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Myriam Edwards MD

Geriatric Syndromes: Memory Problems, Depression, Falls, and Urine Leakage Functional Assessment of the Older Adult II. Myriam Edwards MD Geriatrician, Assistant Professor, and Geriatric Medicine Fellowship Program Director Hurley Medical Center / Michigan State University.

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Myriam Edwards MD

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  1. Geriatric Syndromes: Memory Problems, Depression, Falls, and Urine LeakageFunctional Assessment of the Older Adult II Myriam Edwards MD Geriatrician, Assistant Professor, andGeriatric Medicine Fellowship Program Director Hurley Medical Center / Michigan State University Geriatric Education Center of Michigan

  2. Geriatric Education Center of Michigan activities are supported by a grant from the U.S. Department of Health and Human Services, Health Resources and Services Administration, Public Health Service Act, Title VII, Section 753(a). This module was developed by Mark Ensberg, MD Geriatric Education Center Michigan State University

  3. Quality of Life

  4. Geriatric syndromes • Groups of specific signs & symptoms that occur more often in elderly • Can impact morbidity & mortality • Contributing factors: • Normal aging changes • Multiple comorbidities • Adverse effects of therapeutic interventions

  5. Resources: Memory Impairment www.alz.org www.worriedaboutmemoryloss.com www.dementiacoalition.org

  6. Screening for Depression

  7. How can clinical presentation differ in older adults? • Masked depression • Denial of sadness • Anxiety • Somatic Symptoms • Multiple other medical conditions • Depression and Memory Impairment

  8. DSM IV – Major Depression Sad mood Loss of Interest or pleasure –anhedonia Feelings of Guilt / worthlessness / burden Loss of Energy, fatigue Trouble Concentrating / making decisions Changes in Appetite (weight gain or loss) Restless, Psychomotor agitation or slowing Sleep changes Suicidal Ideation-thought of death

  9. EPIDEMIOLOGY AMONG OLDER ADULTS • Minor depression • 15% of older people • Causes  use of health services, excess disability, and poor health outcomes, including  mortality • Major depression • 6%–10% of older adults in primary care clinics • 12%–20% of nursing home residents • 11%–45% of hospitalized older adults • Bipolar disorder • Common diagnosis among aged psychiatric patients • Does not “burn out” in old age

  10. DIAGNOSIS IN OLDER PATIENTS IS DIFFICULT BECAUSE THEY . . . • More often report somatic symptoms • Less often report depressed mood, guilt • May present with “masked” depression cloaked in preoccupation with physical concerns and complicated by overlap of physical and emotional symptoms

  11. DSM-IV DIAGNOSTIC CRITERIA FOR MAJOR DEPRESSION • Gateway symptoms (must have 1) • Depressed mood • Loss of interest or pleasure (anhedonia) • Other symptoms • Appetite change or weight loss • Insomnia or hypersomnia • Psychomotor agitation or retardation • Loss of energy • Feelings of worthlessness or guilt • Difficulty concentrating, making decisions • Recurrent thoughts of suicide or death

  12. DIAGNOSTIC CHALLENGES IN MEDICAL SETTINGS • Symptoms of depressive and physical disorders often overlap, eg: • Disturbed sleep • Fatigue • Diminished appetite • Seriously ill or disabled people may focus on thoughts of death or worthlessness, but not suicide • Side effects of drugs for other illnesses may be confused with depressive symptoms

  13. CLINICAL COURSE IN MAJOR DEPRESSION • Recurrence, partial recovery, and chronicity . . .  disability  use of health care resources  morbidity and mortality suicide

  14. OLDER ADULTS AND SUICIDE • Older age associated with increasing risk of suicide • One fourth of all suicides occur in people  65 years • Risk factors: depression, physical illness, living alone, white male, alcoholism • Violent suicides (eg, firearms, hanging) are more common than non-violent methods among older adults, despite the potential for drug overdosing

  15. Falls • Ask & evaluate every patient! • Get Up and Go • Look for signs of injury

  16. Medi - CARE for Falls Medi - cations Chronic Risk Factors Acute (short term) Risk Factors Rehab (activity) Related Risk Environmental Risk

  17. GAIT IMPAIRMENT • Gait disorders are common and a predictor of functional decline • Certain gait-related mobility disorders progress with age and are associated with morbidity and mortality • Community-dwelling older adults with gait disorders, particularly neurologically abnormal gaits, are at higher risk of institutionalization and death Slide 18

  18. CONDITIONS CONTRIBUTING TO GAIT DISORDERS IN PRIMARY CARE SETTINGS • Degenerative joint disease • Acquired musculoskeletal deformities • Intermittent claudication • Impairments following orthopedic surgery • Impairments following stroke • Postural hypotension • Dementia • Fear of falling Usually multifactorial Slide 19

  19. GAIT ASSESSMENT: KEY POINTS • Careful medical history and physical exam can elucidate contributing factors • Use a gait assessment tool (eg, timed Get Up and Go test) • Establish person’s comfortable gait speed; use as both assessment and outcome measure • Remember that most gait disorders are associated with underlying disease Slide 20

  20. THE TIMED GET UP AND GO TEST (1 of 2) Record the time it takes a person to: • Rise from a hard-backed chair with arms • Walk 10 feet (3 meters) • Turn • Return to the chair • Sit down Slide 21

  21. THE TIMED GET UP AND GO TEST (2 of 2) • Most adults can complete in 10 sec • Most frail elderly adults can complete in 11 to 20 sec • ≥14 sec =  falls risk • >20 sec  comprehensive evaluation • Results are strongly associated with functional independence in ADLs Slide 22

  22. FALLS • Definition: coming to rest inadvertently on the ground or at a lower level • One of the most common geriatric syndromes • Most falls are not associated with syncope • Falls literature usually excludes falls associated with loss of consciousness Slide 23

  23. EPIDEMIOLOGY OF FALLS Each year 30%–40% of community-dwelling persons aged ≥65, and about 50% of residents of long-term- care facilities, experience falls Slide 24

  24. EPIDEMIOLOGY OF FALLS • Annual incidence of falls is close to 60% among those with history of falls • Complications of falls are the leading cause of death from injury in persons aged ≥65 Slide 25

  25. MORBIDITY AND MORTALITY • Most falls by older adults result in some injury • 10%–15% of falls by older adults result in fracture or other serious injury • The death rate attributable to falls increases with age • Mortality highest in white men aged ≥85: 180 deaths/100,000 population Slide 26

  26. SEQUELAE OF FALLS • Associated with: • Decline in functional status • Nursing home placement • Increased use of medical services • Fear of falling • Half of those who fall are unable to get up without help (“long lie”) • A “long lie” predicts lasting decline in functional status Slide 27

  27. COSTS OF FALLS •  Emergency department visits •  Hospitalizations • Indirect cost from fall-related injuries like hip fractures is substantial Slide 28

  28. CAUSES: INTRINSIC • Age-related decline • Changes in visual function • Proprioceptive system, vestibular system • Chronic disease • Parkinson’s disease • Osteoarthritis • Cognitive impairment • Acute illness • Medication use(see next slide) Slide 29

  29. CAUSES: MEDICATION USE • Specific classes, eg: • Benzodiazepines • Antidepressants • Antipsychotic drugs • Cardiac medications • Hypoglycemic agents • Recent medication dosage adjustments • Total number of medications Slide 30

  30. Ask about Urine Leakage Do you make it to the bathroom every time you have to go? • History • Brown Paper Bag Test (Med Review) • Bladder Log / Diary • (PVR / Bladder Scan)

  31. PREVALENCE OF UI • Affects 15%–30% of community-dwelling older adults • Affects 60%-70% of residents of long-term-care institutions • Prevalence increases with age • Affects more women than men (2:1) until age 80 (then 1:1)

  32. IMPACT OF UI ON OLDER ADULTS • Morbidity • Sleep deprivation, falls with fractures, sexual dysfunction • Depression, social withdrawal, impaired quality of life • Cellulitis, pressure ulcers, UTIs • Costs: >$26 billion annually

  33. IMPACT OF UI ON OLDER ADULTS • Morbidity • Cellulitis, pressure ulcers, UTIs • Sleep deprivation, falls with fractures, sexual dysfunction • Depression, social withdrawal, impaired quality of life • Costs: >$26 billion annually

  34. FACTORS CONTRIBUTING TO OR CAUSING UI IN OLDER PERSONS • Comorbid disease • Degenerative joint disease • Sleep apnea • Congestive heart failure • Severe constipation • Diabetes • Neurological/Psychiatric • Stroke • Parkinson’s disease • Normal pressure hydrocephalus • Dementias • Depression • Function and environment • Impaired cognition • Impaired mobility • Inaccessible toilets • Lack of caregivers

  35. MEDICATIONS THAT CAN CAUSE OR WORSEN UI • Alcohol • α-Adrenergic agonists • α-Adrenergic blockers • ACE inhibitors • Anticholinergics • Antipsychotics • Calcium-channel blockers • Cholinesterase inhibitors • Estrogen • GABAergic agents • Loop diuretics • Narcotic analgesics • NSAIDs • Sedative hypnotics • Thiazolidinediones • Tricyclic antidepressants

  36. Transient Incontinence Delirium Drugs Retention Restricted Mobility Infection Inflammation Impaction Polyuria Pharmaceuticals

  37. Persistent Incontinence • Urge • Stress • Overflow • Functional • Mixed

  38. URGE INCONTINENCE • Most common type of UI in older persons • Associated with uninhibited bladder contractions, called detrusor overactivity (DO) • Signs and symptoms: • Abrupt/compelling urgency, frequency, nocturia

  39. STRESS INCONTINENCE (1 of 2) • Second most common type in older women; postprotatectomy stress UI increasingly common in men • Occurs with increased intra-abdominal pressure, in the absence of a bladder contraction • Often coexists with urge UI (mixed UI)

  40. UI WITH IMPAIRED BLADDER EMPTYING • Results from detrusor underactivity, bladder outlet obstruction, or both • Leakage is small but continual; PVR is elevated • Symptoms: dribbling, weak urinary stream, intermittency, hesitancy, frequency, nocturia • Associated urge and stress leakage may occur

  41. OUTLET OBSTRUCTION • Second most common cause of UI in older men • Most obstructed men are not incontinent • Causes in men: BPH, prostate cancer, urethral stricture • Uncommon in women; usually due to previous anti-UI surgery or large cystocele

  42. MANAGEMENT OF UI: OVERVIEW • Goal: relieve the most bothersome aspect(s) • Stepped management strategy: Surgery Drugs Behavioral Lifestyle

  43. ADDRESSING COMORBIDAND LIFESTYLE FACTORS • Correct/address underlying medical illnesses, functional impairments, and medications that may contribute to UI • Weight loss for moderately obese • Manage fluid intake: avoid caffeine, alcohol; minimize evening intake • In smokers with stress UI: tobacco cessation

  44. BEHAVIORAL THERAPY • Bladder training and pelvic muscle exercise (PME):effective for urge, stress, and mixed UI • Prompted voiding:cognitively impaired patients

  45. SUMMARY (1 of 2) • Urinary incontinence is common in older adults & results in impaired quality of life, morbidity, and increased costs • Age-related changes & common disorders/impairments increase an older person’s risk of incontinence • Evaluation is based on history, physical, and focused laboratory testing

  46. SUMMARY (2 of 2) • Treatment is stepwise, starting with remediation of comorbid and lifestyle factors, progressing to behavioral therapy, medications, and, if necessary, surgery • Indwelling catheters should be used with caution, only when absolutely necessary

  47. Resources Falls Fuller, G. F. (2000). Falls in the elderly http://www.aafp.org/afp/20000401/2159.html Timed Get Up & Go Test http://www.hospitalmedicine.org/geriresource/toolbox/pdfs/get_up_and_go_test.pdf

  48. Resources Urine Leakage Urinary Incontinence Assessment in Older Adults Part I – Transient Urinary Incontinence http://www.hartfordign.org/publications/trythis/issue11-1.pdf Diagnostic Evaluation of Urinary Incontinence in Geriatric Patients http://www.aafp.org/afp/980600ap/weiss.html

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