Geriatrics- falls and incontinence Flashcards
Describe changes in postural control during the aging process
Increasing age is associated with: Diminished proprioceptive input Slower righting reflexes Diminished strength of muscles important in maintaining posture Increased postural sway
Describe changes in gait during the aging process
In general, older people do not pick up their feet as high
Older men tend to develop wide-based, short-stepped gaits
Older women often walk with a narrow-based, waddling gait
Definition of orthostatic hypotension
A drop in SBP of 20 mm Hg or more when moving from a lying to a standing position
What can contribute to hypotension in the elderly?
Postprandial decrease in BP
What are the pathologic conditions that increase in prevalence with increasing age and that can contribute to instability and falling?
Degenerative joint disease Healed fxs of the hip and femur Muscle weakness as a result of disuse and deconditioning Diminished sensory input Impaired cognitive function Podiatric problems
What is a frequently overlooked cause of falls?
Environmental factors
What are some of the more common causes of syncope in older people?
Vasovagal responses Carotid sinus hypersensitivity CVD Acute neurological events PE Metabolic disturbances
Factors associated with falls among older nursing home residents
Recent admission Dementia Hip flexor muscle weakness Certain activities (toileting, getting out of bed) Psychotropic drugs causing daytime sedation CV medications Polypharmacy Low staff-pt ratio Unsupervised activities Unsafe furniture Slippery floors
What is a drop attack?
What is it often attributed to?
Sudden leg weakness causing a fall without loss of consciousness
Vertebrobasilar insufficiency and often precipitated by a change in head position
Only a small proportion truly have had a drop attack
What is a more uncommon precipitant of falls in older persons?
Vertigo
Causes and PE findings of vertigo
Disorders of the inner ear
Vertebrobasilar ischemia and infarction and cerebellar infarction
Nystagmus
How is orthostatic hypotension best detected?
Take the blood pressure and HR in supine position, after 1 minute in the sitting position, and after 1 and 3 minutes in the standing position
What can cause orthostatic hypotension or worsen it to precipitate a fall?
Low cardiac output from heart failure or hypovolemia
Overtreatment with CV meds
Autonomic dysfunction
Impaired venous return
Prolonged bed rest with deconditioning of muscles and reflexes
Eating a full meal
Drugs that should be suspected of playing a role in falls
Diruetics Antihypertensives and alpha blockers Cholinesterase inhibitors Antidepressants Sedatives Antipsychotics Hypoglycemics Alcohol
Disease processes associated with falls
Cardiac arrhythmias Aortic stenosis Reflex increase in vagal tone Acute strokes TIAs Parkinsons Normal-pressure hydrocephalus Cerebellar d/os Intracranial tumors Subdural hematomas Urinary tract disorders
Hx components of falls
General medical hx and meds
Pt’s thoughts about what caused the fall
The circumstances surrounding it, including ingestion of a meal and/or meds
Any premonitory or associated sx
Whether there was loss of consciousness or signs of seizure
PE components of falls
Head, skin, extremities, and painful soft tissue areas should be assessed to detect any injury that may have resulted from a fall
Give careful attention to vital signs
Postural blood pressure and pulse determinations
Visual acuity
CV exam to focus on arrhythmias and signs of aortic stenosis
Examine extremities
Special attention to the feet
Neurological
Mental status
Gait and balance
Workup for falls
No specific workup If acute illness suspected: CBC Lytes BUN Chest film EKG Vit D Ambulatory monitoring if suspected arrythmia or heart block Echo if aortic stenosis is suspected Anterior circulation TIA suspected: noninvasive vascular studies CT or MRI- high suspicion of subdural hematoma
Tx for falls
Treat underlying causes PT OT Pt education Environmental manipulations Hip protectors- the jury is out
Definition of incontinence
The involuntary loss of urine or stool in sufficient amount or frequency to constitute a social and/or health problem
Specific questions to ask about incontinence
Do you have trouble with your bladder?
Do you ever lose urine when you don’t want to?
Do you ever wear padding to protect yourself in case you lose urine?
What does continence usually require?
Effective functioning of the lower urinary tract
Adequate cognitive and physical functioning
Motivation
An appropriate environment
Age-related changes involving incontinence
Bladder capacity declines
Residual urine increases
Involuntary bladder contractions become more common
Decline in bladder outlet and urethral resistance pressure in women
Decreased estrogen
Prostatic enlargement is associated with decreased urine flow rates and involuntary bladder contractions in men
Abnormalities of AVP and ANP levels
Acute incontinence
When the incontinence is of sudden onset, usually related to an acute illness or an iatrogenic problem, and subsides once the illness or medication problem has been resolved
Pneumonic for potentially reversible conditions that cause incontinence
Delirium
Restricted mobility, retention
Infection, inflammation, impaction
Polyuria, pharmaceuticals
Meds that can cause or contribute to urinary incontinence
Diuretics Anticholinergics Psychotropics: -TCAs -Antipsychotics -Sedative-hypnotics Narcotics Alpha-adrenergic blockers Alpha-adrenergic antagonists Cholinesterase inhibitors ACE inhibitors CCBs Gabapentin, pregabalin, glitazones Alcohol Caffeine
What are the 4 basic types of incontinence?
Stress
Urge
Incontinence associated with incomplete bladder emptying
Functional
Definition of stress incontinence
Involuntary loss of urine (usually small amounts) with increases in intra-abdominal pressure
Common causes of stress incontinence
Weakness of pelvic floor musculature and urethral hypermobility
Bladder outlet or urethral sphincter weakness
Definition of urge incontinence
Leakage of urine because of inability to delay voiding after sensation of bladder fullness is perceived
Common causes of urge incontinence
Detrusor overactivity, isolated or associated with one or more of the following:
Local GU condition such as tumors, stones, diverticula, or outflow obstruction
CNS d/os, such as stroke, dementia, parkinsonism, spinal cord injury
Definition of incontinence associated with incomplete bladder emptying
Sx are variable and nonspecific
Classic overflow incontinence involves leakage of urine resulting from mechanical forces on an overdistended bladder with little or no sensation of urinary urgency
Common causes of incontinence associated with incomplete bladder emptying
Anatomic obstruction by prostate, stricture, cystocele
A contractile bladder associated with DM or spinal cord injury
Neurogenic, associated with multiple sclerosis and other suprasacral spinal cord lesions
Definition of functional urinary incontinence
Urinary incontinence associated with inability to toilet because of impairment of cognitive and/or physical functioning, psychological unwillingness, or environmental barriers
Common causes of functional urinary incontinence
Severe dementia and other neurological d/os
Psychological factors such as depression and hostility
How to rule out common reversible factors that can cause acute incontinence
Brief hx
PE
Postvoid residual determination
Basic lab studies (UA, culture, and serum glucose)
Evaluation of persistent urinary incontinence- hx
Characteristics of the incontinence Current medical problems and medications The most bothersome sx The impact of the incontinence on the pt and caregivers Bladder records or voiding diaries
PE of persistent urinary incontinence
Focus on abdominal, rectal, and genital examinations and an eval of lumbosacral innervation
Give special attention to mobility, mental status, meds, and accessibility of toilets
Pelvic exam in women- careful inspections of the labia, vulva, and vagina for signs of inflammation suggestive of pelvic prolapse and atrophic vaginitis
Workup of persistent urinary incontinence- basic
Clean urine sample for UA
Persistent microscopic hematuria (>5 RBC per high-power field) in the absence of infection is a potential indication for further eval with cytology and/or cystoscopy
In non-institutionalized pts, treat bacteriuria before further eval
Take a PVR, except for those with pure sx of stress incontinence, urgency incontinence, or overactive bladder who have no sx of voiding difficulty and have no RFs or urinary retention
Pts with residual volumes of >200 mL should be considered for further eval
In older men, consider a noninvasive flow rate determination
Further eval of persistent urinary incontinence
Unexplained polyuria- BG and calcium
Pts with sig urinary retention- renal function tests and consider for renal u/s and urodynamic testing
Present microscopic hematuria int he absence of infection- urine cytology and urologic eval
Recent and sudden onset of irritative urinary sx who have RFs for bladder CA- urologic eval
Women with marked pelvic prolapse- GYN eval
Tx options for generic urinary incontinence- nonspecific supportive measures
Education Modifications of fluid and medication intake Use of toilet substitutes Environmental manipulations Garments and pads
Tx options for generic urinary incontinence- behavioral interventions, pt dependent
Pelvic muscle exercises
Bladder training
Bladder retraining
Tx options for generic urinary incontinence- behavioral interventions, pts independent
Scheduled toileting
Habit training
Prompted voiding
Tx options for generic urinary incontinence- drugs and periurethral injections
Antimuscarinics
Alpha-agonists
Alpha-antagonists
Estrogen
Tx options for generic urinary incontinence- surgery
Bladder neck suspension or sling
Removal of obstruction or pathologic lesion
Tx options for generic urinary incontinence- mechanical devices
Penile clamps
Artificial sphincters
Sacral nerve sphincters
Tx options for generic urinary incontinence- catheters
External
Intermittent
Indwelling
Primary tx for stress incontinence
Pelvic muscle exercises Other behavioral interventions Alpha-adrengic agonists Topical estrogen Periuethral injections
Primary tx for urge incontinence
Bladder relaxants
Topical estrogen if atrophic vaginitis present
Bladder training
Primary tx for overflow incontinence
Surgical removal of obstruction
Bladder retraining
Intermittent catheterization
Indwelling catheterization
Primary tx for functional incontinence
Behavioral interventions
Environmental manipulations
Incontinence undergarments and pads
Antimuscarinic MOA for urinary incontinence
Increase bladder capacity and diminish involuntary bladder contractions
Type of incontinence that antimuscarinics treat
Urge or mixed with urge predominant
Potential common adverse effects of antimuscarinics
Dry mouth Constipation Blurry vision Elevated IOP Cognitive impairment Delirium
MOA of alpha-adrenergic antagonists for urinary incontinence
Relax smooth muscle of urethra and prostatic capsule
Type of incontinence that alpha-adrenergic antagonists treat
Urge incontinence and related irritative sx associated with benign prostatic enlargement
May be more effective in combination with an antimuscarinic drug
Potential common AEs of alpha-adrenergic antagonists for urinary incontinence
Postural hypotension
MOA of pseudoephedrine for urinary incontinence
Stimulates contraction of urethral smooth muscle
Alpha-adrenergic agonists available for urinary incontinence
Pseudoephedrine
Duloxetine
Type of incontinence alpha-adrenergic agonists treat
Stress
Potential common AEs of pseudoephedrine
HA
Tachycardia
Elevation of BP
MOA of duloxetine
Increases alpha-adrenergic tone to the urethra
Potential AE of duloxetine
Nausea
MOA of topical estrogen cream
Strengthen periurethral tissues
Type of incontinence topical estrogen cream treats
Urge associated with severe vaginal atrophy or atrophic vaginitis
Potential AE of topical estrogen cream
Local irritation
MOA of vaginal estradiol ring
Increase periurethral blood flow
Type of incontinence vaginal estradiol ring treats
Stress
MOA of arginine vasopressin for urinary incontinence
Prevents water loss from the kidney
Type of incontinence arginine vasopressin treats
Nocturia that is bothersome and does not respond to other txs
Potential AEs of DDAVP oral (arginine vasopressin category)
Hyponatremia
Potential AEs of nasal spray (arginine vasopressin category)
Flushing
Nausea
Rhinitis
MOA of bethanechol for urinary incontinence
Stimulate bladder contraction
Type of incontinence treated by bethanechol
Acute incontinence associated with incomplete bladder emptying in the absence of obstruction
Possible AEs of bethanechol
Bradycardia Hypotension Bronchoconstriction Gastric acid secretion Diarrhea
