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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

Geriatrics

Dan Cushman

Dan Cushman 2010


Urinary incontinence
Urinary Incontinence

Dan Cushman 2010


Urinary incontinence1
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


The 4 basic causes
The 4 Basic Causes

  • Urologic

  • Neurologic

  • Functional/Psychological

  • Iatrogenic/Environmental

They can be mixed!

Dan Cushman 2010


Overactive bladder
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


Overactive bladder1
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


Anatomy
Anatomy

Detrusor

Trigone

Internal sphincter

External sphincter

Dan Cushman 2010


Sympathetic system
Sympathetic system

  • Travels via hypogastric nerve

  • Has alpha and beta receptors

  • Uses Norepinephrine

  • Facilitates bladder filling

Dan Cushman 2010


Somatic fibers
Somatic fibers

  • Travel via pudendal nerve

  • Uses Acetylcholine

  • Increased tone during filling phase

  • Prevents outflow of urine

Dan Cushman 2010


Parasympathetic system
Parasympathetic system

  • Travels via pelvic nerve

  • Acetylcholine, acting on muscarinic receptors

  • Causes bladder emptying

  • Increased tone during emptying phase

Dan Cushman 2010


Pick the system
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


Urinary reflex
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


Age related changes
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


Acute causes of ui
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


Persistent causes of ui
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


First 2 questions of the history
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


Urinary tract symptoms
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


Past gu history
Past GU History

  • Childbirth

  • Surgery

  • Urinary retention

  • Recurrent UTIs (>= 2 in past year)

  • Treatment

  • Response

  • Why no longer using it

Dan Cushman 2010


Fluid intake pattern
Fluid Intake Pattern

  • Type and amount of fluid

  • Caffeine

  • Alcohol

Dan Cushman 2010


Beer s list
Beer’s List

Dan Cushman 2010


Side effects
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


Side effects1
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


Side effects2
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


Avoid which medications
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


Avoid which medications1
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


Avoid which medications2
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


Main anticholinergic drugs 6
Main anticholinergic drugs (6)

  • Muscle relaxants

  • Urinary antispasmodics

  • Scopolamine/Atropine

  • COPD (e.g. ipratropium)

  • Antihistamines

  • TCAs

Dan Cushman 2010


Polypharmacy
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


Geriatric domains
Geriatric Domains

Dan Cushman 2010


4 geriatric domains
4 Geriatric Domains

Dan Cushman 2010


Psychological domain
Psychological Domain

Mood

disorders

Cognitive disorders

Depression

Dementia

Anxiety

Delirium

Dan Cushman 2010


Functional domain
Functional Domain

ADLs

IADLs

Transfers

Telephone

Dressing

Transportation

Feeding

Cooking

Toileting

Shopping

Showering

Housework

Medicines

Manage $$

Dan Cushman 2010


Geriatric depression scale
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


Pain management
Pain Management

Dan Cushman 2010


Non pharmacologic analgesics
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


Medication choice principles
Medication choice principles

  • Pattern of pain

  • Avoid toxicity

  • Consider added benefits

  • Route of administration & patient-specific factors

Dan Cushman 2010


Who pain ladder
WHO Pain Ladder

Pain level (1-10)?

Medication?

Pain level (1-10)?

Medication?

Pain level (1-10)?

Medication?

Dan Cushman 2010


Pain relievers which class of pain
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


3 nsaid contraindications
3 NSAID contraindications

  • Abnormal renal function

  • Peptic ulcer disease

  • Bleeding diathesis

Dan Cushman 2010


Adverse effects of opioids 7
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


Bonus constipation question
Bonus Constipation Question!!!!

Why do opioids cause constipation?

They bind to mu receptors in the intestinal tract

Dan Cushman 2010


Opioid guidelines
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


End of life care
End-of-Life Care

Dan Cushman 2010


Most important part of breaking bad news
Most important part of breaking bad news

  • Don’t be an asshole

Dan Cushman 2010


Spikes
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


Class
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


Steps of death pronouncement
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


Which stage of dying
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


Put the following in the correct order of occurrence
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


Put the following in the correct order of loss before dying
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


Deaths that may cause complicated bereavement
Deaths that may cause complicated bereavement

  • Violent and sudden deaths

  • Deaths in which the bereaved may feel some sense of responsibility

  • Deaths of young people

  • Highly dependent on the deceased, such as elderly spouses

  • Previous history of mental health

  • Poverty and cultural isolation

Little known fact: the word “bereavement” comes from the Oregonian word “beaverment,” which came each year when beaver hunting season ended

Dan Cushman 2010


Should you during a conversation announcing someone s death
Should you (during a conversation announcing someone’s death)…?

No

  • Answer a page?

  • Eat a hamburger?

  • Use the word “died?”

  • Say “I have some bad news…?”

  • Use puppets to explain the scenario?

  • Ask if the patient has questions?

  • Perform testicle twisting?

No

Yes

Yes

No

Yes

Still no

Dan Cushman 2010


Thanks for the memories
Thanks for the memories! death)…?

Dan Cushman 2010


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