This chapter discusses the assessment and laboratory findings, imaging, diagnosis and management of ascites. A common complication of cirrhosis is ascites, or the accumulation of fluid in the abdominal cavity. Ascites that develops from cirrhosis is associated with portal hypertension. The patient with cirrhosis and ascites may complain of increased weight gain, lower extremity edema, and abdominal bloating or distension. Physical examination findings may reveal a distended or even tense abdomen, positive fluid wave, dullness to abdominal percussion, and peripheral edema. Routine laboratory testing, such as complete blood count, complete metabolic panel, and liver function testing, should be performed with new-onset ascites and at routine return visits. Patients with cirrhosis and ascites can develop electrolyte imbalances and renal failure. Ultrasound is helpful to determine whether ascites is present if there is any uncertainty upon physical examination. Patients should abstain from alcohol consumption and avoid using nonsteroidal anti-inflammatory drugs.
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This chapter shows the importance, for older persons, of support groups. In spite of the changes that have occurred in the American family, and all the negative things that fill the popular press concerning family relationships, the family is still the backbone of support for most older people. To some extent, the type of family support older people obtain depends on whether they are living in the community or in an institutional setting such as a group home, retirement village, or nursing facility. Whether a person is married, has great impact on that person’s support within a family setting including emotional, financial, and physical support, particularly in times of illness or infirmity. The success of a second marriage depends to a considerable extent on the reaction of the adult children of the elderly couple. Older grandparents, no matter how motivated, can find caring for grandchildren to be very tiring.
Delirium, also known as acute confusional state, organic brain syndrome, brain failure, and encephalopathy, is a common occurrence among medical and surgical patients and causes extensive morbidity and mortality. This chapter provides an updated review of delirium, including pathophysiological correlates, clinical features, diagnostic considerations, and contemporary treatment options. The defining features of delirium include an acute change in mental status characterized by altered consciousness, cognition, and fluctuations. The chapter explores the risk factors for delirium. These can be divided into two categories: predisposing factors and precipitating factors. Imbalances in the synthesis, release, and degradation in gamma-aminobutyric acid (GABA), glutamate, acetylcholine, and the monoamines have also been hypothesized to have roles in delirium. GABA is the primary inhibitory neurotransmitter in the central nervous system (CNS) and medications such as benzodiazepines and propofol have known actions at GABA receptors and have been associated with delirium.
This chapter shows how the United States and the world are experiencing an aging evolution we are growing older. America is going through a revolution. As a whole, Americans are becoming older, and there are many more older people among people than ever before in our history. Obviously all cohorts of the population youth, young adults, middle-aged, young-old, oldest-old are heterogeneous. When some people think about the elderly as a whole, they picture frail, weak, dependent persons, some in nursing homes and many confined to their homes. The chapter demonstrates the differences the various age categories have in relation to selected chronic health conditions that cause limitations of activity. Widowhood is much more common for elderly American women than for older men. The aging of Baby Boomers will solidify the shift America is experiencing with the aging of its population. Centenarians make up a small percentage of the total U.S. population.
Inflammatory bowel disease (IBD) is a broad diagnosis that includes two major chronic diseases: ulcerative colitis (UC) and Crohn’s disease (CD). IBD is typically diagnosed in young adulthood. Smoking has been associated with a higher risk of developing CD. UC is an inflammatory disease of the mucosa of the colon and rectum. Typical symptoms include bowel movement urgency, tenesmus and bloody diarrhea. CD is a chronic inflammatory disorder of the alimentary tract. It is associated with high levels of proinflammatory cytokines. Referral to a gastroenterologist specializing in IBD may be needed. To confirm diagnosis, a flexible sigmoidoscopy is necessary in cases of UC and a colonoscopy is necessary in cases of CD. The goal for treatment of IBD is to suppress the immune system and help heal the bowel. Initial treatment for patients with mild to moderate UC includes 5-aminosalicyclic acid compounds.
Some drugs, like aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs), have been blamed for peptic ulcer formation. The most common peptic ulcers are duodenal ulcers. Risk factors for the development of peptic ulcer disease are chronic NSAID use, older age, Helicobacter pylori infection, use of anticoagulant or anti-platelet medications, history of prior ulcers, use of corticosteroids, alcohol use, and smoking. One of the goals of treatment for the patient with peptic ulcer disease is eradication of H. pylori infection. Complications that develop if peptic ulcer is untreated include gastrointestinal bleeding, gastric cancer and gastric outlet obstruction, with bleeding the most common. Most patients with peptic ulcer disease are asymptomatic. When symptoms do arise, dyspepsia is a common complaint. Sucralfate, a formula of aluminum hydroxide and sulfated sucrose, is given to patients with peptic ulcer disease to protect the gastric and duodenal mucosa.
Primary progressive aphasia (PPA) is the term applied to a clinical syndrome characterized by insidious progressive language impairment that is initially unaccompanied by other cognitive deficits. This chapter describes several variants of PPA and more than one etiology. It explains three main variants of PPA, namely, semantic Variant of PPA (svPPA), nonfluent/agrammatic variant of PPA (nfvPPA) and logopenic variant of PPA (lvPPA), and also describes criteria for their diagnoses. The defining symptom of PPA is the presence of a language impairment for at least 2 years in the absence of any other significant cognitive problem. Assessment of other cognitive domains is challenging because many tests of memory, attention, executive functioning, and visual-spatial skills rely on language processes in some manner. There are no drug therapies proven to arrest progression of signs and symptoms of PPA due to frontotemporal lobar dementia (FTLD) or Alzheimer’s disease (AD) pathologies.
Dementia is an umbrella term for conditions such as Alzheimer’s disease (AD), dementia with Lewy bodies (DLB), vascular dementia (VaD), and frontotemporal dementia (FTD). Under that umbrella, FTD, also known as frontotemporal lobar degeneration (FTLD), can be further categorized to define a group of neurodegenerative disorders resulting from a progressive deterioration of the cells in the anterior temporal and/or frontal lobes of the brain. More specifically, ventromedial-frontopolar cortex is identified with metabolic impairment in FTD. This chapter elaborates on the history, epidemiology, pathophysiology, clinical features, treatment, and outcomes of FTD. The history and background section of each of the FTD categories highlights the evolution of the disease conceptualization. The FTD subtypes are conceptualized in three categories: neurobehavioral variant, motor variant, and language variant. The chapter illustrates the features of all three categories of FTD.
The concept of Mild cognitive impairment (MCI) makes a lot of sense in that individuals are typically not “normal” one day and “demented” the next. In theory, especially for progressive neurodegenerative conditions, such as Alzheimer’s disease (AD), frontotemporal dementia (FTD), the development of dementia may take months or years. The clinical syndrome of MCI due to AD can be identified via a neuropsychological evaluation or less-sensitive cognitive screening measures. Much of what we are learning about MCI, and therefore refining its diagnostic criteria, is coming from two large-scale studies of cognition and aging: Alzheimer’s Disease Neuroimaging Initiative (ADNI) and Australian Imaging, Biomarkers and Lifestyle (AIBL). According to the most recent research diagnostic criteria for MCI due to AD, evidence of beta-amyloid deposition, neuronal injury, and/or other biochemical changes needs to be seen to increase confidence of the etiology of MCI. Cholinesterase inhibitors remain the primary pharmacological treatment for AD.
This chapter discusses the incidence and risk factors, assessment, laboratory and image testing, diagnosis and treatment of constipation. Constipation affects 15" of adults in Western countries and 33" of patients older than 60. History is important when trying to determine the cause of constipation. The patient should be asked for a detailed description of bowel movements, including how many per day or week, how often, and how long has constipation been a problem. A complete blood count and complete metabolic panel should be obtained. Several electrolyte imbalances can cause constipation. Constipation is often caused by inadequate fiber intake or hydration, inactivity, or can be medication-related. Providers should encourage patients with acute constipation to increase hydration and fiber intake to 20 to 35 grams per day. Nutritional modification may be enough to resolve constipation and can likely prevent further episodes. In some cases of chronic constipation, nonpharmacologic treatments are helpful.