Common Geriatric Problems Flashcards
3 major obstacles to receiving appropriate preventative care for seniors:
Access
Cost
Ageism
Main preventative healthcare measures:
Smoking cessation
Nutrition
Exercise and mobility
Safety programs
The following conditions are extremely common in the geriatric population:
► Hypertension ► Urinary incontinence ► Falls ► Osteoporosis ► Dementia
Hypertension
1970s - ignore elevated blood pressures in the elderly,
1980s - docs did not believe that antihypertensive drugs could improve outcome in the elderly
NOW:
effective treatment of isolated systolic or systolic/diastolic hypertension can reduce the morbidity and mortality of coronary heart disease. Elevated systolic blood pressure in the elderly is more significant than elevated diastolic blood pressure.
**check every geriatric patient for orthostatic changes. If orthostatic changes are apparent, always check that patient’s BP in the standing position, whenever possible.
Causes of 2ndary HTN
Renal disorders: Renal artery stenosis due to atherosclerosis, Renal parenchymal disease, Renal neoplasms
Endocrine disorders
Drugs
Atherosclerotic disease
Dx of 2ndary HTN
Systolic blood pressure is > or equal to 140mm Hg and/or diastolic pressure is > or equal to 90mm Hg, documented on at least three separate occasions, with at least two separate measurements on each occasion.
Tx of 2ndary HTN
Tx of HTN in elderly patients = greater potential for adverse effects, such as predisposition to:
heart failure, stroke, renal failure, CAD and peripheral artery disease.
treatment goal: decrease the risk of developing these complications.
Lifestyle Modifications HTN
initiated with all patients even if starting them on drug therapy.
Limit salt intake under 2.3 g daily exercise diet (non-packaged foods) smoking cessation decrease alcohol intake
Drug Therapy HTN
BP reduction with the use of any drug or drug combination compared with either placebo reduces cardiovascular morbidity and mortality.
The magnitude of the benefit is proportional to the reduction in systolic BP and is greater in the elderly than in younger patients.
All of the commonly used antihypertensive drug classes, with one exception, the beta-blockers, appear to be equally effective in reducing outcomes.
Diuretics and beta blockers both reduce the occurrence of adverse events related to cerebrovascular disease however diuretics are more effective in reducing events related to coronary heart disease. Treated patients are less likely to develop severe hypertension or congestive heart failure.
In most instances, low-dose diuretic therapy should be used as initial antihypertensive therapy in the elderly
Thiazide diuretics
Beta Blockers
Beta-blocker use in the treatment of hypertension in the elderly has come into question in large part because of the:
Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) trial, which was stopped early because of increased mortality in the beta-blocker (Atenolol)-diuretic arm vs. the CCB-ACE inhibitor arm and the
Losartan Intervention for Endpoint Reduction in Hypertension (LIFE) trial, in which Losartan-based therapy outperformed Atenolol-based therapy despite equivalent BP reductions.
Furthermore, meta-analyses has shown that beta-blocker (principally Atenolol)-based treatment was less effective than other treatments and only slightly better than placebo in preventing most cardiovascular disease outcomes.
Coupled with their unfavorable metabolic profile (i.e., reduced insulin sensitivity and increased incidence of new-onset diabetes) and a constellation of adverse effects:
erectile dysfunction
cold extremities
depression/lack of energy
weight gain
These outcome findings have caused beta-blockers to lose their favored status as initial therapy for hypertension.
When would beta blockers be indicated? What specific patient population?
When would beta blockers be contraindicated?
Initial drug therapy per Up to date:
For older hypertensive patients who require medication and who do not have an indication for a specific drug, the following is recommended as initial monotherapy (preferred):
low-dose thiazide-type diuretic or
long-acting calcium channel blocker* or
angiotensin-converting enzyme (ACE) inhibitor/angiotensin II receptor blocker (ARB).
dosing
Elderly patients are more prone to orthostatic and/or postprandial hypotension.
Therefore, in the absence of a hypertensive emergency, blood pressure reduction should always be gradual in older adults.
Days to weeks to attain desirable result
BP GOALS
Generally, a blood pressure goal is to attain:
a systolic pressure of 125 to 135
Should you wean a geriatric patient off their drug therapy once optimal blood pressure is obtained and maintained?
BP - NATUROPATHIC
Hibiscus Tea?
Celery: 4 – 6 daily; contains 3n-butylthalide; acts as a diuretic
DASH-s – 50% of population is salt-responsive
Encourage Mg (dark leafy greens), Ca, K, CoQ10 (200-300mg), Fish Oil (1.5g of EPA daily – likely 3g daily based off of CA research)
Arginine more useful in younger population rather than elderly (CI in CA - inc vascular growth)
Decrease alcohol and caffeine
Cardiotone (for hard/tricky cases) – includes Raulfia
Hawthorne – 1 tsp daily; Garlic (CI anticoags)
Other common geriatric problems
Urinary incontinence, osteoporosis, falls, and dementia have three major things in common.
These conditions are more prevalent in the geriatric population then in younger patients.
They can result from physiologic and pathologic changes that occur with age.
They can result in significant functional decline of the individual
Urinary Incontinence
Urinary incontinence is the involuntary loss of urine in a quantity or frequency great enough to cause either a social or health problem.
The development of incontinence is not considered to be a normal part of aging.
Urinary incontinence is a major factor in the decision to pursue nursing home placement for a chronically ill patient.
Urinary incontinence is a largely neglected problem which can be successfully treated or cured.
Incontinent patients are predisposed to skin breakdown and pressure sores, social isolation and depression, urinary tract infection and falls (especially in nocturnal trips to the bathroom).
Categorized as acute or chronic
Epidemiology of Urinary Incontinence
Urinary incontinence occurs in an estimated 15% to 40% of individuals greater then 65 years of age living on their own outside of a care facility.
Up to 35% to 60% of acutely hospitalized geriatric patients are found to be incontinent.
Approximately 40% to 80% of elderly patients in long-term care are diagnosed as having urinary incontinence.
It is estimated that only 20% of all individuals with incontinence ever seek medical evaluation of their condition.
Acute Incontinence
Acute incontinence: defined as being transient, reversible and likely due to an external cause DIAPPERS Delirium Infection Atrophic urethritis and vaginitis Pharmaceuticals Psychiatric disorders (esp depression) Excessive urine output Restricted mobility Stool impaction
Chronic Urinary Incontinence
Chronic urinary incontinence is generally divided into four/five categories:
Stress incontinence – MC due to pelvic muscle weakness
Tx: pelvic floor exercises (kegels)
Urge incontinence
Overflow incontinence
Detrusor underactivity
Functional incontinence
Stress Incontinence (outlet incontinence)
Stress incontinence is the leakage of urine which can follow any increase in intra-abdominal pressure: coughing, sneezing laughing or bending over.
Stress urinary incontinence is usually due to pelvic floor muscle weakness and diminished resistance to pressure by the urinary sphincters.
Urge Incontinence (detrusor overactivity)
Urge incontinence is an involuntary loss of urine while suddenly feeling the need or urge to urinate.
Urge incontinence is generally due to involuntary and inappropriate detrusor muscle contractions due to damage to the nerves to the bladder, damage to the central nervous system or to a problem with the muscles themselves.
Irritation to the bladder wall can also result in urge incontinence.
Urge incontinence is also described as “spastic bladder” or “overactive bladder”.
Tx: treat the underlying cause – think other concomitant diseases (such as – neuro adverse effects – MS, stroke, parkinsons, alzheimers, things that cause irritation – infection, bladder CA, stones
Overflow incontinence (outlet obstruction)
Overflow incontinence is leakage of urine from a distended bladder.
Bladder enlargement may be due to outlet obstruction as can be seen in men with prostatic hypertrophy or in woman with obstruction due to pelvic mass or urethral fibrosis.
Overflow incontinence can be seen in spinal cord patients or patients with diabetic neuropathy (neurogenic or atonic bladder).
The anal reflex and “saddle” sensation are usually absent.
Medications such as the narcotics or anticholinergics can also result in an atonic bladder
Detrusor Underactivity
Causes urinary retention and overflow incontinence
Causes:
Injury to the nerves supplying the bladder
Autonomic neuropathy of diabetes
Parkinson’s
Alcoholism
Men with chronic outlet obstruction
Detrusor Underactivity
Causes urinary retention and overflow incontinence
Causes:
Injury to the nerves supplying the bladder
Autonomic neuropathy of diabetes
Parkinson’s
Alcoholism
Men with chronic outlet obstruction
Questions around incontinence
Questions regarding urination should include the frequency and pattern of urination (periodic/constant/day/night, with stress/at rest/ with coughing, sneezing or laughing?)
> 7 voids daily = frequency
2+ voids nightly = nocturia
Any sense of urgency, hesitancy, dribbling interrupted stream, or sense of incomplete void?
Current pattern of bowel regularity.
Medication list
Fluid intake
Caffeine use – if so, amount/ time of day
ETOH use – if so, amount and time of day
Distance to toilet
Ease in use of toilet
Consider asking the patient to return with a 1 to 3 day voiding diary.
Time of day, approximate amount, are their pants wet or dry by the time they get to the restroom, other comments
Objective Eval of Incontinence
Abdominal Neuro Rectal (impaction, BPH) Pelvic (prolapse, vaginal tone) Functional status – gait, balance,
Labs for incontinence
The initial lab evaluation for all patients with incontinence is a urine analysis to rule out cystitis.
Check for markers of infection such as leukocyte esterase or nitrite. If positive, send urine for culture and sensitivity.
Also assess for the presence of hematuria, glycosuria and proteinuria.
Tx of incontinence
Treatment is aimed at first treating the reversible causes.
Simple behavioral maneuvers such as establishing a toilet regimen.
Kegel exercises should be practiced for all causes of incontinence.
Topical estrogen is a treatment option in women with stress incontinence related to vaginal atrophy.
Good perineal care may prevent local irritation.
Recommend the decreased use or avoidance of alcohol and caffeine, particularly if nocturia is a problem.
Always consider food sensitivities.
Eliminate the use of NutraSweet.
Always consider referral to a urologist.
Additional evaluation can include abdominal/ pelvic ultrasound, MRI, cystoscopy, measurement of bladder volume, and I.V.P.
Kegels
Kegel exercises involve repetitive contractions of pelvic floor muscles.
Maneuvers such as valsalva and urine flow interruption allow for identification of target muscles.
Patients are then instructed to contract and release the pelvic floor muscles.
10 repetitions constitute a set – consider a regimen of 3 to 5 sets a day.
Pelvic floor PT
Vaginal cones with weights – twice a day for 15 – 20 mins
Bot Med Tx of Urinary Incont
Botanical “urinary sedatives” include but are not limited to: Althea officinalis - marshmallow Equisetum arvense - horsetail Hypericum – St. john’s Wort Sambucus nigra - elderberry Serenoa repens – saw palmetto Zea mays – corn silk Piper methysticum – kava kava Scutellaria spp. – skullcap Gylcyrrhiza glabra – licorice Mullien root
Bening Prostatic Hypertrophy Bot Med
Herbal options for BPH include but are not limited to:
Pygeum africanum: extract (standardized to 14% triterpenes) 50 – 100 mg BID
Serenoa repens – saw palmetto: 30 mg BID.
Urtica dioica
Zn (15 – 30 mg; with long term use, also supplement Cu)
Omega 3s, Flax Seeds – inc SHBG – binds testosterone
omeopathy: urge to urinate
Apis Argentum nitricum Belladona Causiticum Chimaphila Kali carbonicum Merc-c
