1. Geriatrics Dan Cushman Dan Cushman 2010

2. URINARY INCONTINENCE Dan Cushman 2010

3. Urinary Incontinence Not a normal part of aging Definition: Involuntary loss of urine, severe enough to cause social and/or health problems To be continent, one needs to have: – Properly functioning lower urinary tract – Proper mobility & dexterity with motivation – An appropriate environment Dan Cushman 2010 Normal/Not Normal? Voluntary? 3 Items

4. The 4 Basic Causes 1.Urologic 2.Neurologic 3.Functional/Psychological 4.Iatrogenic/Environmental They can be mixed! Dan Cushman 2010

5. Overactive Bladder Definition: a strong and sudden desire to urinate A type of urge incontinence – It is possible to see OAB without (urge) incontinence though Dan Cushman 2010 ??

6. Overactive Bladder Not to be confused with overactive adder A good history and physical is key in the differentiation of the two Dan Cushman 2010 BLADDER ADDER

7. Anatomy Detrusor Trigone Internal sphincter External sphincter Dan Cushman 2010

8. Sympathetic system Travels via hypogastric nerve Has alpha and beta receptors Uses Norepinephrine Facilitates bladder filling Dan Cushman 2010

9. Somatic fibers Travel via pudendal nerve Uses Acetylcholine Increased tone during filling phase Prevents outflow of urine Dan Cushman 2010

10. Parasympathetic system Travels via pelvic nerve Acetylcholine, acting on muscarinic receptors Causes bladder emptying Increased tone during emptying phase Dan Cushman 2010

11. Pick the system! Pudendal nerve Hypogastric nerve Pelvic nerve Acetycholine NE Facilitates bladder filling Increased tone during emptying phase Somatic Sympathetic Parasympathetic Parasymp. + somatic Sympathetic Symp. + somatic Parasympathetic Dan Cushman 2010 Somatic/Sympathetic/ParasympatheticCharacteristic

12. Urinary reflex Urination is a reflex that can be inhibited by higher brain centers. – Sacral micturation center is a parasympathetic reflex arc – Desire to void between 150mL and 300mL Dan Cushman 2010

13. Age-related Changes Bladder overactivity Detrusor hyperactivity with impaired contractility Urethral sphincter Pelvic floor weakness Cystocele Atrophic vaginitis BPH/Prostate Cancer Often idiopathic, can be caused by stroke, dementia, PD, SCI, or irritation of bladder DHIC – urgency, hesitancy, straining, weak urinary stream, feelings of incomplete emptying Think urgency or stress incontinence; can be caused by childbirth, surgery, or loss of estrogen Urgency, pelvic organ prolapse Urgency, difficulty voiding, and urinary retention Can manifest as urgency, with symptoms of OAB Voiding difficulty, symptoms of OAB; increased sensitivity to endogenous acetylcholine Dan Cushman 2010

14. Acute Causes of UI D R I P elirium estricted mobility and retention nfection, inflammation, and impaction olyuria & pharmaceuticals Psychotropics Anticholinergics Narcotics Diuretics Anti-Cholinesterases Alpha agonists Alpha antagonists ACEI, NSAIDs, CCBs, All potentially reversible Dan Cushman 2010

15. Persistent Causes of UI Stress Urge Functional Overflow Loss of small amounts of urine, due to intraabdominal pressure; unusual in men Variable amount of urine loss Mobility problems or functional impairment Loss of small amounts of urine, due to overdistended bladder Dan Cushman 2010

16. First 2 questions of the history… “Tell me about the symptoms you are having” “What are your expectations from the assessment and treatment?” Dan Cushman 2010

17. Urinary Tract Symptoms Bladder storage difficulty or overactive bladder (urinary freq, urgency, nocturia) Bladder emptying difficulty (hesitancy, slow stream, straining, incomplete emptying) Stress incontinence (leakage with cough) Leakage without warning Other symptoms (dysuria, hematuria, suprapubic discomfort) Dan Cushman 2010

18. Past GU History Childbirth Surgery Urinary retention Recurrent UTIs (>= 2 in past year) Treatment Response Why no longer using it Dan Cushman 2010

19. Fluid Intake Pattern Type and amount of fluid Caffeine Alcohol Dan Cushman 2010

20. BEER’S LIST Dan Cushman 2010

21. Side Effects Sedation + Increased risk of falls Sedation + anticholinergic CNS toxic reactions Confusion + sedation + anticholinergic Anticholinergic Confusion Dan Cushman 2010 Long-acting benzodiazepenes TCAs Indomethacin Antihistamines Muscle Relaxants GI anti-spasmodics (Dicyclomine, hyoscyamine, propantheline) Meperidine

22. Peptic ulcer disease CNS stimulation + angina + HTN + MI Renal failure + GI bleeding + HTN + CHF Insomnia + agitation (long t 1/2 ) Exacerbation of bowel dysfunction Renal impairment Hypotension + dry mouth Side Effects Dan Cushman 2010 Ketorolac Amphetamines NSAIDs (Naproxen, oxaprozin, piroxicam) Fluoxetine Stimulant laxatives (bisacodyl, cascara sagrada, neoloid) Nitrofurantoin Doxazosin

23. CNS + extrapyramidal effects Hypotension + constipation Hypotension + CNS side effects Aspiration Confusion + delirium Goggles (extremely dangerous in NH setting) Side Effects Dan Cushman 2010 Thioridazine Short-acting nifedipine (procardia and adalat) Clonidine Mineral oil Cimetidine Beer

24. Pseudoephedrine, amphetamines NSAIDs Clozapine, chlorpromazine, thioridazine ASA, NSAIDs, Clopidogrel, Dipyradimole Anticholinergic drugs Alpha blockers, TCAs, long-acting benzos TCAs Avoid which medications…? Dan Cushman 2010 HTN Ulcers Seizure disorders Disorders of blood clotting  ↑ bleeding Bladder outflow obstruction Stress incontinence Arrhythmias

25. Decongestants, MAOIs, amphetamines Metoclopramide, conventional antipsychotics Anticholinergics, muscle relaxants, stimulants Long-term benzos, sympatholytics CNS stimulants, fluoxetine Benzos, TCAs, SSRIs SSRIs Avoid which medications…? Dan Cushman 2010 Insomnia Parkinson’s Disease Cognitive Impairment Depression Anorexia & malnutrition Syncope or falls SAIDH/hyponatremia

26. Buproprion Olanzapine CCBs, anticholinergics, TCAs Thiazide diuretics Loop diuretics Avoid which medications…? Dan Cushman 2010 Seizure disorder Obesity Chronic constipation Hyponatremia Patients at risk for dehydration

27. Main anticholinergic drugs (6) Muscle relaxants Urinary antispasmodics Scopolamine/Atropine COPD (e.g. ipratropium) Antihistamines TCAs Dan Cushman 2010

28. Polypharmacy Dan Cushman 2010 Which benzo has a t 1/2 of up to 1 week? Diazepam (Valium) What is bad about geriatric use of fluoxetine (Prozac)? Long t 1/2, lots of side effects Which geriatric syndrome is caused by SSRI use? Falls (as many as with TCAs!) How ball can cat eat red meat? Delirium Remember the active metabolites!

29. GERIATRIC DOMAINS Dan Cushman 2010

30. 4 Geriatric Domains Dan Cushman 2010

31. Psychological Domain Dan Cushman 2010 Mood disorders Cognitive disorders Depression Anxiety Dementia Delirium

32. Functional Domain Dan Cushman 2010 ADLsIADLs Transfers Dressing Telephone Transportation Feeding Toileting Showering Cooking Shopping Housework Medicines Manage $$

33. 3 ± 2 (1-5) 7 ± 3 (4-10) 12 ± 2 (10-14) Not diagnostic Geriatric Depression Scale Dan Cushman 2010 Normal score Mildly depressed score Very depressed score Is a score of 12 diagnostic of depression?

34. PAIN MANAGEMENT Dan Cushman 2010

35. Heat/Cold Physical therapy/exercise Emotional support / biofeedback Change in position / improvement in body mechanics Relieve pressure points Use of pillows / foam pads to support painful sites, e.g., limbs Comfortable clothing Care in assistance with moving the person Distraction / Redirection Alternative therapies Non-pharmacologic analgesics Dan Cushman 2010

36. Pattern of pain Avoid toxicity Consider added benefits Route of administration & patient- specific factors Medication choice principles Dan Cushman 2010

37. WHO Pain Ladder Dan Cushman 2010 Pain level (1-10)? Medication?

38. Pain relievers – which class of pain? Hydrocodone Hydromorphone Acetaminophen Oxycodone Codeine Morphine Fentanyl Dan Cushman 2010 Moderate Severe Mild Moderate or Severe Moderate Severe

39. Abnormal renal function Peptic ulcer disease Bleeding diathesis 3 NSAID contraindications Dan Cushman 2010

40. Constipation Sedation including respiratory depression Impaired cognitive performance (including delirium) Falls Nausea and vomiting Pruritus Myoclonus Adverse effects of opioids (7) Dan Cushman 2010 Which symptom usually does not resolve when opioid levels reach steady state?

41. Bonus Constipation Question!!!! Dan Cushman 2010 Why do opioids cause constipation? They bind to mu receptors in the intestinal tract

42. Opioid Guidelines Dan Cushman 2010 What % of the daily dose is the breakthrough dose? 10% If pain is not controlled, increase opioid by what %? 25-50% Do what if the patient develops N/V? Give anti-emetic 1mg IV morphine = ?mg PO morphine 3mg Morphine + VA Nursing home = ? Bore-phine I will also accept “still not enough pain control” I will also accept “a very powerful sedative”

43. END-OF-LIFE CARE Dan Cushman 2010

44. Don’t be an asshole Most important part of breaking bad news Dan Cushman 2010

45. SPIKES S P I K E S etting up the interview erception (of the patient) nvitation nowledge mpathy / Emotions trategy & summary Dan Cushman 2010 Little known fact: People who use mnemonics to try and appear empathic never appear empathic, especially when they mouth “Perception” for the P.

46. CLASS C L A S ontext istening skills cknowledgement of patient’s emotions trategy for clinical management ummary Dan Cushman 2010 Little known fact: the CLASS protocol was created by a professor in an academic institution.

47. Identify patient by tag No response to verbal or tactile stimuli Absence of heart sounds & pulse Listen for respirations Pupil location + absence of pupillary light reflex Steps of death pronouncement Dan Cushman 2010 Little known fact: It is actually not OK to perform any testicle twisting during the death pronouncement. This is a common intern mistake.

48. Which stage of dying? Bed-bound Coma Loss of ability to eat/drink Fever Death Rattle Altered respirations Increasing time sleeping Dan Cushman 2010 Early Late Early Late Mid Late Early

49. Put the following in the correct order of occurrence Death rattle Cyanosis Lack of radial pulse Respiration with mandibular movement Dan Cushman 2010 First Third Fourth Second

50. Put the following in the correct order of loss before dying Speech Hearing Touch Vision Thirst Hunger Dan Cushman 2010 3 3 5 5 6 6 4 4 2 2 1 1

51. Violent and sudden deaths Deaths in which the bereaved may feel some sense of responsibility Deaths of young people Highly dependent on the deceased, such as elderly spouses Previous history of mental health Poverty and cultural isolation Deaths that may cause complicated bereavement Dan Cushman 2010 Little known fact: the word “bereavement” comes from the Oregonian word “beaverment,” which came each year when beaver hunting season ended

52. Should you (during a conversation announcing someone’s death)…? Answer a page? Eat a hamburger? Use the word “died?” Say “I have some bad news…?” Use puppets to explain the scenario? Ask if the patient has questions? Perform testicle twisting? Dan Cushman 2010 No Yes No Yes Still no

53. Thanks for the memories! Dan Cushman 2010