Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3098_Библиотеки_им_академика_М_И_Перельмана
.pdf
14 - Pain and Sensory Disorders |
427
Table 14-3. Common Treatments for Neuropathic Pain
Class
Medication
Examples
General Adult Treatment
Principles Geriatric Considerations
Tricyclic antidepressants Amitriptyline
Desipramine
Nortriptyline
First-line treatment.
Effective doses lower
than those used for
depression.
Potential for anticholinergic
adverse effects; orthostatic
hypotension; sedating.
Anticonvulsants Pregabalin
Gabapentin
Carbamazepine
Valproic acid
First-line treatment
for neuropathic
pain. Pregabalin has
FDA-approved indication
for DPNP and PHN.
Requires lower starting
doses and slower titration.
Pregabalin and gabapentin
are renally eliminated
and may require dose
adjustments.
Serotonin-
norepinephrine
reuptake inhibitors
Duloxetine First-line treatment for
neuropathic pain. Has
FDA-approved indication
for DPNP.
Not recommended in
hepatic impairment or CrCl
<30 mL/min.
V
enlafaxine First-line treatment for
neuropathic pain.
May need dose reduction in
hepatic or renal impairment.
Opioids Oxycodone May be used as initial
monotherapy or add-on
therapy.
Adverse effects such as
dizziness, sedation,
constipation, and
respiratory suppression
are more common in the
elderly.
Methadone Also has NMDA antagonist
activity.
Has long half-life that
requires careful dose
titration.
Tramadol Also has weak serotonin
reuptake activity.
May increase risk of
serotonin syndrome when
given with antidepressants.
Topical Lidocaine May be used as initial
therapy or as add-on
therapy.
Ease of use in elderly
especially if in patch form.
Capsaicin Useful in localized pain. Causes increased burning
during initial use. Should
not be used in acute
herpes zoster due to risk of
mucosal contact.
CrCl, creatinine clearance; DPNP, diabetic peripheral neuropathic pain; NMDA, N-methyl-D-aspartate;
PHN, postherpetic neuropathy.
https://t.me/medicina_free
428
| Fundamentals of Geriatric Pharmacotherapy
the Beers criteria, use of tricyclic antidepressants
in the elderly is cautioned because of concerns
of hyponatremia or syndrome of inappropriate
antidiuretic hormone and their anticholinergic
effects.
68
Other common oral adjuvant drugs are
not mentioned specifically, but the evidence for
their use comes from studies of disease states
that are more common in the elderly population.
These studies do not specifically include elderly
patients and rarely include more than a few
patients over 75. Results should be extrapolated
with caution because patients with conditions
common in the elderly, such as renal, hepatic,
and cardiac diseases, are excluded from the
studies. A summary of representative trials using
adjuvant drugs for neuropathic pain is included
in Table 14-4.
Topical agents are recommended for well-
localized neuropathic pain.
63
They have the
advantage of few systemic adverse effects or
drug interactions. Lidocaine is most commonly
recommended and has demonstrated efficacy
in small studies of patients with a wide range of
ages.
80,81
Common Problems Encountered
When Treating Elderly Patients
with is Condition
There are often discrepancies in prevalence
studies of pain in older patients because of
the failure to recognize, report, or treat pain in
these patients.
53
Pain in the older population in
general is not adequately treated, whether or not
the patient is cognitively impaired or the pain is
acute or persistent.
82-84
KEY POINT:
Pain is often under-
recognized and undertreated in
elderly patients. Close monitoring and
proactive approaches to dose titration
will provide better management.
Patients with cognitive impairment may not
be able to recall pain over a period of time, but
the ability to report current pain often remains
intact.
85
Rating scales to assess pain in nonverbal
or cognitively impaired patients are available but
not always reliable. More on additional assess-
ment tools is discussed in Chapter 4. Observing
facial gestures, for example, during painful
movements (e.g., during transfers) provides
useful clues to how a patient behaves when in
pain.
85
Similarly, administering a test dose of
an analgesic when pain is suspected and then
observing for a decrease in pain-related behav-
iors may provide helpful information. Family or
caregivers who closely observe these patients
may be called on to report the presence of pain
with relative accuracy.
KEY POINT:
Nonverbal behaviors
suggestive of pain can be observed to assist
in pain management of patients with an
inability to communicate. In patients with
cognitive impairment, close family members
or caretakers are reliable sources for assessing
pain and the ecacy of pain management.
Most adverse effects of analgesics and adju-
vant drugs are transient, and tolerance develops
when they are used consistently. Initially, adverse
effects such as sedation, dizziness, and ortho-
static hypotension caused by antidepressants,
antiepileptic drugs, and opioids can be made
less bothersome by administering these drugs
at bedtime.
Tolerance to opioid-induced constipation
does not typically occur. The goal to managing
constipation is prevention. Older patients are at
greater risk for developing constipation because
of decreased mobility or increased likelihood
of taking concomitant drugs that cause consti-
pation. A bowel regimen containing a stimu-
lant laxative such as senna should be used in
all patients receiving opioids, starting with an
as-needed schedule. The dose can be titrated
upward to ensure bowel movements occur
every 3 days. A stool softener may be added to
improve consistency of the stool and comfort for
the patient.
https://t.me/medicina_free
14 - Pain and Sensory Disorders |
429
Renal and hepatic impairment, whether
age-related or due to other causes, predisposes
patients to toxicities caused by analgesic and
adjuvant drugs. NSAIDs can worsen renal func-
tion by causing vasoconstriction of renal arteri-
oles. Neurotoxicity caused by opioids may rarely
occur and is due to accumulation of renally
eliminated active metabolites or rapid escala-
tion of dose. Signs and symptoms of neurotox-
icity include hyperalgesia, seizures, confusion,
and twitching. Pregabalin, gabapentin, and
duloxetine are renally eliminated and should be
dosed accordingly in older patients. Duloxetine,
tricyclic antidepressants, and most opioids are
hepatically metabolized. Age-related hepatic
impairment partially contributes to the increased
sensitivity of elderly patients to the effects of
these drugs. Longer intervals between doses
and smaller doses of these agents are recom-
mended for initial therapy, with careful titration
to achieve pain control in order to avoid drug-
related problems.
64
Table 14-4. Summary of Trials of the Management of Neuropathic Pain
Tricyclic
Antidepressants
69-71
Serotonin-
Norepinephrine
Reuptake
Inhibitors
72,73
Antiepileptic
Drugs
74-76
Opioids
71,77-79
Study drug(s) Amitriptyline,
desipramine,
nortriptyline
Duloxetine Pregabalin,
gabapentin
Oxycodone,
morphine
Etiology of pain Postherpetic
neuralgia, diabetic
peripheral
neuropathic pain
Diabetic peripheral
neuropathic pain
Postherpetic
neuralgia,
diabetic
peripheral
neuropathic
pain
Postherpetic
neuralgia,
diabetic
peripheral
neuropathic pain
Average ages
(years)
60–71 59–61 62–73 60–71
Size of individual
trials (n)
Less than 50 Over 300 81–217 Less than 65
Average pain
reduction from
baseline (%)
32–66 45 33–40 38–63
Patients with
significant pain
reduction (%)
34–67 39–69 43–61 38–58
Limitations Small study size,
oldest demographic
not represented
Younger patient
population,
studies
supported
by drug
manufacturer,
many
concomitant
disease states
excluded
Pregabalin
studies
supported
by drug
manufacturer,
many
concomitant
disease states
excluded
Most studies
used opioid in
combination with
an adjuvant or
as a comparator
arm
https://t.me/medicina_free
430
| Fundamentals of Geriatric Pharmacotherapy
KEY POINT:
First doses of adjuvant
drugs should be given at bedtime because
adverse eects, such as sedation and
dizziness, will be less bothersome.
Acetaminophen is typically the first agent
used in the older adult because it is relatively safe.
Although it undergoes hepatic metabolism, the
primary route is through sulfation and glucuroni-
dation, processes that generally remain intact
as a person ages. A literature review of adverse
effects of acetaminophen revealed no consistent
age-related hepatotoxicity in daily doses up to
4 g/day.
86
However, with excess amounts of acet-
aminophen, the mixed function oxidase system is
used for metabolism. It requires adequate gluta-
thione to metabolize acetaminophen to an inactive
compound. If glutathione is not available, a toxic
metabolite is produced that causes hepatic cell
necrosis. A maximum dose of 4 g per day of acet-
aminophen is recommended to reduce the risk of
hepatoxicity. Individuals who consume alcohol, are
malnourished, or have pre-existing liver disease
are at an increased risk. The Food and Drug
Administration (FDA) updated labeling require-
ments in an attempt to better educate consumers
about the risk of liver failure from consumption of
multiple acetaminophen-containing products.
87
The concern was that multiple products may be
taken together, thereby exceeding the 4 g/day
limit, a condition determined to increase the risk
of hepatotoxicity. Therefore, the FDA required a
limit of 325 mg per dosage unit in prescription
combination analgesic products. Although it was
not required by the FDA, the manufacturer of
brand name Tylenol is now opting to recommend
a maximum dose of 3,000 mg per day and change
the dosing interval from two pills every 4–6 hours
to two pills every 6 hours in the labeling of Extra
Strength (500-mg) acetaminophen products. This
often causes confusion among healthcare profes-
sionals regarding what the maximum daily dose
should be; however, the salient point is to avoid
prescribing and usage scenarios that result in
unintentional dosage combinations exceeding 4 g
of acetaminophen per day.
Increased adipose tissue in the body compo-
sition of older patients is also a concern with
certain drugs. Fentanyl is highly lipophilic and
may unpredictably release into circulation after
depositing in adipose tissue. In addition, absorp-
tion of transdermal fentanyl is highly variable, may
be affected by normal changes in older skin, and
is temperature dependent. Transdermal fentanyl
should be reserved for patients already stabilized
on an oral or intravenous opioid dose. But if neces-
sary for opiate-naive patients, transdermal fentanyl
should always be started at 25 mcg or less. This
is particularly important in the geriatric population.
Methadone and meperidine are not recom-
mended for use in the elderly. Methadone
is complicated to dose, making an already
dangerous class of drugs in the elderly even
more complicated. It may be of some benefit
in neuropathic pain; however, it should be
managed by a pain specialist. Meperidine is
hepatically metabolized to an active and toxic
metabolite with a longer half-life than the parent
drug. The metabolite is renally eliminated, inter-
acts with other drugs, and accumulates in older
patients. Normeperidine, the active metabolite of
meperidine, can precipitate anxiety, tremors, and
seizures. NSAIDs cause gastrointestinal ulcer-
ation, hypertension, and renal failure and are
not routinely recommended for older patients.
Pregabalin and gabapentin cause edema, often
dose-related and troubling in patients with heart
failure. Tricyclic antidepressants and serotonin
norepinephrine reuptake inhibitors cause cardiac
rhythm abnormalities. In patients with comorbid
conditions that predispose them to these effects,
these agents should be used cautiously, if at all.
Patients cite fear of adverse effects, concerns
for overdosing, and addiction as reasons for
inadequate analgesia.
88
An understanding of the
etiology of pain syndromes, increased sensitivity
to analgesics in older patients, and measures to
prevent adverse effects will promote safer pain
management. Although addiction may occur
in older patients, the fear is often unfounded.
Educating the patient that daily use of opioids to
treat pain is not addiction and that it is similar to
treating high blood pressure with an antihyper-
tensive drug will help to allay this concern.
https://t.me/medicina_free
14 - Pain and Sensory Disorders |
431
Subjective:
TP is a 71-year-old Hispanic woman who presents with a progressive loss of field vision and no
headache or pain.
Past Medical History:
Hypertension and chronic atrial fibrillation.
Medications:
Hydrochlorothiazide 25 mg daily, metoprolol succinate 50 mg daily, ASA 81 mg daily.
Objective:
BP 134/64 mmHg, P 58 BPM, IOP 28 mmHg (normal: 10–22 mmHg).
Assessment:
TP has open-angle glaucoma with elevated IOP with vision loss.
Plan:
Initiate therapy with latanoprost eye drops for open-angle glaucoma.
Rationale:
Prostaglandin analogs are a first-line treatment for open-angle glaucoma as well as beta
blockers. Topical beta blockers would not be a first choice in this patient because she has a
low heart rate due to the beta blocker therapy for atrial fibrillation.
Case Summary:
TP is at risk for glaucoma secondary to age and Hispanic ethnicity. She presents with
symptoms of open-angle glaucoma (loss of field vision). Closed-angle glaucoma is uncommon
and typically presents as an acute worsening of vision with associated eye pain or headache.
Because there are two first-line agents for open-angle glaucoma, concomitant diseases and
ease of use must be carefully considered in an elderly patient. Although administered topically,
beta blockers may have some systemic absorption, which would be additive to an oral beta
blocker. Latanoprost is dosed once daily in the evening, which improves compliance.
C 1: O O C
https://t.me/medicina_free
432
| Fundamentals of Geriatric Pharmacotherapy
C 2: O P C
Subjective:
LM is a 77-year-old man with chronic nonmalignant back pain presenting with worsening
pain that he describes as dull and aching. Until recently his pain had been very well managed
(3/10 visual analog score) with hydrocodone/acetaminophen and occasional ibuprofen but now
requires more frequent doses (up to maximum prescribed) with little added benefit.
Past Medical History:
Hypertension, obesity, obstructive sleep apnea, back pain. Back surgery 8 years ago to repair a
bulging disc.
Allergies:
NKDA.
Medications:
Hydrochlorothiazide 25 mg daily, hydrocodone/acetaminophen 10/325, 2 tabs five to six times
daily, ibuprofen 600 mg three to four times daily, docusate 200 mg twice daily.
Social History:
Retired from construction work. Lives with wife of 45 years.
Objective:
Ht 5´8˝, Wt 265 lb, visual analog score 7/10, BP 154/70 mmHg, P 87 BPM, BUN 25 mg/dL,
serum creatinine 1.4 mg/dL.
Assessment:
LM is experiencing worsening pain that may have components of neuropathic pain and is
not controlled with his current regimen. His daily dose of acetaminophen exceeds maximum
recommendations.
Plan:
1.
Start oxycodone extended-release 30 mg every 12 hours, change hydrocodone/
acetaminophen to 1–2 tablets every 6 hours, as-needed dosing (maximum daily
acetaminophen limited to 4 g), discontinue ibuprofen, and add gabapentin 200 mg at
bedtime for 3 days, then increase to 200 mg twice daily.
2.
Add senna as needed for opioid-induced constipation. Consider docusate in addition to
senna according to patient needs.
3.
Counsel patient and spouse to observe for worsening sleep apnea with addition of long-
acting opioid and gabapentin.
Rationale:
LM has a history of a bulging disc and surgery on his back, has persistent pain that is
worsening, and has neuropathic features. LM should be placed on a consistent opioid regimen
and an adjuvant drug for his neuropathic pain. There is ample evidence to suggest how much
opioid he requires, and an equivalent regimen of a long-acting opioid can be created using
an equipotent dose, adjusted for possible incomplete cross tolerance and renal function. The
combination of hydrocodone/acetaminophen is appropriate for moderate breakthrough pain
as long as the patient does not take excessive amounts of acetaminophen. Ibuprofen should
be discontinued due to its adverse effect on blood pressure and renal function. Gabapentin is
a reasonable choice for the neuropathic symptoms as long as the dose is adjusted based on
renal function. Although LM has not complained of constipation, a stimulant laxative should
be made available with the initiation of scheduled opiate therapy to be proactive. Finally, older
https://t.me/medicina_free
14 - Pain and Sensory Disorders |
433
patients frequently have comorbidities that require more intense monitoring or careful titration.
Patients with obstructive sleep apnea are at an increased risk for respiratory depression from
sedatives and pain medications.
Case Summary:
This patient requires multiple interventions because pain is not sufficiently responding to
increased doses of analgesics. The analgesic drugs LM currently takes could potentially lead
to renal and hepatic toxicity, as well as increasing blood pressure, if they are continued at a
higher frequency. Other classes of analgesics and adjuvant drugs should be considered for
better management of this pain syndrome.
https://t.me/medicina_free
434
| Fundamentals of Geriatric Pharmacotherapy
C S
Visual and hearing impairment are commonly
linked with aging. Patient age is a risk factor for
many causes of decreased visual acuity. Guide-
lines for treatments are developed from studies
that contain many elderly patients. In elderly
patients, however, maintenance of quality of life
is just as important as managing the disease
state. The pharmacist should consider quality
of life when recommending therapy and ensure
adequate communication techniques when
interacting with patients.
Pain management recommendations in the
elderly are largely based on expert opinion and
knowledge of pain syndromes and the altered
pharmacokinetics and pharmacodynamics of
drugs in elderly patients. Pain is a subjective
disease in which patients will direct therapeutic
decisions by rating their pain and pain reduction.
However, in elderly patients, therapeutic choices
must be more conservative.
Treatments for neuropathic and nociceptive
pain have a high rate of adverse effects, such
as sedation, dizziness, confusion, respiratory
suppression, and constipation. Many effects
are transient, but older patients should begin
treatment at lower doses or with longer intervals
between doses in order to lessen these effects.
A balance must be achieved between conserva-
tive dosing and sufficient pain management in
elderly patients.
S-A Q
1. Why does the prevalence of glaucoma
increase in patients over the age of 65?
2.
What age-related changes contribute to the
development of dry eyes?
3.
What are the two general mechanisms of
action in the pharmacotherapy of open-
angle glaucoma?
4. Which common drug classes in the elderly
increase the risk for developing cataract?
5.
Which types of visual impairment have phar-
macologic prevention strategies?
6. Why are elderly patients more at risk for
developing drug-related causes of hearing
impairment?
7. What common disorders in elderly patients
make administration of eye drops more
difficult?
Clinical Pearls
• Patients with cognitive impairment may be resistant to receiving eye drops. Techniques
for administering eye drops to an uncooperative patient include having the patient lay
back or sit in a chair with head back, explaining the process and the expected sensa-
tion of the eye drops in the eye, and pulling down the lower lid to expose conjunctiva to
where the drops are to be applied. If this is unsuccessful and the patient remains with
closed eyes, applying the drop to the inner corner of eye will allow the drop to fall in the
eye when the eyelids are opened.
•
The effective dose of tricyclic antidepressants for neuropathic pain is often less than the
dose used for depression. Desipramine and nortriptyline have less anticholinergic activ-
ity than other tricyclic antidepressants and are preferred over amitriptyline in the elderly
patient but should still be limited to doses of 25–50 mg/day.
https://t.me/medicina_free
14 - Pain and Sensory Disorders |
435
8. What behavior should be avoided when
communicating with a patient with presby-
cusis?
9. What are the most common causes of pain
in elderly patients?
10.
What methods can be used to assess pain
in patients with cognitive impairment?
11.
Which drugs would not be considered first-
line choices in the treatment of neuropathic
pain in elderly patients?
12. How do pain management guidelines for
adult and elderly patients differ?
13.
What physiologic age-related changes
should be considered when designing a
pain regimen for an elderly patient?
14. What points of education are important
when counseling a patient and caregivers
about the treatment of pain?
15.
Which adverse effect of opioids should be
managed with another class of drugs?
16.
In what disease states should pregabalin
and gabapentin be used with caution?
R
1. Lewis T, Warshaw G. Visual and hearing impairment.
In: Landefeld CS, Palmer RM, Johnson MA, et al.,
eds. Current Geriatric Diagnosis and Treatment. New
York: McGraw-Hill; 2004:122.
2.
Foulks GN. Pharmacological management of dry eye
in the elderly patient. Drugs Aging. 2008;25:105–118.
3. e Eye Diseases Prevalence Research Group. Causes
and prevalence of visual impairment among adults in
the United States. Arch Ophthalmol. 2004;122:477–
485.
4.
Johnston CB. Geriatric assessment. In: Landefeld CS,
Palmer RM, Johnson MA, et al., eds. Current Geriatric
Diagnosis and Treatment. New York: McGraw-Hill;
2004:16.
5. National Institute on Deafness and Other Commu-
nication Disorders. Quick statistics page. http://www.
nidcd.nih.gov/health/statistics/quick.htm. Accessed
October 15, 2014.
6. Gates GA, Murphy M, Rees TS, et al. Screening for
handicapping hearing loss in the elderly. J Fam Pract.
2003;52:56–62.
7.
Li J, Tripathi RC, Tripathi BJ. Drug-induced ocular
disorders. Drug Saf. 2008;31:127–141.
8.
American Academy of Ophthalmology Cataract and
Anterior Segment Panel. Preferred practice pattern
guidelines. Cataract in the adult eye. San Francisco, CA:
American Academy of Ophthalmology; 2011. http://
www.aao.org/ppp. Accessed February 9, 2014.
9.
American Academy of Ophthalmology Glaucoma
Panel. Preferred practice pattern guidelines. Primary
angle closure. San Francisco, CA: American Academy
of Ophthalmology; 2010. www.aao.org/ppp. Accessed
February 9, 2014.
10.
Sloan FA, Ostermann J, Brown DS, et al. Eects of
changes in self-reported vision on cognitive, aective,
and functional status and living arrangements among
the elderly. Am J Ophthalmol. 2005;140:618–627.
11.
Age-related eye disease study research group. Cogni-
tive impairment in the age-related eye disease study.
Arch Ophthalmol. 2006;124:537–543.
12. Weinreb RN, Khaw PT. Primary open-angle glau-
coma. Lancet. 2004;363:1711–1720.
13. American Academy of Ophthalmology Cornea/
External Disease Panel. Preferred practice pattern guide-
lines. Dry eye syndrome. San Francisco, CA: American
Academy of Ophthalmology; 2013. www.aao.org/ppp.
Accessed February 7, 2014.
14. Lemp MA. Management of dry eye disease. Am J
Manag Care. 2008;14:S88–S101.
15. Amparo F, Dastjerdi M, Okanobo A, et al. Topical
interleukin 1 receptor antagonist for treatment of dry
eye disease. JAMA Ophthalmol. 2013;131(6):715–723.
16. American Academy of Ophthalmology Retina Panel.
Preferred practice pattern guidelines. Age-related macular
degeneration. San Francisco, CA: American Academy
of Ophthalmology; 2008. http://www.aao.org/ppp.
Accessed February 7, 2014.
17.
Age-related eye disease study group. A randomized,
placebo-controlled, clinical trial of high-dose supple-
mentation with vitamins C and E, beta carotene, and
zinc for age-related macular degeneration and vision
loss. Arch Ophthalmol. 2001;119:1417–1436.
18. Whitcup SM, Cantor LB, VanDenburgh AM, et al. A
randomized, double masked, multicentre clinical trial
comparing bimatoprost and timolol for the treatment
of glaucoma and ocular hypertension. Br J Ophthalmol.
2003;87:57–62.
19. Chew P, Aung T, Aquino MV, et al. Intraocular
pressure-reducing eects and safety of latanoprost
versus timolol in patients with chronic angle-closure
glaucoma. Ophthalmology. 2004;111:427–434.
20. Evans DW, Bartlett JD, Houde B, et al. Latanoprost-
induced stabilization of central visual function in
patients with primary open-angle glaucoma. J Phar-
macol er. 2008;24:224–229.
https://t.me/medicina_free
436
| Fundamentals of Geriatric Pharmacotherapy
21. Chabi A, Varma R, Tsai JC, et al. Randomized clinical
trial of the ecacy and safety of preservative-free
tauprost and timolol in patients with open-angle
glaucoma or ocular hypertension. Am J Ophthalmol.
2012;153:1187–1196.
22.
Sherwood MB, Craven ER, Chou C, et al. Twice-daily
0.2% brimonidine-0.5% timolol xed-combination
therapy vs monotherapy with timolol or brimonidine
in patients with glaucoma or ocular hypertension. Arch
Ophthalmol. 2006;124:1230–1238.
23.
Shin DH, Feldman RM, Sheu WP. Ecacy and safety
of the xed combinations latanoprost/timolol versus
dorzolamide/timolol in patients with elevated intra-
ocular pressure. Ophthalmology. 2004;111:276–282.
24.
Tozer K, Roller AB, Chong LP, et al. Combination
therapy for neovascular age-related macular degenera-
tion refractory to anti-vascular endothelial growth
factor agents. Ophthalmology. 2013;120:2029–2034.
25.
Perry HD, Solomon R, Donnenfeld ED, et al. Evalu-
ation of topical cyclosporine for the treatment of dry
eye disease. Arch Ophthalmol. 2008;126:1046–1050.
26. Sall K, Stevenson OD, Mundorf TK, et al. Two multi-
center, randomized studies of the ecacy and safety
of cyclosporine ophthalmic emulsion in moderate to
severe dry eye disease. Ophthalmology. 2000;107:631–
639.
27.
Kangari H, Eftekhari MH, Sardari S, et al. Short-term
consumption of oral omega-3 and dry eye syndrome.
Ophthalmology. 2013 Nov;120(11):2191–2196.
28. Bhargava R, Kumar P, Kumar M, et al. A random-
ized controlled trial of omega-3 fatty acids in dry eye
syndrome. Int J Ophthalmol. 2013;6(6):811–816.
29. Age-related eye disease study research group. A
randomized, placebo-controlled, clinical trial of
high-dose supplementation with vitamins C and
E and beta carotene for age-related cataract and
vision loss: AREDS report no. 9. Arch Ophthalmol.
2001;119:1439–1452.
30. Clinical trial of nutritional supplements and age-
related cataract study group. A randomized, double-
masked, placebo-controlled clinical trial of multivi-
tamin supplementation for age-related lens opacities.
Ophthalmology. 2008;115:599–607.
31.
Moeller SM, Voland R, Tinker L, et al. Associations
between age-related nuclear cataract and lutein and
zeaxanthin in the diet and serum in the carotenoids
in the age-related eye disease study (CAREDS), and
ancillary study of the women’s health initiative. Arch
Ophthalmol. 2008;126:354–364.
32. Age-related eye disease study research group. e rela-
tionship of dietary lipid intake and age-related macular
degeneration in a case-control study. Arch Ophthalmol.
2007;125:671–679.
33. Tan JSL, Wang JJ, Flood V, et al. Dietary antioxidants
and the long-term incidence of age-related macular
degeneration. Ophthalmology. 2008;115:334–341.
34.
Van Leeuwen R, Boekhoorn S, Vingerling JR, et al.
Dietary intake of antioxidants and risk of age-related
macular degeneration. JAMA. 2005;294:3101–3107.
35.
Chew EY, Clemons TE, Agron E, et al. Long-term
eects of vitamins C and E, beta carotene, and zinc on
age-related macular degeneration: AREDS report no.
35. Ophthalmology. 2013;120:1604–1611.
36.
Chew EY, Clemons TE, SanGiovanni JP, et al. e
age-related eye disease study 2 (AREDS2): study
design and baseline characteristics (AREDS2 report
number 1). Ophthalmology. 2012;119(11):2282–2289.
37.
Chew EY, Clemons TE, SanGiovanni JP, et al.
Lutein plus zeaxanthin and omega-3 fatty acids
for age-related macular degeneration. JAMA.
2013;309(19):doi:10.1001/jama.2013. 4997.
38.
Rosenfeld PJ, Brown DM, Heier JS, et al. Ranibi-
zumab for neovascular age-related macular degenera-
tion. N Engl J Med. 2006;355:1419–1431.
39. Martin DF, Maguire MG, Ying GS, et al. Ranibi-
zumab and bevacizumab for neovascular age-related
macular degeneration. N Engl J Med. 2011;364:1897–
1908.
40.
Chakravarthy U, Harding SP, Rogers CA, et al.
Ranibizumab versus bevacizumab to treat neovascular
age-related macular degeneration. Ophthalmology.
2012;119:1399–1411.
41. VEGF inhibition study in ocular neovascularization
clinical trial group. Year 2 ecacy results of 2 random-
ized controlled clinical trials of pegaptanib for neovas-
cular age-related macular degeneration. Ophthalmology.
2006;113:1508–1521.
42. Dietlein TS, Jordan JF, Luke C, et al. Self-application
of single-use eye drop containers in an elderly
population: comparisons with standard eye drop
bottle and with younger patients. Acta Ophthalmol.
2008;86(8):856–859.
43. Schwartz GF, Hollander DA, Williams JM. Evalua-
tion of eye drop administration technique in patients
with glaucoma or ocular hypertension. Curr Med Res
Opin. 2013;29:1515–1522.
44.
Rosenberg EA, Sperazza LC. e visually impaired
patient. Am Fam Physician. 2008;77:1431–1436.
45. Morgan DE. Assessment and treatment of hearing
loss among elders. In: Osterweil D, Brummel-Smith,
K, Beck JC, eds. Comprehensive Geriatric Assessment.
New York: McGraw-Hill; 2000:253.
46.
Tay T, Wang J, Kiey A, et al. Sensory and cognitive
association in older persons: ndings from an older
Australian population. Gerontology. 2006;52(6):386–
394.
47. Acar B, Yurekli M, Babademez M, et al. Eects
of hearing aids on cognitive functions and depres-
sive signs in elderly people. Arch Gerontol Geriatr.
2011;52(3):250–252.
https://t.me/medicina_free
Соседние файлы в папке Библиотека им академика М.И. Перельмана