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
