Geriatrics - PowerPoint PPT Presentation

Geriatrics

Dan Cushman

Dan Cushman 2010

Dan Cushman 2010

• 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

• Urologic
• Neurologic
• Functional/Psychological
• Iatrogenic/Environmental

They can be mixed!

Dan Cushman 2010

• 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

• 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

Detrusor

Trigone

Internal sphincter

External sphincter

Dan Cushman 2010

• Travels via hypogastric nerve
• Has alpha and beta receptors
• Uses Norepinephrine
• Facilitates bladder filling

Dan Cushman 2010

• Travel via pudendal nerve
• Uses Acetylcholine
• Increased tone during filling phase
• Prevents outflow of urine

Dan Cushman 2010

• Travels via pelvic nerve
• Acetylcholine, acting on muscarinic receptors
• Causes bladder emptying
• Increased tone during emptying phase

Dan Cushman 2010

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

• 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

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

• 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

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

• “Tell me about the symptoms you are having”
• “What are your expectations from the assessment and treatment?”

Dan Cushman 2010

• 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

• Childbirth
• Surgery
• Urinary retention
• Recurrent UTIs (>= 2 in past year)
• Treatment
• Response
• Why no longer using it

Dan Cushman 2010

• Type and amount of fluid
• Caffeine
• Alcohol

Dan Cushman 2010

Dan Cushman 2010

• 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

• 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

• 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

• 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

• 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

• Buproprion
• Olanzapine
• CCBs, anticholinergics, TCAs
• Thiazide diuretics
• Loop diuretics

Seizure disorder

Obesity

Chronic constipation

Hyponatremia

Patients at risk for dehydration

Dan Cushman 2010

• Muscle relaxants
• Urinary antispasmodics
• Scopolamine/Atropine
• COPD (e.g. ipratropium)
• Antihistamines
• TCAs

Dan Cushman 2010

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

Dan Cushman 2010

Dan Cushman 2010

Mood

disorders

Cognitive disorders

Depression

Dementia

Anxiety

Delirium

Dan Cushman 2010

ADLs

IADLs

Transfers

Telephone

Dressing

Transportation

Feeding

Cooking

Toileting

Shopping

Showering

Housework

Medicines

Manage $$

Dan Cushman 2010

• 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

Dan Cushman 2010

• 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

• Pattern of pain
• Avoid toxicity
• Consider added benefits
• Route of administration & patient-specific factors

Dan Cushman 2010

Pain level (1-10)?

Medication?

Pain level (1-10)?

Medication?

Pain level (1-10)?

Medication?

Dan Cushman 2010

Moderate

• Hydrocodone
• Hydromorphone
• Acetaminophen
• Oxycodone
• Codeine
• Morphine
• Fentanyl

Severe

Mild

Moderate or Severe

Moderate

Severe

Severe

Dan Cushman 2010

• Abnormal renal function
• Peptic ulcer disease
• Bleeding diathesis

Dan Cushman 2010

• 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

Why do opioids cause constipation?

They bind to mu receptors in the intestinal tract

Dan Cushman 2010

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

Dan Cushman 2010

• Don’t be an asshole

Dan Cushman 2010

• 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

• 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

• 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

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

• Death rattle
• Cyanosis
• Lack of radial pulse
• Respiration with mandibular movement

First

Third

Fourth

Second

Dan Cushman 2010

3

• Speech
• Hearing
• Touch
• Vision
• Thirst
• Hunger

5

6

4

2

1

Dan Cushman 2010

• 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

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

Dan Cushman 2010