By M. Ur-Gosh. Emmanuel College. 2018.
This might be in terms of self-help strategies which might support a return to work or possibly in communicating with occupational health or the employer cardura 2 mg online prehypertension prevalence. Its not often actually been traditionally the province of the people who do psychological therapy purchase cardura 2mg overnight delivery 5 htp and hypertension. In fact buy 1 mg cardura with mastercard blood pressure drops after exercise, I think they need to think a bit more in terms of how theyre providing a treatment and the idea of how people return to work is not outside their remit. One expert described a patient who was experiencing such severe depression that they were not able to overcome the hurdle of accessing the service. In the end he just hadnt bothered so I just felt really sorry, this is a service meant for depressed people and somehow it was almost as though that very service was putting up barriers to the most depressed. But the reality is people with depression dont have motivation so its a nonsense. This approach was seen as effective for the treatment of depression and consequently in terms of employment. The fundamental aspects were seen as being around addressing negative thought processes and breaking challenges down into manageable elements. Something that we try and work with is setting small achievable goals with people about how they can get back to work. Symptoms of depression and their effects on employment 20 The same expert also mentioned the difficultly for therapists to access training and to upskill themselves in effective therapies. One participant suggested that there may be other treatments and techniques which could help people with depression to get going again and to begin the pathway to recovery. Because I think a lot of how people with Box B: Recovery colleges depression are offered a lot of psychotherapy and Im not sure that thats There are 28 recovery colleges in England, with others in Europe, Canada, New Zealand and the United States. Sometimes people just need help to actually get Recovery colleges deliver comprehensive, peer-led going again and to actually build their education and training programmes within mental health activity level up to get them to a point services with a focus on providing education as a route to recovery, not as a form of therapy. Courses are co- where actually their therapy will be useful devised and co-delivered by people with lived experience rather than trying to offer them therapy at of mental illness and by mental health professionals. Many of the To this end, some participants suggested courses provided by recovery colleges are focussed on other psychological type therapies which employment, skills and education and therefore it is have not yet developed a sufficient particularly relevant for work. Psycho-education is an approach which teaches individuals about their condition and its causes and therefore empowers them to manage and cope with their condition. The provision of psycho-education is a key part of recovery colleges, which seek to use education as a route to recovery, rather than a form of therapy (see Box B). This approach considers the environmental sources of depression and seeks to target behaviours that might maintain or worsen the depression (see Box C). Some evidence indicates that behavioural therapies are as effective for treating depression as psychological cognitive therapies (Ekers et al. It usually involves 8 x one hour weekly sessions (with a follow up a month after treatment) in which clients and providers work towards the goals identified by clients often including a return to work or engagement in meaningful occupation. Evidence on its effectiveness in terms of employment outcomes is however limited, though providers claim there is considerable anecdotal evidence. You really need to be planting in those employment services people who can support you back into work at some level or other. It was supposed to get people to stay at work and retain themselves in work, yet nowhere in that training was there any work focus at all. And every single therapist, and myself included, for many years I would treat symptomology first and then you would look once the symptoms had come down, what now? Experts who had experience of this spoke very positively about their addition in terms of employment outcomes Box D: Work and Learning Coordinator for people with depression. They dont know about coordinator, who provides advice, information and support to individuals (whether in or out of work) how to help people get jobs; you need an with their employment-related concerns. Experts suggested that the value of having such employment specialist roles was in their ability to provide additional support with practical, real-life problems, such as work, allowing Symptoms of depression and their effects on employment 23 the psychological therapist to use their sessions to focus on treatment. In therapy we are quite limited on the number of sessions we can offer, were focusing on the persons depression, and sometimes theres quite practical things that need to be sorted out which we might not really have the time and remit to do within our work. Having employment support as part of therapeutic services was seen as entirely complementary to the health related goals of treatment. I guess from a therapeutic point of view, a clinical point of view, weve been looking at it for somebodys holistic wellbeing actually having a routine, having work to go to or some sort of occupation whether that be volunteering or whatever that may be. If that will help maintain any gains that are made in therapy and help them hopefully not become clinically depressed again in the future because we know how helpful it is to maintain mood and having that regularity of routine and sense of belonging and role in the community. The specification that employment support and therapy be delivered in parallel, with a strong connection and communication between the two types of specialist, is important and allows them to complement each other and keep working towards shared goals. Its great because if the employment specialist is working with someone who starts to deteriorate or is experiencing more difficulties, then we can just get involved and help them with that element while theyre still job hunting. So they never lose that vision of themselves as someone who could potentially work, which is so important. The difficulty is that when you have an employment advisor who sees the patients separately and you have a therapist who is doing the therapy, and the two do not consult, then though the employment advisor can approach your employer in the context of symptoms and treatment and what might help somebody to get back into the workplace its not joined up, its not integrated. The provision of complementary employment specialist support was seen as a valuable way of helping someone progress in terms of employment where that was a goal and more should be done to encourage joint provision of therapeutic and employment services. Symptoms of depression and their effects on employment 24 Occupational Therapy Several participants spoke about the role of Occupational Therapy in influencing employment outcomes for someone with depression. This was mentioned specifically in terms of their role as part of the multi-disciplinary team in secondary mental health services and their often related role in supported employment services (see employment interventions section, p31), where they may supervise or work closely with employment specialists or be a designated Trust vocational champion. We managed, but I do think that having people that are absolutely dedicated to that and have all the links with employers and know exactly whats going on, I think thats really beneficial.
B toms or risk of acute hyperglycemic metformin therapy provide insights for complications should be avoided in future clinical trials and mechanistic stud- It is important to prevent hypoglycemia to all patients generic cardura 2 mg on line low vs diamond heart attack. In- tions should be individualized in can make it challenging for clinicians to tensive glucose control in the Action to older adults purchase cardura 1 mg with mastercard hypertension silent killer. Particular attention help their patients to reach individualized Control Cardiovascular Risk in Diabetes- should be paid to complications glycemic 4mg cardura visa heart attack recovery diet, blood pressure, and lipid targets. C patients to perform complex self-care brain structure or cognitive function during c Treatment of hypertension to indi- tasks, such as glucose monitoring and ad- follow-up (14). Of note, in the Diabetes vidualized target levels is indicated justing insulin doses. C ability to appropriately maintain the tim- no signicant long-term declines in cogni- c Treatment of other cardiovascular ing and content of diet. When clinicians tive function were observed though par- risk factors should be individualized are managing patients with cognitive dys- ticipants had relatively high rates of in older adults considering the time function, it is critical to simplify drug reg- recurrent severe hypoglycemia (19). Lipid-lowering imens and to involve caregivers in all also important to carefully assess and re- therapy and aspirin therapy may aspects of care. There deciency necessitating insulin therapy are ongoing studies evaluating whether and progressive renal insufciency. However, studies examining the causing difculty in complex self-care and functional heterogeneity. These years earlier and have signicant compli- not demonstrated a reduction in brain func- cognitive decits have been associated cations, others are newly diagnosed and tion decline (14). Life expectancies are highly variable but are often longer than clinicians realize. Providers caring for older adults with di- abetes must take this heterogeneity into consideration when setting and prioritiz- ing treatment goals (23) (Table 11. In addition, older adults with diabetes should be assessed for disease treatment and self-management knowledge, health literacy, and mathematical literacy (nu- meracy) at the onset of treatment. A1C is used as the standard biomarker for glycemic control in all patients with diabetes but may have limitations in pa- tients who have medical conditions that impact red blood cell turnover (see Sec- tion 2 Classication and Diagnosis of Diabetes for additional details on the limitations of A1C) (24). In these instances, plasma blood glucose and nger-stick readings should be used for goal setting (Table 11. Healthy Patients With Good Functional Status There are few long-term studies in older adults demonstrating the benets of in- tensive glycemic, blood pressure, and lipid control. Patients who can be expected to live long enough to reap the benets of long-term intensive diabetes manage- ment, who have good cognitive and phys- icalfunction,andwhochoosetodosovia shared decision-making may be treated using therapeutic interventions and goals similar to those for younger adults with diabetes (Table 11. As with all patients with diabetes, diabetes self-management education and ongoing diabetes self- management support are vital compo- nents of diabetes care for older adults and their caregivers. In addition, declining or tients with advanced renal insufciency Recommendations impaired ability to perform diabetes self- and should be used with caution in pa- c In older adults at increased risk of care behaviors may be an indication for tients with impaired hepatic function or hypoglycemia, medication classes referral of older adults with diabetes for congestive heart failure due to the in- with low risk of hypoglycemia are cognitive and physical functional assess- creased risk of lactic acidosis. B ment using age-normalized evaluation may be temporarily discontinued before c Overtreatment of diabetes is com- tools (3,17). B at risk for, congestive heart failure and pairments, it is reasonable to set less inten- those at risk for falls or fractures. Factors to Specialcareisrequiredinprescribing consider in individualizing glycemic goals and monitoring pharmacologic therapies Insulin Secretagogues are outlined in Fig. Glyburide is a tients with poorly controlled diabetes when selecting antihyperglycemic agents. Glycemic goals at a mini- match complexity of the treatment have few side effects and minimal hypo- mum should avoid these consequences. A systematic Vulnerable Patients at the End of Life with diabetes struggle to maintain the review concluded that incretin-based For patients receiving palliative care and frequent blood glucose testing and in- agents do not increase major adverse car- end-of-life care, the focus should be to sulin injection regimens they previ- diovascular events (37). Individualized may be associated with nausea, vomit- dying patient, most agents for type 2 di- glycemic goals should be established ing, and diarrhea. SodiumGlucose Cotransporter 2 tiplemedical conditions is associated with an increased risk of hypoglycemia and Inhibitors Beyond Glycemic Control considered overtreatment but, unfor- Sodiumglucose cotransporter 2 inhibi- Although hyperglycemia control may be tunately, is common in clinical practice tors offer an oral route, which may be important in older individuals with diabe- (3032). There is less evi- patients or their caregivers have good dence for lipid-lowering therapy and as- visual and motor skills and cognitive abil- pirin therapy, although the benets of Metformin ity. Insulin therapy relies on the ability these interventions for primary preven- Metformin is the rst-line agent for older of the older patient to administer insulin tion and secondary intervention are likely adults with type 2 diabetes. Recent stud- on their own or with the assistance to apply to older adults whose life expec- ies have indicated that it may be used of a caregiver. Insulin doses should be tancies equal or exceed the time frames safely in patients with estimated glomer- titrated to meet individualized glycemic 2 of the clinical trials. Providersmay make adjustments fects and may be a reasonable option in and procedures for prevention and man- to treatment regimens by telephone, fax, many older patients. Treatments for each patient low blood glucose levels (#70 mg/dL Other Factors to Consider The needs of older adults with diabetes should be individualized. Low nger-stick blood and their caregivers should be evaluated agement considerations include the glucose values should be conrmed by need to avoid both hypoglycemia and laboratory glucose measurement. So- tion statement Management ofDiabetes cose values greater than 250 mg/dL cial and instrumental support networks in Long-term Care and Skilled Nursing Fa- (13. Further- may not have support to administer their crisis and may lead to poor oral intake, more, therapeutic diets may inadvertently own medications, whereas those living thus requiring regimen adjustment. E and nutritional intake, polypharmacy, and are primary goals for diabetes man- c Patients with diabetes residing in slowed intestinal absorption (42). A patient has the right ualization of health care is important in all after admission and then at least once to refuse testing and treatment, whereas patients; however, practical guidance is every 60 days. Training quently, the concern is that patients may including a reduction in the frequency of should include diabetes detection and have uncontrolled glucose levels or wide nger-stick testing (45). Glucose targets S124 Older Adults Diabetes Care Volume 41, Supplement 1, January 2018 should aim to prevent hypoglycemia and 3. The Diabetes Control and Complications Trial/ need to be mindful of quality of life.
Can J Ophthalmol 2012 cardura 4 mg mastercard arteria auditiva; enzyme inhibition in type 2 diabetes and ne- 112:799805 47(2 Suppl order 2 mg cardura fast delivery arrhythmia recognition test. Compara- Control Cardiovascular Risk in Diabetes Eye Study abetic retinopathy during pregnancy generic cardura 1 mg with amex blood pressure 8050. Diabetic retinopa- blockers for major renal outcomes in patients in persons with type 2 diabetes: the Action to thy in pregnancy. The effect of intensive treatment of dia- for glycemia before conception: the Coronary Ar- nuriaStudyGroup. Early Treatment Diabetic Retinopathy Study Engl J Med 2011;364:907917 factors on patient-reported visual function out- Research Group. Early Treatment Diabetic Reti- and retinal effects of enalapril and losartan in Trial/Epidemiology of Diabetes Interventions and nopathy Study report number 1. Effect of nerenone on albuminuria in pa- lar complications in the Diabetes Control and 95. Curr Diab Rep eral neuropathy among adults seeking treatment neuropathicpainimpact glycemic control? Phar- with painful diabetic peripheral neuropathy: re- tions Trial/Epidemiology of Diabetes Interven- macotherapy for diabetic peripheral neuropathy sults of a randomized-withdrawal, placebo- tions and Complications study. A Diabetic neuropathy: a position statement by the Pharmacotherapy for neuropathic pain in adults: randomizedwithdrawal,placebo-controlledstudy American Diabetes Association. Lancet evaluating the efcacy and tolerability of tapen- 2017;40:136154 Neurol 2015;14:162173 tadol extended release in patients with chronic 100. Diabetes of diabetic etiology: differential diagnosis of diabetic icanAcademyofNeurology;AmericanAssociation Care 2014;37:23022309 neuropathy. Effects of cardiac autonomic dys- treatment of painful diabetic neuropathy: report Am J Gastroenterol 2013;108:1837; quiz 38 function on mortality risk in the Action to Control of the American Academy of Neurology, the 128. Pharmacologic interventions for painful di- report of the task force of the foot care interest of Diabetes Interventions and Complications). J abeticneuropathy:anumbrellasystematicreview group of the American Diabetes Association, with Am Coll Cardiol 2013;61:447454 and comparative effectiveness network meta- endorsement by theAmericanAssociation ofClin- 103. Efcacy, incollaborationwiththeAmericanPodiatricMed- tes treatment on nerve conduction in the Diabe- safety, and tolerability of pregabalin treatment for ical Associationand the Societyfor Vascular Med- tes Control and Complications Trial. Diabetes Care 2008;31:14481454 diabetes-related foot care knowledge and foot diabetes therapy on measures of autonomic ner- 117. Pregabalin madeorthesisandshoesinastructuredfollow-up Diabetes Control and Complications Trial/ in patients with inadequately treated painful di- program reduces the incidence of neuropathic Epidemiology of Diabetes Interventions and abeticperipheralneuropathy:arandomizedwith- ulcers in high-risk diabetic foot patients. Clin J Pain 2014;30:379390 Low Extrem Wounds 2012;11:5964 intensive insulin treatment during the Diabetes 119. Diabetes Care 2010;33:1090 group study in patients with diabetic peripheral abetic foot infections. A randomized double-blind, placebo-, tematic review and meta-analysis of adjunctive sive insulin therapy on cardiac autonomic ner- and active-controlled study of T-type calcium therapies in diabetic foot ulcers. Effectiveness of interventions to enhance healing of 2009;119:28862893 Meta-analysis of duloxetine vs. Hyperbaric oxy- 392399 nol Assess Ser 2017;17:1142 gen therapy for chronic wounds. Londahl M, Katzman P, Nilsson A, and quality of life in participants with chronic treatment of ischemic lower extremity ulcers in Hammarlund C. Accessed 5 October 2017 tice guideline for the use of hyperbaric oxygen with nonhealing ulcers of the lower limb: a 141. Recommendations c Considerthe assessmentofmedical,psychological, functional,andsocialgeriatric domains in older adults to provide a framework to determine targets and ther- apeutic approaches for diabetes management. C c Screening for geriatric syndromes may be appropriate in older adults expe- riencing limitations in their basic and instrumental activities of daily living as they may affect diabetes self-management and be related to health-related quality of life. C Diabetes is an important health condition for the aging population; approximately one- quarter of people over the age of 65 years have diabetes and one-half of older adults have prediabetes (1), and this proportion is expected to increase rapidly in the coming decades. These conditions may impact older adults diabetes self- management abilities (2). Screening for diabetes complications in older adults should be individualized and periodically revisited, as the results of screening tests may impact therapeutic ap- Suggested citation: American Diabetes Associa- proaches and targets (24). Olderadults:StandardsofMedicalCare in therefore be screened and treated accordingly (5). This may S119S125 provide a framework to determine targets and therapeutic approaches. Therefore, it is important to rou- c Screening for early detection of tions have released simple assessment tinely screen older adults for cognitive mild cognitive impairment or de- tools, such as the Mini-Mental State Ex- dysfunction and discuss ndings with the mentia and depression is indicated amination (15) and the Montreal Cogni- patients and their caregivers. Hypoglyce- for adults 65 years of age or older at tive Assessment (16), which may help to mic events should be diligently monitored the initial visit and annually as ap- identify patients requiring neuropsycho- and avoided, whereas glycemic targets and propriate. B logical evaluation, particularly those in pharmacologic interventions may need whom dementia is suspected (i. People withdiabetes mild cognitive impairment or dementia c Older adults who are otherwise have higher incidences of all-cause de- (4). People who screen positive for cogni- healthy with few coexisting chronic mentia, Alzheimer disease, and vascular tive impairment should receive diagnostic illnesses and intact cognitive func- dementia than people with normal glu- assessment as appropriate, including re- tion and functional status should cose tolerance (8). The effects of hyper- ferral to a behavioral health provider have lower glycemic goals (A1C glycemia and hyperinsulinemia on the for formal cognitive/neuropsychological,7. C nicantly improving cognitive function or c Hypoglycemia should be avoided in c Glycemic goals for some older in preventing cognitive decline (9). It should adults might reasonably be relaxed studies in patients with mild cognitive im- be assessed and managed by ad- as part of individualized care, but pairment evaluating the potential bene- justing glycemic targets and phar- hyperglycemia leading to symp- ts of intranasal insulin therapy and macologic interventions.
B Patients with ungradeable retinal photographs should receive slit lamp and indirect ophthalmoscopy examination where possible purchase cardura 1 mg with amex hypertension jnc 7 pdf. For retinal photography this 3 should happen in 500 sets of images per grader per year generic 2mg cardura amex hypertension and stroke. D All graders should have 500 retinal photographs rechecked for quality assurance each year buy cheap cardura 2mg on line arrhythmia cure. One-field retinal photography has been shown to be as sensitive and specific as multiple-field ++ 639, 649 2 photography for detecting referable retinopathy. Automated grading can detect any retinopathy on digital images with at-least-as-high sensitivity to manual screening when compared to a clinical reference standard. The specificity of automated grading is less than manual grading, for equivalent sensitivity. B Automated grading may be used for distinguishing no retinopathy from any retinopathy in a screening programme providing validated software is used. There are no clinical trial data assessing the strategy of whether treatment should be deferred in diffuse maculopathy until visual acuity is affected. A All people with type 1 or type 2 diabetes with new vessels at the disc or iris should receive laser photocoagulation. D All people with type 1 diabetes with new vessels elsewhere should receive laser photocoagulation. A Patients with severe or very severe non-proliferative diabetic retinopathy should receive close follow up or laser photocoagulation. Patients with + 1 type 1 or type 2 diabetes who have severe fibrovascular proliferation with or without retinal detachment threatening the macula also have better visual acuity after vitrectomy. B Vitrectomy should be performed in patients with tractional retinal detachment threatening the macula and should be considered in patients with severe fibrovascular proliferation. C Cataract extraction is advised when sight-threatening retinopathy cannot be excluded. C When cataract extraction is planned in the context of advanced disease, which is not stabilised prior to surgery, the risk of progression and the need for close postoperative review should be fully discussed with the patient. Intravitreal triamcinolone may provide a short term reduction in retinal thickness and a corresponding improvement in visual acuity. A - 1 subgroup analysis did indicate slower progression of diabetic macular oedema in the group treated with 32 mg ruboxistaurin (p=0. Awareness of low vision aids is poor, but once available, patients benefit from 3 being instructed in their use. Delay in registration can lead to reduced awareness of available disability benefits and support. Low vision aid clinics687 and community self help groups688, 689as part of a low vision service can 3 improve the quality of life and functional ability for patients with visual impairment. Screening When sent an appointment for screening, patients should be given the National Screening leaflet outlining: the screening procedure and the difference between screening and treatment the importance of early identification of retinopathy practical information relating to attendance and preparation for screening visits. Diagnosis as partially sighted or blind Patients should be advised of the process for visual impairment registration with the local social work department. This should be done as soon as possible after diagnosis so that benefits, assistance and assessment of support can be put in place. Amputation rates are higher in patients with diabetes than patients without diabetes. There is no evidence to support the frequency of screening; however the guideline group considers that at least annual screening from the diagnosis of diabetes is appropriate. Studies to date have been heterogeneous using different patient populations with small numbers and variable end points giving inconclusive findings. Previous work in this area indicated that at 1+ one year follow up, where patients had agreed personalised behavioural contracts, there was a significant reduction in serious lesions. Programmes which include education with podiatry show a positive effect on minor foot 1+ problems at relatively short follow up. Running-style, cushion-soled 2++ trainers can reduce plantar pressure more than ordinary shoes but not as much as custom-built 709, 710 3 shoes. The use of custom-made foot orthoses and prescription footwear reduces the plantar callus 1+ thickness and incidence of ulcer relapse. Multidisciplinary foot care teams allow intensive treatment and rapid access to orthopaedic and vascular surgery. Wound healing and foot-saving amputations can then be successfully achieved, reducing the rate of major amputations. Clinical experience suggests that in an appropriate setting any of these methods of debridement are useful in the management of patients with diabetic foot disease. Local sharp debridement should be considered first followed by the others depending on the clinical presentation or response of a wound. They are almost as good at reducing pressure, have similar ulcer healing rates 727 2++ (95% v 85%), are more cost effective and less time consuming. A small study of 40 patients suggested that moderate weight bearing following plaster application ++ 730 2 is not detrimental. Use of half shoes reduces the time to complete closure of the ulcer to a mean of 10 3 weeks. B Prefabricated walkers can be used as an alternative if they are rendered irremovable. There is no evidence for the optimal duration or route of antibiotic therapy in the treatment of patients with diabetic foot ulcers.