MANUAL on Geriatric Health Care
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 15@40½ 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- 2@1 % 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- 42@132 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- 43@4 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 12@82 306 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 18@3 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 18@30&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 18@32&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 18@35&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 18@42 43 fu"ikofi.;kddqyRFkdYdSekZalizxk<S nZf?keLrq;äS%AA lq0fp0 18@37 309 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 18@14 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 lq0fp018@38&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,