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Myriam Edwards MD Geriatrician, Assistant Professor, and Geriatric Medicine Fellowship Program Director Hurley Medical Center / Michigan State University Geriatric Education Center of Michigan activities are supported by a grant from the U.S. Department of Health and Human Services, Health Resources and Services Administration, Public Health Service Act, Title VII, Section 753(a). This module was developed by Mark Ensberg, MD Geriatric Education Center Michigan State University Family & Friends Spirituality Activity & Mobility Independence Home Groups of specific signs & symptoms that occur more often in elderly Can impact morbidity & mortality Contributing factors: Normal aging changes Multiple comorbidities Adverse effects of therapeutic interventions www.alz.org www.worriedaboutmemoryloss.com www.dementiacoalition.org PHQ - 2 Other Good Questions • Do you feel sad or blue? • Have you lost interest in doing things that you have enjoyed? • What are you looking forward to? • What do you do for enjoyment? Masked depression Denial of sadness Anxiety Somatic Symptoms Multiple other medical conditions Depression and Memory Impairment Sad mood Loss of Interest or pleasure –anhedonia Feelings of Guilt / worthlessness / burden Loss of Energy, fatigue Trouble Concentrating / making decisions Changes in Appetite (weight gain or loss) Restless, Psychomotor agitation or slowing Sleep changes Suicidal Ideation-thought of death EPIDEMIOLOGY AMONG OLDER ADULTS Minor depression 15% of older people Causes use of health services, excess disability, and poor health outcomes, including mortality Major depression 6%–10% of older adults in primary care clinics 12%–20% of nursing home residents 11%–45% of hospitalized older adults Bipolar disorder Common diagnosis among aged psychiatric patients Does not “burn out” in old age Slide 9 DIAGNOSIS IN OLDER PATIENTS IS DIFFICULT BECAUSE THEY . . . • More often report somatic symptoms • Less often report depressed mood, guilt • Slide 10 May present with “masked” depression cloaked in preoccupation with physical concerns and complicated by overlap of physical and emotional symptoms DSM-IV DIAGNOSTIC CRITERIA FOR MAJOR DEPRESSION Gateway symptoms (must have 1) • • Depressed mood Loss of interest or pleasure (anhedonia) Other symptoms • • • • • • • Slide 11 Appetite change or weight loss Insomnia or hypersomnia Psychomotor agitation or retardation Loss of energy Feelings of worthlessness or guilt Difficulty concentrating, making decisions Recurrent thoughts of suicide or death DIAGNOSTIC CHALLENGES IN MEDICAL SETTINGS • Symptoms of depressive and physical disorders often overlap, eg: Disturbed sleep Fatigue Diminished appetite • Seriously ill or disabled people may focus on thoughts of death or worthlessness, but not suicide • Side effects of drugs for other illnesses may be confused with depressive symptoms Slide 12 CLINICAL COURSE IN MAJOR DEPRESSION Recurrence, partial recovery, and chronicity . . . disability use of health care resources morbidity and mortality Slide 13 suicide OLDER ADULTS AND SUICIDE • Older age associated with increasing risk of suicide • One fourth of all suicides occur in people 65 years • Risk factors: depression, physical illness, living alone, white male, alcoholism • Violent suicides (eg, firearms, hanging) are more common than non-violent methods among older adults, despite the potential for drug overdosing Slide 14 Ask & evaluate every patient! Get Up and Go Look for signs of injury Medi - cations Chronic Risk Factors Acute (short term) Risk Factors Rehab (activity) Related Risk Environmental Risk GAIT IMPAIRMENT • Gait disorders are common and a predictor of functional decline • Certain gait-related mobility disorders progress with age and are associated with morbidity and mortality • Community-dwelling older adults with gait disorders, particularly neurologically abnormal gaits, are at higher risk of institutionalization and death Slide 18 Slide 18 CONDITIONS CONTRIBUTING TO GAIT DISORDERS IN PRIMARY CARE SETTINGS • Degenerative joint disease • Acquired musculoskeletal deformities • Intermittent claudication • Impairments following orthopedic surgery • Impairments following stroke • Postural hypotension • Dementia • Fear of falling Slide 19 Usually multifactorial Slide 19 GAIT ASSESSMENT: KEY POINTS • Careful medical history and physical exam can elucidate contributing factors • Use a gait assessment tool (eg, timed Get Up and Go test) • • Slide 20 Establish person’s comfortable gait speed; use as both assessment and outcome measure Remember that most gait disorders are associated with underlying disease Slide 20 THE TIMED GET UP AND GO TEST (1 of 2) Record the time it takes a person to: 1. Rise from a hard-backed chair with arms 2. Walk 10 feet (3 meters) 3. Turn 4. Return to the chair 5. Sit down Slide 21 Slide 21 THE TIMED GET UP AND GO TEST (2 of 2) • Most adults can complete in 10 sec • Most frail elderly adults can complete in 11 to 20 sec • ≥14 sec = falls risk • >20 sec comprehensive evaluation • Slide 22 Results are strongly associated with functional independence in ADLs Slide 22 FALLS Definition: coming to rest inadvertently on the ground or at a lower level • One of the most common geriatric syndromes • Most falls are not associated with syncope • Falls literature usually excludes falls associated with loss of consciousness Slide 23 Slide 23 EPIDEMIOLOGY OF FALLS 60 50 40 30 20 10 0 Community LT Care Each year 30%–40% of community-dwelling persons aged ≥65, and about 50% of residents of long-termcare facilities, experience falls Slide 24Slide 24 EPIDEMIOLOGY OF FALLS • Annual incidence of falls is close to 60% among those with history of falls • Complications of falls are the leading cause of death from injury in persons aged ≥65 Slide 25Slide 25 MORBIDITY AND MORTALITY • Most falls by older adults result in some injury • 10%–15% of falls by older adults result in fracture or other serious injury • The death rate attributable to falls increases with age • Slide 26 Mortality highest in white men aged ≥85: 180 deaths/100,000 population Slide 26 SEQUELAE OF FALLS • • • Slide 27 Associated with: Decline in functional status Nursing home placement Increased use of medical services Fear of falling Half of those who fall are unable to get up without help (“long lie”) A “long lie” predicts lasting decline in functional status Slide 27 COSTS OF FALLS • Emergency department visits • Hospitalizations • Slide 28 Indirect cost from fall-related injuries like hip fractures is substantial Slide 28 CAUSES: INTRINSIC • Age-related decline • Changes in visual function Proprioceptive system, vestibular system Chronic disease Parkinson’s disease Osteoarthritis Cognitive impairment • Acute illness • Medication use (see next slide) Slide 29 Slide 29 CAUSES: MEDICATION USE Specific classes, eg: Slide 30 Benzodiazepines Antidepressants Antipsychotic drugs Cardiac medications Hypoglycemic agents Recent medication dosage adjustments Total number of medications Slide 30 History Brown Paper Bag Test (Med Review) Bladder Log / Diary (PVR / Bladder Scan) PREVALENCE OF UI Slide 32 Affects 15%–30% of community-dwelling older adults Affects 60%-70% of residents of long-termcare institutions Prevalence increases with age Affects more women than men (2:1) until age 80 (then 1:1) IMPACT OF UI ON OLDER ADULTS Morbidity Sleep deprivation, falls with fractures, sexual dysfunction Depression, social withdrawal, impaired quality of life Cellulitis, Slide 33 pressure ulcers, UTIs Costs: >$26 billion annually IMPACT OF UI ON OLDER ADULTS Morbidity Cellulitis, pressure ulcers, UTIs Sleep deprivation, falls with fractures, sexual dysfunction Depression, social withdrawal, impaired quality of life Slide 34 Costs: >$26 billion annually FACTORS CONTRIBUTING TO OR CAUSING UI IN OLDER PERSONS Comorbid disease • Degenerative joint disease • Sleep apnea • Congestive heart failure • Severe constipation • Diabetes Function and environment • Impaired cognition • Impaired mobility • Inaccessible toilets • Lack of caregivers Slide 35 Neurological/Psychiatric • Stroke • Parkinson’s disease • Normal pressure hydrocephalus • Dementias • Depression MEDICATIONS THAT CAN CAUSE OR WORSEN UI • • • • • • • Alcohol α-Adrenergic agonists α-Adrenergic blockers ACE inhibitors Anticholinergics Antipsychotics Calcium-channel blockers • Cholinesterase inhibitors Slide 36 • • • • • • • • Estrogen GABAergic agents Loop diuretics Narcotic analgesics NSAIDs Sedative hypnotics Thiazolidinediones Tricyclic antidepressants Delirium Retention Infection Polyuria Drugs Restricted Mobility Inflammation Impaction Pharmaceuticals Urge Stress Overflow Functional Mixed URGE INCONTINENCE Most common type of UI in older persons Associated with uninhibited bladder contractions, called detrusor overactivity (DO) Signs Slide 39 and symptoms: Abrupt/compelling urgency, frequency, nocturia STRESS INCONTINENCE (1 of 2) Second most common type in older women; postprotatectomy stress UI increasingly common in men Occurs with increased intra-abdominal pressure, in the absence of a bladder contraction Often coexists with urge UI (mixed UI) Slide 40 UI WITH IMPAIRED BLADDER EMPTYING Results from detrusor underactivity, bladder outlet obstruction, or both Leakage is small but continual; PVR is elevated Symptoms: dribbling, weak urinary stream, intermittency, hesitancy, frequency, nocturia Associated urge and stress leakage may occur Slide 41 OUTLET OBSTRUCTION Second most common cause of UI in older men Most obstructed men are not incontinent Causes in men: BPH, prostate cancer, urethral stricture Uncommon in women; usually due to previous anti-UI surgery or large cystocele Slide 42 MANAGEMENT OF UI: OVERVIEW Goal: relieve the most bothersome aspect(s) Stepped management strategy: Behavioral Lifestyle Slide 43 Drugs Surgery ADDRESSING COMORBID AND LIFESTYLE FACTORS Correct/address underlying medical illnesses, functional impairments, and medications that may contribute to UI Weight loss for moderately obese Manage fluid intake: avoid caffeine, alcohol; minimize evening intake In smokers with stress UI: tobacco cessation Slide 44 BEHAVIORAL THERAPY Bladder training and pelvic muscle exercise (PME): effective for urge, stress, and mixed UI Prompted voiding: cognitively impaired patients Slide 45 SUMMARY (1 of 2) Urinary incontinence is common in older adults & results in impaired quality of life, morbidity, and increased costs Age-related changes & common disorders/impairments increase an older person’s risk of incontinence Evaluation is based on history, physical, and focused laboratory testing Slide 46 SUMMARY (2 of 2) Treatment is stepwise, starting with remediation of comorbid and lifestyle factors, progressing to behavioral therapy, medications, and, if necessary, surgery Indwelling catheters should be used with caution, only when absolutely necessary Slide 47 Falls Fuller, G. F. (2000). Falls in the elderly http://www.aafp.org/afp/20000401/2159.html Timed Get Up & Go Test http://www.hospitalmedicine.org/geriresource/to olbox/pdfs/get_up_and_go_test.pdf Urine Leakage Urinary Incontinence Assessment in Older Adults Part I – Transient Urinary Incontinence http://www.hartfordign.org/publications/trythis/iss ue11-1.pdf Diagnostic Evaluation of Urinary Incontinence in Geriatric Patients http://www.aafp.org/afp/980600ap/weiss.html Home Family & Friends Independence Activity & Mobility Spirituality
