging in developing countries in principles of geriatric medicine:
1990.Edited by M. PP-93-113.New York John Wiley Press.
Pawel, Chuk and Thorson, James A:; Rural elderly and their
needs:understanding, developing and using a needs of assessment, 1990.
Kanas City, MO.
Wan T.M: Stressful life events, social support network and gerentological
health.1982. Lexington: Lexington books.
World health organization:International classification of Impairment,
Disabilities and Handicaps. 1980. Geneva,WHO.
The Merk manual of geriatrics. 1995. IInd Ed. Merk research laboratories,
New Jersey.
Devita V.T., Hellman S., Rosenberg S.A: Cancer principles and practice of
oncology. 6th Ed Pub by Lippin Cott Williams and Wilkins, Philadelphia.
2001; 2609-2653.
Adams R.D., Victor M: Principle of neurology; 7th Ed 2001. McGraw Hill.
Podolsky O.K: Inflammatory bowel disease. N.Engl.J.Med.2002. Aug; 347(6):
417-429.
Cremonini f, Talley N.J: Diagnosis and therapeutic strategies in the
IBS.Minerva Medica. 2004;95(5): 427-441.
Pandey A.K. and Singh R.H. A study of the immune status in patients of
diabetes mellitus their Management with certain naimittika rasayana drugs,
JRAS. Vol.XXIV. No. 3-4.2003, pp-48-61.2
122
11. Singh R.H.:Ayurvediya Nidana Cikitsa ke Siddhanta, Vol. I and II,
1985.Chaukhambha Amarbharti Prakasan. Varanasi.
123
Part – II
Therapeutic Care of the Elderly
124
Chapter-9
Neurodegenerative diseases in the Elderly
1. Introduction:
During last five decades considerable progress has been made regarding the
understanding of mechanism of neurodegeneration. Several diagnostic
procedures have been developed to diagnose neurodegenerative disorders
particularly senile dementia of Alzheimer’s type and Parkinson’s disease.
These clinical conditions are different from the age related neurodegenerative
disorders.
The increasing awareness, development of diagnostic and therapeutic
modalities and life expectancy has increased throughout the world. Obviously
age related brain disorders are also increasing in almost all the population of
the world. The recent epidemiological studies demonstrated that life
expectancy has also increased in developing countries. In Indian population has
also shown increasing trend and about 11 percent of Indian population fall
under category of aged population. The number of aged in India is increasing
day by day and it is expected that by 2020 this number will significantly
increase.
2. Anatomical and physiological considerations:
The nervous system as a whole is a differentiated structure divided into two
major components – visible division and non-visible subtle ultra structures. In
the broad way nervous system can be divided into two component parts i.e.
central nervous system and peripheral nervous system. The neurons are the
basic structure of the brain highly variable in size and morphology. The central
feature of the neurons is cell body which contains the nucleus. The total
diameter is in between, 5-100 micron. The cell body performs all metabolic
functions which regulates the cell functions. The nucleus contains the DNA
molecules which in-code the instructions for the production of protein within
the cells. The proteins are both vital components of cellular structure and are
responsible for intracellular metabolic process.
Axons originates from the cell body is a specialized elongated process
responsible for transmitting the information process from internal and external
environment. Axons vary in length from few µm in the brain and several
centimeters in the peripheral nervous system. The diameter of axons usually
ranges between 1-20 µm. Further, axons divided into two branches along with
their course and at the end divided into many terminal fibrils. At the end of
these fibrils there structure known as synaptic knobs having, 1 µm diameter.
Apart from axon a neuron usually has a number of branches called dendrites.
125
Generally 5µm is the diameter of dendrites. The function of dendrites is to
receive information from other cells and to convey it to the cell body. The
interior of neurons are composed of a viscous fluid called cytoplasm. The outer
boundary of neurons is called membrane. This membrane has a unique property
of selecting information from periphery neurons are surrounded by extra
cellular fluid containing sodium, while intra cellular fluid mainly containing
potassium ion with a positive charge. A nerve impulse is propagated when
there is a transient break down of cellular membranes resulting in a rapid influx
of sodium ion. The peripheral nervous system is connected to the higher
nervous system of brain either via spinal cord or directly via cranial nerves.
The peripheral nervous system is lying out side the boney protection of skull
and spinal column which forms a distribution network to the sense organs and
the muscles. The brain has three major components i.e. hind brain, mid brain
and fore-brain. The hind brain and mid brain are collectively referred to as the
brain stem.
Neurons secrets various neurotransmitters responsible for multiple complex
functions of the brain. They have unique feature of changing from chemical to
electrical impulses. Acetylcholine, dopamine, nor-adrenaline and serotonin are
important neurotransmitters responsible for the mental functions.
Hypothalamus is an important structure of the brain which controls human
behavior and emotion. Most of the neurotransmitter interact with pituitary and
stimulates different hormones released from pituitary which maintains the
physiological homeostasis. Various emotional factors like worry, anxiety, fear,
anger, aggression all are under control hypothalamus which profoundly
influence the bodily functions.
3. Preventive strategies:
The role of Rasayana is important in overall increasing general body immunity
which is helpful in protection of brain by protecting mitochondrial damage.
Inflammation, oxidative injury, environmental toxins and psychosocial stress
are responsible for the development of neurodegenerative disorders.
Considering the etiopathology the preventive measures may be launched by
following various pharmacologic and non-pharmacologic procedures. Recently,
it has been established that psychosocial stress alters the neuro-chemical level
which blocks the functional activity of neurons. This slow down the protein
synthesis in the neurons and results in progressive functional failure the
neurons.
It has been observed that meditation and relaxation improves the mental
performance by preventing the early decline of neurotransmitters particularly
acetylcholine. Regular physical exercise and meditation improves the mental
performance by increasing concentration ability. The yogic meditation is
responsible for increasing alpha activity producing sarine state of tranquility.
Life style which includes the positive thinking, routine practice of asana,
126
relaxation and meditation practices have shown significant impact on brain
functions. The observance of sleep hygiene is essential component for the
prevention of neurodegeneration in aged population.
The brain requires highly specialized type of protein including adequate
amount of glucose and vitamins. The folic acid deficiency produces
hyperhomocysteinemia which is responsible for neurodegenerative and
cardiovascular disorders. Therefore, nutritional components which contain folic
acid, vitamin E, are required in a desired quantity to prevent
neurodegeneration. The environmental pollution mainly aluminium, lead,
mercury are also responsible for neurodegeneration. Therefore preventive
measures may be launched to protect environmental toxins by using rasayana
drugs. The fresh air, daily physical exercise, yogic practices, balanced diet etc.
may be advocated to prevent neurodegeneration.
Ayurveda has mentioned many RasÁyana drugs to prevent the occurrence of
neurodegenerative disorders.
4. Constitutional factors:
Considerable evidence is available to show the association of genomic architect
in the etiopathogenesis of many physical and mental disorders. Recent
investigations in medical genetics have identified specific genes for various
neurodegenerative disorders. The genetic linkage studies suggest that
Alzheimer’s disease is not a single homogeneous disorder, and is caused by a
genetic defect in chromosome 21. In other instances, the disease results from
mono or polygenic genetic defects or from mixed genetic and non-genetic
environmental factors.
According to Ayurveda enhanced vatic activity is responsible for structural and
functional deterioration. Therefore, significance of constitutional assessment is
essential to identify the likely victims and accordingly preventive measures
may be launched.
Neurodegenerative disorders are associated with various etiologic factors.
From the perusal of etiological factors it is evident that neurodegeneration is
associated with vitiation of tridoÒa at physical level and raja and tama at
mental level. Therefore, assessment of deha-mÁnas prakéti is essential for the
prevention and management of neurodegenerative disorders. Several studies
have shown that regimen of life according to prakéti has immense beneficial
effect in the adequate management of neurodegenerative disorders.
6. Cause of pronounced neurodegeneration
Oxidative stress plays an important role in neuronal degenerative diseases
particularly Parkinson’s disease and Alzheimer’s disease. The term oxidative
stress refers to a state in which free radicals and their product are in excess and
127
not capable of anti-oxidant defense mechanisms. This imbalance can occur as a
result of increased free radical production or a decrease in anti-oxidant
defenses. Atoms and molecules that contain impaired electrons are referred to
as free radicals. The free radicals are collectively referred to as reactive oxygen
species (ROS). They are capable of reacting with lipids, proteins, nucleic acids
and other bio-molecules and altering their structure and functions of the brain.
Oxidative stress can produce alterations in the cells with an accumulation of
oxidized products such as aldehydes and isoprostanes from lipid peroxidation,
Protein carbonyls form protein oxidation and base adducts form DNA
oxidation, all of which serve as markers of oxidation. The membrane lipid in
brain contains high level of polyunsaturated fatty acid side chains, which are
prone to free radical attack. In addition to the presence of readily peroxidizable
fatty acids, brain also consumes large quantities of total oxygen for its relative
small weight, contributing further to the formation of ROS. Brain is considered
abnormally sensitive to oxidative damage. Brain also has been shown to
contain mild to moderate level of enzymes such as catalase,
superoxidedismutase and glutathione peroxidase that play an important role in
the metabolism of ROS. Presence of iron in the brain and particularly in area
such as globus pallidus and substantia nigra may also contribute to the
production of ROS.
A number of changes take place in the brain during ageing at molecular,
cellular, structural and functional level. Neural cells may succumb to
neurodegeneration resulting in Alzheimer’s disease or Parkinson’s disease. In
some of the brain regions, there is very little or no change in number of neurons
whereas in some brain region there is neuron loss. References available have
suggested that many neurons remain in the brain throughout life but some times
there may be a continuous replacement of neurons from a pool of stem cells.
Stem cell biology is emerging as one of the specialty area in the field of
‘Neurosciences’ particularly research on ageing that any type of cell in the
body including neurons lost can be replaced. This regeneration capacity may
persist throughout life span. Such cellular signal transduction mechanism like
protein phosphorylation, cellular calcium homeostasis and gene transcription
are disturbed due to advancing age.
Each neurodegenerative disorders is characterized by dysfunction and
degeneration of specific neurons like neurons involved in learning and memory
process such as the hippocampus and cerebral cortex are affected in
Alzheimer’s disease. Dopaminergic neurons in the substantia nigra are
degenerated in Parkinson’s disease which results in motor dysfunction. A
stroke occurs when a cerebral blood vessels ruptures and resulting in
degeneration of neurons in the brain tissue supplied by that vessels.
Recently, it is well documented that inflammatory process is significantly
involved with neurodegenerative disorders. Elevated levels of inflammatory
128
cytokines in Alzheimer’s disease and Parkinson’s diseases particularly tumor
necrosis factor (TNF) and interleukin-Iβ have shown significant association
with the above clinical conditions. Further, the high level of inflammatory
marker CRP is also an important risk factor for the development of such
disorders. Thus the fundamental principle of diseases is based on the
prevention and management of these inflammatory markers. APOE ‘4’,
hyperhomocysteinemia, environmental toxins and infections agents also play
an important role in the causation of neurodegeneration. Inflammation is
responsible for increasing free radical reactive oxygen and nitrogen, ultimately
results in death of genes. The levels of reactive oxygen species (ROS) increase
with age. These inflammatory cytokines bind to the cell membrane, turns on
transduction system which leads to genetic transcription, gene activation and
the production of nitric oxide syntheses, the rate limiting enzyme for nitric
oxide and also for COX-2 enzyme causing increased inflammation. The
individual who receive non steroidal anti-inflammatory agent substantially a
reduced risk of onset of neuro-degenerative disorder is noticed. The
inflammatory marker interleukin-Iβ and TNF-α can be measured in substantia
nigra among Parkinson’s brain.
Diabetes enhances the risk of neurodegenerative disorders. Diabetes has shown
an adverse effect on the hippocampus, the area of memory processing and thus
increases the risk of Alzheimer’s disease. Various researches have
demonstrated that hippocampus is damaged by glucose. Therefore,
Glycosylated end product β-amyloid is important. β-amyloid is a protein that is
actively produced in the brain under influence of specific enzymes, it is
metabolically active protein markedly increases the inflammation in the brain.
Mitochondrial dysfunction reduces adrenotriphosphate (ATP) production and
ultimately leads to calcium influx. Mitochondrial dysfunction is also
responsible for enhancing the cytokine production which increases nitric oxide
production and further resulting in mitochondrial damage. Thus, a number of
factors like genetic, xenobiotic, metabolic, vital, endotoxic drugs cause
mitochondrial oxidative damage leading to activation of mitochondria. This
due to mitochondrial damage production of ATP is significantly reduced
resulting in brain dysfunction. Parkinson’s disease and Alzheimer’s disease are
the resultant effect of mitochondriopathies.
C-reactive protein, an inflammatory marker and high plasma total
homocysteine, generally increased in adiposity cases and significantly
associated with dementia and cognitive decline. Homocysteine is basically a
mitochondrial toxin. Homocysteine causes influx of calcium. It also
metabolized to homocystic acid and homocysteic acid is a direct mitochondrial
poison. Drugs that reduces vitamin B12, B6 and folic acid are enhancing the
homocysteine levels and thus the risk of Alzheimer’s disease and Parkinson’s
disease is significantly increased.
129
Nutritional deficiencies are a prominent problem in elderly persons. Vitamin B12 deficiency is most common that can produce dementia. A number of studies
have reported that diet which is high in Omega 3 fatty acids like fish or marine
oils are associated with a lower incidence of dementia. An increased risk of
dementia was also associated with high dietary intake of saturated fat and
cholesterol.
A decline in memory and cognitive (thinking) function is considered by many
authorities as a normal consequence of ageing. Environmental toxins, vitamins
deficiencies and the process of ageing can alter cognition. The ageing process
generally leads to difficulties with memory. Risk factors for age related
cognitive decline include advancing age, female gender, prior heart attack and
heart failure. People with age related cognitive decline experience deterioration
in memory, learning, attention, concentration, thinking use of language
including neurological disorder (Alzheimer’s disease), vascular disorder (multiinfract disease), inherited disorders (Huntington’s disease) and infection
(viruses such as HIV).
Recently dementia is recognized as a complication of cardiovascular risk
factors and vascular type of dementia is generally accepted. The cardiovascular
metabolic syndrome also known as syndrome x has been recognized as a
clustering of risk factors, which include hypertension, obesity, dyslipidemia
and glucose intolerance, leads to an increased risk of diabetes and
cardiovascular disease. All these factors have been associated with the
increased risk of vascular dementia and Alzheimer’s disease, the two most
common subtypes of dementia in the elderly.
Several cardiovascular risk factors like stroke, coronary heart disease,
atherosclerosis, diabetes, atrial fibrillation high triglycerides levels, high
saturated fat intake and LDL-c, cholesterol level are associated with vascular
type of Demential which is proven by several studies.
Cerebrovascular disease has also been associated with an increased risk of
cognitive impairment and vascular dementia. Other cardiovascular disease,
such as CHD and peripheral arterial disease have been related to cognitive
impairment or vascular dementia.
Further more, several studies observed an association of cognitive impairment
to cardiovascular risk factors, such as hypertention, diabetes mellitus, total
cholesterol level and fibrinogen level.
Evidence is increasing for the association between neurodegenerative disorders
and lipids. Lipids may influence neurodegeneration through direct effect on the
neurons or vessels, through atherosclerosis or by chronic inflammation of the
brain. High density lipoproteins like particles traffic cholesterol in the brain are
related to cholesterol metabolism, which may play an important role in amyloid
β metabolism and deposition in the brain.
130
Apolipoprotein A-1 is the major protein component of HDL and plays an
important role in reverse cholesterol transfer. In a case control study, lower
HDL-c and levels Apolipo (a) 1 were reported in demented subjects.
Obesity occurs in association with hypertension and diabetes and experimental
data suggesting the development of dementia with leptin dysregulation. A
recent prospective study found that obesity in elderly women increases the risk
of dementia. The association of body mass index to dementia is complex.
Several studies showed women with increased body mass index have a greater
risk for dementia than men. European population based cohorts study also
demonstrated that the incidence of dementia was found higher in women.
The ratio of lean to fat mass changes with ageing, resulting in a decreased body
mass index. Dementia affects appetite and causes weight loss. Obesity and
overweight in middle age as measurements by body mass index and skin fold
thickness were strongly associated with risk of dementia in later life,
independent of socio-demographic characteristics and common comerbidities.
Adiposity is one of the components of the metabolic syndrome, which has been
shown to cause cognitive decline, particularly in those with high levels of
inflammation. Adiposity has a direct effect on neuronal degeneration.
Genetically obese, leptin receptor deficient rodents have impaired performance
on spatial memory tasks and long term potentiation of neurons in the
hippocampus. Recently, obesity in elderly women was shown to be associated
with greater cerebral atrophy and white matter hyperintensity.
Excess fat enhances the production of cytokines. Body fat acts as a reservoir
for toxins, for neurotoxins. Thus the dietary regulation have a profound effect
on inflammatory process and also on transcription of genes. A substance called
archidonic acid is derived from animal fat which enhances inflammation.
Docosahexaenoic acid (DHA) play a role in mitochondrial and neuronal
membrane fluidity, signal transduction, neurogenesis, gliogenesis and
synaptogenesis and it reduces COX-2 enzyme and thus reduces inflammation.
Evidence supports the presence of significant disruptions in global serotonergic
neurotransmission in dementia. Serotonergic neurons originating from the
dorsal and median raphe nuclei innervate many structures in the cortex and
limbic system and regulate aggression, mood, feeding, sleep, temperature,
sexual activity and motor activity. Therefore, alterations in the functioning of
the control serotonergic system can be expected to have a clinically discernible
impact on behavior. Serotonin plays an inhibitory role in the human cortex and
mediated by acetylcholine, GABA, nor-adrenaline, histamine and purines.
Several evidence showed these neurotransmitters altered in Dementia and each
has a role in controlling human behavior.
Neuro-chemical and neuropathological disruptions in the serotonergic system
have been established in Dementia. Decreased concentration of 5-HT and its
major metabolite 5-HIAA have been demonstrated in the control nervous
131
system by use of postmortem brain studies particularly in the temporal cortex
and cerebrospinal fluid. The actions of 5-HT are mediated through at least
seven major receptor classes that have differing placements in the synapse,
utilize different second messenger systems and have different locations in the
brain. 5-HT1A receptor are involved with anxiety, depression, sexual behavior
aggression as well as appetite. Decreased 5HT1 receptors was found in people
with age related memory disorder or dementia. Polymorphic variation have
been identified for 5HT2A and 5HT2B receptors that may be risk factors for
BPSD such as visual hallucinations.
Disruptions in serotonergic neurotransmission have also been studied in other
dementing illnesses. Serotonin binding was reduced by 50% in patients with
the multi-infarct type of vascular dementia. Serotonin deficits were also found
in a non-multi-infarct category of vascular dementia in cortical and sub cortical
gray matter. Radioligand binding showed an in fact brain serotonin system both
pre-synoptically and post synoptically in the frontal cortex, temporal cortex and
caudate nucleus in vascular dementia.
Postmortem studies have found decreased 5-HT levels in AD patients in some
areas of the brain with a history of psychotic behaviors, compared with nonpsychotic AD patients. Found that concentrations of serotonin in the frontal
cortex and 5-HIAA in the temporal cortex were significantly lower in patients
on chronic neuroleptic treatment compared with patients not receiving
neuroleptics. A clinical study using CSF levels of the 5-HT metabolite 5-HIAA
found that levels of 5-HIAA in the CSF were positively correlated with anxiety
and fear/Panic.
Loss of cholinergic neurons is an early and consistent finding in AD and is
thought to be essential of the pathophysiology. Numerous studies have
demonstrated profound changes in the cholinergic system in AD, including
deficits in the major cholinergic system arising in the basal forebrain and
projecting to the cortex decreases in the cholinergic markers choline
acetyltransferase (ChAT) and acetylcholinesterase (AChE) in the cortex
particularly the temporal cortex, significant losses of neurons in the nucleus
basalis of Meynert, and reductions in the muscarinic type-2 pre-synaptic
receptor density.
Although the role of the central cholinergic system in cognition is well
recognized but there is only preliminary evidence suggesting that the
neurotransmitter plays an important role in the non-cognitive disorders
associated with dementia.
Serotonin and acetylcholine interact extensively in the human brain. 5-HT
inhibits release of ACh from cortical and hippocampal cholinergic nerve
terminals, via 5-HT1B receptors in the hippocampus. The 5-HT3 receptors may
also inhibit the release of ACh, where as 5HT1A receptors may mediate an
132
increase in ACh release. Thus, disruptions in 5-HT have the potential to
influence an already compensated cholinergic system.
The central serotonergic and noradrenergic system interact in many areas.
Serotonin is a co-transmitter with Nor-adrenaline and uptake of 5-HT and noradrenaline can be accomplished by either 5-HT and Nor-adrenaline can be
accomplished by either 5-HT or nor-adrenaline neurons. The serotonergic
system also inhibits the release of nor-adrenaline via 5-HT1 receptors. Thus,
dysfunction in the serotonergic system will be accompanied by changes in the
nor-adrenaline system. Animal studies have shown that nor-adrenaline neurons
from the locus cerulevs are involved in behaviors such as the sleep-wake cycle,
level of vigilance and emotion. Loss of Nor-adrenaline neurons is correlated
with the severity of dementia.
Serotonergic neurons interact closely with dopaminergic neurons. Via 5-HT1A
receptor, serotonergic neurons either inhibit or increase the release of
Dopamine. Thus, loss of serotonergic neurons will affect the dopamine system.
The dopaminergic system has been implicated in depression, agitation and
psychotic behaviors in non-demented patients and this system has the
potentiality to influence the dementia directly. A neuro-imaging study
demonstrated that disruptions in dopamine metabolism became increasingly
severe as the cognitive impairment progressed.
Serotonin is a co-transmitter with GABA, and GABA agonists can alter the
function of several 5-HT receptors. GABA is the primary inhibitory
neurotransmitter in the CNS. It is a local inhibitory interneuron for other
neurotransmitters that are key in controlling behavior, including serotonin and
dopamine. Through interaction with serotonin, GABA influence many
psychobiological functions such as behavior. Several evidence have established
that the presence and absence of GABAergic abnormality is significantly
associated with behavioral changes in Alzheimer’s disease patients.
7. Diagnostic Criteria:
Several diagnostic criteria have been developed to ascertain the diagnosis of
various type of neurodegenerative disorders. PET scan and other diagnostic
measures are costly and non-accessible to general population. Therefore,
several simpler psychological methods have been developed. Under mass
screening programme these psychosocial parameters have shown strong
correlation with PET/MRT. In laboratory, elevated inflammatory markers can
easily be determined to shown correlation with clinical symptomatology. There
are simple world wide established psychosocial parameters which are easily
applicable in the population with involving high cost. Following psychometric
parameters can be applied for the assessment of neurodegeneration –
Mini-mental State Examination-(Folstein MF et al 1975), Dementia rating
scale-2 (Jurica 2001), Gradual Memory loss along with three out of five
133
complaints – Poor orientation, poor judgment problem solving difficulties,
trouble in functioning of community affairs, inability to function independently
in home, difficulties in hobbies and personal care.
Complaints
Attention
Initiation/ preservation
Construction
Conceptualization
Memory
Total score
Normal Control
79.55
23.55
21.37
2.55
21.18
10.91
Senile Dementia
32.22
10.04
8.93
1.45
9.79
5.87
Behavioral Attention Span (Electronic Device); Memory (STM-Peterson LRS et al 1969;
LTM- Chaudhary OP 1978); Anxiety (Sinha, 1968); Depression (Beck
depression inventory 1961)
Inflammatory markers:
TNF-α and Homocysteine (ELISA kit method); C-reactive protein
(quantitative nephelometric determination of CRP in human serum or plasma
Turbox/Turbox analyzer).
8. Therapeutic modalities:
Ayurveda has adopted holistic approach for the prevention and management of
various mental and physical disorders. This includes the observance of
DinacaryÁ, ètucaryÁ according to deha-mÁnas prakéti.
The neurodegeneration due to hyperhomocysteinemia can be modified by oral
administration of amlavetasa (Hippophae rhamnoides) in the dose of 900
mg/day in two divided doses. Hippophae rhamnoides contains beta carotene
Vitamin B6, Vitamin B12, Folic acid, Vitamin C, Vitamin E, essential fatty
acids, amino acids & trace elements. Hippophae rhamnoides (fruits) contains
high amount of folic acid which reduces the high level of Hcy. The synthetic
folic acid cannot be administered longer time as it produces seizure disorders.
The fruit of hippophae rhamnoides also contain vitamin C and Vitamin E
which is anti-oxidant and prevents the mitochondrial damage and oxidative
stress. The leaves of Hippophae rhamnoides contains variety of flavones which
is also anti-oxidant and prevents the cell death due to cyto-toxic agents.
Recently the role of BrÁhmi (Bacopa monnieri) has been globally recognized
as it prevents the decline of acetylecholine loss. Bacopa monnieri has been
considered as a potent medhya rasÁyana drug and it not only prevents the
memory loss but also enhances the neuronal capability against oxidative stress.
134
Recent researches have indicated that Bacopa monnieri can be given
continuously for several years as a food supplement among all the aged to slow
down the brain ageing.
Recently Centella asiatica (MandÚkparÆÍ) has shown psychotropic property by
acting on specific serotonergic receptors and thus reduces the hyper-excitation
of neurons. Due to its neurochemical actions, it enhances the memory.
Therefore, the combination of Bacopa monnieri and Centella asiatica improves
the overall mental performance.
Withania somnifera (AÐvagandhÁ) is a well known RasÁyana drug in
Ayurveda. It is only drug shown multiple actions on various cholinergic and
serotonergic and nor-adrenergic receptors in the brain. It is also helpful in
inducing sleep by reducing the hyper-excitability of neurons.
Recently many Ayurvedic plant based drugs have shown potential effect in the
prevention and management of diabetes mellitus, anti-obesity effects, antiatherogenic property etc. As these conditions have shown strong association
with neurodegeneration therefore, the drug Dioscorea bulbifera, Salacia species
etc. can be utilized for prevention and management of associated clinical
condition in order to improve the mental performance of aged population.
9. Rehabilitation and occupational therapy:
Psychological rehabilitation methods and various physical methods are
available for geriatric population. In case of stroke, pancakarma therapy can be
administered.
Psychological rehabilitation includes counseling, meditation practices as well
as application of various Ayurvedic formulation found useful in the
management of anxiety, depression and increasing the cognitive abilities.
Several simple procedures have been developed to rehabilitate the aged people
suffering from anxiety and depression. Similarly physical rehabilitation is
possible by practicing some of the asanas including physiotherapy. In case of
vascular stroke specialized type of exercises are introduced to rehabilitate such
patients.
The individual at home can be trained to provide physiotherapy and also for
speech therapy.
10. Life long follow up:
As the neurodegeneration is a life long process therefore there is need of
monitoring to improve the quality of life of aged population. Though, modern
conventional therapy has a potent therapeutic value but due adverse reaction it
can not be given for longer time. Therefore adaptation of Ayurvedic approach
135
is only remedy by which one can prolong the longevity and minimize the
neurodegenerative disorders.
The long term administration of Ayurvedic therapy can be advised without
involving much cost and efforts. The beneficial effect of Ayurvedic modalities
can be evaluated and data generated may be utilized for overall improvement in
quality of life of aged population. The documentation of such data would be
much help in popularizing the Ayurvedic approach involved in
neurodegeneration and neurodegenerative disorders.
11. Common Ayurvedic remedies:
In common practice the Ayurvedic practitioners use some of the following
simple medications in cases of neurodegenerative disorders:
1. Medhya RasÁyana: A combination of ÏankhapuÒpÍ, ManÕÚkaparÆÍ,
YaÒtimadhu and GuÕÚci as decribed by Caraka on priority. These four
herbs can be combined in equal or any other suitably designed proportion
and may be given in a dosage form of pill or syrup for routine use.
2. ÀsavÁriÒÔa recipes viz. SÁrasvatÁriÒÔa and AÐvagandhÁriÒÔa are popular to
be used in the dose of 15-20 ml. 2-3 times a day.
3. CurÆa formulations such as Sarasvata curÆa, Asvagandha curÆa,
Kalyanaka curÆa, Jatamamsi curÆa etc. in the dose of 5 Gms. twice a day
with milk.
4. VaÔÍs and GuÔikÁs viz BrÁhmi VaÔÍ or Medhya VaÔÍ in the dose of two VaÔÍs
2-3 times a day
5. Ghéta preparations are classically indicated in all neuropsychiatric
disorders viz. BrÁhmi Ghéta, VacÁdya Ghéta, Pancagavya Ghéta,
KuÒmÁndÁdi Ghéta etc. in the dose of 1 tsf once or twice a day.
6. RasauÒadhi- SméitisÁgar Rasa, KéiÒna Caturmukha Rasa, UnmÁda gaja
kesari Rasa in dose of 125 mg twice a day.
7. Counselling on SÁttvika diet and wholesome life style on principles of
Ayurevdic SattvÁvajaya.
8. Selective Pancakarma therapy including Abhyanga, Sveda, Nasya,
ÏirodhÁrÁ, Ïirobasti etc.
9. Appropriate management of other associated diseases if any.
10. Life long follow up
136
Recommended Further Reading
1. Caraka, Caraka Samhita, Cikitsa Sthana Chater 28 on Vatavyadhi, Ed.
Sharma P V, Chaukhambha Orientalia, Varanasi.
2. Madhava, Madhav Nidana, Chapter 22, Ed. Yadu Nandan Upadhyay,
Chaukhambha Publication Varanasi.
3. Singh RH, Narsimhamurthy K, Singh G. (2008), Neuronutritional impact of
Ayurvedic Rasayana therapy in brain aging, Biogerontology. 2008
Dec;9(6):369-74. Epub 2008 Oct 18.
4. Dubey, G P. (2007), Brain aging, special publication, CCRAS, New Delhi.
5. Uma Gupata, Aruna Agarwal, G P Dubey, B S Gupta Amelioration of age
related cognitive deficit in rats by Brahmi, Journal of Gerontology, Vol.11,
P-68-71
137
Chapter-10
Neuropsychiatric Disorders in the Elderly
(JarÁ Janya Mano VikÁra)
Introduction :
The five top diagnostic categories of problems generally affecting the
elderly have been found to be cardiovascular - 85%, psychiatric - 48%,
Musculoskeletal 46% eye and ear 23% and hormonal - 18% disorders.
Conservatively it is estimated that 25% of elderly population have significant
psychiatric symptoms. (Pandey B.L. and Singh D.S. 1997). In recognition of
this trend, the psycho-geriatrics has been recognized as area of specialization in
geriatrics.
Common stressors precipitating psychiatric illness in elderly:
It is perhaps the degree and frequency of the stressors associated with
aging that makes the geriatric age group more liable to develop psychiatric
disorders (Kaplan and Sadock). Stressors of aging which leave strong impact
are acute and chronic medical illnesses, concomitant use of therapeutic drugs.
Drug and disease interaction, physical body changes. Loss of one’s job, loss of
financial resources, social status and social network. Psychologial deprivation
of an intimate friend, wife/husband, which create a void which largely remains
unfulfilled.
Special considerations in old age :
The patient :
•
Multiple illnesses (medical and psychiatric)
•
Multimple problems (social, financial, family)
•
Communication difficulty, sensory impairment.
•
Need for collateral sources of information
•
Volnerability to drug side effects.
•
Atypical presentation of disease.
138
•
Misidentifying treatable illness as normal aging.
The social context :
•
Marginal status in society
•
Social isolation, enforced closeness.
•
Threats to autonomy and unwelcome dependence on help.
•
Constraints of institutional life.
•
Interdependence of services for the elderly.
•
Inequalities in the provision of services.
Ethical and legal issues:
•
Conficts of interest between patients and carers.
•
Finances; payment for care or legacies to children? Court of Protection,
Enduring power of Attomey.
Common neuro-psychiatric disorders of elderly.
•
CittÁvasÁda (depressive disorder)
•
Sméti-Buddhi hrÁsa (Dementias and Alzheimers dementia).
•
UnmÁda esp. vÁtic type (Schizophrenia / Paranoid)
•
AtatvÁbhiniveÐa (Delussional disorder).
•
Cittodvega (Anxiety disorder)
•
MÁnas Prakéti VikÁr (Personality disorder)
•
NidrÁ vikÁr (Sleep disorder)
•
MadÁtyaya (Alcohol / drug abuse)
CITTÀVASÀDA (GERIATRIC DEPRESSION)
Prevalence :
Depressive disorders are by far the most frequent mood disorder among
elderly persons, though prevalence of major depressive disorders is 1-2% less
in population aged 65 years as compared to those of lesser age group, Geriatric
139
depression is 10 times more frequent in elderly medically ill patients than
overall geriatric population. It accounts for upto half the workload of a
comprehensive psychogeriatric service.
Geriatric depression is a heterogeneous condition that can result from a
variety of factors like physiological change of aging, disability, loss of
resources changes in lifestyle, associated specific medical illness and drugs.
Clinical picture of depression in elderly:
•
More likely to express somatic complaints.
•
Appear anxious
•
Minimize the presence of guilt feeling.
•
Hypo-chondriacal symptoms in approx. 65% of elderly depressive
patients.
•
Suicidal attempts.
•
Associated cognitive changes - Dementia
•
Obsessiveness and irritability
•
Depressed mood without retardation
•
Predominance of anxiety and agitation.
•
Feeling of unreality.
•
Hyper-chondriacal delusions (Henderson and Gillespie)
Cittodvega (Anxiety disorder) :
Less prevalence in old age
•
When present, associated with medical and psychiatric conditions.
•
Anxiety more often related to object loss of external supplies.
•
Anxiety symptoms are frequently found to be associated with elderly
depression. The designation "Anxious depression" as been used to
describe major depressive disorder (MDD) component by clinically
significant but subsydromal anxiety symptoms.
•
MDD may also present alongwith diagnosable anxiety disorder,
although this presentation is less common is old age.
140
•
Diagnosis of 'Anxious depression" in the elderly is complicated by their
tendency to experience and report psychiatric symptoms as somatic
illness and is associated with a more severe clinical presentation,
increased risks for suicidal ideation, increased disability and poorer
prognosis.
Management :
•
AÐwangadhÁdi cÚrÆa -
5gm twice daily alongwith Medhya KaÒÁya
20ml.
•
Medhya vaÔÍ (500m) - 2 tablets two times a day
(MaÆÕÚkaparÆÍ, YaÒÔÍmadhu, GuÕÚcÍ, ÏankhapuÒpÍ, in equal amounts).
•
Medhya KaÒÁya - 40ml twice a day (Decoction of all the above
medications).
•
BrÁhmÍ VatÍ - (250 mg 2 Tablets thrice or twice a day, depending upon
the patient’s clinical condition.
If associated with reduced sleep, hypertension and excessive stress :
•
SarpagandhÁ Ghana vaÔÍ (250mg) 2 tabs at night time with mÁÉsyÁdi
kasÁya 30ml.
•
SÁraswata cÚrÆa - 1gm twice a day with goghéta 5gm and honey 5 gms.
•
Sméti SÁgar Rasa — 125 mg twice a day, as per need.
•
KéÒÆa Caturmukha Rasa -125 mg twice a day, as per need.
•
Sattvavajaya Cikitsa (Psychotherapy)24 - with emphasis to evaluate the
precipitating cause of the cittavasada / cittodvega and promote nidan
parivarjana.
•
SirodhÁrÁ - For half an hour or 45 minutes using medhya kaÒÁya or
mahÁ nÁrÁyaÆa taila.
•
Sirovasti karma : using mahÁnÁrÁyan taila for 1 hour.
24
Sattvavajaya punah ahitebhyo athebhyo mano nigraha½
141
•
Standard pharmacotherapy for depression may be sufficient but for
many patients must be modified or augmented. All medication must be
started at a low dose, with careful monitoring and should them be built
of gradually until the medication is effective. In conventional modern
system of medicine the following treatment is prevalent.
•
Standard tricyclics may be used
;dothiepin is useful where
anticholinergic side effects are troublesome;
•
Mianserin is safer where cardiotoxicity is a risk. Trazodone is often
well-tolerated and can have a useful relative effect. The place of SSRI's
in old age depression is not yet clear.
•
Lithium is as valuable in the old as the found for prophylasis of manicdepressive disorder or recurrent depression, but the risk of side effects is
greater.
•
Benzodiazepines are avoided even more than in young people, because
of the risks of dependence and confusion associated with their use,
although in occasional cases the benefits of a low steady dose of
benzodiazapine may outweight the disadvantages in the anxiety states.
DRUG USE BASED ON CLINICAL PROFILE:
With retardation
:
Amineptine, Fluoxetine
With agitation
:
Trazodone
With cardiac disease
:
Doxepin, Nitroxazepine
Endogenous or Reactive
:
Mianserin
With anxiety
:
Maprotiline, dothiepin
Atypical hypochondriacal :
MAO inhibitors
Psychotherapy :
•
Psychosocial interventions may also be an important component in the
treatment of these patients. (Ref. Diefenbach GJ et al., Clin. Interv.
Aging 2006, 1 (1) : 41-50).
142
•
Support informed both by psychotherpeutic principles and by practical
common sense is essential.
•
Cognitive therapy has also successfully been used in old age depression.
SM©TI-BUDDHI HRÀSA (DEMENTIA)
•
Essential feature of Dementia include memory impairments, impairment
in atleast one cognitive domain and specific.
•
Significant disturbances of work or social functioning or both.
•
Dementia of Alzheimer’s type (DAT) is a syndrome that is gradual in
onset and progression and without any other identifiable and treatable
cause.
•
D.A.T. accounts for about 50% old aged dementia and is estimated two
afflict 5-10% of people aged sixty five years of age.
•
47% of those aged 85 years or older.
Multi-infarct dementia:
•
Common in men than women
•
In main under 80, probably commoner than Alzheimer's diastase.
•
Cerebrovascular disease.
•
Abrupt onset, often with episode of confusion which party remits.
•
Patchy cognitive impairment, some faculties well preserved.
•
History of hypertension, local neurological signs, and fluctuating
severity may be found.
•
Treatment of hypertension does not cure dementia, but may prevent
progression.
Differential diagnosis:
•
Multi infarct dementia
•
Alcohol and drug related dementia
•
Geriatric depression
•
Age associated memory impairment (AAPI) not progressing to
dementia.
The mini-mental state examination: (Folstein et al., 1975)
143
Diagnosis of dementia mini-mental state examination.
Orientation :
1.
(score - 5)
Can you tell me what, year it is ?, season?, date?, day?, month?
(1 score for each) (score - 5)
2.
Can you tell me where we are ? what town (or village), ?, what street (or
hospital), ?, what house, (Or ward), ?, what state ?, what country ?
3.
Registration :
(score - 3)
I would like you to remember three things for me. The three things are.
(name three objects, taking 1 second to say each). Then ask the patient all
three, after you have said them give one point for each correct answer.
4.
Attention and calculation :
(score - 5)
Serial sevens, give one point for each correct answer, stop after five
answers, Alternative : spell WORLD backwards.
5.
Recall :
(score - 3)
Ask for the names of the three objects learned in question 3 give one
point for each correct answer.
Language :
(score -2)
6.
Point to a pencil and a watch, say 'can you tell me what that is called?
7.
Ask the patient to repeat "No its, ands, or buts". (score -1)
8.
As the patient to follow a three-stage command; 'Please take this
piece of paper in your right hand, fold it in half, and put it on the
floor.
9.
(score - 3)
As the patient to read and follow the written command. (Close
your eyes)
10.
(score -1)
As the patient to write a sentence of his or her choice. (To score
correct, the sentence must contain a subject and a verb.
mistakes do not matter).
11.
Spelling
(score -1)
Draw the design below and ask the patient to copy it. (Draw it
with side of 1.5cm at least to score correct, each pentagon must
have 5 sides and the interesecting sides must form a qudrangle).
(score -1)
144
Total point 30
Cut off point for probable cognitive impairment is 24.
MANAGEMENT - PSYCHOSOCIAL INTERVENTION:
SattvÁvajaya CikitsÁ —
The attempts should be made to evaluate the specific problems of
dementia in each case and the possible solution should be advised based upon
the findings after their analysis Problem
Forgets medication
Possible solutions
Calendar box : neighbour or care assistant sets our
medication.
Forgets familiar people
Explain to the people; show them how to introduce
themselves naturally.
Emotional
reactions
to Reduce stresses on patient, introduce change very
disability clinging, anger, gradually, preferably through one trusted persons.
stubborn adherence to familiar Introduction to supportive, friendly environment.
routines, catastrophic reaction
Night - time restlessness
Reduce daytime boredom, avoid too-early bedtime,
maintain clear diurnal rhythm in household, provide
commode for nocturnal micturition, careful
medication.
Aggression
Try and work out causes : if driven by paranoid ideas,
treat with medication; if not, understand antecedents if
possible, and counsel career accordingly.
Incontinence
Reduce obstacles to continence (difficulty in getting
out of chair or walking awkward geography of house,
complicated clothing, constipation). Regular reminders
or actual taking to toilet, Pads often confuse a patient.
(After C-oppenheimer, essential psychiatry 2nd edition)
Ayurvedic Management
Ïirovasti — with BrÁhmÍ Ghéta (1 litre) for / hour precided by sirobhyanga.
•
BrÁhmÍ ghéta - 10ml twice daily with warm milk.
•
Pancagavya ghéta 10ml twice daily with warm milk.
•
Sméti SÁgar Rasa - 250mg 1 tab twice daily.
•
SÁraswatÁriÒÔa - 20ml after meals with equal amount of water.
Or
145
AÐwagandhÁriÒÔa 20ml after meals with equal amount of water
BrÁhmÍ vaÔÍ - 250 mg twice a day with honey and mÁnsyÁdi KaÒÁya.
If associated with increased restlessness, aggression and sleeplessness
with hypertension •
SarpagandhÁ ghanavaÔÍ (500mg) - 2 tablets twice a day with MÁnsyÁdi
KaÒÁyÁ.
•
Mansyadi kaÒÁyÁ — 40ml twice a day.
If associated with emotional reactions -
•
ÏirodhÁra with medhya kaÒÁya.
•
Caturbhuja Rasa - 125mg and pravÁla piÒÔÍ 250 mg twice a day with
honey.
•
VÁta - kulÁntaka rasa - 250 mg twice a day with honey.
Psychopharmacological interventions : Antipsychotics, antidepressants
benzodiazepines and various investigational compounds. To enhance
cholinergic activity use of agents like physostigmine, choline lecithin and the
cholinesterase inhibiting tetrahydrominoacridine have yielded contradictory
results.
VÀTIK UNMÀD AND ATATVÀBHINIVEÏA
(Schizophrenia and delusional disorders)
•
Elderly patients with late onset schizophrenia have symptoms similar to
early onset schizophrenia but particularly of paranoid type. 25
•
Late onset patients have more persecutory delusions with or without
hallucinations/hallucination with running commentary.
•
Bizzare delusion is more common. The content of the delusions in a
primary paranoid state in old age is often more believable than in young
patients and it maybe important to check whether the delusional belief is
in fact true. Outside the territory of the delusional belief the patient's
social behaviour and day-to-day competence may be little affected.
25
AsthÁnahÁsya smitanétyageeta vÁganaga vikÒepaÆa rodanÁni!
PÁruÒya kÁrÒyÁruÆa varÆatÁ ca jeerne balam cÁniljasya rupam!!
146
•
Primary paranoid states in old are commoner in women, in the presence
of sensory impairment and those with long-standing personality traits of
allofness, withdrawal or suspiciousness.
•
Late onset cases differ from those with looseness of association, in
appropriateness of affect and negative symptoms.
•
D/D : Substances induced psychotic disorders.
•
Underlying neurological and other medical disorders.
Two to eight percent of elderly psychiatric patients suffer from some
type of paranoid symptoms persecutory and somatic delusion in elderly are
usually secondary to another neuropsychiatric disorder.
Usual course is chronic or with partial remission or relief.
Management:
•
UnmÁda gajakesarÍ Rasa - 250 mg, 1 tab three time a day
or Unmad gajunkuja rasa.
•
KéÒÆa Caturmukha Rasa - 250 mg + Pravala PiÒÔÍ 125 mg with VacÁ
cÚrÆa (500 mg) and honey two times a day.
•
BrÁhmÍ vaÔÍ 1 tab twice a day with ÐankhapuÒpÍ swarasa (10ml).
•
SÚtaÐekhara Rasa 250 mg + SarpagandhÁ cÚrÆa 500mg/1 dose, three
times a day with Goghéta.
•
SarpagandhÁ ghanvaÔÍ - 500mg 2 tab in night or 2 tab twice daily as per
clinical condition.
(Monitoring of B.P. is essential while using preparations of
ÏarpagandhÁ)
•
BrÁhmÍ Ghéta - 10ml twice daily with warm milk.
•
KuÒmÁn±a Ghéta - 10ml twice daily with warm milk.
•
Pancagavya GhétÁ - 10ml twice daily with warm milk.
•
Yogendra Rasa - 250mg and VÁta-kulÁntaka and Pravala PiÒÔÍ 125m / 1
dose three times daily with mansyadi kaÒÁya (30ml).
•
Ïiro Abhyanga
147
Hima SÁgar taila or SivÁ ghéta massage over head.
•
Depending upon the patients condition use Satvavajaya Cikitsa,
SiddhÁrthakÁdi agad dravyas for Anjana, Nasya, SnÁna, Lepa etc.
The illness usually responds well to medication but where insight is lost,
treatment may need to be started and be continued with depot medication.
Pimozide or trifluoperazine can be useful drugs, taken as a single daily
does under the supervision.
MÀNAS PRAKèITI VIKÀRA (PERSONALITY DISORDERS):
Aging does not imply linear reduction in severity of personality
disorders, coexistence of personality symptoms and depression often found.
Dependency, helplessness, somatic preoccupation, suspiciousness and
pessimism in elderly may represent long standing character or may be a part of
an acute depression syndrome.
The female predominance in young adult population of historionic,
boderline and dependent personality disorders is retained in the geriatric
population as is the male predominance in narcistic, antisocial, paranoid,
schizoid and schizotypal personality disorders.
Management:
Clearly establish the patient state of physical health.
•
Use the available family and Institutional support.
•
Establish realistic goals, based on a collaterally informed picture of the
patient's long term functioning.
NIDRÀ VIKÀRA (SLEEP DISORDERS)
Sleep disturbances in aged can be due to :
o
Physiological changes of aging
o
Poor sleep hygiene
o
Specific sleep disorders.
148
The changes in sleeping pattern of old age include a reduction of slow
wave sleep (Particularly stage 4 sleep), increased night time wakefulness and
increased fragmentation and sleep by period of wakefulness.
Management :
•
ÏirodhÁrÁ with medhya kaÒÁya for 45 minutes daily for two to three
weeks.
•
Ïirobhyanga with vÁÁta nÁÐaka tailas.
•
AkÒitarpaÆa with TriphalÁ Ghéta.
•
MÁmsyÁdi kaÒÁya 40ml in night with or without honey.
•
JatÁmÁnsÍ hima kaÒÁya - 40ml in night with or without honey.
•
TagarÁdi vaÔÍ - 250mg, 100 twice daily with MahiÒa kseera.
•
SarpagandhÁ ghan vaÔÍ - 2 tab in night with mÁmsyÁdi kaÒÁya 20ml.
•
SattvÁvajaya cikitsÁ for relieving stress, if any stressor is found
apparently causing insomnia.
•
Avoid daytime sleep / Promote physical exertion in elderly.
Hypnotics can be useful for the transient insomnia when use for short
time, their long term use, usually results in habituation, loss of efficacy, drugdependence insomnia, rebound insomnia and nightmares when the drugs are
discontinued.
MadÁtyaya (Alcohol/Drug Abuse)
The prevalence of alcoholism among older people in the community is
quoted as 2-10%. This includes many with onset earlier in life for about 10% of
elderly alcoholics the problem began after 65, often in response to some
environment stress such as bereavement or retirement.
Aetiology of Abuse:
•
Psychosocial factors
•
Late life stressors from retirement s
•
Widowhood.
149
•
Illness and Isolation
•
Freedom from responsibilities of children and carrier.
Diagnosis :
•
Elderly people with alcoholism are not consistently identified.
•
Indicators like housing problems. Fall or accidents, poor nutrition, and
inadequate self care may facilitate diagnosis.
•
May have peripheral neuropathies / elevated liver function test/cortical
shrinkage ventricular dilation in C.T. Scan.
Alcoholism may alternatively be recognized as the underlying cause of a
different psychiatric condition such as dementia. Abstinenance may be easier to
achieve than in the young alcoholic.
Treatment :
Hospitalization is needed for detoxification, parenteral thiamine
administration is helpful. Elderly patients need hydration, correction of fluid
and electrolyte imbalance and nutritional supplementation.
Adjustment reactions :
Psychological symptoms occurring in direct relation to major stress
occur in old age as at an other and the frequently of stressful events (especially
losses) is greater in old age considering the many kinds of loss that old people
bear.
GENERAL PRINCIPLES OF MANAGEMENT
A.
Preventive treatment (NidÁna Parivarjana)
B.
Curative treatment
•
Yukti vyapÁÐraya (Rational therapy)
•
o
Pancakarma
o
Medicinal treatment
o
Other measures (upÁyÁbhiplutÁ)
SattvÁvajaya cikitsÁ (Psychotherapy)
o
Supportive psychotherapy / Assurance.
150
•
o
Replacement of Emotions
o
Psychoshock therapy
Daiva vyapÁÐraya cikitsÁ (Spiritual therapy)
o
Spiritual treatment
o
Occult treatment
Pancakarma Procedures
All the five methods of Pañcakarma have been indicated in mental
disease for complete cure. These include Vamana, Virecana, Ïiro Virecana,
AnuvÁsana and ÀsthÁpana vasti, which are adoptable with cobetweening of
Snehana and Ïvedanakarmas in which application of fixed oils affecting the
specific humour is externally as well as internally used.26
•
Kaphaja - Vaman
•
Pittaja - Virecana
•
VÁtaja - Vasti (Both)
•
Nasya - Teevra Anjana and Nasya.
•
Pañcakarma procedures for eg. Vasti therapy, Ïirovasti therapy,
Pin±asveda therapy and Ïirovirecana therapy are used according to
specific diseases.
These purificatory measures correct the defective humour which is
responsible for disease, as well as it also affects the mental state of the patient.
Unmade vaÔÍke purvam snehapanam viÐeÒavit
KuryÁdÁvéttamarge tu sasneham médu Ðodhanam
(C.Ci. 9 / 26)
Hrdinindriya Ðira½ koÒÔ½e sansuddhe vamanadibhi½ !!
Mana½ prasÁda mÁpnoti smrtim samjnÁm cavindati !!
(C.Ci. 9 /28)
151
By these measures body and mind becomes clear and the patient regains his
memory and consciousness. (Ch.Chi. 9)
However, strenuous pañcakarma procedures like vamana and virecana
etc. should not be used in elderly persons.
GENERAL APPROACH:
•
Elderly with psychiatric complaints and syndromes like depression,
melancholia, phobia etc. are treated with Àyurvedic psychotropic
medications, yogic exercises, meditation and by means of sattvÁvajaya
cikitsÁ (Ayurvedic psychotherapeutic measures).
•
The vÁjikaraÆa drugs like kapikacchÚ and aÐwagandhÁ etc are used in
the treatment of depression. Medhya rasÁyanas are used in the treatment
of anxiety disorder; dementia and other recent studies done on this
category of drugs have shown varying degree of neurotropic and
psychotropic effect. These are also used in degenerative diseases of
brain viz. cerebral atrophy, Alzheimer’s disease and all those cases
(parkinsonism and multi infarct dementia), which present clinically as
cognitive disturbances.
MEDICATIONS :
•
Ghétas have a special place in Management of MÁnas Roga. HingwÁdi
Ghéta, KalyÁÆak Ghéta, MahÁkalyÁÆaka Ghéta, MahÁpaiÐacik Ghéta,
LaÐuúadya Ghéta, PurÁÆa (10 Yrs) Ghéta, Pra-PurÁÆa Ghéta, Sushruta
— Alpacaitasa Ghéta, Ïiva Ghéta, BrÁhmÍ Ghéta, Phala Ghéta.
•
Single drugs : KooÒamÁnda Beej, VacÁ, AÐwagandhÁ, JatÁmÁnsÍ,
ÏankhapuÒpÍ, SarpagandhÁ.
•
Compound formulations : Caturbhuja Rasa, Caturmukha Rasa,
UnmÁda Gajkesari Rasa..
•
Medhya Rasayanas — ÏankhapuÒpÍ (Convolvulus pluricaulis), BrÁhmÍ
(Bacopa monnieri), mandÚkaparÆÍ (Centella asiatica), yaÒÔimadhu
(Glycirrhyza glabra), gudÚcÍ (Tinospora cordifolia), VacÁ (Acorus
152
calamus), AÐvagandhÁ (Withania somnifera) and jyotiÒmatÍ (Celastrus
paniculatus).
•
Neurotropic medications — DaÐamÚla ghanavaÔÍ, daÐÁmulÁriÒÔa,
rasÁyana yogaraja guggulu, Ðuddha kupÍlu, mallasindÚra etc.
•
Herbomineral agents — VÁtagajÁnkuÐa, véhat vÁtacintÁmaÆi rasa,
samÍrapannaga etc.
SattvÁvajaya CikitsÁ :
(a)
Assurance therapy - The individuals whose minds become disordered as
a result of loss of some dearly loved objects, should be consoled by
offering him the substitute or by the sympathetic words.
(b)
Replacement of emotions - Replacement of opposite emotions (Viz.
KÁma for Krodha) is also deemed as a part of SattvÁvajaya. In the case
of mental derangements resulting from an excess of desires, grief,
delight, envy or greed, should be allayed by bringing the influence of
opposite passion to bear on the prevailing one and neutralize it.
(c)
Psychoshock therapy - This important method of treatment has also been
included under SattvÁvajaya (Murthy A.R.V. and Singh R.H. 1987). For
managing acute episodes of mental ailments, Ayurveda describes a
number of methods of psychoshock therapy to restore the patients.
DaivavyapÁÐraya cikitsÁ :
•
In Ayurveda, Deva has been used in the sence of those Karmas which
are related to our past deeds. As we believe in Punarjanma, it is rational
need to devise methods which can effectively deals with Daivakéta
diseases which are not in anyway related to our present life. These
methods create confidence and remove fear and pessimistic : endencies.
•
DaivavyapÁÐraya includes such methods as worships, sacrifices, Yajnas
for the gratification of respected favourites like Rudra GaÆa,
PrÁyaÐcitas and japas etc. If practiced in mental diseases, they act on
the intellect of insane, so that he feels gratification and a freedom from
153
control of evils. Ultimate effect is seen on the psychology of patients, so
that he is cured, because all these methods directly affect the psychic
nature.
Recommended Further Reading
•
Andress R, Bierman El. Hazzard WR, editors: Principle of Geriatric
Medicine, Mc Graw-Hill, New York, 1985.
•
Abram’s R.C. : Personality disorders in the elderly. In Verwoerd’s
clinical Geropsychiatry ed 3, Bienerfeld editor, p. 151, Williams &
Wilhkins, Baltimore, 1990.
•
Abrams R.C. et al., : Personality disorder correlates of late and early
onset depression. 3. Am. Geriatr. Soc. 1994; 41:1.
•
Curtis J.R. et al., : Characteristic diagnosis and treatment of alcoholism
in elderly patients. J.Am. Geriatric. SOG. 1989; 37:310,
•
Dement W. et al., : Changes of sleep and wakefulness with age. In Hon
book on the Biology of Aging, C Finch editor, P. 692, Von Nostrand,
New York, 1985.
•
Flint A : Epidemiology and comorbidity of anxiety disorder in the
elderly. Am. J. Psychi. 1994; 51: 640.
•
Hudson M. F., Johnson T. F. : Elder neglect and abuse: A review of
literature, Ann Rev. Gerontal Geriatr, 1986; 6: 81.
•
Kaplan HI & Sadock BJ: Comprehensive text Book of Psychiatry. 6th
edition, 1995.
•
Paroneke P.A. et al., Anxiety and its association with depression among
institutionalized elderly. Am . Geriatric Psychiatr 1993; 1: 46.
•
Shulman K. & Post F. : Bipolar affective disorder of older age. Br. J.
Psychi. 1980; 136: 36.
•
Yassa R. et al., : The prevalence of late onset schizophrenia in a
psychogeriatric population. J. Geriatric Psychiatry Neuro 1993; 6: 120.
154
•
Singh R.H. “Ayurvedic Psychiatry” in the Holistic Principles of
Ayurvedic Medicine Chaukhamba Sanskrit Pratisthan, 1st Edi. New
Delhi. 1998.
•
Singh R.H. “Geriatrics and Geriatric care in Ayurveda” in the Holistic
Principles of Ayurvedic Medicine Chaukhamba Sanskrit Pratisthan, 1st
Edi. New Delhi. 1998.
•
Sharma S.N. Sharma and Singh S.K. Neuro-psychiatric disorders in
Geriatrics in Geriatric medicine and Gerontrology in Developing
countries Singh D.S. (ed.) Tara Printing works, Varanasi, 1998.
•
Gupta S. Depression in Elderly in Geriatrics in Geriatric medicine and
Gerontrology in Developing countries Singh D.S. (ed.) Tara Printing
works, Varanasi, 1998.
•
Tripathi J.S. and Singh R.H., Ayurvedic Management of Common
Geriatric Problems in Geriatric medicine and Gerontrology in
Developing countries Singh D.S. (ed.) Tara Printing works, Varanasi,
1998.
•
Tripathi J.S. and Singh R.H., A clinical study on personality factors in
cases of residual schizophrenia and its ayurvedic management (M.D.
Ay. Thesis) Department of Kayachikitsa I.M.S., B.H.U., Varanasi. 1992.
•
Tripathi J.S. and Singh R.H., Nootropic effect of Medhya Drugs;
Concepts and Observations, Ph.D. Thesis Department of Kayachikitsa
I.M.S., B.H.U., Varanasi. 1992.
•
Singh R.H, Pancakarma therapy, II ed., 2002 Chaukhabha Sanskrit
Series, Varanasi.
155
Chapter-11
Cardiovascular Disorders in the Elderly
Concept of Geriatric Cardiology
Why Geriatric Cardiology?
With the growing number of elderly individuals in today’s society the health
problems of old age are becoming more and more overt. Accordingly Geriatrics
is emerging as a major medical speciality world over. In India too the last
decade has projected significantly rising rate of population-aging and hence a
great need is now felt to strengthen the geriatric care system in this fast
developing country. Therefore, in nation’s efforts to prevent and effectively
treat heart disease we must include older Indians and take into account their
special needs and concerns.
How the heart grows old?
1. As a person ages, the heart undergoes subtle physiological changes, even in
the absence of disease. The muscles of the aged heart may relax less
completely between beats; as a result, the ventricles become stiffer and may
work less efficiently.
2. In old age, the heart also may not pump as vigorously or as effectively as it
once did.
3. The older heart also becomes less responsive to adrenaline and cannot
increase the strength or rate of its contractions during exercise to the same
extent it could in youth.
4. The vascular system too experiences gradual changes over the decades. The
walls of the arteries tend to lose their elasticity and stiffen, even without
internal blockage from fatty deposits (atherosclerosis).
Factors responsible for heart aging
A number of changes commonly occur in the heart in old age. The most
important of these changes are• Rigidity of the myocardial wall due to an increase in collagen
calcification of the ring of membranous valve between the left atrium
and the left ventricle of the heart, known as mitral valves.
• Some degree of cardiac muscles atrophy.
• Depositing of increasing amounts of age pigment lipofuscin.
• Arterial thickening and fibrosis.
• Rise in systolic pressure with age.
• Fall in the diastolic pressure.
156
Geriatric age group in relation to CVD
As medical progress continues to lengthen expected life spans, the concept of
“elderly” has shifted upward. Although there is no clear-cut threshold of old
age, for purposes of medical classification physicians tend to define “elderly"
as beginning in the range of 65 to 70. In practice, however, treatment decisions
are based not on age alone but on a person’s entire medical profile and mental
outlook.
Ayurvedic consideration of heart aging
Ayurveda says that old age is dominated by the VÁta activity. Naturally VÁta is
RÚkÒa(Dry) and Khara in nature. Due to increase VÁta in elderly, all these
qualities of VÁta becomes more pronounced in every organ of body. This is
how the aging starts. Heart being a organ of prolific activities, aging becomes
more evident. It is increased VÁta in elderly that leads to• Muscles atrophy
• Calcification and stiffness of valves
• Atherosclerosis
• Narrowing of coronary arteries
• Angina
• Myocardial infarction
Concerns of Hªidroga in elderly
There are several concerns of elderly people regarding heart diseases. They
have limited options of diagnostic procedure and treatment because they can
not be subjected to each and every type of treatment procedure, specially the
invasive ones.
Incidence of various cardio-vascular disorders in the elderly specially in
Indian population and regional variation
• Cardiovascular disease–including coronary heart disease, hypertension,
heart valve disease, and rhythm disorders-becomes increasingly
common with advancing age. By the age of 80, for example, 20 percent
of Indians have symptomatic coronary heart disease. There has been a
marked increase in the incidence of heart disease in recent years.
• Heart attacks have become the biggest killer in Asian countries. It is
ranked third in India, after tuberculosis and infections. In India, CVD has
the highest incidence in the state of Punjab and Gujarat.
Anatomical and Physiological considerations
Anatomical and physiological changes in heart and blood vessels of elderly
There is a progressive loss of myocytes with a reciprocal increase in myocyte
volume in both ventricles. The large vessels stiffen, as does the myocardium.
157
As a result, afterload is increased and early diastolic filling is impaired. The adrenergic responsiveness of the heart decreases, limiting the maximum
achievable heart rate (HR).
• LV wall thickness progressively increases
with age independent of cardiovascular risk
factors such as hypertension.
• Enlarging cardiac myocytes (hypertrophy)
rather than an increase in number
(hyperplasia) accounts for ventricular wall
thickening.
•
Local collagen concentration and its
properties are altered in elderly persons. The number of collagen fibers
increase along with increase in nonenzymatic cross-linking.
•
These anatomical and structural changes contribute to an increase in
myocardial stiffness and a decrease in compliance.
• The resting HR does not change with age, but the maximum achievable
HR decreases, with the maximal HR that an 85-year-old person can
achieve
being
approximately 70% of
that of a 20-year-old
person. Because the
stroke volume does not
change over time, the
maximum
cardiac
output (stroke volume x
HR) decreases during
aging,
•
Diastolic
pressure
decreases with age,
compromising
myocardial
perfusion
and worsening overall
cardiac function.
• Normal aging affects
the arterial system.
Surce: Heart disease in the elderly, lawrence h. young,m.d., chapter 21
• Intimal hyperplasia and thickening, with a concomitant decrease in
vascular compliance and increased stiffness, develop with advanced age.
• Intimal thickening is a risk factor for silent coronary artery disease.
• Increases in peripheral vascular resistance lead to an increase in systolic
158
and diastolic pressure, while increases in central artery stiffness lead to
an elevation in systolic pressure but a reduction in diastolic pressure.
TridoÒa and Ojas activity at the level of heart
All the three DoÒa i.e. VÁta, Pitta and Kapha along with Ojas have a dynamic
control over heart. Sympathetic and parasympathetic control over heart is
mediated through TridoÒa.
DOÑA IN HEART
• PRÀÅA VÀYU- Responsible for conduction of heart.
• VYÀNA VÀYU - Responsible for the blood circulation.
• SAMÀNA VÀYU -Responsible for ANNARASA (end product of
digestion) to carry toward heart.
• SÀDHAKA PITTA —Responsible for action of heart. Also called as
SÀDHAKÀGNI and responsible for PURUÑÀRTH i.e. DHARMA,
ARTHA, KÀMA, MOKÑA. It is also called as OJA.
• AVALAMBAKA KAPHA- Responsible for strength of body and mind in
combination with ANNARASA
Aging preventive role of Ojas
Ojas is responsible for maintaining the immune status of the body. Ojas
activities are supposed to be anti-aging and antioxidants. Herbs and activities
which promote Ojas also act as antioxidant and prevent aging process.
Functional variation in the activity of DhÁtu and Mala in the elderly
In elderly due to pronounced VÁta activity Agni becomes abnormal which leads
to deranged digestion. As a result DhÁtu poÒaÆa decreases qualitatively and
quantitatively both. Mala become hard and dry leading to constipation and
further aggravation of CVD.
Cardio-vascular Disorders (Etio-pathological variations in elderly)
Historical Background of Hªidroga in Ayurveda
As per the ancient text BRÀÝHANOPNIÑADA word HèIDAYA is derived from
the letters-hª+da+ya.
Hè-Harne means to receive forcefully i.e. heart receive the blood from
the body.
Da-dane means to donate blood to the body.
Ya(ej) means to remain in circulation.
Thus the literal meaning of the word HèIDAYA is to receive, to eject and
to circulate the blood throughout body.
• Ayurveda is Upaveda of Atharvaveda
159
• Various terms used for denoting heart disease are —
Hªidota,
Hªidaya Roga,
Hªidayama
• Atharvaveda (2500 B.C.) described heart disease in a scattered manner.
• The scattered description of heart disease as collected gives an
impression that heart disease was known and treatment was also
attempted successfully.( Atharvaveda 6/44/3, 2/33/3)
• Except Atharvaveda the elements of heart disease could not be traced,
however few words are indicative for heart disease.
• Description of heart disease in Garu±a PurÁÆa is so comprehensive and
vivid that it looks Ayurveda has adopted its description as such from
Garu±a PurÁÆa.
- Carak SaÞhitÁ — Carak has given a detailed description of heart disease
for the first time. He described five types of heart diseases. Although the
description is found scattered in Sutra sthÁna, Sarira sthÁna, Cikitsa
sthÁna and Siddhi sthÁna.
- SuЪuta has described heart disease one step forward than carak
SaÞhitÁ.
- SuЪuta's description of heart disease is very elaborated and
comprehensive.
- SuЪuta not only described various types of heart disease but he
described a peculiar condition of heart disease called Hrichula (Heart
pain i.e anginal pain)
- SuЪuta described HªichÚla (Anginal pain) in the 43rd chapter of Uttara
tantra- ÏÚla pratiÒedha.
- SuЪuta's description is so vivid that similar excellence is not achieved
by Modern Medicine.
Risk factors for developing heart disease and heart attack
The Various causative factors can be grouped as followings1. Violation of dietary rules.
2. Violation of exercise rules.
3. Not observance of therapy rules.
4. Psycho-somatic factors.
5. As a complication of other diseases.
6. Mental shock.
7. Pollutions.
8. Use of poisons.
9. Undefined causes.
160
SÁmÁnya NidÁna and ViÐiÒta NidÁna of Hªidrog
SÁmÁnya NidÁna (Etiological factors of heart disease)
S.No.
Etiological factors
1
TÍkÒÆa dravya( bitter & spicy )
2
RÚkÒa anna (eatable causing dryness )
3
UÒÆa dravya (things creating heat in body)
4
Viruddha bhojana (incompatible diet )
5
AddhyaÐana (over eating)
6
AjÍrÆa bhojana (eating without digestion )
7
AsÁtmya bhojana ( un adapted diet )
8
Adhika vyÁyÁma(excessive exercise )
9
Veg sandhÁraÆa (holding natural urges )
10
AbhighÁta(trauma)
11
ÀghÁta (shock)
12
CintÁ ( anxiety )
13
Bhaya (phobia )
14
TªaÒa ( mental shock )
15
GadaticÁra (disobeying norms of diet )
16
Chardi (vomitings)
17
Àma (incomplete digestion )
18
Ati virecana (excess loose motions )
19
Ati vasti (excess enemas)
20
KarÒaÆa (excessive thin body)
Ca. Ci.26/77, S. Uttara. 43/3
ViÐiÒta NidÁna (Specific causes)
VÁtaj Hªdrog
3. Excessive intake of dry food.
4. Less intake of food.
5. Grief
6. Exertion
7. Fasting
Pittaja Hªdrog
• Excessive intake of sour, salty and bitter food.
• Intake of food during indigestion.
• Intake of hot food.
• Intake of alcohol
• Anger
• Excessive exposure to sunlight.
161
Caraka
+
+
+
+
+
+
+
+
+
+
+
+
+
SuЪuta
+
+
+
+
+
+
+
+
-
Kaphaja Hªdrog
• Excessive intake of oily and heavy food.
• Adopting sedentary lifestyle.
• Excessive sleeping.
TridoÒaja Hªdrog
All the above causes cumulatively cause TridoÒaja Hªdrog.
Kªimija Hªdrog
• Intake of Ghee, milk, Jaggery etc. in TridoÒaja Hªdrog
• Affliction with disease causing organism.
General Signs and Symptoms of Heart Disease
S.No. Signs & symptoms
1
2
3
4
ÏvÁsa (dyspnoea)
KÁsa (cough)
HikkÁ (hicough)
KaphotkleÐa
(expectoration)
5
Vamana (vomitting)
6
Àsya
vairasya
(distaste in mouth)
7
TªÒÆÁ(
excessive
thirst )
8
VaivarÆa
(discoloration
or
palor)
9
Aruci (anorexia )
10
MurchÁ (shock)
11
Jvara (fever)
12
RujÁ (pain )
13
Pramoha (delusion)
Types of Hªdrog
iUpSo ân;ke;k%
1.
VÁtika
2.
Pattika
3.
Kaphaja
4.
SannipÁtaja
5.
Kªimija
Caraka
SaÞhitÁ
+
SuЪuta
SaÞhitÁ
+
AstÁnga
Sangraha
+
AstÁnga
Hªdaya
+
+
+
+
-
+
+
+
+
+
+
+
+
+
-
+
-
-
-
+
-
+
+
+
+
+
+
+
+
+
+
-
+
+
-
+
-
162
Signs & Symptoms of VÁtika Hªdrog
S.No.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
Signs & symptoms
Heart symptoms
Àyamyate(drawing
pain)
Tudyate(crushing pain)
Nimarthyate(piercing
pain )
DÍryate(craking pain )
Sphotayate(pricking
pain )
PÁtayate(incisoring
pain)
SÚlyate(piercing pain )
Bhidyate(stabbing pain
)
SÚnyate (numbness)
ÏvasÁvarodha
(asphyxia)
DÁrah (tearing pain)
Drava (palpitation)
VeÒtana (twisting pain )
Stambha(shock)
UttamÁrujam (severe
heart pain)
Mental symptoms
Pramoha(deluion)
AkasmÁt dÍnata
(depression)
Ïoka (sadness)
Bhaya (phobia)
Ïabda asahiÒÆutÁ
(unbearable pain)
Alpa
nidrÁ
(sleeplessness)
Carak
SuЪuta
A.S.
A.H.
-
+
-
-
-
+
+
+
-
+
-
-
+
+
+
+
-
+
-
-
+
-
+
+
+
+
+
-
-
+
+
+
+
+
+
+
+
+
-
+
+
+
-
+
+
+
-
+
-
-
+
+
+
+
-
-
+
+
+
+
+
+
-
-
+
+
163
Symptoms of Pittaja Hªdrog
S.No.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Signs & symptoms
Heart symptoms
HªiddÁha ( feeling of
hot
over heart )
Hªidaya klama (heart
fatigue )
Generalised
symptoms
Tikta
vaktre(bitter
mouth)
TiktÁmlodgÁra (bitter
& acidic eructation)
Mukha
ÐoÒa(dry
mouth)
Amlapitta, chardi
(hyperacidity&
vomitting
Sveda (sweating)
Jvara(fever)
OÒa,coÒa,dÁha
(feeling pins, heat)
DhÚmÁyana (feeling
smoke in mouth)
Mental symptoms
MÚrchÁ (fainting )
Bhªma (vertigo )
Moha (delusion )
SantªÁÒa (fear of
death )
Caraka
SuЪuta
A.S.
A.H.
+
-
-
-
+
+
-
-
+
-
-
-
+
-
-
-
-
+
-
-
-
-
+
+
+
+
-
+
+
+
+
+
+
+
+
-
+
+
+
+
+
+
+
+
-
+
+
-
+
+
-
Symptoms of Kaphaja Hªdrog
S.No.
1
2
3
Sygns & symptoms
Heart symptoms
Hªdaya suptatÁ (heart
numbness )
Hªd staimitya (as if heart
covered with wet cloth)
Hªdaya bhÁra (heavy
heart )
Carak
SuЪuta
A.S.
A.H.
+
-
-
-
+
-
-
-
+
-
+
+
164
4
5
6
7
8
9
10
11
12
13
14
15
16
17
AÐmÁvªta hªdaya (heart
covered with bones)
Hªdaya
stabdhatÁ
(bradycardia)
Generalised symptoms
KÁsa (cough )
Staimitya (body covered
with wet cloth )
GurÚtÁ (heaviness in
body )
Àsya
mÁdhurya
(sweetness in mouth)
Kapha
pªaseka(mouth
lined by phlem)
Aruci (anorexia)
Agni
mÁrdava(low
metabolic fire)
Jvara (fever)
Mental symptoms
TandrÁ (drowsiness)
StabdhatÁ (shock)
NidrÁ (sleep)
Àlasya (lazyness )
+
-
+
+
+
+
+
+
+
+
+
-
+
-
+
-
+
+
-
-
-
+
-
-
-
+
+
+
-
+
+
+
-
+
-
+
-
+
+
+
+
-
+
-
+
+
+
+
Symptom of Kªimija Hªdrog
S.No
1
2
3
4
5
Signs
&
symptoms
Heart
symptoms
SÚcibhirava toda
(pricking pain )
Ïastªe
chidya
(cutting by sharp
weapon )
ÏÚla (pain)
Hªdayam
kªikceneva
dÍryate
(saw
cutting pain )
MahÁrujÁ
(severe pain in
heart )
Carak
SuЪut
a
A.S.
A.H.
+
+
-
-
+
-
-
-
-
+
-
+
+
+
+
-
-
165
6
7
8
9
10
11
12
13
Generalised
symptoms
SthÍvan (spitting
)
UtkleÐa
(excessive
salivation )
HªllÁsa (nausea
)
Aruci (anorexia )
Kandu (itching )
ÏyÁva
netªattva(white
eyes )
ÏoÒa (cachexic
body )
Mental
symptoms
Tama (black out
)
+
-
-
-
+
+
+
-
+
+
+
-
+
+
-
+
+
+
+
+
-
+
+
-
-
+
+
+
Heart Pain described by SuЪuta
:tk
vk;E;rs
rq|rs
fueF;Zrs
nh;Zrs
LQksV~;rs
'kwY;rs
fHk|rs
mRreek:te~
vk;E;rs
rq|rs
fueF;Zrs
nh;Zrs
LQksV~;rs
'kwY;rs
fHk|rs
mRreek:te~
Pain
Drawing pain
Crushing pain
Piercing pain
Craking
Pricking pain
Piercing pain
Stabbing pain
Severe Heart Pain
Drawing pain
Crushing pain
Piercing pain
Craking
Pricking pain
Piercing pain
Stabbing pain
Severe Heart Pain
SamprÁpti (etiopathogenesis) of Hªdrog
dQfiRrko:)Lrq ek:rks jlewfPNZr% A
166
HªdayasÚla
VÁtika Hªdrog
VÁtika Hªdrog
VÁtika Hªdrog
VÁtika Hªdrog
VÁtika Hªdrog
VÁtika Hªdrog
VÁtika Hªdrog
VÁtika Hªdrog
VÁtika Hªdrog
VÁtika Hªdrog
VÁtika Hªdrog
VÁtika Hªdrog
VÁtika Hªdrog
VÁtika Hªdrog
VÁtika Hªdrog
VÁtika Hªdrog
âfnLFk% dq:rs 'kwyeqPN~oklkjks/kda ije~ AA
l âPNwy bfr [;krs jlek:rlEHko% AA
lq-la-m-ra- [email protected]
nw"kf;Rok jla nks"kk foxq.kk ân;a xrk% A
âfn ck/kka çdqoZfUr ânzksxa ra çp{krs AA
lq-la-m-ra- [email protected]
PATHOGENESIS
Aggravated dosas vitiates rasa dhatu and reside in the root place of Rasa dhatu
i.e. the heart and produce disorders of the heart.
DoÒa
VÁtÁdi doÒa, VÁta dominant.
DÚÒya
Rasa
AdhisthÁna
Heart
(Location)
How coronary arteries get blocked?
Mainly atherosclerosis and fibrous plaque formation are responsible for
coronary artery blockage. The arteries become "furred up" by fat-rich deposits
in the vessel wall called plaques.
Types of Cardio-vascular disorder more common in the elderly
• Coronary artery disease
• Isolated systolic hypertension
• Orthostatic hypotension
• Heart attack
• Heart failure
• Mitral annular calcification
• Complete heart block
• Atrial fibrillation
• Stroke
Clinical Presentation of Hªdrog (CVD)
What is a Heart Attack?
A heart attack occurs when blood flow to a section of heart muscle becomes
blocked. If the flow of blood is n’t restored quickly, the section of heart muscle
becomes damaged from lack of oxygen and begins to die (infarction).
Warning signs of Heart Attack in elderly
Some heart attacks are sudden and intense -- the "movie heart attack," where no
one doubts what's happening. But most heart attacks start slowly, with mild
pain or discomfort. Often people affected are not sure what's wrong and wait
too long before getting help. Here are signs that can mean a heart attack is
happening:
11. Chest discomfort. Most heart attacks involve discomfort in the center
167
of the chest that lasts more than a few minutes, or that goes away and
comes back. It can feel like uncomfortable pressure, squeezing, fullness
or pain.
12. Discomfort in other areas of the upper body.Symptoms can include
pain or discomfort in one or both arms, the back, neck, jaw or stomach.
13. Shortness of breath.May occur with or without chest discomfort
14. Other signs:These may include breaking out in a cold sweat, nausea or
light headedness.
Stroke Warning Signs
According to the American Stroke Association, these are the warning signs of
stroke:
• Sudden numbness or weakness of the face, arm or leg, especially on one
side of the body.
• Sudden confusion, trouble speaking or understanding
• Sudden trouble seeing in one or both eyes
• Sudden trouble walking, dizziness, loss of balance or coordination
• Sudden, severe headache with no known cause
Cardiac arrest strikes immediately and without warning.
Here are the signs:
• Sudden loss of responsiveness. No response to gentle shaking.
• No normal breathing. The victim does not take a normal breath when
you check for several seconds.
• No signs of circulation. No movement or coughing.
Presenting symptoms and signs of myocardial infarction & myocardial
ischemia
Symptoms:
A common symptom of heart disease is
1. Shortness of breath, which is caused by the blood being deprived of the
proper amount of oxygen.
2. Another common symptom is chest pain or pain down either arm.
3. Palpitation
4. Fainting
5. Emotional instability
6. Cold hands and feet
7. Frequent perspiration
8. Fatigue
Coronary thrombosis normally produces a severe chest pain which may last for
at least half an hour. The pain may radiate down the left arm or up into the jaw.
168
Ischemic heart disease may present with any of the following problems:
o
o
o
Angina pectoris (chest pain on exertion, in cold weather or emotional
situations)
Acute chest pain: acute coronary syndrome, unstable angina or
myocardial infarction("heart attack", severe chest pain unrelieved by rest
associated with evidence of acute heart damage)
Heart failure (difficulty in breathing or swelling of the extremities due to
weakness of the heart muscle)
Angina and its variants in the elderly
A variant form of angina (Prinzmetal's angina) occurs in patients with normal
coronary arteries or insignificant atherosclerosis. It is thought to be caused by
spasms of the artery. It occurs more in younger women.
Angina may further be classified as stable or unstable angina.
Stable angina refers to the more common understanding of angina related to
myocardial ischemia. Typical presentations of stable angina is that of chest
discomfort and associated symptoms precipitated by some activity (running,
walking, etc) with minimal or non-existent symptoms at rest. Symptoms
typically abate several minutes following cessation of precipitating activities
and resume when activity resumes
Unstable angina may occur unpredictably at rest which may be a serious
indicator of an impending heart attack. What differentiates stable angina from
unstable angina (other than symptoms) is the pathophysiology of the
atherosclerosis.
Isolated Systolic Hypertension in old age and presenting symptoms
High blood pressure is more common with advancing age, and so are its
associated complications of —
• Stroke
• Kidney disease
• Heart attack
• Heart failure
By the seventh decade of life, close to half of all Indians have hypertension,
usually of unknown cause. A special type of high blood pressure that is more
common in elderly people is called Isolated Systolic Hypertension. In this
condition, only systolic blood pressure reading is elevated (for example, 160/70
or 200/80).
Orthostatic Hypotension
169
In elderly age group blood pressure is drop down by change of posture and not
so frequently restored as in young’s. This phenomenon is called Orthostatic
Hypotension. Patient may feel giddiness or some time may fall down.
Heart block: It is one of the major conduction defect mostly encountered
during M.I. and later stage.
Heart Failure and features of silent Heart Attack in elderly : It is usually
common in diabetic because due to neurological degeneration, the symptoms of
chest pain and other warning signs least appear.
Fixed and Modifiable Risk Factors
Fixed risk factors
Age
sex
Family history of CVD
Post menopause women
Modifiable Risk Factors
Hypertension, diabetes, hyperlipidemia,
stroke and peripheral vascular disease in first
degree relatives.
Sedentary lifestyle (lack of exercise)
Smoking (tobacco in any form)
Obesity
Hypertension
Diabetes
Hyperlipidemia
Elderly age as risk for CVD? As the age advances number of risk factors
increases, therefore elderly age itself is a risk for CVD.
High Risk Subjects
Family history of CAD, hypertension, diabetes, hyperlipidemia, stroke
and peripheral vascular disease in first degree relatives.
Sedentary lifestyle (lack of exercise)
Smoking (tobacco in any form)
Obesity
Hypertension
Diabetes
Hyperlipidemia
Reversal of Coronary Artery Disease:
1. There is no cure for coronary artery blocks. CABG and angioplasty provide
consistent results but this benefit may not last forever.
2. Attention has now focused onto actual reversal of coronary artery disease.
Initially patients who were not suitable for either of these therapies were
targeted for such studies.
3. This includes regular exercises, yoga, dietetic changes, personality and
behavioural changes, reduction in stress, group discussions and many other
170
things.
4. Some patients did show reduction in severity of blockages on follow-up
angiograms.
What is reversal therapy?
Reversal therapy is an integrated and coordinated approach to reduce and to
reverse the coronary occlusive pathologies mainly by modification of risk
factors and curative therapy.
Reducing Heart Attack Risk
You can reduce your risk of having a heart attack–even if you already have
coronary heart disease (CHD) or have had a previous heart attack. The key is to
take steps to prevent or control your heart disease risk factors.
Six Key Steps to Reduce Heart Attack Risk :
Following these steps, reduce the risk of heart attack:
•
•
•
•
•
•
Stop smoking
Lower high blood pressure
Reduce high blood cholesterol
Aim for a healthy weight
Be physically active each day
Manage diabetes
Effect of reversal therapy:
A physician can influence patients in the decision to adopt a very low-fat diet
combined with lipid-lowering drugs, can reduce cholesterol levels to below 150
mg/dL and uniformly result in the arrest or reversal of coronary artery disease.
Risk Factor Modification-Better Late Than Never: Early risk factors
modification gives better prevention and check the advancement of pathology.
Data from the Framingham Heart Study and other population studies have
shown that most cardiac risk factors continue to exert their influence in old age.
Cholesterol in the elderly:
There is some evidence that not only high total cholesterol but particularly high
levels of “bad”(LDL) and low levels of “good" (HDL) lipoprotein components
are indeed risk factors for older people. Major Risk Factors that affect LDL
Goal are:
• Cigarette smoking
• High Blood Pressure (140/90 mmHg or higher or on blood pressure
medication)
• Low HDL cholesterol (less than 40 mg/dL)
171
Family history of early heart disease (heart disease in father or brother
before age 55; heart disease in mother or sister before age 65)
• Age (men 45 years or older; women 55 years or older)
•
BLOOD CHOLESTEROL LEVEL CHART
Desirable
Borderline(high)
High Risk
Total Cholesterol
<200
200-240
>240
Low Density Cholesterol
<130
130-160
>160
High Density Cholesterol
>50
50-35
<35
Triglycerides
<150
150-500
>500
Good and Bad cholesterol:
• Cholesterol and Triglycerides together constitutes Blood lipids or fats
• High density cholesterol (HDL) (the "good" cholesterol) reduces harmful
low density cholesterol from the blood and tissues and delivers it to the
liver where it is processed for excretion.
• Low density cholesterol (LDL) (the "bad" cholesterol) promotes deposits in
the arteries gradually leading to narrowing and hardening which blocks the
passage of blood. This condition is termed as "atherosclerosis" which leads
to high blood pressure and heart diseases.
• Sedentary life style decreases energy spending by the body and contributes
to overweight and rise in blood lipids. Exercise increases good cholesterol
(HDL) in the body.
Strategies for risk management
Smoking:
6. Simple counseling- establish the desire to quit.
7. Reinforce this verbally and by providing written material.
8. Inform about improvement brought in ex-smokers.
9. Inform about all the smoking related diseases.
10. Emphasise the financial savings.
11. If attempts to stop smoking fail then only move on to minimise
smoking.
12. State should increase taxes, restrict smoking in workplaces and public
places, ban the advertisement of tobacco products
Overweight and Obesity:
A. Encouragement, patience and enthusiasm are needed on both sides.
172
B. Emphasise the immediate benefits viz. improved effort tolerance,
improved appearance and better self esteem.
C. Specify the long term benefits: lower blood pressure, lower risk of heart
attack, diabetes & lung diseases and longer life span.
D. Increase the intake of low calorie food. This controls the appetite. These
include green vegetables, carrot, raddish, tomato, cucumber, fresh fruits
and clear soups.
E. Reduce the intake of high calorie food. These are oil, butter, cheese,
crèam, ghee, paneer, groundnut, coconut and dry fruits like almonds,
walnut, pista, cashew nut etc.
F. Minimise alcohol intake.
G. Drug therapy to reduce weight.
Physical Exercise:
•
•
•
•
•
•
•
•
An exercise programme should be effective, safe and enjoyable.
Brisk walking is probably the best.
Exercise should be quantified with its duration, intensity and frequency.
Initial training should be gentle. It should increase gradually depending
on individual ability.
Young persons and fit middle aged subjects should aim at 20 to 30
minutes of activity 4 to 5 times a week.
An intelligent person can monitor intensity of his exercise by monitoring
his pulse.
In high risk patients, exercise should be monitored and supervised at
least initially. ECG monitoring in the beginning will be ideal.
The exercise must take into account associated diseases like asthma and
peripheral vascular disease.
Lipid Management:
There is sufficient clinical evidence to emphasize lipid lowering as part
of primary and secondary prevention.
ι Appropriate emphasis on diet and exercise is a mandatory part of any
lipid lowering program.
ϕ The dietary guidelines should aim at fully maintaining the pleasures of
eating.
κ Goals of lipid lowering:
•
•
•
•
Primary goal: LDL less than 100 mg/dl
Secondary goal: HDL more than 35 mg/dl
Triglycerides less than 150mg/dl
Low fat diet with less than 30% fat and less than 200 mg cholesterol
173
per day
• Start drugs when LDL more than 130 mg/dl
Ideal lipid lowering diet
Fat to provide 25 to 30% of total calories
Saturated fat less than 7 to 10% of total calories
Less than 200 mg cholesterol per day
At least 25 gm fibre per day
Preferred cooking methods include grilling, steaming, boiling,
microwave cooking and barbecue cooking. Frying is best avoided.
Persons with deranged lipid profile must have a complete lipid profile
done every six months.
Control of High blood pressure (Hypertension):
Goals:
• Less than 140/90 mm Hg
• Less than 135/85 mm Hg in diabetics
• Initiate lifestyle modification in all patients with hypertension
• Drug therapy whenever required
Non-pharmacological treatment:
Weight reduction. Even a loss of 4 to 5 Kg may be helpful in many
patients.
Reduction in alcohol intake
Increase in physical activity and Yoga
Reduction of salt intake to 4 gm per day
Increased intake of fruits and vegetables. This provides adequate
potassium
and reduces fat intake.
-
Pharmacological treatment: Low dose therapy should be initiated. Doses
should be gradually titrated. Try mono-therapy followed by
combinations.
Control of diabetes:
1. Undetected and uncontrolled diabetes is a major problem.
2. Adequate control of diabetes with diet, tablets, insulin injections and
exercise is mandatory.
3. This helps in reducing non-cardiovascular complications as well.
174
Stress Reduction:
-
Urbanization and Westernization of lifestyle are taking the toll.
Fast life now guided by the IT revolution is leaving many of us stressed
out even at the beginning of the day.
People with established cardiovascular illnesses should seriously
consider lifestyle modification. This includes yoga, meditation,
relaxation, exercises and even change of job and / or place.
Awareness of the stress as a risk factor by the patient is very important.
Revascularization: when?
It is beneficial
In selected, restricted circumstances, primarily for 3-vessel disease and
reduced left ventricular function and for hibernating and stunned
myocardium.
Benefits of revascularization procedures on survival in patients with
good left ventricular function have not been convincingly documented.
As per De Feyter PJ, 16 CABG (By-pass surgery) is preferred when:
•
•
•
•
There is multivessel disease.
There is stenosis of the left main coronary artery
The nature of the lesion is highly complex
Vessel provides the sole remaining blood supply to the
myocardium.
Diagnostics
Elderly people with symptoms suggestive of
heart diseases undergo essentially the same
diagnostic process as younger patients. Apart
from routine blood investigations and ECG.
Some noninvasive tests can also be used.
• Echocardiography and nuclear scans
may help to reveal more information
about the heart’s structure and function.
• Echocardiography, in which sound
waves are bounced off the heart's internal
structures, has great value in confirming
valve disease and other malfunctions.
Source:
64 Slice CTCenter, S. S. Hospital, BHU
• Holter monitoring, using a portable electrocardiograph testing device
175
generally worn for 24 hours, helps pinpoint rhythm disturbances under
conditions of daily living.
• TMT( exercise stress test), a standard procedure in diagnosing and
assessing the severity of coronary heart disease, may prove difficult for
older patients who are unable to walk rapidly on a treadmill because of
arthritis, decreased muscle strength, or other medical problems.
•
64Slice CT Angiography is a non invasive angiography giving an idea
about coronary blockage.
•
In specific cases, the use of cardiac catheterization or other invasive
testing is necessary to guide treatment or provide a blueprint for surgery or
angioplasty. The increased range and effectiveness of noninvasive cardiac
testing has been a boon to elderly patients.
ECG WITH SOME CLINICAL FINDINGS
A 55 year old man with 4 hours of "crushing" chest pain. Acute inferior
myocardial infarction
ST elevation in the inferior leads II, III and aVF ,Reciprocal ST depression in the
anterior leads (Ref: ttp://www.ecglibrary.com)
Figure a: 12-lead
ECG recorded while the
patient was experiencing
chest pain (case 2) shows
ST-segment elevation in
leads V1, V2, and V3, and a
slight depression and Twave inversion in leads
DII, DIII, and aVF. Bottom,
b:
right
coronary
angiogram
shows the
complete occlusion of the
proximal right coronary
artery.(Ref: Logeart, D. et
al. Chest 2001;119:290176
292)
Anterior infarction shows ST changes in the anterior precordial
leads.
Recent anterior infarction shows Q waves, inversion of the T wave.
(Mad Scientist Software Dr. Bruce Argyle, MD, Chief of Emergency Medicine at Cottonwood Hospital Medical
Center in Salt Lake City, Utah.)
Treatment modalities available and issues in their applicability in
elderly
SaÞprÁpti Vighatana of Hªdrog : Consistent presence of causative and risk
factors of CVD make the situation worse. One has to break the vicious cycle of
pathogenesis by lifestyle modification and risk factors modifications.
Drugs and the Elderly
Slower metabolism and other physiologic changes in the aging body may cause
drugs to act differently in elderly patients than in younger ones. The following
are some of the cardiovascular drugs to which the elderly may be more
sensitive.
• Many of these drugs can still be used, but the dosage must be adjusted
accordingly.
• High blood pressure medication may produce dizziness and orthostatic
hypotension, especially the vasodilators, diuretics, or some of the
calcium blockers.
• Dizziness from anti-anginal medications (especially nitroglycerin
derivatives) is also more common.
• Toxicity from digitalis (used in heart failure) may be more common.
177
• The use of anticoagulant drugs (to prevent clots) may result in bleeding
more readily and is dangerous in people who are unsteady and subject to
frequent falls.
• Beta blockers tend to slow the heart more.
• Intravenous Iidocaine may cause more confusion,
Revascularization procedures: Main revascularization procedure are-
CABG
Coronary angioplasty(PTCA)
Coronary stenting
PREVENTIVE CARDIOLOGY, PROMOTIVE ASPECTS FOR HEALTHY
HEART
ABCs of Preventing Disease Heart, Stroke and Heart Attack An
individual's lifestyle is not only his or her best defense against heart disease and
stroke, it’s also his
or
her
responsibility.
By
following
these
three simple steps
one can reduce all of
the modifiable risk
factors for heart
disease, heart attack
and stroke.
(Ref:Heart disease
in the elderly:
Lawrence H. Young,
M.D.)
PARADIGM SHIFT
FROM CURATIVE
TO PREVENTIVE CARDIOLOGY
Paradigm has now shifted from curative treatment to preventive and promotive
approaches like risk factor modifications, dietary modifications, yoga and other
relaxation techniques, antioxidant therapy and lifestyle modification are the
mainstay in the management of CVD
LIFESTYLE MODIFICATION
178
Extensive multi-centric studies showed a greater incidence of acute coronary
events (Heart attacks) between 6am to noon as compared to other time of day.
Some of the scientific causes underlying such coronary events are1.
Increase in catecholamines levels in morning.
2.
An increase in platelet agreability.
3.
Enhanced fibrin breakdown due to an increase in plasminogen -activator
inhibitor-1.
4.
Reduced level of heparin.
5.
Assumption of an upright posture.
6.
A decrease in melatonin level.
7.
An increase in serotonin (5-HT).
8.
Lower level of anti-oxidant system.
9.
Stress of facing a new day.
10.
Cholinergic withdrawal.
In Ayurveda certain norms and routine practices for day, night &
seasons (DincaryÁ & ètucaryÁ) have been advised besides mental & behavioral
hygiene (SadÁcÁra). Famous study of Dean Ornish and others is actually based
on such Àyurvedic advises. Their so much advertised programme reversal of
coronary heart disease (re-vascularisation of blocked arteries and prevention of
heart attacks) is nothing but implementation of such Ayurvedic advises from
our texts.
Some of the major recommendations about lifestyle, diet and behavior
from Ayurvedic texts to counteract the above described circadian aggravation
of events of heart attacks and also for primary & secondary prevention of acute
heart events are following1.
The habit of early to bed and early to rise (BªaÞha-muhÚrta rising).
2.
To drink plenty of water on waking up (UÒÁpÁna).
3.
To take early bath with cold water.
4.
To do early morning meditation, yogÁsana & SÚrya-namaskÁra.
5.
To take early morning empty stomach Haritaki (Terminalia chebula)
powder or in any form.
6.
To do herbal tooth brushing with NÍma, KÍkar, Bakula twig with
chewing & tongue cleaning.
7.
To drink cow milk only with the early and light dinner.
8.
To have pleasant and optimistic thoughts for oneself and others.
9.
To prey to own chosen god and goddess for health wealth and
happiness.
10.
To avoid smoking tobacco, alcohol, heavy & fried food.
These recommendations make the person cool and calm, reduces adrenergic
outflow, reduces the circadian effect and induces a relaxation response.
179
DRUG TREATMENT
It has been observed that even after the re-vascularisation procedure like
coronary angioplasty, ballooning, stenting, and even open heart surgery
(CABG), patients may develop subsequent re-blockage and resultant ischaemia
may provoke preoperational symptoms. Statistics showed that within 3 to 5
years almost 50% of such operated cases may develop again ischaemic events.
In such a grave condition, Ayurveda can do miracles. Guided programme,
Ayurvedic medicines and herbs have been proved effective and fully averted
the heart surgeries. Such endeavor must be appreciated, advertised widely to
get the due attention.
Treatment
Elimination of the cause (NidÁna Parivarjana).
Rest - mental and physical relaxation.
Dietary & life style modifications.
Palliative and purification (Ïamana & Ïodhana) treatment.
• In VÁtika Hªdrog PunarnavÁdya Ghªta, HaritkyÁdya Ghªta or
TryÚÒaÆadya Ghªta is given. It alleviates aggravated VÁta.
• In Paittika Hªdrog drug induced purgation (Virecana) is followed by
intake of Pitta alleviating drugs are given. Take these drugs with honey
or currants or sugar.
• In Kaphaja Hªdrog drug induced vomiting (Vamana) is advised. It is
followed by Kapha alleviating treatment. Intake of Cyavana PrÁsa,
Bªahma RasÁyana or/and Àmalaki RasÁyana is advisable.
• In TridoÒaja Hªdrog fasting is advisable followed by doÒa alleviating
treatment.
• In Kªimija Hªdrog drug induced evacuation of bowels, fasting and
therapy improving digestion is recommended. All drugs that work
against disease causing organism are used.
• Use of Arjuna (Terminalia arjuna), Sªnga, Gold, Ginger and KaravÍra
(Nerium indicum) in heart disorders is advisable.
Single Herbs : PuÒkarmÚla, Arjuna, HaritakÍ, TriphalÁ, MethÍ, KarcÚra,
PunarnavÁ, Guggulu, VacÁ, etc have been proved anti-anginal, anti-ischaemic,
anti-hyperlipedemic, anti-arrhythmic, cardio-protective and cardio-corrective
as well. Properly selected drugs for proper case, at proper time, for a proper
period can prevent and avert heart emergencies and surgeries.
Management of Hypertension with Ayurvedic Formulations
1. UÐÍrÁdi cÚrna 3-6 gm twice daily for six weeks.
2. TagarÁdi cÚrna 3-6 gm twice daily for six weeks.
180
Dietary considerations
Pathya-Apathya in Hªdroga (Do’s and don’t s): Diet is an important factor
responsible for coronary heart disease (CHD). A major part of its effect is
mediated through lipo-proteins. A high portion of energy from saturated fat
raises the LDL (bad cholesterol), where as a high portion of energy from
unsaturated fat (soyabean oil, sunflower oil, mustard oil, cotton seed oil, til oil,
rice bran oil, etc) raises HDL (good cholesterol).
To prevent coronary blockage, total fat intake must consist of no more than1015% of the total calorie. Other dietary ingredient with beneficial effect
includes- anti-oxidants, vitamins ( vit-B, C, E ), flavonoids, phyto-estrogens
and fibre, present abundantly in fruits & vegetables.
Do's Have Old ÏÁlÍ rice, wheat, Yava, Mudga (green gram), horse gram, cabbage,
gourd, serpent gourd, Alibanam (Tendil), ginger, garlic, Onion, Dry ginger,
Old pumpkin Pomegranate, mango, grapes, lemon, Orange, Honey, hot water,
Cow's ghee, Ajawayana, Safflower oil, Sunflower oil, Regular exercisewalking, yoga etc.
Don’ts Eat Maize. JvÁr, Varak, Pot hurbs, bitter gourd, Sago ,Pea, Black gram, Cow
pea, Kidney beans, fish, Aquatic animals meat, Red meat, Milk, Milk products.
Avoid stress and fatigue.
Referral Status
Followings are the clinical condition when a patient of CVD needs to be
referred to a heart centre for better management.
• A case of hypertensive crisis.
• A case of long standing unstable Angina
• Acute myocardial infarction
• Tachyarrhythmia
• Heart block
Recommended Further Reading
1.
2.
3.
Ornish D, Scherwitz LW, Billings JH, Brown SE, Gould KL,
Merritt TA, Sparler S, Armstrong WT, Ports TA, Kirkeeide RL,
Hogeboom
C, Brand RJ. Long-term lifestyle changes increase
regression of
coronary heart disease. JAMA. 1998; 280:2001—
2007.
Heart disease in the elderly: Lawrence H. Young, M.D.
Ornish D. Avoiding revascularization with lifestyle changes: the
181
4.
5.
6.
7.
8.
9.
10
Multicenter Lifestyle Demonstration Project. Am J Cardiol. 1998;
82:72T—76T.
Ornish D. Dietary treatment of hyperlipidemia. J Cardiovasc Risk. 1994;
1:283— 286.
Brown SE, Scherwitz LW, Billings JH, Ornish DM, Armstrong WT,
Ports Ôreverse coronary atherosclerosis? The Lifestyle Heart Trial.
Lancet. 1990;336:129—133.
Heart disease prevention: 5 strategies keep your heart healthy MayoClinic.com
Tripath A.K., Singh R.H., Tomer G.S.; Secondary prevention of
Ischemic Heart disease, Ph.D.Thesis, 2000.
Carak SaÞhitÁ : SÚtra SthÁna- 17(Kriyantaí ÐirasÍya adhyÁya), SÚtra
SthÁna - 30(ArthedasamahÁmÚlÍya adhyÁya), CikitsÁ SthÁna 26(TªmarmÍya CikitsÁ adhyÁya), Siddhi SthÁna- 9 (TªmarmÍya Siddhi
adhyÁya).
SuÐruta SaÞhitÁ UtÔar Tantra-42,43
AstÁnga Hªdaya : NidÁna SthÁna -5, CikitsÁ SthÁna -6
182
Chapter-12
Endocrine & Metabolic disorders in the elderly
Introduction:
The endocrine system detects and integrates the humoral and sensory information to
regulate physiological function; i.e.- the process of homeostasis. Age associated
decline in physiological performance is well known and it is accepted that the basis
of this decline is a failure of homeostasis at molecular or organ or system level. A
significant alteration in hormone production, metabolism and action are found during
the process of aging. The scale of age related changes is highly variable and sex
dependent. The decline of each organ or system appears independently and
influenced by diet, environment, and personal habit as well as by genetic factors. In
aged people disease, smoking, sedentary lifestyle and side effect of drugs, all of
which, when combined, it may decrease the physiological reserve and make them
more vulnerable to environmental, pharmacological, pathological challenges. In this
regard only few physiological changes occur in pituitary dynamics, adrenal gland
physiology and thyroid function. However, apparent changes were observed in
glucose homeostasis, reproductive function, calcium metabolism and thermo
regulatory mechanism. The equilibrium concentration of principal hormones are not
necessarily altered with age. But their is a change in endocrine regulatory process and
signal transduction process at the target levels that may lead to endocrine and its
related problems
In Ayurveda the role of Agni is quite relevant to life, age and longevity. It is a
responsible factor for maintenance of health, promotion of physique, and affect all
physiological functions.1, 2 The twenty components of Agni, i.e. 1- JÁÔharÁgni, 5BhÚtÁgni, 7- PÁcakÁ¿Ða and 7- DhÁtvÁgni; have been mentioned in classics of
Ayurved, which are responsible for digestion and metabolism from gross to subtle
level. In variety of etiological factors, aging is an important factor. It may lead to
derange the function of Agni and formation of Àma, i.e. - an unwanted metabolic
waste product at respective level. Àma has tremendous capacity to vitiate the DoÒa
and to disturb the normal homeostatic mechanisms of tissues resulting into various
local as well as endogenous metabolic disorders, i.e. - diabetes mellitus, thyroid
disorders, bone and joint disorders and many more.
Epidemiology of endocrine and metabolic disorders in the elderly:
1
ÀyurvarÆabala¿ svÁsthyamutsÁhopacayo prabhÁ½ I; Ojastejoagnaya½ prÁÆaÐcoktÁdehÁgni
hetukÁ½. II.
ÏÁnteagnomriyate
yukte
cira¿
jÍvatyanÁmaya½
I;
RogÍ
syÁdvikéte,
mÚlamagnistasmÁnniruccyate. II.
( C.S.Ci.15/3-4)
2
Aha¿ vaiÐvÁnarobhÚtvÁ prÁÆinÁ¿ dehamÁÐrita½ I,
PrÁÆÁpÁna samÁyukta½ pacÁmyanna¿ caturvidham II (Sri.Bh.Geeta- 15/14)
183
Diabetes mellitus: Diabetes mellitus and its complications are the important health
care problem in the elderly. WHO has projected 11% of the population as diabetic in
developed nations over the age of 65 years, this will be increased up to 20% by the
turn of this century. In India, it has been estimated that 13% of the adults older than
70 years have diabetes and 11% of the elderly between the ages 60-74 years remain
undiagnosed. The prevalence in the elderly varies from 10- 38% with respect to the
year of the study, the ethnic groups and also in the applied diagnostic criteria.
Hypothyroidism: It is estimated that 2 to 7.4% of people over the age of 60 years
have hypothyroidism. The mean annual incidence of hypothyroidism is up to 4/1000
women and 1/1000 in men. The prevalence of overt hypothyroidism increases with
increase of age. Sub- clinical hypothyroidism is found 5 to 10% over the age of 60
year; it is most common in female than male.
Hyperthyroidism: It is estimated that 0.5 to 2.3% of people over the age of 60 years
suffer from hyperthyroidism. In developed nations hyperthyroidism related death are
common due to Grave’s disease in old age, but toxic multi-nodular and thyroid
adenomas are more common in the elderly. It is 8 to 10 times greater in female than
male.
Hyperparathyroidism/ Hypercalcaemia: Primary hyperparathyroidism and
malignancy associated hypercalcaemia are the most common cause of
hypercalcaemia in old age. The annual incidence of primary hyperparathyroidism is
approximately 1/1000 of population. It is 3 times more prevalent in women than
men.
Hypoparathyroidism: The epidemiological data is not available, though it is rarely
seen in elder age groups.
Hyperlipidemia: At least 25% of men and 42% of women over the age of 65 years
have elevated serum cholesterol level i.e. - > 240 mg/dl. In general elevated levels of
serum cholesterol are associated with coronary heart disease. It is estimated that in
elderly 80% of all deaths occur from hyperlipidemia associated coronary heart
disease.
Osteoporosis: In developed countries as many as 8 million women and 2 million
men have osteoporosis. It is most common problem of elder age group, mostly seen
in females, because of loss of ovarian function at menopause, precipitates rapid bone
loss.
Hypothermia: Approximately 600 elderly people die each year in developed nations
from hypothermia.
Hyperthermia: In every year hundreds of elderly people die from hyperthermia.
Hypoglycemia: In comparison to adult the risk of hypoglycemia is greater in the
elderly; this is due to change in the mental status that impairs the perception or
response to hypoglycemia.
Physiological, endocrine and metabolic changes in the elderly:
In general the endocrine function is decreased in the elderly. This results in the
gradual elevation of the fasting glucose level by 6- 14 mg/dl per decade after age 50
years. It is also common in elderly people to have hypoglycemia following meals, as
well as hyperglycemia caused by insulin resistance. In old age many hormones
remain constant both in amount production and in blood level, such as thyroid
stimulating hormone, but the target organs do not respond to them as well. In relation
to aging, hormones like estradiol and estrogen in women after menopause, and
aldosterone, renin, calcitonin and growth hormone are decreased in both male and
184
female. The important endocrine and metabolic age related physiological changes,
their consequences and effects are given below.
Gland/organ/
system
General
Physiological
changes
Increased body fat
Deceased total
body water
Endocrine
gland
Impaired glucose
homeostasis
Deranged
Thyroxin
production/clearan
ce
Increased or
decreased
PTH hormone
Reduced
Testosterone
hormone in male
Reduced Vit-D
Immune
system
.
Increased ADH,
Reduced Renin
and Aldosterone
Reduced bone
marrow reserve, T
cell function, and
increased
formation of autoantibodies.
Their
consequences
Increased volume
of fat soluble
drug.
Decreased
volume of water
soluble drug.
Increase glucose
level in response
to acute illness.
Deranged
metabolic
function
Effects
Obesity,
Fluid and water
imbalance.
Diabetes mellitus
Hyper or
Hypothyroidism
Altered calcium
metabolism
Hyperthyroidism,
Osteoporosis in female
Failure in orgasm
Impotency
Demineralization
of bone
Fluid and
electrolyte
imbalance
Osteopenia
Related
consequences
Disorders related to
electrolyte i.e.Na,K,etc
Autoimmune disorders
How elderly differ from adult population in general:
Most of the elderly patients with endocrine and metabolic disorders have diminished
level of hormones in the body. The pathogenesis of such disorders in this age group
is similar to that in other age group. There are other age related factors like shift to
sedentary life style, increased adiposity, coexistent medical illness and concomitant
use of multiple drugs that may also contribute related disorders. The elderly people
differ from adult population in various ways, such as:
- Disease presentation is atypical in the elderly.
- Because of decreased physiological reserve (homeostenosis) in the elderly.
- Because many diseases are common in the elderly than adult patients, viz Bactriuria, BPH, low bone mineral density, premature ventricular contraction
etc.
- Because symptoms of disease in the elderly people are often due to multiple
causes, hence the diagnosis differs from younger ones.
185
- Because the older patient is more likely to suffer the adverse consequences of
disease and their treatment.
- Because older patients require only optimal treatment.
How the elderly presents endocrine and metabolic disorders:
Physiological reserve starts declining in third decade; it is gradual and progressive,
although the rate and extent of decline varies. Hence the presentation of metabolic
and endocrine disorders are also varied in the elderly people. Endocrine and
metabolic disorders may be a part of spectrum of age related changes in the
secretion and action of hormones at target level in the elderly. Among all types of
endocrine and metabolic disorders, diabetes mellitus, thyroid disorders, PTH
associated hypercalcaemia, hypothermia; and hyperthermia are most common in the
elderly population, because of age related changes in the secretion and action of
various hormones. In the elderly it is presented in one of the following three ways1. Detected in the middle age live through to become elderly disorders.
2. Detected for the first time in the geriatric age group.
3. Impaired hormone tolerance de novo in the elderly.
Clinical presentation of endocrine and metabolic disorders in conventional
medicine, it presents in
following ways –
•
Atypical presentation.
•
Classical presentation with other common symptoms.
•
Presented with complications.
•
Presented with coexisting disease.
Common endocrine and metabolic disorders in the elderly:
In contemporary system of medicine common endocrine and metabolic disorders are
diabetes mellitus, hypothyroidism, hyperthyroidism, hyperparathyroidism, obesity
and hyperlipidemia, thermoregulatory disorders, disorders of adrenal cortex ,
electrolyte imbalance etc.
Concept of Pitta system in Ayurveda: The digestive and metabolic activity of the
body takes place with the help of Agni i.e. biological biofire. Ayurveda has
conceived twenty components of Agni which function at different levels of
digestion, metabolism and assimilation activity in the body.
1
JÁÔharÁgni- 1: GI biofire: It include various enzyme and hormones located to
the GIT, it performs digestion of food.
2
DhÁtvÁgni- 7: Tissue biofire: It is located in seven DhÁtus and responsible for
tissue metabolism.
3
BhÚtÁgni- 5: Hepatic biofire: It is located all over the body but mainly in liver. It
1
JÁÔhara½ prÁÆinÁmagni kÁyaetyabhidhÍyate I; SÁ cikitsÁ sÍdanti sÁ vai kÁyacikitsaka½ II. ( Bhoja)
2
3
SaptabhirdehadhÁtÁro dhÁtvo dvividha¿ puna½ I; YathÁ svamagnibhi½ paka¿ yÁnti
kiÔÔaprasÁdavat II.
(C.S.Ci-15/15)
BhaumÁpyagneya vÁyavyÁ pañccoÒmÁÆa½ sanÁbhasÁ½ I; PañccÁhÁraguÆÁn svÁnsvÁn pÁrthivÁdÍn
pacanti hi II.
( C.S.Su.-15/13)
186
not only performs biotransformation of food components but is also responsible for
molecular metabolism and assimilation.
4
PÁcakÁ¿Ða-7:
They are generated in GIT as part and parcel of PÁcakÁgni but
stable their function in the tissues i.e-Seven DhÁtus.
JÁÔharÁgni, 5- BhÚtÁgni, 7- PÁcakÁ¿Ða and 7- DhÁtvÁgni;
In this concern JÁÔharÁgni is the most important Agni among all types of Agnis and
it also governs the functions of other Agnis. If the JÁÔharÁgni function is weak it
leads to improper digestion of food items i.e. AjÍrÆa. Again AjÍrÆa leads to
formation of Àma-anna and Àma-rasa. If Àma-anna persists in the GIT, it creates
local auto-reactive phenomena depending upon the strength of Àma. It can lead to
develop local acute and chronic disorders of ÀmÁÐaya and PakvÁÐaya such asDiarrhea, Vomiting, Hyperacidity, Intestinal obstruction, IBD, IBS etc. After
absorption it may lead to systemic disorders, such ÀmavÁta etc by influencing other
kinds of Agnis.5
The function of JÁÔharÁgni, DhÁtvÁgni and BhÚtÁgni is impaired by variety of
exogenous as well as endogenous causative factors that may lead to formation of
auto-reactive substances i.e.- Àma at that level. This form of Àma has physical
similarity to KaphavargÍya DhÁtus, it impaires the function of respective DhÁtus/
tissues, resulting qualitative and quantitative defects of DhÁtus/tissues. Àma has
tendency to block the micro-channels i.e. receptor defect; create antigenic reaction
and if retained in the body act as autotoxin i.e.- Directly destroy the cells. Besides
these qualities of Àma, it is also associated with DhÁtukÒaya and OjokÒaya and VÁta
prakopa. It enhances the normal aging process in old age i.e.-VÁta dominating age;
and is responsible for various autoimmune systemic disorders such as Madhumeha,
GalagaƱa, ÀmavÁta, Medoroga, AsthikÒaya, DhÁtukÒaya etc.
Common endocrine and metabolic disorders:
Diabetes mellitus: Diabetes is among the most common chronic illness which
affects the elderly persons in developed as well as developing countries. The
management of diabetes in elderly is challenging, but it will be rewarding to help an
elderly diabetic to improve the quality of his life and maintain healthy life style.
The detailed guide line for a management of diabetes mellitus has been given separately in the
context of diabetes mellitus vis a vis Madhumeha in this manual.
YathÁ sva¿ sva¿ puÒÆÁnti dehe dravyaguÆÁ½ péthakaí I; PÁrthivÁ½ Párthivagneva ÐeÒÁ½
ÐeÒÁñÐca kétsnaÐa½ II.
(C.S.Ci.- 15/14)
4
SvasthÁnasthasya kÁyÁgnera¿ÐÁ¿
dhÁvédhikÒayodbhava½ II.
dhÁtuÒa
sa¿ÐritÁ½
I;
TeÒÁ¿
sÁdÁtidÍptibhyÁ¿
(A.Hr.Su.- 11/34)
5
Agnireva ÐarÍre pittÁntargata½ kupitÁkupita½ ÐubhÁÐabhÁni karoti I.
C.S.Su.- 12/11)
187
(
Hypothyroidism: It results due to deficiency of thyroid hormone i.e. - T3 and
T4.The cause of primary hypothyroidism is mainly related with thyroid gland and
secondary hypothyroidism with pituitary or hypothalamus. Primary hypothyroidism
is mostly seen in elder age group, especially in females.
Causes of Primary hypothyroidism:
- It is probably the end stage of chronic autoimmune thyroiditis. Circulating
antibody is detected in
80% of the cases.
- Treatment of hyperthyroidism: Radioactive iodine and anti-thyroid drugs.
- Radiation therapy: Cancer therapy of neck and head can affect thyroid gland.
- Surgery: Removal of thyroid gland in advance cases of hyperthyroidism.
- Medications: Several medications can contribute hypothyroidism. Lithium is one
of them.
Clinical presentation of hypothyroidism:
Site of of
clinical feature
Mechanism
clinical
presentation
Skin
Pale and dry skin, weight
gain, brittle nails.
hoarseness of voice and
slow of speech
Deposition of hyluronidase,
Enlargement of tongue
GIT
Constipation and reduced
appetite
Reduced peristalsis and GI
secretions.
188
Diastolic hypertension,
dyspnea and cold
intolerance.
Reduced cardiac output and
ventricular function.
Muscle weakness, pain and
stiffness in joints, unsteady
gait, depression,
lethargyness
Diminished blood supply,
Lack of hormone at target level
Renal
Reduced urine output
Reduced GFR and water
excretion
Female
Irregular menstrual cycle/
Amenorrhea
Suppressed gonadal functions
CVS
Neurological
Differential diagnosis: ENT, nephrological and neurological problems and
dysfunctional uterine bleeding.
Complications:
Hypothermia, LVH, pericardial effusion, angina, MI,
Hypoglycemia.
Investigations:
iv. Thyroid function test- T3, T4, and TSH: ↓ T3 & T4 and ↑TSH level.
v. Anti TPO Ab- It is positive in hypothyroidism
vi. Fasting lipid profile: Presence of hyperlipidemia.
vii.GBP: Indicate normocytic normo-chromic anemia.
viii.
X-chest plain- Heart is small in size.
ix. ECG- Low voltage and bradycardia.
Fig-I. Thyroid gland and and its appearance:
:Thyrotoxicosis in old age
In presence of goiter in old age.
Fig-II. General appearance
Courtesy: www.images.google.com
Courtesy: www.ei.educ.ab.ca
Hyperthyroidism: It is a clinical condition that results from excess thyroid
hormone in the circulation. It is also known as thyrotoxicosis.
Common causes of Hyperthyroidism are:
• Grave’s disease: the exact cause is unknown. It is important cause of
hyperthyroidism in old age.
189
• Non cancerous growth of thyroid gland or pituitary gland.
• Tumor of testes and ovaries.
• Inflammation of thyroid due to viral infections.
• Ingestion of large amount of thyroid hormone or excessive Iodine.
Clinical presentation: The elderly person may not show the classical symptoms of
increased appetite, increased heart rate, exophthalmia, and muscle weakness, though
it is commonly found in young adults. The elderly hyperthyroidism patients present
with- weight loss, fatigue, congestive heart failure, restlessness, nervousness, heat
intolerance, increased sweating, diarrhea, water hammer pulse, palmer erythema and
menstrual irregularities in women.
Differential diagnosis: Neuropsychological disorders, Type I diabetes mellitus.
Complications: Hyperthermia, atrial fibrillation, cardiac failure, osteoporosis,
pathological fracture etc.
Investigations:
• Thyroid function test- T3, T4, and TSH: ↑ T3 & T4 and ↓ TSH
• TPO ant body- it is positive in 80% of the cases.
• Thyroid stimulating immunoglobulin- positive in most of the cases.
• Radioactive iodine uptake- it is increased.
• Serum calcium – it may or may not increase.
• X-ray chest and ECG
•
Hyperparathyroidism/Hypercalcaemia:
In appropriate excess of PTH and its action may result from hyper- secretion,
hyperplasia, and adenoma or carcinoma of the parathyroid gland. Serum calcium
level remains normal as a result of increase PTH, but the balance between bone
resorption and bone formation is altered. By these consequences bone mass is
decrease and increase risk of osteoporosis with aging. Primary hyperparathyroidism
and carcinoma are the most common cause of hypercalcaemia in older age groups.
Causes of hyperparathyroidism:
• Primary- Hyperplasia, adenoma, multiple endocrine neoplasia.
• Secondary- CHF, adult rickets, osteomalacia etc.
Clinical presentation: Older patients of hyperparathyroidism are more likely to
presents with neuropsychiatry symptoms i.e.- depression and cognitive impairment;
and neuromuscular symptoms such as- proximal muscle weakness and osteoporosis.
PTH related osteoporosis is more common in post menopausal women. Some times
patients also complain of polyurea, nocturia, polydepsia, nausea, vomiting,
constipation, bone pain and symptoms of LVH.
Differential diagnosis: Osteomalacia, hyperthyroidism and neuropsychiatric illness.
Complications: Osteoporosis, pathological fracture, renal stones, LVH etc.
Investigations:
• PTH level- increased
• Serum calcium- Hypercalcaemia .
• 24 hour urine calcium estimation- it is increased.
• Estimation of creatinine clearance- this is reduced.
• Bone density measurement – reduced.
• Serum phosphate- reduced.
• X-ray of neck and mediastinum- to find out osteoporosis and fracture.
190
Hypoparathyroidism:
It is rarely seen in elder age group. Neuromuscular manifestation such as tetany,
paresthesia, and mental retardation are the symptoms that draw attention to the
presence of hypoparathyroidism. Some time few patients may presents with vague
and atypical pain. Severe hypocalcaemia produces rhabdomyolysis and in some
cases sensory neural deafness. Lack of PTH reduces the conversion of 25 (OH) D3
into 1, 25 (OH) 2 D3, and hinders the absorption of calcium from gut.
Differential diagnosis: Hypocalcaemia due to other causes.
Complications: Alkalosis, hypocalcaemia, cataract, alopecia, convulsive disorders.
Investigations:
i. Estimation of PTH hormone- reduced.
ii. Serum calcium level- reduced
iii. Serum phosphate- increases.
iv. 24 hour urine- markedly increases.
v. Estimation of vit- D in the serum- reduced.
Hyperlipidemia:
It means an elevated level of lipids in the blood. The commonly measured lipids are
TG and Cholesterol. They are associated with increased risk of coronary heart
disease. CHD is the leading cause of death in the people over the age of 65 years.
Complications: Coronary heart disease, atherosclerotic disorders.
Investigations: Serum triglycerides and cholesterol are measured. These tests are
performed after fasting overnight. As per American Heart Association their
preferred range are given belowCholesterol
Triglycerides
Total cholesterol
LDL
Desirable
<150 mg/dl
<200 mg/dl
<130 mg/dl
Borderline
high
200- 400 mg/dl
200- 239 mg/dl
160- 189 mg/dl
Hypothermia:
High
400-1,000 mg/dl
> 240 mg/dl
> 190 mg/dl
The elderly are at greater risk of metabolic hyperthermia. In old age body is
not so effective to regulate and maintain the body temperature.
Risk factors for hypothermia:
• Decreased heat production due to physical inactivity, hypothyroidism and
malnutrition.
• Increased heat loss due to loss of subcutaneous fat.
• Sedatives and tranquilizers in the elderly can impair judgment.
• Poorly heated room.
Clinical presentation of hypothermia: The symptoms of hypothermia vary
depending upon the core body temperature.
Grade
Core
body
Sign & Symptoms
temperature
Mild
90- 95 degree Fatigue, weakness, slurred speech, slowed gait,
F
confusion, cool skin, apathy, muscle weakness,
shivering may or may not occur in the elderly.
Moderate
82- 90 degree Acute confusion, progressing to unconsciousness,
F
cyanosis, sinus bradycardia, atrial and ventricular
dysarrhythmia, pulse, BP and respiration decrease,
muscle rigidity, slowed reflexes, poorly reactive
191
Severe
<82 degree F
pupils.
Muscle rigidity, unresponsiveness, fixed pupils,
apnea, ventricular fibrillation, a- systole, cardiorespiratory arrest.
Investigations:
• Body temperature >96 degree F
• Hemoconcentration- leucocytosis
• Urine for protein, blood urea
• PR, BP, Serum calcium, etc.
Osteoporosis:
It is defined as reduction of bone mass or bone density. This reduction in
bone tissues is accompanied by deterioration in the architecture of the skeleton,
leads to a markedly increased risk of fracture.
Fig-I Osteoporosis: A common metabolic disorder in old age
Courtesy: www.medicineworld.org
Risk factor of osteoporosis:
15. Aging is an important risk factor.
16. Hypogonadal state.
17. Endocrine disorder- Thyrotoxicosis, Hyperparathyroidism and IDDM.
18. Nutritional and Gastro-intestinal disorders.
19. Rheumatologic disorders.
20. Drug induced- Glucocorticoids, Cytotoxic drugs, Cyclosporine, Thyroxin.
21. Others- Prolonged immobilization, COPD, Sarcoidosis etc.
Investigations:
- Estimation of serum concentration of thyroid hormone, parathyroid hormone,
calciferol, insulin.
- Serum calcium and osteocalcin.
- Serum alkaline phosphate.
- Bone biopsy.
- Bone density measurement.
- X-rays of bones
Complications: Pathological fracture, Renal and bladder stone etc.
Differential diagnosis: Osteomalacia, Osteoarthritis, Fibromayalgia.
Hyperthermia:
The elderly are at an increased risk for heat related illness because they have a
decreased ability to maintain a steady body temperature. It is considered to be life
192
threatening. The mortality rate is very high, and immediate emergency treatment is
needed. Several factors contribute to an older person to develop heat related
illnesses.
• Lack of air conditioning in the room
• Decreased sensitivity to changes in the temperature.
• The ability to sweat decreases with age.
• Presence of chronic diseases such as CHF, diabetes and alcoholism.
• Medications: such as anti-cholinergics, beta-blockers, anti-histaminics and
diuretics.
Clinical presentation: The two most common heat related illness are seen in the
elderly i.e, heat exhaustion and hyperthermia.
Effects on
Heat exhaustion
Hyperthermia
Skin:
Cool,
diaphoresis
clammy,
Temperature:
Slightly
normal
Pulse:
Weak and thready
Bounding
Respiration:
Shallow
Dyspneic
Thirst:
Not so common
More common
General:
Weakness,
dizziness,
feeling faint Anorexia,
nausea, vomiting
Fainting possibly the first sign
Change in behavior, confusion or
coma.
elevated
or
Hot, dry, no diaphoresis.
High i.e. - >104 degree F
Investigations:
•
•
•
•
•
Body temperature >104 degree F
Thyroid functions test
Hemoconcentration
Metabolic acidosis, azotemia.
ECG, HR, X-ray chest
Hypoglycemia: It is a chemical state associated with low or relatively low
plasma glucose concentration (<50 mg/dl). It is associated with signs and symptoms
of autonomic activity and neuroglycopenia.
Causes of hypoglycemia: The primary cause of hypoglycemia is iatrogenic i.e.drug induced, like insulin or sullphonylureas.
Secondary causes:
9. Hormone: hypopituitarism, catecholamine, glucagons
deficiency.
10. Enzyme defect: glucose 6 phosphatase, liver
phosphorylase etc.
11. Malnutrition: poor nutritional intake.
12. Drug induced: Aspirin, propranolol etc.
13. Change in the mental status.
14. Impaired hepatic and renal functions.
Clinical presentation:
• Due to autonomic hyperactivity: palpitation, sweating, anxiety, tremor,
193
nausea, hunger.
• Due to neuro-glycopenia: headache, fatigue, dizziness, confusion, amnesia,
seizure, coma, death.
• The risk of hyperglycemia is greater in the cognitively impaired elderly
persons.
Differential diagnosis: Hyperglycemia and neurological disorders.
Treatment: In conscious patients during attacks glucose or sugar containing liquid
may be given. If a patient is unable to take oral glucose, 50 ml of 50% glucose is
given via i.v. route and the patient is encouraged to take frequently small feeds and
glucose.
Drugs:
• Glucogan: 1-2 mg i.m., but it is expensive for routine use.
• Glucocorticoids: 100 mg of hydrocortisone hemisuccinate or 4 mg of
dexamethasone.
• Adrenaline: 0.5 ml of 1:1000 adrenaline is given s.c.. It stimulates hepatic
gluconeogenesis.
• Mannitol and frusemide are used to induce diuresis to reduce cerebral edema.
Hormonal and metabolic assays:
Hormonal
metabolic
investigations
and Normal values
Insulin fasting
In serum 6 to 26 µIu/ ml
In hypoglycemia it is < 5 µIu/ ml
Thyroid stimulating hormone
(TSH):
Triiodothyronine T3:
Thyroxine- T4:
In serum 0.4 to 5µU/ ml
In serum- 70- 190 mg/dl
FreeT4 in the serum- 0.8- 2.4µg/dl
total 4.5- 11.5 µg/dl
Parathyroid hormone (PTH):
10 to 60pg/ml vary with serum calcium.
Testosterone:
Total plasma bound
Adult male- 30 to 100 mg/dl,
Adult female- 25to 90 mg/dl
Adenocorticotropic hormone
(ACTH):
Serum 15 to 70 pg/dl
Catecholamines (free):
In urine- 110 µg/ 24 hours
Cortisol:
In serum: 5 to 25 µg/dl
In urine- 10 to 50 µg/ 24 hours
Aldosterone:
In serum- 210 mEq/day
In urine- 5 to 19 µg/ 24 hours
Glucogon:
In plasma- 50 to 100 pg/dl
Growth hormone:
After 100 gm oral glucose: In serum- <2ng/dl
Calciferol( Vit.D):
D2- 25 to 45 pg/dl
D1 - 15 to 80 ng/dl in summer
D1- 14 to 42 ng/dl in winter
194
Serum electrolyte:
Na- 136 to 146 mEq/l
K- 3.5 to 4.5 mEq/l
Cl- 98 to 110 mEq/l
Ca- 8.4 to 10.2 mg/dl
Phosphorus- 3 to 5.5 mg/dl
Mg- 1.7 to 2.6 mg/dl
Actual plasma bicarbonate – 22 to 26 m mole.
Lipid profile:
Total cholesterol- 140 to 220 mg/dl
HDL cholesterol
in male: 35- 55 mg
in female: 45 – 65 mg/dl
TG
40 to 160 mg/dl
FFAs
8 – 25 mg/dl
Phospholipids
in male- 125 to 275 mg/dl
in female- 35 to 135 mg
Serum proteins:
Total protein: 6.3 to 7.9 g/dl
Albumin- 3.5 to 5.3 g/dl
Globulin- 1.8 to 3.6 g/dl
The limitations of conventional drugs and place of Ayurvedic management of
endocrine and metabolic disorders:
1. Problem with conventional drugs: Drug resistance, drug intolerance,
hypersensitivity, side effects, and formation of antagonists during the treatment of
metabolic and endocrine disorders.
2. Ayurvedic drugs: Most of the Ayurvedic drugs used as a medicine act in terms
of nutrition dynamics than drugs dynamics. Ayurvedic drugs are soft medications
and are more near to food. The action is proportionate to the Pañcabhautika
composition which in turn is responsible for Rasa, GuÆa, VÍrya, VipÁka and
PrabhÁva of the respective drugs. Depending upon the above factors a drug affords
to produce its effect on DoÒa; VÁta, Pitta and Kapha. Ayurvedic drugs not only
have property to subside or cure the endocrine and metabolic disorders but also have
RasÁyana, ojovardhaka, JÍvanÍya and Balya properties. By virtue of these properties
Ayurvedic drugs alone or in combination with modern medicine, have capacity to
reduce the conventional drugs requirement, prevent or delay the long term
complications, and maintain over all health in the elderly. Large number of DÍpana
and PÁcana remedies and Agni/ Ojas promotive measures have potential to help the
management of endocrine malfunctions. Ingredients like- ÏuÆÔhÍ, PippalÍ, TrikaÔu,
Pañcakola and LavaÆa are most frequently used for the management of endocrine
and metabolic disorders.
Diagnostic criteria, Investigation, treatment and Referral criteria of
Endocrine and Metabolic disorders in the elderly
LEVEL- I: AT GERIATRIC CLINIC
Clinical diagnosis and Investigation of common Endocrine and Metabolic
disorder:
195
Disorder + Clinical diagnosis
Investigation
Diabetes mellitus: Clinically the patients
may or my not have the classical triad of
symptoms
i.e. polyphagia, polyurea, and polydepsia.
This increase the possibilities that it
remain undiagnosed for many years.
Besides this elderly diabetetic have some
additional symptoms, viz- dehydration,
confusion, incontinence, weight loss,
fatigue and other associated
complications.
Random plasma glucose
8 hours fasting plasma glucose
2 hours plasma glucose on OGTT
Glycosylated hemoglobin %
Urine routine examination for
sugar, and ketone bodies
Other investigations TLC, DLC, ESR, Hb, etc.
Hypothyroidism: In elderly the diagnosis
of hypothyroidism is challenging in
comparison to younger people. The
common symptoms in the elderly areconstipation, dry skin, hoarse voice,
muscle aches, pain and tenderness in
joints, unsteady gait, depression and
lethargyness; mainly present in these
patients.
Thyroid function testsTSH, T4, & T3.
Anti TPO antibody
Lipid profile- Cholesterol, TG,
LDL, HDL, VLDL
X ray chest, ECG, HR, GBP etc.
Hyperthyroidism: Clinically the elder
person may not show the classical
symptoms of increased appetite, increased
heart rate, exophthalmia and muscle
weakness. In the elderly the important
symptoms are- Aterial fibrillation, CHF,
weight loss and fatigue. Besides this the
elderly persons are also more likely to be
apathetic and depressed.
Thyroid function testTSH, T4, & T3.
Fluid and electrolyte
X ray chest, ECG, HR,
GBP etc
Hyperparathyroidism/
Hypercalcaemia: It is characterized by
bone pain, pathological fracture, general
weakness, muscle wasting and muscle
weakness, deafness, polyurea, nocturia,
polydepsia, nausea, constipation etc.
Serum PTH level
Serum Uric acid
Serum Calcium level,
Bone density
24 hours urine Calcium &
Phosphorus
X-ray & CT scan for Neck and
mediastinum.
Hypoparathyroidism: It is very less
common in elder age group. Neuromuscular irritability is the only symptoms
that draw attention to the presence of
hypoparathyroidism. Some times few
Serum PTH level
Serum calcium level
Serum phosphorus
Vit-D concentration in serum
Please see the detail aspect of diagnostic criteria,
investigations and treatment plane, which is separately
mentioned in the manual of diabetes mellitus in the
elderly
196
patients presents with vague and atypical
cramps.
Hyperlipidemia: Clinically it is
associated with insulin resistance
syndrome, obesity, and hypothyroidism. It
is important risk factors for coronary
heart disease.
Lipid profile- total cholesterol, TG,
LDL, VLDL, HDL.
Blood sugar
ECG
X-ray chest.
Hyperthermia: It is also known as heat
stroke. It is considered to be a life
threatening in the elderly. The common
sign/symptoms of hyperthermia are- hot
and dry skin, no diaphoresis, increased
body temperature, breathlessness,
fainting, metabolic acidosis, azotemia,
confusion, delirium and lastly coma.
Body temperature >104 degree F
Thyroid functions test
Hemoconcentration
Ketone bodies
ECG,
HR,
X-ray chest.
Hypothermia: The elderly are at a
greater risk for hypothermia than adult.
The early features are- fatigue, weakness,
slurred speech, slow gait, confusion, cold
skin , apathy and shivering may or may
not be occurs in the elderly.
Body temperature <96 degree F
Hemoconcentration-leucocytosis
Urine for protein
blood urea
PR,BP
Serum calcium & serum electrolyte
Thyroid functions test.
Osteoporosis: It is most common
problem in elder age group, mostly seen
in female after menopause. The early
features are – bony pain,
muscular weakness, wasting of muscle,
general weakness, irritability, fatigue,
fracture etc.
Thyroid function test.
Parathyroid function test.
Serum calcium, bone density.
Serum alkaline phosphatase.
Bone X-rays and bone biopsy.
Treatment of common Endocrine and Metabolic disorders in the elderly:
Goals of therapy
•
•
•
•
•
•
•
: to eliminate symptoms related to particular endocrine gland.
: to prevent and treat acute complications of endocrine glands.
: to eliminate/reduce the complications of respective endocrine disorders .
: to maintain the desirable body weight.
: to achieve normal life style.
: to attain utility towards family and society.
: to educate for successful long term management.
Ayurvedic approach:
In Ayurvedic system of medicine: Sa¿Ðodhana and Sa¿Ðamana are the important
therapeutic measures described in the classics of Ayurveda. Sa¿Ðodhana i.e. - biopacificatory therapy is designed for elimination of MalÁs, which is responsible for
pathogenesis of respective diseases. This process not only improves the function of
deranged Agnis, DoÒas and body channels i.e.- Srota¿si, but also improves the over
197
all health of the patient. During procedure it need close monitoring of vital functions
and strength of the patients, especially in old age. It is especially indicated in the
management of Diabetes mellitus, Obesity & hyperlipidemia, and disorders of GI
tract. Ïamana therapy is mainly targeted to the site of particular disease, by
pacifying the deranged DoÒa, Mala, and DÚÒya. The Ïamana therapies for certain
diseases are given below.
Diabetes mellitus- It is well correlated to the Madhumeha of Ayurveda. The
common drugs which are prescribed in its management are-- NiÐÁ, ÀmalakÍ, ÏilÁjatu,
PippalÍ, Gu±ÚcÍ, Nimaba KÁrvellaka, Udumbara, MethikÁ,, MÁmajjaka, Bilva,
BasantakusamÁkara rasa, PramehÁntaka rasa, ÏivÁ guÔikÁ, TrivaÉga bhasma and
many neo-herbal/ herbo-mineral formulations.
Hypothyroidism- The common thyroid disorders described in ayurveda is
GalagaƱ. It is caused by deranged function of VÁta & Kapha doÒa and Meda
dÚÒya. Pittaja galagaƱ is not described in the classics, because GalagaƱ never
under goes inflammation and suppuration. As per DoÒic predominance the VÁtaja
type of GalagaƱ is comparable to hyperthyroidism and Kaphaja and Medaja
GalagaƱ to hypothyroidism in conventional system of medicine. Though in
conventional system of medicine in thyroid disorders the inflammatory mechanism
is involved and it represents the clinical feature too. Such thyroid disorders can be
managed by decoction of KÁñcanÁra, PippalÍ cÚrna, KÁñcanÁra guggulu,
AmrityÁdya taila, JalakumbhÍ pañcÁÉga antradhuma bhasma, AÐvagandhÁ cÚrÆa,
PravÁla bhasma ÀrogyavardhanÍ vati etc,. Beside this, neck exercise and Yogic
practices are also recommended.
Hyperthyroidism- This disease occurs due to hyperactivity of Pitta System and is
correlated with TÍkÒÉÁgni and Bhasmaka roga. Regarding its management ÏÍta,
Guru, Picchila, SnigdhaÀhÁra is indicated. The common drugs used for its
management are- PravÁla piÒÔÍ, Samirapannaga rasa, KÁñcanÁra guggulu,
TéÉapaÉcamÚla kvÁtha, and Medhya RasÁyana drugs etc.
Obesity& Hyperlipidemia- It is an important disease from the treatment point of
view, because Caraka proclaims that due to presence of therapeutic variant, it is not
easy to cure like emaciated and malnourished patients. Hence therapeutic measures
like Sa¿Ðodhana and Sa¿Ðana were used with caution in these patients. The
common drugs used for its management are- TriphalÁ guggulu, Medohara guggulu,
Rajata bhasma, ÀmalakÍ rasÁyana, PippalÍ rasÁyana, Pañacakola cÚrÆa, etc.
Hypothermia- UÒÆopacÁra-UÒÆa snÁna, AvagÁha and PariÒeka. The drugs for its
management are- AgarÚ, Tagara, KastÚrÍbhairava rasa. etc.
Hyperthermia-ÏÍtopacÁra-ÏÍtala snÁna AvagÁha and PariÒeka. Drugs likeCanadanÁdi vati, PravÁla piÒÔÍ , MukÁ piÒÔÍ TéÆapañcamÚla kÁtha etc are useful.
Conventional Approach:
Diabetes mellitus:
Regarding treatment plan please refer to the chapter on diabetes mellitus in the
elderly in this manual.
Hypothyroidism:
1. Primary hypothyroidism: It is managed by replacing thyroid hormone for life
long period with Levothyroxine sodium. The average starting dose of
Levothyroxine for elderly patients is in the range of 12.5- 50 µg/day, which
198
is approximately one third to one half the usual dose of young adult. The
drug should be preferably ingested on empty stomach. Its absorption is
hampered by antacids. In elders with known CVD, it is best to start with
12.5µg/day to avoid unwanted effect on cardiovascular status. Its monitoring
is done on the basis of TSH level.
2. Secondary hypothyroidism: The replacement is similar to the treatment of
primary hypothyroidism, but other hormonal replacement i.e. Cortisol; may
be required to manage it.
3. Sub-clinical hypothyroidism: The decision to treat with Levothyroxin should
be individualized.
4. Preparations like JalakumbhÍ PancÁÉga in the form of VaÔÍ CÚrÆa, Bhasma,
SanjÍvanÍ VaÔÍ AÐvagandhÁ cÚrÆa, DaÐamÚlaghana VaÔÍetc are commonly
used in Ayurvedic practice.
Hyperthyroidism:
The management of hyperthyroidism differs depending upon the etiology of the
disease and the severity of the symptoms. The treatment option is Propylthiouracil or
methimazole.
• Anti-thyroid medication should be individualized and try to start with the
lowest effective dose to reduce side effect such as rashes, thrombocytopenia
and anemia.
• Radioactive iodine: It destroys the thyroid gland and stops excess production
of thyroid hormone. In ongoing treatment monitoring is important.
• Surgery: It is rarely indicated to remove thyroid gland in elderly patients.
• Preparations of JalakumbhÍ, KÁñcanÁra, Guggulu, MuktÁ PiÒÔÍ etc are
commonly used in Ayurvedic practice.
Hyperparathyroidism associated hypercalcaemia:
Its management depends upon the degree of hyperparathyroidism and urgency of
situation.
• Reduce intestinal calcium absorption: Reduce calcium intake in diet and use
Oral inorganic phosphate- 0.5-3.5 gm/day.
• First line therapy: Maintain hydration with isotonic saline as per need i.v. every
2 hour and Glucocorticoids 200- 300 µg/day.
• In acute cases: Bisphosphonate in the dose of 7.5 mg/kg body weight in 4 hours
is very effective therapy, if patient is not responding to it, try Mithramycin 25
µg/kg via i.v route.
• In life threatening situation: Calcitonin 100 U/day should be given with close
monitoring of PTH and serum calcium level.
Hypoparathyroidism: The management of hypoparathyroidism is life long with
close monitoring of PTH. The main aim of treatment is to normalize the serum
calcium and phosphorus level.
• Calcium supplement: Calcium gluconate or calcium carbonate in the dose of
1 – 3 gm in divided doses is very effective. It is usually given with meals and
with Vit.-D preparation to ensure its better absorption. Natural organic
calcium preparations of PravÁla in the form of PravÁla Bhasma, PravÁla
PiÒÔÍ, PravÁla PañcÁméta can be used.
• Vitamin D3 (Calcitriol): It is given in the dose of 0.5- 3 µg/day, when
serum PTH level is markedly reduced.
• Skeletal deformity: It requires surgical intervention.
199
Hyperlipidemia: In general treatment for high cholesterol and TG there is a need
of multiple approach and it is closely monitored by the physician. Ayurvedic
formulations of Guggulu, VacÁ and PuÒkaramÚla are popularly used in the
Ayurvedic practice. Dietary control and regulated exercise ie. PathyÁpathya and
VyÁyÁma, are the sheet anchors in the management of hyperlipidemia and its related
disorders.
Preventive measure:
o Maintain a healthy weight by reducing calories in diet.
o Reduce the amount of saturated fat and cholesterol in the diet.
o Aerobic exercise- jogging, running, etc.
o Yogic practices and asana in supervision of Yoga expert.
o Life style modification and change in eating habits.
o Stop smoking – because it reduces the HDL level and increases the tendency
to clot blood.
o Alcohol should be used in moderation, if possible try to avoid it.
Pharmacological measure: In available drugs Statins are the best to achieve the
Goals. Other medications used to lower cholesterol and Tg levels are –
Nicotinic acid- lowers TG, LDL and raises HDL cholesterol.
Clofibrate- raises the HDL level and lowers TG level.
Gemfibrozil- raises HDL cholesterol level.
Resins: Cholestyramine, Colestipol - to promote increased disposal of
cholesterol from GIT.
Preparations of Guggulu, VacÁ, ÏallakÍ and PuÒkaramÚla are commonly used
in Ayurvedic Practice.
Hypothermia: Education of the elder and their family are crucial in the prevention
and cure of mild i.e. - body temperature >93.2 degree F, to moderate i.e. – body
temperature 86- 93.2 degree f, hypothermia. It includes• Maintain room temperature 65 degree F or more.
• Dress in numerous loose layers.
• Limit exposure to the cold.
• Eat well because a layer of fat reduces heat loss.
• Cover the elderly person during a bath and dry completely afterward.
• Encourage exercise to help the person by generating heat.
• KastÚrÍ, Makaradhvaja, and other Ojovardhaka remedies are
popularly used in Ayurvedic practice .
Severe hypothermia: It is considered as a medical emergency and commonly
associated with cardiac arrest.
5. At this point invasive re-warming techniques are necessary, it includes Peritoneal lavage with warmed fluid.
Esophageal re-warming tubes.
Cardiopulmonary bypass and extracorporeal circulation.
1. If the patient is in cardiac arrest basic cardiac life support needs to be initiated.
Lastly prolonged CPR and aggressive re-warming techniques are necessary.
Hyperthermia: It is a medical emergency and the treatment is generally
performed by emergency personnel or in the hospital. The primary goal is to lower
the core temperature. During management one most important thing to do
immediately is to check and protect the airways, after that rapidly lowering the body
200
temperature is important. But it is not > 102 degree F within the first hour of
treatment. If temperature is lowered to quickly, it will cause shivering and the
temperature will not decrease.
Cooling the patient: it can be done by following techniques:
• Hypothermic blanket.
• Wrapping the patient in wet, ice filled towels.
•
Ice water emersion.
National institute of aging gives following recommendations for the management of
hyperthermia.
Drink plenty of fluids, avoid caffeine and alcohol.
Try to minimize the temperature at home.
Social services may be able to provide resources for the elderly to obtain an air
conditioner.
Elderly person does not exercise when he is hot.
Teach patients and families the early signs and symptoms of heat related illness.
There is rich scope of using Ayurvedic coolants and DÁha PraÐamana remedies in
these cases viz- Candana, UÐÍra, IkÒu, MuktÁ etc.
Osteoporosis: The treatment of patients with osteoporosis involves management
of acute fracture as well as treatment of underlying disease. The principles of
management as below.
• Reduced risk factors of osteoporosis.
• Reduced risk of falling in old age.
• Nutritional recommendation-Calcium 1 gm to 1.2 gms/ day, Vit- D- 400 IU
between 50 to 70 years, 600 IU more than 70 years of age.
1. Vit- K and Magnesium is also required.
2. Promote exercise and fracture cases referred to Orthopedic surgeon.
3. Use formulations of PravÁla, Ïankha, Ïukti, VarÁÔikÁ, Kaparda, MuktÁ etc
for long term.
Referral criteria:
* Those that are not responding therapeutic measures
*
*
*
*
*
*
Those that have adverse consequences of therapeutic measures.
In cases of target organ damage.
Presence of acuteness of diseases.
In adverse consequences of diseases itself.
At least one a year for a detail assessment of the target organ involvement.
Patients with severe infection, marked weight loss & breathlessness.
LEVEL 2: AT REGIONAL GERIATRIC CENTER
Clinical diagnosis: Same as level 1 + fresh cases of endocrine and metabolic
disorders reported directly. Evaluate the risk factors and complications of metabolic
and endocrine disorders.
Risk factors for metabolic and endocrine disorders in the elderly:
Age ≥ 65 years.
Overweight i.e. - body mass index ≥25kg/m2
Gradual loss of weight.
Habitual physical inactivity
Member of high risk ethnic population
Hypertensive (≥140/90 mm of Hg)
HDL cholesterol ≤ 35mg/dl or triglyceride ≥250 mg/dl
201
Polycystic ovarian syndrome
Carcinoma of testes and ovary
Associated with other coexisting disease.
Receiving prolonged corticosteroids.
Prolonged use of other medications, like- Amiodarone, Aspirin, Propranolol,
Lithium Compound, Iodine, and Hormones.
Investigation: Same as Level 1 + fresh cases of endocrine and metabolic disorders
reported directly.
There is need of repeated investigations, if endocrine and metabolic disorders are not
under control or it may persist with associated complications.
Treatment: Same as Level 1 + management of complications of endocrine and
metabolic disorders such as- Hyperosmolar non-ketotic coma, Hypoglycemia,
Myxoedema coma,Thyroid storm etc.
Referral criteria:
Same as Level 1 +
13. In dose titration for ongoing 3-4 drugs regimen.
14. No response to the emergency treatment.
15. If there is a need of educator, behavioral
specialist, foot specialist, endocrinologist,
cardiologist, etc.
16. The patients who has complications of
endocrine disorders.
17. In cognitive impairment.
LEVEL 3: AT ADVANCED/SPECIALIZED GERIATRIC CENTER
Clinical diagnosis: Same as level 1 and 2+ complicated cases referred from level 1
or 2+ also assess the severity of endocrine and metabolic diseases and its associated
complications.
Investigation: Same as level 1 and 2 + fresh cases of endocrine and metabolic
disorders reported directly.
Treatment: Same as Level 1 and 2 + additionally to modify the medications, if
endocrine and metabolic disorders are not under controlled and it may be associated
with complications. If the target response of treatment is not achieved and
complications may also persist, now asses it again and refer it to the specialist, likeendocrinologist, cardiologist, nephrologists, neurologist etc for the assessment of
severity of disease, their proper care and management.
Common Ayurvedic Recipes:
A. hypo-functioning of Agni and Endocrine system:
•
•
•
•
•
•
PippalÍVardhamÁna RasayÁna.
CouÉÒaÔha PraharÍ PippalÍ 500 mg TDS with honey.
AgnituÆÕÍVaÔÍ- 1 TDS.
KravyÁda Rasa- 250 mg BD.
PippalyÁsava- 20 ml BD after meal with equal quantity of water.
CitrakÁdÍ VaÔÍ 2 pills twice a day for chewing 10 minutes before meals.
B. Hyper-functioning of Agni and endocrine system:
•
•
•
•
ÀmalakÍ RasÁyana.
BrÁhmÍ VaÔÍ.
PravÁla PiÒÔÍ.
SÁrasvatÁriÒÔa.
202
•
•
ÏaÉkhapuÒpÍ Svarasa.
GuÕÚcÍ Svarasa.
Recommended Further Reading
1. Brown AF, Mangione CM, Saliba D, et al. California Healthcare
Foundation/American Geriatrics Society Panel on Improving Care
for Elders with Diabetes. Guidlines for improving the care of Older
person with diabetes mellitus. J Am Geriatr Soc. 2003; 51(5 Suppl
Guidelines):S265–S280.
2. Dwarkanatha C. Digestion and metabolism in Ayurveda, 1986. Sri
Baidyanath Ayurveda Bhawan Pvt. Ltd. Calcutta.
3. The American association of clinical endocrinologists medical
guidelines for clinical practice for the Management of diabetes
mellitus. Endocrine practice 2007: 13 (Suppl 1):1-66.
4. Ebersole P, Hess P. Geriatric nursing and Healthy Aging. St.Louis:
Mosby, 2001.
5. Hogstel MO, Zembruski CD,et al: Gerontology: Nursing: Care of
the old Adult. Albany NY: Delmar, 2001.
6. Pandey A.K. and Singh R.H.: A Study of the Immune status in
patients of diabetes mellitus and their management with certain
Naimittika RasÁyana drugs. JRAS. Vol XXIV. No. 3-4. 2003:4861.
7. Reports on Physical activity and health. JAMA 1996; 276: 522
8. Sharma PV. Classical uses of medicinal plants, 1986:
Chaukhambha Publications, Varanasi.
9. Singh R.H. Kayachikitsa Vol. I and II, 1985. Chaukhambha
Surabharati Prakasan. Varanasi.
10. Singh R.H. The holistic principles of Ayurvedic Medicine, 1998.
Chaukhambha Publications, Varanasi.
11. Wyne KL, Drexler AJ, Miller JL et al. Typr II Diabetes
management. A postgraduate medicine special report. Posgrad
Med.2003; 5: 63-72.
203
Chapter-13
Diabetes mellitus vis-a-vis Madhumeha in the Elderly
General introduction:
Diabetes mellitus is one of the oldest disease recognized since antiquity. It has been
accepted by medical historians that diabetes mellitus was first known to Indians
since pre-historic periods. But its actual cause is still unknown. The first recognized
written text of human civilization, i.e., èg Veda (1500BC) contains hymns which
include description of various medical conditions including diabetes. In classical
texts of Ayurveda diabetes mellitus is mentioned as a sub types of Prameha,
MÚtrÁtipravétaja VikÁra and complication of Prameha. Caraka has described
Prameha as AnuÒaÉgÍ VyÁdhi. As per Cakrapanidutta AnuÒaÉgÍ means PunarbhÁvÍ
i.e. the disease which is very difficult to cure. Now it is possible to classify the
diabetics into primary and secondary types as well as Insulin dependent and Non
Insulin dependent types. It is amazing that 7 century B.C. Ayurvedic texts like
Caraka and SuÐruta Sa¿hitÁ have been described high caloric diet and sedentary
habit as an important causative factors of Apathyanittaja Prameha and
genetic/hereditary factors described as Sahaja Pramrha.1 ,2 Beside these causative
factors, diabetics are again divided in two groups in terms of the constitution and
body weight viz-1. KéÐa PramehÍ- thin diabetics and 2. SthÚla PramehÍ- obese
diabetics. These two types of diabetics have been described to be treated on two
different lines of management. This insight of Ayurveda is comparable to the latest
modern development in this field. Thus the information available in the classics of
Ayurveda show that diabetes mellitus vis a vis Madhumeha as a disease was well
known to the propounders of Ayurveda. Its etiological factors, pathogenesis,
classification, clinical symptoms, complications as well as treatment modalities,
appear well comparable to the latest knowledge of conventional medicine. It is a
multi-factorial metabolic disorder in men and women, all over the world. It is the
most common endocrine disorder, caused by absolute lack of insulin or a relative
lack of insulin that is insufficient to overcome insulin resistance. Its manifestations
include hyperglycemia, other metabolic derangements, and long term damage to
blood vessels, eyes, nerves, kidney, and the heart. It is a leading cause of cardiac
death, nonfatal MI, heart failure and stroke. It is also the most common cause of
adult blindness, end stage renal disease, non-traumatic leg amputation and
neuropathy.
Prevalence of diabetes mellitus:
The recent years have shown a significantly rising trend in the incidence of this
disease all over the world. India has not remained an exception and one finds that the
incidence of diabetes mellitus is rising with an alarming rate. Approximately 150
1
ÀsyÁsukha¿ svapnasukha¿ dadhÍni grÁmyaodakÁnÚparasÁ½ payÁñsi I.
NavÁnnapÁna¿
gu±avaikéta¿
ca
prameha
hetu½
kaphakécca
( C.S.Ci.- 6/4)
2
Daopramehobhavataí sahajaoapathyanimittaÐca I.
( S.S.Ci.-11/3)
204
sarvam
II.
million of people world wide have diabetes; its number is projected by WHO to be
double by the year 2025. Its incidence has been estimated to be around 15% of Indian
population. The data published by the International Diabetes federation in the year
2006 the number of people with Type II diabetes in India is around 30.9 million and
this is expected to rise to 69.9 million by 2025. WHO also has projected India as the
leading country in the world, as per diabetic concern. It is an epidemic in many
developing and newly industrialized nations. It is certain to be one of the most
challenging health problems in the 21st century.
The prevalence of diabetes mellitus in the elderly:
Diabetes mellitus and its complications are the important health care problems in the
elderly. WHO has projected in developed nations 11% of the population as diabetics
over the age of 65 years, this will be increased up to 20% by the turn of the century.
In India as per 1981 census 3.8% of the population is above the age of 65 years. This
is projected to reach 18% by mid of 21st century. Epidemiological studies have
revealed a progressive increase in the prevalence of diabetes mellitus in the elderly.
Several factors are responsible for this trend, among them area. The long lasting disease due to improved therapeutic remedies (Laaksonen et
al, 2005).
b. The increased life span expectancy (Wilson et al, 1986, Stolle et al, 1997).
Diabetes mellitus is appearing to be one of the most important factors to enhance
aging process. It has been estimated that 13% of the adult older than 70 years have
diabetes and 11% of the elderly between 60-74 years remain undiagnosed. The
prevalence of diabetes in the elderly varies from 10- 38% with respect to the year of
the study, the ethnic groups and also in the applied diagnostic criteria. The average
life span in India has increased over the years; due to general, social, economical and
medical improvement. Now in India the prevalence of diabetes increases with age,
at present 2 million elderly diabetics have been reported in India.
How the elderly diabetics differ from adult population:
Most of the elderly patients of diabetes mellitus have NIDDM. The pathogenesis of
NIDDM in elderly age group differs due to increased process of aging in the beta
cells of pancreas. This can be triggered by variety of exogenous and endogenous
toxins. In spite of these etiological factors, the pathological process of diabetes
mellitus is similar to the other age groups. Thus the over all impact of etiological
factors and pathological process will cause diminished insulin secretion in relation to
the patient’s need. Insulin resistance is the major factors in the pathogenesis of
diabetes melliltus. There are other age related factors like shift to sedentary life style,
increased adiposity, coexistent medical illness and concomitant use of multiple
glucose tolerant drugs that may also contribute to the hyperglycemia. Elderly
diabetics differ from adult population in various ways, such as:
•
Disease presentation is atypical in the elderly.
•
Because of decreased physiological reserve (homeostenosis) in the
elderly.
•
Because many diseases are common in elderly than younger patients,
viz Bacteriuria, low bone mineral density, premature ventricular
contraction etc.
•
Because symptoms of disease in the elderly people are often due to
multiple causes, hence the diagnosis differs from younger ones.
205
•
•
Because the older patient is more likely to suffer the adverse
consequences of disease and their treatment.
Because older patients require only optimal treatment.
Clinical Presentation of diabetes mellitus in the elderly:
Hyperglycemia in the elderly may be a part of spectrum of age related changes in
carbohydrate tolerance, which ranges from mild insulin resistance to full blown
diabetes mellitus. Among all types of diabetes NIDDM is most common form of
diabetes in the elderly population, because of age related changes in the secretion and
action of insulin. Beside faulty dietary habit, physical and mental inactivity may lead
to the development of diabetes mellitus in genetically susceptible individuals in the
elderly. Hyperglycemia in the elderly may present in one of the following three
categories.1. Diabetes detected in the middle age live through to become elderly diabetic.
2. Diabetic detected for the first time in the geriatric age group.
3. Impaired glucose tolerance developing diabetes mellitus de novo in the elderly.
SamprÁpti GhaÔaka ( Pathological component) in diabetes mellitus vis a
vis Madhumeha
•
DoÒa-
TridoÒa (specially Kapha DoÒa).
•
DÚÒya-
Rasa, Rakta, MÁ¿sa, Meda, Kleda, MajjÁ, Oja, Ïukra, Jala
(specially Meda).
•
Status of AgniJÁÔharÁgni Véddhi due to increased function of SamÁna
VÁyu,
this
happens
due
to
SrotÁvarodha.
Functions of DhÁtvÁgnis and BhÚtÁgnis (specially Medoagni)
are also deranged in diabetes.
•
Site of Àma formation- At the level of JÁÔharÁgni, DhÁtvÁgnis and BhÚtÁgnis.
•
Involvement of SrotasaSrotasa.
•
SrotoduÒÔi –
Atipravétti and SaÉga.
•
AdhiÒÔhÁna-
Vasti ie- urinary system.
•
PratyÁtma LakÒaÆa-
PrabhÚtÁvilamÚtratÁ.
•
SaÉcÁrasthÁna-
SarvÁÉga ÏarÍra via RasÁyanÍ.
•
Roga MÁrga-
ÀbhyÁntara.
•
VyÁdhi SvabhÁva-
CirakÁrÍ.
Specially Rasavaha, Medovaha and MÚtravaha
206
•
SádhyÁsÁdhyatÁ•
•
•
Kaphaja-SÁdhya
Pittaja-YÁpya
VÁtaja-AsÁdhya
Table 1. Classification of diabetes mellitus in the elderly
Classification of diabetes mellitus is similar to that in other age groups.
I- In conventional medicine:
a). Type I diabetes (IDDM):It accounts for 5-10% of all cases. More
common in early age group.
B. Immune mediated
C. Idiopathic
b). Type II (NIDDM): It accounts for 90-95% of all cases. More common in
middle and older age group.
• Insulin resistance
• Insufficient insulin production from pancreatic beta cells
The genetic predispositions along with behavioral and environmental risk
factors are responsible for development of insulin resistance and diabetes.
c). Other specific types:
• genetic defect of beta cell function or insulin action
• drug or chemical induced
• disease of the exocrine pancreas
• endocrinopathies
• viral infections
• genetic syndromes sometimes associated with diabetes
like- Down’s syndrome, Turner’s syndrome etc
d). Gestational diabetes mellitus (GDM):
It is defined as glucose intolerance that is first identified during pregnancy.
II- In Ayurveda:
1. Etiological- two types
“Dao pramehau bhavataí- Sahajoapathyanimittasca” (Su. Ci. 11/3)
a). Sahaja prameha:(patients of Type I)
- MÁtépitébÍjadoÒakéta, i.e. defects in• BÍja- sperm/ ovum
• BÍjabhÁga- chromosome
• BÍjabhÁgÁvayava- genes
b). Apathyanimittaja prameha:(patients of Type II)
It is caused by• faulty dietary habit
• sedentary life style
• lack of physical exercise
• psychological factors: worry, grief, anger, anxiety etc.
2. Constitutional-2:
SthÚla (obese) pramehÍ: patients of NIDDM.
207
KéÐa (lean) pramehÍ: patients of IDDM.
3. DoÒic-3:Urinary Abnormalities.
3. Kaphaja-10 types
4. Pittaja-6 types
5. VÁtaja-4 types
4. Prognostic-3:
• SÁdhya: curable
• YÁpya: palliative
• AsÁdhya: untreatable
Table 2. Differentiating features of Type I and Type II diabetes
Type I diabetes
Type II diabetes
Incidence
5-10%
90-95%
Primary defect
Autoimmune
or
idiopathic Genetic, environmental
resulting in
destruction of beta cells; insulin factors
insulin resistance with a
deficiency is usually absolute.
combined
insulin
secretary defect; insulin
deficiency is relative
Presentation
Acute onset of symptoms
May present with keto-acidosis
Age at presentation is <20 years
Most of the patients are not obese.
Subtle
symptoms
unnoticed for years.
Presentation associated
with complications
Keto-acidosis is rare, it
may occur in severe
illness.
Age at presentation is
>45
years.
Most of the patients are
obese.
Family history
No
Present
Body built
Lean and thin
Obese
Sex ratio
M: F – 1:1
F>M, In India M>F
Genetic link
Link with class II MHC antigens
No link with class II
MHC antigens
Insulin
requirement
Low to moderate
Low, moderate to high
Causes of death
Nephropathy,
Hypoglycemia
CHD,
208
Ketosis, Nephropathy,
Gangrene
Stroke,
Table 3. Pathological changes associated with NIDDM in the elderly
Glucose intolerance:
λ Impaired fasting plasma glucose- 100- 125 mg/ dl
µ Impaired oral glucose tolerance – 140-199 mg/dl
Dyslipidemia:
• Triglyceride >150 mg/dl
• HDL cholesterol <40 mg/dl in men and < 50 mg/dl in female
• Increase small, dense, atherogenic LDL and ApoB particles
• Postprandial elevation of triglyceride rich lipoproteins
Endothelial dysfunction:
• increased mononuclear cell adhesion
• elevated plasma concentration of cellular adhesion molecules
• impaired endothelial dependent vasodilatation
Hemodynamic changes:
• Augmented sympathetic nervous system activity
• Renal sodium retention
• Elevated blood pressure
Prothrombotic factors:
• Increased plasminogen activator inhibitor-I
• Increased fibrinogen
Inflammation:
• Increased C- reactive proteins, WBC, Uric acid etc.
The clinical presentation of diabetes in elderly:
Clinical presentation of diabetes mellitus in the elderly is notably different than the
adults. It presents in the following ways1. Some patients have atypical presentation- i.e. –
Fatigue, pruritus vulvae, incontinence of urine and stool along with weight
loss.
2. Some patients have classical presentation with other common symptoms- i.e.Polyuria , polydipsia, polyphagia, joint pain, blindness, dizziness, banalitis etc.
• Some patients have serious complications- i.e. Hyperosmolar-ketotic coma,
diabetic
Keto-acidosis, hyperglycemia, hypoglycemia.
• Some patients may be detected with coexisting diseases, like- Cataract,
Glaucoma, PVD, CVD, CVA, Nephropathy, neuropathic pain and ulceration.
Prakéti: In Ayurveda seven types of DoÒa Prakéti and three types of MÁnas Prakéti
have been described to determine the total personality make up of an individual
Prakéti is genetically predetermined and represents the sum total of the physique,
physiology and psyche. Thus in Ayurveda the Prakéti is an important consideration
in the understanding of human life, health, disease susceptibility, preventive and
promotive of health care as well as treatment requirement of patients. In Ayurveda
aging of an individual is a progressive process of decline of physiological functions
of an organ or system. This happens due to predominance of DoÒa and dietary
pattern in their respective age group i.e. - Kapha in early age group, Pitta in middle
age group and VÁta in older age group. That is why propounders of Ayurveda have
mentioned RasÁyana remedies to prevent the process of aging and to cure the
209
diseases in respective age group. Prakªti plays an important role in progression,
prognosis and treatment of a disease. In general equality in Prakéti, DoÒa, and
DÚÒya infers bad prognosis, means not easy to cure but Diabetes mellitus vis a vis
Madhumeha is an exception to this general rule. Diabetes mellitus is a Kapha doÒa
and KaphavargÍya dÚÒya (Rasa, MÁ¿sa, Meda, MajjÁ, Ïukra etc, especially Meda)
dominating disease, their progression, prognosis and treatment in relation to Prakéti
is given in following table.
Table-4:
Prakéti
Progression
Prognosis
Slowly progressive
Good
Treatment
Due
to
large
availability of drugs.
Medium progressive Medium
Due
to
medium
Pitta prakéti
availability of drugs.
Highly progressive
Bad
Due
to
minimal
VÁta prakéti
availability of drugs.
In aging process VÁta is a dominant DoÒa in the elderly, it again appears to enhance
the pathological changes, consequences and their effect in the body to the elderly
diabetics of related Prakéti. It is mostly observed in VÁta Prakéti related elderly
diabetics. Hence in Ayurveda role of Prakéti is not only important to know the effect
on pathological process, consequences, and effect, but also to know the therapeutic
intervention in a particular disease.
Kapha prakéti
Screening for diabetes mellitus in Asymptomatic individuals:
Testing for diabetes should be considered in all individuals at the age of ≥45 years. If
it is normal, it should be repeated at 3 year intervals. Testing should be carried out
more frequently in individuals, who—
are obese ( > 120%desirable body weight or BMI ≥27 kg/mt2)
have a first degree relative with diabetes.
are a member of a high risk ethnic population.
habitually physically inactive.
history of gestational diabetes.
are hypertensive (≥140/90 mm of Hg)
have HDL cholesterol level < 35 mg/dl and/ or triglyceride level ≥ 250
mg/dl.
on previous testing has IGT or FPG.
History of vascular disease.
Diagnostic criteria, investigation, treatment and referral criteria of
diabetes mellitus
LEVEL-I: AT GERIATRIC CLINIC
Diagnostic criteria of diabetes mellitus: It is similar to general diagnostic
criteria of diabetes mellitus. It is broadly divided into two categories• Clinical diagnosis: It is mainly based on the classical symptoms of diabetes
along with complications and other coexisting diseases. They are- Polyuria,
polydepsia, polyphagia, joint pain, impotency, incontinence of urine, fatigue,
banalities, blurred vision, cardiac pain, neuropathy, nephropathy, ulceration,
dementia, cognitive impairment etc. Besides this, history taking, general and
210
systemic examination should be carried out to look for target organ
involvement and to rule out other causes of diabetes mellitus. It may also be
diagnosed during screening for some other disorder.
B. Laboratory diagnosis: The American Diabetes Association requires the presence
of one of the following criteria for the diagnosis of diabetes (ADA-2006)
Diabetes is diagnosed by measuring blood glucose levels.
It is diagnosed by three ways and each must be confirmed on subsequent day. They
are Classical symptoms of diabetes + casual glucose concentration ≥ 200
mg/dl.
Fasting plasma glucose (FPG) ≥ 126 mg/dl.
2- hour plasma glucose (PPG) ≥ 200 mg/dl during on OGTT
*The fasting plasma glucose test is preferred because of administration convenience,
acceptability to the patients and lower cast. Fasting is defined as no caloric intake for
at least 8 hours.
*2-hour plasma glucose test requires the use of a glucose load containing 75 gm
glucose in water followed by plasma glucose measurement 2 hours later.
* Casual plasma glucose test should be performed any time of the day without regard
to last meal.
Table 5.
Casual plasma
2-hour
Category
Fasting
Glucose in mg/dl
plasma
plasma
in
Glucose
in Glucose
mg/dl
mg/dl
Normoglycemia
<100
<140
IFG/IGT
100-125
140-199
Diabetic range
≥126
≥200
>200 + classical
Symptoms
of
diabetes
IFG- impaired fasting glucose
OGTT- oral glucose tolerance test.
IGT- - impaired glucose tolerance PPG- post prandial glucose.
Glycosylated hemoglobin (HbA1c) test: It is an important glycemic parameter to
assess the severity of disease in clinical practice. By this test plasma glucose can also
be calculated. The expected values of HbA1c % is given in table 6.
Table 6:
Category
Expected values in %
Non diabetic
4.5- <7
Good control
7- <9
Fair control
9-<10
Poor control
≥10
< 1% rise in the HbA1c= 1.7mmole/l (30mg/dl) increase in the mean glucose load>
Other laboratory tests in elderly diabetics: In symptomatic individuals following
laboratory tests are routinely performed to assess the therapeutic response and other
associated complications, viz4. Blood for - TLC, DLC, ESR, Hb%.
5. Urine for – glucose, protein, ketone bodies and microscopic
examination for
presence of pus cells.
6. Blood sugar- fasting and PP.
211
7. Glycosylated Hb- ( HbA1c, it is <7% in normal individuals) for
assessing the degree
of glycemic control & monitoring treatment.
8. Blood urea , Serum creatinine, Lipid profile, Serum cholesterol, CRP,
NCV etc .
Evaluation of Type II diabetes in the elderly: Each diabetic patient can be
evaluated by4. Eating pattern, nutritional status and body weight history.
5. Symptoms related to diabetes mellitus.
6. Laboratory tests and investigations related to diabetes mellitus.
7. Frequency, severity and causes of acute complications.
8. Symptoms and treatment of complications.
9. Prior or current infections.
10. Other medications that may affect blood glucose levels.
11. Risk factors for atherosclerosis.
12. History and treatment of other conditions, including endocrine and eating
disorders.
13. Family history of diabetes and other endocrine disorders.
14. Life style, cultural, psychological and educational factors that influence the
management.
15. Tobacco, alcohol and controlled substance use
Goals of therapy: to achieve normoglycemia and HbA1c at lowest possible
level.
: to eliminate symptoms related to hyperglycemia.
: to prevent and treat acute complications.
: to eliminate/reduce the long term micro and macro vascular
complications.
: to maintain the desirable body weight.
: to achieve normal life style.
: to attain utility towards family and society.
: to educate for successful long term management.
The plan of management in the elderly diabetics:
The optimal management requires a coordinated team approach aimed at intensive
glycemic control, improving insulin sensitivity, treatment of dyslipidemia and
hypertension, management of diabetes related complications and patient education.
Ayurvedic Approach:
The bio-purificatory(Pañcakarma) measures, i.e.Vamana, Virecana, ÀsthÁpana
Vasti, AnuvÁsana Vasti and Ïirovirecana are contraindicated to some extent in the
elderly diabetics. The treatments of Diabetic mellitus vis-à-vis Madhumeha as
mentioned in Ayurvedic classics can be broadly divided into four groups NidÁna parivarjana- Avoidance of etiological factors, i.e.-faulty lifestyle, faulty
dietary habit, mental stress, day sleep and awakening in night.
ÀhÁra- Diet is an important regimen for the control of diabetes mellitus. It is an
important measure for the obese diabetics. Role of diet in controlling diabetes
continues important as it was thousands of years ago.KaÔu, Tikta, KaÒÁya Rasa,
UÒÆa, Laghu, RÚkÒa properties of food are prescribed in diabetes.
VihÁra- The role of exercise has been emphasized by AcÁrya SuÐruta in the
212
1.
2.
3.
4.
management of poor and rich diabetic patients. Recent evidences show that
exercise, meditative Àsanas & life style management not only improve
hyperglycemia but are also believed to improve the pancreatic and liver
functions.
AuÒadha/ Ayurvedic formulations- In Ayurvedic classics a number of herbal and
herbo-mineral drugs are advocated for the treatment of Prameha in general.
Drugs having KaÔu (pungent), Tikta (bitter) and KaÒÁya (astringent) Rasa are
indicated in all types of Prameha, i.e. diabetes.
• Herbal drugs:viz-VijayasÁra, NiÐÁ, ÀmalakÍ, MÁmajjaka, JambÚ,
Bilvapatra, Tejapatra, Nimba, KÁrvellaka, PippalÍ. GuÕÚcÍ,Khadira,
Kramuka, BhÚmyÁmalakÍ, etc
• Mineral drugs: viz-ÏilÁjatu, SvarÆamÁkÒika, ÏivÁguÔikaÁ, TrivaÉga
Bhasma, Naga Bhasma etc.
• Herbo-mineral preparation:
Classical: BasantkusamÁkara rasa, PramehÁntaka vaÔÍ,
CandraprabhÁ VaÔÍ etc.
Neo-formulations. Hayponid, Amaree plus granules and tablet, Diabecon etc.
Yoga therapy: under care of a trained Yoga therapist.
Geriatric Pañcakarma: viz- AbhyaÉga, Svedana, PiÆÕasveda, KÁyÁseka and
ÏirodhÁrÁ under supervision of a trained Pañcakarma therapist.
Commonly used Naimittika Rasayana drugs in diabetes mellitus
Fig-1.
Fig-II
Fig-1. Amalaki:Embelica officinalis,Family-Euphorbiaceae.
Source: www.nutritionalsupplementsbyde.com
Fig-II. Haridra: Curcuma longa, Family- Gingiberaceae
Source: www.bikudo.co
Fig-III. Mamjjaka:Enicostema littorale. Famil - Gentianaceae,
Source: infomedicinalplant.blogspot.com
Conventional Approach:
Fig-III
The elderly diabetics have varied co- morbid conditions and broad differences in
functional status. Drug interactions are common in this age group and life
expectancy varies. Hence the ultimate goal is not only to achieve the laboratory
norms, but also to improve the quality of life. The cornerstone of the treatment in the
elderly diabetics is similar to the other age groups, which consist of- Diet – Individualized
213
- Diet + exercise
- Diet + exercise +oral hypoglycemic drugs
- Diet + Insulin- (subcutaneous injection).
The problem with conventional drugs and place of Ayurvedic drugs in the
management of elderly diabetics:
No doubt modern medicine may have found a way to bring the cases of diabetes
mellitus under control to some extent, yet the effort can not be considered as final.
Even though majority of the patients remain well for certain period with the current
therapeutic measures, the underside, however must not the lost sight. It is because of
danger of complications such as-drug resistance, hypersensitivity and antagonist
formation with insulin, drug intolerance, fear of hypo and hyperglycemic episode
with Sulphonylureas. This seeks great attention from the present day practitioners
and researchers to evaluate the present status of this chronic health hazard and to
evolve newer strategies in their management.
In this regard Ayurvedic drugs not only have Pramehaghna ie.- anti-diabetic
property but also have RasÁyana effect i.e. improve nutritional pool, Ojovardhaka
effect i.e. immuno enhancer, JívanÍya effect i.e. longevity enhancer and Balya effect
i.e. vitalizer. By virtue of these properties Ayurvedic drugs alone or in combination
with modern medicine, have capacity to reduce the insulin as well as oral
hypoglycemic drug requirement, prevent or delay the long term complications, and
maintain over all health in elderly diabetics.
Positive effect of exercise in Type II diabetes:
All the patients should be encouraged to perform aerobic activity 30-45 minutes on
most of the days of the week. The positive effect of exercise are many; among them
are decrease in blood glucose concentration, enhanced insulin sensitivity, decrease in
glycosylated Hb, improved mild to moderate hypertension, reduced triglyceride
concentrations, increased HDL level, increased energy expenditure and improved
lean body mass, improved cardiovascular fitness, enhanced physical strength, sense
of well being and enhanced quality of life.
General instruction to the elderly diabetics during exercise.
• Check blood glucose levels before and after exercise.│
• Carry some sort acting sugar to treat hypoglycemic episodes.
• Drink extra sugar free liquid before, during and after exercise.
• Keep a diabetic information card in the pocket.
• To make a phone call in case of an emergency.
• Stop exercise if pain develops in legs or chest and notify to the physician.
• Inspect feet for cuts, blisters, callouses before and after exercise.
• Stop exercise in case of acute medical or surgical illness.
• Too elderly patients should never go for exercise without supports.
• Brisk walking and vigorous exercise is generally avoided,
General guidelines for diet in diabetics: Dietary measures are required in the
treatment of all diabetic patients to achieve the over all therapeutic goal.
214
Table 7. Dietary recommendation
Food composition
Carbohydrate
carbohydrates.
Protein
Fat
Fruits
Fibers
Common salt
of
Recommendation
-
-
15-25% of total calories. Avoid cattle meat and eggs.
25- 35% of total calories. Total fat intake in the form of
cholesterol is <200mg/day.
fresh fruits up to 400g/day. Avoid juices.
30-40gm/day preferably from natural sources.
up to 6-8g/day. Reduce intake of to 4g/day in presence
hypertension, renal failure and cardiac problems.
included in diet plan, they provides antioxidants, trace
element, minerals etc.
try to avoid it and use SÔeviÁ, MadhuyaÒÔhÍ as natural
Condiments & spices Artificial sweeteners
sweetener.
Alcohol
Tobacco
40-50% of total calories. To encourage complex
-
if possible, it is totally avoided.
avoid its use in any form.
Dosing schedule, indication and preparation of Insulins:
In general the individual with type I diabetes requires 0.5-1.0 U/kg per day of insulin
divided into multiple doses. Insulin therapy is also required in patients of NIDDM
associated with complications, grossly under weight. Initial dosing schedule should
be conservative; approximately 40-50% of the insulin should be given as basal
insulin. A single daily injection of insulin is not appropriate therapy in type I
diabetes, the commonly used regimen consists of twice daily s.c. injection of an
intermediate acting (NPH or Lente) mixed with short acting insulin before the
morning and evening meal. Such regimens usually prescribe 2/3 of the total dose in
morning and one 1/3 before the evening meal. The following are the insulin
preparations that can be started at level 2 & 3 and continued/monitored at level 1.
• Rapid acting insulin: The rapid acting insulins preparations are regular insulin,
insulin lispro and insulin aspart. Regular insulin can be administered by
subcutaneous and intravenous route in diabetes related emergencies.
• Intermediate acting insulin: The intermediate acting insulin are NPH and Lente
insulin these get absorbed slowly and the total duration of action is 12 to 16 hrs.
• Long acting insulin: The long acting insulin is basal insulin. The two insulins
available are insulin Glargine and insulin Detremir. Their total duration of
action is for 24 hrs.
• Premixed insulin therapy: rapid acting insulin such as plain insulin is mixed
with NPH insulin in a concentration of (30/70) or (50/50). These can be used in
patients who are unable to mix insulin.
• Insulin delivery: The insulin is delivered in the subcutaneous space by using
insulin syringes or insulin pens. The sites for injection are the anterior
abdominal wall, thigh, buttocks and arms.
215
Treatment algorithm:
New patients of diabetes mellitus
Patients of IDDM
NIDDM
↓
Diet + Insulin
Exercise
Patients of
↓
Diet
↓
Controlled
Uncontrolled
+
↓
↓
↓
↓
Mild diabetics +
no complications
Severe, underweight diabetics
+complications
↓
↓
(with pregnancy, infections,
surgery)
Grossly obese
Well nourished
↓
↓
↓
Biguanides
Sulphonylureas
Insulin is the drug of
choice
↓
↓
↓
↓
↓
Controlled
Uncontrolled
Controlled
Controlled
↓
Add/ substitute other oral hypoglycemic drugs
│
Controlled ← → Uncontrolled → Switch over to insulin
Oral hypoglycemic drugs:
The drugs available for treatment of Type II diabetes are many and the choice of
OHD is extremely complex. It depends upon the physician's judgment about the best
combination of drugs for the patients of diabetes.
**Oral hypoglycemic drugs are usually initiated when dietary modification and
exercise fails to achieve euglycemia and HbA1c in patients of Type II diabetes
mellitus.
** In the elderly diabetics oral hypoglycemic drugs should be started at minimal
doses, because of low physiological reserve and increased process of aging. Thus the
dose of any hypoglycemic drug is gradually increased till the satisfactory control is
attained.
*Tolbutamide and Glipizide are relatively safe in the elderly diabetics.
216
Table 8. List of oral hypoglycemic drugs used for Type II diabetes in the elderly:
Drug class
Sulphonyl
ureas:
Chlorprop
amide
Tolbutami
de*
Glimeprid
e
Glipizide*
Glyburide
Glybaride
Glitinides
Repaglinid
e
Nateglinid
e
Biguanide
s
Metformin
Daily
doses
Duraton of
action
in hrs
100500 mg
500mg3gm
1-8 mg
2.5-40
mg
1.25-20
mg
0.75-12
mg
>48
6-12
24
12- 18
12- 24
12- 24
4 mg
120 mg
2- 6
500mg1gm
5
Specific
advantages
Side
effect
Contraindicati
ons
Lower
fasting
blood
glucose
Hypogly
cemia
Hyperins
ulini-mia
In Renal and
Liver disease
In the elderly
Hypogly
cemia
Weight
gain
Adverse
GI
effects,
lactic
acidosis,
anemia
Liver disease
Lower post
prandial
blood
glucose
Improved
lipid profile,
no
hypoglycem
ia
In old age(≥80
years)
Renal,
CHF,
liver
disease
metabolic
acidosis
ΑlphaRenal and liver
Flatulenc
Target pp
glucosidas
e,
GI disease
glycemia,
25e
discomfo
rare
100mg
inhibitors
rt
hypoglycem
25Acarbose
ia
100mg
miglitol
No hypoEdema,
Thiozolidi
glycemia,
2-8mg
Renal disease
weight
ne-diones
glycemic
15Rosiglitaz
and CHF
gain,
45mg
one
anemia,
durability,
pioglitazin
osteopor
↓insulin
e
osis.
resistance
Referral criteria:
• In uncontrolled diabetic patients.
• In acute complications.
• In long term micro and macro-vascular complications.
• In cases of target organ damage.
• In adverse consequences of Sulphonylureas and Insulin.
• At least one a year for a detailed assessment of the target organ involvement.
• Patients with severe infection, marked weight loss & breathlessness.
217
LEVEL 2: AT REGIONAL GERIATRIC CENTER
Clinical diagnosis: Same as level 1 + reporting fresh cases directly.
Evaluate the risk factors for NIDDM as per given table and also look for
complications of diabetes mellitus.
Risk factors for NIDDM in the elderly diabetics:
*
*
*
*
*
*
*
*
*
*
*
*
*
Age ≥45 years
Overweight i.e. - body mass index ≥25kg/m2
First degree relative with diabetes
Habitual physical inactivity
Member of high risk ethnic population
Impaired fasting glucose or impaired glucose tolerance
History of gestational diabetes
Hypertensive (≥140/90 mm of Hg)
HDL cholesterol ≤ 35mg/dl or triglyceride ≥250 mg/dl
History of vascular disease
Polycystic ovarian syndrome
Associated with other coexisting disease.
Receiving prolonged corticosteroids.
Complications of Type II diabetes in the elderly:
Hyperglycemia in the elderly is an important health care problem; even milder
degree of glucose intolerance enhances the morbidity risk in older individuals.
Acute complications:
• Diabetic ketoacidosis
• Hyperosmolar coma
• Hypoglycemia
Chronic complications:
Micro-vascular
16. Retinopathy- 25% in elderly diabetics
17. Neuropathy- proximal motor neuropathy
- Autonomic neuropathy
18. Nephropathy
Macro-vascular
•
•
•
•
Peripheral arterial disease
Diabetic foot syndrome
Cerebro-vascular disease
Coronary heart disease
218
Fig-I
Fig-II
Diabetic foot gangrene
Source: www.erc.montana.edu
Stages
of
Retinopathy
Fig-III
diabetic
Stages of diabetic Retinopathy
Source :www.faculty.washington.edu
Source: www.netheryeye.com
Others complications: Decreased resistance to infections
Skin changes
Poor wound healing
Cataracts, glaucoma
Infertility, depression, dementia etc.
Investigation: Same as Level 1 + reporting fresh cases directly
There is need of repeated investigations, if diabetes is not under control or it may
persist with associated complications.
Treatment: Same as Level 1 +
Screening, prevention
complications:
and
treatment
guidelines
for
diabetic
Complicatio Screening
n
Prevention/Treatment
Cardiovascu
lar disease
* Screen annually for
cardiac
risk factors.
* Exercise stress test
for high
risk individuals.
* Ankle/ brachial
index.
•
Use Antiplatelet, ACEI, or ARB,
Statin.
•
Control cardiac risk factors.
•
Re-vascularization of high grade
arterial stenosis.
•
Referral to cardiologist for chest
pain,
uncontrolled BP etc.
Retinopathy
Annual
ophthalmoscopic
examination - dilated
pupil
Nephropathy Screen
•
•
for •
219
Tight control of glycemia/BP
Laser photocoagulation for
nonproliferative retinopathy,
proliferative retinopathy, macular
edema.
Tight contro of glycemia/BP ACEI
microalbuminuria.
and
blood urea, serum
creatinine.
•
to
Neuropathy
Annual foot
NCV Test.
exam.
Foot ulcers
* Self exam. for foot
trauma.
* Annual foot
examination.
Infections
* Complete blood •
count
•
* Blood for culture •
and
sensitivity test.
•
•
•
or ARB.
Possible protein restriction Referral
nephrologist for GFR < 60 cc/min
Tight control of glycemia
Foot care instruction
Specific measures based on
peripheral/autonomic neuropathy.
Well fitted shoes, callus
debrdement,
Proper foot/nail care.
Antibiotics –local as well systemic
·
Revascularization of high grade
arterial
Use suitable antibiotic
Hepatitis vaccinations
Infuenza/pneumococcal vaccines
*ACEI- angiotensin converting enzyme inhibitor, ARB- angiotensin receptor
blocker,
NCV- nerve conduction velocity, BP- blood pressure, GFR- glmerular filtration rate
Referral criteria: Same as Level 1.
• In dose titration for ongoing 3-4 drugs regimen.
• No response to the emergency treatment.
• If there is a need of diabetes educator,
behavioral specialist, foot specialist,
• The patients who have complications of
diabetes.
• In cognitive impairments.
LEVEL 3: AT ADVANCED/SPECIALIZED GERIATRIC CENTER
Clinical diagnosis: Same as level 1 + reporting fresh cases directly.
Complicated case referred from level 1 & 2
Diagnostic criteria: Same as level 1 & 2.
Investigation: Same as level 1 & 2 + reporting fresh cases directly.
Treatment: Same as Level 1& 2 + additionally to modify the medications, if
diabetes is not under control and it may be associated with micro and macro-vascular
complications, increased oxidative stress due to irreversible glycosylation in
diabetics, which in turn leads to decreased nitric oxide levels, endothelial
dysfunction and further tissue damage. This process may leads to an increased
frequency of macro vascular and micro vascular complications. In addition, to
increased levels of aldose reductase activity in the nerves and lens of the eye, can
accumulate excess sorbitol, resulting in neuropathy and cataracts respectively.
Treatment target for elderly diabetics is given below.
220
Category
Glycemic control
HbA1c%
Fasting glucose
Post prandial glucose
Blood pressure
( mm of Hg)
Lipids ( mg/dl)
LDL
Triglycerides
HDL
Normal
American diabetic
association target
<6.o
<100
<140
<120/80
<7.0
90-130
<180
<130/80
Varies
<150
>40 mg/dl
<100
<150
>40 mg/dl
The guidelines for ongoing medical care in the elderly diabetics;
- Self monitoring of blood glucose.
4. HbA1c testing -2-4 times per year by an endocrinologist.
5. Patient education in diabetes management (annual).
6. Medical nutrition therapy and education ( annual).
7. Eye examination annual by an eye specialist.
8. Foot examination (1-2 times per year by physician, daily by patients).
9. Screening for diabetic nephropathy (annual).
10. Blood pressure measurement (regular).
11. Lipid profile (annual).
If the target response of treatment is not achieved and complications may also
persist, now assess it and refer to respective specialists, like- endocrinologist,
cardiologist, nephrologist, neurologist etc for the assessment of severity of disease,
and management strategies.
Ayurvedic management of diabetes mellitus vis a vis Madhumeha in
the elderly :
Therapeutically diabetic patients have been categorized into two groups depending
upon the physical strength and involvement of DoÒa and DÚÒya.1
•
SantarpaÆa measures: In KéÐa MadhumehÍ i.e.- lean and thin diabetics.
In VÁtaja MadhumehÍ i.e.- patients of type-I diabetes.
In VÁtaja MadhumehÍ associated with complications
•
ApatarpaÆa measures: In Kaphaja and Pittaja MadhumehÍ i.e- patients of
type-II diabetes.
Patients of type-II diabetes associated with complications.
Beside these measures, Caraka has been advocated pacificatory measures such as
decoctive preparations, powder of barley (Yava), and quantitative as well as
qualitative light diet in the management of diabetic patients who are not suitable to
Sa¿Ðodhana measures 2. The over all management of diabetes mellitus vis a vis
1
SthÚla½ pramehÍ balavÁnihaika½ kªÐastathaika½ paridurbalaÐca I.
Sa¿béaÉhaÆa¿
tatrakéÐasya
kÁrya¿
sa¿Ðodhana¿
(C.S.Ci.-6/15)
2
Sa¿Ðodhana¿ nÁrhati ya½ pramehÍ tasya kriya sa¿ÐamanÍ prayojyÁ I.
221
doÒabalÁdhikasya
II.
Madhumeha as mentioned in Ayurvedic classics can broadly be divided into three
categories.
I. Diet1:
The role of diet in the management of diabetes mellitus has same importance as it
was thousands years back. Dieting is an important measures for the obese diabetics
and a special dietary regimen is to be planned to lean and thin diabetics during
management.
The food which is enriched with alcohol, milk, oil, ghee, flour, syrup, and meat of
the animals which are residing in water or near water should be avoided ( S.S.Chi;
11: 5).
Foods like Yava (barley), bitter, pungent, and astringent vegetables, meat of animals
residing in hot climate and pulses/cereals like-ÏyÁmaka. Kodrava, UddÁlaka,
GodhÚma, and Kulattha are to be taken by all patients of diabetes mellitus
(ÏoÕhala K.C. KhaÆÕa; 30: 41-42).
II- Exercise:
The role exercise has been described in detail in the classics of Ayurveda for the
management of diabetes mellitus in poor and rich diabetics.
• For poor patients- there is indication of light exercise and earn his living by
begging.
• For rich patient – there is indication of heavy exercise and earn his living by
begging.
III- Drugs:
Biopurificatory measures i.e. Pañcakarma, should be avoided in the elderly
diabetics.
In the classics of Ayurveda a number of herbal, minerals and herbo-minerals drugs
are advocated for the treatment of diabetes mellitus. But in general the drugs having
property antagonistic to DoÒa and DÚÒya like- KaÔu, Tikta, and KaÒÁya Rasa, and
having Ojovardhaka and RasÁyana property are to be used in diabetic patients.
In the Ayurvedic classics various preparations have been advocated for the treatment
of diabetes mellitus. On the basis of physical strength of the patient and strength of
disease following drugs are commonly prescribed as a single drug or in
combinations or with compound drugs in Ayurvedic practice.
Single drugs preparations:
•
•
•
•
•
•
•
•
ÀmalakÍ CÚrÆa- 8 gms in two divided doses.
HaridrÁ CÚrÆa- 8 gms in two divided doses.
MÁmajjaka CÚrÆa- 6 gms in two divided doses.
Ïuddha Silajita- 1 gm in two divided doses
VijayasÁra CÚrÆa- 4-6 gms in two divided doses.
KÁrvellaka Svarasa- 20-40 ml in two divided doses.
JambÚbÍja CÚrÆa- 6-12 gms in two divided doses.
Gu±ÚcÍ Svarasa- 10 to 20 twice a day.
Compound drug preparations:
ManthÁ½ kaÒÁyÁ yavacÚrÆa lehÁ½ pramehaÐÁntye laghavaÐca bhakÒyÁ½ II.
C.S.Ci.-6/18)
1
SaÒaÒÔika¿ syÁttéÆadhÁnyamanna¿ yavapradhÁnastu bhavet pramehÍ I.
Yavasya bhakÒyÁn vividhÁÉstathÁadyÁt kaphapramehÍ madhusa¿prayuktÁn II
(C.S.Ci.-6/21)
222
(
• BasantakusamÁkara rasa- 250 mg in two divided doses.
• PramehÁÉtaka VaÔÍ- 500 mg in two divided doses.
• CandraprabhÁ VaÔÍ-1 gm in two divided doses.
• TrivaÉga Bhasma- 500 mg in two divided doses.
• MadhÚkÁsava- 40 ml in two divided doses with equal quantity of water.
• In case of diabetic neuropathy:
AÐvagandhÁ CÚrÆa/Tab- 6 gms/4 Tab in two divided doses.
DaÐamÚlÁdi Taila and PrasÁraÆÍTaila – for local application.
• Diabetes associated with cardiac problems:
-PuÒkarabrÁhmÍ Guggulu Tab- 2 BD.
-Arjuna CÚrÆa 2 gms as a KÒÍrapÁka twice in a day.
-Preparations of MuktÁ and PravÁla -500 mg twice in a day.
• Diabetes associated with renal problems:
-PunarnavÁ Svarasa- 40 ml in two divided doses.
-PunarnavÁÒÔaka KvÁtha- 20 ml twice in a day.
-CandraprabhÁvaÔÍ- 250 mg twice in a day.
• Diabetes associated with retinopathy:
-SaptÁméta lauha- 500 mg twice in a day.
-TriphalÁ Ghéta as Netra TarpaÆÁrtha as well as orally in the dose of 2 gms/day.
Recommended Further Reading
1. American diabetic association: Treatment target for diabetes. Diabetes care
20007; 30 (Suppl. I): S 4- S41,
2. American diabetic association: Criteria for the diagnosis of diabetes
mellitus.Diabetes care 2007;30(Suppl.I):S42- S47.
3. American diabetic association: Standards of medical care in diabetes.
Diabetes care 2007; 30(Suppl.I): S 4- S41.
4. American Diabetes Association. Standards of medical care in diabetes.
Diabetes Care. 2004;27 (Suppl 1):S15–S35.
5. Anti-diabetic therapy for type II diabetes. JAMA 2002; 286: 360- 382.
6. Blaum CS. Management of diabetes mellitus in older adults: are national
guidelines appropriate? J Am Geriatr Soc. 2002; 50:581–583.
7. Brown AF, Mangione CM, Saliba D, et al. California Healthcare
Foundation/American Geriatrics Society Panel on Improving Care for Elders
with Diabetes. Guidlines for improving the care of the Older person with
diabetes mellitus. J Am Geriatr Soc. 2003; 51(5 Suppl Guidelines):S265–
S280
8. Circulation 2002; 106: 3145-31421.
9. Lancet 2002; 360:2-3, BMJ 2003; 326:1419-24910. Long term glycemic controle related to mortality in type II diabetes. Diabetes
Care 1995; 18:1534-1543.
11. Pandey A.K. Study of Immune status in patients of diabetes mellitus and the
role of Pañcakarma and Naimittika rasÁyana. MD (Ay.) 2002, thesis under
Prof. R.H. Singh, Kayachikitsa, IMS, BHU, Varanasi.
12. Singh R.H. Ayurvediya Nidana Cikitsa ke Siddhanta,Vol.Iand II,(1985).
Chaukhambha Amarbharti Prakasan. Varanasi.
223
13. Singh R.H.(2005): Kayachikitsa Vol. II Section 6. Chaukhabha Surbharti
Prakashana, Varanasi.
14. Singh R.H. Panchakarma therapy: 2nd Ed (2002); Chaukhambha Sanskrit
Sereis office, Varanasi.
15. Singh R.H. The holistic principles of Ayurvedic Medicine, 1998.
Chaukhambha Publications, Varanasi.
16. Pandey A.K. and Singh R.H.: A Study of the Immune status in patients of
diabetes mellitus and their Management with certain Naimittika RasÁyana
drugs. JRAS. Vol XXIV. No. 3-4. 2003; 48-61.
224
Chapter-14
Respiratory Diseases in the Elderly
Introduction:
Respiratory diseases result in great morbidity and mortality in the elderly people.
The burden of major respiratory diseases is increasing in this age group. It is an
important problem of old age after musculo- skeletal disorders. At least 80% of all
hospital admissions among the elderly in developed countries belong to respiratory
problems. In addition to the burden of respiratory problems in this age group, the
atypical and non specific presentation of respiratory disorders are common in this
age group. The sensitivity and specificity of physical signs may be diminished with
the advancement of age. There is an age related reduction in cardiovascular response
to hypoxia together with an age related impairment of subjective appreciation of
broncho-constriction and breathlessness. The cardiovascular physiological response
is altered due to sedentary life style, psychological stress, social stress, and variety
of disabilities in the elderly, resulting decline in exercise capacity. Hence the
respiratory and cardiovascular disorders influence each other.
The ancient Ayurvedic texts have given vivid description of the etio- pathogenesis,
clinical presentation and management of allergy and respiratory disorders. As per
Ayurvedic texts the common respiratory disorders are KÁsa- infective, non infective
and autoimmune bronchitis and pneumonia,ÏvÁsa-asthma/COPD, emphysema and
bronchiectasis, PratiÐyÁya- recurrent common cold and sinusitis, RÁjayakÒmÁpulmonary tuberculosis etc; which result due to derangement of PrÁÆavaha srotasa
by variety of exogenous as well as endogenous etiological factors.
Anatomical and physiological considerations in the elderly:
Anatomical changes in the elderly lung: The major anatomical change found in
the aging lung is the smaller size of airways; this is due to alteration in the
supporting connective tissues.
Increase in the diameter of alveolar ducts with reduced morphology of alveolar sacs
occurs due to changes in the relative proportions of decreased elastic tissues and
increased collagen in the normal process of aging. The thoracic cage compliance
decreases due to age associated kypho-scoliosis, calcification of inter costal
cartilages and arthritis of casto-vertebral joints. Weakness of respiratory muscles due
to age associated muscle atrophy is obvious.
Physiological changes in the elderly lung: The following physiological changes
occur in the lung with the advancing of age:
1. Decrease in the elastic recoil of lung.
2. Decrease in pulmonary compliance.
3. Decrease in oxygen diffusion capacity.
4. Premature airway closure leads to mismatch ventricular perfusion and
increased alveolar arterial oxygen gradients.
5. Air trapping due to small airway closure.
6. Decreased expiratory flow rates.
225
Senile Respiratory morbidities:
Senile structural and functional changes produce predictable changes in the
pulmonary function tests in the elderly patients. There is a progressive decrease in
the vital capacity in the elderly due to increased stiffness of the chest wall, loss of
elastic recoil of lung, decreased force generated by the respiratory muscles. Because
of this mechanism the residual respiratory volume also increased, so that the total
lung capacity remains constant. The functional residual capacity (FRC) is also
increases with age. Burr et al in 1985 showed that there is a progressive decline in
the FEV1 and FVC with age. This has been estimated that FEV1 decreases in non
smokers by 30 mL/ year in men and 23 mL/ year in women, and the rate of decline
is even greater after 65 years. Enright et al in the year1994 showed that maximal
inspiratory and expiratory pressure decreases with age, the age related changes are
greater in men than women. In general healthy elderly individual the diaphragm
strength is reduced by 25% in comparison to young adults.
Pulmonary function test & Lung volume in healthy Adult and in the Elderly
Pulmonary physiology
Values by Spirometry
Man aged 40
Women aged 40
Elderly
changes
FVC1
in men
4.8 L
3.3 L
↓20
in women
FEV12
in men
3.8 L
2.8 L
Lung volume
TLC3
old age
FRC4
age
Residual volume
1
2
3
4
76%
4.8 L
9.4 L/s
6.4 L
2.2 L
1.5 L
. FVC- forced vital capacity
. FEV1- forced expiratory volume in 1 second
.TLC- total lung capacity
. FRC- functional residual capacity
226
77%
3.6 L
6.1 L
4.9 L
2.6 L
1.2 L
mL/yr
↓30 mL/yr
↓23
in women
FEV1/FVC
Maxim. mid expiratory flow
Maxim. expiratory flow rate
↓22 mL/ yr
mL/yr
↓ with age
Constant in
↓ in old
↑ in old age
Inspiratory capacity
age
Expiratoy reserve volume
Vital capacity
4.8 L
3.2 L
1.7 L
3.7 L
2.3 L
1.4 L
↑ in old
↑ in old age
↓ in old age
Gas exchange function is also altered in the elderly due to change in the pulmonary
function and architecture of the chest wall. Various studies have shown that PaO2,
both at rest and in exercise gradually declines with age. Ventilation during exercise
in the elderly is associated with more abdominal contribution than in adult and a
concomitant change in the respiratory pattern. The ventilation response to hypoxia
or hypercapnea are diminished in the elderly, due to reduced peripheral chemosensitivity, reduced neural support to respiratory muscles and lowered mechanical
efficiency. Due to these functional changes and depressed immune response in the
elderly, the etiological factors easily hamper the respiratory system that may lead to
variety of upper and lower respiratory tract disorders.
Epidemiology of common respiratory diseases in the elderly:
Bronchial asthma:
The prevalence of bronchial asthma is more common in the elderly. Now it is
increasing further due to the increased number of elderly population in developed as
well as developing countries. More than 20 million cases of asthma are noted in
developed countries in old age group and 4000 people die each year due to asthma
Chronic obstructive pulmonary disease (COPD):
It is a leading cause of breathing disability, 5th over all leading cause of death in the
elderly in developed & developing countries. It is most common respiratory problem
in geriatric age group. 80 to 90% cases of COPD are caused by smoking.
Pulmonary tuberculosis:
Epidemiologically the rates for active cases of tuberculosis are greater in the elderly
than young adults, despite the PPD test decreases with increase of age. Case rates
are higher in nursing home population than in the community. The mortality rates
are 10 times higher in the elderly than young and middle age. Annually 8 to 10
million new cases of tuberculosis have been reported by WHO.
Pneumonia:
It is the 4th over all leading infectious cause of death in the elderly. Half of the cases
of pneumonia were reported in person more than 65 years of age.
Bronchiectasis:
Prevalence of bronchiectasis has declined with availability of broad spectrum
antibiotics. This disease is fairly common in developing countries, India is one of
them. In the elderly poor nutrition, impaired defense mechanism and diminished
cilliary function favors the pathogenesis of bronchiectasis.
Lung cancer:
Lung cancer is the leading cause of cancer related death, both men and women in the
world. It is principally a disease of the elderly and prevalent in 7- 8th decade due to
long exposures to tobacco and carcinogens.
Interstitial lung fibrosis:
It is the common form of interstitial lung disease of unknown etiology in old age.
227
Several risk factors appear to be associated with the development of interstitial lung
fibrosis. The survival
rate of interstitial lung fibrosis ranges from 30 to 50% after diagnosis.
• Many less common conditions and diseases are also affecting the respiratory
system in the elderly, including – Congestive heart failure, Gastro -esophageal
reflux, Guillain Barre Syndrome, Myasthenia Gravis etc.
Definition, Etiology and clinical presentation of common respiratory
disorders in the elderly
Definition
of
respiratory disorder
Bronchial asthma: It
is
a
disease
characterized
by
variable
airflow
obstruction,
airway
inflammation
and
bronchial
hyperresponsiveness
by
variety of internal as
well
as
external
stimuli.
COPD: It is defined as
progressive
development
of
chronic
airflow
obstruction due to
chronic bronchitis or
emphysema or both. It
is
principally
a
geriatric disorder.
Pulmonary
tuberculosis:
It
remains a major public
health problem in most
developing countries.
The rates for active
T.B. cases are higher
in the elderly.
Pneumonia: It is an
acute inflammation of
the lung parenchyma,
of infective or non
infective
origin,
Etiology
Clinical presentation
Nonatopic
asthma- usually
starts at an early
age and provoked
by allergens.
Atopic asthma-it
is also known as
intrinsic asthma
common in adult
and old
age group.
Cigarette
smoking is the
single
most
important
and
most
prevalent
factor for the
development of
COPD.
Besides this air
pollution,
occupation and
infection are also
important.
It is similar to younger age group.
But in geriatric age it presents
with episodic wheezing, dyspnea
and cough. It is triggered by viral
infection, environmental allergens
or irritants, emotional triggers and
adverse drug effects.
The
immune
status in the
elderly patients is
greatly reduced.
It is caused by
Mycobacterium
tuberculosis.
Only 50% of
cases of CAP
etiological agents
are found. The
most common is-
228
Chronic bronchitis- Episodic
cough, copious and purulent
sputum production, most common
in winter months,
Emphysema- exertional dyspnea
with minimal scanty and mucoid
sputum. Patients are asthenic and
distressed.
It is most common form of
tuberculosis in old age group. The
common features are- cough,
weight loss, hemoptysis and low
grade fever. In some patients
night sweats may or may not be
present.
Patients
have
atypical
presentation- it may be latent,
coming on with or without chill,
cough and expectoration. Only
56% of CAP patients have at least
presenting
with
pulmonary
consolidation.
Community acquired
pneumonia is most
common in elder age
group
Streptococcus
pneumoniae, H.
influenzae,
Legionella
pneumophila,
Chlamydia
pneumoniae and
Gram-ve bacilli.
Bronchiectasis: It is a
localized irreversible
dilation and distortion
of the bronchi. The
disease runs a chronic
course, characterized
by repeated bronchial
infection
and
hemoptysis.
Interstitial
lung
fibrosis:
Interstitial
lung fibrosis is a form
of diffuse interstitial
lung disease, with
generalized
involvement of lung
interstitium. It is called
diffuse because of the
widespread
involvement.
Bronchial
obstruction,
bronchial
infection in past,
repeated
chest
infection
and
immobile
cilia
syndrome.
In 50%cases it is
idiopathic
in
nature.
No
secondary cause
is identified in
these patients.
one of three respiratory symptoms
i.e. cough, fever and shortness of
breath. It may increase the
mortality rate in the elderly
Patients have clinical history of
chronic cough with copious
purulent
expectoration
and
postural relationship. Fever and
other constitutional symptoms
may occur during episodes of
bronchial infection. Hemoptysis is
very common in this case.
The most prominent symptom is
progressive
breathlessness,
present in over 90% of the
patients. Some complains of –dry
cough, with scanty mucoid
sputum. Constitutional symptoms
are- malaise, weakness, and
fatigue, myalgias, fever and
weight loss.
Complications and differential diagnosis of respiratory problems in
the elderly
Respiratory
disorders
Bronchial
asthma
COPD
Pulmonary
tuberculosis
Complications
Differential diagnosis
Permanent structural
changes
and
frictional stress during
breathing
Secondary
erythrocytosis,
pneumo-thorax,
pulmonary
artery
hypertension,
RVH,corpulmonale
Hemoptysis, pleural
effusion
tubercular
pneumonia. Intestinal
Chronic
bronchitis,
Emphysema,
Acute LVH, Upper airway obstruction,
229
Chronic infection, Upper airway
obstruction, Pulmonary eosinophilia
etc.
Infections of the respiratory system,
tumors, occupational lung disease,
sarcoidosis.
Pneumonia
Bronchiectasi
s
Interstitial
lung fibrosis
tuberculosis.
Tubercular meningitis
Respiratory
failure,
pleural
effusion,empyema,
hemolytic
anemia,meningitis,
thrombo-cytopenia
etc.
Lung
abscess,
pneumothorax,
anemia, hemothorax,
broncho-pleural
fistula.
Hypertrophic
osteoarthropathy,
Pulmonary
hypertension,
cor
pulmonale.
Lung abscess, tuberculosis, COPD,
and bronchial asthma.
Pneumonia, COPD, and bronchial
asthma etc.
COPD, Asthma, Cardiac failure,
Pulmonary thrombo-embolism.
Special diagnostic procedures in respiratory system
The diagnostic modalities available for the assessment of the patients with suspected
or known respiratory disease are imaging studies and techniques for acquiring
biologic specimens. In some cases it involves direct visualization of part of
respiratory system.
Sputum examination:
It is an important component in the clinical examination of the patient with
respiratory diseases. It is one of the most valuable investigations in pulmonary
tuberculosis, fungal lung disease and the cytology of sputum is extremely important
in the diagnosis of malignant cells.
Hematological test:
It may help in the diagnosis of variety of respiratory disorders. Complete blood
count is an important component in diagnosis, it denote –
Anemia– in unexplained dyspnea.
Polycythaemia - in chronic bronchial asthma and COPD.
Leucocytosis- in bacterial infection of lung of upper and lower respiratory tract.
Eosinophilia- in eosinophilic lung disease and allergic lung diseases.
Increased ESR- in tuberculosis, carcinoma of bronchus, lymphomas and collagen
vascular diseases. It is prognostic tool in above mentioned diseases.
Skin test:
Immediate skin test-The suspected allergen such as pollen, moulds, or dust is
inoculated into the skin by a scratch. A positive test within 25 to 30 minutes,
indicate Type I hypersensitivity to the antigen. This is useful in the diagnosis of
allergic asthma, occupational asthma and allergic rhinitis.
Delayed skin test- The Type I hypersensitivity reaction starts within 42 to 72 hrs and
it is useful for the diagnosis of tuberculosis and sarcoidosis.
X-ray chest:
Routine x-ray chest is done for evaluation of diseases involving the lung
parenchyma, the pleura and lesser extent to the airways and mediastinum.
230
Lateral decubitus views are often useful for diagnosis of presence of abnormalities
and free flowing fluid in the pleural as well as pleural cavities.
Apical lordotic views are useful to visualized disease at the lung apices.
X- ray chest: Showing barrel shaped
Advanced X-ray chest: Arrow showing
area of chest deformity and trapping of air tuberculosis
in COPD
Source: www.wikimedia.org
Source:www.graphics8.nytimes.com
X-rays AP and Lt Veiw : showing Pneumonic
consolidation in lt lower lobe of lung
Source: www.medvarsity.com
X-ray chest AP veiw: showing lt. lobar
pneumonia
Source: www.mesothelioma-health.org
Computed tomography (CT):
It offers several advantages over routine chest radiography.
It makes possible to distinguish between densities that would be superimposed on
plain radiography.
It distinguishes subtle differences in density between adjacent structures and in
providing accurate size of the lesions, in identifying and characterizing the diseases
adjacent to the chest wall or spine and calcification in pulmonary nodules. It is an
important tool in the staging of lung cancer. It makes possible to distinguish vascular
from non vascular structures.
CT Angiography: The pulmonary emboli can be detected in segmental and large
pulmonary arteries by this technique.
High resolution CT: It allows better recognition of subtle lung parenchymal and
airway diseases such as- bronchiectasis, emphysema and diffuse pulmonary disease.
Magnetic resonance imaging:
Its role is very little in the evaluation of respiratory diseases than that of CT.
231
Scintigraphic imaging:
Radioactive isotopes are administered by i.v. of inhaled routes; allowing the lung to
be imaged with gamma camera. The most common use of such imaging is to
evaluate pulmonary embolism.
It is useful in patients with impaired lung function and who is being considered for
lung resection. Gallium imaging has been of diagnostic value in patients of
Pneumocystis carinii and other opportunistic infections.
Pulmonary angiography:
By this technique the pulmonary arterial system can be visualized. It is performed in
cases of pulmonary embolism. It demonstrates the consequences of an intravenous
clot or an abrupt termination of the vessels. In other respiratory diseases it is less
common in use.
Ultrasound:
It is not useful for evaluation of the lung parenchyma. However, it is often used as a
guide to the placement of needle for sampling of pleural fluid.
Fibro-optic bronchoscopy:
The inner surface of the tracheo-bronchial tree can be examined by this technique. It
is also used in the removal of foreign bodies and management of haemoptysis.
Broncho alveolar lavage is done by this technique to study of cells; it is very useful
for the diagnosis of certain lung cancers, sarcoidosis, silicosis, and idiopathic
pulmonary fibrosis.
Thoracocentesis and pleural fluid examination:
It refers to temporary insertion of a needle or a catheter into the pleural space. This
is usually done to remove air or fluid collected in the pleural cavity. The drawn fluid
is examined to ascertain whether it is a transudate or is exudate.
Lung biopsy:
There are five ways of lung biopsy, such as-Trans-bronchial biopsy: helps in the diagnosis of diffuse lung disease.
-Per-cutaneous needle aspiration biopsy: fluid and cells are aspirated into a syringe
and submitted for
cytological studies and for stains & culture of micro-organisms.
-Cutting needle biopsy - high degree of accuracy is obtained.
- High speed drill biopsy - it is used for the diagnosis of non granulomatous diffuse
diseases of the lung
- Open lung biopsy- it is most invasive procedure, generally not in practice.
Complication of lung biopsy:
Empyema, broncho-pleural fistula and post operative inspiratory failure.
Cancer of respiratory tract:
Lung cancer is the leading cause of cancer related deaths in the developed countries
for men and women. The incidence of lung cancer is increasing because of the rise
in the aging population. It is primarily a disease of elderly due to longer time
exposure to tobacco and other carcinogens. Smoking is the predominant risk factor
associated with lung cancer, others are- airflow obstruction, family history of lung
cancer and respiratory exposure to asbestos or radon gas. Although adeno-carcinoma
is the most common lung cancer of respiratory tract, but squamous cell carcinoma is
the most common form in elderly, and it has strong correlation with smoking.
232
X-ray chest: Showing infiltrative areas in
left lung field.
X-ray chest: showing healthy lung field
and cancerous lung field in a circle
Source:: www.wikimedia.org
Source: www.spacedaily.com
Histological classification of lung cancer
Cell type
Squamopus
carcinoma
Frequency
in %
35-45
Small cell carcinoma
20
Adenocarcinoma-itis
Brochogenic, acinar,
broncheo- alveolar.
25-30
Large cell carcinoma
10
Mixed forms
10-20
Other features
It is most common in central or hilar
than peripheral. It generally remains
localized early in the diagnosis of
disease.
It is mostly in central than peripheral.
Most common in the elderly.
Patients have widespread disease at
the time of diagnosis
It is most common cell type occurring
in non smokers, especially in women.
They are often localized as a
peripheral nodule with regional nodal
metastasis.
With or without mucin, giant and
clear cell variants
Mixed feature
Clinical presentation:
Lung cancer may be presents in a number of different ways. Cough, weight loss,
wheezing and fever are the most common early symptoms, may be accompanied by
sputum. Repeated episodes of scanty hemoptysis are common in bronchial
carcinoma. Chest pain, dysphagia and pleural effusion are due to local extension of
tumor. Other signs and symptoms depend upon the different stages of the cancer.
Differential diagnosis:
Tuberculosis, pneumonia, pulmonary infection, bronchial adenoma, rheumatoid
nodule.
233
Treatment:
Surgical resection –It is the treatment of choice for non small cell lung cancer
(NSCLC). It offers survival rate > 75% in stage Ist and 50% in stage IInd.
Radiation:
In most of the cases surgery is not possible and such patients are offered only
palliative treatment. Over all 35% response is achieved by radiation. Radiation
pneumonia is an important consequence of this technique.
Chemotherapy:
The goal of chemotherapy is prolongation of survival and amelioration of
symptoms, generally combination therapy is preferred. Chemotherapeutic agents’
like- Cisplatin, Vinblastin, Mitomycin, Etoposide, are commonly used.
Prognosis:
The over all prognosis of bronchial carcinoma is very poor. Age is an important risk
factor in the prognosis. It also seems that co-morbid conditions are most common in
the elderly than younger one.
Respiratory infection:
The death from respiratory infection is common in the elderly population,
epidemiological studies of infection are patchy and many specifically excluded in
elderly people. The best estimate is that the death rate from respiratory infection for
the over 65 years approaches > 500/10,000 population/ year. This figure is 50 time
higher than young adults.
Following are the common factors, which differ from adults and are responsible for
respiratory infection in old age –
• A depressed immune response
• An increased closing volume of lung
• An increased prevalence of CLD
• Immobility and malnutrition
• Institutionalization increases proximity of infection
• Colonization of the upper respiratory tract by pathogens
• Lack of receipt of influenza and pneumonia vaccine
• Other associated chronic illness in the elderly
A decline in the innate i.e. neutrophils, and specific immunity i.e. lymphocyte, has
been observed in the elderly. Diet and exercise may also influence age related
changes in the immune response, Macrophage and lymphocyte function appear to be
largely affected by aging. Mostly cell mediated immunity is greatly affected during
the process of aging.
The important evidence in favor of this is to:
• Reduced thrombopoetin level and involution of thymus with aging.
• Diminished delayed hypersensitivity and loss of memory T cell function.
• Reduced helper T cell and increase T suppressor cell.
• Reduced interleukin -2 production and increased reactivation of tuberculosis.
• Herpes zoster in elderly individual.
Infection of upper respiratory tract:
It is mostly caused by Virus than bacterial and is precipitated by variety of external
and internal allergens. They are- common cold, rhinitis, sinusitis, influenza, acute
bronchitis of upper respiratory tract.
Infection of lower respiratory tract:
Pneumonia is an important lower respiratory tract infection.
234
How respiratory infection of old age differs from adult:
Many respiratory infections in the elderly have atypical presentations i.e. respiratory
symptoms may be latent and physical signs ill defined and changeable. Patients may
present with a functional decline, confusion, falls, exacerbation of an underlying
illness such as COPD or angina or metabolic abnormalities. In a retrospective study
of pneumococcal pneumonia in the elderly, only 48.3% of the patients had
respiratory symptoms on presentation.
Treatment of infection:
Preventive measures: - Avoid respiratory irritants
- Avoid cigarette smoking and
pollution.
- Frequent hand washing
- Use humidifier
- Increase liquid intakes
- Cardio-vascular exercise
- Healthy and nutritious diet
-Regular checkups
- Immunization for flu and pneumonia.
Pharmacological measures:
1- Respiratory care medications- decongestant, cough suppressant, expectorants and
bronchodilators.
2- Pain relievers: NSAID- Diclofenac Na, Ibuprofen etc.
3- Antiviral medications- Amantadine.
4- Antibiotic medications- broad spectrum antibiotics should be used in clinical
practice.
5-Antiallergic medications- Cetrizine, Levo-cetrizine, CPM, Loratadine etc.
6-Oxygen therapy- patients breathe via a mask, nasal canula or trachea catheter. This
can be carefully regulated and monitored frequently by physician.
Ayurveda believes that respiratory infections are caused by variety of etiological
factors such as fumes, dust, cold things etc. Besides these etiological factors, Susruta
has also conceived invasion of micro-organism in relation to ÏoÒa, Jvara etc in
KuÒÔhanidÁnasthÁna1. It creates the disturbance of the VÁta doÒa alone or in
combination with other DoÒa i.e. VÁta-pitta, VÁta kapha and VÁta-pitta- kapha and
undergoes in the process of genesis of respiratory infection
Avoidance of etiological factors i.e. NidÁna parivarjana is an important land mark
of Ayurvedic therapeutics. The following Ayurvedic drugs are commonly used for
prevention and cure of respiratory infectionSingle drugs:
PippalÍ, HaridrÁ, ÀmalakÍ, ÏigrÚ, Nimba ÏirÍÒa, TulasÍ etc.
Compound drugs: Tribhuvana kÍrtirasa, LakÒmÍbilÁsa rasa, Agastya harÍtakÍ,
ÏigrÚ guggulu, RasasindÚra, SamÍrapannaga rasa, ÏriÉga bhasma, LavaÉgÁdi
vaÔÍ VyoÒÁdi vaÔÍetc.
Neo-formulation: Tablets and Syrups Septilin and Nirocil, Tab. Purim, Tab
Immumod,
Cap. Herbal antibiotic, Probiotics and immuno enhancer drugs like
Amrita, Haridra etc.
1
PrasaÉgÁd gÁtrasaïsparÐÁnniÐvÁsÁt sahabhojanÁt I.
SahaÐayyÁÁsannÁccÁpi vastramÁlyÁnulepanÁt II.
KuÒÔha¿ jvaraÐca ÐoÒaÐca netrÁbhiÒyanda eva ca I.
Aopasargika rogÁÐca saækrÁmanti narÁnnaram II.
(S.S.Ni.-5/32-33)
235
Iatrogenic disease/ Nosocomial infection:
It is defined as infection acquired during or as result of hospitalization. They may
affect patients and hospital staff or vice versa. Infection occurs by means of direct
contact, common vehicle spread, and air borne spread or vector borne spread. In the
hospital direct person to person transmission between an infected patient, staff
members or visitors and non infected patients. Indirect transmission takes place
through equipments supplies and hospital procedures. This type of transmission is
more common in iatrogenic disease. Pneumonia is the most common form of
Iatrogenic disease/ Nosocomial infection; others are- pleuritis, spread of cancer,
radiation pneumonia, pneumothorax, pulmonary hemorrhage.
Treatment modalities:
• Immunisation of health care workers at risk.
• Isolation of high risk patients.
• Antibiotic prophylaxis for specific conditions.
• Proper elimination of hospital waste.
• Application of guidelines for prevention
Respiratory problems caused by chronic consumption of drugs:
Respiratory problem
Bronchial hyper-reactivity/
contrast medium,
Spasm
blocking
drugs
Isolated cough
Drugs
Asprin and other NSAID, iodine containing
beta- adrenoceptor blocking drugs neuromuscular
ACE inhibitors
Alveolar infiltrate with
hydralazine, gold,
or without fibrosis
Busulphan, cyclophosphamide, methotrexate,
penicillamine, nitrofurantoin, amiodarone.
Pleural fibrosis
Practolol
Eosinophilia
erythromycin, NSAIDs
Beta-lactam antibiotics, sulphonamides,
Lupus syndrome
INH, hydralazin, procainamide
Pulmonary embolism
Contraceptive pills
Pulmonary hypertension
Amphetamines, cocaine, IV drug abuse.
Respiratory problems caused by chronic inhalants and smokes:
Problems
General agents
236
Examples
Industrial bronchitis
fumes
-
Occupational asthma laboratory animals,
Irritants
-
Chemicals, animal proteins,
Plants proteins, metals
Isocyanates,
flour, nickel
Hypersensitivity pneumonitis - Biological dust
actinomycetes
Pneumoconiosis
coal
Lung Cancer
arsenic,
-
Gas, smoke,
- Thermophilic
- Mineral dust
- Asbestos, silica,
- Radiation, animal dust, plant dust
- Asbestos,
radon
DIGNOSTIC CRITERIA, INVESTIGATIONS, TREATMENT & REFERRAL
LEVEL 1: AT GERIATRIC CLINIC:
Diagnostic criteria:
Table ---Clinical diagnosis and investigations of common respiratory
diseases in the elderly
Respiratory disease
Investigations
Clinical history of dry cough,
Bronchial
dyspnea, and wheez with an
asthma
episodic presentation specially
in night.Both phase respiration
becomes
prominent
and
expiration becomes prolonged.
In
some cases it is
precipitated by variety of
allergens, and stressors.
Physical findings are barrel
chest deformity, tympanic
sound on percussion, pulsus
paradoxus, expiratory rhonchi
on
auscultation
and
prominence of
sternocleidomastoid muscle.
Clinical
presentation
of
COPD
chronic cough with
exacerbation in winter, in
smokers/ex
smokers
or
occupational exposure to
smoke or dust. Physical
findings are barrel chest
deformity, tympanic sound on
237
Clinical diagnosis
•
•
•
In some cases haemogram
reveals eosinophilia.
Sputum microscopic :
presence of charcotleyden
crystal, eosinophils, &
curshman spirals.
Chest X-ray- prominence
of
bronchovascular
markings
and
hyperinflation of lung.
Haemogram
reveals
polycythemia.
Chest X-rays- findings of
hyper inflation of lung and
evidence
of
bullous
formation.
Sputum culture and
microscopic examination.
Pulmonary
tuberculosis
Pneumonia
Bronchiectasis
percussion,
adventitious
rhonchi or creptations on
auscultation would be helpful
in the diagnosis
of COPD .
Clinical history of chronic
productive cough ≥ 3 weeks,
evening rise temperature,
night sweat, gradual weight
loss and some times with
haemoptysis. On
physical
examination findings are –
patient becomes lean & thin,
chest becomes flat, dull sound
on percussion at infiltrative
areas and resonant at the site
of cavitations, creptations at
flaring areas and tubular
breath sound at cavitations on
auscultation.
Clinically it is presented in
two ways1.Typical presentation: it is
characterized by sudden onset
of fever, productive cough,
purulent sputum,shortness of
breath and chest pain. Sign of
pulmonary consolidation may
be
found
on
physical
examination i.e.- dullness,
increased fremitus, egophony, bronchial
breath sound and rales.
2. Atypical presentation:it is
common in older age group
and presents with gradual
onset, dry cough, shortness of
breath, prominence of extrapulmonary systems; such as –
headache, myalgia, fatigue,
sore throat, nausea, vomiting
and diarrhea.
Clinical history of persistent
and recurrent cough along
with purulent production of
sputum. Haemoptysis occurs
in 50 to 70% of cases.
In some cases patients are
asymptomatic or may have
non productive cough. On
238
•
•
•
•
•
•
•
Haemogram
–↑
lymphocytes & ESR.
Mountoux
testnot
significant in the elderly.
Sputum for AFB.
PPD skin test.
Sputum
culture
Mycobacterium
Chest X-rays- findings of
upper lobe infiltration with
cavitations.
Serum- IgG and IgM for
tuberculosis .
(a) Sputum- routine and
microscopic exam.
(b) Sputum- culture and
sensitivity test.
(c) Blood count- TLC, DLC,
ESR and Hb%.
(d) Chest X-rays- confirm the
presence and Location of
pulmonary infiltrate,
extent of pulmonary
infection, cavitations etc.
•
•
•
•
Sputum – routine and
microscopic examination.
Sputum- culture and
sensitivity test.
Blood count – TLC, DLC,
ESR, Hb%.
Chest X-rays- prominent
cystic space with or
Lung cancer
Interstitial
lung fibrosis
examination local findings are
variable,
combination
of
coarse crepitation and rhonchi
over damaged airways on
auscultation.
In few cases clubbing may be
present.
It is based on clinical history,
physical
examination,
performance
status and weight loss. Only 5
to 15% elderly patients are
identified with lung cancer,
rest are asymptomatic for
prolong period or may be
associated
with
other
respiratory
diseases.
The
physical sign and symptoms
depend upon local tumor
growth, invasion in the
surrounding
areas
or
obstruction
of
adjacent
structure.
Clinical history of exertional
dyspnea, dry
cough, fatigue, in patients with
interstitial lung fibrosis; frank
haemoptysis and acute chest
pain are rarely seen in
interstitial lung fibrosis.In
such cases physical findings
are not specific. The most
common
findings
are
tachypnea and bibasilar end
inspiratory coarse crepitation,
Cyanosis and clubbing occur
in some patients in advanced
stage of the disease.
without air liquid levels in
most of the cases. Other
findings are peri-bronchial
Inflammation.
Sputumroutine
and
microscopic
Sputum- cytology for
identification
and
differentiation
between
healthy and malignant
cells.
Chest
X-raysnot
confirmatory
in
carcinoma of lung.
CT- Scan- Thorax, Lung,
& mediastinum.
Blood count – TLC, DLC,
ESR, Hb%, Platelet count.
Lung biopsy- for histopathologic examination.
• Sputum Examination is
not significant.
• Not
confirmed
by
haemogram.
• Chest
X-rayreveals
honeycombing appearance
of lung parenchyma , it
indicates poor prognosis of
the disease.
Brief profile of respiratory disorders as described in Ayurveda
Respiratory
disorders
ÏvÁsa
general
Hetu
SamprÁpti
RÚpa
(
GhaÔaka
(Important
Etiology) (Component of clinical features)
pathogenesis)
in Dust,
-DoÒafumes, cold Kapha
place, cold -DÚÒya-
Probable
modern
correlate
in AsthmaVÁta- Difficulty
breathing,
Bronchial asthma.
PÁrÐvaÐÚla, Pain in Cardiac asthma.
239
Tamaka
ÏvÁsa
seasons,
excessive
exercise,
suppression
of natural
urges etc.
PrÁÆavÁyu,
Anna.
-AdhiÒÔhÁnaPrÁÆavahasrotas
Pitta
a
and
SthÁna.
-SrotoduÒÔiSaÉga
&
VimÁrgagamana.
-do-
DoÒaKapha AtÍva TÍvra Vegam, Bronchial Asthma
pradhÁna VÁta ÏvÁsam
PrÁÆa
Rest is similar to PrapÍÕakam,
ÏvÁsa.
Pramoha,
Muhurmuhuí
ViÐuÒka KÁsa and
ÏvÁsa, ÀsÍnolabhate
Ïukham etc.
TamasÁ
Vardhate
TamobhavÁ
SaÉtamaka
Pratamaka
ÏÍtaprÁgvat PittÁnuvandhÍ
ai½
Vivardhate
KÁsa
general
in DhÚmopagh
Áta,
Rasa/Raja,
RÚkÒÁnna,
KÒavathu
VegÁvarodh
a
KÒataja KÁsa Excessive
coitus,
weight
lifting,
fighting,
and
excessive
exercise.
-DoÒaVÁta
Kapha
-DÚÒyaSvara,Rasa,
Anna.
-AdhiÒÔhÁnaGala
-SrotasaPrÁÆavaha
&
Annavaha.
-SrotoduÒÔiAtipravétti.
cardiac
region, Renal asthma.
Tastelessness
in
mouth,
flatulence,
and increase in ÏÍta
VÁta, Jala and ètu.
Tama, MÚrcchÁ, and Acute stage of
relieved by cold bronchial asthma
therapeutic measures. status asthamaticus
Jvara, MÚrcchÁ and Bronchial asthma
respiratory
exacerbate by cold with
therapeutic measures. tract infection
VÁtaja
KÁsaPrasaktavega, Sula,
non-productive
coughing.
infective
Pittaja
KÁsa- Acute/
SÁdÁhavega, Jvara, bronchitis
and
productive
coughing
with
yellowish sputum.
Kaphaja
KÁsa- Chronic bronchitis
Productive
coughing,
KaÆÔhe
KaÆÕÚ, whitish and
thick sputum.
VÁta PradhÁna SaÐÚla KÁsa, ÏÚla
Rest is similar to PradhÁna,
KÁsa.
and
haemoptysis
PÁrÁvata KÚjana¿.
240
Whooping cough
and
Tropical
pulmonary
eosinophilia
Bronchiectasis or
Emphysema
or
Pleuritic
chest
pain.
KÒayaja KÁsa DhÁtukÒaya
without
upasarga/
saÉsarga.
TridoÒa
Jvara, Bronchitis due to
GÁtraÐÚla,
PradhÁna.
DÁha, PrÁÆa, Bala emaciation of body
Rest is similar to & MÁ¿sa KÒaya, tissues.
KÁsa.
SapÚya and Sarakta
niÒÔhÍvana.
Pulmonary
Tuberculosis
RÁjayakÒmÁ
DhÁtukÒaya
due
to
VegÁvarodh
a,
SÁhasa,Ksa
ya
ViÒamÁÐana
.
-DoÒa- TridoÒa.
-DÚÒyaRasa,
Rakta, MÁ¿sa,
Ïukra.
-SrotasaPrÁÆavaha,
Rasavaha,
Ïukravaha.
-AdhiÒÔhÁnaUrasa.
A¿Ða
PÁrÐvÁbhitÁpa½.
SantÁpa½
KarapÁdayo½.
Jvara½ SarvÁnga½.
A¿ÐaÐÚla &
ÏoÆitadarÐanam.
ÏoÒa
DhÁtukÒaya
due
to
AtivyavÁya,
Ïoka, JarÁ,
VyÁyÁma,
Adhva,
VraÆa,
Ura½ KÒata.
- DoÒa TridoÒa.
-DÚÒyaSarvadhÁtu
specially Rasa
and Ïukra.
-AdhiÒÔhÁnaSarvaÐarÍra.
There is feature of Gross emaciation
DhÁtukÒaya
&
BalakÒaya
with
minimal KÁsa.
Ura½ KÒata
Excessive
physical
labor,
Ativyavaya,
RÚkÒa, Alpa
and
PramitÁÐan
a
-DoÒa-VÁta
PradhÁna
Rasa,
-DÚÒyaRakta, -MÁ¿sa,
Asthi.
-AdhiÒÔhÁnaUrasa.
Uroruk,
Bronchiectasis and
ÏoÆitacchardi, KÁsa, Lung abscess.
Jvara,
sputum
becomes yellowish,
greenish, and foul in
smell.
In spite of these respiratory disorders, JarÁ KÁsa is also mentioned by
Madhukosakara in the context of KÁsa Roga. JarÁ KÁsa is primarily VÁta DoÒa
PradhÁna but other DoÒas are also involve in the pathogenesis of JarÁ KÁsa . Hence
their line of management is also based on DoÒic involvement and is similar to KÁsa
regimen. Preferably RasÁyana drugs like- HaridrÁ, ÏigrÚ, ÏaÔÍ, KaracÚra etc; should
be used in the management of JarÁ KÁsa.
Treatment of common respiratory diseases in the elderly:
Ayurvedic Approach:
Ayurvedic texts have described in detail the etio-pathogenesis and management of
respiratory disorders such as KÁsa, ÏvÁsa, PratiÐyÁya, RÁjayakÒmÁ, KÒatakÒÍÆa and
unique concept of infectious disease in KuÒÔha nidÁnasthÁna by ÀcÁrya SuÐruta.
241
As per Ayurveda respiratory disorders are mainly Kapha dominating but VÁta and
Pitta doÒa are also involved in different proportion in different consequences.
Human body always reacts with the exogenous and endogenous environment to
counteract the strength of antigenic substances in different ways.
It may react to the body externally through BÁhyamÁrga manifesting as diseases of
upper respiratory tract such as common cold, sinusitis, rhinitis, influenza, acute
bronchitis, bronchogenic pneumonia etc.
When the body reacts to the internal antigens through ÀbhayÁntaramÁrga, it
manifests in the form of lower respiratory tract disorders such as bronchial asthma,
COPD, cancer of lung, pneumonia, tuberculosis of lung, and other autoimmune
disorders of respiratory tract.
Both these types of diseases are essentially the reaction of the body to the antigenic
materials i.e. ViÒa dravyas; present in the exogenous or endogenous environment.
The diagnostic procedure in such conditions, mainly consist of identifying the nature
of internal triggering factors like Àma and or ViÒa dravyas of the external
environment. The principles of treatment of respiratory disorders are given below.
1. NidÁna parivarjana: i.e. Avoidance of etiological factors.
• Dietory restriction for eliminating Agnimandya, thus reducing the chances of
Ama formation.
• Avoiding ingestion or contact of Visa dravyas.
2. ÀmapÁcana: Promote Agni by DÍpana and PÁcana drugs like CitrakÁdi vaÔÍ,
TrikaÔu CÚrÆa etc.
3. Sa¿Ðodhana: i.e. Biopurificatory measures: It is generally individualized and it
depends upon the body strength of the patients and onset of disease. Vamana karma
is an important treatment for upper respiratory tract disorders and in asthma patients
having good physical strength. Virecana karma is specially indicated in the
management of Tamaka ÐvÁsa.
4. Sa¿Ðamana/palliative treatment:
Single drugs: Caraka has described 10-10 drugs each in KÁsahara and ÏvÁsahara
MahÁkasÁya for the management of KÁsa and ÏvÁsa roga. Now a days following
single drugs are commonly used to treat the respiratory disorders- ÏirÍÒa, VÁsaÁ,
HarÍtakÍ, BhÁraÉgÍ, PuÒkaramÚla, TulasÍ, AnnatamÚla, ÏaÔÍ, KarcÚra, KaÉÔakÁrÍ,
VacÁ, DugdhikÁ, DhattÚra, VibhÍtakÍ etc.
KaÒÁy: ÏirÍÒÁdi kaÒÁya, GojihvÁdi kaÒÁya, Puskarmuladi kaÒÁy, Vasadi kaÒÁy.
CÚrÆa: SitopalÁdi CÚrÆa, TÁlÍÐÁdi CÚrÆa, ÏaÔyÁdi CÚrÆa, PuÒkaramÚla CÚrÆa,
AjamodÁdi CÚrÆa, KaÔaphalÁdi CÚrÆa, KarpÚrÁdi CÚrÆa .
VaÔÍ: ElÁdi VaÔÍ, LavaÉgÁdi VaÔÍ, VyoÒÁdi VaÔÍ, SÁrivÁdi VaÔÍ.
Guggulu: ÏigrÚguggulu, AmétÁguggulu.
Avaleha: CyavanaprÁÐÁvaleha, VÁsÁdiavaleha, HaridrÁkhaÆÕa, AgstyaharÍtakÍ,
CitrakaharÍtakÍ,
VyÁghrÍharÍtakÍ.
Àsava/ AriÒÔa: KanakÁsava, DrÁkÒÁriÒÔa.
Ghéta: ManíÐilÁdighéta, VÁsÁghéta.
Rasa: RasakuÔhÁra rasa, ÏvÁsakuÔhÁra rasa, Kaphaketu rasa, KaphakartarÍ rasa,
ÏvÁsakÁsacintÁmaÆi rasa, LaghumÁlinÍvasanta, SvarÆavasantamÁtÍ TribhuvanakÍrti
rasa, LakÒmÍvilÁsa rasa, GodantÍ bhasma.
242
Conventional Approach:
Bronchial asthma/ COPD
:
Elimination of the causative factor is the corner stone in the management of
bronchial asthma. Rehabilitation is necessary at all levels, it includes exercise
training and nutritional therapy. In addition, cessation of smoking is mandatory.
Pharmacological treatment:
In mild cases one should start with Solbutamol MDI (100µg inhalation) 2 to 4
times/day or as per need.
In moderate to severe cases start with oral Theophyline sustained released
preparation (150mg BD), inhalational Ipratropium bromide (20µg; 3 to 4 times/day),
inhalational Solmeterol (50µg) or Formetrol(12µg) twice daily, Oxygen therapy and
inhalational Solbutamol (100µg) on the basis of need. In the presence of infection
course of oral/i.v/i.m antibiotics for 7 to 10 days are required.
*Bronchial asthma/COPD is well comparable to Tamaka ÏvÁsa in Ayurveda.
Preparations like HaridrÁkhaÆÕa, ÏirÍÒÁdi kaÒÁya, GojihvÁdi-kvÁtha, ÏvÁsakuÔhÁra
rasa, KanakÁsava, AgastyaharÍtakÍ, ÏvÁsaksacintÁmaÆi rasa, SitopalÁdi CÚrÆa, etc
are commonly used in Ayurvedic practice..
Pulmonary tuberculosis:
The WHO has recommended the following guide lines for the treatment of
pulmonary tuberculosis in the form of Revised National T.B Control Program.
Category I: New cases of smear positive• Initial phase: 4 drugs regimen for 2 months or Up to sputum smear is
negative but not more than 3 month.(Drugs- Isoniazid, Rifampicin,
Pyrazinamide and Ethambutol)
• Continuation phase: 2 drugs regimen for 4 months. (Drugs- Isoniazid and
Rifampicin)
Category II: In relapse and treatment failure cases, the recommended regimens are- Initial phase: 3 month- 5 drugs (Streptomycin, Isoniazid, Rifampicin,
Pyrazinamide and Ethambutol) regimen for 2 months and 4 drugs (Isoniazid,
Rifampicin, Pyrazinamide and Ethambutol) regimen for one month. If
sputum smear is positive after 3 months continue initial phase of 4 drugs
regimen for one month.
- Continuation phase: Isoniazid, Rifampicin, and Ethambutol are given either
three times a week
or daily for 5 months under close supervision.
Category III: In smear negative cases with limited parenchymal involvement, the
recommended regimens are Initial phase: 3 drugs i.e.-Isoniazid, Rifampicin, Pyrazinamide; regimens are
given daily or three times weekly for 2 months.
Continuation phase: Isoniazid, Rifampicin is given daily or three times
weekly for 2 months.
Category IV: Chronic cases of tuberculosis that remain smear positive after
completing the treatment regimen under supervision. These patients are resistant to
multi drugs. They should be treated with at least three new drugs of second line
243
ATD and treatment continues for 12 months after becoming smear negative.
Assessment of treatment is based on sputum conversion.
* Pulmonary tuberculosis is well correlated with the RÁjayakÒmÁ of Ayurveda.
Preparations like VÁsÁ, RudantÍ, Rasona, Nagabala, as a single drug and NÁradÍya
lakÒmÍvilÁsa
rasa, SvarÆavasantamÁtÍ, DrÁkÒÁsava, CyavanaprÁÐa avaleha,
AmétÁriÒÔa, Candraméta rasa etc. as compound drugs are commonly used in clinical
practice. In Ayurveda AjÁ MÚtra is advocated for its management. The basic
treatment is to promote Oja Bala ( immune strength) of the patient through nutrition
and RasÁyana therapy.
Pneumonia:
Preventive measures:
It includes stop smoking; maintain hygiene of patients and care takers, frequent
change of posture, chest physiotherapy, better surrounding, fresh air and nutrition
etc..
Pharmacological:
Immunization of high risk patients and immediately start effective chemotherapy for
patients with contagious disease. Influenza, and Pneumococcal pneumonia vaccine
for the elderly is strongly advocated. It is based on the patient’s medical background,
age and by suitable antimicrobial therapy viz.
Penicillin G:
6to 10 lacs IV 4 hourly in Streptococcus pneumoniae and other
gram +ve organisms.
Erythromycin: 500 mg 6 hourly in all above + Legionella and Chlamydia.
Cefotaxime:
1 gram 12 hourly in anaerobes + above.
Metronidozole: 500 mg IV or Orally 8 hourly.
Gentamycin:
5 mg/kg IV in divided doses 8 hourly
*In Ayurveda preparations like- ÏigrÚ guggulu, AmétÁ, PippalÍ, ÏéÉga bhasma,
RasasindÚra, TÁlÍÐÁdi cÚrÆa, KªÒÆacaturmukha
rasa, TribhuvanakÍrti rasa,
GodantÍ rasa and KastÚrÍbhairava rasa are prescribed in management of such
cases.
Bronchiectasis:
It is largely a preventable disease in elderly. Pharmacological treatment consists of
postural drainage of the secretion, expectorants, bronchodilators, and broad
spectrum antibiotics; i.e. - Ampicilin, Cloxacilin, Gemifloxacin, Laevofloxacin,
Amikacin, II and III generation cephalosporin.
Regular physical therapy in the correct position to prevent the accumulation of
secretions and repeated bronchial infection.
Surgical resection of the affected pulmonary segment is indicated in the presence of
complications.
* In Ayurveda Agastya rasÁyana, VyÁghrÍharÍtakÍ avaleha, VyoÒÁdi vaÔÍ,
AmétÁriÒÔa, and some neo- Ayurvedic formulation are being used in its treatment.
Bronchiectasis should be treated on the lines of UraíkÒata as described in
Ayurvedic texts. Prognosis in advanced cases is unfavorable.
Lung cancer:
The treatment of lung cancer varies and it depends upon the types of the disease,
stage of the tumor and host factors, such as age, general condition, presence of
complications and other associated disorders. The current treatment modalities in
244
lung cancer are – surgical resection, radiation therapy, and chemotherapy.
Radiotherapy and chemotherapy can relieve distressing symptoms in few cases.
Besides this general palliative and supportive care of patients are of immense
importance. The related symptoms should be treated by appropriate measures.
In Ayurveda NÁgabalÁ, Rasona, KÁñcanÁra guggulu. SaÉjÍvanÍ vaÔÍ, TriphalÁ
guggulu, ÀbhÁ guggulu are used to provides symptomatic relief to some extent.
Preparations of BhallÁtaka, ÀmalakÍ, AÐvagandhÁ, AmétÁ and ÏigrÚ are used besides
HÍraka Bhasma in some cases.
Interstitial lung fibrosis: The treatment of ILF is not satisfactory. The mainstay of
treatment is the anti-inflammatory therapy, largely with corticosteroids.
Prednisolone: 1 to 1.5 mg/kg for period of 6 to 12 weeks. Maintenance dose is 15 to
20 mg daily and is continued for1 to 2 years or even more.
• Colchicine is the safest alternative and is used in a dose of o.6 to 1.2 mg/day
for a period of 6 to 12 months. It is preferred drug in elderly patients.
• Oxygen therapy is important in its management.
• Lung transplantation is advised in advanced cases to save life of the patients (
of course with great limitations).
In Ayurveda some RasÁyana drugs like PippalÍ, BhallÁtaka, MadhuyaÒÔÍ KupÍlu etc,
along with anti KÁsa regimen. Ayurvedic preparations of Guggulu, HaridrÁ, ÏirÍÒa,
ÏigrÚ and VaruÆa are also used in such cases as anti-inflammatory recipes.
Preventive measures of respiratory disorders:
Remove allergens from the home, including dust, dust mites, cleaning
chemicals, pets and carpets.
• Wash all linens, blankets etc at least once a week in hot water.
• Use only allergen proof pillows and blankets
• Clean the home thoroughly.
• Establish a no smoking policy in the home and avoid second hand smoke.
• Investigate neighborhoods thoroughly before you move to avoid
environmental pollution.
• Investigate workplace environments to avoid exposure to fumes, molds or
dust.
• In daily routine drink plenty of fluids and consume healthy and nutritious
diet.
• Advice to maintain the hygiene of patients and caretakers.
• Immunization for flue and pneumonia.
• Cardio-vascular and other suggestive exercises.
• Oxygen therapy.
• Regular medical check-ups.
Referral criteria
No response to pharmacological treatment in 4-5 days.
Evidence of increase in severity/ complication
Acute respiratory complication that not responds to medication.
Respiratory problems associated with other organs.
•
LEVEL 2: AT REGIONAL GERIATRIC CENTER
245
Clinical diagnosis: Same as level 1+ the fresh cases may be reported directly +
Also try to assess the complications of respiratory diseases separately as mentioned
above in this section.
Investigation: Same as level 2 + the fresh cases may be reported directly.
Treatment: Same as level 1 +
* High grade antibiotics may be required in this stage
* Management of emergency cases of respiratory system with help of broad
spectrum antibiotics, Systemic glucocorticoids, bronchodilators via IV route.
Besides this controlled oxygen therapy and chest physiotherapy is the corner stone
in the management of respiratory problems.
Referral criteria: Same as Level 1 +
• For the dose titration for ongoing 3-4 drugs regimen in COPD /Asthma,
Pneumonia and
Lung Cancer etc.
No response to the emergency treatment.
Onset of new physical sign i.e. cyanosis, confusion, and hyperventilation.
Associated with co-morbidities, such as- diabetes, cardiac disease etc.
Diagnostic uncertainty.
To assess severity of disease and complications.
For assessment of rehabilitation.
LEVEL 3: AT ADVANCED/SPECIALIZED GERIATRIC CENTER
Clinical diagnosis: Same as level 1 and 2 + the fresh cases may be reported directly
Complicated cases referred from level 1 and 2.
Also assess the complications as well as status of the patients in old and
new cases.
Investigation: Same as level 2 + the fresh cases may be reported directly.
•
Confirm diagnosis and severity of respiratory disease with the help of
Spirometry.
•
Perform sputum/ fluid/ secretion/ tests for routine as well as culture
and sensitivity to
confirm bacterial infection and application of suitable antibiotics.
•
For tuberculosis perform PPD test as well as immunological test i.e. Ig
G and Ig M.
•
For lung cancer perform- FNAC, and cytological examination to
confirm the diagnosis.
•
Arterial blood gas to detect hypoxia.
•
CT scan: In Lung cancer and complicated cases of COPD.
•
Routine investigation is mandatory to assess the therapeutic response.
Treatment: Treatment is same as level 1 and 2. + Such types of centers having
facilities for special advice and intensive respiratory facilities. This includes assisted
ventilation and all other steps of acute respiratory care, like- monitoring of vital
parameters, blood gas analysis, and maintenance of BP, fluids, electrolytes, nutrition
and general organ functions. Surgical resections are required in selected patients for
partial or complete lung. Lung transplantation is required in complicated cases of
lung cancer, interstitial lung fibrosis and COPD. Lastly the patients are referred to
the specialist such as TB and chest and Cardiothoracic surgeon for better assessment
and proper management.
246
Ayurvedic treatment guidelines in respiratory disorders.
After appropriated Snehana and Svedana karma, therapeutic emetic and purgative
should be given according to the need of the patient and strength of disease. No
doubt Vamana and Virecana are found effective in allergic and autoimmune
respiratory disorders but their use in elderly age group need very careful
monitoring. Ordinarily it should be avoided
Pacificatory measures are to prescribe in different respiratory disorders keeping in
mind the predominance of DoÒa, DÚÒya and the site of involvement of disease.
Preferential prescription of respiratory disorder is given below.
• SitopalÁdi or TÁlÍÐÁdi CÚrÆa- 6 .gms in three divided doses with honey.
• ÏirÍÒÁdi KvÁtha- 40 ml in two divided doses, after meal.
• HaridrÁkhaÆÕa- 1 tsf morning and evening with honey.
• LavaÉgÁdi VaÔÍ- 1-1 tab. four times for chewing.
Beside these therapeutic measures, the other Ayurvedic drugs should be
incorporated in the prescription, based on the clinical symptomatology of the patient
viz.•
•
•
•
•
•
In non-productive cough: ÏéÉgyÁdi CÚrÆa- 2 gms BID, AgastyaharÍtakÍ- 5
gms TDS, TaÉkaÆa- 500 mg TID, YvakÒÁra- 500 mg TID, Ïuddha NarasÁra250 mg TID, ÏigrÚguggulu-250 TIDetc are to be given.
In productive cough: CandrÁméta Rasa- 200 mg TID, Abhraka Bhasma250 mg TID, Malla SindÚra- 75 mg TID, ÏéÉgÁbhra Rasa- 250 mg TID,
Kaphaketu Rasa- 125 mg, VÁsÁriÒÔa- 20 ml BID etc. are to be given with
honey.
In presence of fiver: SañjÍvanÍ VaÔÍ 250 mg BID, GodantÍ bhasma- 500 mg
TID, AmétÁriÒÔa-20 ml BID etc are to to given.
In KÒataja KÁsa- PrÁvÁla PañcÁméta-250 mg TID, LÁkÒÁ CÚrÆa- 1 gm,
MuktÁpiÒÔÍ- 250 mg TID, VásÁdi avaleha- 3 gm TID, ElÁdi VaÔÍ- 1-1 tab four
times of chewing, and CaÉdanabalÁlÁkÒÁdi Taila of local application.
In Rajayaksma i.e-tuberculosis1. Anti TridoÒa regimen should be followed as per rule.
2. Virecana Karma is contraindicated because there is indication to
restore Mala.
3. The following Ayurvedic drugs should be used along with with antitubercular drugs for better management viz- SvarÆavasantamÁtÍ rasa250 mg TID, Candramrta rasa- 250 mg TID, Sarvajvarahara lauha250 mg TID, CyavanaprÁÐÁvaleha- 5 gms BID, DrÁkÒÁriÒÔa- 20 ml
BID after meal, CaÉdanÁdi Taila – for local application.
In Bronchial-asthma- Mild purgative should be given in elderly age group.
1. Acute stage: Soma CÚrÆa- 1 gm BID with honey and KanakÁsava- 20
ml BID with 250 mg of Narasara and equal quantity of water.
2. Chronic stage: ÏvÁsakuÔhÁra rasa -125 mg TID, ÏvÁsakÁsacintÁmaÆi250 mg, TÁlÍÐÁdi CúrÆa - 2gm TID, VÁsÁsvarasa- 20 ml BID,
ÏigrÚguggulu-250 TID, ÏirÍÒÁdi kaÒÁya-20 ml BID etc.
3. Asthma due to cardiac origin- NÁgÁrjunÁbhra rasa- 250 mg TID,
PuÒkarabrÁhmÍ guggulu- 250 mg BID, KaravÍrayoga-500 mg TID,
ÏvetaparpaÔÍ- 250 mg TID, HédyÁrÆava rasa- 200 mg BID,
ArjunÁriÒÔa- 20 ml BID with equal quantity of water, after meal.
247
•
•
•
In common cold: CitrakaharÍtakÍ- 3 gms BID with hot water, ÏirÍÒÁdi
kaÒÁya, or GojihvÁdi kaÒÁya- 20 ml BID, ÏigrÚguggulu- 250 TID,
HaridrÁkhaÆÕa- 3 to 4 gms BID with honey.
In lateral chest pain: PuÒkaramÚlÁdi CÚrÆa- 2gms BID, DaÐamÚlariÒÔa- 20
ml BID, Rest of the treatment is similar to KÁsa.
In Hemoptysis: PravÁlapiÒÔÍ- 250 mg BID, Bolabaddharasa- 250 mg BID,
LÁkÒÁ CÚrÆa- 1 gm BID ÏéÉgbhasma- 250 mg TID etc are to be given with
VÁsÁsvarasa and honey.
Recommended Further Reading
1. American thoracic Society. Treatment of tuberculosis and tuberculosis
infection in adults and children. Am J Respir Crit Care Med 1994;
149:1359-1374.
2. Braman SS. Aging and lung: physiology and clinical consequences. Pulm
Perspectives, Northbrook, IL: American College of chest Physician, 1997;
14:6-8.
3. Braman SS. Asthma in the elderly. Contemp Intern Med 1995; 7: 13-24.
4. Ferguson GT, Cherniak RM. Management of chronic obstructive pulmonary
disease. N Engl J Med 1993; 328:1017-1022
5. Holtage ST, Dow L. Airways disease in the elderly: an easy to miss
diagnosis. J Respir Dis 1988; 9: 14-22.
6. Mountain CF. Revision in the International system for Staging of Lung
Cancer. Chest 1997; 111:1710-1717.
7. Miller RA. The aging immune system: Primer and Prospetctus. Science
1996; 273:70-74..
8. Saviteer SM, Samsa GP, Rutala WA. Nosocomial infections in the elderly:
increased risk per hospital day. Am J Med 1988; 84:661-666
9. Sharma PV. Classical uses of medicinal plants, 1986: Chaukhambha
Publications, Varanasi
10. Singh R.H. Ayurvediya Nidana Cikitsa ke Siddhanta, Vol.II, (1985).
Chaukhambha Amarbharti Prakasan. Varanasi.
11. Singh R.H. (2005): Kayachikitsa Vol II Section 3. Chaukhambha Surabharati
Prakashana, Varanasi.
12. Singh R.H. Panchakarma therapy: 2nd Ed (2002); Chaukhambha Sanskrit
Sereis office, Varanasi.
13. Singh R.H. The holistic principles of Ayurvedic Medicine, 1998.
Chaukhambha Publications, Varanasi
14. Standards for the diagnosis and treatment of patients with COPD: a summary
of the ATS/ERS position paper. Eur. Respire J 2004; 23:932-946.
15. Yellin A, Benfield JR. Surgery for bronchogenic carcinoma in the elderly.
Am Rev Respir Dis 1985; 131-197.
16. Yoshikawa TT. Antimicrobial therapy for the elderly patient. J Am Geriar
Soc 1990; 38:1353-1372.
248
Chapter-15
Agni Evam Mahasrotas Vikara in Jaravastha
(Gastro-Intestinal Diseases of the old age and their
care)
Introduction
Besides many other factors Agni plays an important role in aging process. In
elderly age VÁta doÒa becomes overt and Agni is notably depleted. This
situation augments senility. Hence, in principles it is advocated to promote
Agni and to palliate VÁta doÒa in order to retard aging. In the same sequence
the elderly persons suffer from diseases and disorders hall-marked with
aggravated VÁta and depleted Agni. Therefore promotion of Agni is the sheat
anchor in Geriatric health care. The present chapter intends to present a brief
account of the role of Agni in aging, common GIT diseases of old age and their
routine care. For specialized care the readers are advised to refer to specialty
literature.
Concept of Agni (Body fire)
Concept of Agni in Ayurveda: The concept of Agni is original contribution of
Ayurveda. According to Atreya in Charaka Samhita that one dies if this Agni
(fire) is extinguished, lives long free from disorders if it is functioning
properly, gets ill if it is deranged, hence Agni (digestive and metabolic fire) is
the root cause of all ailments.
Types of Agni
Thirteen types of body fire (Agni) have been enumerated in Ayurvedic classics,
their locations are also described, which are as follows:
Type of Agni
Number
Location
JatharÁgni
One
GrahaÆÍ
DhatvÁgni
Seven
Rasa-rakta-mÁmsa-meda-asthi-majjÁÐukra
BhutÁgni
Five
Péthvi-ap-tejas-vÁyu-ÁkÁÐa
Of these, JatharÁgni (digestive fire) is regarded as the master of all agnis
because increase and decrease of other agnis depends on the digestive fire.
Hence one should maintain it carefully by taking properly the wholesome food
and drinks because the maintenance of life span depends on Agni VyÁpÁra.
The normal digestive fire (SamÁgni) in a person taking proper food maintains
the equilibrium of dhÁtus by regular digestion.
249
Master of All Agnis
The Agni which digests food is regarded as master of all agnis because increase
and decrease of other Agnis depend on the digestive power. The food nourishes
dhÁtus, ojas, strength; complexion etc depending on Agni because rasa-raktamÁmsa-meda-asthi-majjÁ-Ðukra and finally ojas (pure essence) can't be
produced from undigested food.
Importance of Agni
Àyu (life span), VarÆa (complexion), Bala (strength), SvÁsthya (health), UtsÁha
(enthusiasm), Upacaya (corpulence), PrabhÁ (lusture), Ojas (pure essence of
sapta dhÁtus), Teja (energy) Agni (heat processes), PrÁÆa (vital breath) - all
these depend on bio fire.
Location of JaÔharÁgni
The PrÁÆa vÁyu when receiving function caries the food to the ÁmÁÐaya
(stomach) where the food is disintegrated by fluids (digestive juices) and
softened by fatty substances gets acted upon by the digestive fire (JaÔharÁgni)
shaken to enhance by the samÁna vÁyu. Thus the digestive fire cooks from
below the food situated in the stomach for division into rasa (nutritive fraction)
and mala (excretion) in the same way as it cooks the rice grains with water kept
in a vessel and transform into boiled rice. GrahaÆÍ is the seat of Agni and is
called so because of holding food.
Location of DhÁtvagni
The dhÁtus-rasa-rakta-mÁmsa-meda-asthi-majjÁ-Ðukra supporting the body
undergoe two-fold conversion into excretion and essence having been acted
upon by the respective one of the seven agnis. Thus it is obvious that seven
agnis are located in respective dhÁtus present in the body.
Location of BhÚtÁgni
Five Agnis pertaining each to péthvi, ap, tejas, vÁyu and ÁkÁÐa digest the
respective fraction of the food and nourishes respective properties of bhÚtas.
One who is in depleting state of Agni feels his heart as stretched, abdomen as
still and heavy and has foul, sweet eructaions, malaise and lack of desire for
women. He passes stool as broken mixed with Áma and mucus and heavy.
Though not emaciated he has debility and lassitude.
Deranged JaÔharÁgni and Its Types
Three types of Vikéta JaÔharÁgni (deranged digestive Agni): ViÒama (irregular),
TikÒÆa (intense), Manda (diminished) have been enumerated. TikÒÆa,
MandÁgni and ViÒamÁgni lead to disorders in the body. Digestive fire if
irregular causes disequilibrium in dhÁtus because of irregular digestion and if
250
intense having little fuel dries up the dhÁtus. Diminished digestive fire burns
the food incompletely which goes either upwards or downwards.
Etiology
The grahaÆÍ disorder is caused by VÁta, Pitta and Kapha and all three doÒas
combined. VÁyu is vitiated due to intake of kaÔu (pungent), tikta (bitter), kaÒÁya
(astringent), atirukÒa (too rough) and ÐÍta (cold) articles, little or no food, too
much traveling on foot, suppression of urges, excessive sexual intercourse,
envelop the agni and thus makes it sluggish.
Aetiopathogenesis
Because of this, food is digested with difficulty and hyperacidity associated
with coarseness in body, dryness in throat and mouth, hunger, thirst, blurred
vision, tinnitus, frequent pain in sides, thighs, groin and neck, visÚcikÁ, cardiac
pain, emaciation, debility, abnormal taste in mouth, cutting pain in abdomen,
greed for every food item, lassitude, tympanitis during and after taking meal,
suspicion of vÁtagulma, heart disease or splenomegaly arise.
The patient passes stool as liquid, dried, thin, undigested, with sound and froth
frequently and with difficulty after a long time. He also suffers from cough and
dyspnoea.
By intake of pungent, uncooked, burning, sour, alkaline food etc. pitta gets
aggravated and extinguishes the fire by flooding over like hot water. Thus the
patient having yellowish lusture passes frequently undigested bluish or
yellowish liquid stool associated with fetid and sour eructation, burning in
cardiac region and throat, anorexia and thirst.
Kapha aggravated by intake of food, which is heavy, too unctuous, cold etc.
over-eating and sleeping just after meals extinguishes the fire. Then the
affected person digests the food with difficulty and is inflicted with nausea,
vomiting, anorexia, sliminess and sweetness in mouth, cough, spitting and
coryza.
Thirteen types of body fire (deha-agni) i.e. JaÔharÁgni one, DhÁtvagni-seven
and BhutÁgni-five are described in Ayurveda. Their locations and functions are
also described. In aged persons this JaÔharÁgni is deranged due to vitiated vÁta,
therefore, utmost care of JaÔharÁgni is needed to maintain it properly in all
elderly individuals.
251
DehÁgni (Body Fire) and its Disorders
The JaÔharÁgni is the master Agni and governs all other Agnis.
• The seven agnis pertaining to each to Rasa-rakta-mÁmsa-meda-asthimajjÁ-Ðukra (the dhÁtus supporting the body) undergo two fold
conversion into excretion and essence having been acted upon by the
respective one of the seven agnis.
• Five agnis pertaining to péthvi, ap, tejas, vÁyu and ÁkÁÐa digest the
respective fraction of the food and nourishes respective counterparts in
the body.
Cause of Vikéta Agni:
Agni is deranged by abhojana (fasting), ajÍrÆa (eating during
indigestion/improper digestion / during process of digestion) atibhojana (over
eating), viÒamÁsana (irregular eating), asÁtmya (not suitable to prakéti of an
individual), guru (heavy), ÐÍta (cold), atirukÒa (excessive rough) and samduÒÔa
bhojana (contaminated food), vireka (purgation), vamana (emesis), sneha
(unction), vibhrama (confusion), vyÁdhikarÒaÆa (emaciation due to disease),
deÐa, kÁla and étu vaiÒamya (abrupt change of place, time and season),
vegavidhÁraÆa (suppression of natural urges). The Agni thus deranged becomes
unable to digest even the light food and the food being undigested gets
acidified and becomes toxic i.e AnnaviÒa.
• This toxic substance: When combines with Kapha, it gives rise to
YakÒmÁ (phthisis), PÍnasa (coryza) Kaphaja prameha (diabetes mellitus)
and other kaphaja disorders. When combines with pitta it produces
burning sensation, thirst, disorders of mouth, acid gastritis and other
paittika disorders. When combines with vÁta, it produces various vÁtika
disorders.
• Persisting deranged agni causes early ageing and various disorders
in the body, therefore, one must take care of agni.
•
MahÁsrotasa, its VikÁra and JarÁ-avasthÁ
MahÁsrotasa has three major parts,
• ÀmÁÐaya: (stomach) is the seat where ingested food is collected.
• GrahaÆÍ : GrahaÆÍ is the seat of agni is called so because of holding up
the food. It is situated in between the ÀmÁÐaya (stomach) and pakvÁÐaya
(large intestine).
• PakvÁÐaya: The seat where digested food from GrahaÆÍ is forwarded, in
other words the seat where digested food is retained for absorption.
ÀmÁÐaya is known as seat of ÐleÒmÁ, GrahaÆÍ as seat of Pitta and PakvÁÐaya
is the seat of VÁta.
A person suffering from disorders of Agni at different levels if do not take
proper treatment leads to early JarÁ-avasthÁ or premature aging.
252
In JarÁ-avasthÁ due to vitiation of VÁta, the commonest complaint is difficult
defecation. In all such cases, a person should be given laghu (light), drava
(liquid), snigdha (unctuous), pichhila (sliminess) dietary substances to combat
VÁta.
Identification of AuÒadha Dravyas and their influence on Agni
•
In all such patients and in JarÁ-avasthÁ, Agni is diminished at various
levels. For them DÍpaniya drugs have been advocated. DÍpaniya drugs
are those, which stimulate JaÔharÁgni (digestive fire). Digestive fire is
known as root of all agnis. Stimulation of JaÔharÁgni ultimately
influences DhÁtvÁgni and BhutÁgni too. In Caraka Samhita following
drugs are described in DÍpaniya MahÁkaÒÁya, they are: PippalÍ (Piper
longum), PippalÍmÚla (root of Piper longum), Cavya (Piper chava),
Citraka (Plumbago zeylanica), Ïéngavera (Zingiber officinalis),
Amlavetasa (Hippophoe rhamnoides), Marica (Piper nigrum), AjamodÁ
(Carum roxburghianum), BhallÁtakÁsthi (nut of Semecarpus
anacardium), Hingu niryÁsa (exudate of Ferula foeitida).
•
Identification of fruit and root of Piper longum, leaf and fruit of Cavya,
root of Plumbago zeylamica, rhizome of Zingiber officinalis, fruit of
Hypophae rhamnoides), fruit of Piper nigrum, fruit of Carum
roxburghianum, nut of Semecarpus anacardium and exudate of Ferula
foctida is very much essential for their desired effects.
RasÁyana remedies for VÁrdhakya
•
According to Caraka the means by which one gets the excellent rasÁdi
saptadhÁtus-rasa-rakta-mÁmsa-meda-asthi-majjÁ and Ðukra are
RasÁyana. The very object of RasÁyana is to live long life through
better nutrition.
•
In VÁrdhakya saptadhÁtus kÒaya is one of the main features which lead
to senility and various disorders in accordance with the rasÁdi
saptadhÁtus.
•
Caraka Samhita, Susruta Samhita and Samhitas of Vagbhatta describe
hundreds of RasÁyana drugs of plant origin many of which are
commonly available even today for use. (See Chapter -4)
•
Several Compound pharmaceutical forms are also available for the
promotion of health in vÁrdhakya
Influence of ÀhÁradravya on Deha-Agni
•
All substances of audbhida (plant) and jÁngama (animal) origin having
Guru (heavy), ÏÍta (cold), RukÒa (non-unctuous), TikÒna (sharp), Sara
(unstable), KaÔhina (hard), Khara (rough) SthÚla (gross) and SÁndra
(solid) if taken regularly cause derangement of DehÁgni- JaÔharÁgni and
253
DhÁtvÁgni, which ultimately lead to improper formation of saptadhÁtusrasa-rakta-mÁmsa-meda-asthi-majjÁ and Ðukra.
•
Substances of above two origin having laghu (light), uÒÆa (hot),
snigdha (unctous), manda (mild), sthira (stable), médu (soft), viÐada
(non-slimy), ÐlakÒÆa (smooth), sÚkÒma (fine) and drava (liquid) are
good to maintain DehÁgni- JaÔharÁgni and DhÁtvÁgni. They never cause
derangement in JaÔharÁgni and thus DhÁtvagni also act properly in the
formation of rasa-rakta-mÁmsa-meda-asthi-majjÁ and Ðukra.
Therefore, in jarÁvasthÁ, laghu, uÒÆa, snigdha, manda, sthira, médu, ÐlakÒÆa,
and drava substances, would be best to maintain dehÁgni and in the formation
of saptadhÁtus.
Substances having Madhura rasa but not guru and ÐÍta in guna like hot cows
milk, amla rasa but not TikÒna, uÒÆa in guna like Àmalaki fruit; tikta rasa but
not RukÒa and ÐÍta like guÕÚci would be beneficial in jarÁvasthÁ.
The GIT Disorders of Elderly and their Management
The common GIT diseases prevalent in old age are AgnimÁndya, AjÍrÆa,
Vivandha, ÀnÁnha, JarÁtisÁra, grahaÆÍ roga, PakvÁÐayagata vÁta vyÁdhi or
Irritable Bowel Syndrome, Inflammatory Bowel disease, ArÐa, Bhagandara,
Ántra cyuti or Hernia- Inguinal and ventral, Gulma, Udara roga, UdÁvarta,
Dyspepsia, GIT Malignancies, specially Cancer of colon.
All these condition will have to be diagnosed in routine manner with necessary
diagnostic aids avoiding extensive invasive techniques in view of the fragile
health. However management strategies will have to be planned in special
consideration of the old age and associate diseases. The dosage schedule and
safety precautions will have to be given special importance besides careful
monitoring. Remedies for few very common clinical conditions are described
below.
1. Constipation is the commonest complaint of the elderly people. The safe
prescription are Haritaki curna 5-6 Gms at bed time or TriphalÁ curna 1-2
Tea Sponfull at bed time. Those who prefer liquid preparations AbhayÁriÒÔa
20-25 ml once daily at bed time is given. Many patients especially those
suffering from IBS do well with Isabgol 10 Gms at bed time. EraÆÕa Sneha
15-20 ml or Trivéta curÆa 6 Gms or MadhuyaÒÔÍ curÆa 6 Gms may be
preferred in certain cases. Higher doses of strong purgatives like
preparations containing Senna and JaipÁla (JamÁlaghoÔÁ) should be
avoided. The patient may be advised to take plenty of fluids and green
vegetables and fruits in daily diet.
2. AgnimÁndya with loss of appetite and digestion deficit is another important
complaint. DÍpana and PÁcana remedies are prescribed. CitrakÁdi vaÔÍ 2
pills chewed before each meal promotes appetite and improves relish.
Ginger with salt chewed in the beginning of a meal is also a good appetizer.
HingvaÒtaka curÆa with a spoon of ghee in the first feed is a good
254
3.
4.
5.
6.
appetizer. HingvÁdi vaÔÍ or LasunÁdi, ArkapuÒpÁdi vaÔÍ, Kupilu HingvÁdi
vaÔÍ, Agni TuÆdÍ vaÔÍ, PÁcana curÆa and Bhaskara lavana are good DÍpana,
PÁcana formulations and are used in the dose of 3-4 Gms twice a day after
15-20 minutes after major meals.
Diarrhoea of different severity and duration may need management in an
elderly person. Suitable Ayurvedic recipes are KutajÁriÒta, BilvÁsava,
Kutaja Bilva PÁnaka, KutajÁdi ViÐeÒa yoga, DÁÕima Catuísama,
ÏatapuÒpÁdi curÆa, GangÁdhara curÆa, LÁyi curÆa in suitable doses.
Acidity, Dyspepsias, Amlapitta or PariÆÁma ÏÚla are treated with Ïankha
vaÔÍ, Ïankha BhaÒma, SÚta Ïekhara Rasa, Àmalaki RasÁyana and DhÁtri
Lauha etc.
Irritable Bowel Syndrome, Inflammatory Bowel Disease and suspected
malignancies of large intestine may need careful diagnostic assessment for
specialized care but in all such cases use of Ayurvedic medications like
preparations of Bilva, Isabgol alongwith Medhya RasÁyana recipes are of
great help. PicchÁ Vasti should be tried in all such cases with benefit.
Non drug prescriptions of suitable dietary regimen, relaxing stressfree life
style, Satsanga and YogÁbhyÁsa should be encouraged in all patients of
older age groups. PrÁÆÁyÁma and Meditation should also be introduced and
the patient should always be kept under observation for any probable
progression of the disease.
Recommended further reading
1. Caraka, Caraka Samhita, Cikitsa sthana, Chapter 15. Ed. Sharma P V.
Chaukhambha Orientalia, Varanasi
2. Madhava, Madhava Nidana Chapter 4, Ed. Singhal et al, Chaukhambha
Surbharati, Varanasi.
3. Sharma P V (2000) Dravayguna Sutram, Chaukhambha Publications,
Varanasi.
4. Singh, R H (2001) Kayachikitsa Vol. II Section I, Chukhambha Surbharati
Prakasana, Varanasi.
5. Sushruta, Sushrita Samhita Ed. Singhal, G D et al. Chaukhambha
Surbharati, Varanasi.
6. Udupa K N and Singh R H (1978) science and philosophy of Indian
Medicine, Baidyanath Ayurveda Bhawan, Nagpur
255
Chapter-16
Musculoskeletal & Joint Diseases in the Elderly
Introduction
Musculoskeletal pain and discomfort are common complaints for older adults.
It is observed that arthritis is the leading chronic disease that increases in
prevalence and incidence with age. The number of adults who present to
primary physicians with arthritic complaints exceeds only by those with
cardiovascular diseases and perhaps respiratory diseases. All this means that
the subject of arthritis in older persons is a highly relevant concern to primary
physicians and one in which training and education in this field for these health
care providers are necessary.
In Ayurveda, musculoskeletal diseases are described under various diseases.
Among them the major diseases are ÀmavÁta, SandhivÁta, VÁtarakta,
AsthikÒaya, Kraustuka Ðhirsa, which are described in the ancient classical
Samhitas.
Issues and concerns in musculoskeletal diseases in the elderly
• The diagnosis and management of joint pain in elderly can be a difficult
process and one that is often complicated by diagnostic uncertainty
because of atypical manifestations and the presence of co morbid
conditions.
• The care of older adults with Rheumatic conditions challenges the
practitioners at several levels. Symptom reporting and the clinical
presentations may differ in older adults.
• Patient may mistakenly attribute their painful and other symptoms to
“old age” and dismiss them without reporting these to a physician.
• Patient may also inaccurately attribute their musculoskeletal pain to
arthritis without necessary medical confirmation.
• High prevalence of certain specific conditions such as Osteoarthritis and
Polymayalgia Rheumatica and its greatest impact on elderly that results
from immobility.
• The superimposition of arthritic disorders on other medical problems
prevalent in the elderly such as cardiovascular diseases, respiratory
diseases and other systemic diseases.
• The use of multiple medications by the elderly for multiple conditions
thereby creating the potential for adverse effects from drug interactions.
• Clinicians are also challenged by atypical non-classical and even vague
presentations of arthritic disorders that may lead to inappropriate
diagnosis.
256
Common Musculoskeletal diseases in elderly
Though there are number of diseases causing joint pain in elderly but the major
and important diseases which are prevalent can be categorized under two broad
headings.
1. Articular
SandhivÁta (Osteoarthritis)
ÀmavÁta (Rheumatoid Arthritis)
VÁtarakta (Gout)
AsthikÒaya (Osteoprosis)
2. Periarticular
Polymyalgia Rheumatica (PMR)
Giant Cell Arteritis
Others
Causes and other factors for various joint disorders
Factors contributing to the high prevalence of musculoskeletal problem in
elderly population are as mentioned below.
1.
2.
3.
Aging effects on components of the musculoskeletal system leading
to osteoarthritis and osteoporosis.
• The skeleton
• Articular cartilage
• Soft tissues (muscle, ligaments, tendons, meniscus, joint capsule)
• Neurological function (joint proprioception)
Common disorders with peak incidence in younger adults but which
cause increasing pain and disability with age without shortening life
span.
• Rheumatoid arthritis
• Seronegative Spondarthritides
• Musculoskeletal trauma
Other disorders of the musculoskeletal system with a high incidence
• Crystal related arthropathies
• Polymyalgia Rheumatica
Aetiology of the diseases described in Ayurveda
SandhivÁta:
No specific etiology of SandhivÁta is mentioned. The etiology of VÁtavyÁdhi in
general has to be taken as etiological factors for SandhivÁta too.
Two mechanisms are involved in vÁta prakopa27
• DhÁtukÒaya
• MÁrgÁvarodha
27
Okk;ks/kkZrq{k;kRdksiks ekxZL;koj.ksu okA ¼p- fp- 28%59½
vÁyordhÁtukÒayÁtkopo mÁrgasyavareÆa vÁ . ( ca. ci. 28:59)
257
General etiology:
ÀhÁraja NidÁna (Dietary factors): Excessive indulgence of atirukÒa katu,
tikta, kaÒÁya/ÐÍta/laghu dietary articles and alpamÁtrÁ
VihÁraja (Life style related) Atimaithuna, vegÁvarodha, langhana,
rÁtrijÁgaraÆa, atipathagamana.
MÁnasika NidÁna (Mental Factors): CintÁ, Ðoka, krodha bhaya etc
Àgantuja (Traumatic): AbhighÁta, MarmÁbhighÁta
ètujanya (Seasonal Factors) : VarÒÁ étu, PrÁgvÁta étu, Ïarada étu.
ÀmavÁta
It is discussed under three headings:
A.
Direct etiological factors28: (Responsible for both Àmotpatti and
VÁta Prakopa)
ViruddhÁhÁra : One must take proper quantity and quality of diet as per
his own agnibala (Digestive power). Eighteen factors are responsible
for dietetic incompatibilities. Eight qualities of diet and dietetics that is
called as aÒtÁhÁra vidhiviÐeÒÁyatana which are the guidelines for ideal
diet. If it is not followed properly, these may act as causative factors for
the diseases.
Viruddha ceÒtÁ: Any type of improper exercise is also considered as
causative factor for ÀmavÁta.
MandÁgni:
It is a major etiological factor for the development of
ÀmavÁta.
AniÐcalatva (sedentary life style): A person who is very lethargic and do
very limited physical activity, kapha doÒa increases and gets vitiated
leading to production of Àma.
VyÁyÁma soon after consuming Snigdha ÁhÁra is a causative factor for
ÀmavÁta.
B.
Causes of Àmotpatti
Dietetic indiscretions: Abstinence from food, over eating, indigestion,
and ingestion of unwholesome food, heavy, indigestible food or cold
food.
Adverse effect of therapeutic measures like Virecana, Vamana,
Snehana, Basti etc.
Incapability of climate culture, weather.
Psychological factors like anger, rage, greed, anxiety etc.
All above factors affect the jaÔharÁgni that produces Áma.
C.
Causes of vÁtaprakopa
28
fo#)kgkjps’VL; eUnkXusfuZ”pyL; pA fLuX/ka HkqDrorks º;Uua O;k;kea dqoZrLrFkkAA ¼ek- fu- 25%1½
viªddhÁhÁraceÒtasya mandÁgnerniÐcasya ca, snigdhaï bhuktavato hyannaï vyÁyÁmaï
kurvatastathÁ . ( Ma. Ni. 25:1)
258
ÀhÁra
:
VihÁra
MÁnasika vikÁra
:
:
RukÒa, ÏÍta, Laghu, Alpa
ÀhÁra Sevan
Excess VyavÁya, VyÁyÁma etc.
CintÁ, Ïoka, Bhaya, etc.
VÁtarakta
ÀhÁra29 (Dietary factors):
Excessive intake of saline, Sour, Pungent, Alkaline, unctuous-hotuncooked food and oily substances.
Intake of putrified or dry meat of aquatic animals.
Excessive intake of kulattha. mulaÐaka, mÁÒa, leafy vegetables and
meat.
Excessive intake of curd, kÁnji, and different types of alcoholic and milk
products.
VihÁra30 (Life style related):
Intake of food before previous meal is not digested.
Sleeping during day time and remaining awake at right.
Riding over horses, camels or vehicles drawn by them. Excessive
aquatic games, swimming and jumping, indulgence in sexual
intercourse.
Suppression of nature urges, lazy and obese having high sugar diet,
sedentary life style.
AsthikÒaya
The common etiological factors are vÁtika ÁhÁra and vihÁra, Ati VyÁyÁma, Ati
samkÒobha, and excessive rubbing of the bones etc.
Clinical Presentations
SandhivÁta (Osteoarthritis):
It is a heterogeneous condition with a variety of causes and pattern of
expression. Older age is the most significant factor in its development in
a general population. The joint most commonly affected is the knee and
osteoarthritis of knee is one of the most common causes of pain and
disability.
Epidemiology
• Prevalence rises steeply with age after 50 in men and age 40 in
women.
29
yo.kkEydVq{kkjfLuX/kks’.kkth.kZ HkktuS%A fDyUu”kq.dkEcqtkuwiekalfi.;kdewydS%AA
dqyRFkek’kfu’iko”kkdkfniyys{kqfHk%A n/;kjukylkSohj”kqDrrdzlqjkloS%AA ¼ek- fu- 23% 1] 2½
lavaÆÁmlakatÚkÒÁrasnigdhoÒÆÁjÍrÆa bhÁjanai, klinnaÐuÒkÁïbujÁnÚpamÁïsapiÆyÁkamulakaih .
kulatthamÁÒaniÒpÁvaÐÁkÁdipalalekÒubhih, dadhyÁrnÁlasauvÍraÐuktatakrasurÁsavaih .
( Ma. Ni. 23 :1,2)
30
fo#)k/;”kudzks/kfnokLoIuiztkxjS%A ¼p- fp- 29%6½
izk;”k% lqdqekjk.kka feF;kgkjfogkfj.kke~A LFkwykuka lqf[kuka pkfi dqI;rs okr”kksf.kre~AA ¼lq- fp- 5%5½
virÚddhÁdhyaÐanakrodhadivÁsvapnaprajÁgaraih. ( ca. ci. 29:6)
prÁyaÐah sukumÁrÁÆÁÞ mithyÁhÁravihÁriÆÁm , sthÚlÁnÁm sukhinÁm cÁpi kupyate vÁtaÐoÆitam.
(Su. Ci. 5:5)
259
• Hand and knee osteoarthritis are more common in women than
men.
• Hip Osteoarthritis is less common and its prevalence rate in men
and women appear to be more similar.
• Polyarticular osteoarthritis and isolated knee arthritis are slightly
more common in women than men.
Clinical Features
The clinical presentations as described in Ayurveda31 are
ÏÚla (Pain and inability to movement of joint)
Ïopha (Swelling)
ÀÔopa (Crepitus)
Stambha (Stiffness)
The typical clinical presentations as described in modern medicine are:
• Pain: Intensity is mild to moderate. Worsened by use of involved
joints and improved with rest. Pain at rest or during the night
usually indicated severe diseases. Early in the course pain is
usually localized.
•
Morning Stiffness: Stiffness after inactivity that improves with
use of the joint. The stiffness can last
from 5-30 min and can involve one or
more joints.
Bony swelling: Bony Swellings are
•
found around the involved joints. The
most characteristic bony swelling is
the Heberden’s and Bouchard’s nodes
Osteoarthritis which reveals Heberden’s and
of hand osteoarthritis.
Bouchard’s
nodes.Note
the
bony
enlargement of the distal and proximal
interphalangeal joints.
Source: www.arthritispractitioner.com
• Crepitus: Coarse crepitations are usually felt on movement of
involved joint. In severe disease condition they can be audible.
• Joint deformities: Progressive deformities in the involved joint
• Deficit in range of motion (ROM)/ Loss of movement
• Instability
• Loss of function
ÀmavÁta (Rheumatoid arthritis)
Rheumatoid arthritis is a relatively common medical problem in the
elderly, which is a chronic inflammatory systemic disease that produces
its most prominent manifestations in the hinged joints. It is usually
polyarticular and symmetrical in distribution.
Epidemiology
• Prevalence increases with age and especially frequent in elderly
women.
31
gfUr lfU/kxr% lU/khu~ “kwykVikS djksfr pAA ¼ ek- fu- 22%21½
hanti sandhigata sandhÍu ÐúlÁtapau karoti ca . (Ma. Ni. 22:21)
260
• The highest incidence is found in 4th & 5th decades but new cases
continue to arise in 9th decade.
Clinical Features
The clinical features as described in Ayurveda are divided into two
categories
1.
SÁmÁnyalakÒaÆa32 (General symptoms) :
Angamarda (Pain all over the body), Gaurava (Heaviness),
TriÒÆÁ (Thirst), Aruci (Loss of Taste), AngaÐÚnatÁ (Swelling of
body parts), Jvara (Fever), Àlasya (Lack of enthusiasm), ApÁka
(Indigestion)
2.
Pravéddha lakÒaÆa33 (specific symptoms)
SarÚjaÐotha and VéÐcikadaÞÐa vedanÁ in Hasta, pÁda, Ðiro,
Gulpha, Trika, JÁnÚ and UrÚ Sandhi which shift from place to
place (Sweling and pain resembling scorpion bite in the joints of
hands, feet, cervical region like skull, ankle, sacrum, knee and
thigh.
Besides these above symptome other symptoms include
Agnidaurbalya (Poor disetion), Antrakujana (Intestinal
gurglings), Aruci (Anorexia), GÁtragaurava (Heaviness of the
body), LÁlÁpraseka (Salivation), Vairasya (Bad taste in the
mouth), DÁha (Burning Sensation), UtsÁhahÁni (Lack of
enthusiasm), KukÒi kÁÔinatÁ (Hardness and pain in abdomen),
Chardi (Vomiting), BahumutratÁ (Profuse urination), MÚrchÁ
(Fainting), Hédgraha( Pain in precordial region), Bhrama
(Giddiness), TéÒÆÁ (Thirst), Vidvivandha (Constipation), ÀnÁha
(Distention) etc.
The typical clinical presentations described in modern medicine are:
• Persistent joint inflammation: It is a central diagnostic feature
of Rheumatoid arthritis.
• Swollen, tender and stiff joints
• Morning stiffness: Prolonged and may last over an hour.
Generalized stiffness can precede or accompany the insidious
onset of arthritis in the small joints of hands and feet, wrists and
knees.
32
vaxenksZ·#fpLr`’.kk º;kyL;a xkSjoa Toj% A vikd% ”kwurk·axkukekeokrL; y{k.ke~AA ¼ek- fu- 25 % 6½
aÉgamardoarucistéÒÆÁ hyÁlasyaÞ gauravaÞ jvara, apÁkah ÐúnatÁÉgÁnÁmÁmavÁtasya lakÒanam.
(Ma. Ni. 25:6)
33
l d’V% loZjksxk.kka ;nk izdqfirks Hkosr~A gLriknf”kjksxqYQf=dtkuw#lfU/k’kqAA
djksfr l#ta ”kksFka ;= nks’k izi|rsA l ns”kks #trs·R;FkSZ O;kfo) bo o`f”pdS%AA
tu;sRlks·fXunkSoZY;a izlsdk#fpxkSjoe~A mRlkggkfu oSjL;a nkga p cgqew=rke~AA
dq{kkS dfBurka ”kwya rFkk funzkfoi;Z;e~A r`V~NfnZHkzeewPNkZ”p g`n~xzga foM~foc)rke~
tkM;kU=dwtekukga d’Vka”pkU;kuqinzoku~AA
¼ek- fu- 25%7&10½
sa kaÒtah sarvarogÁÆÁm yadÁ prakupito bhavet, hastapÁdaÐirogilphatrikajÁnÚrudsndhiÒu
karoti sarujam Ðotham yatra doÒa prapadyate, sa deÐorujateatyartha vyÁviddha iva véÐcikaih
janayetsoagnidaurvalyam prasekÁéci gauravam, utsÁhahÁni vairasyam dÁha ca bahumutratÁm
kukÒau kathinata Ðúlam tathÁ nidrÁviparjayam, tétchardibhramamurchÁ hédgraha (vidvivaddhatÁm
jÁdyÁntrakÚjamÁnÁham kaÒtÁmÐcanyanupadravamn . (Ma. Ni. 25: 7-10)
261
• Symmetrical involvement of joints: Involvement is bilateral,
symmetrical and usually involved the hands (Proximal
interphalangeal and Metacarpophalangeal joints), wrists and feet
(Proximal interphalangeal and Metatarsophanlgeal joints). The
elbows, knees and ankles are often involved as well.
• Constitutional symptoms: Malaise, weight loss, occasional
intermittent fever.
• Deformity of joints on progression of
disease: Ulnar deviation, Swan neck
deformity of fingers.
• Extra-articular features: Subcutaneous
nodules on extensor surface of elbow or
sites of pressure i.e lower back or in
Deformities distinctive to late-stage
some parts of hands.
Rheumatoid arthritis such as ulnar
deviation of the bones of the hands,
or swan-neck deviation of the finger
www.nytimes.com
Difference in the manifestation of RA in elderly
Though the “Elderly onset” Rheumatoid arthritis (EORA) can
present some similar features to those seen in “Younger onset”
Rheumatoid arthritis (YORA), but a subset of EORA patients exhibit
a clinical feature that is quite different, which is mentioned below.
Clinical feature
YORA
EORA
Age of onset
30-50 Years
More than 60 years
Onset
Gradual
Abrupt
Number of joints
Multiple
Few
Type of joints
Small, Distal
Large, Proximal
Morning Stiffness
Moderate
Severe and prolonged
ESR
Normal to high
significantly high
Rheumatoid Factor
Seropositive
Seronegative
VÁtarakta (Gout)
It is a syndrome caused by an inflammatory response to the formation of
urate crystals. These crystals develop secondary to hyperuricemia. It can
occur both in acute and chronic form.
Epidemiology
• In males the hyperuricemia rises steeply after puberty and in
females after the menopause.
• It is rare in children and pre-menopausal women.
• It is uncommon in men under the age of 30 and the peak onset in
men is between 40-50 yrs. In women it occurs later.
Clinical Features
Caraka described the prodromal symptoms34 which are important
because these symptoms precede the fully manifested disease. These
34
Losnks·R;FkZ u ok dk’.;Z Li”kkZKRoa {krs·fr#d~A LkfU/k”kSfFkY;ekyL;a lnua fiM+dksxe%AA
tkuqta?kks#dV;algLriknkaxlfU/k’kqA fuLrksn% LQqj.ka Hksnks xq#Roa lqfIrjso pAA
262
symptoms help in recognizing the disease very early.
• SvedabÁhulya or SvedabhÁva ( Abnormal perspirations)
• KÁrÒÆya (Hyperpigmentation of skin)
• SparÐÁjÆtva ( Anaesthesia)
• KÒateatirÚk (Exaggarated pain on injury)
• SandhiÐaithilya, Àlasya, SadanaI (Sublaxation of joints, Easy
fatigue)
• PiÕakodgama (Tophi or Boils and curbuncles)
• Nistoda, SphuraÆa, Bheda, Supti, KandÚ, in ÐÁkhÁ and Sandhi
(Hyperasthesia)
• Punah punah Sandhi ÐhÚla (Frequent joint pain)
• TvakvaivarÆya and Mandalotpatti (Altered skin colours and
blisters)
Sushruta has described the progression of the disease35 as mentioned
below
• Pain usually starts from the legs
• Pain also starts sometimes even from the hands
• Pain spreads to other parts of the body slowly similar to the
spread of poison of rat bite.
Acharaya Caraka has described the clinical features in two stages.36
UttÁna : Itching, burning sensation, pricking pain, throbbing sensation
and contraction, Skin became brownish black, red or coppery in colour
GambhÍra : Oedema, stiffness, hardness ,excruciating pain in interior of
the body. Blackish brown or coppery colouration of skin, burning
sensation, pricking pain, itching sensation and suppuration of joints.
The natural progression of Gout involves three stages i.e. asymptomatic
hyperuricemia, acute gout, and chronic tophaceous gout (CTG). The
typical clinical presentations are:
1. Asymptomatic hyperuricemia
• It is more frequent than gout.
• Risk of gout increases with a rising level of S.Uric acid.
• Many years of hyperuricemia may precede the onset of acute
gout.
• Many individuals with hyperuricemia do not develop disease.
daMw% lfu/k’kq #XhkwRok HkwRok u”;fr pkld`rA oSo.;Z e.MyksRifRroZkrkl`d iwoZy{k.ke~AA ¼p- fp- 29½
svedoatyrtha na va kÁrÒÆya sparÐÁjÆatvam kÒateatiruk, sandhiÐhaithilyamÁlasyam sadanam piÕokdgama
jÁnÚjanghorÚkatyamsahastapÁdÁÉga sandhiÒu, nistodah sphuraÆam bhedo gurutvam suptireva ca.
kaÆdÚh sandhiÒu rugbhutva bhutva naÐhyati cÁsakét, vaivarÆya maÆdalotpattirvÁtÁsék pÚrvalakÒaÆam.
(Ca. Ci. 29)
35
ikn;kseZwyekLFkk; dnkfp)Lr;ksjfiA vk[kksfoZ’kfeo dzq)a rÌsgeqiliZfrAA ¼lq- fu- 1½
pÁdayormÚlamÁsthÁya kadÁcidhastayorapi, ÀkhorviÒamiva kruddham taddehamupasarpati. (Su. Ni. 1)
36
mRFkkueFk xEHkhja fMfo/ka rr~ izp{krsA Ro³~ekalkJ;eqRrkua xEHkhja RoUrjkJ;e~AA ¼ p- fp- 29½
utthÁnamatha gambhÍram dvividham tat pracakÒate, tvaÉmÁmsÁÐrayamuttanam gambhÍram
tvantarÁÐrayam. ( Ca. Ci. 29)
263
• When there is a severe acute overproduction of Urate, there is a
higher risk of acute gout.
2. Acute gout
• Characterized by rapid onset of pain, its exquisite nature and the
swelling and associated redness around the affected joint.
• The classic presentation is in the first metatarsophalangeal joint.
Many joints may be involved.
• The lower limbs are involved more
frequently than the upper limbs.
• Redness over the affected joints is a
feature that sets gout apart from most
other non-infected causes of arthritis.
The usual presentation of gout is an acute,
extremely painful monoarticular attack that
most
frequently
affects
the
first
metatarsophalangeal joint (great toe)
Source: www.arthritispractitioner.com
• The swelling can be very marked over
the entire region.
• Pain begins in the night or early
morning.
• Affected joint is exclusively tender and
sensitive even to light touch.
A typical case of acute gout involving
the distal interphalangeal joint.
Source: www.arthritispractitioner.com
3. Chronic Tophaceous Gout (CTG)
• Characterized by the formation of Tophi. These are firm nodular
or fusiform swellings more common on the hands and feet and
around the ear.
• The inflammation is often mild although
there can be superadded acute episodes.
• Most of the disability is due to the
presence of tophi that can become
ulcerated and infected.
A case of chronic tophaceous gout
involving both hands
Source:www.arthritispractitioner.com
AsthikÒaya (Osteoporosis)
WHO defines Osteoporosis as a systemic skeletal disease characterized
by low bone mass and micro architectural deterioration of bone tissue
leading to enhanced bone fragility and a consequent increase in fracture
risk.
Epidemiology
• The prevalence of Osteoporosis in the hip increases in women
from 8% in the 7th decade to 47.5% in the ninth decade.
264
• The prevalence of Osteoporosis in the forearm, spine or hip rises
from 21.6 to 70%.
• 54% of 50 years old women sustain osteoporosis related fractures
during their remaining lifetime.
• Significant morbidity, mortality and medical exposure result from
Osteoporosis related fractures.
• Spinal fractures which occur in 25% of women by age 65 cause
pain, deformity and disability.
Clinical Features
Osteoporosis is often asymptomatic and frequently discovered
accidentally. The clinical presentations are:
• Back Pain: Most frequently occurring symptom usually
localized to the midthoracic spine or to the low back.
• Collapse of vertebra: may occur insidiously causing shortened
stature.
• Severe back pain: due to vertebral fractures or severe pain due
to fracture of the neck of femur following trauma in some
patients.
• Recurrent fracture of vertebral bodies: It results in spinal
deformities, kyphosis of the dorsal spine, reduction of the lumbar
lordosis, limitation of the movement of the spine.
Polymyalgia rheumatica (PMR) and Giant Cell Arteritis
(Temporal arteritis)
These two are related diseases that form two ends of a single spectrum.
Epidemiology
• These diseases are relatively uncommon.
• The mean age of onset is 70 yrs with a range of 50-90 yrs.
• Onset is characteristically dramatic and many patients can give
the exact date and time of the first symptoms.
• The incidence of Polymyalgia Rheumatica increases with each
decade over the age 50 but varies with the ethnic background of
population.
Clinical Features common to both
• Both Polymyalgia rheumatica and Giant Cell Arteritis are
associated with fever, fatigue, anorexia, weight loss, depression
and occasional fever.
Clinical Features of Polymyalgia rheumatica
• Onset usually involves pain and stiffness in
muscles of the shoulder and neck.
• There is eventual involvement of the pelvic
girdle in some patients.
Source:www.allaboutarthritis.com
• Symptoms are bilateral and symmetric.
• Stiffness is a predominant feature especially after rest or in the
morning and usually lasts for longer than an hour.
265
• Muscle pain is diffuse, movement accentuates pain and it can be
worse at night.
• There is often an associated synovitis especially of knees, wrists
and small joints of the hands.
• The arthritis may overlap with rheumatoid diseases in an elderly
person.
Clinical Features of Giant Cell Arteritis (temporal Arteritis)
• Headache is a predominant symptom and is present in a majority
of cases.
• It often begins early in the course of the disease and may be
presenting symptom.
• Pain is severe and localized to the temple and may be associated
with scalp tenderness.
• Visual disturbance is seen in 25% of cases, visual loss is less
common but blindness remains a significant risk.
• Rare features include hemiparesis, peripheral neuropathy and
deafness.
Complications, chronicity and prognosis of musculoskeletal disorders
SandhivÁta (Osteoarthritis)
• Progressive cartilage destruction, malalignment, joint effusions
and subchondral e collapse causing irreversible deformity.
• Periarticular muscle atrophy.
• As far as prognosis is concerned symptom remission and
improvement is extremely uncommon. At 10-15 yrs follow up
about half the patients with knee osteoarthritis experienced
deterioration while the other half show no change.
ÀmavÁta (Rheumatoid arthritis)
• Development of extra-articular complications including
cutaneous vasculitis, Gastrointestinal and neurological diseases
and is related to the duration of the disease.
• Early and progressive disability and loss of function beyond that
seen in younger adults with Rheumatoid arthritis due to the
association of other co morbid conditions that work in synergy
with arthritis to enhance disability.
• Prognosis of rheumatoid arthritis is poor. Patients with severe RA
are most likely to die early.
• Late onset seronegative RA is associated with a fairly good
prognosis for most and remits spontaneously for some.
VÁtarakta (Gout)
• Major complication of hyperuricemia is nephrolithiasis from uric
acid stones.
• Multiple joint involvements may be a complication of untreated
Chrinic tophaceous gout.
266
• Recurrent untreated gout attacks and local deposition of urate
destroy bone and joints leading to joint deformities and
remarkable disabilities.
• In view of prognosis, the natural history of acute gout varies;
mild attack may resolve within 1 or 2 days. More severe attacks
may last 1 or 2 weeks.
AsthikÒaya (Osteoporosis)
• Hip fractures are the most clinically significant consequences of
osteoporosis resulting in the greatest morbidity, mortality and
expense.
• There is up to 24% increased mortality within 1 year of hip
fracture and approximately 50% of survivors are incapacitated,
many permanently.
Polymyalgia rheumatica (PMR)
• Symptoms of PMR may cause patients to withdraw from their
usual social activity or produce profound depression.
• Although muscle weakness is uncommon, the patient may be
unstable and subject to falls due to pain and stiffness.
• There may be association of synovitis especially of knees, wrists,
small joints of the hands.
• The arthritis may overlap with rheumatoid diseases in elderly.
Giant Cell Arteritis (Temporal arteritis)
• Blindness remains a significant risk owing to involvement of the
ophthalmic artery which is an end artery.
• Involvement of Coronary artery occasionally leads to myocardial
infarction.
Clinical Diagnosis and Diagnostic problems in the elderly
SandhivÁta (Osteoarthritis)
It is diagnosed by a triad of typical symptoms, physical findings and
Radiographic changes. The American college of Rheumatology has set
forth criteria that have excellent precision for identification of patients
with symptomatic OA and that do not rely solely on Radiographic
findings.
Diagnosis of OA by ACR Criteria:
Hand:
Hand pain, aching or stiffness
And
Hard tissue enlargement of 2 or more select joints
And
Fewer than 3 swollen metacarpophalangeal joints
And
2 or more distal interphalangeal hard tissue enlargement
Or
Deformity in 2 or more select joints
267
Knee:
Hip:
Knee pain
And
Radiographic osteophytes
And
One or more of the following
• Age 50 or more
• Morning stiffness<30 minutes
• Crepitus on motion
Hip pain
And
2 or more of the following
• ESR<10mm/hr.
• Radiographic
femoral
or
acetabular
osteophytes
• Radiographic joint space narrowing
Physical signs:
• Bony joint enlargement may be accompanied by crepitus and
limited range of motion (ROM)
• Heberden’s and Bouchard’s nodes of the distal interphalangaeal
and proximal interphalangeal joints of hand.
• Tenderness on palpation at the joint line, painful motion and
limited range of motion.
Diagnostic Algorithm to Osteoarthritis/Differential diagnosis
Although the diagnosis of OA is straightforward, one should ascertain
that painful symptoms are indeed attributable to OA. Nerve entrapment
and infection and vascular disorders may be mistakenly attributed to OA
when typical radiographic abnormalities are present. In addition
periarticular symptoms and inflammatory diseases may be
superimposed on osteoarthritis. To differentiate the superimposed
conditions on OA, the following algorithm may be helpful.
Algorithmic approach to OA
Are systemic symptoms present?
Yes
• Genralised morning sickness
• Fever
• Anorexia
• Weight loss
• Fatigue
No
Rheumatoid arthritis
Are painful symptoms due to disorders other than or superimposed on
OA
Periarticular
Articular
Systemic
Bursitis
Infectious arthritis
Malignancy
Tendinitis
Crystalline diseases
Neuropathy
Fibromyalgia
Internal derangements
Thyroid disease
Primary bone
Hemarthroditis
Primary muscle
268
Diagnostic problems/special diagnostic considerations in elderly
• Inflammatory OA and destructive diseases in the elderly deserves
special considerations.
• Destructive OA with radiographic findings of rapid severe joint
destruction can be diagnostic problem
• The X-ray changes mimic septic arthritis, Rheumatoid and
seronegative arthritis.
ÀmavÁta (Rheumatoid arthritis)
• Severe and prolonged morning stiffness
• Remission and exacerbation of symptoms
• Presence of subcutaneous nodules
• Symmetrical polyarthritis and joint swelling.
Diagnostic problems/special diagnostic considerations in elderly
• Presentation of an acute arthritis in one large joint or even in
multiple joints should not simply be accepted as acute flare of
Rheumatoid arthritis.
• Fever and especially mental status changes with or without an
elevated blood leukocyte count are clues to make the physician
think rather of septic arthritis.
• Unrecognized septic arthritis can be a highly lethal complication.
• The diagnosis can only be made or excluded by aspirating the
joint and subjecting the fluid for culture and analysis.
• Blood culture may be needed to exclude sub-acute bacterial
endocarditis even the RA is diagnosed in a patient with
polyarthritis, fever, anemia, elevated ESR and a positive test for
RF.
• The differential diagnosis between RA and PMR required
consideration especially when patients with apparent PMR have
synovitis.
VÁtarakta (Gout)
Acute stage:
• Pain in night or early in morning in first metatarsopahalangeal
joint with pain free period between the attacks.
• Tenderness in joints and sensitivity to light touch.
Chronic stage
• Polyarticular pain with out pain free period.
• Tophi can develop in any area.
Diagnostic problems/special diagnostic considerations in elderly
• Sometimes gout present early in its course with polyarticular
involvement and can be easily compared with other form of
arthritis.
• In elderly population, gout is often more indolent and is
frequently mistaken for OA which result in delay in diagnosis.
• In elderly people, polyarticular gout can be the presenting feature
of an attack especially in elderly women.
269
• Precipitating factors for the gout like acute illness, trauma,
surgery, alcohol and drugs deserves attention during diagnosis.
• Associated disorder with the gout seen frequently in elderly are
obesity, hypertension with diuretic therapy, hyperlipidemia and
other vascular disorder along with Diabetes mellitus, which need
special attention during management.
AsthikÒaya (Osteoporosis)
Physical signs
• Localised bone tenderness is usually not a prominent feature.
• Fragility fracture: Most common sites are vertebra, proximal
femur or Hip, distal forearm or wrist.
• Pain at the site of fracture
• Spinal deformities due to recurrent fracture of vertebral bodies,
kyphosis of dorsal spine, scoliosis, reduction of the lumbar
lordosis.
• Limitation of motion of spine, decrease in body height.
• In efficient respiratory motion of the thoracic cage due to
deformity of the thorax may result in recurrent pulmonary
infection.
Diagnostic problems/special diagnostic considerations in elderly
• A through medical history should include question about
menstrual history, nutrition, exercise patterns and family history
of osteoporosis.
• Risk factors such as smoking, alcohol and caffeine intake should
be assessed.
• Causes of secondary osteoporosis like oral steroid therapy, male
hypogonadism, hyperthyroidism, myeloma, skeletal metastasis
and anticonvulsant therapy may be considered to differentiate fro
primary osteoporosis.
• Postmenopausal women should have their height measured once
in a year to assess for loss of height.
• If a height of 2 inches (5 cms.) from pre menopausal height has
occurred, then evaluation of osteoporosis may be done.
Polymyalgia rheumatica (PMR)
Physical sign
• Physically, the patient may appear chronically ill and may have a
depressive effect.
• Range of motion of the shoulder and hip is frequently limited by
pain and stiffness.
• Stiffness is a predominant feature especially after rest or in the
morning.
• Pain & Stiffness: In any place i.e. neck or torso, shoulder &
upper arm, Hips & thighs.
• Presence of morning stiffness lasting over 1 hr. and persistence of
symptoms of more than 2 weeks supports the diagnosis.
270
Diagnostic problems/special diagnostic considerations in elderly
• Since several disorders mimic PMR, it requires special
consideration in the elderly for exclusion of other similar
diseases.
• RA in the elderly patient may begin with months of muscular
aches and stiffness before the onset of inflammatory joint
changes.
• It is suggested that late onset seronegative RA in fact is articular
manifestation of PMR.
• PMR often involved the joints of the fingers and the wrist in a
pattern similar to RA.
• Polymyositis has been confused with PMR but patients with
polymyositis usually have proximal muscle weakness and less
muscular pain.
• Endocrine disorders such as hypothyroidism may have muscular
pain and/or a myopathy with weakness similar to PMR
Giant Cell Arteritis (Temporal arteritis)
• Presence of persistent headache.
• Location of headache is usually temporal. Any location of
headache may occur.
• In absence of headache some patient may be profoundly ill with
constitutional symptoms.
• Sensation of nodules over the scalp, pain in jaws on chewing,
tongue pain, throat pain and unexplained cough.
Diagnostic problems/special diagnostic considerations in elderly
• Though visual loss is less common, but blindness remains a
significant risk due to involvement of ophthalmic artery.
• So frequent examination of vision is necessary to rule out the
blindness in elderly.
• Since involvement of coronary artery may occasionally lead to
MI, frequent checking of heart is necessary to rule out the
involvement of coronary artery.
Diagnostic algorithm for joint pain
• The first step in diagnosing the cause of joint pain is to determine
if the patient truly has a joint problem or a periarticular problem
such as bursitis, tendonitis, or PMR.
• The next key differentiating factors are the number of joints
involved and the presence of inflammation.
• Predominantly single joint involvement is a monoarticular
process, whereas multiple joint involvements are termed
polyarticular.
• The presence of warmth, swelling, effusion or erythema is
indicative of inflammation or infection.
A schematic representation is given in Annexure-I
271
Laboratory diagnosis, ancillary tests and its limitations
• Laboratory tests for joint pain problems lack the sensitivity and
specificity required for diagnostic studies recommended for general
population.
• Laboratory tests are most valuable when used selectively.
• Laboratory blood testing is non specific and insensitive for
diagnosing most elderly patients with joint pain.
• However some of the standard diagnostic tests should be used
mainly for determination of prognosis or planning treatment.
SandhivÁta (Osteoarthritis)
No such laboratory tests are helpful in diagnosis but following tests are
supportive of diagnosis.
• ESR test: May be done to exclude from RA. ESR is rarely
elevated in OA.
• Imaging study:
Plain Radiograph: The important
findings are
Loss of joint space or
Asymmetric
joint
space
narrowing.
Subchondral bony sclerosis
Marginal osteophytes and bone
cysts.
X-ray
anteroposterior
view
shows
degenerative changes of osteoarthritis.
Tibial spiking
Source: www.jortho.org
Loss of alignment
MRI: It is useful when there is a need to evaluate patients for
spinal stenosis, internal knee derangements or avascular
necrosis.
ÀmavÁta (Rheumatoid arthritis)
• ESR test: It is usually elevated. Its high value indicates a poor
prognosis.
• CRP: It is an indicator of inflammatory process. High value
indicates a poor prognosis.
• RA Factor: It assists in both diagnosis and assessment of
severity. In elderly patients a cautious approach to the
interpretation of this test is required because;
Firstly the reference range of normal reports generated in
healthy young adults may not be appropriate for elderly.
Secondly the RF has many false positive and false
negative results.
Some patients with RA can be seronegative especially
early in the course of the disease.
The false positive rate of RF also increases with age.
272
• Imaging study:
Plain
radiograph:
erosion
or
unequivocal decalcification adjacent to
involved joints.
This image shows the contrast of an X-ray of a normal hand on the left to that of a patient
with RA on the right. This inflammation, bone errosion, and bone displacement is shown in
the right side of the figure
Source: www.webmd.com
VÁtarakta (Gout)
• S. Uric Acid: It is influenced by several factors and therefore has
limited value during an acute attack. Elevated Uric acid in the
presence of a monoarticular, inflammatory arthritis supports a
diagnosis of gout but does not exclude the diagnosis if normal.
• Synovial fluid analysis: This is an important procedure to
establish the diagnosis of gout. The joint fluid is inflammatory
with decreased viscosity, high protein level and elevated
polymorphonuclear leucocytes. The leucocyte count is generally
about 50,000/cumm. Presence of crystal is a confirmatory test for
the gout.
• Imaging study:
Plain radiograph: During an acute attack, there may be a soft
tissue swelling or effusions.
AsthikÒaya (Osteoporosis)
No laboratory tests can confirm the diagnosis of osteoporosis but the
following tests may be used mainly to exclude the secondary causes of
osteoporosis.
Name of the tests
Secondary causes of osteoporosis to
be excluded
Complete Blood count Malnutrition
S.Urea & Electrolytes
Renal osteodystrophy
LFT
Alcohol abuse
S.Calcium, phosphorus Osteomalacia, Hyperparathyroidism,
& alkaline phosphates
Vit. D deficiency
TSH
Hyperthyroidism
S.Albumin & Total
Malnutrition and Multiple Myeloma
Protein
• Bone Mineral Density Measurement: It can establish or
confirm a diagnosis of osteoporosis, help determining the
severity of the disease, provide a baseline to monitor changes in
the condition over tissue or in response to therapy and possibly
predict future risk of fracture.
• Imaging study:
Plain radiograph: X rays are generally performed to confirm
that a fracture in long bones has occurred and to determine its
position prior to subsequent fixation. Spine X rays should be
considered in patients with acute back pain, loss of height or
273
kyphosis, to look for evidence of vertebral deformation,
degenerative arthritis.
Polymyalgia rheumatica (PMR) and Giant Cell Arterirtis (GCA)
• ESR: It is usually but always not elevated. So, it is unusual to
make the diagnosis of PMR or GCA in the presence of normal
ESR.
• CRP: There is often an associated rise in CRP levels and a mild
anemia.
• RF: It is usually negative.
• Biopsy of temporal artery: It should be undertaken in case of
GCA and if there is diagnostic doubt. There will be arterial wall
necrosis and multinucleated giant cells within the medial portion
of the vessel.
Errors in Diagnosis
• Failure to differentiate periarticular disease from other causes of
joint pains
Although many elderly patients attribute their musculoskeletal
symptoms to arthritis, quite often these symptoms are related to
diseases of the soft tissue structures within and around the joints.
• Failure to consider the diagnosis of septic arthritis in a patient with
chronic arthritis
Because of the presence of an underlying chronic arthritis,
clinicians may fail to consider septic arthritis when there is
exacerbation of arthritic symptoms.
Septic arthritis should always be considered in a patient who
experiences an acute flare of his or her arthritis.
The presence of malaise, fever or other systemic symptoms or
erythema in a single joint, can help the clinician differentiate a
simple exacerbation from suspicion of a septic joint.
If the symptoms of the exacerbation are atypical for that patient,
septic arthritis should also be considered.
Approach to treatment
SandhivÁta (Osteoarthritis)
Non-Pharmacological Approach
• Patient Education
Education of patient and counseling to improve coping skills,
management of stress and understanding of the disease process.
Self help information and resources
• Social and psychological support
Encouragement of social interaction
Coordination of support group and support services
• Exercise
General conditioning with low-impact aerobic exercises, such
as walking or aquatics.
Stretching and strengthening exercise for muscles around
affected joints.
274
Maintain range of motion.
Treatment of coexisting diseases that might interfere with
exercise ability.
• Physical modalities
Application of heat: hydrotherapy, paraffin baths, shortwave or
microwave diathermy
Application of ice for spasm or to limit swelling
Use of transcutaneous electrical nerve stimulation, especially
for lumbar spine, hip or knee involvement.
Pharmacological Approach: A stepped approach to management of
pain should be taken.
• Acetaminophen: It is drug of first choice and as effective as
NSAIDS but has fewer GI side effects
• Topical analgesics: Capsaicin or methylsalicylate cream can be a
useful adjuvant therapy for patients who receive minimal relief
with analgesics or NSAIDs.
• NSAID: If there is no response to acetaminophen, then an NSAID
can be added or used alone. In patients with severe osteoarthritis,
who are not candidates for joint replacement, tramadol 50 mg four
times daily or opoid analgesics can also be effective.
Toxic effects of NSAIDs
• Gastrintestinal hemorrhage
• Perforated ulcer
ÀmavÁta (Rheumatoid arthritis)
Non-Pharmacological
Approach:
Managed
or
coordinated
multidisciplinary care through a team effort can be effective in the
maintenance of function and productivity of patients with RA.
• The initial corner stone is patient education and physical therapy.
• The patient should be advised to perform stretching and
strengthening exercise.
• Resistance training is known to improve strength, gait and
balance; help in the control of pain and alleviate fatigue.
Pharmacological Approach:
• Initial Therapy: Use of NSAIDs with an aim to reduce joint
pain and swelling and improve function.
• Glucocorticoids: Low dose glucocorticoids and local injections
of glucocorticoids are often highly effective in providing relief of
symptoms in patients with active RA.
• Disease-modifying antirheumatic drugs: All patients whose
RA remains active despite adequate treatment with NSAIDs and
those with erosive disease are candidates for DMARDs. The most
commonly used DMARDs are hydroxychloroquine (HCQ),
sulfasalazine (SSZ), methotrexate (MTX), gold salts and
azathioprine (AZA).
275
VÁtarakta (Gout)
Non-Pharmacological Approach
• Short term bed rest for 24 to 48 hours especially in patients who
have lower extremity acute attacks.
• The use of warm compresses should be avoided in acute gouty
arthritis as it appears to worsen the crystal induced inflammation.
Pharmacological Approach
• Treatment of acute gouty arthritis
NSAIDs: It is used most frequently to treat acute gout. It
should be started early and continued for atleast 24 hrs. after
resolution of symptoms.
Cholchicine: It is also effective. The initial oral dose is 1.2
mg followed by 0.6 mg every hour until the pain resolves.
Glucocorticoids: These are effective in patients who do not
respond to NSAIDs or Cholchicine.
ACTH: ACTH can also be used to treat gout especially in
polyarticular gout.
• Long term treatment: This involves the normalization of
Hyperuricemia; thus preventing further gouty attacks.
Allopurinol: It is the drug of choice because of its
effectiveness and ease of use. It should be used in the patients
with a history of nephrolithiasis or who are hyperexcretors of
Uric acid.
Uricosuric medications: It can be used in patients who
excrete low level of uric acid in their urine and no history of
renal disease
Polymyalgia rheumatica (PMR) and Giant Cell Arterirtis (GCA)
PMR without temporal arteritis
Corticosteroids: A prompt response to corticosteroids can be
regarded as confirmation of the diagnosis.
NSAIDs: The corticosteroids can be switsched to an NSAID
if their symptoms completely resolve and the ESR
normalizes.
• PMR with temporal arteritis:
Highere doses of Corticosteroids: Higher dose is necessary
to treat patients with temporal arteritis. Dose reduction
requires careful monitoring of the patient’s symptoms as well
as ESR level, which should be assessed every 2 to 3 weeks.
Ayurvedic principle of treatment, Pancakarma procedures and
Ïamana therapies.
Ayurvedic principle of treatment
SandhivÁta (Osteoarthritis)
It is not mentioned in any of the classics under a separate heading but all the
authors have described the line of management of VÁta lodged in the joints.
276
Principle of Treatment
• NidÁnaparivarjana.
• Snehana: Bahya & Abhyantara- Snehapana, Snigdha Mamsa rasa etc.
• Svedana: Appropriate method to be selected
• SamÐodhana: Approprite methods like Virechana, Basti, Basti on the
involved joints if suitable
Some commom drugs useful for the treatment of SandhivÁta
Single drugs : AÐvagandhÁ, BalÁ, DaÐamÚla, Ïunthi Guggulu, Eranda,
Nirgundi, RÁsnÁ, Rasona,
Swarasa : Nirgundi, PrasÁriÆÍ
KvÁtha : DaÐamÚla, RÁsnÁsaptaka, RÁsnÁdi, MÁÒabalÁdi
VaÔi : Agnitundi vati, Sanjivani Vati
Guggulu : YogarÁja guggulu, VÁtÁri guggulu, LÁkÒÁdi Guggulu RÁsnÁdi
guggulu, TrayodaÐanga Guggulu, RaÁayana YogarÁja Guggulu
BhaÒma : Godanti BhaÒma ,Svarna BhaÒma, PravÁla BhaÒma, MuktÁ
Ïukti
Rasa : VÁtagajÁnkuÐa Rasa, MahÁvÁtavidhvamsana Rasa, VÁtacintÁmani
Rasa, LakÒmivilÁsa Rasa
Àsava/AriÒta DaÐamÚlariÒta, AÐvagandhÁriÒta
Taila / Ghéta : Eranda Taila, NÁrÁyana Taila, ViÒagarbha Taila, Kubja
PrasÁriÆÍ Taila, PrasÁriÆÍ iTaila, DaÐamÚladi Ghéta
Standard Treatment guideline for SandhivÁta
1. NidÁnaparivarjana
2. VÁtahara ÀhÁra
3. Bahi½parimÁrjana Karma: Abhyanga, Sveda, VyÁyÁma etc.
4. SamÐodhana: Virecana or Basti as per the condition
5. RasÁyana Sevana as per the need
6. YogarÁja Guggulu: 1gm three times with suitable kaÒÁya
7. VÁtacintÁmani: 125 mg + PravÁla Bhasma 125mg : two doses if the
coditon is severe
8. MahÁnÁrayaÆa Taila Abhyanga two times daily
9. AÐvagandhÁ RasÁyana: 5gms. At bed time
ÀmavÁta (Rheumatoid arthritis)
Principle of Treatment
Langhana
: For ÀmapÁcana
Virecana
: For purgation of Àma
Ïodhana and KÒÁra Basti: If condition is not improved by langhana and
Virecana.
Local Treatment : RukÒa Sveda for PÁcana and Ïodhaan of Àma
located at Sandhi,
Ïamana CikitsÁ : By KaÔu, Tikta ÀhÁra dravya alongwith DÍpana and
PÁcana AuÒadhis
277
SnehapÁna and local Snehana: VÁtaghna SnehapÁna and Ïothaghna
lepa in NirÁmÁvasthÁ
Some commom drugs useful for the treatment of ÀmavÁta
Single drugs : BhallÁtaka, Nirgundi, RÁsnÁ, PunarnavÁ, ÏunthÍ,
PippalÍ, Guggulu, Eranda, AÐvaandhÁ, Rasona, GuÕÚci, ÏilÁjatu,
Svarasa : Nirgundi, PunarnavÁ, RÁsnÁ, PrasÁriÆÍ
KvÁtha:
DaÐamÚlÁdi,
RasnÁpancaka,
RÁsnÁdi,
ÏunthyÁdi,
RÁsnÁsaptaka, PunarnavÁÒtaka
CÚrna : AjamodÁdi curna, BaiÐvÁnara curna, PathyÁdi curna,
Pancakola curna, Pancasama curna, ÏatapuÒpÁdi curna
Vati : AgnitundÍ vati, CitrakÁdi vati, Rasona vati, Sanjivani Vati
Guggulu : YogarÁja guggulu, AmétÁdi guggulu, SinghanÁda
guggulu,VÁtÁri guggulu, RÁsnÁdi guggulu
Rasa : ÀmavÁtÁri Rasa,VÁtagajÁnkuÐa Rasa, MahÁvÁtavidhavamsana
Rasa, SamÍrapannaga Rasa, Malla SindÚra
BhaÒma : Godanti BhaÒma, Swarna BhaÒma, Banga BhaÒma
Àsava/AriÒta : DaÐamÚlÁriÒta, PunarnavÁriÒta, AmétÁriÒta
Taila / Ghéta: Eranda Taila, : DaÐamÚlÁdi Ghéta, PrasÁriÆÍ Taila
PunarnavÁdi Ghéta, AmritÁ Ghéta, ÏunthÍ Ghéta
Snehana : Only indicated in nirÁmÁvasthÁ (free from Àma)
In pain - MahÁviÒagarbha taila, Pancaguna taila.
In stiffness : Dhattura Taila, SaindhavÁdi Taila,
PrasÁriÆÍ Taila.
Svedana: Saindhava BÁlukÁ Sveda, SthÁnika / SÁrvadaihika
Sankarasveda, NÁdi sveda, Patrapotali sveda
Virecana : Haritaki Curna, Eranda taila, PathyÁdi vati, MadhuyaÒti
curna
Basti : NÁrÁyaÆa Taila, SaindhavÁdi taila, DaÐamÚla kvÁtha, KÒÁra
basti
Lepa : Nirgundi patra lepa, Erandapatra lepa, DaÐÁnga lepa, HaridrÁ
lepa
Pathya
Rasona, Ïunthi, Hingu, YavÁnÍ, JÍraka, Marica, ÏÁlÍcÁval, Yava, Parval,
Nimbapatra, Madhu, UÒÆa jala, Katu-tikta ÁhÁra dravya, Médu
VyÁyÁma, Pancakola siddha jala, RukÒa bÁlukÁ sweda.
Apathya
KÒÍra, Dadhi, MistÁnna, Matsya, MÁÒa, PurvÍvÁyu, MeghavyÁpta ÁkÁÐa,
AsÁtmya ÁhÁra, VegavidhÁraÆa, RÁtrijÁgaraÆa, CintÁ, Ïoka, Àlasya.
Standard Treatment guideline for ÀmavÁta
1. Advice for NidÁna Parivarjana
2. Laghu RukÒa UÒÆa KaÔu Tikta ÀhÁra
3. Bahi½parimÁrjana Karma: Suitable VyÁyÁma and CankramaÆa etc.
278
4. In NirÁmÁvasthÁ: Médu Virecana or Basti preceded by suitable Snehana
& Svedana as per the condition
5. SamÐamaniya svedana (as per the need) ÀmÁvasthÁ: BÁlukÁ Saindhava
ÏuÒka sveda
NirÁmÁvasthÁ: NÁÕÍ sveda (DaÐamÚla)
JÍrnÁvasthÁ: ÑaÒÔiÐÁli pinÕa sveda for 15-20 days
6. SanjivanÍ vaÔÍ 500 mg +Ïu. KupilÚ 150 mg + Rasa SindÚra 100 mg: in
three divided doses with honey.
7. ÀmavÁtÁri Rasa 500 mg two times
8. DaÐamÚlÁriÒta 20 ml two times
9. SaindhavÁdi Taila for Abhyanga in NirÁmÁvasthÁ
VÁtarakta (Gout)
Principle of Treatment
RaktavisrÁvaÆa - by Ïénga JalaukÁ, AlÁbu, SirÁ vedha etc. preceded by
suitable Snehana, Svedana, Médu Virecana , Basti (contraindicated in
VÁtarakta having VÁta predominance)
Frequent Méduvirecana and Basti karma
Bahi½parimÁrjana – by suitable Abhyanga, seka, pradeha, lepa etc.
UttÁna VÁtarakta:Àlepa, Abhyanga, PariÒeka, UpanÁha
Gambhira VÁtarakta: Virecana, AsthÁpana, SnehapÁna
External Application- PiÉÕa taila, Ïatadhauta ghéta, TagarÁdi pralepa,
Àmalaka siddha PurÁÆa ghéta
Some commom drugs useful for the treatment of VÁtarakta
Compound preperations : GuÕa Haritaki, PippalivardhamÁna yoga,
NimbÁdi curna, CopachinyÁdi curna, GuÕuci Yoga, ÑilÁjatu yoga,
Àraghvadha, Trivétta, BhringarÁja svarasa etc
Guggulu: Kaishore guggulu, AmritÁ guggulu, GokÒurÁdi guggulu,
PunarnavÁdi guggulu
Ghéta : Guduci ghéta, BalÁ ghéta
Taila : Pinda taila, MaricÁdi taila, Guduchi taila, Sukumar Taila,
KhudÁakpadmak taila, Amétadi taila
KaÒÁya : ManjisthÁdya kvÁtha, patolÁdi kvÁtha
Àsava/AriÒta:ManjisthÁdyÁrista,Sarivadyarista, CandanÁÁsava
Rasa :RasamÁnikya, Arogyavardhini vati, Sarveswar rasa, PravÁla
Panchaméta, VÁtaraktÁantaka Rasa, ShilÁjatu Yoga, GuÕucyÁdi Lauha
Standard Treatment guideline for VÁtarakta
1. Advice for NidÁna Parivarjana
2. Suitable ÀhÁra, VihÁra and rest
3. SthÁnika Prayoga: Suitable Abhyanga, Ñeka, Pradeha, lepa etc.
4. SamÐodhana: Virecana, Basti and Rakta mokÒana as per need
5. CopacinyÁdi curna 5 gms two times
279
6.
7.
8.
9.
Kaishore Guggulu 1gm three times with suitable PatolÁdi KaÒÁya
Arogyavardhini Vati 1gm at bed time
ManjisthÁdyÁriÒta 20 ml two times after meals
VataraktÁntaka Rasa 150 mg + PravÁla PancÁméta 150 mg + Ïénga
BhaÒma 300 mg in three divided doses with honey
10. PinÕa Taila for local application
AsthikÒaya (Osteopororsis)
Principle of Treatment
The following therapy may be advocated
• Snehana
• Svedana
• BéhmaÆa
• Basti
Some commom drugs useful for the treatment of AsthikÒaya
Single drugs: AÐvagandhÁ, ÏatÁvarÍ, PravÁla Bhasma/PiÒti, MuktÁ PiÒti,
EranÕa.
Compound preparations: LÁkÒÁdi Guggulu, PunarnavÁdi ManÕÚr, DhÁtri
Lauha, Àmalaki RasÁyana, SvarÆa Vasanta MÁlati, AgnitunÕi VaÔi, SanjivanÍ
VaÔi, DaÐamÚla Ghana VaÔi
Standard Treatment guideline for AsthikÒaya
The details of guideline for treatment has been given in Chapter 22 of this
manual
Referral requirement
• A geriatrician will ordinarily manage with patients in geriatric care
services.
• However, some patients with gross deformities and situations
warranting surgical interventions and physical medicine aids will have
to be referred to specialized Rheumatology Care Clinics,
Physiotherapists and Orthopedic surgeons.
Recommended Further Reading
1. Brocklehurst’s text book of Geriatric medicine and Gerontology, 6th Edition
2. Clinical Geritrics – Isadore Rossman- 3rd Edition
3. Caraka Samhita, Cakrapani commentary edited by Yadavji Trikamji
Acarya, Chaukhambha Prakashan, Varanasi.
4. Kayachikitsa Vol I & II by Prof. R H singh, Chaukhambha Sanskrit
Pratisthan, Varanasi
5. Madhav Nidanam, Madhukosa commentary edited by Yadunandan
Upadhyay, Chukhambha Sanskrit Sansthan, Varanasi
6. Reichel’s Care of the elderly – Clinical aspects of aging – 5th edition
7. Sushruta Samhita, Dalhana commentary edited by Yadavji Trikamji
Acarya, Chukhambha Orientalia, Varanasi
8. Twenty common problems in Geritrics – Adelman/ Daly
280
Annexure-I
A Diagnostic Algorithm for joint pain
Consider
periarticular
disease
PMR
Joint pain
Pain localized
to joint
Yes
Number of
joints involved
Polyarticular
Monoarticular
Inflammatory
Consider
Gout
CPPD
Septic arthritis
Non inflammatory
Inflammatory
Consider
Osteoarthritis
Consider
Rheumatoid
Arthritis
281
Non inflammatory
Consider
Osteoarthritis
Chapter-17
Urinary diseases and other surgical problems of the elderly
Introduction
Urogenital disorders are comprised of diseases of Urinary and Genital
system.
• These are diseases of Kidneys, Ureter, Urinary bladder, Prostate
gland, Urethra, Seminal vesicles, Testes, Penis, Uterus, Ovaries and
Vagina.
• Common conditions are inflammatory, hormonal, degenerative and
immunological in nature.
Senile factorsIn elderly age hormonal imbalance, degeneration and impaired immunity are
the common causes.
Common ailmentsName of organ
Kidneys
Elderly ailments
Nephhritis, Hydronephrosis,
Neoplasia, Stones, Renal failure
Polyp, Stones, Hydroureter
Retention of urine, Diverticulum,
Neoplaisa
Prostatitis, Benign Hyperplasia,
Malignancy
Urethritis, Stricture, Incontinence
Epididymoorchitis, Hydrocoele,
Neoplasms
Leukoplakia, Phimosis,
Paraphimosis, Neoplasm
Endometriosis, Cervicitis, Fibroid,
Malignancy
Cysts, Neoplasm
Vaginitis, Neoplasia, Bertholins
gland tumour
Ureters
Urinary bladder
Prostate gland
Urethra
Testes
Penis
Uterus
Ovaries
Vagina
Clinical Identification
MÚtrÁghÁta- Partial or complete retention of urine due various causes
arising from urinary bladder etc.
282
MÚtrakéchhra- Difficult micturition due to multi factorial origin in
relation to disturbances in organs structurally or physiologically.
MÚtrÁÐmari- Usually are formed in kidneys and may get lodge in ureter,
bladder and increases in size. They are of many types and causes colic
pain, polyuria, heamaturia, urinary obstruction etc. They are usually
formed by deranged calcium metabolism and stasis of urine.
Nephritis- Usually occurs as Pyelonephritis usually due to
hematogenous infection or ascending infection in the urinary tract. It is
of Acute and Chronic type.
Hydronephrosis- An aseptic dilatation of the kidney due to a partial or
complete obstruction to the outflow of the urine. It is of two typesA) Unilateral
B) Bilateral
Causes are- Benign Prostatic Hyperplasia, Carcinoma of the Prostate,
Post operative bladder neck scarring, Urethral stricture and Phimosis.
Renal failure- Characterized by partial or complete cessation of renal
function. May be Acute or Chronic. Causes may be systemic like severe
fluid loss, drug toxicity etc. or local like nephritis, hydronephrosis etc.
Arbuda (Neoplasm)- - Renal neoplasia may be benign or malignant.
Benign neoplasm are Adenoma, Angioma and Angiomyolipoma
Malignant neoplasm in elderly is hypernephroma (syn. Garwitz’s
tumour). Hypernephroma spread into lungs causing cannon ball
deposits.
Hydroureter-Usually associated with hydronephrosis and occurs due to
urine outlet obstruction like ureteric stones, urinary bladder stone,
prostatic enlargement etc.
MÚtrÁghÁta (Retention of urine)- Very common problem in elderly
people. Causes are bladder outlet obstruction, urethral stricture, spinal
nerve compression, prostatitis, blood clot in bladder, smooth muscle cell
dysfunction associated with aging, phimosis, post operative
complications etc.
Bladder diverticulum- Occurs commonly in elderly age due to
retention of urine. Causes back pressure changes in kidney due to stasis
of urine in the bladder. They are the source of recurrent urinary tract
infection.
AÐmari(Stones)- Stones may occur in bladder or may come through
ureters or kidneys. They may cause pain, heamaturia, retention of urine,
hydronephrosis and renal failure
283
Arbuda (Neoplasm)- - .May be benign like angioma, myoma, fibroma
or malignant like transitional cell carcinoma and pure adeno -carcinoma.
They cause haematuria, pain, urine retention, renal failure etc.
MÚtrÁÒÔhÍlÁ (Benign Hyperplasia)-Associated with symptoms of
prostatism and urodynamic evidence of bladder outflow obstruction. It
may cause acute or chronic retention of urine, impaired bladder
emptying, haematuria and pain leading to hydronephrosis and even renal
failure.
Carcinoma- Usually originates in peripheral zone of prostate. Causes
bladder outlet obstruction, pelvic pain, haematuria, bone pain, anaemia,
renal failure etc.
Urethritis- Occurs due to infection like gonococcal , non specific and
Rieter’s syndrome and causes pain, burning sensation during
micturition.
Stricture- May occur due to trauma, post inflammatory like gonorrheal,
tuberculous etc., instrumental indwelling catheter, urethral endoscopy,
postoperative etc. Causes retention of urine, urethral diverticulum,
periurethral abscess, urethral fistula, renal failure etc.
Arbuda (Neoplasm)- - Benign neoplsms are polyps, genital warts and
angioma whereas carcinoma of urethra is also reported to occur rarely.
Epidydimoorchitis- Common inflammatory condition causing pain and
swelling in scrotum. Filariasis is the one among common causes.
MÚtravéddhi (Hydrocele)- Abnormal collection of serous fluid in some
part of processus vaginalis usually tunica ,produces enlargement in size
of scrotum. It occurs due to trauma, infection like pyogenic, filariasis
etc.
Arbuda (Neoplasm)- Carcinoma may be flat, infiltrating or papillary
associated with inguinal lymphadenopathy.
Leukoplakia- Leukoplakia of glans is the discoloration of outer surface
epithelium and thought to be precancerous stage.
NiruddhaprakaÐa (Phimosis)- This is caused by adhesion between foreskin of
prepuce and glans penis. It causes pain, swelling and even retention of urine.
Paraphimosis- Retraction of foreskin of prepuce causes obstruction of return
of venous and lymphatic from glans. It may be reason of retention of urine.
284
Diagnostic point-
Clinical- Renal pain, Ureteric pain, Bladder pain, Prostatic pain,
Seminal vesicle pain, Urethral pain, Uraemia,Retention of urine,
Oedema, Hamaturia, Anaemia, Renal failure, unwanted mass, Non
healing ulcers, Coma.
Laboratory- Urine-may show RBCs, Pus cells, Protien or Nitrates,
Bladder tumour antigen in urine (BTA-Bard test), Cultures and
sensitivity test of urine, Biochemical examination of glucose, bilirubin,
hemoglobin etc., Low Hb%, Raised blood urea, Raised Serum
creatinine, Deranged Serum electrolytes.
Histopathological- FNAC &Biopsy.
Radiological- Renal function test Intravenous urogram, Retrograde
ureteropyelography, Antegrade pyelography, Digital substraction
arteriography (DSA), Cystography, Urethrography, Cystoscopy,
Urethroscopy, Ultrasonography and Transrectal Ultrasonography, CT
scan, MRI.
Management Criteria
Medical- Panchakarma-specially vasti therapy, Sanshaman drugs like
preparations of Varuna, Shigru, Punarnava, Trinapanchamula,
herbomineral drugs like preparations of Shilajatu, Antibiotics, Diuretics,
Dialysis, Chemotherapy, Radiotherapy.
Surgical- Curative and palliative procedures like Nephrolithotomy,
Pyeloplasty, Prostatectomy, Urinary diversion operations,Orchidectomy,
Amputation of penis, Excision of tumors, Urethroplasty etc.
Preventive goals- ÀhÁra- vihÁra, RasÁyana and Pancakarma. Surgical
procedures like circumcision, excision of tumors in early stage.
Complication profile
Patient related – Due to age related changes in body organ system
proper absorption, assimilation, distribution and biological effect of
drugs do not occur causing inadequate result of treatment. Impaired
immune system of senile body may cause adverse effects of drugs.
Drugs and procedure related- Senile change in general body
constitution and organ system restricts the use of drugs in required dose
and sometimes required procedures also can not be performed.
285
Limits of approaches
Metabolic- Metabolic disorders in elderly age are very common with
various impairment of body organ system- like Diabetes with
impairment of Renal and Cardiac functions which limits the use of drugs
in required dose along with limitations of use of desired procedures also.
Degenerative- Degenerative changes in body and organ system causes
restriction of use of drugs and procedures e.g. cerebral, cardiac and
vascular etc. degenerative changes causing limitations of drugs and
procedures.
Therapeutic- Due to metabolic, degenerative, hormonal and
immunological changes in body many of the drugs and procedures
may not be used in proper dose and at desired time like restriction of
drug uses in renal and hepatic function impairment which common in
elder age group
286
Chapter-18
Ano-Rectal Disorders of The Elderly
Introduction
Anorectal diseases are the diseases which occur in and around the anal canal
and rectum.
• Common conditions are haemorrhoids, fissure in ano, fistula in
ano, anal polyp, proctitis, pilonidal sinus, rectal prolapse,
neoplasia of anal canal and rectum.
• Per rectal bleeding, pain, constipation, mass in or out side of the
anal canal and anemia are the common concerns of the patient.
Senile factors- In elderly age gastrointestinal upset, nutritional factors,
degenerative changes and impaired immunity are the common predisposing
factors.
Individuals over 60 years of age are reported to have higher plasma
concentration of endorphins that mediate binding to endogenous opiate
receptors in the lower gastro intestinal tract. This can potentially inhibit
colonic motility and increase resting anal tone.
Rectal sensation depends on the integrity of the sacral spinal cord which
is not altered with normal aging. Older adults with constipation however
can have two types of rectal pathology.
Increased rectal tone and reduced compliance.
Rectal dyschezia which is characterized by reduced rectal tone ,variable
degree of rectal dilatation ,impaired rectal sensory threshold and higher
volume rectal distention required to induce reflex relaxation of internal
anal sphincter .Individuals with rectal dyschezia are more likely to have
a rectal impaction .The neuro-pathophysiology of rectal dyschezia are
compatible with diminished para sympathetic outflow from the sacral
cord and can occur in older adults with ischemia to sacral cord and
spinal stenosis . Changes have been observed in older individuals with
constipation including colorectal dysmotility, increased colorectal
diameter and impaired rectal sensation.
287
Common ailmentsStructures
Elderly ailments
Anal canal
Haemorrhoids, Fissure in ano, Fistula
in ano, Incontinence, Stricture and
Anal growth
Rectum
Proctitis, Fistulous communication,
Rectal prolapse and Carcinoma
Perineum
Perianal abscess, Gluteal sinus,
Pilonidal sinus
Clinical Identification
Constipation- Constipation is one of the important common digestive
problems in the older adults. 70-80% of patients over 60 years had 5-7
bowels per week .In a study most mobile elderly subjects evacuated
dense capsules within 5 days after ingestion ,while immobile subjects
had a very long transit time.
Constipation is defined as the passage of uncomfortably hard stool or
inability to pass a stool even when the bowel is full and causing a
sensation of need to evacuate.
Hard stool impaction in the rectum causes local abnormalities proximal
or diffuse colonic disturbances or systemic derangements such as
angina, myocardial infarction or arrhythmias
International workshop on constipation classified constipation on the
basis of stool frequency, consistency, difficulty of defecation.
1. Functional constipation .It refers to slow transit of the stool.
2. Recto sigmoid outlet delay. It refers to anorectal dysfunction. It is
characterized by prolonged defecation more than 10 minutes to
complete
bowel defecation or having the feeling anal blockage.
Common problems associated with constipation
GIT Disorders
Anal fissure
Fistula in ano
Hemorrhoids
Pruritus ani
Inflammatory bowel disease
Colon cancer
288
Mechanical obstruction
Stricture from diverticula or ischemia
Rectocele
Hernia
Volvulus
Helminthic infestation
Stercoral ulceration
Proctitis
Rectal prolapse
Anorectal infection
Mechanical obstruction of urinary tract
Ischemic colitis
Ceacal rupture
Metabolic and endocrine diseases
Diabetes mellitus
Hypothyroidism
Hyperparathyroidism
Hyper calcemia
Hypokalemia
Hypomagnesaemia
Uremia
Heavy metal poisoning
Porphyria
Neurological diseases
Parkinson disease
Spinal cord compression
Cerebro vascular disease
Psychological and environmental
Depression
Cognitive impairment
Immobility
Diet and hydration
Medication
Terminal reservoir syndrome
Others include
Recurrent genitourinary infection
Skin infection and sepsis
Stercoral ulcerationStercoral ulceration refers to an ulcer that is intimately associated with and
underlies an adherent mass of stool .Such ulcers are found at the same location
289
where fecalomas are found namely the recto sigmoid junction followed by the
transverse colon.
FecalomaWhen fecal matter stagnates in the colon and acquires characteristics of a
tumor, the term fecaloma is used. Fecalomas may complicate chronic
constipation of any cause and may be initiated by anti diarrheal medication,
confined to the bed or colonic neoplasia. Their presence is suggested by the
association of constipation, meteorism and an abdominal mass. Most fecalomas
occur in the rectum. The mass must be removed either manually or by careful
catharsis or rarely by operation.
Fecal Impaction Fecal impaction is the most commonly identified cause of diarrhea in elderly
patients. In such cases the static stool proximal to an obstructing fecal mass is
liquefied and oozes out of the rectum. Because of the long standing nature of
this impaction, the rectum develops a high maximum tolerable volume with a
diminished awareness of the rectal filling and urge to defecate. Hence the
overflow runs out of the anal canal because of the sphincteric dysfunction.
The treatment is directed to removing the impaction and treating underlying
disorders if any.
Rectal ProlapseRectal prolapse may occur as a complication of constipation because of
anorectal muscle dysfunction or the associated straining of stool. Prolapse is
much more common in women than in men. Mucosal prolapse is called as
partial prolapse and complete full thickness of rectal wall is called as complete
prolapse. In the absence of neuromuscular disorder, the treatment of
constipation is the keystone of rectal prolapse therapy and operative repair of
the prolapse is done in severe cases.
Laxative useLaxative use is prevalent in the elderly, but only in a few cases must laxatives
be taken chronically. An acute episode of fecal impaction or constipation can
usually be treated safely with a saline enema. Soap water enema are irritating
may cause severe colitis. Once acute constipation has been relieved, dietary
manipulation with high fiber content food, suppositories and weekly enemas
can be used .The most common causes of constipation are bad habits and
improper diets. Simple measures such as heeding the call to stool and setting
aside the time necessary for a undisturbed bowel movement is rewarding.
Simple exercises such as daily walk are to be encouraged. The patients who
290
frequently impacted should be maintained with stool softeners. Drastic
purgatives should be avoided.
Cathartic colonWhen the colon is damaged by chronic laxatives abuse the term cathartic colon
is used. Right colon is most often involved.
Benign TumorThe older is the population greater is the frequency of polyps. Hyperplasic
polyps are so common in elderly subjects that some authorities consider them a
normal aging change in the colonic mucosa. This is a benign condition.
Neoplastic growthAdenomas are the most common neoplastic polyp in the colorectum.
Ascending colon is the most common site in 60-80 age group. Risk of
malignancy is greatest in villous type of adenoma. Some adenomas are not able
to be visualized with 60 cm flexible sigmoidoscopy. Benign colonic polyp
frequently causes symptoms and even bleeding is usually occult. Acute and
severe hemorrhage requires exclusion of another cause.
Villous adenoma especially when large and distal, commonly cause
constipation or mucoid diarrhea and occasionally prolapse. Profuse mucorhea
may result in hypokalemia with proximal lesions. The colon can absorb the
fluid secreted by tumor and patient may do well for many years. When the
tumor becomes large, a syndrome of volume depletion, electrolyte imbalance
especially hypokalemia, hyponitremia, hypoalbuminemia and finally
circulatory collapse may occur. This clinical picture may resemble adrenal
insufficiency, diabetic coma, sprue syndrome, or laxative abuse. Villous
adenoma is soft and may be easily missed by per rectal examination.
Polypectomy may reduce subsequent incidence of colorectal carcinoma by
75%.Repeat colon examination in one year is advisable. A completely excised
benign polyp that contains a focus of intramucosal carcinoma superficial to the
musculature (Carcinoma in situ) requires frequent surveillance but no further
immediate therapy
Carcinoma colonThe incidence of carcinoma of colon rises progressively with the advance of
age and peaks in the eighth decade .Right colon is mostly affected. Occult
blood loss sufficient to cause symptoms of anemia occurs in about one third of
the patients with right sided carcinoma and only later to do alteration of bowel
habits, obstruction and weight loss occur. In left colon the clinical presentation
291
is usually more obvious with increasing obstruction and occasionally rectal
bleeding.
Carcinoma of the rectumCarcinoma of rectum often presents with bleeding and change in bowel habit.
Patients may manifest morning diarrhea. Tenesmus or a harassing sense of
incomplete evacuation is common. Rectal cancers are within reach of the
examining finger in about three fourth of the instances compared with left
colon lesion in which the tumor mass itself is palpable in fewer than half of the
cases. Palpable lymphadenopathy is unusual with metastatic colon cancer,
although a sentinel lymph node is usually present in the left supra clavicular
space. Hepatomegaly usually indicates spread to the liver. Routine lab studies
are rarely helpful in establishing the diagnosis. Anemia, leucocytosis and an
elevated serum alkaline phosphatase level usually suggest advanced disease.
Flexible sigmoidoscopy is the superior routine diagnostic procedure. Treatment
includes Radiation therapy, Surgery and Chemotherapy.
Carcinoid Tumor in the rectumThey are usually less than 1 cm in size and are clinically silent.
Proctosigmoidically, these lesions usually appear as small slightly yellowish or
tan nodules or sub mucosal tumors. Local excision or fulguration is the
preferred therapy. Their prognosis is good because of small size and low
incidence of overt malignancy.
Anal MalignanciesVarieties of malignant process occur in the anal region because of the
histological complexity and varied type of epithelial surface and soft tissues
that share this small area. The three most commonly encountered lesions are
squamous cell carcinoma, cloagenic carcinoma and malignant melanoma.
Squamous cell carcinomaIt constitutes 90% of primary carcinoma of anus and is slightly common in
women. Bleeding is the most common symptoms followed by anal discomfort,
complaints frequently and erroneously attributed to hemorrhoids. As the tumor
grows it restricts the anal passage and causes constipation and diminished stool
caliber. In women anal cancers are associated with second cancers of the
adjacent squamous epithelial lined structures. (E.g. vagina, vulva, and cervix.)
Metastasis is via adjacent structures and via lymphatics. Treatment includes
local excision and abdomino perineal resection for the extensive tumors.
Radiation therapy is a palliative treatment when operation is considered
unwise.
292
Malignant melanomaThe anus is the most common site for malignant melanoma after the skin and
the eye. Most such patients present with rectal bleeding or an anal or inguinal
mass. Melanoma may resemble a thrombosed hemorrhoid, however pigmented
naevi are seldom seen in this area. And any pigmented lesion should be
considered as melanoma until proven otherwise. About half of the lesions will
be amelanotic and grossly may resemble haemorrhoidal tags. Lymphogenous
and hematogenous spread occur easily and the prognosis is dismal.
HemorrhoidsVaricosities of anal canal are known as hemorrhoids. It may be internal or
external depending upon the position of varicosities. Those above the Hilton
line are called as internal hemorrhoid which is covered by mucous membrane
and below are called as external hemorrhoid, ,lined by skin. Vascular
hemorrhoids which are the extensive dilatations of the terminal superior
haemorrhoidal plexuses are common in young age .Mucosal hemorrhoids are
sliding down of thickened mucous membrane which conceals the underlying
dilated veins. When there is further hypertrophy mucosal suspensory ligaments
become lax and the pile mass remains prolapsed, this type more found in the
elderly. The mucosa overlying the hemorrhoids undergo squamous metaplasia
.Mucus discharge, pruritus ani and anemia are associated complaints. Primary
hemorrhoids are found in the 3,7 and 11 ‘o’ clock positions. Sigmoidoscopy
should be done if there is history of bleeding and altered bowel habit to exclude
any rectal pathology such as carcinoma.
Fissure in anoIt is a linear ulcer in wall of anal canal. In majority of cases it is found in the
posterior wall. There are two types, Acute and chronic. In acute the ulcer is
surrounded by edema and inflammatory indurations .It is always associated
with spasm of internal anal sphincter. This type is more found in the younger
age. When it fails to heal it will gradually develop in to a deep undermined
ulcer with continuing infection and edema and below the ulcer a hypertrophied
anal papilla and skin tag develops. The infection can cause a low anal fistula in
ano. Chronic type is found in the elderly individuals.
Ano-rectal abscesses Ano rectal abscesses usually follow a crypto-glandular infection .They are
named according to the site such as perianal, Ischiorectal, pelvi rectal and sub
mucous variety. Abscess, which develops from a fissure bed is called Fissure
abscess. In any cases of abscesses Crohn’s disease, Tuberculosis and other
associated diseases should be eliminated. Most of the cases can be diagnosed
293
by digital examination and in doubtful cases Fistulogram, Trans rectal
endosonography, MRI can be used.
Fistula in anoThis is a tract lined by granulation tissue which opens in the anal canal or in the
rectum and superficially in the skin around the anus. An associated intermittent
swelling with pain, discomfort and discharge in the perianal region can be
obtained. Inspection and palpation usually delineate the course and nature of
the fistula. When the internal opening is found above the dentate line, the
fistula is called high anal type and below it is called low anal fistula.
Sigmoidoscopy is mandatory to rule out any proximal disease of inflammatory,
neoplastic nature or otherwise. Scrapings should be examined bacteriologically.
In case of recurrent and multiple fistulas one should always try to eliminate
tuberculosis, Crohn’s disease, ulcerative colitis, lymphogranuloma inguinale
and colloid carcinoma of rectum. In elderly individuals fistula with specific
pathology must always be suspected. To understand the ramifications of the
fistulous tract Fistulogram, Trans rectal endosonography, MRI can be used.
Pruritus aniPruritus ani is associated with many clinical conditions. Mucus discharge from
the anus due to hemorrhoids, fissures, fistula, polyps, colloid carcinoma of
rectum skin tags and condyloma are some of them. Apart from this vaginal
discharges and parasitic lesions and poor hygiene may cause pruritus.
Anal pain
If a patient complaints pain alone during defecation, anal fissure and
proctalgia fugax are to be suspected. Pain with lump- perianal hematoma,
anorectal abscess, carcinoma of anal canal.
Pain with some thing coming out with bleeding- Prolapse rectum, prolapsed
hemorrhoid prolapsed rectal polyp, intussusceptions.
Pain with bleeding - Anal fissure, thrombosed and strangulated anal piles, anal
carcinoma, rupture of ano-rectal abscess.
Bleeding Bleeding may be associated with pain or without pain.
Painful bleeding is found in Fissure in ano, Fistula in ano, Carcinoma of the
anal canal, ruptured perianal hematoma, ruptured anorectal abscess,
endometriosis and Injury.
294
Painless bleeding is found in Polyp, villous adenoma, blood after defecation in
hemorrhoids, blood with mucus in Ulcerative colitis, Crohn’s disease,
intussusception, ischemic colon, blood mixed with stool in Carcinoma of the
colon and blood streaked on stool in carcinoma of rectum.
Stricture of the rectum and anal canalIt is the narrowing of the lumen of rectum and anal canal. In old age, senile
anal stenosis occurs due to chronic internal sphincter contraction .Annular
carcinoma causes stricture and rarely premalignant condition (Villous
adenoma) causes stricture. Stricture may develop due to cicatricial contraction
during healing process of the ulcers of the rectum caused by Tuberculosis,
gonorrhea, soft sore syphilis, dysentery.
Diagnostic point
Clinical-Pain, Per rectal bleeding, Perianal mass, Perianal swelling,
Peria anal abscess, Perianal wounds, Peri anal discharges and Prolapse
of Rectal tissue.
Laboratory- Low Hb%, Raised blood urea, Raised Serum creatinine,
Deranged Serum electrolytes.
Histopathological- FNAC &Biopsy.
Radiological- Structural changes in USG, CT scan, MRI.
Management CriteriaFor any disease of the ano-rectal region, the concept of treatment according to
the medicines used may be divided into two categories.
1. Local
2. General.
1. Local Treatment. :The local treatment is the application of drugs locally like application of taila,
ghéta, agnikarma etc. Important treatment procedure for anorectal diseases is
Vasti therapy in which administration of medicines in the form of enema is
prepared with ghéta, Taila and milk with the help of different other drugs. Most
of the drugs, which are used in Vastikarma, are VÁta-ÏÁmaka, VraÆa ÏodhanaRopaka and Pitta ÏÁmaka. There are three types of Vasti described by Sushruta
and other Ayurvedic authors:
(i)
AnuvÁsana Vasti
(ii)
PichhÁ Vasti and
(iii)
KaÒÁya Vasti.
295
The Vasti Karma or enema therapy should be done only by the experts in Vasti
therapy because there are more chances to injure the anal canal and the other
nearby structures during the process of administration of the Vasti. This
procedure is useful in diseases like fissure in ano, constipation, piles etc. This
procedure not only helps in easy evacuation of the bowl but also heals the local
pathologies due to the effect of the medicaments used.
AvagÁha sveda is the process where in Svedana or sudation is given to
the structures around the anal region by submerging these structures in water. It
can either be done with plain water or with medicaments added to it. It is
usually usefull in diseases like fistula in ano, fissure, piles, perianal abscess etc.
It cleans the local parts, maintains wound surface clean, and reduces pain.
2. General Treatment:Medical treatment advised by Acharya Sushruta in different ano-rectal diseases
includes snehana, svedana, vamana virecana, raktavisrÁvana etc .All the
Acharyas have stressed the use of drugs, which are DÍpana, PÁcana,
Anulomana and Raktastambhaka in their action.
Para-Surgical Treatment
Those patients who do not get relief by medical treatment should be treated on
lines of Para surgical methods. These are KÒÁrakarma, Agnikarma and
RaktamokÒaÆa.
KÒÁrakarma
According to Acharya Sushruta, soft, extensive, deeply situated and projecting
pile mass is curable by the KÒÁra karma. The caustics should be applied by a
ladle, a brush or a rod. This procedure can also be used in other diseases like
hypertrophied papilla, sentinel tag of fissure etc.
KÒÁrasÚtra
KÒÁrasÚtra are medicated thread made up of SnuhÍ latex, ApÁmÁrga KÒÁra, and
HaridrÁ powder. It has got anti bacterial and anti inflammatory action. It
destroys the unhealthy granulation tissue and promotes healing .The judicious
application of KÒÁrasÚtra therapy in Fistula in ano yields significant results by
means of complete cure and preventing post operative complications such as
incontinence and recurrence which are inevitable in lay open surgeries.
296
Agnikarma
Agnikarma is also indicated for the treatment of ArÐas. Rough, firms, thick and
hard pile mass are curable by Agnikarma. This procedure is done with hot
ÏalÁkÁ.
RaktamokÒaÆa
In addition to all such measures mentioned by Acharya Sushruta, Acharya
Vagbhatta has advised RaktamokÒana to be done with the help of JalaukÁ, SÚci
and KÚrca, in those pile masses which are of hard consistency, elevated and
when ever the vitiated blood is accumulated in the piles.
Surgical management
Benign and malignant conditions of anorectal area require complete excision
and there after medical management can be followed to avoid recurrence.
Hemorrhoids which are not amenable to medical management can be excised
considering the general health of the patient. Associated conditions like
Diabetes mellitus make the surgical management risky as it delays healing.
Poor general health and personal hygiene in old age will be a potential risk in
the management of perineal wound following surgeries or Para surgical
methods like KÒÁrasÚtra therapy. Maintenance of continence is an important
aim of all surgical procedures of perianal region.
Preventive goals- ÀhÁra- vihÁra, RasÁyana and Pancakarma
The amount of fiber in the diet has been shown to influence bowel function and
increasing fiber intake decreases the incidence of constipation .Increased
dietary fiber results in stool weight and frequency. Fluid intake of more than
1500 ml per day is important in maintaining bowel function. Increased physical
activity reduces constipation in older adults. Keeping good personal hygiene
and bowel habits will decrease the incidence of anorectal disorders in old age.
Complication profile
Patient related – Due to age related changes in body organ system
proper absorption, assimilation, distribution and biological effect of
drugs do not occur. Impaired immune system of senile body may cause
adverse effects of drugs. Atrophic changes in the body organ system
also restrict response of treatment procedures.
Drugs and procedure related- Senile changes in general body
constitution and organ system restricts the use of drugs in required dose
and sometimes required procedures also can not be performed.
297
Senile anatomical and physiological changes occurring in old age is a
challenge for any kind of therapy .In addition to this the psychological
conditions of the patient itself should be in balancing state for the
success of any therapeutical intervention.
Constipation is one of the commonest ailments in the old age. It can be
prevented by changes in the dietary habit, hydration, high fiber content
food and light exercises.
Wound healing in elderly individuals is slow which is further
complicated by conditions like Diabetes mellitus. So any kind of
surgical intervention should be advised after considering these factors.
Periodical medical screening, especially for anorectal complaints should
be advised once in a year. Early detection will aid early therapeutic
management and will prevent further advancing of ailments.
Limits of approaches
Metabolic- Metabolic disorders in elderly age are very common with
various impairments of body organ system such as Diabetes with
impairment of Renal and Cardiac functions limits the use of drugs in
required dose along with limitations of use of procedures also.
Degenerative- Degenerative changes in the body and organ system
cause restriction of use of drugs and procedures e.g. cerebral and other
neurological degenerative changes causing limitations of drugs and
procedures.
Therapeutic- Due to metabolic, degenerative, hormonal and
immunological changes in the body many of the drugs and procedures
may not be used in proper dose and at desired time.
298
Chapter-19
Wound management in the Elderly
Introduction
Wounds are very common condition characterized by discontinuity of surface
epithelium resulting from various etiologies.
• This condition may occur in any system or organ of the body.
• Common conditions are ulceration in the skin or mucous membrane
resulting from trauma, infection, nutritional and pressure factors.
Senile factors- In elderly age hormonal imbalance, degeneration,
nutritional, pressure ischemia and impaired immunity are the common
predisposing factors
Common ailmentsCausative factors
Elderly ailments
Hormonal changes
Diabetic ulcers
Vascular changes
Arterial ulcers, Venous ulcers
Infestations
Filarial ulcers
Infections
Infective ulcers
Neurogenic
Trophic ulcers
Pressure necrosis
Tropic ulcers
Trauma
Traumatic ulcers
Specific infections
Tubercular ulcers
Post operative
Meleney’s ulcer
Malignancy
Dusta vrana, Epithelioma and
Marjolins ulcer
299
Clinical IdentificationDiabetic ulcersFoot ulceration is common in both type I and Type II diabetes. Diabetics have
impaired wound healing and impaired resistance to infection. The diabetic foot
problems can be divided into three clinical entities:
5. Neuropathic.
6. Neuroischemic
7. Ischaemic.
Venous ulcersVeins carry deoxygenated blood back to the lungs. Veins contain valves that
prevent backflow, but when these valves become incompetent, too much blood
remains in the tissues. This condition is called congestion. Venous congestion
commonly affects the legs, causing swelling (edema) and a brownish
discoloration from the hemoglobin of the immobile red blood cells that leak
out. Venous ulcers are the most common wounds affecting the legs, and are
frequently found on the ankles. They are shallow, not too painful, and may
have a weeping discharge. They are caused by unrelieved venous hypertension
resulting from:
4. Deep vein thrombosis resulting in damage to the venous walls causing
incompetence of this inturn leading into high venous pressure.
5. Incompetence in the superficial veins alone usually the long saphenous
vein.
6. Congenital valve dysplasia.
BurnsMost burns occur in the home. They can be caused by scalding hot liquids,
grease fires, car accidents, chemical explosions, frayed electrical cords, house
fires, hot objects (stoves, irons, tailpipes), or even the sun. A first-degree burn
results in a superficial reddened area like that caused by mild sunburn. A
second-degree burn results in a blistered injury that heals spontaneously after
the blister fluid has been removed. A third-degree burn penetrates the layers of
the skin and will usually require surgical intervention in order to heal.
Immediate care of a burn consists of cooling the affected area. Superficial
burns heal on their own within two weeks with routine wound care and
protection from infection. Deeper burns require medical attention, including
nutritional support and assessment of lung function, and may require skin grafts
and vascular or reconstructive surgery.
Filarial ulcers The most spectacular symptom of lymphatic filariasis is
elephantiasis—thickening of the skin and underlying tissues. Elephantiasis is
caused when the parasites lodge in the lymphatic system. Elephantiasis affects
mainly the lower extremities, whereas ears, mucus membranes, and amputation
stumps are rarely affected; however, it depends on the species of filaria. W.
300
bancrofti can affect the legs, arms, vulva, breasts, while Brugia timori rarely
affects the genitals. This disease is not known to be fatal, although it can
obviously cause a fair amount of pain to the infected.
Arterial ulcers- The arteries supply blood, which carries the oxygen that cells
need to live. If arterial circulation is partially or completely blocked, the tissue
will begin to die, resulting in a painful wound. Impaired circulation of this type
usually occurs in the extremities (arms and legs), especially on the toe of the
foot, and is signaled by lack of pulse; cool or cold skin; skin that appears shiny,
thin, and dry; loss of skin hair; and delayed capillary return time.
Ischemic leg ulcer-Ischemic leg ulcers are a result of peripheral vascular
disease. PVD which affects 20-25% of the elderly population leads to
claudication, critical limb ischemia, gangrene and ischemic ulcers. An ischemic
leg ulcer is usually localized to the foot or the outer side of the lower leg. There
are usually other signs of compromised arterial supply, such as atrophy of the
skin of the toes. The ischemic ulcer is often more painful and has less discharge
than a venous ulcer, as perfusion to the distal extremities decrease, patients
develop rest pain and gangrene. With such low pressures, tissue oxygen
available for nutrition falls to very low levels causing cell death and ulceration.
Pressure ulcers: Also known as bedsores, pressure ulcers are very common in
older and immobile persons. When too much pressure is placed on them, cells
do not get enough oxygen. Such pressure occur when cells are sandwiched
between a bony prominence (elbow, heel, or tailbone) and a hard surface (bed
or wheelchair). Those cells closest to the bone begin to die, and the wound
spreads toward the skin surface. Thus, a pressure ulcer indicates not only a
surface wound, but also a deep tissue wound. Pressure sores can occur in
various situations.
Tubercular ulcers- Mostly results from bursting of caseous lymph nodes. It
also may develop when cold abscess from bone and joint tuberculosis breaks
out on the surface, usually seen on the neck, axilla and groin. Characteristic
features are undermined thin reddish blue edge, pale granulation tissue with
scanty serosanguineous discharge in the floor and slight induration on the base.
Tropic ulcers- This is an acute, non-specific localized necrosis of the skin and
the subcutaneous tissue, which is endemic in tropical countries. These are
almost always seen in the lower extremities. They are usually superficial but
depending upon the virulence of the organism and host immunity, they may
spread rapidly causing muscle necrosis and osteomyelitis of the underlying
bone. .
Trophic ulcers- Such ulcers have punched out edge with slough in the floor
resembling a gummatous ulcer. Bed sores, perforating ulcers are the examples.
These ulcers develop due to repeated trauma to insensitive part of the body.
301
These ulcers are commonly seen on the ball of the foot when patient is
ambulatory and on the buttock, on the back when patient is not ambulatory.
Buerger's Disease: Buergers disease is an inflammatory occlusive disease
which involves all layers of medium sized and small arteries of the extremities.
Majority of the patients develop critical limb ischemia with trophic lesions
which are distal to ankle. The disease though commences peripherally, may
gradually extend proximately occluding the larger arteries. Smoking is very
closely related to Buerger's disease.
Gangrene- Gangrene is a medical term used to describe the death of an area of
the body. It develops when the blood supply is cut off to the affected part as a
result of various processes, such as infection, vascular disease, or trauma.
Gangrene can involve any part of the body; the most common sites include the
toes, fingers, feet, and hands.
Meleney’s ulcer- These ulcers are seen in post operative wounds either after
the operation of perforated viscus or for drainage of empyema thoracis. This is
usually due to symbiosis action of microaerophilic non heamolytic streptococci
and heamolytic staphylococcus aureas. The edge is undermined, floor contains
abundant foul smelling granulation tissue with copious seropurulent discharge.
There is usually pain and features of toxemia.
DuÒÔa vraÆa- Acharya Sushruta has elaborately described about DuÒÔa vraÆa.
These are special type of vraÆa which due to any external or internal factors,
reduced to a condition where wound healing is delayed.
Diagnostic point
Clinical-Ulceration, Pus discharge, Pain, Bleeding, Spreading of ulcers,
Impaired healing from longer duration, traumatic, Gangrene, Coma.
Laboratory- Raised TLC, Raised Neutrophils, Raised Lymphocytes,
Raised blood sugar level, Low Hb%, Pus culture and sensitivity,
Immunoglobulins.
Histopathological- Biopsy.
Radiological- Peripheral color Doppler, X-ray, CT scan, MRI.
Management Criteria
Medical- Pancakarma, SaÞÐamana drugs, RaktavisrÁvaÆa, Antibiotics,
Diuretics, Dialysis, Chemotherapy, Radiotherapy.
Surgical- Curative and palliative. Excision of ulcers, amputation of
body parts.
Preventive goals- ÀhÁra- vihÁra, RasÁyana and Pancakarma, Exercise and
care of predisposing factors like Diabetes, Smoking etc.
302
Complication profile
Patient related – Due to age related changes in body organ system
proper absorption, assimilation, distribution and biological effect of
drugs do not occur. Impaired immune system of senile body may cause
adverse effects of drugs. Especially poor nutrition and poor oxygenation
of body tissues impairs the healing process.
Drugs and procedure related- Senile change in general body
constitution and organ system restricts the use of drugs in required dose
and sometimes required procedures also can not be performed.
Limits of approaches
Metabolic- Metabolic disorders in elderly age are very common with
various impairment of body organ system- like Diabetes with
impairment of Renal and Cardiac functions limits the use drugs in
required dose along with limitations of use of procedures also.
Degenerative- Degenerative changes in body and organ system causes
restriction of use of drugs and procedures e.g. cerebral and other
neurological degenerative changes causing limitations of drugs and
procedures.
Therapeutic- Due to metabolic, degenerative, hormonal and
immunological changes in body many of the drugs and procedures may
not be used in proper dose and at desired time.
303
Chapter-20
Adjuvant therapy for Cancer
Introduction
Neoplasia are the unwanted growth of normal tissue which does not either
responds to the treatment or partially responds to the treatment.
• These diseases may occur in any system, organ, tissue of the body.
• Common conditions are unlimited proliferation of the cells.
Senile factors- In elderly age hormonal imbalance, degeneration and
impaired immunity are the common predisposing factors.
Common ailmentsOrgan system
Elderly ailments
Urogenital system
Hypernephroma, Carcinoma of
Urinary bladder, Carcinoma of
Penis.
Respiratory system
Carcinoma of lungs, Carcinoma
of bronchus, Carcinoma of larynx.
Nervous system
Brain tumors
Gastrointestinal system
Carcinoma of stomach, Pancreatic
tumors, Carcinoma of gall
bladder.
Clinical IdentificationHypenephroma- This is an adenocarcinoma and is the most common
neoplasm of the kidney. It arises from renal tubular cells. It grows into renal
vein. Pieces of growth are swept into the circulation and end up in the lungs
where they grow to form cannonball secondary deposits. Haematuria and clot
colic are the presenting features.
Bladder carcinoma- Carcinoma may be transitional, squamous or
adenocarcinoma. Occupational workers like textile workers, dye workers, tyre
rubber and cable workers, petrol workers, heavy vehicle drivers, leather
workers and the like are at excess risk of bladder cancer. Painless haematuria,
bladder outlet obstruction, anaemia and pelvic discomfort are the presenting
features.
304
Prostatic carcinoma- Various malignancies of prostate are microscopic latent
cancer found on autopsy or at cystoprostatectomy, tumours found incidently
during TURP or following screening by PSA measurement, early localized or
advanced localized prostate cancer and occult prostate cancer. Commonly it
causes pelvic pain, haematuria, bladder outlet obstruction, anemia, bone pain
and renal failure etc.
Carcinoma of Penis- Carcinoma of the penis may be flat, infilatrating or
papillary. Leukoplakia and Pagets disease of penis often results into carcinoma
of penis. Earliest lymphatic spread is to the inguinal and then to the iliac nodes.
Presenting features are discomfort, discharge, ulceration and growths
Carcinoma of Testis- On the basis cellular involvement tumors of testis are
described as seminoma, teratoma, mixed seminoma and teratoma, interstitial
tumors, lymphoma and other tumors. Presenting features are enlargement of
testes, para aortic lymph node enlargement, sometimes septate and lobulated
appearance.
Carcinoma of Bronchus- This may be squamous cell carcinoma,
adenocarcinoma, small cell carcinoma and alveolar cell carcinoma. Presenting
features may be persistent cough, weight loss, dyspnoea, nonspecific chest
pain, pleural effusion, clubbing, pulmonary osteoarthropathy etc.
Carcinoma of the breast-Carcinoma may be ductal, lobar, colloid, tubular or
medullary. Breast cancer may arise from the epithelium of the duct system
anywhere from the nipple end of major lactiferous ducts to the terminal duct
unit which is in the breast nodule. Presenting features are hard lump, indrawing of nipple, peau d’orange, frank ulceration and fixation to the chest
wall.
Brain tumors- These are gliomas, pineal tumors, neuronal tumors, nerve
sheath tumors, meningeal tumors, pituitary tumors, lymphomas, metastatic
tumors. Presenting features are raised intracranial pressure, focal neurological
signs, organic mental changes and seizures.
Intraspinal tumors- Lumps within the spinal cord may be intradural or
extradural, benign or malignant. Presenting features may be pain, radicular
sign, spinal cord/cauda equine signs.
Carcinoma of gall bladder- Incidence in India is 9% of billiary tract diseases,
in over 90% cases gall stones are present. Patients are usually in late 70s with a
female to male ratio of 5:1.Tumor is usually scirrhous but squamous cell and
mixed squamuos adenocarcinoma is found. Presents as mass in upper abdomen,
jaundice, loss of appetite, colic pain etc.
Carcinoma of pancreas- It is the disease of 70s age group. Predisposing
factors are tobacco, smoking and chronic pancreatitis. Usually ductal cell
305
adenocarcinoma is found. It presents as epigastric discomfort, anorexia, weight
loss, palpable liver, palpable gall bladder and even metastatic lymph nodes in
the neck.
Gastric carcinoma- Carcinoma of the distal stomach and body of the stomach
is most common in low socioeconomic group whereas proximal gastric
carcinoma seems to affect higher socioeconomic group. Carcinoma of the distal
stomach and body of the stomach is associated with H. pylori infection.
Patients with pernicious anemia, gastric surgery and gastric atrophy are at
increased risk.
Hepatocellular carcinoma- Patient often presents with chronic liver disease or
with anorexia and weight loss of an advanced carcinoma.
Diagnostic point
Clinical-Haematuria, Uraemia, Oedema, Anaemia, Renal failure,
Haemoptysis,Respiratory failure, Cardiac failure, Intestinal obstruction,
Vomiting,
Diarrhoea, Haematemesis, Non
healing
ulcers,
Gangrene,Coma.
Laboratory- Low Hb%, Raised blood urea, Raised Serum creatinine,
Deranged Serum electrolytes, Deranged LFT.
Histopathological- FNAC &Biopsy.
Radiological- Structural changes in USG, CT scan, MRI.
Management CriteriaThe treatment of Arbuda has been described elaborately in different Ayurvedic
texts. Caraka has described the management of Arbuda while describing the
management of localized “Ïotha”. In all Ayurvedic classics the management of
Granthi and Arbuda has been considered as the same.
Arbuda is a disease, which cures with great difficulties and some are fatal
(Raktaja and Medaja Arbuda). So before treating such a difficult disease the
physician or surgeon must realize the prognosis of the disease and should
prognosticate the patient's relatives.
The principles of treatment of Granthi and Arbuda have based on SaÞÐodhana
CikitsÁ37, a primary approach for the treatment of almost all diseases. Apart
from SaÞÐodhana CikitsÁ, local and systemic use of medicines, para-surgical
37
la’kksf/krs Losfnre’edk"BS% lkaxq"Bn.MSfoZy;sniDoeA
foikVî pksn~?k`R; fHk"kd~ ldks’ka ’kL=s.k nX/ok oz.kofPpfdRlsr~AA p0fp0 [email protected]
306
and surgical procedures or combination of all these forms of treatment were
adopted on those days for the management of Arbuda. To obtain DoÒa
sÁmyatÁ, Snehana, Vamana and Virecana are indicated.
Another Sushruta’s method of treatment of Arbuda is preservation of Rogibala
draws the attention. Sushruta has described that the patient's body resistance
i.e. Rogibala38 is one the important factors, which should be preserved
carefully as Rogibala arrests the progress of disease i.e. Rogabala. Langhana is
one of the principles of treatment for Kapha predominant diseases but has not
been accepted in the management of Arbuda by Sushruta as Langhana may
reduce the Rogibala.
Treatment of VÁtaja Arbuda
Local Treatment39
[1] UpanÁha
[2] NÁdi Sveda
[3] RaktamokÒaÆa
UpanÁha
Various medicated poultices are mentioned for the management of VÁtaja
Arbuda. KuÒmÁnda, ErvÁrÚka, Coconut, PriyÁla and Castor seeds boiled with
milk, water and ghee, mixed with oil should be applied locally. Another
medicated poultice made up of boiled meat has also been described.
NÁÕÍ Sveda
Fomentation of the local part in the form of NÁÕÍ sveda may also be tried.
RaktamokÒaÆa
Blood letting with the help of Ïénga has been described for treatment of VÁtaja
Arbuda.
Systemic Treatment
38
39
xzfUFk"oFkkes"kq fHk"kfXon/;kPNksQfØ;ka foLrj’kks fof/kK%A
j{ks}ya pkfi ujL; fuR;a rnzf{kra O;kf/kcya fugfUrA lq0fp0 [email protected]
okrkcqZna {khjÄz̀rkEcqfl)S:".kS% lrSyS:iukg;sÙkqA
dq;kZPp eq[;kU;qiukgukfu fl)S’p ekalSjFk oslokjS%AA
Losna fon/;kr~ dq’kyLrq ukMîk J`axs.k jäa cgq’kks gjsPpAA
okr?ufu;Zgwi;ksEyHkkxS% fl)a ’krk[;a f=o`ra fics)kAA lq0fp0 [email protected]&31
307
Medicated Ghee preparation boiled with decoction of vÁyu nÁÐaka drugs is
indicated with milk or kÁnjika.
Treatment of Pittaja Arbuda40
Local
[1] UpanÁha
[2] Svedana
[3] Lepana
[4] RaktamokÒaÆa
The Arbuda should be well rubbed with the leaves of Udumbara or other
leaves having rough surfaces followed by plastering with fine dust of
Sarjarasa, Priyangu, Raktacandana, Rodhra, Arjuna and YasÔimadhu mixed
with honey.
Another alternative plaster composed of Àragvadha, Gogi, Soma and ÏyÁmÁ
has been described.
Above local application of medecaments has been advised after RaktamokÒaÆa.
Systemic
SaÞÐodhana CikitsÁ should be done by Virecana. Medicated Ghee prepared
with MadhuyasÔi, DrÁkÒÁ, ÏyÁmÁ, Girihwa, Anjanaki and Yavatikta should be
used internally.
Treatment of Kaphaja Arbuda41
Local
Local application of various medicated pastes have been advised by Sushruta,
which should be used after SaÞÐodhana CikitsÁ (Vamana). The paste of the
drugs used for Vamana and Virecana may be applied locally to arrest the
disease.
Ksara in cow’s urine can also be used in Kaphaja Arbuda for local application.
Local application of drugs has been advised only after RaktamokÒaÆa.
Treatment of Medaja Arbuda
40
41
Losnksiukgk e`noLrq dk;kZ% fiRkkcqZns dk;fojspua pAA
fo?k`"; pksnqEcj’kkdxksthi=SHkZ̀’ka {kkSæ;qrS% izfyEisr~AA
’y{.khÑrS% ltZjlfiz;axq¯iÙk´~jks/kzkºoStu;f"V dkgSo%AA
folzkO; pkjXo/kxksftlkek% ’;kek p ;ksT;k dq'kysu y ysisAA
’;kekfxfjºok´~tudhjls"kq æk{kkjls lIrfydkjls pAA
?k`ra ficsr~ Dyhrdlaizfl)a fiÙkkcqZnh rTtBjh p tUrq%AA lq0fp0 [email protected]&34
’kq)L; tUrks% dQts·cqZnsrq jäs·ofläs rq rrks·cqZna rr~ A
æO;kf.k ;kU;w/oZe?k’p nks"kku~ gjfUr rS% dYdÑrS% izfnº;kr~~AA
diksrikjkorfoM~fofeJS% ladkL;uhyS% ’kqdykaxyk[;S%A
ew=SLrq dkdknfuewyfeJS% {kkjizfnX/kSjFkok izfnº;kr~AA lq0fp0 [email protected]&36
308
Susruta has given more importance to surgical and para-surgical approaches for
the management of Medaja Arbuda. But medicated paste containing HaridrÁ,
GéhadhÚma, Lodhra, Patanga, Mana½ÐilÁ and HaritÁla mixed with honey may
be used locally.
Para-surgical Treatment of Arbuda
Para-surgical approaches includes RaktamokÒaÆa
Agnikarma,
KÒÁrakarma
Maggotification.
RaktamokÒaÆa
RaktamokÒaÆa (blood letting) is indicated after SaÞÐodhana CikitsÁ in the
management of VÁtaja, Pittaja, Kaphaja and Medaja Arbuda. Application of
Ïénga, JalaukÁ and AlÁbÚ for blood letting has been advised respectively in
VÁtaja, Pittaja and Kaphaja Arbuda. In Medaja Arbuda blood letting has been
advised after making incision of the Arbuda.
Agnikarma and KÒÁrakarma
Agnikarma and /or KÒÁrakarma used alone or in combination with surgery for
the management of (i) Kaphaja Arbuda
(ii) Medaja Arbuda
(iii) Arbudas, which do not response to medical treatment.
Recurrence of tumour after surgical excision was well known to Sushruta and
his idea about recurrence was that even the last particle of doÒa of an Arbuda
left unremoved would lead to a fresh growth and bring on death just like the
last particle of an unextinguished fire. Hence, it should be excised totally42.
It is just possible that surgically a small part of a tumour might have remained
unremoved. Hence, for a complete removal of the doÒa i.e. tumour, Agni
Karma and KÒÁrakarma have been advocated specially after surgery.43
42
oz.ka izfrxzká e/kqizxk<S¢% dj´~trSya fon/khr ’kq)s AA
l’ks"knks"kkf.k fg ;ks·cqZnkfu djksfr rL;k’kq iquHkZofUr AA
rLekn’ks"kkf.k leq)j¢Ùkq gU;q% l’ks"kkf.k ;Fkk fg ofg~u%AA lq0fp0 [email protected]
43
fu"ikofi.;kddqyRFkdYdSekZalizxk<S nZf?keLrq;äS%AA lq0fp0 [email protected]
309
Maggotification
Maggotification is another important para-surgical treatment of Arbuda. In this
unique technique gradual destruction of tumour mass can be achieved by
maggotification of the tumour for which to attract the flies Kulattha, oil cakes
of Sesamum, powder of dry meat etc. pasted with curd should be applied over
the Arbuda so that worms and parasites may be produced to consume the
Arbuda. When only a small part of Arbuda is left unconsumed, it should be
removed and ulcer should be burnt with fire.
Surgical Management
Indication
If Granthi or Arbuda does not resolve or respond to the proper medical
treatment it should be treated surgically.44
The ideal surgical treatment of Arbuda are(i) Excision (ii) Excision and scrapping
Sushruta has described principles of excision of Arbuda which includes - (a)
The excision should be complete and all efforts should be made to remove the
tumour mass completely otherwise it may lead to recurrence and poor
prognosis. (b) Efforts should be made to prevent intra-operative spread of
tumour to distal place for which application of metal tourniquets made up of
iron, copper, zinc and lead should be applied around the Arbuda and mass
should be destroyed by Agni, KÒÁra or surgically according to the depth of the
root of the Arbuda.45 These principles of treatment occupy an important place in
surgical oncology even to day. Application of tourniquets, no touch technique
of excision and ligation of feeding vessels are some of the important operative
techniques, which are still in practice for prevention of spreading of tumour.
After surgical excision the area should be cauterized by Agni or KÒÁra to
achieve a complete cure. Ïodhana Karma of the wound should be undertaken
44
v;eZtkra ’keeiz;kUreiDoesokigjsf}nk;ZA
ngsr~ fLFkr¢ pkl`ft fl)dekZ l|%{krksäa p fof/ka fon/;kr~AA
lq0fp0 [email protected]
45
vYikof’k"Vs ÑfeHkf{krs p fy[ksÙkrks·fXua fon/khr i’pkr~A
;nYiewya =iqrkezlhliÍS( lekos"V; rnk;lSokZAA
{kkjkfXu’kL=k.;lÑf}n/;kr~ izk.kkufgalu~ fHk"kxizeUr%AA
vkLQksr tkrhdjohji=S% d"kk;fe"Va oz.k’kks/kukFkZe~AA
[email protected]&39
310
after excision of Arbuda and cleaning of wound by decoction of AparÁjitÁ,
Cameli and KaravÍra. The oil prepared from boiling of BhÁrangÍ, BiÕaÉga and
paste of TrÍphalÁ may enhance healing of the wound. Suppurated wound may
be treated according to measures of DuÒÔavraÆa.
Preventive goals- ÀhÁra- vihÁra, RasÁyana and Pancakarma
Complication profile
Patient related – Due to age related changes in body organ system
proper absorption, assimilation, distribution and biological effect of
drugs do not occur. Impaired immune system of senile body may cause
adverse effects of some drugs. General body condition is poor in
patients of malignancy because of disease and treatment procedures
therefore desired response of therapy can not be achieved.
Drugs and procedure related- Senile changes in general body
constitution and organ system restricts the use of drugs in required dose
and sometimes required procedures also can not be performed.
Limits of approaches
Metabolic- Metabolic disorders in elderly age are very common with
various impairments of body organ system like Diabetes with
impairment of Renal and Cardiac functions limits the use of drugs in
required dose along with limitations of use of procedures also.
Chemotherapeutic drugs used for treatment of tumors causes metabolic
disturbances in the body resulting restriction of effect of treatment
procedure.
Degenerative- Degenerative changes in body and organ system cause
restriction of use of drugs and procedures e.g. cerebral, cardiac, gastro
intestinal and other degenerative changes causing limitations of drugs
and procedures.
Therapeutic- Due to metabolic, degenerative, hormonal and
immunological changes in body many of the drugs and procedures may
not be used in proper dose and at desired time.
311
Chapter-21
Pancendriya VikÁra
(Sense organ diseases of the elderly)
Eyes, Ears , Nose, Tongue and Skin
Introduction
The Sense organs are the most important and highly differentiated end organs
which are mainly responsible for different types of sense of perception such as
darÐana, Ðravana, ghrÁna, rasanÁ and sparÐana. The perceptions of sense
organs to living beings are the unique and choicest gift of Almighty .As like
the other structures, organs, systems of the human body it is obvious and
inevitable that all the sense organs are also involved with various ailments
leading to the manifestation of different sense organ disorders (Pancendriya
vikÁra ) in old age . Our aim should be to detect and identify the diseases in
early stage, to start the treatment accordingly in prodromal stage, to take such
modalities to arrest the progress of disease process and finally to refer to higher
center for better management in critical condition. Thus it is important to
explore the therapeutic potential of Ayurveda in the management of some
intractable sense organ disorders in old age .This leads and potentials may
further be subjugated by the creation of good scientific evidence base which
will ultimately mainstream the strength of Ayurveda by sustainable utilization
across the country and the Globe as well.
Issues and Concerns in Pancendriya VikÁra in Elderly
The concept of sense organs in Ayurveda not only cling to sense perception but
it has got an inevitable role in maintaining the Physical as well as the mental
health of human beings .we get descriptions of sense organs in all classical
texts like Astanga Hridaya, Sushruta Samhitha, Caraka samhitha etc but we get
idea about Panca Pancaka only in Caraka Samhitha Indriya, IndriyÁdhiÒÔhÁn,
IndriyÁrtha, Indriya dravya and Indriya buddhi are the five integral units of
Panca Pancaka. The perception of Sense is a complex procedure and can be
possible by the combined action of this panchpanchaka along with ÁtmÁ &
manas.
AsÁtmyendriyÁrtha Samyoga
Depending on the intensity and nature of stimuli comes in contact with the
sensory organ IndriyÁrtha samyogas are divided into a) Samyak yoga : When
appreciable amount of stimuli come in contact with sense organ b) Atiyoga :
excess stimuli,c) HÍnayoga: stimuli so less or not sufficient enough to produce
normal perception d) MithyÁ yoga: when the nature and quality of stimuli
312
change e.g. hearing fearful noise, rough noise etc are considered as MithyÁ yoga
of ear,and so on in case of other sense organ. These abnormal perceptions are
responsible for creating pathological lesions locally as well as generally.
Indriya pradoÒaja vikÁra
IndriyopaghÁta (total destruction of sense) indriyÁbhitÁpa (slight defect in
perceiving IndriyÁrtha) are the two indriya pradoÒaj vikÁra. The changes in
sense organs affected in elderly are svabhÁvika vyÁdhi (pariÆÁmajanya)
according to Acharyas, it is unavoidable and may not respond to treatment and
it is because of this reason Acharyas insist to start RasÁyana therapy in middle
age and to continue according to RasÁyana therapy.
The different senses affected in elderly include - eye, ear, nose, tongue and
tactile sense organ. Among these senses, which affect very badly and create
social isolation are decreased hearing and visual problems.
Anatomical and Physiological Changes in Sense Organs in Elderly
Cornea tends to be flattened with age leading to astigmatism, fatty invasion of
corneal margins (Arcus senelis). Sclera becomes less elastic and takes on a
more yellow coloration due to fatty deposition. The ciliary body thickens and
its processes become hyalinised,changes in trabecular mesh work,through
which aqueous humor flow as it leaves the eye occur such as endothelial
proliferation ,thickening and sclerosis of the tissue . These changes in the
trabecular mesh work coupled with the increase sclera rigidity might expect to
give rise in intraocular pressure in all aging eyes. The lens undergoes a number
of anatomic and metabolic changes , with the advance of age the ability to
increase thickness and curvature of lens in order to focus upon the near object
is gradually lost .This condition is called presbyopia. Vitreous commonly
detaches from its natural connection, resulting retinal tears which sometimes
may leads to retinal detatchment. Vitreous may under go degenerative changes
causing floaters .Retinal changes in the normally aging eye are essentially
limited to the vasculature, the arterioles are narrowed, pale, less brilliant,
straighter in their course. The veins too are proportionately narrowed.These
vascular changes are felt to be the result of increase in vessel rigidity related to
generalized fibrosis .The choriocappilaries at the posterior pole is grossly
affected, there may be loss of vision resulting from senile macular
degeneration.
As a result of changes in elastic tissue ,loss of orbital fat and decrease in
muscle tone the following changes like enophthalmous ptosis, entropion,
trichiasis occurs in old age .Altered or decreased tear secretion is commonly
seen in old individuals and that may be a major cause of discomfort and
inflammation of eye resulting xerophthalmia & dry eye syndrome .
Eye Problems of the elderly
Cataract, Glaucoma, senile macular degeneration, Retinopathies etc. are
common among the age related problems of Eye.
313
Cataract
A common of all those conditions which causes loss of vision, not rectified
with corrective eye glasses. Cataract occurs to some degree in over 95% of
those above 65 years of age. The symptoms related to cataract are some what
diverse. In addition to a decrease in visual acuity, mono ocular diplopia or even
polyopia can be the complaint .Increasing myopia is common and in
presbyopia hypermetropic individual can lead to read without glasses for the
first time in years, giving the mistaken impression that the vision has actually
improved .Light may diffracted by lens opacification producing haloes around
light, this may be differentiated from glaucoma, prulent conjunctivitis and
corneal oedema. Senile cataracts are either nuclear with the innermost portion
of lens involved or cortical with the portion of lens between nucleus and
capsule are involved or posterior sub capsular cataract where lental changes
occurs infront of post Lens capsule.
Glaucoma
Glaucoma is a symptom complex characterised by elevation of the intraocular
pressure defect in field of vision and cupping of optic disc resulting optic
neuropathy. The most widely accepted general classification of Glaucoma
include
1. Primary Glacoma
a) Simple glaucoma (primary open angle glaucoma)
b) Closed angle glaucoma (primary closed angle glaucoma)
2. Secondary Glaucoma: Due to pre existing ocular diseases .It may be either
opened or closed.
3. Congenital Glaucoma: Due to obstructions resulting from congenital
anomaly in the angle of anteriorchamber
The two basic types of primary glaucoma are most frequently seen in older
patients.
Senile Macular Degeneration
It is a common lesion of macular area of retina in old age .As the macular area
is specifically concerned with central and precise vision, a lesion here usuall
produces a gradually increasing loss of central vision, which may be severe
producing a central scotoma.
Vascular diseases
Eye signs are prominent factor in vascular diseases of both the extra cranial
and intra cranial blood vessels .Those conditions which are prone to develop
in old age are as the result of arteriosclerosis.Occlusion of the Retinal artery,
Temporal arteritis, occlusion of central retinal vein and occlusive
cerebrovascular diseases are the common lesion which involve the eye during
the pathological process .The symptoms range from total loss of vision to
314
abnormalities in vision ,visual fields , ocular motility pupillary abnormalities ,
non physiological nystagmus, loss of binocular coordinative ability and
certainly the funduscopic abnormalities be the clue leading to the diagnosis of
such cases.
Causes of various sense organ disorders and their clinical
presentation
Ayurvedic Aspects:
It is difficult to get separate aetiological factors for the different problems of
sense organ of aged individuals, but we get an elaborate description regarding
causative factors of ailments of sense organs that can be invariably applicable
to the problems of old group. In addition to AsÁtmyendriyÁrtha samyoga,
Ayurveda gives much emphasis to food and habits of the individuals, for e.g.
food items like vinegar, sour items, hot & spicy etc are indicated to have some
role in producing eye diseases like wise habits like taking cold items after
exposure to hot, sleeping during day time and walking throughout night are
causative factors for doÒik vitiation according to Ayurvedic concepts.
In addition to the above said reasons Ayurveda recommend certain life styles
named DinacaryÁ (Daily routine) & ètucaryÁ (To be followed in different
seasons) which is said to have definite role in eliminating the doshas vitiated
daily and in various seasons.
One who follows all the above said restrictions and recommendations along
with adequate RasÁyana therapies can off course delay the aging procedure
But the pace of the life is in such a way that there is no time to meet such
needs though it is effective .
SamprÁpti (Pathogenesis)
We get Ayurvedic references similar to various pathologies related to eye, ear,
nose etc. in elderly .The cataract mimic the signs of Kaphaja Timira and
Kaphaja LinganÁÐa in immature and mature stage respectively According to
acharya the vitiated kapha doÒa when localize in deeper part of déÒÔi it results
in the development of Kaphaja LinganÁÐa and can only be cured through
surgery.
The symptoms of Glaucoma having much resemblance with the signs and
symptoms of Adhimantha. The site of lesion according to Acharya is SarvÁkÒi
where all parts of the eye actively involve in the pathology.
Causes of sense organ disorders currents:
The changes in different sense organs in elderly are definitely influenced by
hereditary tendencies which appeared to be transmitted by a dominant pattern.
315
Cataract:
It is probable that the causes of lens opacification are many and varied, but
basically loss of transparency is related to a change in the internal Structure of
lens, this change is related to either accumulation of water between lens fibers
intracellularly producing a deffractive effect, or to a coagulative opacification
wherein the lens protein becomes insoluble and opaque.
Glaucoma:
The development of glaucoma in elderly is usually due to the anatomical
changes that occur at the angle of anterior chamber and in trabecular meshwork
in the later period of life. In addition to that glaucoma can also develop as a
sequel along with the formation of cataract due to the changes in the angle and
also due to leakage of lens matter in to the anterior chamber obstructing the
angle .When the obstruction is at the level of angle the type of glaucoma may
be closed angle glaucoma and changes in trabecular meshwork usually create a
chronic simple glaucoma.
ARMD
The senile (Age related) macular degeneration and other retinal problems are
usually related to the vascular changes like arteriosclerosis of choroid as well
as the vessels related with the vascular supply of eye. ARMD is devided in to
two types: non exudative (dry) and exudative (wet). The two common features
of both types are drusen ( an amorphous material that accumulate in the retina )
and degeneration in the are of macula which result in decreased central vision
80% of individuals have non exudative, although exudative is less frequently,
it causes more severe visual loss .
Non exudative is marked by accumulation of drusen throughout the retina. It
has yellowish appearance on funduscopic examination. Exudative or (wet)
ARMD is characterised by the appearance of choroidal neovascularization and
haemorrhage .It is these two characteristics that lead to the severe loss of
vision.
Clinical Presentation
Eye
Cataract:
Diminished vision of gradual onset, black spots in the visual field which is not
movable along with the movement of head, diplopia, polyopia haloes etc are
the common complaints of patient during different stages of cataract formation
leading to total loss of vision, usually bilateral in nature, but manifest in one
eye earlier .If not accompanied with other complications like glaucoma the eye
is free from other symptoms. On examination the lens appears to be opaque,
and in mature cataract it is pearly white in colour
316
Glaucoma
The presentation of glaucoma are entirely different .In closed angle glaucoma
the patient complaints of pain, redness, head ache usually one sided, sudden
onset of diminished vision, photophobia, haloes sometimes coloured haloes etc
but a patient with chronic simple glaucoma never exhibit such symptoms, the
peripheral field of vision of the patient get constricted gradually and only in the
later stage of the disease the patient may get aware of his defect.
Macular Degeneration
Depending on the type of ARMD the clinical presentation may also vary.The
onset of visual loss is acute in wet type compared to the other variety.
As the macular area concerns with central and precise vision there may be
progressive loss of central vision, but the peripheral field may be normal.
There may not be any change in gross appearance of the eye Patient may
complaints of missing of circular areas in the visual field
Complications, Chronicity, Prognosis of sense organ disorders.
Cataract
Development of glaucoma is a usual complication of cataract, which may
usually, occurs during development of cataract and also as a complication of
hyper maturity. During the development of cataract when the lens imbibes
more and more water and swells which bulges forward reducing the angle of
anterior chamber, there by obstructing the passage of aqueous flow resulting
increased I.O.P, Glaucoma can also develope due to escape of lens material in
to the anterior chamber through intact capsule provoking a macrophage
response in the anterior chamber. The lens material and the macrophages cause
obstruction to the aqueous flow by becoming concentrated in the chamber.
When a deep anterior chamber with advanced cataract and signs of acute
glaucoma, the syndrome of phacolytic glaucoma should be identified and
immediate lens extraction should be performed.
Glaucoma
It is not identified at the onset of Acute glaucoma may surely ends in total loss
of vision due to lack of structural and functional integrity e.g. optic atrophy,
corneal haziness and absolute glaucoma having no perception of light finally
Phthisis bulbi but there may not be much complication in chronic simple
glaucoma rather than gradual constriction of visual field .
ARMD
There may be sudden loss of vision which can’t be retained in any way in wet
variety as there is disorganization of structures followed by leaking of exudates
and blood in sub retinal space.
317
Upadravas of Pancendriya VikÁra
Acharya vagbhata explains 6 types of upadravas for Kaphaja LinganÁÐa.
According to him surgery is contra indicated when Kaphaja LinganÁÐa (mature
cataract) accompany any of this six upadravas .when we analyse the lakÒanas
(signs & symptoms) described for those upadravas it is understood that these
are some changes which occurs in the lens or its capsule and can be
appreciated from outside. It is possible to get such upadravas even in this era
and a study reveals that the patients with such upadravas surely have a history
of either systemic or ophthalmic pathology .The upadravas are the following
Àvartaki
:
when the eye moves involuntarily
ÏarkarÁ
:
:
Chatraki
Rajeemathi
:
Chinnamsuka :
Chandraki
when the lens surface show white dots
:
When the colour of lens is yellowish brown like old
Umbrella made of palm leaf
When there are lines over the lens surface
When the lens matter appears to be broken
When the colour of lens is like that of kamsya
According to Acharya hathÁdhimantha is the complication of all sorts of
adhimantha when it is not treated properly in the initial stage .Which is having
much similarity to absolute glaucoma. There is indication of sudden loss of
vision in pittadhimanth when treated improperly.
Clinical Diagnosis and Diagnostic Problems in Elderly
Cataract :
1.
Mature cataract appears to be pearly white in colour and can be
appreciated even with help of a torch, and absence of iris shadow.
2.
Visual acuity should be recorded
using Snellen’s visual acuity
chart for each eye separately,in mature cataract it is reduced to hand
movements
3.
SLIT LAMP biomicrscope reveals absence of 4th perkinzee sansons
image and detects the exact site of lenticular opacity and nature of
cataract.
4.
Ophtalmoscopy shows absence of red glow in mature cataract.
Glaucoma
1.
Measuring I.O.P. using Schiotz or applanation tonometer, measuring
Perkinz hand held
tonometer
or
non
touched
pneumatic
tonometer.
2.
Assessing the field of vision using field analyzers
3.
Gonioscopy to measure the angle of anterior chamber
318
4.
Ophthalmoscopy to assess the fundal changes like Glaucomatous
cupping etc
5.
Recording visual acuity &examination of the eye using slit lamp are
extremely important in each visit.
6.
Some provokative tests such as dark room test, water drinking test,
mydriatic test etc are also important to differentiate between POAG &
PACG.
Macular Degeneration:
1.
Ophthalmoscopy, scanning laser ophthalmoscopy
2
Recording of visual acuity for distance and near with Snellen’s Chart and
Visual field recording by various methods such as confrontation method
Perimetry, Scotometry, Gold Mann perimetry and by Humphrey field
analyser.
3.
Fundal Photography and fluorescein fundal angiography.
4.
Amsler grid test, O.C.T (Optical coherence tomography)
Errors in Diagnosis
Errors in diagnosis can occur frequently if care should not be given in
differentiating the condition during the first visit itself, which may leads to
irreversible damages to the sense organs.For eg All routine examinations
checking visual acuity, field of vision, measuring I.O.P. and fundal
examinations are extremely important in each and every case with diminished
vision in elderly care should be taken during hearing test to differentiate the
varities in case of hearing impairment.
Approach to treatment, Non pharmacological and pharmocological
Cataract : Medical - if the cataract is immature, to delay the progress 1.Topical eye drops containing iodide, salts of potassium or calcium 2. Vit –E,
C Aspirin (orally) and 3. Measures to improve vision by prescribing glass,
mydriatics, use of dark goggles.
Surgical management is advisable in mature cataract and this is the only
treatment protocol of mature cataract both in modern and Ayurvedic science
and having no alternative. People should be made aware of Eye health care
services available to them and patients should be motivated not to hesitate to
go for surgery for fear of operation rather to encourage coming forward for
operation. Due to technical innovation the patients may get the benifits like a
reduction in the period of hospital stay, unrestricted patients activity after
discharge and a decrease in the time for visual rehabilitation
The types of surgeries include Extracapsular extraction, intra capsular
extraction, needling, Phaco emulsification, cryo extraction small incision
cataract surgery with intra ocular lens implantation (IOL) etc.
319
Glaucoma
Treatment should not be instituted unless visual field defects or anomalies of
optic disc can be demonstrated or the I.O.P is greater than 30mmof Hg. The
treatment of open angle glaucoma is essentially medical and surgery should be
restored only when the medical therapy has failed to control the pressure (IOP)
and when increased cupping of the optic disc continues or increasing visual
field defects occur. The management of closed angle glaucoma is basically
surgical ,but medical treatment is definitely necessary preoperatively during
the acute stage to lower the I.O.P.and to relieve pupillary block so that surgery
can be performed under the most ideal condition .Prophylactic peripheral
iridectomy is the choice of surgery which can be recommended soon after the
acutely involved eye is attended .
Medical Therapy
• Topical beta blockers as eye drops .(Timolol, Beta xolol, Pindolol etc )
• Cholinomimetic (Parasympathomimetic
(Pilocarpine
Neostigmine , etc)
)
Drugs
as
eye
drops
• Adrenergic drugs as eye drops
• Carbonic Anhydrase inhibitor (orally &locally )
• Prostaglandine agonist as eye drops
• Oral glycerine and urea.
• Intra venous Manitol 10%-20% etc
Surgical Management
Various types of filtration operation, Peripheral iridectomy &iridotomy,
Trabeculectomy, Trabeculoplasty, Argon laser Trabeculectomy and various
types of artificial shunt implantation.
Macular Degeneration
Even though there is no specific treatment for degenerative macular
degenerationintroduction of laser photocoagulation, Photodynamic therapy,
Trans papillary thermotherapy, anti oxidants ie Vit A, E, C, and zink, copper,
selenium orally seems to have some role in restraining the the prognosis of
pathology especially in wet type in addition to that magnifiers, strong reading
aids and telescopic lenses may be heilpful in allowing the patient to carry on a
more normal existence.
Ayurvedic Principle of Treatment
According to Ayurvedic concepts the pathological lesions occur in old
individual can be considered as svabhÁvikavyÁdhi,and is difficult to to cure
completely so with an intention to delay the aging process Acharya
320
recommend to start rasÁyana therapy in the middle age itself, more over the
acharya devide the life span in to three different stages and the influence of
dosas may vary in these periods for eg:kapha dosa The eye is one of the most
important and highly differentiated end organ which is mainly responsible for
sense of sight . The vision is the unique and choicest gift of Almighty .As like
the other structures, organs, systems of the human body it is obvious and
inevitable that the eye is also involved with various ailments leading to the
manifestation of different ocular diseases in old age. Our aim should be to
detect and identify the diseases in early stage, to start the treatment accordingly
in prodomal stage, to take such modalities to arrest the progress of disease
process and finally to refer to higher center for better management in critical
condition. Thus it important to explore the therapeutic potential to Ayurveda in
the management of some intractable ocular disorders in old age.
Kapha Dosa in bÁlya(up to 16yrs) , pitta – in yauvana(16yrs-80yrs), and vÁta
during vÁrdhakya (above 80yrs).During bÁlya there is much development for
dhÁtu, indriya ,and for Ojus , in yauvana there is no such increase and on the
commencement of vÁrdhakya there will be marked decrease for all most all
dhÁtus ,indriya bala and oja . This is the basic reason for all ailments related
with elderly according to the concept of Ayurveda. So in case of old age
sensory organ disorders attempts should be made to alleviate or to specify
vitiated vata dosha.
Inaddition to the above said factors Acharya gives idea about various
aetiological factors (nidÁna) affecting the different sense organs , Avoiding
such nidanas are equally important as giving treatment because Ayurveda
insists “ avoiding nidÁna “as a method of treatment and treatment should be
started earlier in prodomal stages of the diseases (PÚrva rÚpa)
Even though pariÆÁmajanya vikÁras are incurable, acharya suggests treatment
for all most all diseases of old age, so it is easy to get Ayurvedic reference for
treatment of cataract, glaucoma, macular degeneration, deafness etc.
Treatment of Cataract- Ayurvedic approach
SnehapÁna
Rakta mokÒhaÆa
Virecana
Nasya
Anjana
Ïirovasti
ÏirodhÁrÁ
Vasti
TarpaÆa
321
PuÔapÁka
Lepa
Seka
Anjana & ÁÐcyotana (eye drops )
Sirovasti
TarpaÆa
Nasya
ÏirodhÁrÁ
These are the treatment modalities of diminished vision. The choice of drug
may vary depending on the involvement of different doÒas .for eg cataract is a
kapha predominant condition , the choice of drug would be kapha Ðamana or
having lekhana property ,incase of macular degeneration we should opt
combinations having tridoÒa Ðamana property .
Common Medicines Used For the Treatment of Cataract
1.
2.
3.
4.
5.
6.
7.
MahÁ thriphalÁ ghéita
ThriphalÁ ghéita
TilatailÁdi nasya taila for nasya
SitairandÁdi nasya
AkÒabÍjÁdi anjana
VimalÁnjana
Kacayapana anjana
Independent of Doshik status triphalÁ is advisable to all patients with
diminished vision, along with honey and ghee in asama mÁtrÁ it acts as
rasayana .Acharya also advise different methods of administration of triphalÁ,
according to him triphalÁ cÚrÆa along with svarÆa bhaÒma, lohabhaÒma, yaÒÔi
cÚrÆa, tÁpya can be advisable in diminished vision of various entity according
to their doshic status.
Implementing above said Ayurvedic measures in middle age or at least in early
stage of the disease is found to be effective in delaying the progress of the
disease.
The Treatment of Glaucoma
Ayurveda recommend sirÁ vedha. SuÐÍta lepa (mukhalepa. sirolepa &
purampata) Seka (over head, eye) virecana & snehapÁna for the management
of acute Glaucoma. After subsiding the acute symptoms nasya, tarpaÆa,
putapÁka, sirovasti etc can be advised.
322
According to Vagbhatacharya there is high risk of total loss of vision in
various Adhimantha and in pittÁdhimantha there is chance of sudden loss of
vision. Now with the invention of various sophisticated instrument the
diagnosis and treatment of glaucoma becomes easy, even then there is no
solution for maintaining the vision of the patient.
So for the management of glaucoma a combined therapy is the best option of
treatment.
The modern medcines including surgeries are so effective in controlling the
I.O.P, and through different kriyÁkalpas the vision can be preserved and
restored.
Precautions, Complications and Limitations of Procedures
Visual impairment has been implicated as a risk factor for a number of
problems including hip fractures, falls and poor motility. Some studies have
also linked increased mortality with visual impairment. In addition to that
visual &hearing impairment may cause social isolation, which is most
distressing to the elder population. So giving more care especially to these two
sense organs is extremely important.
Though it seems to be hard to practice the DinacaryÁ (daily routine) &
ètucaryÁ, implementing Ayurvedic measures at least in the beginning of 4th
decade when the body exhibits the early changes of aging like presbyopia can’t
be neglected in any cause. We get references of Netra saÞrakÒaÆa- Eye care,
specially designed to protect the vision of individuals, which can be applicable
to each and every persons depending on the general condition of the body.
Acharya advise triphalÁ cÚrÆa along with honey and ghee, raktamokÒaÆa,
Ðodhana therapies (virecana & nasya ) , good mental health (cheerfulness),
Anjana karma, pÁda saÞrakÒaÆa (caring the foot, e.g. padÁbhyanga –applying
oil under the foot ) and taking ghee are certain Ayurvedic measures in terms
of eye care , these can also be adopted as early precautionary measures in
order to maintain the health of eye ,likewise karÆa pÚraÆa using oils which is
having the property to rejuvenate the nerves is an ideal method in keeping the
health of ear, it is under stood that the ear should be free from other complaints
like oozing etc.
Doing Danta manjana, Mukha dhÁvan, Kabala, and gandÚÒa ie - filling the
oral cavity with medicated oil or even with gingely oil and with varieties of
decoction on doÒic basis is helpful in discarding the ailments as well as
maintaing the health of oral cavity.
Nasya and Dhoomapana are much helpful in eliminating pathologies related to
ear, nose and, throat & oral cavity.
Complications usually occurs either due to negligence from the side of
individual or due to lack of proper diagnosis & treatment in the early stage of
the disease and it can be avoided by giving proper awareness to the elder
323
community , Regular screening, proper examination
adequate treatment.
and
by extending
Taking RasÁyanas in middle age, adopting the life style proposed by acharya
(DinacaryÁ , ètucaryÁ) strictly following the restrictions in ÁhÁra and vihÁra
implementing Ayurvedic measures at the onset of disease, it is possible to
either delay or arrest the progress of pathologies related to sense organs in
elderly.
Anatomical and Physiol0gical Changes of Ear in Elderly
Atrophic And sclerotic changes of tympanic membrane are common in the
aged, but do not usually cause appreciable losses of hearing .The most
common disorder due to inner ear and retro cochlear changes is presbyacusis
ie,the loss of hearing due to the process of aging which is thought to be as a
result of degenerative changes in old age . Any condition which reduces the
blood supply to the inner ear can cause additional hearing loss.There are two
types of pathologic changes involved in presbyacusis 1)The epithelial atrophy
begins in middle age and is characterised by progressive degeneration of the
sensory hair cells ,supporting cells and stria vascularis of cochlea from basilar
turn to apex 2) The second type neural atrophy begins later life and is
associated with degeneration of cells of spiral ganglion and neurons of the
cochlear nerve and higher auditory pathways.
Common sense organ diseases in elderly, hearing impairment, visual
impairement.
Hearing and visual impairment are the common disorders in the elderly. Both
of these sensory deficits are predictive of subsequent functional impairment, as
well as cognitive impairment and social isolation. Thus it is important to
identify the individuals with hearing and or visual impairment, and to find out
the cause and initiate appropriate therapies.
Ear:
Hearing and equilibrium must receive major emphasis when speaking about
E.N.T. problems in any age group especially in older age group. Although
some people retain usable hearing through out their life, most develop some
hearing deficiency which interferes with good communication.
The most common cause of sensory neural hearing loss in elderly is
Presbyacusis affecting more than 30% of elderly individuals over the age of
75years. It is bilateral hearing loss starting in the higher frequency ranges
above 2000 Hz. It usually starts in middle age and progresses with age
.Eventually perception of lower frequencies become impaired .Presbyacusis
interferes with speech discrimination .It affects men more than women .Exact
cause is unknown but presbyacusis is probably due to cumulative damage of
cochlea .
324
Vestibular Disorders:
In the geriatric patients vertigo is often associated with vascular changes. Some
patients with vertigo exhibit osteoarthritis changes in the cervical vertebrae.
The mechanism of this condition is thought to be due to constriction of one or
both of the vertebral arteries in the encroached foramen producing a transient
ischemia of inner ear. Any other disorders which cause transient interruption
or decrease of blood supply to the brain may also produce these vertiginous
episodes .Many persons who describe dizziness or spatial disorientation have
no demonstrable organic disease. In the absence of systemic diseases the
practitioner should obtain otological or neurological consultation
The ear:
Decreased hearing may either results from faulty conductive mechanism or
due to some defects in the sensory neural mechanism of the the ear considering
the elderly even though there is possibility of impacted cerumen and sclerotic
changes in tympanic membrane which in turn create conductive loss ,the most
frequent cause of hearing loss is defective sensory neural mechanism. As the
sensory neural elements of hearing are closed tied together it is often difficult
to determine just how much each is contributing.
The exact cause is unknown but the hearing loss of presbyacusis is probably
due to the damage in the cochlea .In addition there appears to be a central
auditory processing disorder occurring at the same time, because the difficulty
with speech discrimination is more than would be expected resulting from just
the hearing loss.
Presbyacusis can be worsened by a number of conditions including
cerebrovascular diseases, diabetes mellitus, hypothyroidism, hypertension and
chronic lung disease. It can also be worsened by factors such as chronic
alcohol abuse and long term noise exposure.
Hearing Impairment
If not diagnosed and cared in the initial stage of the disease there may be
progressive hearing loss which may be so severe so that the personal as well as
the social life of the individual may affected badly.
Hearing Impairment
1. Examination of the ear with the help of otoscope
2. Hearing tests such as voice test, Tunnig fork examination (Rinnie’s
Webber’s, ABC Test)
3. Pure tone audiometry.
4. Speech Audiometry
5. Vestibular evaluation
6. Radiological investigation.
7. Bekesy and impedence Audiometry.
325
There are two reliable screening tests that can be used by an office based
clinician. The Hearing Handicape Inventory in the Elderly –Short Version
(HHIE-S) and portable audioscopy can be used either individually or in
combination to screen for hearing loss.
HHIE-S is a 10 item questionnaire with scores ranging from 0-40, with 0 being
no hearing impairment to 40 being maxing hearing impairment. The overall
accuracy of the HHIE-S is 75% using a cut off score of 26.
A portable audioscope is easy to use and has a sensitivity of 87-96%and a
specificity of 70% -90%. For screening purpose, the clinician need only test the
patient at 1000- 2000 Hz. These tones are in the speech perception range.
Patients, who fail either the HHIE-S or portable audioscopy, or both, should
be referred for formal audiologic testing. Formal audiologic assessment in a
sound proof room is considered to be standard for the diagnosis of hearing loss
which includes pure tone audiometry, speech reception threshold, bone
conduction testing, evaluation of acoustic reflexes and tympanometry.
Laboratory Diagnosis, Ancillary
Blood pressure
Blood sugar (fasting & post prandial)
Routine examination blood
Serum cholesterol
Lipid profile
Blood urea
Uric acid
Serum Creatinine
Routine examination of urine & stool.
Earing Handicap Inventory for the Elderly – Short Version
(HHIE-S)
1. Does a hearing problem cause you to feel embrassed when you meet
new people?
2. Does a hearing problem cause you to feel frustrated when talking to
members of your family?
3. Do you have difficulty hearing when some one speaks in a whisper?
326
4. Do you feel handicapped by a hearing impairment?
5. Does a hearing problem cause you difficulty when visiting friends
relatives or neighbours?
6. Does a hearing problem cause you to attend religious services less
often tha you would like?
7. Does a hearing problem cause you to have arguments with family
members?
8. Does a hearing problem cause you difficulty when listening to TV or
radio?
9. Does a hearing problem cause you difficulty with your hearing limits
or hampers your personal or social life ?
10. .Does a hearing problem cause you difficulty when in a restaurant
with relatives or friends?
Note: Scoring YES = 4 , NO = 0 , sometimes = 2 Hearing
handicape inventory for the elderly ; a new tool .
Hearing Impairment:The standard treatment of hearing impairment falls into one of the three
categories, medical, surgical and rehabilitation. The choice of treatment
depends on diagnosis.
Decreased Hearing
Consumption of DhÁnwantaram taila, KÒhÍrabalÁ taila, IndukÁnta ghéta,
SaribÁdi vati, Bhairava rasa, Indravati. DaÐamÚlÁriÒÔa, balÁriÒÔa and
AÐvagandhÁriÒÔa are said to be effective for the managenment of deafness
(S.N). SnehapÁna along with nasya and karÆapÚraÆa with ÏambÚkÁdi taila,
Bilva taila, KÒÁrataila etc are also advisable. .
Rhinological Problems
The rhinological disorders of the aging are not considerably different from
those of younger patients. Postnasal drip resulting in frequent clearing of throat
is very common but usually there is little change in the nose or naso pharynx.
There may be a loss of smell as one grows older .Frequently there is a
complaint of dryness of nasal vestibules. Epistxis is sometimes encountered in
the geriatric population as a result of hypertension and other arterial vascular
diseases.
327
The Tongue
This organ can manifest various diseases and deficiencies which will be
indicated by depilation and fissuring. In older persons among whom many or
all of the teeth are lost, the transference of mastication from the teeth to tongue
may very well be the reason for the apparent enlargement of the tongue.
The loss of taste buds, especially the circumvallate and foliate papillae initially
results in a diminution of taste perception and frequently proceeds to appetite
loss as well.
The loss of sweet taste perception is important. An increased sugar intake
usually follows, and the increased tendency to diabetes mellitus among the
elderly can lead to systemic problem.
Also restoration such as lower dentures or removable partial dentures with the
taste bud response and may induce dietary and nutritional problems.
Geriatric Problems of Sense Organs (Eye, Ear, Nose &Tongue)
Which Need Referral for Better Care & Management
Glaucoma , retinal vascular diseases, cataract, ocular surface disorders (dry
eye)ocular lid diseases (entropion & ectropion ) are some conditions related to
advanced stages in old age which require extreme care and sometimes
reference to better institution for specialist treatment in order to avoid the
deterioration of vision .
Referral criteria
Glaucoma
For accurate Diagnosis of the case .* Referring the patient to a higher
institution is very important in case of Glaucoma as the vision lost once can’t
be retained at any cost ,. so accurate diagnosis should be made in early
moment of consultation , and needs complicated instruments and those who
lack such facilities can refer the pt for better diagnosis .
• Early stage of primary open angle glaucoma which is very difficult for a
physician to diagnose, which is a silent killng disease.
• Stages of acute congestive glaucoma
• Absolute glaucoma (pain full blind eye ) patient seeks medical treatment
of intense pain
For better treatment.
When the medical treatment failed to maintain the normal IOP and there is
gradual reduction in vision the pt. should be referred for surgical management
to ophthalmic surgeon.
328
Cataract
In case of mature stage of cataract patient has to refer to authentic specialist
(ophthalmologist) for surgical management whether in mobile camp district
eye hospital, state medical college, eye hospital or regional eye hospital.
Retinal vascular diseases.
The technology is developed in such a way that now the treatments can be
delivered at the site of lesion, it doesn’t matter how interior and how delicate
the retina is!
So patients with the history of sudden loss of vision, diabetes, hypertension,
hyper cholestremia can be referred for routine examination and for treatment to
ophthalmologist.
AMRD, Ocular Surface Disorders, and Lid Diseases
In all these advanced diseases patient has to dispose of proper places such as
ophthalmologists for better management.
Diseases of Skin (SparÐanendriya) in the elderly
Skin, besides its sensorial function, provides extensive covering of the body
and protects it from invasion of external morbid agents both physical and
microbial. The aging process produces overt changes in the skin and its
appearance. With advancing age due to progressive dehydration of skin and
involution of the cells and tissues of the skin there occurs dryness, stiffness and
hypo-elasticity of the skin with formation of surface wrinkles which are the
hallmark of biological aging. Skin consists of three major layers viz Epidermis,
Dermis and subdermis which perform different functions in the life time.
Ayurvedic texts describe finer details of seven layers of skin performing
different functions. To sustain the luster and complexion of skin in advancing
age it is necessary to provide adequate nutrition and hydration. Sharangadhara
while describing the sequential changes in Aging points out that Fifth decade of
life is hallmarked with senile changes of skin. Skin care is, most needed in 4th
and 5th decade.
The common diseases of skin are different kinds of allergies, acute and chronic
viz. Urticarias, eczemas, drug reactions and psoriasis. Skin infections, both
fungal and bacterial are very common. Leprosy largely affects the skin. Several
auto-immune and collagen diseases afflict skin particularly in old age.
Malignancies of skin particularly Melanoma is equally important to be
identified early for logical treatment in time.
Ayurvedic classics describe seven major skin diseases (MahÁkuÒÔha) simulating
different kinds of Leprosy and Eleven minor skin diseases (KÒudra kuÒÔha)
with elaborate clinical and therapeutic descriptions. Àrogya vardhini,
Pancatikta Ghéta, KhadirÁriÒÔa, panca NimbÁdi Curna, SÁrivÁdyÁsava and
Gandhaka RasÁyana are common Ayurvedic medications. Use of 777 oil a
329
Siddha Medicine preparation is claimed to be notably beneficial in case of
Psoriasis and SomarÁji (Psoralia corylifolia) oil is an established medicine for
treatment of Vitiligo and leucoderma. Tubaraka is classically advocated as a
Naimittika RasÁyana for KuÒÔha roga in Ayurveda. HaridrÁ and ÏirÍÒa are
commonly used in all forms of skin allergies while Nimba is generic herbal
drug for treatment of skin infections. TailÁbhyanga, KÁya Seka and Annalepa
are useful restorative measures for diseases of BÁhya MÁrga i.e. dermatoses
including neurodermatosis and neuropathies.
Recommended Further Reading
1.
The Merck Mannual of Geriatrics - 3rd Editiob. Merck.H. Bear
2.
On Aging and Old age Basic problem – G.K. Merck.
3.
Hand Book of Geriatric Assessment – Gallo.
4.
Introduction of Ayurveda & History, (Published by Ayush.)
5.
Charaksamhitha (Related
Samsthan,Varanasi
6.
Susruthsamhita, (Related portions)- Chaukhambha Sanskrit
Samsthan,Varanasi
7.
Ashtangahridaya, (Related portions) Chaukhambha Sanskrit
Samsthan,Varanasi
8.
Madhavnidan, (Related
Samsthan,Varanasi
9.
Shargadhara samhita, (Related portions) Chaukhambha Sanskrit
Samsthan, Varanasi
10.
Chakradatt, (Related
Samsthan,Varanasi
11.
Bhavaprakash (Related portions)
Samsthan,Varanasi
12.
Bhaishajyaratnavali Etc (Related portion ) Chaukhambha
Sanskrit Samsthan,Varanasi
portions)-Chaukhambha
portions)
portions)
330
Chaukhambha
Chaukhambha
Sanskrit
Sanskrit
Sanskrit
Chaukhambha Sanskrit
Chapter-22
Geriatric Women Health Care
The phenomenon of aging and the changes related to aging are common to both
male and female. They are vulnerable to different geriatric diseases to the same
extent and need specific management of old age diseases as per the type of
disease. The structural and functional differences related to the reproductive
system in case of women differentiate them from men. Specifically talking in
terms of elderly women, the menopause is the most dramatic event in their life
and is signaled by cessation of normal cyclic ovarian activity resulting into
permanent discontinuation of menstruation. A woman of geriatric age feels as
she is a dethroned queen, during this period her reproductive life ceases and
some may think as her feminism also. A single event of menopause
characterizes significant changes in a women's life. Due to onset of menopause,
majority of gynecological and systemic diseases occur because of deficiency of
hormones especially estrogen and progesterone, which are collectively
described as post menopausal syndrome.
Besides genetic predisposition, probably overtaxation of womanhood may be a
major contributory factor, however alteration in hormonal status particularly
oestrogen deficiency coupled with certain psychosocial, personal and economic
alterations may also be considered as triggering points Over consciousness for self and devotion of less time for care of other
family members.
Stress and strain (physical and psychological both).
Non-observance of dietetics and mode of life during menstrual bleeding,
pregnancy and puerperium.
Altered sex behaviour, dietetic pattern (i.e. almost absence of use of
flax-seed i.e. atasÍ, a good source of natural phytoestrogen i.e. lignans
contributing to additional selective oestrogen enzyme modulator or
SEEM and fenugreek i.e. methÍ, seed; a good nutrient and appetizer as
sweet meat specially during winter atleast in UP, Bihar etc.) and mode
of life,
Race for materialistic gains.
Self abandonment in all walks of life.
Lack of self abnegation.
Environmental pollution.
Overuse of drugs, cosmetics and other synthetic agents.
Hormones for contraception, menstrual irregularity and postponement of
menstruation etc.
Intoxication /addiction particularly smoking.
331
Perimenopause and climacteric :
The median age of menopause is between 50 and 52 years and may be
preceded by a period of menstrual irregularity.
The perimenopause is the period immediately before and after the menopause.
It may last for 4 years. The climacteric is the period of time when a woman
passes through a transition from the reproductive stage of life to the
postmenopausal years, a period marked by waning ovarian function.
Structural and functional changes:
There is a slow change in the general outlook of the woman. The skin
becomes thin and prone for superficial lacerations and bruising.
Axillary and pubic hair become scanty and in later part may be absent
altogether.
Ovaries although an endocrine organ, but are markedly affected in the
geriatric women resulting in shrinkage in size, thinning of cortex, with
increase in the medullary component. There is abundance of stromal
cells which have got secretary activities and continue to produce
androgen.
Adrenal glands also secrete androgen.
Thus cumulative effect is a decrease in oestrogen androgen ratio. This
results in increase in facial hair growth and change in voice. As obese
patients convert more androgen to oestrone, they are less likely to
develop symptoms of oestrogen deficiency.
In the breast, fat is reabsorbed and the glands atrophy. Nipples decrease
in size. Ultimately, breast becomes flat and pendulous and may be
tender at times.
Pathophysiology of Menopause / Menopausal Syndrome
Sushruta attributed ageing and diseases as the causes for the menopause
jarÁ pakva ÐarÍrÁÆÁm yÁti pañcaÐata½ kÒayam. (Su.Sh. 3-11). Daily
consumption of ghee, milk and articles which increase kapha can delay
the onset of menopause (GhéÔa kÒÍrÁdi nityÁsu muditÁsu kaphÁtmasu
Ártavam tiÒÔhati ciram, viparÍtÁstvato anyathÁ (Astanga samgraha. Sh.
1- 69).
Raja½ (menstrual fluid) is described as upadhÁtu of rasadhÁtu RasÁt
stanyam tato raktam (Ca. Ci. 15-17). Raja as an upadhÁtu has been
clearly mentioned in Ayurvedic classics. The word “Raja½” itself is
polysementic in nature. It has been used in the sense of ovum, menstrual
blood, ovarian hormones etc. at different places and contexts.
There is yet another term Àartvam, which needs to be properly defined.
BhÁvaprakÁÐa has equated Àartvam to Ïukra dhÁtu (Àrtavam api
Ïukravat Bh. Pr. 29-221). It is responsible for conception, strength and
complexion of women. Ïonita, Rakta, Rajas and Àrtava have been used
332
synonymously at various places in classics. With aging, of the three
DoÒas, VÁyu increases and there occurs the decline of Pitta and Kapha.
There also occurs the decline in all the seven dhÁtus starting from Rasa.
As per division of age fifty years fall under the category of middle age
having physiological predominance of pitta. In menopausal women due
to kÒaya of dhÁtus, vÁta gets aggravated. During adulthood besides
physiological predominance of pitta, the women possess Ártava, thus
have more Ágneyatva than males. Though age related decrease in pitta is
gradual, yet cessation of Ártava is often sudden and this sudden decrease
in Ágneyatva and predominance of vÁta in otherwise pitta dominant
phase influences status of pitta, which also gets slightly vitiated.
Generally due to inherent or natural power of self defense and
spontaneous healing (doctrine of swabhÁvoparamavÁda expounded by
Caraka), this alteration in doÒic status does not cause any symptom,
however if other factors disturb the normal homeostasis, the symptoms
of aggravation of vÁta and/or pitta and some times kÒaya of kapha as
well as dhÁtus particularly rasa may appear. As in this condition it is
always anuloma kÒaya; however later on asthikÒaya also takes place,
because asthi is the seat of VÁyu. Fracture of hip and neck of femur are
frequently seen in elderly, which is in conformity with Ayurvedic
concepts that considers Uru (thigh) and KaÔi (hip bones and joints) as
the specific sites of vÁta doÒa. Aggravated vÁta with pitta desiccate jala
tatva the binding material thus particles of péthvi mahÁbhÚta get
loosened and are pushed out by vÁta, known as osteoporosis, decrease in
kapha hampers replacement of bone minerals.
Hormonal changes during perimenopause
Can be been divided in three phases:
Phase I: Hypothalamic - pituitary hyperactivity:
Starts 10-15 years before menopause.
Compensatory for decreased follicular hormone (inhibition) secretion.
Evidenced by raised FSH (more than 40 IU/ML) and normal LH. In the
patients of premature menopause FSH was low or normal while LH was
very high.
Phase II: Ovulation and corpus luteum failure:
Starts 2 to 8 years before menopause as an-ovulatory cycles or shortened
lucteal phase. Menstrual cycle length (determined mainly by the
follicular phase) increases prior to anovulation.
Deficient progesterone and continued unoppsed oestrogen secretion.
Dysfunctional uterine bleeding, endometrial hyperplasia and possibly
carcinoma.
Phase III : Ovarian follicular failure:
Fall in oestradiol secretion (less than 20 pg/ml) and cessation of menses
(depleted follicle supply).
333
Ovarian stroma remains active. Androstenedione (half that before
menopause) derived mostly from adrenal cortex and partly from ovary.
Increased testosterone secretion by ovary.
Oestrone (main postmenopausal oestrogen) produced by extraglandular
conversion of androgens thus only 10 to 50 percent of postmenopausal
women are oestrogen deficient. Menopause does not affect the role of
body weight (and age) in androgen aromatization.
There is a 10 to 20 fold increase in FSH and 3 fold increase in LH. The
maximum level is attained in 1 to 3 years after menopause and a gradual but
slight decline occurs, thereafter. FSH levels are higher than LH due to the
faster clearance of the latter. The half-life of LH is 30 minutes and that of FSH
is 4 hours.
Specific disease in elderly women
Post menopausal syndrome.
Osteoporosis
Atrophic / Senile vaginitis.
Senile pyometra.
Post menopausal bleeding
Diabetes mellitus
Hypertension
Post menopausal syndrome (PMS)
This occurs due to oestrogen deprivation during phase-III of menopause.
Symptoms of oestrogen deprivation frequently seen in menopausal women are :
Disturbances in menstrual pattern,
Vasomotor instability,
Psychophysiologic symptoms,
Atrophic conditions,
Osteoporosis and
Cardiovascular disease.
The vasomotor flush is the hallmark of female climacteric. There is sudden
onset of reddening of skin over the head, neck and chest, accompanied by a
feeling of intense body heat and associated with profuse sweating. They are
more frequent and severe at night or during stress. It lasts in most women for 12 years but for longer than 5 years in 25-50 percent.
The psychophysiologic problems includes irritability (92%) lethargy/fatigue
(88%), depression (78%), headache (71%) forgetfulness (64%), weight gain
(61%), insomnia (57%), backache/Joint pain (48%), palpitations (44%) crying
spells (42%), constipation (37%), and decreased libido (20%). The metabolism
of tryptophon a, serotonin precursor, seems to be affected because of ostrogen
deprivation.
334
The vagina and urethra have a common embryologic origin and so both are
affected by oestrogen deficiency. Genitourinary atrophy leads to stress
incontinence, frequency, nocturia, urgency, painful micturition, poor stream
and incomplete bladder emptying. Vaginal atrophy causes dyspareunia.
All these symptoms are due to aggravation of vÁta and/or pitta and decrease of
kapha and kÒaya of rasa or asthi dhÁtu, few examples are cited here Hot flushes
Sweating
All psychological problems
Palpitation etc,
Arthralgia, myalgia
Osteoporosis
Sleep problems
Physical and mental
exhaustion
↑ vyÁna vÁyu, pushing rakta into peripheral
vessels
↑ pitta with vÁyu influencing rasa dhÁtu
↑ vÁyu with ↑ sÁdhaka pitta and ↓ kapha with
kÒaya of rasa dhÁtu
↑ vÁyu with kÒaya of rasa dhÁtu
↑ vÁta, ↓ kapha particularly ÐleÒaka kapha
↑ vÁta with pitta desiccates binding material
and
↓ kapha hampers replacement of bone
minerals.
↑ vÁta ↓ kapha
↑ vÁta with pitta, ↓ kapha and kÒaya of rasa
dhÁtu
Investigations and assessment:
Though the definite diagnostic criteria is raised serum FSH level (>30 mIU/ml)
and decreased serum estradiol (<35pg/ml), yet emphasis is always on
symptoms. Symptoms scales for aging women are being used for years and the
interest of health workers/scientist for measuring health related quality of life
(HRQOL) has increased in recent years.
To understand and measure chief symptoms with their severity two clinical
parameters are commonly used i.e. Kupperman index (KI) and Menopausal
Rating Scale (MRS). In MRS symptoms/complaints are given under three
dimensions i.e. psychological, somato-vegetative and urogenital factors.
Though in both these parameters number of symptoms enlisted are eleven, yet
there is some difference as given hereunder.
335
Above table shows that in KI urogenital symptoms do not find a place, while in
MRS vertigo, headache and formication are not listed. The scoring system of
both these is also different. In KI maximum scores depending upon severity are
thirty-one with highest scores i.e. twelve to hot flush, followed by paresthesia
and insomnia (four to each); the severity is classified under four category i.e.
none, slight, moderate and marked. In MRS all the symptoms are categorized
under five i.e. none, mild, moderate, severe and very severe with score
numbers 0-4 respectively.
336
This variation in appreciation of symptoms is due to difference in the location
of work, meaning thereby that these scales may not be equally
applicable/suitable to India and no specific demographic data seem to have
been published so far, in other words region-wise demographic study of
symptomatology of Indian women is the pre-requisite before adventuring in the
path of study related to menopausal syndrome.
Management
Pharmacotherapy
Hormone replacement therapy (H.R.T.): Estrogen and Progesterone
Estrogen replacement therapy (ERT):
Use only in women who have had
hysterectomy
Local estrogen therapy:
Useful in women with original
symptoms.
337
Hormone replacement therapy (HRT)
Oestrogens recommended for HRT are
ethinyl oestradiol (5-10 ug),
conjugated equine oestrogen (0.625-1.25 mg),
oestrogen sulphate. These can be given orally or in oestrogen containing
vaginal creams or transdermal patches (0.05-0.10mg every 3-4 days).
Regimen
(a) Sequential and (b) Continuous
Sequential: 0.625mg conjugated oestrogen either daily or 1-25 days of
each month.
10mg medroxy progesterone acetate daily for first 14 days of the month
or last 10 days of oestrogen.
Continuous : 0.625 mg conjugated oestrogen daily
2.5 mg medroxy progesteron acetate (MPA) daily (or 0.35 mg
norethindrone).
Oestrone sulphate 0.625 mg can be used in place of conjugated
oestrogen (0.625 mg).
Alternatives to HRT
Vasomotor symptoms : Clonidine, propranolol, Antidepressants, regular aerobic
exercise, deep breathing, dietary phytoestrogens.
Vaginal dryness : Vaginal lubriants and moisturizers, regular sexual activity.
Depression : Antidepressants, psychotherapy.
Sleep disturbances : Prescription hypnotica, behavioural therapy.
Osteoporosis (PMO)
The problem is more acute in western world. An estimated 29.6 million women
in United States had osteoporosis in 2002, the number is expected to rise to
35.1 million in 2010 and 40.9 million by 2020.
Sequelae of hormone withdrawal increases oesteoclastic activity in the bones
resulting in greater re-absorption of bone and relative loss of trabecular bone.
There is decline in the collagenous organic matrix specially affecting the
vertebral body, femur neck and distal radius. Resulting osteroporosis affects the
long bones with greater liability to fracture. This also results into physical
deformity like hunch back, fracture proneness and symptoms.
BMD measurements
A bone mineral density (BMD) test called duel energy x-ray absorptiometry
(DEXA/DXA) is the best way to check bone health, measurements give an
accurate reflection of bone mass and confirm diagnosis of osteoporosis. T score
≤ - 2.5 confirms the diagnosis of osteoporosis, as per recommendation of
WHO. X-ray of long bones gives an idea about the relative osteoporosis
338
Treatment
Following regimen gives promising results
Walk, light exercises, sÚrya namaskÁra
Ïukti bhasma 500 mg with honey twice daily either on empty stomach
or at least 2 hours after meals. Massage with nÁrÁyaÆa oil followed by sun bath (in the morning hours)
EraÆÕÁdi tablets a non-classical preparation described below in the dose
of 1 gm (two tablets) thrice daily with luke warm water.
SÁrasvatÁriÒÔa and aÐvagandhÁdyÁriÒÔa 10 ml each after meals twice.
Evening meals by 8 PM.
Washing of feet with warm water then oil massage of soles before going
to bed.
EraÆÕÁdi tablets of 500 mg are made with powders of root of EraÆÕa (Ricinus
communis Linn); root of red PunarnavÁ (Boerhaavia diffusa Linn.), whole
plant of BalÁ (Sida cordifolia Linn.), whole plant of BrÁhmÍ (Bacopa monnieri,
Linn.) Pennel), root of AÐvagandhÁ (Withania somnifera Dunal) and Guggulu
all in equal quantity triturated with juice of all five parts of guÕÚci (Tinospora
cordifolia (Willd) Miers).
Calcium supplementation for women
Premenopause (mid 20s to early 50s): 1000 mg calcium/day, 200 IU Vit. D/day
Menopause : (Early 50s to late 60s): 1000 mg calcium/day, 400 - 800 IU Vit.
D/day
Post menopause : (Late 60s, early 70s and beyond): 1000 mg calcium/day, 800
IU Vit. D/day, if taking ERT, 1500mg calcium/day, 800IU Vit. D/day, if not
taking ERT.
A number of estrogenic compounds, selective estrogen receptor modulators
(SERMs), bisphosphonates, calcitonin and parathyroid hormones (PTH) have
been tried to preserve bone mineral density (BMD). Since all these drugs have
disadvantages and side effects, hence search for alternative is on.
Phytoestrogens have been shown to be beneficial in the management of post
menopausal osteoporosis.
Senile vaginitis / Atrophic vaginitis
In post menopasual women, there is atrophy of the vulvovaginal structures due
to deficiency of oestrogen. The vaginal defense is lost and the mixed pathogens
normally present in the vagina gain footings. There may be desquamation of
the vaginal epithelium which may lead to formation of adhesions and bands
between the walls.
Common Clinical features are:
Postmenopausal yellowish or blood stained vaginal discharge.
339
Discomfort and soreness in the vulva.
Evidences of pruritus vulvae
The vaginal examination is often painful and the walls are found
inflamed on examination.
Investigations
Diagnosis is achieved by examination under anaesthesia, diagnostic curettage,
cervical cytology or biopsy. These procedures are urgently indicated.
Treatment
Since at this age, the disease is not due to kapha (no itching but discomfort
only) thus contrary to young age, here treatment is to normalize vÁta, increase
pitta and improve local conditions for which karañjÁdi ghéta picu is preferred.
Oestrogen (ethinyl oestradiol - 0.01 mg) daily for three weeks is effective. It
improves the resistance of vaginal epithelium, raises the glycogen content and
lowers the vaginal pH.
Local application of oestrogen vaginal cream (conjugated oestrogen cream 125
mg) by an applicator is equally effective
Post menopausal bleeding
Bleeding per vagina following established menopause is called postmenopausal
bleeding. The significance of postmenopausal bleeding should not be
underestimated. As many as one-third of the cases of post menopausal bleeding
are due to malignancy.
The common causes of postmenopausal bleeding are Genital malignancy
Decubitus ulcer
Dysfunctional uterine bleeding (DUB)
Urethral caruncle
Senile endometritis
Uterine polyp
Unknown
Diagnosis
To establish the diagnosis, initial step is to establish the fact that it is
vaginal bleeding and not bleeding per rectum or haematuria.
Amount of bleeding, number of episodes, sensation of something
coming out of the introitus, urinary problems like dysuria or frequency
of urination, Intake of oestrogen - Even if the history of intake is
present, should be enquired. Full investigations should be carried out to
exclude malignancy.
340
Obesity and hypertension should be excluded.
Speculum examination: Very helpful and Punch biopsy is to be taken.
Cervical smear along with endocervical sampling for cytological
examination for malignant cells.
Aspiration cytology - For endometrial carcinoma.
Pipelle endometrial sampling can be done with a long and narrow
plastic cannula. Adequate sample is obtained with the procedure and the
tissue is subjected for histological examination.
Special investigations
Ultrasonography transvaginal probe (TVS): is more accurate because of its
proximity to the target tissue (Endometrium). Endometrial thickness less than
5mm indicates atrophy on the other hand, thick polypoid endometrium (910mm) irregular texture, fluid within the uterus require further evaluation
(exclude malignancy).
Treatment
Treatment is directed to the cause, if detected. In case of recurrences or
continued bleeding, it is better to go for laparotomy and to perform
hysterectomy, with bilateral salpingo-oophorectomy. Principle of treatment
according to Ayurveda is on the line of Aségdara.
Senile pyometra
Collection of pus in the uterine cavity is called pyometra. The prerequisities for
pyometra formation are : Occlusion of the cervical canal and enough sources
of pus formation inside the uterine cavity with presence of low grade infection.
The cervical canal gets blocked due to senile narrowing by fibrosis or due to
debris. The accumulated pus distends the uterine cavity. The postmenopausal
atrophic myometrium fails to expel the collected pus. Thus, the uterus gets
enlarged more and more with thinning of its wall.
The organisms responsible are coliforms, Streptococci or Staphylococi. Rarely,
it may be tubercular.
Clinical features
Intermittent blood stained purulent offensive discharge per vagina.
Occasional pain in lower abdomen.
On examination, Suprapubic swelling may be felt of varying size.
Internal examination reveals offensive discharge escaping out through
the cervix. Pelvic ultrasonography reveals distended uterine cavity with
accumulation of fluid within.
Diagnosis is confirmed by dilatation of the cervix when pus escapes. In
every case, all types of investigations are to be made to exclude
malignancy of the uterus and endocervix.
341
Treatment
Pyometra is drained by simple dilatation of the cervix. Even in nonmalignant cases or in cases of recurrence, hysterectomy may be
indicated. Definite surgery for malignancy is to be done following
drainage of pus. Use of appropriate antibiotics is indicated.
Since the condition is caused by increased pitta withholding rakta of
garbhÁÐaya gata sirÁs which causes pÁka inside the garbhÁÐaya
antahkalÁ, hence triphalÁ guggulu, Ðigru guggulu and NyagrodhÁdhi
kaÒaya etc. are useful in this condition.
The hypertension and diabetes are described at length in another section of the
manual.
Referral criteria
Patients with extensive osteoporosis leading to fractures and not
responding to treatment should be referred.
Patients having uncontrolled profuse vaginal bleeding should be referred
to higher centres for management.
Patients with strong possibility of malignant disease, endometrial or
cervical carcinoma and those with established malignancy should be
referred to oncological specialists.
Those patients of pyometra, vaginal bleeding etc. where panhysterectomy is indicated should be referred to Gynecologist / surgical
specialists.
Recommended Further Reading
1. Charaka Samihita (Ch.S.), Pub. by Chaukhambha Sanskrit Series Office
Varanasi; both parts Pt ed; Part 1-1969; Part 11-1970.
2. Delmas PD: Treatment of postmenopausal osteoporosis, Lancet 2002;
359:20 18-2026.
3. Ketiang NL, Cleary PD, Rossi AS, et al: Use of hormone replacement
therapy by postmenopausal women in the United States. Ann. Intent
Med. p. 1999; 130:545-553.
4. Kupperman HS, Blatt MHG, Wiesbader H and Filler W: Comparative
Clinical evaluation of estrogen preparations by the menopausal and
amenorrrhoea indices J. Clin. Endocrinol 1953, 13 ;688-63 7.
342
5. Kupperman HS, Wetchler BB and SIatt MHG, Contemporary therapy of
the menopausal syndrome JAMA 1959, 171:1627-1637.
6. Lothar AJ HeLnemann, Peter Potthoff and Hermann PG Sceidey Health
and quality of life outcomes 2003; 1:28
7. Palep H.S. Post menopausal problems in Ayurveda in Proceeding of
second national Ayurveda congress Feb. 2002 Hyderabad, Sawpernika
foundation for research health and education, Chennai.
8. Schneider HPG, Heinemann EM, Rosemeier HP, Potthoff P and Behre
HM: The Menopause Rating Scale (MRS) : Comparison with
Kupperman Index and Quality of Life Scale SF-36 Climacteric
2000:3:50-58.
9. Schneider HPG, Heinemann LAJ, and Thiele K: The Menopause Rating
Scale (MRS) : Cultural and Linguistic translation into English1 Life and
Medical Science online 2000:3:DOI: 101072/L00305326.
10. Singh S.K.
and Agarwal
J.K.
Agarwal N.K.
Menopause –
Pathophysiology, Clinical and Hormonal profile in Trends in Geriatric
Medicine, Tara Printing works, 1996.
11. Singh S.K. and Agarwal J.K. Hormone replacement therapy in Trends in
Geriatric Medicine, Tara Printing works 1996.
12. Tiwari P: Gynecological problems in geriatric women’s in Trends in
Geriatric Medicine, Tara Printing works 1996.
13. Tiwari
P.V.:
Ayurvediya
Prasuti
Chaukhambha Orientellia, Varanasi.
343
Tantra
avum
Stree
Roga,