INJURIES IN ELDERLY PEOPLE

Many of us have experienced the anxiety of having to deal with an older member of the family or a friend who incurred an injury as a result of a fall.

Falls among older individuals have been accepted and viewed as unavoidable accidents. But this is not necessarily so. The physical and psychological damage done as a result of the fall can be averted if proper precautions are taken.

Hip, and fracture neck of femur are the most devastating, especially in older women with osteoporosis. Even if the physical injury is not debilitating, the damage to the psyche is tremendous, leading to fear and self imposed exile from any kind of activity which in itself leads to a decrease in health and fitness. It is like a self-fulfilling prophecy — they are afraid they will fall, restrict activity, incur muscle atrophy, loss of strength and balance and therefore fall once again when they try to get around even to navigate the most minor tasks.

Some of the most common causes for falls are: the immediate physical environment; poor fitness levels in terms of strength, balance, gait, agility and speed and reaction time; intake of sedating medication or anything that alters cognition; middle ear imbalance leading to vertigo and dizziness; vision problems; other medical problems like Parkinson’s, Diabetes, Multiple Sclerosis; and improper footwear
Simple modifications

Many of the above factors can be addressed by making simple modifications to the immediate environment and intervention to improve fitness levels, strength and balance

Use antiskid tiles wherever possible. Fix railings in the bathrooms for support. Steer clear of carpets that may be tripped on, sharp edges and corners, flimsy stools and chairs, wet areas, stairs without railings and poorly designed or ill fitting footwear.

Some forms of medication, like sedatives, antihistamines, some antihypertensives can lead to dizziness, postural hypotension and hence a tendency to lose balance.

Older individuals who have been active all their lives, participated regularly in fitness programmes and maintained their weight within the optimum range while also maintaining optimum muscle mass have a lower incidence of falls and injury when compared to the unfit, overweight, person.

This may be one reason to encourage people to keep exercising throughout their lives with alterations in routine depending on the age and their state of health.

An exercise programme for the elderly should include balance and strength besides a basic cardio routine. The "principle of specificity" of exercise indicates that in order to improve the condition of a particular system; the exercise should target that system.

"Use it or lose it". This is the dictum for any aspect of fitness including muscle mass/strength. Deterioration is evident with disuse and sedentary living. A strength training programme that targets the major muscle groups can improve leg and hip extensor strength. This improves ability to walk easier, climb stairs, arise from a seated position in a chair or on the floor or bend to pick up something from the floor.
Strength training

Upper body strength (which tends to diminish rapidly due to neglect) is required to perform simple tasks like lifting, reaching and carrying.

Strength training can be performed using resistance bands that are colour coded to differentiate levels of strength, or with other forms of external weights like ankle weights, wrist bands or even dumbbells under guidance.

Is muscle strength related directly to balance? Not necessarily so, according to some studies. Large bulky muscles and enormous strength do not directly translate to great physical balance.

However, weak muscles definitely render an individual more prone to falling down as a result of poor balance and the inability to support ones own body weight properly. Movements of the body mandate a certain level of equilibrium and the ability to accommodate this shift in centre of gravity.

For instance, getting up from a seated position changes the centre of gravity from a lower to a higher level from the floor, thereby decreasing stability. Adequate balance and strength of leg muscles will ensure that one doesn’t tip over during the process.

In order to improve balance, ensure good vision, absence of a vestibular problems and an optimum somatosensory system. This system enables the body to understand its position in relation to its environment through a sophisticated neuromuscular network. The body is constantly kept informed of its position and contact with other objects like the floor or a chair. If there is any compromise in this mechanism (and it has been found that the sensory system diminishes with age), balance may be affected.
Simple moves

Simple tasks like standing on one foot for as long as possible, standing with feet as close together as possible, with heel to toe, putting on pants while standing up, walking on a straight line, getting up from a chair and walking forward, turning and coming back to sit in the chair as fast as possible can be practiced to improve balance.

Specific tests are available to assess balance, strength and proprioception. Some examples of the tests include one leg balance test, "get up and go" test. These act as guidelines to structure the routine for the individual client.

Please note that older adults with poor balance should never be allowed to exercise or perform any of these moves unsupervised.


Some common causes

The immediate physical environment

Poor fitness levels in terms of strength, balance, gait, agility and speed and reaction time

Intake of sedatives, medication or anything that alters cognition.

Middle ear imbalance leading to vertigo and dizziness

Vision problems

Other medical problems like Parkinson’s, Diabetes, Multiple Sclerosis

Improper footwear

To improve balancce

Stand on one foot for as long as possible

Stand with feet as close together as possible, with heel to toe

Put on pants while standing

Walk on a straight line

Get up from a chair and walk forward

Turn and come back to sit in the chair as fast as possible

TIPS TO COPE ALZHEIMER’S

It was in 1907 that Alois Alzheimer described a devastating progressive disease presenting with memory loss and accelerated ageing; but even 100 years later, we have no real remedy for Alzheimer’s disease which is becoming increasingly common i n India too. Earlier it was thought that Alzheimer’s was "rare" in India; studies reported that multi-infarct dementia caused by reduced blood flow to the brain (very common in diabetics and hypertensives), infections of the brain like TB and cysticercosis, alcoholism and simple malnutrition were responsible for dementia in the elderly Indian rather than Alzheimer’s.

But recent studies, particularly from Kerala, have shown that about three per cent of the elderly over 65 years of age have dementia; and what is more, the majority of them qualify by a process of exclusion, to be stricken with Alzheimer’s disease. Unfortunately, there is no simple test to diagnose Alzheimer’s disease. A PET scan can detect the illness but extremely high cost and non-availability make it a non.-option.

Detection by exclusion

However, a good rule of thumb would be to subject the elderly who present with memory problems to other tests that could detect a treatable problem. A simple vitamin B12 assessment could pick up many treatable, reversible cases; a high BP or elevated blood sugar could point to other treatable causes and so on. By a process of exclusion one zeros in on Alzheimer’s disease. What next?

Pharmacotherpy for the associated behaviour problems such as delirium, anxiety, depression etc helps manage the patient better; but none of the drugs, including Donepezil, which is the one most widely used, are able to reverse the process.

However, there is a lot of evidence building up that nutritional supplementation helps in slowing the progression of Alzheimer’s disease. Though purists who practise only evidence-based medicine may not agree, commonsense dictates that one try out nutritional supplementation when one’s near and dear ones are stricken with the disease. The Net is replete with reports from highly reputed medical journals about the benefits of nutritional supplements. From the food and beverage angle, it seems wise to give these patients green tea and fresh apple juice. These contain anti-oxidants and flavonoids which help stem the progression of Alzheimer’s. Adding a lot of turmeric into curries cooked can help as curcumin present in turmeric has shown benefit in some studies. Supplementing B6, B12 and folic acid is a good idea as these help reduce harmful homocysteine levels; high homocysteine levels have been implicated as one of the causes of Alzheimer’s disease. In many studies, improvement has occurred with omega3 fatty acids. Ginkgo tea or proprietary ginkgo biloba preparations have been found to be useful. Lipoic acid and co-enzymeQ are two dietary supplements which have also shown benefit. Reducing calorie intake has also been found to help.
No side-effects

The plus point is that these simple dietary changes and supplementation are safe; they do not have the side-effects of Schedule-H drugs. In private practice one does not have the where-with-all for pukka scientific studies. But the elders I have seen in my practice have done well with addition of these simple measures. The ones who have benefited most are those with Mild Cognitive Impairment (MCI) rather than advanced dementia. .

Keeping the patient mentally active is crucial. Encourage reading, doing crossword puzzles, reciting slokas, singing... Listening to music that they used to listen to in their youth and middle age can help too, as musical memories are among the strongest.

IS SECOND-HAND SMOKE DANGEROUS ?

"Dad, please do not fill the room with dirty air. Please, give me a room to breathe."

Have you ever felt your child’s agony when you light up?

"I smoke in the balcony when my child is in the bedroom. I avoid smoking in front of my kids." This is the explanation I get from my educated patients.

But while they may smoke outside; how many wash their hands and clean their teeth before they hold their children.

"Okay I should not smoke at home. But tell me, is it possible to go out 20 times a day, especially in this cold?" argues a heavy smoker.

Yes, it is difficult to go out for a smoke every time. But are people justified in smoking inside homes, and exposing innocent people to thousands of poisons with every puff.

Many now work in "smoke-free offices" and since the government has also taken disciplinary action for "smoking in public places", smokers are cautious while lighting up in public places. But unfortunately, the situation at home needs to be addressed.

What is passive smoking?

First of all, we need to understand what passive smoking is. Passive smoke or environmental tobacco smoke (ETS) is a mixture of mainstream smoke (exhaled by smokers); and side stream smoke (freshly generated from a passively lit cigarette); as well as contaminants that diffuse through the cigarette paper and mouth end between puffs.

ETS contains more than 4,000 chemical compounds and is even more carcinogenic than active smoking. Second hand smoke is a major source of indoor air pollution.

Tobacco smoke is an irritant. Some of the immediate effects include eye irritation, headache, cough, sore throat, dizziness and nausea. Short-term exposure to tobacco smoke also has a measurable effect on the heart. Just 30 minutes is enough to reduce coronary blood flow.

Alarmingly, nearly 700 million children, almost half of all children worldwide, live in the home of a smoker. Infants of mothers who smoke have five times the risk of sudden infant death syndrome (SIDS). They also suffer from reduced birth weight and reduced lung functioning.

Effects on health

Passive smoking increases the risk of lower respiratory tract infections such as bronchitis, pneumonia and bronchiolitis in children; and is a risk factor for new cases of asthma.

Passive smoking is also associated with middle ear infection in children as well as possible cardiovascular impairment and behavioural problems. Passive smoking may also affect children’s mental development. A U.S. study found deficits in reading and reasoning skills among children even at low levels of smoke exposure

In the longer term, passive smokers suffer an increased risk of a range of smoking-related diseases. Even a short period can have immediate adverse effects on the cardiovascular system and interferes with the normal functioning of the heart, blood, and vascular systems in ways that increase the risk of a heart attack.

Non-smokers, who are exposed to passive smoking in the home, have a 25 per cent increased risk of heart disease and lung cancer. A major review by the Government-appointed Scientific Committee on Tobacco and Health (SCOTH) concluded that passive smoking is a cause of lung cancer and ischemic heart disease in adult non-smokers
Protect yourself

The UN Surgeon General says that the only way to fully protect yourself and your loved ones from the dangers of second hand smoke is through 100 per cent smoke-free environments. The single best way to create a smoke free environment is to Quit Smoking.

Quitting requires planning, and a strong will. Also, there are effective support systems to help in the process.

A Structured Tobacco Cessation Clinic will definitely help you as it combines intensive psychotherapeutic interventions, along with pharmacotherapy to reduce the withdrawal symptoms.

Nicotine Replacement therapy and pharmacotherapy are also available to make the process easier. New drugs promise greater success in managing the cravings effectively.

Everyone knows smoking is bad for smokers and their families. Everyone understands that cigarettes are smoking people to disease and death very fast. Still they continue to abuse their bodies.

Protect yourself and your family

Make your home and car smoke-free.

Ask people not to smoke around you and your children.

Make sure that your children’s day care center or school is smoke-free.

Choose restaurants and other businesses that are smoke-free.

Thank businesses for being smoke-free. Let owners of businesses that are not smoke-free know that second hand smoke is harmful to your family’s health.

Teach children to stay away from second hand smoke.

Avoid second hand smoke exposure especially if you or your children have respiratory conditions, heart disease, or if you are pregnant.

Talk to your healthcare provider about the dangers of second hand smoke.

Quit smoking.

A NEW SET OF TEETH

A dental implant is an artificial substitute for a normal tooth. Natural teeth are lost due to damage in accidents, poor dental hygiene, genetic and other factors. Dental implants using the new Zygoma technique give the patient a new tooth or set of teeth through a treatment that is quick with long-lasting effects and almost pain-free.

What is a dental implant?

The normal tooth structure consists of a root and a crown. The root is enclosed in the jawbone and gums and the crown is the visible part of the tooth.

A dental implant is an artificial substitute for the root. It is usually made of titanium, which is a bio-compatible material i.e. it will not be rejected by our body.

After a healing period, an artificial crown is placed on top of the implant. Thus the implant closely resembles a natural tooth.

How many teeth can be replaced with implants?

If all the teeth are missing, the complete set of teeth in the jaw can be supported by four or six implants. The number of implants is determined on a patient to patient basis, depending on criteria such as bite force, location of missing teeth, quality of jawbone…

Are implant teeth fixed or removable?

Implants are placed in, fixed and integrated to the jaw bone. However the artificial teeth placed on top of the implant can be fixed or removable. The former is more common.

What are the benefits of dental implants?

They feel and look like your own teeth. Dental implants restore confidence in speaking, laughing and chewing with comfort and without worries of sudden dislodgement. Implants preserve the integrity of facial structures.

When teeth are replaced using traditional tooth-supported bridges, the teeth on either side of the missing tooth are ground down so that the bridge can be cemented on to them. This structure can never be replaced. Implants do not need the grinding down of the adjacent natural teeth.

Can anyone receive dental implants?

The patient must be in good health and have proper bone structure and healthy gums for a successful implant. People who are unable to wear removable dentures may also be good candidates. Patients with well-controlled diabetes or blood pressure can also undergo implants.

In patients with bruxism(grinding or clenching teeth) and poor oral hygiene, heavy smokers or those who have undergone radiation therapy in the jaw, the success rate for implants reduces.

Does the treatment take a long time?

Usually the treatment is done in two phases. In the first stage, the implant is placed in the jaw and the gums are closed over it.

After a healing period of three to six months, the implant will be checked and measurements made for the artificial teeth (prosthesis) ,which will be placed over the implant.

However, thanks to the combination of CT Imaging Technology and software for implant planning, implants are placed as a ‘key hole’ procedure and artificial teeth are fixed immediately on the implant within an hour.

This ‘teeth in an hour’ concept, however, has a few pre-requisites such as normal volume of jawbone, good range of mouth opening and adequate primary stability of the implant.

Does the patient need to be hospitalised?

Hospitalisation is an exception and not the rule. Majority of patients can be managed under local anaesthesia. Anxious patients are helped with nitrous oxide sedation or intravenous sedation techniques. A few patients, especially those requiring extensive bone grafting, will require general anaesthesia.

Can implants be done for elderly people?

Implants can be done in older people also. However certain issues such as osteoporosis (especially in post-menopausal women not on HRT), long history of heavy smoking, uncontrolled diabetes have to be kept in mind while planning implants.

Can implants be done for children?

Implants are generally contra-indicated in growing ages. Continued jaw growth can lead to altered implant levels and difficulty in fabricating the artificial teeth. However, in certain conditions such as ectodermal dysplasia, implants can be given during childhood.

What is Zygoma Implant?

In some patients, the upper jaw bone is not adequate to take implants. In such cases the hip bone is grafted into the upper jaw. Later implants are placed and artificial teeth fixed. In the new zygoma technique, bone grafting is not necessary.

The zygoma implant is a longer implant, which is placed in the upper jaw bone extending up to the zygoma (cheek bone) and artificial teeth are placed on it (without the need for extensive bone grafting procedure).

F&Q ON STEM CELL TRANSPLANT

Recently there have been a number of articles on stem cell transplantation, which has generated lot of interest among the public. By definition a stem cell is one capable of self renewal and multiplication. Every living tissue has its origin from the stem cell.

Stem cell transplantation was first used in the treatment of blood disorders and it was a breakthrough. Conventionally known as bone marrow transplantation, the stem cells responsible for production of the blood cells reside in the bone marrow, which is a special tissue inside the cavity of the bones. The blood cells originate from the bone marrow from a parent cell or the "stem cell".

A more comprehensive terminology for bone marrow transplantation is haematopoietic stem cell transplantation or blood stem cell transplantation.

The word Haematopoiesis means blood cell production, which includes red cells, white cells and platelets.

What are the sources of haematopoietic stem cells?

The sources are bone marrow; from the blood circulation, also known as peripheral blood stem cells and Umbilical cord blood.

How is the stem cell obtained from the donor?

To collect stem cells from the bone marrow, the donor is given general anaesthesia and bone marrow is aspirated from multiple sites in the hip bone and collected in a bag. This takes about one to two hours depending on the quantity required, which again depends on the weight of the patient. There is usually no risk to the donor.

To collect stem cells from peripheral blood, the donor is given a special injection called growth factors to stimulate production of the stem cells in increased numbers. These will be circulating in the blood stream.

The donor is connected to a machine called the cell separator machine, which can separate the stem cells from the donor’s blood and return the rest of the blood to the donor.

How is the blood stem cell given to the patient?

It is given simply as an intravenous infusion like blood transfusion. The stem cells will automatically find their way home, which is the bone marrow. It will replace the patient’s diseased marrow to give healthy blood cells.

What are the prerequisites for transplants?

The main prerequisite is that the blood group should match. It is common knowledge that if a patient requires blood transfusion only the same group has to be used. Similarly for transplanting blood stem cells there is a system called Human Leucocyte antigen or HLA. These are proteins present on the surface of most of the cells. This system recognises self from non-self.

If a patient is exposed to stem cells with a different HLA antigen specificity, the patient’s immune system will recognise the stem cells as foreign and reject it.

Before a patient is scheduled for blood stem cell transplantation, it is mandatory to choose a donor with an identical HLA type. This can be checked by simple tests.

Who can be the donors for blood stem cell?

Siblings of the patient or a twin; Extended family members; Unrelated donors

What are the chances that a sibling will have identical HLA?

The HLA system for each individual is derived from both parents. Each individual inherits a set of antigens (proteins) from each parent. There is a one in four chance that the individual will have a HLA identical sibling. If there is no sibling donor, one has to explore options with extended family members or unrelated donors.

How are unrelated donors identified?

In the developed countries, there is a national bone marrow donor registry. It enrols voluntary donors who are willing to donate their bone marrow. The bone marrow registry maintains their data base with their HLA typing. Their fitness to donate marrow is also assessed.

The bone marrow registry is linked to other international registries. If a patient needs blood stem cell transplantation and if the patient has no suitable family donor, a search is made through the national registry on the electronic data base.

What is the consequence to the donor?

Bone marrow is a replenishable tissue. Donating bone marrow is more or less like donating blood. So there is no damage to the donor.



A donor is connected to a machine that separates stem cells from the blood.

What are the other sources?

Umbilical cord blood is a recent source, which shows great promise for patients who lack a family donor. Umbilical cord blood is rich in blood forming stem cells. Umbilical cord is the connecting link between the mother and the foetus.

Once the baby is born the umbilical cord is severed and disposed off. The discovery that the umbilical cord blood is a rich source of blood stem cells has led to the formation of cord blood banks around the world and the cord blood stem cells are stored for lifesaving purposes.

There are a number of private and public cord blood banks in many countries and it is networked.

What are the advantages of cord blood stem cells?

Cord blood stem cells are easily available. The degree of matching required between the patient and the donor can be less stringent compared to conventional bone marrow transplantation.

What are the diseases that can be treated by this method?

It can be classified into three main groups of diseases. Malignant diseases like Leukaemia or cancer of the blood cells; diseases where blood production itself is defective like Aplastic anaemia; and genetic diseases like Thalassemia and immune deficiency conditions.

How is the patient prepared?

For the donor blood stem cells to get into the patient’s bone marrow and start functioning, the patients have to be treated with high dose of chemotherapy to knock out his immune system and also to eradicate the diseased bone marrow.

What happens till the new bone marrow starts functioning?

This is a very critical period, as the patient will be left with no immunity till the new blood stem cells take over and he/she is highly susceptible to infections.

The patient has to be nursed in a very clean environment preferably in a room that can deliver filtered air so that all the micro organisms are filtered.

The patient will also require blood product support and antibiotic support. The need for a very aggressive supportive care makes blood stem cell transplantation expensive.

Can blood stem cell transplant be offered to patients in all age groups?

Till some years ago blood stem cell transplantation was offered to patients up to the fourth decade. With advances in techniques now we are able to offer blood stem cell transplantation even to elderly patients.

Can the patient’s own stem cells be used?

Yes in some situations patient’s own stem cells are collected, stored and transplanted after high dose chemotherapy treatment.

THE BENEFITS OF USING STEROID INHALERS

I often hear from my patients about someone with asthma who became very sick, was admitted in hospital in a serious condition or died. In all these situations, the commonest answer that emerged was the non-usage of the steroid inhaler (preventor).

The term "steroids" is scary to many. It has earned notoriety in sports due to various other reasons. But, in respiratory medicine, it is a widely prescribed medicine. Although heavily prescribed, they are often not used either because patients misunderstand the side effects or they don’t perceive the benefits immediately as with bronchodilators (relievers).
How it acts

Bronchodilators are used to open the airways quickly but the steroid acts slowly to bring the airways back to normal by reducing the inflammation so that the need for bronchodilators is reduced. By not using steroid inhalers, the inflammation continues unhindered resulting in piling up of mucus and swelling of the mucosa. At this stage, even if one uses a bronchodilator the effect is not perceived. If more doses are used, the benefit of bronchodilation is not perceived but toxicity starts. One of the serious side effects of reliever inhalers without steroid inhalers is sudden death due to uncontrolled asthma.

Another problem that occurs with regular use of bronchodilators without steroid inhalers is the development of fixed airway abnormalities. Simply put, the routine reliever dosage cannot open airways and a bigger dose does not mean increased benefit. At this stage even steroid inhalers would take longer to repair the airways or may fail.
Importance of inhalers

This highlights the importance of the steroid inhalers. In one study, Suissa and colleagues looked at 31,000 people between the ages of five and 44 years. Most patients used steroid inhalers. The researchers found that for every additional canister of steroid inhaler used the chances of death from asthma decreased by 21 per cent. They found a bigger effect when they looked at inhaled steroid usage in the last six months — a 54 per cent decrease in asthma deaths for every additional canister used. This was published in New England Journal of Medicine in 2000. The death rate increases significantly in the first three months if one stopped using steroid inhalers.

The message is: even in low doses steroids accrue benefits. In optimum doses not only is asthma control optimum but also serious problems ending in death can be prevented. Another reassuring aspect is the absence of side effects due to steroid inhalers. Clearly the benefits outweigh the risks.

COMPULSIVE SHOPPING

Anamika had anticipatory excitement as she stepped into the shopping mall. She had been feeling bored and lonely since the morning and couldn’t resist the urge to shop. She felt happy as she waded through some of the shops. The attention and ca re she received from the salespersons made her feel important. She bought a few clothes, a pair of studs, a watch, a handbag and some cosmetics.

The happiness lasted for the six hours that she spent at the mall. Once she returned home, she opened the cupboard to put the bags in. Inside, she saw many more unopened shopping bags staring back at her — purchases made over the past two weeks.
Preoccupation with shopping

Though not an illness, "Compulsive shopping" leads to considerable distress for the person and the family members due to financial consequences. The compulsive buyer has a frequent preoccupation with buying. He/she buys articles on an impulse, things that are not needed and are not affordable. The commonly bought items by women are clothes, accessories, jewellery, footwear and cosmetics. Men buy electronic gizmos and automobile spares. The shopping experience is pleasurable but subsequently the person feels guilty. Most of the purchased objects are not used. Some are returned or given away.

Compulsive shopping was observed about 100 years ago. Kraepelin and Bleuler (famous for describing Schizophrenia) described it and called it Oniomania. (‘Onio’ means buying). Interest in the phenomenon tapered subsequently.

Recent studies have suggested that a significant percentage of compulsive shoppers have underlying depression. The urge to shop is intensified by sadness or loneliness. The act of shopping is an attempt to feel better and it helps for a while; being pampered by the salespersons acts as a balm.

Compulsive shopping is also considered as a variant of Compulsions as in Obsessive Compulsive Disorder (OCD). The major difference is, in OCD, the urge to perform the compulsion is distressing and the person tries to control it. Compulsive shopping, on the other hand, is pleasurable. Some consider compulsive shopping an addiction. According to them, the person is vulnerable to addiction and shopping is just the context. And yes, there is a cynical view that ‘Compulsive shopping’ is another example of psychiatrists trying to medicalise any atypical human behaviour.

Compulsive shopping needs to be differentiated from the indiscriminate shopping seen in an illness called Mania. Hypomania is a milder form of mania. A person suffering from mania would be elated and the excessive happiness leads to excessive speech, activity and spending. They go on giant shopping sprees. While the motivation for shopping in mania is excessive happiness, it is sadness and boredom in compulsive shopping. Another uncommon reason for increased spending is ‘Revenge spending’ where the person splurges to deplete someone else’s reserves.
Treatment

By the time help is sought, most compulsive shoppers have huge debts on multiple credit cards and loans. Regret about the loans and anxiety about their repayment is seen. Frequent harassment by credit card "recovery teams" add to the distress. Marital discord is a consequence as the spouse tries to control the person’s buying behaviour and feels frustrated.

Treating the underlying depression, when present, has helped some to grow out of compulsive shopping. Cognitive behaviour therapy has also been used with varying results.