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Although a healthy dietary pattern emphasizes cer- tain food groups order pariet 20 mg amex chronic gastritis guideline,49 each food group makes a particular contribution (see Box 4-1) generic 20 mg pariet mastercard gastritis and gerd. Chapter 4 / Toward Nutritional Health: Choosing Food or Supplements 85 The five food groups provide a rough guide generic pariet 20 mg amex gastritis symptoms medication, but health may be improved by improvising within defined boundaries such as increasing plant foods and reducing animal products discount pariet 20 mg on line gastritis symptoms blood. Balancing the Five Food Groups Although all food groups should be represented in the diet, there is a clear advantage associated with increasing the intake of certain food groups. Epidemiologic studies suggest that milk and milk products fit well into a healthy eating pattern emphasizing cereals and vegetables. Many studies have linked increased consumption of milk and milk prod- ucts with lower blood pressure and a reduced risk of hypertension. Calcium, bioactive peptides produced during digestion of milk proteins, and uniden- tified components in whole milk may protect against hypertension. Lactoferrin may play an important role by binding pro-oxidative iron ions, and vitamin C interacts with iron and fat-soluble antioxidants. Vitamin E and carotenoids act as fat-soluble antioxidants in the milk fat globule. The concentrations of antioxidants in milk are affected by cow feeding rations and milk storage conditions. Eat a plant-rich diet: Have five or preferably 10 servings of vegetables, fruits, cooked tomato, and/or soy products daily. Avoid pickles and smoked foods: Restrict salt intake to 5 g, and preferably 3 g, daily. Limit fried and broiled foods: Eat fresh food or prepare food on grill or in microwave. Although health benefits became evident with the consumption of at least three servings each day,54 an increase from two fruits and three vegetables to two average-sized (120 to 150 g) pieces of fruit and five average-sized (60 to 90 g) servings of vegetables daily is rec- ommended. Red food, such as tomatoes rich in lycopene, may promote prostate health; and yellow-green vegetables, such as corn and leafy greens rich in lutein and zeaxanthin, may enhance retinal health. An improved health outcome is more likely if, instead of merely eating eight servings of fruits and vegetables daily, a color code is used. The objective becomes to eat a serving of each color of fruit or veg- etable daily. A survey of a cross-sectional sample of North Americans indicated that animal protein consumption was consistently higher in persons with higher cholesterol concentrations and consumption of plant proteins was consis- tently higher among persons with lower cholesterol concentrations. Dairy products in turn provide more dietary protein than grains, the major source of plant protein. Both the amount and the source of protein are impor- tant health-disease variables. Mediterranean diets are characterized by plen- tiful consumption of fruits, vegetables, and whole grains; moderate intake of alcohol; and limited consumption of animal products, saturated and hydro- genated fats, and refined carbohydrates. If the intake from a particular food group is to be increased, other foods must be restricted to retain overall energy balance. Although omission of particular food groups is not without its hazards,62 careful food selection can result in dietary balance. The spec- trum of plant-based diets ranges from the plant-only diets of vegans and fruitarians to the plant-rich macrobiotic, lactovegetarian, semi-vegetarian, and meatless diets. Plant protein sources in the vegetarian diet are largely legumes, nuts, and cereals. Foods in the vegetarian diet, if eaten alone, may provide an inade- quate complement of amino acids. Complementary protein mixtures may be substituted to overcome such deficiencies and result in a diet that approxi- mates the high biologic values of proteins found in animal products. Legumes are limited in their content of methionine and other sulfur- containing amino acids. Good complementary protein pairs include the following: ● Lentils with wheat or rice ● Soybeans with rice ● Peas with wheat ● Beans with corn Regular consumption of nuts is associated with a one-third decrease in the risk of a major coronary event in adult women. Nuts are a rich source of L-arginine, and results of animal studies have indicated that this amino acid improves endothelial dilation and decreases platelet aggregation and monocyte adhesion. Nuts, because of their content of phy- tosterols, especially β-sitosterol, appear to offer some protection against colon, prostate, and breast cancer. Roasted peanuts contain 61 to 114 mg of phytosterols per 100 g, depending on the peanut variety, 78% to 83% of which is in the form of β-sitosterol. Peanut flour, which results from partial removal of oil from peanuts, contains 55 to 60 mg of phytosterols per 100 g. Unrefined 88 Part One / Principles of Nutritional Medicine peanut oil with 207 mg of phytosterols per 100 g is a richer source of phy- tosterols than unrefined olive oil. Refining results in a reduction in phyto- sterol concentration, but hydrogenation after refining has a minimal effect on phytosterol content. Of the legumes in the vegetarian diet, soybeans are a particularly inter- esting food source. Soybeans are a better source of minerals than other beans; and soybean-based foods are, for practical purposes, the only nutri- tionally relevant dietary sources of isoflavones. Inclusion of soybeans in a plant-based diet provides the following68: ● Protein of high biologic value. An average daily intake of 25 g of soy protein may be obtained from any combination of the following: 0. Substituting soy protein for high-fat animal protein diets has a beneficial effect on serum lipid levels. The beneficial cardiovascular effect is not only related to the type of protein ingested, it is also linked to the type of fat consumed. Soybeans are rich sources of polyunsaturated fat (20%) compared with other beans (1%). Soy fiber supplements improve glucose tolerance and insulin response in subjects with glucose intolerance. An apple, an orange, or 10 dried apricot halves provide 3 g of fiber, as does a half cup of cooked oatmeal. Eating whole foods provides a fiber advantage: a slice of whole-meal bread has 2 g of fiber, and a slice of white bread, 0. Although availability varies depending on processing and phytate content, soybeans are a good vegetable source of minerals. The concentration of minerals are as follows: iron, around 16 mg/100 g dry weight; zinc, 4. Raffinose, stachyose, and verbascose serve as prebi- otics and are fermented in the intestine to gas and short-chain fatty acids that may hinder hepatic cholesterol synthesis. At higher doses, flavonoids may act as mutagens, pro-oxidants that gener- Chapter 4 / Toward Nutritional Health: Choosing Food or Supplements 89 ate free radicals, and as inhibitors of key enzymes involved in hormone metabolism. Caution should be exercised in ingesting them at levels above that which would be obtained from a typical vegetarian diet. The concentration of isoflavones is around 1 to 3 mg per gram of soy protein; one serving of traditional soy foods provides 25 to 40 mg of isoflavones.
Women who have been assaulted or who are victims of abuse often feel too ashamed and afraid to report the incident order pariet 20mg on-line gastritis kronis adalah. Violence against women in any form is a crime pariet 20 mg without a prescription gastritis symptoms nhs direct, regardless of who committed the violent act cheap pariet 20mg without a prescription gastritis diet . It is always wrong discount pariet 20 mg on line chronische gastritis definition, whether the perpetrator is a family member, colleague, acquaintance, or stranger. If you or someone you know has been sexually, physically, or emotionally abused, seek help from other family members and friends or the employee assistance program. Learn how to minimize your risk of becoming a victim of sexual assault or sexual abuse before you find yourself in an uncomfortable or threatening situation. Violence among crew requires involvement of the chain of command, and should be reported to legal authorities when appropriate. Calcium Both women and men need enough calcium to build maximum bone mass during their early years of life. Low calcium intake appears to be one important factor in the development of osteoporosis. Osteoporosis is a condition in which progressive loss of bone occurs with aging, leaving the bones susceptible to fracture. The most important time to get a sufficient amount of calcium is when bone growth and consolidation are occurring. The foods that top the calcium charts including milk, cheese, and ice cream are not lightweights in calories and fat, so choose the low-fat or fat-free versions. Other good sources of calcium include salmon, tofu, certain vegetables including broccoli, legumes such as peas and beans, seeds, and nuts. Iron For pre-menopausal women, the recommended daily allowance for iron is 15 to 18 mg per day, more than the recommended daily allowance of 0-10 mg for men. Pre-menopausal women need more of this mineral because they lose iron during menstruation. Dietary iron from plant sources is found in peas and beans, spinach and other green leafy vegetables, and iron fortified cereal products. The addition of even relatively small amounts of foods containing Vitamin C substantially increases the total amount of iron absorbed from a meal. After menopause, a woman’s need for iron is lower and unlikely to require supplementation. Calories and Weight Control Cutting back on calories is not always the answer to losing weight. You cannot cut back on calories and eat all the necessary nutrients if you are taking in fewer than 1500 calories per day. The fewer the calories you eat, a harder it is to meet 7-9 your daily nutritional requirements. Look to eliminate any sources of “empty” calories from your diet, such as sodas and other sweetened beverages, sugary snack foods, added fats, and alcohol. If you find you are gaining weight, you need to think of not only cutting calories, but also about increasing physical activity. Physical activity burns calories, increases the proportion of lean to fat body mass, and raises your metabolism. Eating Disorders Two common types of eating disorders are anorexia nervosa and bulimia. Some behaviors associated with these conditions are starvation, self-induced vomiting, excessive exercise, and the misuse of laxatives or diuretics. Symptoms of eating disorders are fear of gaining weight, food obsessions, avoidance of meals, rigid dieting and fasting, rigorous exercise, weight loss, unusual mood states (such as confusion, lethargy, and depression), swollen salivary glands, erosion of dental enamel (from stomach acid dissolving teeth during vomiting), dark circles under the eyes, low self-esteem, declining performance, and lack of menstrual periods. Eating disorders are extremely damaging to the mind and body, and can be fatal if untreated. The female athlete triad is found among female athletes trying to balance the pressures of body image and peak physical performance. The triad is marked by inadequate food intake, menstrual abnormalities (irregular or absent cycles), and bone loss (weak bones at increased risk for fractures). In well-nourished women, heavy physical training may not result in amenorrhea (three or more missed menstrual cycles), which may reflect malnutrition. It is key to establish a healthy relationship between food, body image and performance. Resources to help with eating disorders are found at: National Institute of Mental Health http://www. Choose a diet low in animal fat and sodium, and rich in fruits, vegetables, whole grains, and 7-10 low-fat or nonfat dairy products. Be aware that sexual activity can transmit disease, and modify behavior accordingly. Medical experts agree that good health depends on use of preventive services and good personal lifestyle habits. Chemical agents are typically manmade through the use of industrial chemical processes. Biological agents are either replicating agents (bacteria or viruses) or nonreplicating materials (toxins or physiologically active proteins or peptides) that can be produced by living organisms. Nuclear/radiological threats primarily derive from the release of ionizing radiation from a deliberate attack with a nuclear or radiological bomb. The first section of this chapter will focus on biological agents, the second part on chemical agents. The chapter ends with a discussion of potential nuclear and radiological exposures. Note that there is significant overlap in the symptoms caused by and initial responses to biological and chemical agents. Wherever appropriate, discussion will describe approaches to both biological and chemical agents. They hurled the plague stricken corpses over the city walls and introduced an epidemic among the defenders. Some historians feel this to be the initiation of the Black Death pandemic that spread throughout Europe. It is felt that the English provided smallpox-laden blankets to Indians loyal to the French during the French and Indian War from 1754 to 1767. A plague epidemic in China and Manchuria in 1940 followed reported over-flights by Japanese airplanes releasing plague-infested fleas. Over many years, various countries have been documented to have some type of offensive biological development program. It is therefore prudent that we be aware of the most likely agents to be used and what we can do to counter and treat these agents. Thus, it is important for persons afloat to be familiar with potential threats, and especially critical for those responsible for health care underway to have an understanding of the medical aspects of bioterrorism. Medical defense against and treatment for biological terrorism is an unfamiliar area to most providers of health care during peacetime. However, effective medical countermeasures are available against many of the bacteria, viruses, and toxins that might be used as biological weapons against people. The goal of this section is to serve as a reference and to help the reader develop an understanding of the biological threats and the medical supplies useful in defending against these threats.
The second level of hierarchy is the use of environmental controls to prevent the spread and reduce the concentration of droplet nuclei purchase 20 mg pariet mastercard gastritis journal articles. Ventilation is the movement and the replacement of air in a building with air from the outside or with clean cheap pariet 20mg otc gastritis diet treatment, recirculated air discount 20 mg pariet free shipping gastritis diet 4 idiots. When fresh air enters a room pariet 20 mg free shipping gastritis diet , it dilutes the concentration of particles in room air, such as droplet nuclei. There are two types of ventilation: • Natural ventilation • Mechanical ventilation Natural Ventilation Natural ventilation relies on cross ventilation in a building designed for good air exchange; for example, the use of open doors and windows to bring in air from outside. Natural ventilation can be useful for nontraditional facility-based and congregate settings that do not have a central ventilation system. In these settings, waiting rooms, shelter dormitories, or other rooms in which people congregate should have an operable window, door, or skylight that is kept open as often as possible. If the direction of airfow is unknown, staf should sit near the fresh air source and clients should sit near the exhaust location (Figure 7. In addition to these environmental measures, cough etiquette and respiratory hygiene should be encouraged to further reduce risk (Figure 7. Mechanical ventilation consists of • Local exhaust ventilation; and • General ventilation. Local exhaust ventilation stops airborne contaminants before they spread into the general environment. Local exhaust ventilation includes the use of • External hoods; • Booths; and • Thents. Local exhaust ventilation should be used for cough-inducing and aerosol-generating procedures (Figure 7. The lamps are used to inactivate the tubercle bacilli contained in the droplet nuclei. Administrative and environmental controls minimize the number of areas in which exposure to M. These control measures also reduce, but do not eliminate, the risk for exposure in limited areas. The efectiveness of a respiratory-protection program requires the development of written standard procedures. Standard procedures should include information and guidance for the proper selection, use, and care of respirators. It is also important to understand the diference between respirators and surgical masks. Chapter 7 – Tuberculosis Infection Control 215 Indicate whether the types of environmental controls below are primary or secondary controls. Educating patients on respiratory hygiene and the importance of cough etiquette D. Respirators are designed to protect health-care workers and other individuals from inhaling droplet nuclei. Tose inmates who must be transported should wear a surgical mask during transport. The absolute number and population density of persons sharing the same breathing space is important. Conversely, the smaller the population and less crowded the shelter, the lower the risk. Homeless shelters should implement a tracking system for clients and establish a mechanism for sharing this information with state and local health departments when appropriate. These include airborne precaution capabilities and a respiratory-protection program. In addition, ambulances should allow for the maximum amount of outdoor air to be circulated in the vehicle. Nontraditional settings include correctional facilities, homeless shelters, long-term care facilities, home-based health-care, and emergency medical services. Emergency medical services has a documented overall high level of transmission of M. Depending on the environment, these tiny particles can remain suspended in the air for several hours. For most patients, infectiousness appears to decline rapidly after adequate and appropriate treatment is started; however, the rate of decline varies from patient to patient. Environmental controls, which prevent spread and reduce concentration of droplet nuclei; and 3. Respiratory-protection controls, which further reduce risk of exposure in special areas and circumstances. The second level of hierarchy is the use of environmental controls to prevent the spread and reduce the concentration of infectious droplet nuclei and includes primary and secondary controls. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. Inhibition of cell wall synthesis (bactericid) Cell wall controls osmotic pressure Filamentation Lysis I. Cephalosporins β–lactam + 6 membered /=cephem-/ ring with sulphur • more possibilities for substitution • also against Gram negatives! N • derived from penicillins O • imipenem, meropenem, ertapenem • class B β–lactamase = carbapenemase C I. Colistin): – desintegration of cell membrane – against Gram-negatives, for local treatment – (burns, ear, eye - Pseudomonas! Chloramphenicol • acts on 50S ribosomal subunit • Streptomyces venezuelae (Ehrlich) • wide spectrum dysbacteriosis!! Alteration of target by mutation • decreased or no affinity • penicillins (pbp), • aminoglycosides and macrolides (30S and 50S ribosomal subunits), • quinolons (gyrase genes: gyrA,B) 3. Efflux pump • removal of antibiotic • not very effective • macrolides, quinolons, tetracycline 4. Periodontal diseases range from simple gum inflammation to serious disease that results in major damage to the soft tissue and bone that support the teeth. Whether your gum disease is stopped, slowed, or gets worse depends a great deal on how well you care for your teeth and gums every day, from this point forward. These bacteria, along with mucus and other particles, constantly form a sticky, colorless “plaque” on teeth. Plaque that is not removed can harden and form “tartar” that brushing doesn’t clean. The “periodontitis” (which means bacteria cause inflammation “inflammation around the of the gums that is called tooth”). The Gingivitis is a mild form of body’s immune system fights gum disease that can usually the bacteria as the plaque be reversed with daily spreads and grows below the brushing and flossing, and gum line. Bacterial toxins and regular cleaning by a dentist or the body’s natural response to dental hygienist.
If you think your child Symptoms has Mono: Your child may have a sore throat buy 20mg pariet visa follicular gastritis definition, swollen glands 20mg pariet for sale gastritis juicing, Thell your childcare headache 20 mg pariet gastritis symptoms foods avoid, fever purchase pariet 20 mg without a prescription gastritis symptoms constipation, and sometimes a rash. Childcare and School: Less common problems include jaundice (yellowing of the No, as long as the child skin or eyes) and/or enlarged spleen or liver. Sports: Children with an Spread enlarged spleen should avoid contact sports - By kissing or sharing items contaminated with saliva. Call your Healthcare Provider ♦ If anyone in your home has symptoms of mononucleosis. Your child may need bed rest, to drink plenty of water, and to avoid some physical activities. Prevention Wash hands after touching anything that could be contaminated with secretions from the nose or mouth. Mosquito-borne diseases are viral diseases that are spread by infected mosquitoes. The many viruses have the potential of causing serious disease affecting the brain and central nervous system. Removal of potential breeding sites is important in preventing the spread of mosquitoes. Birdbaths, wading pools, dog bowls, and other artificial containers of water should be emptied weekly to eliminate mosquito-breeding areas. Mosquitoes breed in water and artificial containers, especially flower pots, birdbaths, cans, children’s toys, wading pools, tire swings, old tires, or anything that will hold a small pool of water should be emptied or discarded. Rarely, swelling of the spinal cord and brain (encephalitis), inflammation of the ovaries (oophoritis) or breasts (mastitis), and deafness may occur. Other examples of how the virus can be spread is through sharing toys, beverage containers, eating utensils, and smoking materials (cigarettes), and kissing. Exclusion will last through at least 26 days after the onset of parotid gland swelling in the last person who developed mumps. A blood test specific for mumps antibody should be done as soon as possible after symptoms begin. Sometimes, healthcare providers will obtain a second blood test 2 to 3 weeks later. Encourage parents/guardians to keep their child home if they develop symptoms of mumps. Wash hands thoroughly with soap and warm running water after contact with secretions from the nose or mouth. If you think your child Symptoms has Mumps: Your child may have swollen glands in front of and below the ear. Childcare and School: Contagious Period Yes, until 5 days after For 2 days before until 5 days after swelling begins. Call your Healthcare Provider If two or more cases of If anyone in your home: mumps occur in your ♦ was exposed to mumps and has not had mumps or childcare or school, public mumps vaccine in the past. Prevention All children by the age of 15 months must be vaccinated against mumps or have an exemption for childcare enrollment. An additional dose of mumps is highly recommended for kindergarten or two doses by eighth grade enrollment. When a mumps outbreak is identified, exemptions in childcare centers or schools will not be allowed. Students who refuse immunization should be excluded until at least 26 days after the onset of parotitis in the last person with mumps in the affected school or childcare center. Norovirus is often incorrectly called the “stomach flu”, although it is not caused by the influenza virus. In addition, fever, headache, muscle aches, fatigue, and stomach cramps can occur. The illness can be mild to moderately severe with symptoms usually lasting 24 to 48 hours. Spread can occur when people do not wash their hands after using the toilet or changing diapers. People can also get sick by eating food items contaminated during preparation or serving. Person-to-person spread often occurs within families, schools, nursing homes, cruise ships, in childcare settings, and communities. No one with vomiting and/or diarrhea should use pools, swimming beaches, recreational water parks, spas, or hot tubs for 2 weeks after diarrhea and/or vomiting symptoms have stopped. Staff must avoid food preparation when diarrhea and vomiting are present and for at least 3 days after diarrhea and/or vomiting have stopped. Wash hands thoroughly with soap and warm running water after using the toilet and changing diapers and before preparing or eating food. Staff should closely monitor or assist all children, as appropriate, with handwashing after children have used the bathroom or been diapered. In the classroom, children should not serve themselves food items that are not individually wrapped. If you think your child Symptoms has Norovirus: Your child may have watery diarrhea, vomiting, and Thell your childcare fever. Other symptoms may include headache, stomach provider or call the cramps, and tiredness. Childcare and School: Spread Yes, until the child has been free of diarrhea and vomiting for at least - By eating or drinking contaminated food or beverages. Prevention Wash hands after using the toilet and changing diapers and before preparing food or eating. The cough may occur in sudden, uncontrollable bursts, sometimes ending with high-pitched whooping sounds and/or vomiting. Wash hands thoroughly with soap and warm running water after contact with secretions from the nose or mouth. Preventive treatment may be considered for close contacts who are at a higher risk for more severe disease, including infants and immuno- compromised persons. If you think your child has Symptoms Parapertussis: Your child may have a runny nose, sneezing, or mild Thell your childcare coughing. If your child has been infected, it takes 6 to 21 days (usually 7 to 10 days) for symptoms to start. Childcare and School: No, if the child is healthy Spread enough for routine activities. Contagious Period Unknown, but likely to be most contagious at the time of early cold-like symptoms. Call your Healthcare Provider ♦ If anyone in your home is coughing for more than 7 days.
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It also has a narrow therapeutic range pariet 20 mg cheap gastritis diet quotes, particularly in individuals whose food and fuid intake may be spotty buy 20 mg pariet gastritis diet . Therapy beginning with divalproex sodium (Depakote®) at a low dose such as 125 to 250 mg po bid and gradually increasing to effcacy discount 20 mg pariet with mastercard diet during acute gastritis, or to reach a blood level of 50-150 mcg/ml is recommended cheap pariet 20 mg otc definition de gastritis. Several other anticonvulsants are sometimes used for treatment of mania, including lamotrigine (Lamictal®), topiramate (Topamax®), and carbamazepine (Thegretol®). Divalproex is also associated with neural tube defects when used during pregnancy. As discussed for depression, the doctor may wish to prescribe one of the newer antipsychotics which have fewer parkinsonian side effects. In cases of extreme agitation, a rapidly acting injectable agent may be necessary. Obsessions and Compulsions Obsessions are recurrent, intrusive thoughts or impulses. Compulsions are sometimes related to obsessions, such as an obsessive concern with germs. Obsessions are usually a source of anxiety and the individual may struggle to put them aside, whereas the acting out of compulsions generally relieves anxiety and may not be as strongly resisted. These individuals may worry about germs or contamination, or engage in excessive checking of switches or locks. For relentless perseverative behavior unresponsive to these agents, one might consider neuroleptics. The onset of delusions or hallucinations should prompt a search for specifc causes or precipitating factors, including mood disorders, delirium related to metabolic or neurologic derangements, or intoxication with or withdrawal from illicit or prescription drugs. Once these possibilities have been eliminated, neuroleptics may be employed to treat the schizophrenia-like syndromes. Some individuals may respond completely and others only partly, reporting that “voices” have been reduced to a mumble, or become less preoccupied with delusional concerns. Neuroleptics are also used to control chorea and some very resistant individuals may be convinced to accept an antipsychotic as part of a treatment for the suppression of involuntary movements. Or perhaps the “delusion” in this case is better thought of as a preoccupation or an over-valued idea. People with delusions will rarely respond to being argued with, but a clinician may certainly express skepticism regarding a delusional belief. Caregivers should be encouraged to respond diplomatically, to appreciate that the delusions are symptoms of a disease, and to avoid direct confrontation if the issue is not crucial. Her family reports that the man in question was her physician, but that he retired several years ago, is not currently caring for her, and has no idea of the relationship that she believes they share. Her children reminded her that the doctor is already married and she told them that he plans to leave his wife for her. She tells her psychiatrist that she can hear the internist sending her messages of love at night, because they live on opposite sides of a lake and his voice carries across the water. Her delusions have so far proven unresponsive to three different antipsychotic drugs and usually do not interfere with her daily activities. The current stumbling block, however, is that her family wants her to make the transition to assisted living and she refuses to go, insisting that her gentleman friend will care for her at home. The dysexecutive syndrome is easy to recognize but somewhat diffcult to characterize. It can be easy to under-estimate the impact of the personality changes that make up the syndrome and not give them the clinical attention they deserve. Essentially, there are both disinhibited symptoms such as perseveration (persistent repetition of a word, phrase or gesture), irritability, impulsivity, and jocularity, and defcit symptoms, such as apathy, loss of spontaneity, and indifference. Although they may be different sides of the same coin, we will deal with some of the major components of the executive dysfunction syndrome separately, for the purpose of discussing treatment. The family may be confronted with someone who looks and sounds just like the wife, sister, friend or mother she used to be, but who shows no interest in previous responsibilities, is capable of callous actions and statements, and who commits grievous errors in judgment despite repeated negative consequences. The individual with the disease may not notice the progressive change in their behavior and may dismiss concerns raised by the family. It can be a source of confict between individuals and caregivers, who know the person is physically capable of activities but “won’t” do them. Apathetic individuals may be uninterested or even resistant to treatment, because, by defnition, they do not care, although there have been instances of insightful people with apathy, who request treatment because they are aware of the effects their apathy is having on their families. They need to know that their loved one is not bothered by the apathy, and that the family can adopt a combination of exhortation and accommodation to address the condition. Apathetic individuals, like those with depression, may be sluggish, quiet, and disengaged. By and large apathetic people will say they are not sad, but in distinguishing between the two, it is important to ask not only about the person’s mood, but about other depressive symptoms as well, such as a change in sleeping or eating patterns, feelings of guilt, or suicidal thoughts. Depressed people who also suffer from apathy should be treated aggressively for their depression, which may cause the other symptoms to improve. Individuals with primary apathy sometimes respond to psychostimulants such as methylphenidate (Ritalin®), pemoline (Cylert®) or dextroamphetamine (Dexedrine®). These medicines are highly abusable and may exacerbate irritability, so they should be used with caution. Anecdotal reports have been published of the successful treatment of apathy with amantadine, bromocriptine, and selegiline. Apathy can be worsened by medications known to blunt emotion or slow cognitive processing, such as neuroleptics or benzodiazepines. Nonpharmacologic Approaches to Treating Apathy While apathetic individuals have trouble initiating actions, they will often participate if someone else sets up the activity and works along with them to sustain energy and attention. Maintaining a regular schedule, increasing environmental stimulation, such as involvement in a day program, avoiding open-ended questions or tasks, and providing cues may also help. On their return, however, he shows no interest in cleaning the fsh, does not want to talk about his day, and simply turns the television on. When the doctor asks why he did not want to go fshing, he replies “I just didn’t care. When pressed by the family to prescribe a treatment, the doctor explains that while there may be a few medications which could help, it is probably most important for the man’s family and friends to understand his changing needs and to realize that apathy does not cause the man distress. The doctor suggests that a regular schedule of activities may be more helpful than spontaneous suggestions, and the man’s family gets him enrolled in a three day a week morning activity program at the local veteran’s center. This reduced mental and emotional fexibility may present as diffculty switching topics or letting go of an idea. Oftentimes this will be triggered by some loss of autonomy, and the preoccupation will revolve around something like the restoration of driving privileges, the ability to go hunting with shotguns, or control of fnances. Other times the topic will be less predictable, an imagined slight, an unfulflled responsibility, a fnancial concern, or animosity toward an acquaintance or neighbor. Management of Perseveration or Fixation When dealing with fxations, the family should be encouraged to “pick their battles. There is some theoretical basis for a dopamine-augmenting strategy in the treatment of executive dysfunction. She demands that he keep six different kinds stocked in the refrigerator and will demand a glass of a specifc juice to the exclusion of all other activities.
