Wednesday,
May 19, 1999
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Old age:
bright prospects Oh, the pancreas! Coping with stress: a
strategy |
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Old
age: bright prospects As age advances, there is a gradual physiological degradation of all body systems. By themselves, these age-related physiological changes may not always be of clinical significance when the system is at rest, but may become important when the system is stressed, as by exercise, disease, or drug administration, and of course, by psychological trauma, which is quite frequent in old age. For example, tachycardia bloodlessness in the young in response to bloodlessness or pyrexia may not be evident in older patients and a bearable psychological shock in young age may trigger off a fatal latent angina in old age. Again, impaired physiological function in old age may affect susceptibility to disease like impaired immune response to tuberculosis in the elderly. Similarly drug-handling tends to alter with age due to impairment in hepatic and renal clearance. Likewise, the reference ranges of various laboratory tests may be affected with age. On the other hand, treatable diseases may be missed by being ascribed to old age. For example vague musculo-skeletal symptoms of osteomalacia or polymyalgia rheumatica or impaired exercise tolerance of late onset asthma or cardiac failure may be overlooked to the detriment of the elderly patient. It may be the pathological change, rather than the decaying physiology, which may be the major cause of treatable morbidity and preventable mortality and may be overlooked by merely attributing it to an old age symptomatology. Therefore, while gradual physiological decline is inevitable in old age, this should not result in undue pessimism in the elderly especially amongst their relatives, attendants and health workers. And this is the crux of health promotion for the elderly. The natural reserve capacity of most vital organs of the body is considerable. Therefore, by ensuring good preventive and promotive measures, we must strive not only to promote good health but also to prolong the inexorable physiological degradation for as long as possible in old age. Let us not ignore the following 10 groups of symptom-complex in old age, which must be taken note of , thoroughly investigated and treated: * Pain anywhere, however, mild, if persistent, especially in head, eyes, the chest, the abdomen and the musculo-skeletal region. * Breathlessness or difficult breathing while at rest or on ordinary effort, and persistent cough. * Retention and incontinence, urinary or faecal, however, mild. * Blood in stools, urine, sputum, vomit or from nose. * Persistent alternate diarrhoea and constipation. * Puffiness and swelling of hands, face, feet and any foot problems. * Rapid audio-visual impairment. * Episodes of confusion, depression, failing memory, tremors, falls and syncopes. * Dermal rashes, itches and urticaria-local or general. * Episodes of hypotension, hypertension and hypothermia. These and many more may be merely visible tips of serious but preventable and curable underlying pathological icebergs of old age maladies, which should not be brushed aside as inevitable old age "Khung te khurk". It is proposed to periodically elaborate and deliberate on some of these geriatric health problems for the benefit of the elderly (courtesy Health Tribune ) during the International Year of the Old. Dr
(Brig) M.L.Kataria is honorary consultant, Senior
Citizens' Health Care Centre, Lajpat Rai Bhavan,
Chandigarh. |
Oh,
the pancreas! The pancreas is a very important gland in the body. Its functions are important. It digests food and produces insulin — the main chemical for balancing the sugar level in the blood. The pancreas is a solid gland, 25 cm long, behind the stomach and attached to the back of the abdominal cavity. The head of the gland is closely attached to the duodenum (the first part of the small intestine) into which the stomach empties partially digested food. Pancreas adds its digestive juice to this partially digested food. Running behind the body of the pancreas are many important blood vessels. Because of its position in the body, it is not easy for a surgeon to operate on the pancreas. Two main problems arise if the pancreas is not working. (A) Food is poorly absorbed resulting in weight loss, and diarrhoea (undigested fat causes pale, bulky and smelly motions). (B) If too little insulin is made, diabetes may develop, with weight loss and frequent passage of urine. Two common conditions that affect the pancreas are inflammation of the pancreas — pancreatitis (the causes include alcohol abuse, gallstone disease, trauma), and cancer of the pancreas. There is an enormous expenditure of medical resources for both diagnosis and management of these cases (either medically or surgically). There are virtually no data on the impact of pancreatic disease on our society — rehospitalisation (a frequent occurrence), unemployment, disability, and mortality. There are important information gaps. We know little about the incidence of pancreatic disease among diverse geographic and socio-economic groups. There is now an array of diagnostic studies that can be performed to evaluate patients with suspected pancreatic diseases. A very useful single and painless way of obtaining a picture of the pancreas gland is an ultrasound scan (pictures are made by using sound waves, which bounce off solid organs and can be recorded on a scanner). Using ultrasound control, it is possible to take a small sample from the pancreas using a needle through which a little piece of gland can be sucked out and then examined under the microscope. CT scan (in which the patient moves through a large doughnut which carries out the X-ray as the patient moves through) shows excellent pictures of the pancreas. ERCP — a flexible telescope is passed through the mouth and the stomach and lies opposite the opening of pancreas in the bowel. A contrast medium is injected to outline the pancreatic duct. It is a useful procedure not only for diagnosis but also for treatment. There has been no satisfactory way to identify patients at risk of cancer and there is no method of screening that leads to an early diagnosis and potential cure. Cancer commonly arises in the head of the gland and may block the bile duct (draining liver juice into the intestine) causing jaundice, dark urine and itching of the skin; and/or if may block the main pancreatic duct causing poor digestion, weight loss and loose motions. Cancer often causes pain in the abdomen or back. Unfortunately, it has often spread beyond the gland by the time its causes have produced sufficient symptoms for the sufferer to seek medical advice. It is often very difficult or impossible to remove it by an operation. In most of the cases, it may be necessary to bypass any blockage caused by the tumours. Chronic diseases of the pancreas (chronic pancreatitis — stones in the pancreatic duct, and duct disruptions) can result in severe disability. Although chronic alcohol use remains the primary risk factor, the actual mechanism of injury and damage is still not entirely clear. The role of endoscopic and surgical treatment is uncertain. It is controversial: how best to manage the pain associated with pancreatic diseases which is incapacitating, overwhelming and truly intractable that prevents the ability to function productively in society? Acute pancreatitis and its complications are also common with considerable mortality. New endoscopic approaches to acute pancreatic disease have dramatically changed the management of such patients. A better understanding of the physiologic features of pancreatic disease has led to the use of damage-limiting agents that could block mediators of pancreatic inflammation. The diagnosis and management of pancreatic disease remain a significant challenge for the future despite enormous advances in diagnosis and therapy. We need to know whether new diagnostic studies can lead to the early discovery of cancer, and whether we can successfully manage pain in these patients whose disease has progressed despite our best efforts. The
department of surgery at the PGI, Chandigarh, is
organising a three-day conference (October 8-10) to
discuss important information gaps in the diagnosis and
management of the challenges posed by pancreatic
diseases. Successful management requires an integrated
approach of a dedicated team able to exploit alternative
approaches currently available and under development. |
Coping
with stress: a strategy Modern living has brought with it not only innumerable means of comfort but also a plethora of demands that tax man's body and mind. Stress is the awareness of a demand which exceeds the coping ability of an individual. The ability to cope with a stressful situation is the ultimate deciding factor that can free an individual from stressful agents. If the demands outweigh the coping abilities, a state of imbalance develops. The body is burdened with a weight beyond its tolerance capacity. The body is able to bear with a temporary imbalance and bounce back. However, if the situation persists, wear and tear occur on the body as signs of excessive stress, resulting in exhaustion or development of stress-related illnesses. The human body is equipped with indicators of stress. An important sign of stress is an increase in the heart rate to enable blood to flow to the muscles to prepare them for action. A number of chemicals associated with stress are released to free energy reserves in case they are needed. In short, the body mobilises its resources for either "a fight or a flight response". The organs concerned with this response are the adrenal glands lying atop each kidney. Stress may be classified as (a) physical (b) physiological (c) psychological or (d) socio-cultural. Physical stress may involve a temporary physical pressure like the carrying of a heavy load for a short distance. Relieving oneself of this form of stress is within one's discretion. Physiological stress is indicated by body symptoms. Psychological stress results in alterations in thinking and feeling. Socio-cultural stress brings about a change in one's behaviour. It is important to be aware of characteristic stress signs and identify the potential cause of the imbalance so as to be able to find the means of coping with it. The physiological signs include sore muscles, an upset tummy, headache, a high rate of heart beat, diarrhoea, sweating from hands, dry mouth, restlessness and fatigue. Psychological signs are characterised by worrying, difficulty in concentration, forgetfulness, nervousness, feeling of sorrow, anger — or feeling pressured for time. Socio-cultural signs involve overindulgence in substances such as alcohol, drugs or food. Other characteristics are insomnia, rushing around, irritability or being accident-prone. Stress can originate either in a person or in the surrounding environment. However, whatever the origin, it reflects on the behaviour and reaction of an individual resulting in a chain of stressful episodes. (a) Personal sources: These may be cognitive or behavioural. In cognitive sources, the way we talk to ourselves as we approach and deal with life events will either reduce or heighten the magnitude of stress reactions. Say, for example, undermining feelings of self-worth or increase in anxiety and agitation results in blocking of the solution to the problem. In behavioural sources self-defeating behaviours such as partying too much, waiting for the eleventh hour to start studying for examinations or sleeping through classes can become habitual sources of stress. Learning how to interact with stress, proper time-management and setting priorities can resolve some of the stress sources. (b) Environmental stresses: These include major life events and daily hassles. Major life events include coping with the death or the serious illness of a family member. ordinary daily hassles include difficult colleagues, work overload and financial worries. These disruptive events can even lower the immune response making an individual more vulnerable to illnesses. The self-monitoring of stress-triggers enables one to realise that some stressful situations are changeable and controllable while others are beyond one's control and just need to be accepted or tolerated. Controllable or modifiable stress sources demand problem-focused coping which requires interacting and approaching the problem's source in an effort to reduce it. However, uncontrollable situations demand emotion-focused coping which reduces the internal emotional and physiological responses helping one to learn to tolerate the situation. Using the wrong type of coping strategy for the confronting situation adds to the stress problem. A student, who has to appear for an examination, may use an emotion-focused strategy to distract himself until the last possible moment instead of using a problem-focused method of planning and studying. Alternatively, a situation like the end of a romantic relationship, which simply has to be accepted, is sometimes dealt with by a problem-focused coping strategy such as trying to make amendments with the partner instead of using an emotion-focused strategy. (i) Controllable stress strategies are problem-focused. Behavioural methods to deal with them include planning time schedule, seeking information to solve problems, talking with resource individuals, avoiding stress-triggering situations and arranging situations to encourage coping. Cognitive methods involve mental rehearsing of situations one wants to cope, arguing with oneself on what is realistic and having positive task-oriented thoughts. (ii) Uncontrollable stress strategies are emotion-focused. They help to reduce the internal stress response so as to tolerate the situation more easily. Cognitive methods include limiting worrying time, looking for the silver lining in the stress-forming cloud, stopping negative thoughts when they occur and making a positive comparison of one's situation to those of other persons. Behavioural methods include avoiding situations that serve as painful reminders, physical exercise to reduce tension, muscular relaxation, pleasurable hobbies and social support. In
conclusion, stress can be managed effectively either by
choosing a problem-focused or an emotion-focused
strategy, depending on the stress triggers. If the
targeted stress source is within your control, choose a
strategy that can reduce the source. If it is beyond your
power to change, try a strategy to reduce internal stress
response. In a nutshell, heads you win and tails also you
win, if you learn to relax. |
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