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Geriatrics

Geriatrics. Dan Cushman. Urinary Incontinence. Urinary Incontinence. Not a normal part of aging Definition: Involuntary loss of urine, severe enough to cause social and/or health problems To be continent, one needs to have: Properly functioning lower urinary tract

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Geriatrics

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  1. Geriatrics Dan Cushman Dan Cushman 2010

  2. Urinary Incontinence Dan Cushman 2010

  3. Urinary Incontinence • Not a normal part of aging • Definition: Involuntary loss of urine, severe enough to cause social and/or health problems • To be continent, one needs to have: • Properly functioning lower urinary tract • Proper mobility & dexterity with motivation • An appropriate environment Normal/Not Normal? Voluntary? 3 Items Dan Cushman 2010

  4. The 4 Basic Causes • Urologic • Neurologic • Functional/Psychological • Iatrogenic/Environmental They can be mixed! Dan Cushman 2010

  5. Overactive Bladder • Definition: a strong and sudden desire to urinate • A type of urge incontinence • It is possible to see OAB without (urge) incontinence though ?? Dan Cushman 2010

  6. Overactive Bladder • Not to be confused with overactive adder • A good history and physical is key in the differentiation of the two BLADDER ADDER Dan Cushman 2010

  7. Anatomy Detrusor Trigone Internal sphincter External sphincter Dan Cushman 2010

  8. Sympathetic system • Travels via hypogastric nerve • Has alpha and beta receptors • Uses Norepinephrine • Facilitates bladder filling Dan Cushman 2010

  9. Somatic fibers • Travel via pudendal nerve • Uses Acetylcholine • Increased tone during filling phase • Prevents outflow of urine Dan Cushman 2010

  10. Parasympathetic system • Travels via pelvic nerve • Acetylcholine, acting on muscarinic receptors • Causes bladder emptying • Increased tone during emptying phase Dan Cushman 2010

  11. Pick the system! Characteristic Somatic/Sympathetic/Parasympathetic Pudendal nerve Hypogastric nerve Pelvic nerve Acetycholine NE Facilitates bladder filling Increased tone during emptying phase Somatic Sympathetic Parasympathetic Parasymp. + somatic Sympathetic Symp. + somatic Parasympathetic Dan Cushman 2010

  12. Urinary reflex • Urination is a reflex that can be inhibited by higher brain centers. • Sacral micturation center is a parasympathetic reflex arc • Desire to void between 150mL and 300mL Dan Cushman 2010

  13. Age-related Changes Often idiopathic, can be caused by stroke, dementia, PD, SCI, or irritation of bladder • Bladder overactivity • Detrusor hyperactivity with impaired contractility • Urethral sphincter • Pelvic floor weakness • Cystocele • Atrophic vaginitis • BPH/Prostate Cancer DHIC – urgency, hesitancy, straining, weak urinary stream, feelings of incomplete emptying Think urgency or stress incontinence; can be caused by childbirth, surgery, or loss of estrogen Urgency, pelvic organ prolapse Urgency, difficulty voiding, and urinary retention Can manifest as urgency, with symptoms of OAB Voiding difficulty, symptoms of OAB; increased sensitivity to endogenous acetylcholine Dan Cushman 2010

  14. Acute Causes of UI • D • R • I • P • elirium • estricted mobility and retention • nfection, inflammation, and impaction • olyuria & pharmaceuticals Psychotropics Anticholinergics Narcotics Diuretics Anti-Cholinesterases Alpha agonists Alpha antagonists ACEI, NSAIDs, CCBs, All potentially reversible Dan Cushman 2010

  15. Persistent Causes of UI Loss of small amounts of urine, due to intraabdominal pressure; unusual in men • Stress • Urge • Functional • Overflow Variable amount of urine loss Mobility problems or functional impairment Loss of small amounts of urine, due to overdistended bladder Dan Cushman 2010

  16. First 2 questions of the history… • “Tell me about the symptoms you are having” • “What are your expectations from the assessment and treatment?” Dan Cushman 2010

  17. Urinary Tract Symptoms • Bladder storage difficulty or overactive bladder (urinary freq, urgency, nocturia) • Bladder emptying difficulty (hesitancy, slow stream, straining, incomplete emptying) • Stress incontinence (leakage with cough) • Leakage without warning • Other symptoms (dysuria, hematuria, suprapubic discomfort) Dan Cushman 2010

  18. Past GU History • Childbirth • Surgery • Urinary retention • Recurrent UTIs (>= 2 in past year) • Treatment • Response • Why no longer using it Dan Cushman 2010

  19. Fluid Intake Pattern • Type and amount of fluid • Caffeine • Alcohol Dan Cushman 2010

  20. Beer’s List Dan Cushman 2010

  21. Side Effects • Sedation + Increased risk of falls • Sedation + anticholinergic • CNS toxic reactions • Confusion + sedation + anticholinergic • Anticholinergic • Anticholinergic • Confusion Long-acting benzodiazepenes TCAs Indomethacin Antihistamines Muscle Relaxants GI anti-spasmodics (Dicyclomine, hyoscyamine, propantheline) Meperidine Dan Cushman 2010

  22. Side Effects • Peptic ulcer disease • CNS stimulation + angina + HTN + MI • Renal failure + GI bleeding + HTN + CHF • Insomnia + agitation (long t1/2) • Exacerbation of bowel dysfunction • Renal impairment • Hypotension + dry mouth Ketorolac Amphetamines NSAIDs (Naproxen, oxaprozin, piroxicam) Fluoxetine Stimulant laxatives (bisacodyl, cascara sagrada, neoloid) Nitrofurantoin Doxazosin Dan Cushman 2010

  23. Side Effects • CNS + extrapyramidal effects • Hypotension + constipation • Hypotension + CNS side effects • Aspiration • Confusion + delirium • Goggles (extremely dangerous in NH setting) Thioridazine Short-acting nifedipine (procardia and adalat) Clonidine Mineral oil Cimetidine Beer Dan Cushman 2010

  24. Avoid which medications…? • Pseudoephedrine, amphetamines • NSAIDs • Clozapine, chlorpromazine, thioridazine • ASA, NSAIDs, Clopidogrel, Dipyradimole • Anticholinergic drugs • Alpha blockers, TCAs, long-acting benzos • TCAs HTN Ulcers Seizure disorders Disorders of blood clotting  ↑ bleeding Bladder outflow obstruction Stress incontinence Arrhythmias Dan Cushman 2010

  25. Avoid which medications…? • Decongestants, MAOIs, amphetamines • Metoclopramide, conventional antipsychotics • Anticholinergics, muscle relaxants, stimulants • Long-term benzos, sympatholytics • CNS stimulants, fluoxetine • Benzos, TCAs, SSRIs • SSRIs Insomnia Parkinson’s Disease Cognitive Impairment Depression Anorexia & malnutrition Syncope or falls SAIDH/hyponatremia Dan Cushman 2010

  26. Avoid which medications…? • Buproprion • Olanzapine • CCBs, anticholinergics, TCAs • Thiazide diuretics • Loop diuretics Seizure disorder Obesity Chronic constipation Hyponatremia Patients at risk for dehydration Dan Cushman 2010

  27. Main anticholinergic drugs (6) • Muscle relaxants • Urinary antispasmodics • Scopolamine/Atropine • COPD (e.g. ipratropium) • Antihistamines • TCAs Dan Cushman 2010

  28. Polypharmacy Remember the active metabolites! Which benzo has a t1/2 of up to 1 week? Diazepam (Valium) What is bad about geriatric use of fluoxetine (Prozac)? Long t1/2, lots of side effects Which geriatric syndrome is caused by SSRI use? Falls (as many as with TCAs!) How ball can cat eat red meat? Delirium Dan Cushman 2010

  29. Geriatric Domains Dan Cushman 2010

  30. 4 Geriatric Domains Dan Cushman 2010

  31. Psychological Domain Mood disorders Cognitive disorders Depression Dementia Anxiety Delirium Dan Cushman 2010

  32. Functional Domain ADLs IADLs Transfers Telephone Dressing Transportation Feeding Cooking Toileting Shopping Showering Housework Medicines Manage $$ Dan Cushman 2010

  33. Geriatric Depression Scale • 3 ± 2 (1-5) • 7 ± 3 (4-10) • 12 ± 2 (10-14) • Not diagnostic Normal score Mildly depressed score Very depressed score Is a score of 12 diagnostic of depression? Dan Cushman 2010

  34. Pain Management Dan Cushman 2010

  35. Non-pharmacologic analgesics • Heat/Cold • Physical therapy/exercise • Emotional support / biofeedback • Change in position / improvement in body mechanics • Relieve pressure points • Use of pillows / foam pads to support painful sites, e.g., limbs • Comfortable clothing • Care in assistance with moving the person • Distraction / Redirection • Alternative therapies Dan Cushman 2010

  36. Medication choice principles • Pattern of pain • Avoid toxicity • Consider added benefits • Route of administration & patient-specific factors Dan Cushman 2010

  37. WHO Pain Ladder Pain level (1-10)? Medication? Pain level (1-10)? Medication? Pain level (1-10)? Medication? Dan Cushman 2010

  38. Pain relievers – which class of pain? Moderate • Hydrocodone • Hydromorphone • Acetaminophen • Oxycodone • Codeine • Morphine • Fentanyl Severe Mild Moderate or Severe Moderate Severe Severe Dan Cushman 2010

  39. 3 NSAID contraindications • Abnormal renal function • Peptic ulcer disease • Bleeding diathesis Dan Cushman 2010

  40. Adverse effects of opioids (7) • Constipation • Sedation including respiratory depression • Impaired cognitive performance (including delirium) • Falls • Nausea and vomiting • Pruritus • Myoclonus Which symptom usually does not resolve when opioid levels reach steady state? Dan Cushman 2010

  41. Bonus Constipation Question!!!! Why do opioids cause constipation? They bind to mu receptors in the intestinal tract Dan Cushman 2010

  42. Opioid Guidelines What % of the daily dose is the breakthrough dose? 10% If pain is not controlled, increase opioid by what %? 25-50% Do what if the patient develops N/V? Give anti-emetic 1mg IV morphine = ?mg PO morphine 3mg Morphine + VA Nursing home = ? Bore-phine I will also accept “still not enough pain control” I will also accept “a very powerful sedative” Dan Cushman 2010

  43. End-of-Life Care Dan Cushman 2010

  44. Most important part of breaking bad news • Don’t be an asshole Dan Cushman 2010

  45. SPIKES • S • P • I • K • E • S • etting up the interview • erception (of the patient) • nvitation • nowledge • mpathy / Emotions • trategy & summary Little known fact: People who use mnemonics to try and appear empathic never appear empathic, especially when they mouth “Perception” for the P. Dan Cushman 2010

  46. CLASS • C • L • A • S • S • ontext • istening skills • cknowledgement of patient’s emotions • trategy for clinical management • ummary Little known fact: the CLASS protocol was created by a professor in an academic institution. Dan Cushman 2010

  47. Steps of death pronouncement • Identify patient by tag • No response to verbal or tactile stimuli • Absence of heart sounds & pulse • Listen for respirations • Pupil location + absence of pupillary light reflex Little known fact: It is actually not OK to perform any testicle twisting during the death pronouncement. This is a common intern mistake. Dan Cushman 2010

  48. Which stage of dying? Early • Bed-bound • Coma • Loss of ability to eat/drink • Fever • Death Rattle • Altered respirations • Increasing time sleeping Late Early Late Mid Late Early Dan Cushman 2010

  49. Put the following in the correct order of occurrence • Death rattle • Cyanosis • Lack of radial pulse • Respiration with mandibular movement First Third Fourth Second Dan Cushman 2010

  50. Put the following in the correct order of loss before dying 3 • Speech • Hearing • Touch • Vision • Thirst • Hunger 5 6 4 2 1 Dan Cushman 2010

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