Medicine For the Elderly Flashcards
4 types of incontinence?
Urge
Stress
Overflow
Functional
Define urge incontinence?
Urinary incontinence is accompanied by or immediately preceded by urgency (complaint of sudden compelling desire to pass urine which is difficult to defer)
Symptoms/ signs of urge incontinence?
urinary frequency but only small voided volumes
urgency - may be triggers
nocturia
FUN - frequency, urgency, nocturia
What is a common treatable cause of urge incontinence?
atrophic vaginitis which can be treated with topical oestrogens
What is the most common cause of urge incontinence?
idiopathic detrusor overactivity (in middle aged females)
Management of urge incontinence?
- Treatment: lifestyle advice, bladder drill, medication, botox, neuromodulation, reconstructive surgery
- Medications: mirabegron, solifenacin, oxybutynin, tolterodine
- If there are also features of stress incontinence the person should be offered pelvic floor physio
Define stress incontinence?
- This is the involuntary leakage of urine on effort, exertion, sneezing or coughing causing increased intra-abdominal pressure without a detrusor contraction
- It is due to damage or weakness of the pelvic floor/ urethral function
Risk factors for stress incontinence?
Risk factors include pregnancies, childbirth, menopause, increased age, obesity, smoking (because this causes a chronic cough)
Examination for stress incontinence?
- On examination can ask the patient to do a standing or supine stress test where you ask the patient to cough and look for leakage of urine
- Also want to test dipstick and residual volume before doing further studies
Management of stress incontinence?
- Conservative management: lifestyle advice, pelvic floor physio, pessaries, medication, incontinence pads, surgery
- Medications: this includes duloxetine which is a combined NA and SSRI thought to increase intraurethral closure pressure
Explain what is meant by overflow incontinence?
- Occurs due to the bladder not emptying properly when urinating causing urine to leak out later
- This is more common in men due to prostatic obstruction but in women can occur due to obstruction of the urethra (caused by prolapse) or a poor contractile bladder muscle
Symptoms of overflow incontinence?
- Ask about symptoms of prostatic enlargement – dribbling, incomplete emptying, poor stream, difficulties initiating stream
- Acutely the person may complain of painful urinary retention, in later presentation they may have a palpable bladder, chronic retention, wet at nights and renal impairment, mass is dull to percussion
Management of overflow incontinence?
Treat prostatic enlargement - alpha blockers to relax bladder neck muscles e.g. alfuzosin, tamzulosin. 5 alpha reductase inhibitors to shrink the prostate e.g. finasteride
If someone has had chronic/ bad acute retention they may need taught self catherisation and may never be able to pass urine spontaneously again
Define functional incontinence?
When a patient has other co-morbidities e.g. poor mobility that means they cannot make it to the bathroom in time or they have dementia so don’t go etc.
List some intrinsic factors that can contribute to falls?
- Diabetes – neuropathy causing altered proprioception and vision
- Arthritis – altered gait
- Parkinson’s disease – altered gait
- Incontinence – increased rushing to the toilet
- Cognition – dementia
- Impaired vision and hearing
- Postural hypotension and cardiac arrhythmias
- Age related changes in gait, postural reflexes, muscle strength
- Acute infection can cause worsening of factors already present
List some extrinsic factors that can contribute to falls?
- Medications
- Environmental e.g. rugs, furniture, stairs
- Inappropriate footwear
- Inappropriate use of walking aids
List some medications that can contribute to falls?
- Drugs linked to falls causing postural hypotension: nitrates, ACEi, anticholinergics, L dopa, anti-platelet agents, SSRIs
- Drugs linked to falls causing confusion or sedation etc: benzodiazepines, antipsychotics, opiates, codeine-based analgesia, anticonvulsants, anti-arrhythmic drugs
- Diuretics also increase falls by causing someone to rush to the toilet
What is a common cause of drop attacks?
carotid sinus syndrome
Explain what carotid sinus syndrome is and how you test for it?
- More common as age increases, there is abnormal activation of carotid sinus (where baroreceptors located) which leads to symptoms secondary to cerebral hypoperfusion
- If suspect can do CS massage test looking for pause in HR > 3 seconds, drop in systolic BP > 50 or both
- Some centres you can do a tilt test
- These need referred to cardio – may need a pacemaker
What extra thing do you need to ask about in a falls history?
bone protection
List Fried Frailty characteristics?
- Unintentional weight loss
- Self-reported exhaustion
- Weakness measured by grip strength
- Slow walking speed (1m per second, if slower then that’s a slow walking speed)
- Low physical activity
What is the clinical frailty scale/ rockwood frailty scale?
- Deficit accumulation – another way to define frailty
- Common and used on wards
- Frailty
What is electronic frailty index?
- Useful in general practice when have more information
* Uses routine data to identify older people with mild moderate and severe frailty
Explain what is meant by the comprehensive geriatric assessment and the components?
MDT approach to care essentially composed of medical, functioning, psychological and social/ environment
Medical – Problem list – Co-morbid conditions and disease severity – Medication review – Nutritional status
Functioning – Basic ADLs – Extended ADLs – Activity/exercise status – Gait and balance
Psychological
– Mental status/cognitive function
– Mood/depression testing
Social/ Environment – Informal needs and assets – Social circle – Care resource eligibility & resources – Safety
What is delirium?
- An acute deterioration in mental functioning arising over hours or days that is triggered mainly by acute medical illness, surgery, trauma or drugs
- Pathophysiology is not well understood
Risk factors for delirium?
- Increased age (as someone gets older there is less needed to cause it- a young person could go into delirium but the trigger would have to be larger)
- Pre-existing cognitive impairment
- Post-operative
- Sensory impairment (makes orientation worse)
- Previous episode of delirium
- Drug/ alcohol dependence
- Depression
- Polypharmacy
- Multiple co-morbidities
- ICU Admission
Causes of delirium?
almost anything but some common causes below:
- D- Drugs (most common= benzodiazepines, narcotics, anticholinergics (e.g. oxybutynin))
- E- electrolyte disturbance (e.g. hyponatraemia)
- L- lack of drugs (withdrawal)
- I- infection (UTI, sepsis, pneumonia)
- R- reduced sensory input
- I- intracranial (e.g. stroke/ subdural haemorrhage)
- U- urinary retention
- M- metabolic (e.g. AKI, hypoglycaemia, hypothyroid, B12, Ca)
Signs and symptoms of delirium?
- Acute onset
- Transient and fluctuating course- lucid intervals
- Lasts days to months depending on underlying cause
- Contrast to dementia which is slow and progressive
- Altered consciousness
- Inattention and impaired memory
- Emotional disturbance
- Sleep cycle reversed
- Insomnia
- Disturbing dreams and nightmares
- Disorientation
- Hallucinations and illusions (visual hallucinations common vs psychiatric issues which are more commonly auditory)
Explain the two types of delirium?
- Hyperactive > agitated, aggressive, wandering, easy to diagnose
- Hypoactive > withdrawn, apathetic, sleepy, coma, harder to diagnose but twice the mortality rate
What are 2 screening assessment for delirium?
4AT and Confusion assessment method (CAM)
What are the components of the 4AT?
ALERTNESS, AMT4 (age, dob, place, year), ATTENTION (months of year backwards), ACUTE CHANGE OR FLUCTUATING COURSE
What are the components of CAM?
acute change in mental status and fluctuating mental status over course of day AND inattention AND 1 of disorganized thinking or altered level of consciousness – can be practically quite difficult to use but is a nice definition of delirium
Describe the think delirium time bundle?
- Delirium is often multifactorial so you shouldn’t stop looking just because you have identified one cause
- Triggers - investigate – manage – engage
- History and physical exam (neuro is important)
- NEWS- think sepsis
- Blood glucose
- Medication review
- Pain review
- Assess for urinary retention and constipation
- Assess hydration and fluid balance
- Bloods- FBC, U+E, Ca, LFTs, CRP, Mg, glucose
- Symptoms and signs of infection
- ECG
- Imaging depends on findings
Management of delirium?
Treat underlying causes
Manage environment and provide support:
- Educate staff
- Reality orientation: communicate, clock, calendar in room
- Correct sensory impairments: glasses and hearing aids
- Bright side room with unnecessary noise reduced, unsafe objects removed
- Ensure basic needs are met
Prescribe:
- Sedating drugs can worsen delirium
- Alcohol withdrawal- reducing scale BZD
- Standard antipsychotic used is haloperidol
- If someone has PD/ LBD can’t give haloperidol so give lorazepam
Review frequently and follow up
May need AWI act or mental health act
List some problems caused by constipation?
- Abdominal pain
- Vomiting/ nausea
- Rectal discomfort
- Overflow diarrhea
- Urinary retention/ UTIs
- Rectal bleeding from haemorrhoids
- Delirium
- Depression
List some causes of constipation?
- Low fibre intake
- Dehydration
- Opioids and anti-cholinergics
- Reduced mobility (physically stops people getting to toilet and also moving around helps constipation)
- Parkinsons
Describe assessment of constipation?
3 main questions:
1. Frequency of passing stools and what is their normal (should move bowels at least 3 every 3 days)
2. Consistency using Bristol stool chart
3. Any difficulties evacuating/ feeling of incomplete emptying
• Also ask about fluid intake, diet and exercise
• Examination: abdominal examination, rectal examination
What are the 2 main groups of laxatives?
those targeting hard stool issue
those that are stimulant
Give some examples of laxatives that work by targeting hard stool?
osmotic laxatives e.g. laxido and lactulose which are both sachets and softener laxatives e.g. docusate tablets
Give some examples of stimulant laxatives?
Senna (tablet) and biscodyl (tablet)
When should you consider rectal preparations for treatment of constipation? What are some examples?
- Consider if really full and unable to pass
* Options: glycerine suppositories, microenemas e.g. microlette, phosphate enemas
Who should oxybutynin not be used in?
should not be used in elderly due to increased risk of falls - should use solifenacin, tolteridone or mirabegron instead
(for urge incontinence)
Bone protection for patients who are starting long term steroids ______
should start immediately
Explain what vertebrobasilar insufficiency is and how it would present?
Caused by atherosclerosis in vertebrobasilar arteries. The insufficiency is exacerbated by patient extending their neck. Often results in falls. Patient is elderly has falls, and gets dizzy on extending their neck.
What is indicative of a positive Dix Hallpike?
rotatory nystagmus
