Geriatrics Flashcards
Definition of Mild Neurocognitive Disorder (Mild Cognitive Impairment)?
Cognitive changes with measurable deficits in one or more cognitive domain
Peservation of independence or minimal impairment in ADLs and IADLs and not meeting criteria for major NCD
Investigations for Mild Neurocognitive Disorder (Mild Cognitive Impairment)?
Establish a baseline for follow-up
Clinical interview with patient and caregivers is the cornerstone of mild NCD evaluation
Neuropsychological testing
• MMSE (not sensitive to early cognitive change) or MoCA (more sensitive, score <26 is impaired); should not be used in isolation
• if abnormal, follow-up in one year to monitor cognitive and functional decline
Neuroimaging: role uncertain; a non-contrast brain CT is often ordered to evaluate for structural abnormalities (CVD, SDH, NPH, or mass lesion)
Most common subtype of Mild Neurocognitive Disorder?
Amnestic subtype is the most common and most associated with AD pathology
Treatment of Mild Neurocognitive Disorder?
Non-pharmacologic management: exercise training for 6mo is likely to improve cognition; insufficient evidence to support or refute cognitive intervention, it may improve outcome on select cognitive measures
No evidence for cholinesterase inhibitors, anti-inflammatory agents, vascular risk factor modification
Definition of Major Neurocognitive Disorder?
- Acquired, generalized, and (usually) progressive impairment of cognitive function associated with impairment in ADLs/iADLs (i.e. shopping, food preparation, finances, medication management)
- Diagnosis of major NCD requires presence of significant cognitive decline in at least 1 domain from a previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) based on:
• A) concern of the individual or a knowledgeable informant AND
• B) substantial impairment in cognitive performance either documented by standardized exam - Not due to other CNS, psychiatric, or systemic condition, drugs or delirium
Depression vs Dementia
Depression Dementia Motor Slowing + +/- Sad Mood + +/- Slow Responses + - Memory + + Recognition - + Cortical Deficits - +
Delirium vs Dementia
Delirium Dementia Rapid Onset + - LOC Change + - Fluctuating + +/- (DLB) Memory + + Motor Behaviour + - Medical Etiology + +/0
History that should be asked for Major Neurocognitive Disorder?
- “Geriatric Giants”
• confusion/incontinence/falls
• memory and safety (wandering, leaving doors unlocked, leaving stove on, losing objects, driving)
• behavioural (mood, anxiety, psychosis, suicidal ideation, personality changes, aggression)
• polypharmacy and compliance (sedative hypnotics, antipsychotics, antidepressants, anticholinergics) - ADLs and IADLs
- Cardiovascular, endocrine, neoplastic, renal ROS, head trauma history
- Alcohol, smoking
- Collateral history
Physical exam for Major Neurocognitive Disorder?
Blood pressure
Hearing and vision
Neurological exam with attention to signs of parkinsonism, UMN findings
General physical exam with focus on CVD, patient- specific risk factors, and history
MMSE or MoCA, clock drawing, frontal lobe testing (go/no-go, wordlists, similarities, proverb)
Ddx for Major Neurocognitive Disorder?
o Alzheimer’s Disease (Mixed/Vascular)
o Vascular Ischemic Dementia
o Dementia w/ Lewy Bodies
o Fronto-temporal Dementia
Investigations for Major Neurocognitive Disorder?
Blood Tests - Systemic/Metabolic: CBC (ESR optional), electrolytes, Glucose, LFTs, Renal Fcn, TSH, B12 (Folate optional)
Other Tests - Infectious/Neoplastic: CXR, UA, CSF, HIV, Syphilis
Imaging: Recommended in most situations - MRI
Definition of Alzheimer’s Disease?
Beyond criterion for NCD, the core features of Alzheimer’s disease include an insidious onset and gradual progression of cognitive and behavioural symptoms
Typical presentation: amnestic
• Mild phase: impairment in memory and learning sometimes accompanied with deficits in executive function
• Moderate-severe phase: visuoconstructional/perceptual-motor ability and language may also be impaired
• Social cognition tends to be preserved until late in the course of the disease
Approximately 1% of AD results from an autosomal dominant single-gene mutation (_____, ______ or ______), which is associated with an early onset of symptoms.
Amyloid precursor protein, presenilin 1, or presenilin 2
Pathophysiology of Alzheimer’s Disease?
Accumulation of extraneuronal beta-amyloid plaques and intraneuronal tau protein tangles is associated with progressive brain atrophy.
Risk factors for Alzheimer’s Disease?
- Age is the greatest risk factor
- Genetic susceptibility polymorphism: apolipoprotein E4 increases risk and decreases age of onset
- Other factors include: traumatic brain injury, family history, Down syndrome, low education, and vascular risk factors (e.g. smoking, HTN, hypercholesterolemia, DM)
Clinical features of Alzheimer’s Disease?
Cognitive impairment
• memory impairment for newly acquired information (early)
• deficits in language, abstract reasoning, and executive function
Behavioural and psychiatric manifestations (80% of those with major NCD)
• Mild NCD: major depressive disorder and/or apathy
• Major NCD: psychosis, irritability, agitation, combativeness, and wandering
Motor manifestations (late) • gait disturbance, dysphagia, incontinence, myoclonus, and seizures
4As: amnesia, apraxia, agnosia and aphasia
Protection factors of Alzheimer’s Disease?
Protective Factors: Physical activity, diet, mental stimulation, social engagement, management of vascular RF
Treatment options for Alzheimer’s Disease?
- No cure or truly effective treatment.
- Cholinesterase inhibitors (e.g., donepezil, rivastigmine, and galantamine) may slow clinical deterioration by 6-12 months in up to 50% of patients with mild-to-moderate AD.
- The NMDA receptor antagonist, memantine, may provide a modest benefit to patients with moderate-to-severe disease.
- Antipsychotic medications are often used to treat agitation and aggression.
- Supportive care via behavioral, social, and environmental interventions.
- Care of the caregiver - refer to supportive services like the Alzheimer Society
- Advance directives and planning safety - driving – other driving options MARD/wandering/fire safety
- Treat depression, even with coexistent dementia.
Side effects of cholinesterase inhibitors?
S/E: Most common side effects are GI (primarily diarrhea, nausea and vomiting) – less so with donepezil. Anorexia/weight loss. Bradycardia and hypotension (enhanced vagal tone) - falls. Sleep disturbances (insomnia, vivid dreams – more common on donepezil)
Second most common single cause of major NCD after AD, accounting for approximately 20% of major NCDs.
Vascular Dementia (Vascular Cognitive Impairment)
Cognitive decline in vascular dementia occurs as a result of at least one of the following mechanisms:
Large vessel strokes, usually cortical.
Small vessel strokes (lacunar infarcts) to subcortical structures.
Microvascular disease affecting the periventricular white matter.
Major risk factors for Vascular Dementia (Vascular Cognitive Impairment)?
Major risk factors are the same as those for CVD (i.e. HTN, DM, smoking, obesity, high cholesterol levels, high homocysteine levels, other risk factors for atherosclerosis, atrial fibrillation, and conditions increasing risk of cerebral emboli)
Clinical manifestations of Vascular Dementia (Vascular Cognitive Impairment)?
- Presentation and progression of cognitive impairment are variable.
• Classically demonstrates a stepwise deterioration corresponding with the occurrence of micro-infarcts (i.e., multi-infarct dementia).
• May present with acute onset followed by partial improvement.
• May have an insidious onset with gradual decline similar to AD. - Complex attention and executive functions are the cognitive domains typically affected in small vessel disease.
- Confirmation of the diagnosis requires neuroimaging with findings that correlate to the clinical picture.
Treatment of Vascular Dementia (Vascular Cognitive Impairment)?
No cure or truly effective treatment.
Manage risk factors with a goal of preventing future strokes.
Symptomatic treatment is similar to AD.
What are the core features of Lewy Body Disease?
- Waxing and waning of cognition, especially in the areas of attention and alertness.
- Visual hallucinations-usually vivid, colorful, well-formed images of animals or small people.
- Rapid eye movement (REM) sleep behavior disorder (not currently included in the DSM-5 core features)-violent movements during sleep in response to dreams, often of fighting.
- Development of extrapyramidal signs (Parkinsonism) - tremor, akinesia, rigidity, postural instability at least 1 year after cognitive decline becomes evident.
- Lewy is slow-y, sleepy, slippy and sees things (halLEWYcinations)
What are the suggestive features of Lewy Body Disease?
- Pronounced antipsychotic sensitivity (i.e., extra-pyramidal symptoms).
- Postural instability and recurrent falls.
- Loss of consciousness or transient unresponsiveness.
- Autonomic dysfunction.
- Diminished sense of smell.
- Non-visual hallucinations and delusions.
- Excessive sleepiness.
- Depression, anxiety, and apathy.
What are the indicative biomarkers of Lewy Body Disease?
- REM sleep without atonia (RWSA) demonstrated via polysomnography.
- Decreased 123 iodine-MIBG uptake on myocardial scintigraphy.
- Evidence of reduced dopamine receptor uptake in the basal ganglia via SPECT or PET.
Diagnosis of possible NCD with Lewy bodies?
Possible NCD with Lewy bodies: Only one core feature without evidence from indicative biomarkers OR one or more indicative biomarker(s), but no core clinical features.
Diagnosis of probable NCD with Lewy bodies?
Probable NCD with Lewy bodies: Two or more core features OR one core feature and one or more indicative biomarker(s).
Treatment of Lewy Body Disease?
- Cholinesterase inhibitors for cognitive and behavioral symptoms.
- Quetiapine or clozapine for psychotic symptoms. Monitor closely for adverse effects, such as extrapyramidal signs, sedation, increased confusion, autonomic dysfunction, and signs of Neuroleptic Malignant Syndrome (NMS).
- Levodopa-carbidopa for Parkinsonism - May exacerbate psychosis or REM sleep behavior disorder.
- Melatonin and/or clonazepam for REM sleep behavior disorder.
Frontotemporal Degeneration (FTD) includes a diverse group of clinical and pathological disorders that typically present between the ages of ____
45 & 65
Genetics of Frontotemporal Degeneration (FTD)?
Most often familial (40%) than AD – usually autosomal dominant, families can have coexistant ALS. Common mutations in FTD found in – progranulin (PGRN) - blood levels can be measured.
Behavioral variant (3+) of Frontotemporal Degeneration (FTD)
BEACH (behavioural disinhibition, empathy decrease, apathy, compulsions, hyperorality)
• Disinhibited verbal, physical, or sexual behavior.
• Overeating or oral exploration of inanimate objects.
• Lack of emotional warmth, empathy, or sympathy.
• Apathy or inertia.
• Perseveration, repetitive speech, rituals, or obsessions.
Pathology of Frontotemporal Degeneration (FTD)?
Marked atrophy of the frontal and temporal lobes.
Diagnosis of Frontotemporal Degeneration (FTD)?
- Definitive diagnosis cannot be made until autopsy.
- FTD is probable if frontotemporal atrophy is evident on structural imaging or hypoactivity is visualized on functional imaging in context of the characteristic clinical signs.
Treatment of Frontotemporal Degeneration (FTD)?
- Symptom-focused.
- Serotonergic medications (e.g., SSRIs, trazodone) may help reduce disinhibition, anxiety, impulsivity, repetitive behaviors, and eating disorders.
In Parkinson disease dementia (unlike in dementia with Lewy bodies), cognitive impairment that leads to dementia typically begins _____ after motor symptoms have appeared.
10 to 15 years
Parkinson disease dementia may affect multiple cognitive domains including attention, memory, and visuospatial, constructional, and executive functions. _______ typically occurs earlier and is more common in Parkinson disease dementia than in Alzheimer disease.
Executive dysfunction
What would you see on neuroimaging for normal pressure hydrocephalus?
Enlarged ventricles on neuroimaging
Language variant (primary progressive aphasia) of Frontotemporal Degeneration (FTD)?
- Difficulties with speech and comprehension.
* Relative sparing of learning/memory and perceptual-motor function.
Features that differentiate Frontotemporal Degeneration (FTD) from AD?
Features that differentiate from AD – loss of personal awareness, hyper-orality, stereotyped repetitive behaviours, decreased speech, visuospatial functions preserved.
Clinical manifestations of Frontotemporal Degeneration (FTD)?
- Cognitive deficits in attention, abstraction, planning, and problem solving.
- Behavioral variant (3+): BEACH (behavioural disinhibition, empathy decrease, apathy, compulsions, hyperorality)
- Decline in social cognition and/or executive abilities.
- Language variant (primary progressive aphasia):
- Many individuals have features of both the behavioral and language variants.
- Increased sensitivity to adverse effects of antipsychotics.
Normal pressure hydrocephalus triad?
Wet, wacky, and wobbly
- Triad of dementia, gait disturbance and urinary incontinence
- Gait is unique – cant lift legs off ground, but if lying down can mimic walking
What is frailty?
Frailty: clinically – recognizable state of decreased reserve in older adults with increased vulnerability to acute stressors resulting from functional decline across multiple physiologic system
What is the etiology of frailty?
o Medications
o Environmental/Social (e.g., isolation, poverty, elder abuse, neglect)
o Medical disease
o Malnutrition (e.g., from poor dentition, malabsorption, dysphagia – skeletal atrophy in first 1/3 of esophagus)
o Psychiatric (e.g., mild cognitive impairment, dementia, depression, psychosis)
o Changes in visual acuity
o Changes in auditory acuity
o Decreased mobility
What are the symptoms of frailty?
Symptoms include generalized weakness, exhaustion, slow gait, poor balance, decreased physical activity, cognitive impairment, and weight loss
What is included in the comprehensive geriatric assessment?
- Includes: Past Medical History, Medications (optimization), Allergies, Social History, Function, Physical Exam, and Geriatric Review of Systems (cognition, mood, sleep, pain, nutrition, falls, continence, vision/hearing, skin, and safety)
- Screen for elder abuse and neglect
- Assessment of the impact of symptoms on activities of daily living
- Caregiver support
Which scale can be used to estimating severity of frailty and can guide GOC?
Clinical Frailty Scale
Which scale can be used to define frailty components?
Edmonton Frail Scale
Which cardiovascular medications should you avoid in the geriatric population?
Alpha blockers for HTN (doxazosin)
Central alpha agonists for HTN (clonidine)
Digoxin for 1st line afib/HF
Amiodarone for 1st line afib
Who qualifies for Supportive Living SL3?
- Individuals who are medically and physically stable
- Living with physical disability, mental health diagnoses, or mild dementia with no known risk of wandering, and who are not a risk to self or others
- Must be able to move independently or with the assistance of one other person
- Could be experiencing increased healthcare needs that cannot be scheduled
- Are able to use a call system to get help
Which endocrine medications should you avoid in the geriatric population?
Sliding scale insulin
Long acting sulfonylureas
Which CNS medications should you avoid in the geriatric population?
Anticholingeric antidepressants (e.g. TCAs)
Antipsychotics
Benzos
Z drugs (zopiclone)
Which GI medications should you avoid in the geriatric population?
Metoclopramide or long term PPIs
Which GU medications should you avoid in the geriatric population?
Anticholinergics or alpha blockers
Which pain medications should you avoid in the geriatric population?
NSAIDs or opioids as 1st line
Who qualifies for Supportive Living SL4/D?
- Individuals who have more complex medical needs that are predictable and safely managed with onsite, professional nursing (LPN level) and the direction of the case manager
- May require chronic disease management
- May require the following types of assistance with daily activities:
- Complete meal assistance including tube feeds
- Mechanical lift transfers
- Two person transfers
- Medication assistance or administration
- DSL4D is for individuals with moderate to severe dementia, who may have a high risk of wandering and unpredictable behaviours but who are not a safety risk to themselves or others
What are the topics to discuss for a dying patient?
Goals of Care: disease vs. symptom management
▪ Advance directives, power of attorney, public guardian, and trustee)
▪ Location (e.g. hospice, home, palliative care facility, etc.
▪ Patient wish (medical assistance/feasibility to fulfill)
▪ Physician assisted death (patient-initiated discussion)
▪ Treatment options and likelihood of success
Common Medical Interventions: mechanical ventilation, antibiotic therapy, feeding tubes
Resuscitation Options: and likelihood of success, i.e. Full Code vs. DNR states incl. preferences for CPR, intubation, ICU admission, artificial hydration)
SDM: If wishes unknown, act in the patient’s best interest, taking the following into account
- Values and beliefs held by the patient while capable
- Whether well-being is likely to improve with vs. without treatment
- Whether the expected benefit outweighs the risk of harm
- Whether a less intrusive treatment would be as beneficial as the one proposed
What are Instructional Advance Directives
The patient sets out his/her decisions about future health care, including who he/she would allow to make treatment decisions on his/her behalf and what types of interventions he/she would want
What is a Power of Attorney for Personal Care
A legal document in which one person gives another the authority to make personal care decisions (health care, nutrition, shelter, clothing, hygiene, and safety) on their behalf if they become mentally incapable.
What is a Guardian of the Person
Guardian of the Person: someone who is appointed by the Court to make decisions on behalf of an incapable person in some or all areas of personal care, in the absence of a POA for personal care.
What is a Continuing Power of Attorney for Property
Continuing Power of Attorney for Property: legal document in which a person gives another the legal authority to make decisions about their finances if they become unable to make those decisions.
What is a Public Guardian and Trustee
Public Guardian and Trustee: acts as a SDM of last resort on behalf of mentally incapable people who do not have another individual to act on their behalf.
What is a Guardian of Property
Guardian of Property: someone who is appointed by the Public Guardian and Trustee or the Courts to look after an incapable person’s property or finances.
Symptom relief of pain in the dying patient?
▪ Opiates
▪ Corticosteroids can reduce the pain of inflammation and swelling.
▪ Tricyclic antidepressants (eg, nortriptyline, doxepin) help manage neuropathic pain; doxepin can provide bedtime sedation as well.
▪ Gabapentin 300 to 1200 mg orally 3 times a day can help relieve neuropathic pain
Symptom relief of dyspnea in the dying patient?
▪ General comfort-oriented treatments including positioning (eg, sitting up), increasing air movement with a fan or open window, and bedside relaxation techniques.
▪ Opioids: Low doses of morphine 2 to 10 mg sublingually or 2 to 4 mg subcutaneously every 2 hours as needed helps reduce breathlessness in an opioid-naive patient
Symptom relief of anorexia in the dying patient?
▪ IV fluids, total parenteral nutrition, and tube feedings do not prolong the life of dying patients, may increase discomfort, and even hasten death
Symptom relief of N/V in the dying patient?
▪ The 5-hydroxytryptamine (5-HT)3 antagonists ondansetron and granisetron often dramatically relieve nausea
▪ Octreotide 150 mcg subcutaneously or IV every 12 hours inhibits gastrointestinal secretions and dramatically reduces nausea and painful distention
▪ Corticosteroids should be used in the management of bowel obstruction caused by malignancy.
What is included in R1 GOC?
R1 - Patient is expected to benefit from and is accepting of any appropriate investigations/interventions that can be offered including attempted resuscitation and ICU care.
Symptom relief of constipation in the dying patient?
Most patients do well on a twice daily regimen of a mild stimulant laxative (eg, casanthranol, senna). If stimulant laxatives cause cramping discomfort, patients may respond to an osmotic laxative, such as lactulose or sorbitol started at 15 to 30 mL orally 2 times a day and titrated to effect.
What is Terminal Respiratory Secretions (“Death Rattle”) and how to minimize it?
Terminal Respiratory Secretions (“Death Rattle”): noise caused by the oscillatory movement of mucous secretions in the upper airway with inspiration and expiration
To minimize the death rattle, caregivers should limit patients’ fluid intake (eg, oral, IV, enteral) and position patients on their side or semi-prone
What is included in R2 GOC?
Patient is expected to benefit from and is accepting of any appropriate investigations/interventions that can be offered including attempted resuscitation, intubation and ICU care, but excluding chest compression
What is included in R3 GOC?
Patient is expected to benefit from and is accepting of any appropriate investigations/interventions that can be offered including attempted resuscitation and ICU care, but excluding intubation and chest compression
What is included in M1 GOC?
All clinically appropriate medical and surgical interventions directed at cure and control of condition(s) are considered, excluding the option of attempted life-saving resuscitation followed by ICU care.
What is included in M2 GOC?
All clinically appropriate interventions that can be offered in the current non-hospital location of care are considered. If a patient does not respond to available treatments in this location of care, discussion should ensue to change the focus to comfort care. Life-saving resuscitation is not undertaken except in unusual circumstances
What is included in C1 GOC?
All care is directed at maximal symptom control and maintenance of function without cure or control of an underlying condition that is expected to cause eventual death. Treatment of intercurrent illnesses can be contemplated only after careful discussion with the Patient about specific short-term goals.
What is included in C2 GOC?
All care is directed at preparation for imminent death [usually within hours or days] with maximal efforts directed at symptom control.
Bill C-14 Criteria for MAID
o Patient is eligible for publicly-funded health services in Canada
o At least 18 yr of age, and has capacity for clear and freely given consent
o Grievous and irremediable medical condition: in an advanced state of irreversible decline incapability
o Suffering intolerable to the patient, not relieved under conditions they consider acceptable
o Natural death is reasonably foreseeable
Definition of falls?
Defintion: Unintentionally coming to rest on the ground or floor with or without injury
Other complications associated with falls?
Other complications include the loss of mobility (in part through fear of falling), admission to long-term care facility, and depression.
Remaining on the floor for > 2 hours after a fall increases risk of?
Remaining on the floor for > 2 hours after a fall increases risk of dehydration, pressure ulcers, rhabdomyolysis, hypothermia, and pneumonia.
What are some intrinsic factors associated with falls?
Intrinsic factors such as: history of falling, gait or balance abnormalities (vertigo), medical conditions - LUTS, stroke, dementia/cognitive impairment, afib, aortic stenosis, orthostatic hypotension, carotid stenosis, visual impairment, decreased hearing, OA and neurological conditions such as Parkinson disease and peripheral neuropathy
What are some medications associated with falls?
Medication effects, particularly due to polypharmacy (>4 meds) or use of drugs such as diuretics, antihypertensives, benzos, antidepressants (SSRI), painkillers (opioids), alcohol
What are some environmental factors associated with falls?
Environmental factors in the home or institutional settings such as tripping hazards, inadequate lighting, or the absence or improper use of assistive devices
Conduct yearly screening for falls and gait or balance difficulties in community-dwelling adults ___ years old
Conduct yearly screening for falls and gait or balance difficulties in community-dwelling adults ≥ 65 years old.
What should be asked on history for falls?
- S – Symptoms before fall, after; timeline gap suggests (LOC)
- P – Previous falls
- L - Location
- A – Activity preceding falls – transfers, walking, head turning
- T – Time of day, after a meal/meds
- T – Toxins, trauma – physical +/- psychological
What should be completed on physical exam for falls?
- VS – BP low, orthostatic drop
- Cardio: HR and rhythm, murmurs
- MSK: ROM, feet, nails, footwear, evidence of OP
- Cognitive assessment: sMMSE
- Neuro: focal signs, visual acuity, hearing power, sensory, cerebellar
- Gait and balance - Get Up and Go Test, Timed Up and Go (TUG) Test – get up walk 3 meters and sit down, abnormal is >15s, Romberg
Investigations for falls?
o CBC, urea, Cr, lytes, CK, Ca, B12, CRP, blood glucose
o ECG
o Others: echo, holter, Vit D, parathyroid hormone, CT head
Management of falls?
o Treat acute injuries or medical conditions
o Review meds: Add meds – rx for osteoporosis, vit D 1000units
o Physiotherapy to mobilize, OT re aids
Prevention of falls?
o Ensure properly fitting shoes
o Take time to stand up
o Home safety assessment - OT
o Physio to help assess gait and work on strength/balance exercises. In particular, functional and balance training and tai chi appear to be beneficial for fall prevention.
o Optometrist – vision assessment
o Personal alert button, falls detector, bed occupancy sensors
Definition of elder abuse?
Includes physical abuse, sexual abuse, emotional/psychological abuse, financial exploitation and neglect
What should you ask on history for elder abuse?
o Interviewed alone
o Inquire about general safety
o Direct questions about mistreatment: physical violence, restraints, neglect
o The nature, frequency, and severity of events should be elicited
o Social and financial resources
o Caregiver burnout
o Recent stressful events (eg, bereavement, financial stresses)
o Patient’s illness (eg, care needs, prognosis)
Signs of elder abuse
Behaviour
Withdrawal by the patient
Infantilization of the patient by the caregiver
Caregiver’s insistence on providing the history
General Appearance
Poor hygiene (eg, unkempt appearance, uncleanliness)
Inappropriate dress
Skin and mucous membranes
Poor skin turgor or other signs of dehydration
Bruises, particularly multiple bruises in various stages of evolution
Pressure ulcers
Deficient care of established skin lesions
Head and Neck
Traumatic alopecia (distinguished from male- or female-pattern alopecia by distribution)
Trunk
Bruises
Welts (shape may suggest implement—eg, utensil, stick, belt)
GU region Rectal bleeding Vaginal bleeding Pressure ulcers Infestations
Extremities
Wrist or ankle lesions suggesting use of restraints or immersion burns (ie, in a stocking-glove distribution)
MSK
Previously undiagnosed fracture
Unexplained pain
Unexplained gait disturbance
Mental and emotional health
Depressive symptoms
Anxiety
What should be performed on physical exam for elder abuse?
o MMSE
o Mood or emotional status
o ADLs
Investigations for elder abuse?
Imaging and laboratory tests (eg, electrolytes to determine hydration, albumin to determine nutritional status, drug levels to document compliance with prescribed regimens) are done as necessary to identify and document the abuse.
Risk factors for elder abuse?
Situational Factors: Social
Victim Characteristics
Physical or emotional dependence on caregiver
Lack of close family ties
History of family violence
Dementia or recent deterioration in health
Prepetrator Characteristics
Related to victim
Dependency on older adult (e.g. financial dependency)
Management of elder abuse?
o An interdisciplinary team approach (involving physicians, nurses, social workers, lawyers, law enforcement officials, psychiatrists, and other practitioners)
o Culturally sensitive education (eg, teaching victims about abuse and available options, helping them devise safety plans)
o Trauma-informed psychologic support (eg, short-term or long-term psychotherapy for the victim and possibly the family that recognizes and addresses specific traumas and the role of trauma in the person’s life)
o Law enforcement and legal intervention (eg, arrest of the perpetrator, orders of protection, legal advocacy including asset protection)
o Alternative housing (eg, sheltered senior housing, nursing home placement)
o Referral to services to provide basic support (such as transportation and food assistance) and reduce social isolation
Why are women more prone to urinary incontinence?
More common in women because shorter urethra and women have trauma to pelvic floor (giving birth)
When does stress incontinence peak?
Stress incontinence peaks around child-bearing years
The micturition centre (Barringtons nucleus) is located
In the pons
Definition of frequency?
Voiding > 8 times per day (24 hours)
Definition of nocturia?
Voiding > 2 times at night
Definition of nocturnal enuresis
‘bed wetting’; leaking urine during sleep
Risk factors for prolapse
Risk Factors for Prolapse: genetics + surgery (any surgery that changes the angle of the vagina - Hysterectomy, bladder surgery) + obesity + parity/childbirth + smoking + constipation + excessive weight lifting or coughing + advancing age
Changes in the bladder with age
o Contractility unchanged o Contractile force reduces – deposition of collagen within the detrusor o Increased bladder mass in men o Increased PVR o Reduced maximum cystometric capacity
Definition of hesitancy?
Difficulty starting voiding
Risk factors for stress urinary incontinence?
Stress – vaginal delivery, pregnancy, obesity, aging, genetics, menopause, pelvic surgery, radiation, heavy lifting, smoking (chronic cough)
Risk factors for urge urinary incontinence?
Urge – aging, menopause, obesity, lifestyle (get when you are older)
What are the symptoms of prolapse
Problems with urination, vaginal fullness, pressure, pulling sensation, pain with sex, problems w/ BMs
What is stress urinary incontinence?
Involuntary loss of urine on effort or physical exertion/coughing/sneezing (increases in intra-abdominal pressure).
What is mixed incontinence?
Leakage with urgency and increased intra- abdominal pressure
Pathogenesis/causes of stress urinary incontinence?
▪ Urethral Hypermobility: insufficiency support of pelvic floor/vag connective tissue to urethra/bladder neck = urethra/bladder neck cannot close against the anterior vaginal wall ~ ^intra-abdo pressure = closure
▪ Intrinsic Sphincteric Deficiency: loss of i-urethral mucosal/muscular tone that keeps urethra closed (neuromuscular damage, usually following surgery/TURBT) ~ ^intra-abdo pressure = leakage.
Pathogenesis/causes of overflow incontinence?
▪ Detrusor Underactivity: spinal cord/MS injury, medications - anticholinergics and opioids, impaired contractility/efficiency with age, or trauma/fibrosis/low estrogen state, neuropathy (DM, alcoholism, V-12 deficiency), usually idiopathic
▪ Bladder Outlet Obstruction: external compression of urethra. Men – BPH, prostate cancer or urethral stricture. Women – cystocele, previous surgery. Both- fecal impaction
What is overflow incontinence?
Overflow Incontinence (voiding dysfunction): Leakage of urine secondary to bladder overfilling or urethral blockage (bladder outlet obstruction (stricture/prolapse) or bladder atony (neurologic/medication). Bladder pressure overcomes urethral pressure. Rare in women except with prolapse or post-surgical where bladder below urethra. Common in men (prostate)
What is overactive incontinence?
Symptoms complex containing at least one of the following: frequency, urgency, urge incontinence or nocturia
Functional incontinence
Functional incontinence: Leakage of urine associated with cognitive, psychological or physical impairments of toileting
Acute causes of urinary incontinence
DIAPPERS:
Delirium + Infection (UTI) + Atrophic Vaginitis (geriatric) + Pharma/Psycho (anticholinergics/diuretic) + Endocrine (uncontrolled DM, hypercalcemia) + Restricted mobility + Stool impaction
Reversible causes overactive bladder
Reversible: medications, alcohol and caffeine intake, or constipation/stool impaction
Pathogenesis/causes of urge incontinence?
● Detrusor Overactivity - may be idiopathic or may result from dysfunction of the frontal micturition inhibitory center (commonly due to age-related changes, dementia, or stroke) or outlet obstruction
● Bladder oversensitivity from infection
● Neurologic disorders (MS, spinal cord injury or CVA) - Causes uninhibited detrusor muscle contractions
● 85% is idiopathic
OFUI – obstruction symptoms?
OFUI – Obstruction Symptoms: slow stream, hesitancy, incomplete emptying sensation, straining
OFUI symptoms?
OFUI Symptoms: loss of urine w/ no warning, change in position – urinary hesitancy, slow flow, nocturia, etc.
UUI/OBUI symptoms?
UUI/OBUI Symptoms: frequent, small volume voids that keep patient up/worse after diuretic, can’t make it to toilet/leaks with urgency. Increases risk of hip fractures in elderly – trying to rush to bathroom
SUI symptoms?
SUI Symptoms: urine loss with ^intraabdo pressure
Cystocele symptoms?
Bulge sensation, frequency, urgency, SUI – since as the bladder prolapses, the urethra moves
Uterine prolapse symptoms?
Uterine – low backache (ligaments or uterus insert at the back), cervical erosion or bleeding
Rectocele symptoms?
Rectocele – constipation – can cause it, digitation to have BM. Terminal rectocele = have to push into vagina to cause BM
Medications that can worsen urinary incontinence
Alpha adrenergic agonists, ACEi, anticholingerics, CCBs, cholinesterase inhibitors, diuretics, lithium, opioid analgesics, sedatives, SSRIs, gabapentin, NSAIDs, glitazones
What should be asked on history for urinary incontinence?
▪ Onset: Activities that bring on UI - Stress vs urge
▪ LUTS – Storage and voiding sx
▪ Bladder emptying
▪ Irritative symptoms - Dysuria, hematuria
▪ Bowel Hx
▪ Medical conditions that could affect bladder function - DM, MS, neurologic, drugs
▪ Medications
▪ Pelvic surgery
▪ Obstetrical Hx
▪ O/G Hx - Attention to symptoms of atrophy, coital incontinence
▪ Social Hx - FLUID intake, mobility, cognition, moking
Pale, thin vaginal mucosae with loss of rugae indicate
Pale, thin vaginal mucosae with loss of rugae indicate atrophic vaginitis.
When the opposite wall is stabilized with a speculum, bulging of the anterior wall indicates a _____, and bulging of the posterior wall indicates a _______.
Cystocele
Rectocele or enterocele
What should be done on physical exam for urinary incontinence?
▪ General (edema, neurologic abnormalities, mobility, cognition, dexterity)
▪ Abdomen (distended bladder, kidney enlargement)
▪ Pelvic examination in women: atrophic vaginitis and urethritis, urethral hypermobility, and pelvic floor weakness (do kegels on digit exam) with or without pelvic organ prolapse.
▪ Rectal examination can identify fecal impaction, rectal masses, and, in men, prostate nodules or masses.
▪ Cough Stress Test
Instant leakage with cough stress test?
Instant leakage = stress incontinence likely.
Delayed or persistent leakage with cough stress test?
Delayed or persistent leakage = detrusor instability, overflow.
No leakage with cough stress test?
No leakage = repeat in upright position
Investigations for urinary incontinence?
o Urinalysis – microscopic hematuria, urine culture – rule out UTI
o Bun, Cr, CBCd, lytes, Ca, glucose level
o Postvoid residual – rule out void dysfunction. Start to be concerned if volume >150mL. <300ml can be ignored if asymptomatic
o If AUB: consider endometrial biopsy OR renal/pelvic U/S
o If Rectal Sx: barium enema, anal manometry, defecography, endoanal U/S
o Cystoscopy: when hematuria + recurrent UTI + failed mgmt. of urgency + heavy smoker/urge/irritative bladder sx + prior failed surgery + voiding dysfunction + bladder pain
o Urodynamics - urology
Management of prolapse?
Manage medical probs, avoid heavy lifting, treat constipation, HRT, weight loss, bladder training, physio, or pessaries (individually sized, may predict surgical effect – good to add HRT**, check voiding function regularly) or reconstructive (vaginal or abdo)/obliterative (vaginal colpocliesis) surgery to address incontinence.
Management of stress urinary incontinence?
▪ Surgery: birch repair (or TVT or TOT)
- Burch repair – Reforming the bladder floor - Periurethral ligaments have stretched out so stitch them to cooper’s ligament so the urethra can’t move
- TVT – bladder sling
▪ But lifestyle (weight loss, fluid management, smoking cessation – chronic cough), pelvic floor muscle contractions/kegels (levator ani muscle), pessaries (ones with knobs) can help
Medication for neurogenic bladder?
Bethanechol
Management of urgency incontinence?
▪ Behavioural: avoid bladder irritants + weight loss + prompted voiding/fluid mgmt. Problematic Fluids: alcohol, carbonated bev caffeine, milk/products, citrus
▪ Pelvic Floor Muscle Rehab: kegels + urge suppression techniques
▪ Pessary: small insertable device or barrier or cup – puts pressure on urethra to prevent leakage
▪ Medication: Anticholinergics (oxybutynin) (antagonize detrusor contraction/evacuation of urine blocking parasympathetic triggers (stops release of ACh). Second line beta3 agonists to enhance detrusor smooth muscle relaxation
▪ Botox: refractory treatment or neurogenic (lasts 5-9 months)
▪ Sacral Neuromodulation: electric stim signaling from somatic/afferent nerves involved in micturition reflex pathway (lead at S3 sacral foramen, impulse delivered)
▪ Posterior Tibial Nerve Modulation: tibial nerve (L4/S3 fibers) same innervation/spinal segments as bladder/pelvic floor, stimulate these nerves.
▪ Local Vaginal Estrogen: help irritative bladder symptoms or vaginal dryness, help with pessary fitting
▪ Surgery: Augmentation cystoplasty. Intermittent self-catheterization may be required if augmentation cystoplasty results in weak bladder contractions or poor coordination of abdominal pressure (Valsalva maneuver) with sphincter relaxation
Side effects of oxybutynin?
Side Effects: dry mouths, dry eyes, drowsiness, cognitive impairment, impaired gut motility/constipation
Contraindications of oxybutynin?
Contraindications: narrow angle glaucoma or voiding dysfunction
What is augmentation cystoplasty?
Augmentation cystoplasty - section of intestine is sewn into the bladder to increase bladder capacity
Definition of fecal incontinence?
Involuntary or inappropriate passing of feces that impacts social functioning or hygiene
Three subtypes of fecal incontinence
- passive incontinence: involuntary discharge of stool or gas without awareness
- urge incontinence: discharge of fecal matter in spite of active attempts to retain bowel contents
- fecal seepage: leakage of stool following otherwise normal evacuation
Risk factors of fecal incontinence
Risk factors: constipation, age >80yr, female sex, urinary incontinence, impaired mobility, dementia, neurologic disease
Etiology of fecal incontinence
o Physiological changes with age >80yr (e.g. decreased external sphincter strength, decreased resting tone of internal sphincter, weakened anal squeeze, increased rectal compliance, and impaired anal sensation)
o Trauma (e.g. vaginal delivery, pudendal nerve damage, cauda equina)
o Iatrogenic
Surgical (e.g. anorectal surgery, lateral internal sphincterotomy, hemorrhoidectomy, colorectal resection)
Radiation (e.g. pelvic radiation)
o Neurogenic (e.g. neuropathy, stroke, MS, diabetic neuropathy)
o Anorectal/colorectal diseases (e.g. rectal prolapse, hemorrhoids, IBD, rectocele, cancer)
o Medication (e.g. laxative, anticholinergics, antidepressants, caffeine, muscle relaxants)
o Cognitive (e.g. dementia, willful soiling with psychosis)
o Constipation/fecal impaction
What should be asked on history for fecal incontinence?
o Onset, duration, frequency, amount, type of leakage (solid, liquid, or gas), presence of urgency, nocturnal episodes, and precipitating events (occurring in the setting of diarrhea, medication use).
o The presence of lower back or perineal pain and motor or sensory symptoms in the lower extremities, and urinary incontinence are suggestive of a neurologic cause of incontinence (eg, spinal cord lesion).
o A history of prior anorectal surgery, pelvic irradiation, diabetes, or neurologic disease
o Obstetrical - vaginal deliveries, prolonged labor, the use of forceps, and perineal laceration.
Physical exam for fecal incontinence?
o Abdominal examination for masses, inspection of the perineum for breakdown and infection, testing of S2 to S4 nerve routes, anal wink testing, and digital rectal examination.
o Functional and cognitive limitations should be considered
Investigations for fecal incontinence?
o Differentiate true incontinence from frequency and urgency (e.g. IBS, IBD)
o Stool studies
o Complete blood count and calcium, thyroid-stimulating hormone, and hemoglobin A1c levels.
o If FI is associated with a change in frequency or consistency of stool, consider a colonoscopy to rule out malignancy.
o In patients who fail to respond to initial management, we perform anorectal manometry and endorectal ultrasound.
Management for fecal incontinence?
o First-line treatments are nonpharmacologic strategies such as reducing functional barriers, dietary changes, and education about positioning and environmental factors.
o Medical therapies include psyllium for mobile patients with loose stools. Antimotility agents (loperamide) might help chronic diarrhea and those with past anorectal surgery and passive FI.
o Refractory cases with sphincter dysfunction or injury might benefit from interventions such as sacral neuromodulation, sphincter repair, or sphincteroplasty.
