geriatrics 1 geriatrics geriatrics health problems waleed a. almalik md. assisstant prof, geriatrics...

Geriatrics 1 Geriatrics GERIATRICS HEALTH PROBLEMS WALEED A. ALMALIK MD. ASSISSTANT PROF, GERIATRICS MEDICINE. KING SAUD BEN ABDULAZIZ UNIVERSITY FOR HEALTH SCINCES (KSAU-HS ). GERIATRICS MEDICINE, KING ABDULAZIZ MEDICAL CITY (KAMC).

Geriatrics 2 Life Expectancy Current ageMalesFemales At birth68.976.6 55 y20.626.6 65 y13.918.3 75 y8.711.6 85 y5.56.9

Geriatrics 3 US Census Data and Projections YearPop. (millions) Age 65+Age 75+ 1960181 m9.2 %3.1% 1980222 m11.2 %4.2 % 2000260 m12.2 %5.5 % 2020 est.290 m15.5 %5.9%

Geriatrics 4 Key Indicators of Well-Being Health Status The leading causes of death for older Americans are heart disease, cancer, and stroke (respectively). Mortality rates for heart disease and stroke have declined by about a third since 1980. Mortality rates for cancer have risen slightly over the same period In 1995, 58% of persons over 70 reported having arthritis, 45% reported hypertension, and 21% reported heart disease In 1998 4% of persons 65-69 had moderate to severe memory loss compared to 36% of persons 85+ 23% of persons 85+ reported severe symptoms of depression

Geriatrics 5 Key Indicators of Well-Being (Contd) Health Risks and Behaviors The majority of persons 70+ reported engaging in some form of social activity during a 2-week period. 2/3 age 70+ reported satisfaction with their level of social activities In 1995, 1/3 of older Americans reported a sedentary lifestyle Self-reporting re: diet: 21% good, 67% need improvement, 13% poor Older persons are much less likely to be victims of both violent and property crime than persons age 12-64

Geriatrics 6 Key Indicators of Well-Being (Contd) Health Care Older persons of all ages are generally satisfied with their health care and few report difficulty obtaining health care services In 1996 average annual expenditure on health care: age 65-69: $5,864; age 85+: $16,465 In 1997, 4% of population 65+ resided in nursing homes; were women Older persons receiving home care in 1994: 64% relied exclusively on informal (unpaid) care, 8% received only formal care and 28% received a combo of informal and formal care

Geriatrics 7 General Principles of Aging: Old Folks Are Different Atypical presentation of acute illness Multiple concurrent problems Non-specific symptoms Hidden illness Under-reporting Multiple losses condensed into a short time span Expected physiologic aging changes

Geriatrics 8 Atypical Presentation of Acute Illness Only 40% of elderly fit the classic one symptom=one disease model Acute myocardial infarction without chest pain Acute hyperthyroidism without tachycardia, weight loss, etc. Acute infection without rising WBC count or typical fever Fatigue as chief presenting complaint of CHF

Geriatrics 9 Non-Specific Symptoms Confusion Self-neglect Falling Incontinence Apathy Anorexia/weight loss Dyspnea Fatigue Taking to bed

Geriatrics 10 Hidden Illness: You Must Ask, They Wont Tell! Sexual dysfunction Depression Incontinence Musculoskeletal stiffness Alcoholism Hearing loss Memory loss

Geriatrics 11 Under-Reporting Due To: Belief that symptoms are due to old age Fear or denial Concern about cost Embarrassment Mental impairment Concern about ill spouse Previous bad experience with health care system Fear of institutionalization

Geriatrics 12 Multiple Concurrent Losses Loss of physical health Loss social contacts: friends/family die Loss of familiar roles: mother, wife, employed person Loss of financial security: retirement, widowhood Loss of independence and power Loss of mental stability

Geriatrics 13 Normal Aging vs. Disease Aging is NOT a disease Learn to separate pathologic processes from the aging process Concentrate on how physical problems interfere with the ability of the person to remain independent (functional in their usual environment)

Geriatrics 14 Normal Aging vs. Disease (Contd) Normal aging Crows feet Presbycusis Seborrheic keratoses; loss of skin elasticity Benign forgetfulness Decreased blood vessel compliance Increase in % body fat Disease Macular degeneration Tympano-sclerosis Basal cell CA Dementia Athero-sclerosis Hypertension Obesity

Geriatrics 15 Laboratory Values that Do Not Change with Aging Hepatic function (ALT, AST, GGPT, Bilirubin) Coagulation tests Chemistries: electrolytes, total protein, calcium, phosphorus ABGs: pH, PaCO2 Hemoglobin, RBC indices, platelet count

Geriatrics 16 Laboratory Values that Do Change with Aging Decreases: Serum albumin, magnesium, PaO2, T3, T4, Creatinine clearance, white blood cell count Increases: Alkaline Phosphatase, uric acid, blood sugar, TSH, BUN/Creatinine

Geriatrics 17 Health Maintenance in the Elderly Recommend primary and secondary disease prevention screening Review all medications Control all chronic medical problems Optimize function Verify the presence of an adequate support system Discuss and document advanced directives

Geriatrics 18 Primary Preventing the occurrence of disease or injury Examples: Immunizations, Safety Equipment or Clean water Secondary Early detection and intervention preferably before the condition is clinically apparent Screening programs: Breast cancer screening BP screening Tertiary Minimizing the effects of disease and disability by surveillance and maintenance aimed and preventing complications Prevention

Geriatrics 19 Primary and Secondary Preventions BP screening Influenza, pneumonia, tetanus immunizations Obesity (height and weight) Smoking cessation Consider ASA to prevent MI/CVA Cholesterol screening Diabetes Mellitus screening Osteoperosis screening - females

Geriatrics 20 Cancer Screening Breast Cervical usually not >65 Colorectal Prostate-discussion Skin (Risk-based) Hearing/visual impairment screening Cognitive impairment screening Consider TSH in women Primary and Secondary Preventions (Contd)

Geriatrics 21 Iatrogenesis: A Definition Any illness that results from a diagnostic/therapeutic intervention or the omission of such intervention that is not a natural consequence of the patients disease

Geriatrics 22 Caring for Hospitalized Elderly 20-36% of older patients have their hospitalization prolonged by major adverse events One study compared those under 65 to those over 65: complication rate was 29% vs. 45% Another study showed hospital related complications in 40.5% of those > 70, and 8.5% of those < 70

Geriatrics 23 The Hospital Cascade of Disasters Hospitalization new environment and new medications acute delirium more new drugs and/or restraints more agitation; Foley inserted poor oral intake dehydration IV fluids increased and/or NG tube placed for feeding We now have the potential for congestive heart failure, thrombophlebitis, pulmonary embolism, aspiration pneumonia, falls and fractures, pressure sores, urosepsis, septic shock, etc...

Geriatrics 24 Drugs: Polypharmacy Alterations in drug disposition and tissue sensitivity Drug-to-drug interactions Changes in renal/hepatic elimination Medications errors Medication side effects (expected) The Hospital is a Hazardous Place...

Geriatrics 25 The Hospital is a Hazardous Place... (Contd) Bed rest and immobility General cardiac and muscle deconditioning Postural lightheadedness, hypovolemia, hypotension Pressure sores Constipation/fecal impaction Atelectasis and pneumonia Thrombophlebitis and thromboembolism Urinary incontinence

Geriatrics 26 Therapeutic and diagnostic procedures Angiography GI endoscopy and its preparation TUBES: IVs, NGs, Foleys, restraints, dialysis and transfusions Surgery and anesthesia Nosocomial Infections Pneumonia, C. difficile, MRSA The Hospital is a Hazardous Place... (Contd)

Geriatrics 27 The Hospital is a Hazardous Place... (Contd) Under nutrition Cognitive impairment Social isolation Poor dentition Impaired thirst perception Limited access to food and fluids Chronic disease

Geriatrics 28 Keys to Prevention A Checklist to Monitor the Hospitalized Diagnosis Medications Nutrition Continence Cognition Emotional status Mobility The Caregiver

Geriatrics 29 Diagnosis Keep accurate medical and surgical diagnosis lists Prioritize medical therapies, addressing reversible problems first Clarify the specific medical goals of the hospitalization Carefully select diagnostics: Is this procedure necessary and how will it change my management?

Geriatrics 30 Medications Make an accurate list of all medications on admission, including OTCs and herbals Always consider adverse drug effects as the cause of new symptoms Monitor appropriate blood levels (Digoxin, dilantin) Try to control pain without narcotics first Monitor/review need for medications daily

Geriatrics 31 Nutrition Avoid long NPO periods if possible Albumin and total cholesterol signal poor nutritional state Provide vitamin supplementation Adjust fluid therapy on an individual basis Ask about nausea/anorexia, food satisfaction daily The hospital is an excellent place to obtain a professional nutritional consultation

Geriatrics 32 Maintain mobility and cognitive function to avoid incontinence Reduce IV fluid rates at night Avoid anti-cholinergic medications Reassure the patient that new urinary incontinence is usually temporary Monitor bowel function early and daily to prevent incontinence, constipation and food refusal Continence

Geriatrics 33 Cognition Premorbid cognitive disorders lead to a very high incidence of delirium--expect it, prevent it Carefully monitor fluids and electrolytes Minimize psychoactive medications Use acetaminophen around the clock to manage fever and/or pain Use environmental strategies (lights, family sitters during the night) Address hearing and vision problems

Geriatrics 34 Emotional Status Address anxiety, pain and insomnia early Depression common: 20-60% of hospitalized elderly; treat it Frequently update family; hold patient/family conferences to allay fears and clarify the plan

Geriatrics 35 Mobility Avoid physical restraints including Foleys Encourage patient range of motion activities and resistive exercises in bed Expect self-sufficiency Enlist PT/OT therapists early for those with poor mobility and transfer skills If bed immobile, inspect for skin pressure areas daily

Geriatrics 36 The Care Giver Is there a competent, willing and acceptable caregiver? Assess care giver burden/burnout Identify patients at risk for skilled nursing facility placement Anticipate post-hospital needs such as medical equipment, oxygen and home care services

Geriatrics 37 Drug Therapy in the Elderly Prescription drug expenses make up ~ 7% of total health care spending in elderly 65% of Americans age 65+ use at least one prescription medication Elderly (65+) use 30% of Rx drugs and 40% of OTC drugs Elderly with drug coverage average-18 prescriptions per year Elderly in nursing homes receive an average of 7 different medications

Geriatrics 38 Pharmacokinetics: Absorption Physiologic change No significant change in gastric pH; decreased absorptive surface and splanchnic blood flow; generally preserved gastric emptying time Clinical significance Little to none

Geriatrics 39 Pharmacokinetics: Distribution Increased body fat Significance: Fat soluble drugs cross membranes more easily and spread widely (diazepam) Decreased lean body mass Significance: Water soluble drugs cross barriers less easily and are largely confined to lean body tissue (cimetidine, digoxin, ethanol)

Geriatrics 40 Pharmacokinetics: Distribution (Contd) Decreased serum albumin and lower protein binding Significance: Lower protein binding in elderly (theophylline, warfarin, cimetidine) Exception: lidocaine binds primarily to alpha-1-acid-glycoprotein and it shows higher binding in the elderly

Geriatrics 41 Pharmacokinetics: Hepatic Metabolism Physiologic change Decreased liver mass and hepatic blood flow Clinical significance Phase 1 reactions altered (oxidation, reduction, hydrolysis) Phase 2 reactions (conjugation) not significantly affected

Geriatrics 42 Pharmacokinetics: Renal Elimination Physiologic change Creatinine clearance reduced with aging or disease Clinical significance Dose adjustments required for drugs predominantly excreted by the kidneys (digoxin, LMWH)

Geriatrics 43 Contributors to Noncompliance in Older Adults Complex treatment regimens and dosing schedules Medication side effects Physical disability (dysphagia, arthritis) Cognitive impairment Poor communication Inadequate understanding of therapy High cost of medications

Geriatrics 44 Contributors to Polypharmacy Patient Borrowing or sharing medications Failing to understand instructions Saving medication for later use Combining Rxs with OTCs and Herbals Visiting more than one physician Doctor Failing to review the patients medications Prescribing medications for common and non-life threatening symptoms Treating multiple symptoms or illnesses with several drugs

Geriatrics 45 Principles of Appropriate Drug Prescribing Be alert to the possibility of drug interactions and adverse drug reactions Consider efficacy, cost (generic vs. brand), and ease of administration Avoid using multiple drugs with similar actions and toxicity Do not prescribe drugs longer than necessary; discontinue if no longer indicated

Geriatrics 46 Principles of Appropriate Drug Prescribing (Contd) Keep the drug regimen simpleonce or twice daily dosing Be aware that patients may visit other prescibers Initiate therapy with the lowest recommended dose and increase slowly (Start low, go slow) Justify the use of each drugwhat is the active problem you are treating?? Understand the pharmacokinetics and pharmacodynamics of drugs prescribed

Geriatrics 47 Principles of Appropriate Drug Prescribing (Contd) Psychotropic drugs (all of them) and cardiovascular drugs (all of them) cause undesirable side effects. Use them with caution Review all meds at each patient visit (brown bag test) including indications and dosing Ask about the use of OTCs and herbals Involve the patient in decision making and maintain open communication Encourage the patient to report any new or unusual symptoms

Geriatrics 48 Goals of Geriatric Assessment Improve diagnostic accuracy Define functional impairment Limit iatrogenesis Prevent cascade of disasters Recommend optimal living situation Predict outcomes Monitor clinical change over time

Geriatrics 49 Data-Gathering Listen to patient but verify with competent observers May be very time intensive--use two or more sessions if necessary Chief complaint may be misleading Medication history is pivotalbrown bag Tailor the review of systems Family history often unhelpful Always seek data regarding functional abilities

Geriatrics 50 Review of Systems/(Function) Appetite/weight change Fatigue Falling/gait/balance Sleep Depression Hearing/visual loss Alcohol use Joint pain, stiffness, ROM Cough/Dyspnea Constipation/laxativ e use or abuse Incontinence Frequency/Nocturia Memory loss/confusion Headache Transient weakness or visual symptoms (TIAs)

Geriatrics 51 Areas of Assessment Functional assessment Mobility, gait and balance Sensory and Language impairments Continence Nutrition Cognitive/Behavior problems Depression Caregivers See Appendix A at End of Chapter

Geriatrics 52 Functional Assessment Activities of Daily Living (ADL): Feeding, dressing, ambulating, toileting, bathing, transfer, continence, grooming, communication Instrumental ADL (IADL): Cooking, cleaning, shopping, meal prep, telephone use, laundry, managing money, managing medications, ability to travel

Geriatrics 54 Mobility, Gait and Balance Get up and go test: rise from a sitting position with arms crossed, walk in a straight line for 15-20 feet, turn, return to chair and sit down Maintain standing balance when receiving a slight sternal nudge Bend down and reach as if to pick up an object Shoulder/hand function Feet: structural problems, neuropathy, proper foot wear

Geriatrics 55 Sensory Impairments Visual testing Read a sentence from the newspaper Pocket Snellen chart Diabetics need annual dilated eye exam by ophthalmologist Auditory Testing Assess hearing during history-taking Whisper words behind the back Finger Friction: rub your thumb and index finger in front of ear Formal audiometric evaluation

Geriatrics 56 Continence A hidden disease; you must ask Simple screening questions Office evaluation often adequate to make a major difference Incontinence section to follow

Geriatrics 57 Nutrition Assess any patient admitted to the hospital or nursing home Assess for weight change, anorexia, chewing or swallowing problems Questions about alcohol a MUST (use CAGE) Low albumin and total cholesterol may be clues 2-3 day diet journal may be the most helpful screening tool Establish and record serial weights (minimum yearly) and heights (minimum Q3Y)

Geriatrics 58 Cognitive Problems Goals of cognitive screening Detect unsuspected mental impairment Provide baseline for future encounters Discover those at risk for delirium Provide concrete data for competency/decision-making opinions Dementia section to follow

Geriatrics 59 Depression Commonly missed Somatic complaints often predominate Many, many drugs should be suspected Suicide in elderly males is high Target your search: recent bereavement, psychosocial losses, dementia, functional impairment, severe illness or surgery Geriatric Depression Scale See Appendix B at End of Chapter

Geriatrics 60 Care Givers Lack of a willing or capable care giver is a prominent reason for ECF placement Is the care giver acceptable to the elder? Is the care giver evidencing burn-out? Is there evidence of elder abuse or neglect? Zarit Burden Interview is a short instrument that can introduce the topic of caregiver stress in a non-threatening way

Geriatrics 61 Putting it All Together: the Care Plan List all problems (physical, social, functional) List the strengths you find in the present situation and build on them Reduce the list to those problems that are out of control and/or you can remedy Treat acute medical problems with appropriate aggressiveness Manage chronic problemscontrol, not cure Address routine health maintenance Do the medications relate 1:1 to an active problem?

Geriatrics 62 What functional problems are most amenable to intervention? Is there evidence of chronic uncontrolled pain? Is there evidence of dementia or depression? Treat it Are there any geriatric syndromes to address? Is the living situation appropriate? Is there evidence of a willing, capable, appropriate and acceptable care giver? Would any community resources benefit the situation? The Care Plan (Contd)

Geriatrics 63 Mistreatment of Elders Elder abuse shall mean an act or omission which results in harm or threatened harm to the health or welfare of an elderly person. Abuse includes intentional infliction of physical or mental injury; sexual abuse; or withholding of necessary food, clothing and medical care to meet the physical and mental needs of an elderly person by one having the care, custody or responsibility of an elderly person

Geriatrics 64 Types of Abuse and Neglect Physical abuse: Intentional infliction of physical discomfort, pain or injury Hitting, slapping, inappropriate use of restraints, sexual assault Psychological abuse: Intentional infliction of mental anguish or provocation of fear of violence or isolation Name-calling, chronic verbal aggression, intimidation, threats of institutionalization, withholding security and affection, withholding contact with family or friends

Geriatrics 65 Types of Abuse and Neglect (Contd) Material abuse: misappropriation or misuse of funds or possessions Fraud, theft, extortion/use of undo influence to persuade elderly to relinquish control, use or ownership of funds or possessions Neglect: withholding of physical, material, or emotional necessities of physical and mental health whether intentionally or unintentionally

Geriatrics 66 Risk Factors for Maltreatment Female, living alone, over age 75 Poor health/functional status Cognitive impairment Abuser suffers substance abuse/mental illness Dependence of abuser on victim (such as shared living arrangements) Elders needs exceed caregivers abilities Social isolation History of family violence/antisocial behavior

Geriatrics 67 Presentations Suggesting Abuse Delay between injury/illness and seeking care Disparity in history from patient and suspect Implausible or vague explanations provided by either party Frequent visits to the ER for exacerbations of chronic disease despite a plan for medical care and apparently adequate resources

Geriatrics 68 Presentations Suggesting Abuse (Contd) Numerous injuries at various stages of healing Elder presents with poor nutrition, hygiene, or misses appointments Presentation of impaired elder without a caregiver

Geriatrics 69 Abuse/Neglect Indicators No food, or rotten food in the house Clothes extremely dirty or uncared for Not dressed appropriately for the weather Utilities cut off Gross accumulation of garbage, papers and clutter Signs checks over to others; out of money by second week of the month

Geriatrics 70 Abuse/Neglect Indicators (Contd) Swollen eyes or ankles, decayed teeth or no teeth Bites, fleas, sores, lacerations Untreated pressure sores Broken glasses frames or lenses Medication non-compliance Refusal to accept presence of visitors Unjustified pride in self-sufficiency Vague health complaints

Geriatrics 71 AMA Proposed Screening Questions Has anyone at home ever hurt you? Has anyone ever touched you without your consent? Has anyone ever made you do things you didnt want to do? Has anyone taken anything that was yours without asking? Has anyone ever scolded or threatened you?

Geriatrics 72 Have you ever signed any documents that you didnt understand? Are you afraid of anyone at home? Are you alone a lot? Has anyone ever failed to help you take care of yourself when you needed help? AMA Proposed Screening Questions (Contd)

Geriatrics 73 Documentation is Essential Use quotations or verbatim comments made by the patient in describing an event or situation Detail descriptions of all injuries, using body charts and/or color photographs

Geriatrics 74 Management of Confirmed Mistreatment Two pivotal questions: Does the patient accept or refuse intervention? Does the patient retain decision-making capacity?

Geriatrics 75 Intervention Currently there is no therapy of choice Many victims refuse help Victims often deny abuse Most elderly persons would rather receive inadequate care living with their family than excellent care in an institution Do not attempt or initiate individual heroic rescues

Geriatrics 76 Intervention (Contd) Hospitalize if emergency intervention is required Report incident to Adult Protective Services Decompress the situation: Adult day care, respite housing, counseling, support groups Legal aid Home Health Assistance

Geriatrics 77 Medical Care in the Nursing Home Skilled nursing beds: 1.5-2 million in US 5% of those over 65 live in a NH 45% of NH residents are over age 85 75% of NH residents are female 60% have moderate-to-severe dementia 50% admitted to NH die there Cost: $20-45K per patient per year

Geriatrics 78 Types of NH Residents Short-stayers: 1-6 months Terminally ill Short term rehabilitation Debilitated post-acute care hospitalization Long-stayers: 6 months to years Primarily cognitively impaired Significant impairments of both cognitive and physical functioning Primarily physically impaired

Geriatrics 79 Factors Precipitating NH Placement Care requirements exceed the ability of care giver Behaviors due to dementia: nocturnal wandering, aggressive behavior,etc Bed bound status requiring total ADL support Bowel and/or bladder incontinence Recurrent falling Insufficient financial resources to maintain help at home

Geriatrics 80 Falling: A Geriatric Syndrome 30% of persons 65+ fall at home each year 50% of persons 80+ fall at home each year 66% of fallers will fall again in six months If an elder is hospitalized due to a fall, only 50% will be alive in a year Falls are common in the hospitalized, most on the night of admission Falls result in 250,000 hip fractures per year

Geriatrics 81 Complications of Falls Medical Fractures Subdural hematoma Sprains, bruises, hematomas, lacerations Psychological FFF (3F syndrome): Fear of further falling: Decreased confidence isolation and withdrawal depression reluctance to go outdoors

Geriatrics 82 Complications of Falls (Contd) Social Loss of independence Risk of nursing home placement Increased immobilization Further loss of muscle tone and strength DVT/pulmonary embolism Hypothermia Dehydration Osteoporosis Pulmonary infections

Geriatrics 83 Medical Risk Factors for Falls Poor vision: cataracts, glaucoma,macular degeneration CV: postural hypotension, syncope, arrhythmias, drop attacks Lower extremity dysfunction: arthritis, weakness, foot problems, peripheral neuropathy Gait and Balance: CVA, Parkinsons, myelopathy, cerebellar disorders

Geriatrics 84 Types of Falls: Intrinsic vs. Extrinsic Intrinsic factors: Changes in postural control: Decreased proprioception, righting reflexes, muscle tone and strength; increased postural sway Decreased foot swing height, slower gait Decreased depth perception, clarity, dark adaptation, color sensitivity, visual fields; Increased sensitivity to glare

Geriatrics 85 Types of Falls (Contd) Extrinsic factors Poor lighting Objects on the floor (clutter, pets, throw rugs) Unstable furniture Poor or absent railings Low beds or low toilet seats

Geriatrics 86 Take a Fall History Inquire about the circumstances of the fall Inquire about injuries or loss of continence Medication history Are there any risk factors?

Geriatrics 87 Fall-Related Physical Exam Vital signs (postural blood pressure) Assess mobility: Get-up-and-go test MMSE Visual exam Cardiac evaluation Neurologic evaluation Musculoskeletal (including feet) exam

Geriatrics 88 Management and Prevention of Falls Treat immediate medical problems Assess and alter environment as necessary Attempt to modify any risk factors Consider rehab (strengthening exercises) Prescribe assistive devices, if necessary Teach patient how to get up if they do fall Consider a personal emergency response system (Help, Ive fallen..) Hip protectors reduce fracture incidence by 50%

Geriatrics 89 Urinary Incontinence: A Geriatric Syndrome The involuntary loss of urine sufficient in amount or frequency to be a social or health problem. Urinary incontinence (UI) is a symptom, not a specific disease

Geriatrics 90 UI: Prevalence 15-30% in community dwelling elders (only half report so this is an estimate) 30-35% of elderly in acute care hospitals 50% of those living in nursing homes UI is never a normal part of aging, despite ubiquitous advertising for absorbents

Geriatrics 91 UI: Risk Factors Females 2:1 Age Parity Dementia Polypharmacy UI is independently and positively associated with poor self-rated health

Geriatrics 92 Basic Bladder Anatomy and Physiology Functionally, urinary incontinence is due to: Failure to store urine (because of bladder OR because of the urethra) Failure to empty urine (because of bladder OR because of the urethra)

Geriatrics 93 Physiology Emptying the bladder involves stimulation of cholinergic receptors and inhibition of alpha and beta adrenergic receptors Filling the bladder involves inhibition of cholinergic receptors and stimulation of adrenergic receptors Stimulation of alpha adrenergic receptors increases sphincter and urethral tone, and inhibition decreases it

Geriatrics 94 Causes of Transient UI- DIAPERS D: Delirium/confusional states I: InfectionUTIs A: Atrophic urethritis/vaginitis P: Pharmaceuticals (hypnotics, diuretics, anticholinergics, alpha-adrenergic agents, calcium channel blockers) P: Psychological E: Excessive urine production R: Restricted mobility S: Stool impaction

Geriatrics 95 General Principles of Diagnosing UI Basic history and physical Urinalysis PVR (post-void residual) determination Voiding diary Labs: BUN, Cr, Glucose, Ca++ Imaging tests Urodynamic and endoscopic tests rarely needed to diagnose

Geriatrics 96 Types of UI Stress (Urethral insufficiency) Overflow Urge (Detrusor instability) Functional Involuntary loss of urine, usually small amounts with increased intra- abdominal pressures Leakage of small amts. resulting from mechanical forces on an overdis- tended bladder Leakage, usually large amts, due to inability to delay voiding after sensation of fullness Urine loss due to inability to toilet; impaired cognition or physical functioning Environmental barriers

Geriatrics 97 Symptoms Stress Functional UrgeOverflow Urine loss with coughing, sneezing, etc. Loss of small amts of urine. PVR > 100 cc Sudden urge to urinate. Loss of moderate amts. PVR < 100 cc Loss of small to large amounts PVR minimal

Geriatrics 98 Cystometric Findings StressFunctionalUrgeOverflow Normal Little or no detrusor contractions despite high bladder volume Involuntary detrusor contractions that can not be suppressed Normal

Geriatrics 99 Common Causes Obesity, laxity of pelvic floor, spondylosis Peripheral (pudendal) neuropathy Post-radiation Outlet obstruction (BPH, fecal impaction), urethral stricture, anticholin-ergic meds, diabetic neuropahy, multiple sclerosis Local GU conditions (UTI, stones, diverticuli), decreased cortical inhibition (CVA, dementia, Parkinsons tumor) Physical restraints, dementia, sedative use, diruetics, arthritis, muscular weakness, cluttered home, poor lighting, neglect of bedbound StressFunctionalUrgeOverflow

Geriatrics 100 Kegels, weight loss, various surgical proceduresest rogens, alpha- adrenergic agents; pessaries Primary Treatments TURP, intermittent cath; timed voidings; trial of cholinergic drugs; trial of alpha-blocker agents; urologic referral Bladder training; scheduled toileting; trial of antispas-modics; Kegel exercises Remove or replace offending drugs; improve patient mobility; night-time urinal or bed side commode; scheduled toileting StressFunctionalUrgeOverflow

Geriatrics 101 Delirium An acute confusional state Transient reduction in the clarity of awareness of the environment Fluctuating level of consciousness A syndrome, usually referable to an underlying disease process

Geriatrics 102 Risk Factors for Delirium in Hospitalized Four strong predictors of delirium Age > 80 Prior cognitive impairment Fracture on admission Institutionalization prior to admission Other predictors: Systemic infection, narcotic or neuroleptic use

Geriatrics 103 Causes of Delirium Organ Failure Respiratory failure Congestive heart failure Hepatocellular failure Infections Acute bronchitis/Bronchopneumonia Bladder infection Septicemia Metabolic Dehydration Hypo/hypernatremia Hypoxia, uremia, hypo/hyperglycemia

Geriatrics 104 Causes of Delirium (Contd) Drugs: ANY, ANYTHING NEWLY ADDED Anticholinergics (including anticholinergic antidepressants, and antihistamines) Antibiotics Narcotics Neuroleptics Anticonvulsants Digoxin & other antiarrhythmics Alcohol/alcohol withdrawal

Geriatrics 105 Causes of Delirium (Contd) Neurologic causes Subdural hematoma CVA Cerebral infections Raised intracranial pressure Miscellaneous Postoperative delirium Sensory deprivation Recent institutionalization Change of living arrangement

Geriatrics 106 Assessment of Delirium History Prior functional status: ADLs/IADLs Alcohol use: they wont tell you Prior cognitive function Time course of changes in consciousness Medications used, both RX and OTC Physical examination Neurologic examination (including mental status) Rectal (fecal impaction)

Geriatrics 107 Assessment/Treatment (Contd) Initial labs Chem profile CBC w. diff UA CXR EKG Pulse ox or ABGs Serum albumin Consider Ammonia level Blood/urine cultures CT/ MRI of head Drug levels Serum/urine drug screens (alcohol) Thyroid function PVR urine CSF exam Folate/B12 levels

Geriatrics 108 Dementia Memory impairment Cognitive impairment as evidenced by one of the following: aphasia, apraxia, agnosia, disturbance in executive functioning The cognitive deficit causes significant impairment in social or occupational functioning Does not occur exclusively during the course of delirium

Geriatrics 109 Types of Dementia Alzheimers disease (AD)-- > 60% Vascular (multi-infarct) dementia-- 15- 20% Mixed dementia: AD + vascular features All others rare: AIDS, Parkinsons, Lewy-body dementia, Downs syndrome Reversible dementias: depression, thyroid disease, vitamin deficiency, infections, normal pressure hydrocephalus

Geriatrics 110 Alzheimers Disease Pathologically deposits of plaques (amyloid) and neurofibrillary tangles (tau protein) Average time between diagnosis and death: 10 years Early: personality changes, irritability, anxiety, depression Late: 50% develop agitation, delusions, hallucinations, or paranoia

Geriatrics 111 Vascular Dementia Dementia is present Two or more of the following are present: Focal neurological signs on physical exam Onset was abrupt, step-wise or stroke- related Brain imaging shows multiple strokes Diagnosis requires presence of cardiovascular disease, dementia and a definite temporal relationship between the two

Geriatrics 112 Lewy Body Dementia Dementia present Two of the following core features: Fluctuating cognition with pronounced variation in attention and alertness Recurrent well-formed visual hallucination Spontaneous motor features of Parkinsonism Supportive features: repeated falls, syncope, transient LOC, neuroleptic sensitivity, systematized delusions

Geriatrics 113 Reversible Dementias Chronic infections Chronic heart failure Chronic obstructive pulmonary disease Drug-induced cognitive impairment Thyroid disease Normal pressure hydrocephalus (cognitive impairment, gait disturbance and urinary incontinence) Alcohol related dementia Vitamin B12 deficiency

Geriatrics 114 Depression vs. Dementia Depression can look like dementia (pseudodementia) Duration is weeks to months, not months to years Islands of recent and long term memory loss Language preserved History of depression usually positive Responds to questions with I dont know Patients impression of disability: exaggerated Screen with Yesavage Geriatric Depression Scale

Geriatrics 115 Diagnostic Tools Focused medical and family history Physical examination and laboratory tests Functional status examination Mental status examinations Assessment for Depression Brain scans (CT or MRI) Neuropsychological testing usually not needed

Geriatrics 116 Common Laboratory Tests: Rule Out Reversible Causes CBC Comprehensive chemistry profile Thyroid function tests Vitamin B12 & Folic acid ESR VDRL HIV if high risk

Geriatrics 117 Mental Status Screening Tests Mini Mental Status Exam (Folstein) Considered the gold standard screen Maximum score of 30, cut-off of 21-23 for dementia Requires verbal and written responses No time limit Reproducible over time Specificity goes down, sensitivity rises with higher educational levels

Geriatrics 118 Mental Status Screening Tests (Contd) CAST: Cognitive Assessment Screening Test (AFP 54: 1957-62) Written, self-administered test No time limit Set Test Category fluency: name 10 colors, towns, fruits, animals 80% of demented score less than 15/40 Considered a measure of executive,i.e., frontal lobe functioning

Geriatrics 119 Mental Status Screening Tests (Contd) Clock Drawing Person is presented a paper with a 4-6 circle drawn and is asked to write the numbers and draw hands of a clock to show 10 past 11 Use as a qualitative, not quantitative screen Yesavage Geriatric Depression Screen Previously described

Geriatrics 120 Dementia Management (YES, Dementia is Treatable) Maximize function and independence Maintain safe and secure environment Maintain adequate nutrition and hydration Enhance cognition (medications available) Treat mood and behavior problems Educate/support care givers Expect regular physician office visits

Geriatrics 121 Cholinesterase Inhibitors Widespread use and multiple trials confirm that these drugs offer a plateau in functional decline and positively influence behavioral manifestations Cognitive decline is postponed, but these drugs do not influence neuronal decline All patients in whom AD is clinically confirmed and categorized as mild to moderate should be offered a long term therapeutic trial Probably help vascular and Lewy body dementia too, though not labeled

Geriatrics 122 Cholinesterase Inhibitors (Contd) Donepezil: (Aricept) HS dosing, 5-10 mg., metabolized by P-450 system Rivastigmine: (Exelon) 1.5-6 mg BID with meals; available in liquid form Galantamine: (Reminyl) 4-12 mg BID with food; avoid with hepatic impairment

Geriatrics 123 Other Non-Traditional Drugs Antioxidants (Vitamin E) & Ginkgo Biloba extract: benefit supported by a single clinical trial NSAIDs and estrogen replacement therapy: benefit supported by epidemiologic evidence but not confirmed by prospective trials

Geriatrics 124 Behavioral Modifications Create a predictable schedule: active day, quiet night Maintain a familiar, calm environment Foster reminiscence: photos, music, objects Keep life simple; reduce choices Match activities to capabilities and preferences Avoid overwhelming situations (family reunions) and challenges (shopping) Learn dementia speak: dont reason or argue with a demented person

Geriatrics 125 Drug Therapy for Behaviors: The Last Resort Behavior must present clear danger to self or others Behavior prevents necessary care (feeding, hygiene, wound care) Discuss indications in progress notes and with patient advocate Use time-limited medication trials Antipsychotics, benzodiazepines,mood stabilizers

Geriatrics 126 End Stage Care Palliative management of medical problems Focus on quality of life Be firm about aggressive medical interventionsthese are rarely indicated Institute and follow DNR instructions

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