Myriam Edwards MD
description
Transcript of Myriam Edwards MD
GERIATRIC SYNDROMES: MEMORY PROBLEMS, DEPRESSION,
FALLS, AND URINE LEAKAGEFUNCTIONAL ASSESSMENT OF THE OLDER ADULT II
Myriam Edwards MD Geriatrician, Assistant Professor, and
Geriatric Medicine Fellowship Program Director
Hurley Medical Center / Michigan State University
Geriatric Education Center of Michigan
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 byMark Ensberg, MDGeriatric Education CenterMichigan State University
QUALITY OF LIFE
Home
Inde-pendence
Activity & Mobility
Spiritu-ality
Family & Friends
GERIATRIC SYNDROMES 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
RESOURCES: MEMORY IMPAIRMENT
www.alz.org
www.worriedaboutmemoryloss.com
www.dementiacoalition.org
SCREENING FOR DEPRESSION
• Do you feel sad or blue?• Have you lost interest in doing
things that you have enjoyed?PHQ - 2
• What are you looking forward to?• What do you do for enjoyment?
Other Good
Questions
HOW CAN CLINICAL PRESENTATION DIFFER IN OLDER ADULTS?
Masked depression Denial of sadness Anxiety
Somatic Symptoms Multiple other medical conditions Depression and Memory Impairment
DSM IV – MAJOR DEPRESSION 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
Slide 9
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 10
DIAGNOSIS IN OLDER PATIENTS IS DIFFICULT BECAUSE THEY . . .
• More often report somatic symptoms
• Less often report depressed mood, guilt
• May present with “masked” depression cloaked in preoccupation with physical concerns and complicated by overlap of physical and emotional symptoms
Slide 11
DSM-IV DIAGNOSTIC CRITERIA FOR MAJOR DEPRESSION
Gateway symptoms (must have 1)• Depressed mood • Loss of interest or pleasure (anhedonia)
Other symptoms• 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
Slide 12
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 13
CLINICAL COURSE IN MAJOR DEPRESSION
Recurrence, partial recovery, and chronicity . . .
disability
use of health care resources
morbidity and mortality
suicide
Slide 14
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
FALLS Ask & evaluate every
patient!
Get Up and Go
Look for signs of injury
MEDI - CARE FOR FALLS
Medi - cationsChronic Risk FactorsAcute (short term) Risk FactorsRehab (activity) Related RiskEnvironmental Risk
Slide 18 Slide 18
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 19 Slide 19
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
Usually multifactorial
Slide 20 Slide 20
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)
• Establish person’s comfortable gait speed; use as both assessment and outcome measure
• Remember that most gait disorders are associated with underlying disease
Slide 21 Slide 21
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 22 Slide 22
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
• Results are strongly associated with functional independence in ADLs
Slide 23 Slide 23
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 24Slide 24
EPIDEMIOLOGY OF FALLS
Each year 30%–40% of community-dwelling persons aged ≥65, and about 50% of residents of long-term-
care facilities, experience falls
Community LT Care0
10
20
30
40
50
60
Slide 25Slide 25
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 26 Slide 26
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
• Mortality highest in white men aged ≥85: 180 deaths/100,000 population
Slide 27 Slide 27
SEQUELAE OF FALLS• 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 28 Slide 28
COSTS OF FALLS• Emergency department visits
• Hospitalizations
• Indirect cost from fall-related injuries like hip fractures is substantial
Slide 29 Slide 29
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 30 Slide 30
CAUSES: MEDICATION USE Specific classes, eg:
Benzodiazepines Antidepressants Antipsychotic drugs Cardiac medications Hypoglycemic agents
Recent medication dosage adjustments
Total number of medications
ASK ABOUT URINE LEAKAGE
History Brown Paper Bag Test
(Med Review) Bladder Log / Diary (PVR / Bladder Scan)
Do you make it to the bathroom every time you have to go?
Slide 32
PREVALENCE OF UI Affects 15%–30% of community-dwelling
older adults
Affects 60%-70% of residents of long-term-care institutions
Prevalence increases with age
Affects more women than men (2:1) until age 80 (then 1:1)
Slide 33
IMPACT OF UI ON OLDER ADULTS Morbidity
Sleep deprivation, falls with fractures, sexual dysfunction
Depression, social withdrawal, impaired quality of life
Cellulitis, pressure ulcers, UTIs
Costs: >$26 billion annually
Slide 34
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
Costs: >$26 billion annually
Slide 35
FACTORS CONTRIBUTING TO OR CAUSING UI IN OLDER PERSONS
Comorbid disease• Degenerative joint disease• Sleep apnea• Congestive heart failure• Severe constipation• Diabetes
Neurological/Psychiatric• Stroke• Parkinson’s disease• Normal pressure
hydrocephalus• Dementias• Depression
Function and environment• Impaired cognition• Impaired mobility• Inaccessible toilets• Lack of caregivers
Slide 36
MEDICATIONS THAT CAN CAUSE OR WORSEN UI
• Alcohol• α-Adrenergic agonists• α-Adrenergic blockers• ACE inhibitors• Anticholinergics• Antipsychotics• Calcium-channel
blockers• Cholinesterase inhibitors
• Estrogen • GABAergic agents• Loop diuretics• Narcotic analgesics• NSAIDs• Sedative hypnotics• Thiazolidinediones• Tricyclic antidepressants
TRANSIENT INCONTINENCE
Delirium DrugsRetention Restricted Mobility Infection Inflammation ImpactionPolyuria Pharmaceuticals
PERSISTENT INCONTINENCE
Urge Stress Overflow Functional Mixed
Slide 39
URGE INCONTINENCE Most common type of UI in older persons
Associated with uninhibited bladder contractions, called detrusor overactivity (DO)
Signs and symptoms: Abrupt/compelling urgency, frequency, nocturia
Slide 40
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 41
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 42
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 43
MANAGEMENT OF UI: OVERVIEW
Goal: relieve the most bothersome aspect(s)
Stepped management strategy:
Lifestyle
Behavioral DrugsSurgery
Slide 44
ADDRESSING COMORBIDAND 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 45
BEHAVIORAL THERAPY Bladder training and pelvic muscle exercise
(PME): effective for urge, stress, and mixed UI
Prompted voiding: cognitively impaired patients
Slide 46
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 47
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
FallsFuller, 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/toolbox/pdfs/get_up_and_go_test.pdf
RESOURCES
RESOURCES
Urine LeakageUrinary Incontinence Assessment in Older Adults Part I – Transient Urinary Incontinence http://www.hartfordign.org/publications/trythis/issue11-1.pdf
Diagnostic Evaluation of Urinary Incontinence in Geriatric Patients http://www.aafp.org/afp/980600ap/weiss.html
QUALITY OF LIFE
Home IndependenceActivity & Mobility
SpiritualityFamily & Friends