qusetions_Geriatric Medicine

Educational objective: Review common causes of urinary incontinence in the elderly population.

Urinary incontinence is common in elderly persons: about 30% of the elderly report difficulty holding urine until they go to the bathroom some of the time, and 8% report difficulty most or all of the time. Urinary incontinence affects quality of life and contributes to institutionalization.

An efficient approach to transient or recent-onset incontinence consists of evaluation for commonly occurring precipitants, as specified by the mnemonic DIAPPERS: Delirium, Infection, Atrophic vaginitis, Pharmaceuticals, Psychological factors (depression, etc.), Excess urine output (excess fluid intake, alcohol, caffeine, diuretics, peripheral edema, hyperglycemia, hypercalcemia), Restricted mobility, and Stool impaction.

This patient appears to have a slowly progressive dementia with features typical of Alzheimer’s dementia. Urinary incontinence occurs in the course of this illness, most likely due to apraxia, decreased awareness, decreased mobility, inability to find the bathroom, and other factors. A vital function of the physician caring for persons with dementia is to minimize “excess disability” from medications, medical conditions, and other causes.

Benzodiazepines are commonly associated with confusion, particularly in patients with chronic cognitive impairment, and are therefore best avoided. In addition, these medications are frequently associated with urinary incontinence, most likely through decreased mental functioning.

Condom catheter may eventually be useful in the management of this patient’s incontinence, but it is inappropriate to treat the symptom of incontinence without addressing potential treatable acute and chronic causes.

B-blockers are not commonly associated with incontinence. Although excess disability due to medical illness occurs in demented patients, it is not efficient to investigate occult problems with blood tests before treating likely causes of new onset incontinence.

Although prompted voiding has been successful in improving urinary incontinence in nursing home patients who initially respond to this approach, it would be more appropriate first to remove common precipitating factors.

Educational objective: Review assessment of functional capability among the elderly population.

Assessment of the activities of daily living is an integral part of the assessment of the elderly patient. Activities of daily living include the following:

Basic activities of daily living Dressing, Eating, Ambulating, Toileting, Hygiene (DEATH) Instrumental activities of daily living Shopping, Housekeeping, Accounting, Food preparation, Transportation (SHAFT)

It is enough to first inquire about one or two instrumental activities of daily living. If the patient is capable of those, there is no need for further inquiry.

Educational objective: Review causes of presbycusis.

Presbycusis is characterized by gradual hearing loss with aging that is manifested by difficulty understanding speech in noisy surroundings. Hearing loss is sensorineural with loss of the neuroepithelial cells, lesions of the neurons and of the stria vascularis. Hearing aids are the most common modality of treatment.

Hippocampus, frontal and temporal lobes demonstrate the most striking cortical loss in patients with Alzheimer’s disease. Major association areas are also involved with significant cortical atrophy. Relatively spared areas include the motor and sensory cortex as well as the visual cortex.

Dizygotic twins are 2-3 times less concordant for Alzheimer’s disease than monozygotic twins. Dementia occurs in the other twin within 5 years only in about 50% of patients studied. It has also been shown that genetic influences are more pronounced in cases of early onset of the disease. The APOE4 gene mutations are shown to be associated more with late onset disease rather than in those found in twins. Twins studies cannot rule out environmental influences in any given disease.

Criteria for the clinical diagnosis of Alzheimer's disease include the following:

• Impairment of two areas of cognition.
• Progressive decline in the memory function.
• No disturbance in consciousness.
• No systemic disease or disorder that could account for dementia.

Although changes in personality and myoclonus may occur in patients with Alzheimer’s disease, these changes are not required for diagnosis.

Dependence for activities of daily living is late in occurrence and is not included in the diagnostic criteria.

Alzheimer’s disease can be definitely diagnosed only by brain biopsy, but clinical characteristics can identify most patients with the disease. Neurofibrillary tangles (swollen neurons filled with submicroscopic filamentous structures that are approximately 10 nm in diameter), and neuritic amyloid plaques (clusters of degenerating neurons which are associated with extracellular arrays of linear filaments of amyloid) are main features of the pathology in affected patients. The most affected cell group is large neurons (greater than 90 mm2). More than 60% of such cells are lost during the progression of the disease. Magnetic resonance imaging usually shows atrophy of the cortex and hippocampal area as well as loss of the cortical markings, enlarged ventricles and enhancements of the meninges.

There is no effective pharmacologic therapy for Alzheimer’s disease; care for every case should include attention to the safety of the patient, needs of the family and primary caregiver, as well as symptomatic management of the patient.

Overflow incontinence, the most common cause of urinary incontinence in men, is due to detrusor weakness and/or bladder outlet obstruction. Leakage is typically small in volume, but its continual nature may lead to significant wetting. The postvoid residual volume is elevated, and urinary stream may be weak. Dribbling, intermittency, hesitancy, frequency and nocturia are also symptoms.

Bladder outlet obstruction is the second most common cause of urinary incontinence in older men, resulting from benign prostatic hyperplasia, prostate cancer or urethral stricture. Most obstructed men do not have urinary incontinence. Detrussor overactivity occurs in approximately 2/3 of men with obstruction, resulting in urge symptoms. Overflow incontinence, in those cases, occurs when obstruction causes detrusor decompensation.

Urge incontinence is abrupt, precipitant urgency with moderate to large urinary leakage, often in association with nocturia and frequency. Cause of urge incontinence is presumed to be uninhibited bladder contractions and detrusor overactivity. Detrusor overactivity has, however, been found in continent, healthy elderly individuals, suggesting that overactivity alone is not enough to cause incontinence. Detrusor overactivity may be caused by interruption of CNS inhibitory pathways in the case of stroke or cervical stenosis, etc. Bladder irritation caused by infection, bladder stones, inflammation, or neoplasms also may lead to detrusor overactivity. It appears that overactivity of detrusor muscle may be related to aging also, and it is idiopathic in many cases.

Multiple pregnancies are implicated in the development of stress incontinence by weakening of the pelvic floor muscles.

Physicians have recognized the right of the patient to participate in medical decision-making for the last 25 years. The principle of autonomy, or the right to make choices about one’s own life, has now become the centerpiece of modern American biomedical ethics. Approximately 50% of the individuals over 85 have dementia, which usually precludes their understanding of the medical issues and requires surrogate decision-making. In addition, many cognitively intact elderly people are delirious during an acute illness and are incapable of complex discussions about their care at the time when many important decisions have to be made. In these cases where a patient can’t make decisions, a surrogate decision-maker must be identified.

The physician must assess the patient’s decision-making capacity before concluding that the patient cannot speak for himself or herself.

Educational objective: Review similarities between hypothyroidism and depression in the elderly.

Hypothyroidism is often associated with depression, which may be quite severe. Also, albeit more rarely, myxedematous may become confused, paranoid, or even manic (“myxedema madness”). Screening of psychiatric admissions with FT4 and TSH is an efficient way to find those patients who will frequently respond to levothyroxine therapy alone or in combination with psychopharmacologic agents. Levothyroxine is also used in low dose to potentiate antidepressive therapy in the patients with major depression.

Symptoms of tricyclic antidepressant overdose include agitation, hallucinations, urinary retention, confusion, hypothermia, hypotension, ventricular tachycardia (preceded by prolongation of the QRS complex and QTc interval), and seizures.

Prolonged QRS complex (>0.10 sec) or QTc interval (>0.42 sec) should be treated with sodium bicarbonate. Ventricular arrhythmias often respond to phenytoin (15-20 mg/kg for adults) with concurrent systemic alkalinization. If there is no response to this therapy, lidocaine (1 mg/kg IV followed by a titrated infusion) may be used. Physostigmine (1-2 mg IV slowly for adults or 0.5 mg IV slowly for children) may be indicated in reversing cardiac arrhythmias that are due to vagal blockade or for anticholinergic effects. Seizures usually respond to IV boluses of diazepam (0.2 mg/kg).

The best therapy for this woman is daily low-dose continuous estrogen and progesterone. She has symptoms of estrogen deficiency (hot flashes and vaginal dryness) and is at increased risk for cardiovascular disease (positive family history and abnormal lipid profile) as well as osteoporotic fractures (positive family history and decreased bone density in the hip area).

Vaginal estrogen creams will help vaginal symptoms but have no effect on hot flashes and risk from cardiovascular disease or osteoporosis. The use of PO or transdermal estrogens alone is contraindicated in women with a uterus because of their effect on endometrium (hyperplasia). The addition of progesterone provides protection against the effects of unopposed estrogen. Among the regimens that combine estrogen with progesterone, transdermal estrogen preparations have the least beneficial effect on the lipid profile; therefore an oral estrogen/progesterone regimen is preferable in this woman.

Since she does not wish to resume uterine bleeding, therapy with low-dose continuous estrogen and progesterone is more likely to result in an atrophic endometrium and amenorrhea than cyclic estrogen–progesterone regimens. The family history of breast cancer in one second-degree relative is not a contraindication to the use of estrogen.

Bisphosphonate therapies are shown to have beneficial effects on bone mineral density but there is no effect on the rest of the postmenopausal syndrome.

Educational objective: Emphasize the increase in older age groups in the U.S.A.

Between 1980 and 1991 the population of those over 85 grew by 41% to a total of 3.2 million people, while those 75 to 84 experienced a 33% increase to a total of 10.3 million. Overall, U.S. population grew 11% in same time period. An even faster acceleration of increase in the older population will begin around 2010 when the group that was part of the sharply increased birth rate following the end of World War II (“baby boomers”) begin to age and become part of the population 65 and over. Between then and 2030, it is expected that the older population will increase 75% while those under 65 will increase only 6.5%. Since 1960 the age group 85 and older has increased 232%.

Educational objective: Review important epidemiologic characteristics of the elderly in U.S.A.

Most older men are married, and most older women are not. In 1990 among those aged 65 and older, almost twice as many men were married (74% versus 40%). More than three times as many women were widowed (14% of men, 49% of women). These differences result from the fact that women have longer life expectancy and that men are likely to marry younger women. One important consequence of this pattern is that men are more likely than women to have a spouse to assist them in the face of disability and frailty.

This same dynamic is reflected in the living arrangements of American older persons and is greatly influenced by age and race. For example, in 1990, among those aged 65 to 74 the highest proportion of the population was married and living with a spouse. White men made up the majority of this group; 80.3% were married and living with a spouse. Black women were the least likely to be married and living with a spouse (29.6%). In 1990 more than 9 million persons over 65 were living alone (79% of them were women).

Educational objective: Emphasize education as an important health-related factor.

Education is not only considered to be an indicator of economic status but it has also been shown to be associated with better health. Those aged 65 and over are less likely than younger adults to have high levels of education. Only 55% of the current older population has at least a high school education, whereas 82% of those 25 to 64 do. The tendency of younger cohorts to have higher educational attainment is apparent when the whole is broken down into smaller age categories. Of those aged 65 to 69, 63% have completed high school, but of those 70 and over, 46% have done so. In the coming decades more and more elderly persons are expected to have attained higher levels of education. This trend has many positive implications for health, the use of health care, change of health habits, and an increase in the positive attitudes and behaviors associated with greater education.

Educational objective: Emphasize importance of functional capacity in elderly.

The presence of multiple chronic conditions increases the difficulty of measuring and describing health status. This is why the assessment of functional limitation is used to diagnose a person’s overall need for health and health-related care, to monitor improvement, and to measure effect of health care and associated services on outcome. Functional capacity is subdivided into activities of daily living, including ability to transfer (in the household), bathe, feed, toilet, and dress.

Instrumental activities of daily living encompass more complex tasks such as cooking, shopping, housekeeping, managing money, and social activities. Though the results from the many national and regional surveys of this approach vary, they all find similar trends of these parameters being useful in assessing and planning health care.

Educational objective: Review clinical features of delirium.

The most prominent feature of delirium is disturbance of consciousness and attention. This is usually evident when observing patient’s behavior during the medical interview. Easily distracted patients, and those who have difficulties focusing, have a high likelihood of delirium (it is important to keep in mind, however, that a variety of behavioral problems can be seen in patients with delirium).

In milder cases of delirium, bedside tests of attention may be helpful. The digit span test and vigilance `A’ test are examples of such tests. Patients who are unable to recall and repeat a sequence of 5 digits (meaning they have digit span less than 5) have a high likelihood of delirium.

Angry outbursts may be a sign of delirium, but these are much less likely in older patients who tend to have “quiet” forms of delirium. Delirium also may alter the sleep-wake cycle but in hospitalized patients this disturbance is most commonly caused by a noisy and interruptive hospital environment as well as by acute disease itself.

Mini-Mental Status exam has poor specificity for delirium.

Educational objective: Review decrease in protective function of the skin with aging.

Aging brings a number of alterations in skin and mucous membranes that diminish its effectiveness as a barrier. A decrease in the surface acidity and an increase in the dryness of skin due to a decrease in the eccrine gland secretion may alter the skin microbial flora. The skin itself is thinner, and so older persons are more likely to sustain pressure ulcers, lacerations, or abrasions in response to minor trauma. These lesions provide portals of entry for skin bacteria to cause tissue infection or bacteremia.

The mucous membranes of the genitourinary tract and respiratory tree also appear to be less effective in their barrier function. The colonization of both areas by gram-negative organisms is increased. Alterations in secreted mucous in both areas may lead to increased bacterial adherence. Those alterations include changes in the surface glycosaminoglycans, modifications of fibronectins such that adherence is facilitated and secreted antibodies to bacterial fimbria are decreased. Alterations in ciliary function in the respiratory tree also occur.

Educational objective: Review factors that make the elderly more susceptible to infections.

As a result of age-related impairments in swallowing, older persons normally aspirate very small amounts of mouth content. The cough mechanism is impaired with age, with the result that the force of the cough is decreased and the closing volume of lung is earlier because of a loss of elasticity and modification of the lung architecture. This earlier closing volume appears to prevent adequate clearance of the portions of the lung with a cough (impairment of the ciliary action in the respiratory tract is also important).

The urine is less acidic, less concentrated, may have less urea, and appears to have a lower concentration of bacterial adherence-blocking proteins such as the Tamm-Horsfall mucoprotein. The prostatic fluid has less antibacterial activity, and there is less prostatic fluid in the urine of the older man. The bladder of the older person is less completely emptied, which allows pooling of the residual urine and incomplete dismissal of contaminating bacteria. The older person also has a higher potential for obstruction of the urinary tract as a consequence of benign prostatic hyperplasia (BPH), uterine prolapse, urethral stricture, and renal or bladder calculi.

Neutrophil count does not decline with advancing age.

Educational objective: Review physiological changes occurring with aging.

Presbyopia is an age-related change in vision where the closest distance of focusing increases due to loss of the elasticity of the lens and atrophy of the ciliary muscle.

Presbycusis is the loss of hearing in both high and low frequencies due to loss of the cochlear neurons, stiffening of the basilar membrane, loss of the hair cells in the organ of Corti, thickening of the capillaries of the stria vascularis (which is the source of endolymph), and degeneration of the spiral ligament.

Body height starts to diminish after reaching its peak in the ages between 30-40. Height loss is on average 5 cm by the age of 75. This loss is due to increased hip and knee flexion, decreased vertebral body height, vertebral disk compaction, and the flattening of the foot arch.

Although changes in the muscle vary significantly between individuals there is an average relative muscle mass loss between 30-40% from age 30 to age 80.

Change of the heart with aging consists of an increase of the left ventricle mass, diminishing mass of the sinus node, calcium deposition in valves, and lipofuscin in the myocardium. Also, there is a decrease in the intrinsic sinus rate and in spontaneous heart rate variability. Systolic and diastolic blood pressures increase, maximum heart rate diminishes, but ejection fraction and resting cardiac output remain unchanged.

Educational objective: Review the changes in intellectual capabilities with aging.

Cross-sectional research often finds that older people perform less well than younger people on typical, standardized intelligence tests. Such studies show that intellectual abilities as measured by such tests peak in the early 40s and then gradually decline. However, cross-sectional studies confound aging effects with cohort effects. The people in the older cohorts generally had fewer years of education and fewer test-taking experiences than younger people sampled in these studies. When the comparisons are corrected for education levels, the differences in intelligence test scores of different age groups are much smaller.

Longitudinal studies present a more optimistic picture of intelligence and aging. The best of these use sequential designs in which successive cohorts are followed over time. To show a true age effect, different cohorts must show the same changes at about the same age regardless of the historical period. These studies have found that decrements in intelligence testing performance are not observed until after the age of 67, and they remain fairly modest until the age of 81. Furthermore, much of the decline seen in late life is attributable to the slowing of processing and increasing response times. When slowing is extracted from the data analyses, age decrements are significantly attenuated. It appears that healthy elderly persons may need a little more time to complete intelligence tests but do as well as younger people if allowed extra time.

Educational objective: Review diagnostic modalities for osteomyelitis.

Bone biopsy of the underlying bone is the most reliable method of establishing the diagnosis of osteomyelitis in cases of the decubitus ulcer resistant to therapy. Three-phase bone scintigraphy is often used to diagnose bone involvement in infections, but in this case may not clearly establish diagnosis as pressure can produce heterotopic bone formation. This will then lead to scintigraphic and radiographic changes that falsely resemble osteomyelitis. Surface culture of the ulcer or the bone exposed in the ulcer can reflect surface contamination and often does not correlate with the cause of the bony infection. The clinical picture of osteomyelitis is not specific enough to allow diagnosis.

Educational objective: Review the decision-making process for cases in which an incapacitated patient has designated a decision-maker by power of attorney.

A durable power of attorney for health care which takes written form is authorized by statute in practically every state. It enables a decisional person to appoint someone else (the agent) to make future medical treatment choices for him or her in the event of decisional incapacity. The agent may or may not be a family member. A durable power of attorney, unlike a living will, supplies an actual person who is available when decisions must be made and who is authorized to advocate for and interpret the expressed and inferred wishes of the patient. The availability of such an agent is advantageous both to the patient who needs advocacy and the physician who is trying to act according to the wishes of the incapacitated patient.

In this case the patient’s wife acts as the patient’s agent, and her instructions take precedence over all other wishes of the family members.

Educational objective: Review the staging of pressure ulcers.

Pressure ulcers are staged as follows:

• Stage I
  • – Nonblanchable erythema of intact skin, the heralding lesion of skin ulceration. In individuals with darker skin, discoloration of the skin, warmth, edema, induration, or hardness may also be indicators.
• Stage II
  • – Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater.
• Stage III
  • – Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.
• Stage IV
  • – Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts also may be associated with stage IV pressure ulcers.

Educational objective: Review different methods of debridement for pressure ulcers.

Moist, devitalized tissue supports the growth of pathological organisms. Therefore, the removal of such tissue favorably alters the healing environment of a wound (this has, however, not been studied in randomized trials).

Mechanical methods of debridement include wet-to-dry dressing, hydrotherapy, and wound irrigation, use of dextranomeres, enzymatic debridement, and sharp surgical debridement.

Surgical debridement should be used to remove areas of thick, adherent eschars and devitalized tissue in extensive ulcers. As the most rapid means of debridement, it is urgently indicated when there are signs of advancing cellulitis or sepsis (bone biopsy should be done at same time if osteomyelitis is a consideration).

Educational objective: Review the mechanism by which wet-to-dry dressing accomplishes debridement of devitalized tissue.

Wet-to-dry dressings adhere to devitalized tissue. Once the dressings are dry – usually within 4-6 hours – they can be removed and the devitalized tissue will be removed with them. The debriding function of the dressing is at least partly defeated if the dressing is moistened prior to removal. One disadvantage of wet-to-dry dressings is that they adhere to the viable tissue also so that some of the healthy granulation tissue can be removed along with the necrotic debris. The process of dressing removal may be painful; thus adequate analgesia is required. Once the wound is clean and granulating, moist dressing can be used to promote healing by secondary intention, or the wound can be repaired surgically.

Educational objective: Review mechanism of enzymatic debridement of devitalized tissue.

Enzymatic debridement is accomplished by applying topical debriding agents to devitalized tissues on the wound surface. This option should be considered when individuals cannot tolerate surgery or are in long-term care facilities or receiving care at home (it is important to note that this recommendation holds only if ulcer is not infected). Collagenase is a Food and Drug Administration (FDA) approved preparation used for enzymatic debridement. Research findings indicate that collagenase promotes debridement and growth of granulation tissue within 3-30 days. Enzymes can be used alone to break down the eschar, or after sharp surgical debridement, or in conjunction with any other form of mechanical debridement (wet-to-dry dressings, wound irrigation, hydrotherapy, etc.).

Educational objective: Review important clues to inability of patients to swallow safely after stroke.

After a stroke about 25-45% of all patients develop dysphagia. The main problem that stems from dysphagia is aspiration pneumonia, which, if it develops, greatly complicates the clinical course and contributes to mortality. The patient in question had an attack of cough after an attempt to eat. This is a common sign of dysphagia. Physical examination of this patient revealed several findings that suggest dysphagia (facial nerve paresis and dysarthria). It is a common misconception that presence or absence of a gag reflex correlates with the risk of aspiration. This is not true. More important in the assessment of the aspiration risk are speech articulation, ability to swallow, and tongue movement. This patient has enough signs and symptoms to justify formal swallowing evaluation prior to beginning oral intake.

Many patients with dysphagia aspirate silently, without coughing or choking. Nurse’s supervision during the feeding may not ensure that successful suction will be possible if patient aspirates while eating.

Dysphagia after stroke commonly improves. Hence, a permanent form of enteral feeding, such as a gastrostomy tube, is not necessary.

Modification of the diet structure (giving clear liquid diet, etc.) may be a part of the dysphagia management in some circumstances, but liquids have the greatest potential for aspiration.

A nasogastric tube also may be used in certain circumstances, but it carries the risk of paranasal sinus infection as well as aspiration of regurgitated gastric content or leaked gastric content from a malpositioned tube.

Educational objective: Illustrate the presentation of acute mesenteric ischemia.

This patient has had food fear due to chronic mesenteric ischemia or “abdominal angina”. She has developed an acute event, has precipitated an episode of acute mesenteric ischemia, and has presented early in its course when the symptoms are more severe than physical findings. The single most important step is to do an arteriogram and start vasodilator therapy even before surgery to reverse the vasoconstriction that may persist even after surgical correction of the vascular occlusion. Reference: 1. Eldrup-Jorgensen J, Hawkins R E, Bredenberg C E: Abdominal Vascular Catastrophes. Surgical Clinics of North America. 77:1305-20, 1997. 2. Montgomery R A, Venbrux A C, Bulkley G B: Mesenteric Vascular Insufficiency. Current Problems in Surgery. 34:941-1025, 1997.