geRIA | Urinary Incontinence | Balance (Ability)

Geria vs Standard medical evaluation o It focus on elderly individual with complex problems o It emphasize functional status and quality of life o It frequently takes advantage of an interdisciplinary team of providers o Standard medical evaluation test to miss some prevalent medical problems o Five I  Intellectulal  I?  I?  I?  Iatorogenic diseases List of areas o Current sx and illness and their functional impact o Current drugs o Relevant past illness o Recent and impending life changes o Objective measurement of overall personal and social functionality o Mini-mental state exam (MMSE) o Mobility Gait  Fall assessment Geria areas to assess o Rehabilitation status and progress o Substance abuse o Nutritional status and need o Disease risk factors Demographic data o History data; subjective o Medical decision on accurate info o Challenging especially of patient with impaired cognition o Always note the identity of the historians and your assessment of the reliability and objectivity Chief complaint and present illness o 1st elederly patient may present with non specific apparently unrelated and trivial complaints o Older patient may interpret their problem or dysfunction as normal signs of aging o Fear and denial may also play a role o 2nd Multiple problems is the rule o 3rd insurmountable communication barriers  Culture incompatibility  Memory loss  Depression

but can be permanent if not corrected  Loss of near vision(Presbyopia)  Common with age  Loss of central vision  Macular degeneration  Loss peripheral vision  Glaucoma. Stroke  Glare from lights at night  Cataracts  Eye pain .   Hearing impairment Past medical history o Intensive o Source should be more distant o Central to the assessment objective is careful documentation of all  Treatments. Medications their doses.can be prevented. indication and effects Nutritional o Geria is vulnerable to inadequate nutria  Limited dentition or ill fitting dentures  Diminished appetite  Prevalent drug reactions  Lack of financial resource  Non Compensated disabilities o Asessment  BMI  Changes in body weith (10%--> 1 month)  Functional status  Food intake by food groups  Vitamin and mineral supplements o Nutri history performed with some version of a nutria health checklist o A detailed dietary assessment using 24-hour recall “usual intake” or food record o A physical exam with particular _____?___ to signs associated with over consumption and inadequate nutrition o Selected lab test if applicable o Dietary assessment  Quantitative and qualitative 2nd meeting  Review of systems o Emphasize questions specifically pertaining to the functional capabilities of elders o ROS information is obtained as part of a typical geriatric assessment o ROS Visual.

stroke . hesitancy  Benign Prostatic Hyperplasia  Urinary Incontinence  Detrusor instability ROS Musculoskeltal  Proximal muscle pain/weakness  Polymylagia rheumatic  Joint Pain  Osteoarthritis. rheumatoid arthritis  Back Pain  Osteoporotic compression fracture. cancer ROS Neurologic/Psychiatric  Syncope  Postural hypotension. SOB  Chronic Obstructive Pulmonary Disease(either destruction of alveoli or inner lining of the bronchial vessels) ROS Gastro Intestinal  Constipation  Hypothyroidism. hypokalemia. dehydration. inactivity.o o o o o o o  Glaucoma ROS Audiotry  Hearing loss  Cerumen. hypoglycemia  Transient loss of power sensation or speech  Transient Ischemic attack  Persistent aphasia or dysarthria  Stroke  Disturbance of gait  Parkinson’s disease. inadequate fiber.  Fecal Incontinence  Rectal carcinoma ROS Genitourinary  Urinary frequency. Paget’s Disease  Loss of high-frequency range(prebycusis)  Common with age ROS Cardio  Difficulty eating or sleeping. drug-induced ototoxicity. seizure. cardiac dysrhythmia. Shortness of Breath . over fatigue. drugs. colorectal cancer. orthopnea  Congestive Heart Failure ROS Pulmonary  Chronic cough. aortic stenosis.

and treat these common conditions  Delirium  An acute disorder of attn. drugs. multiinfarct dementia Management of Common Clinical Disorder in Geriatric Patients o Aging predisposes elderly to chronic diseases. behavioral. implying DHN o Identify high-risk patients and prevent incidence of delirium  Appropriate medical. evaluate. impaired cognition . sleep apnea. and global cognitive fxn  Common and potentially preventable  Elderly patients who develop delirium are at risk  Future functional decline ( a loss of independence in their performance of daily activities)  Cognitive decline. and fluctuating course o Has a reduced ability to focus attention  Incoherent or tangential speech  . and pharmacologic approaches.  Clinical Features o Presents with an acute change in mental status and CF of disturbed consciousness . and a loss of independence in the performance of daily activities (functional decline) o Clinical Disorders often manifest as geriatric syndromes  Multifactorial health conditions  Accumulated effect of impairments on multiple systems o Geriatric syndromes increase in frequency and clinical importance in advanced age o Estimated 90 mil people live with at least one chronic condition o Rates of chronic conditions are highest among the elderly o 88% at least one chronic condition o Identify. mood disorder  Loss of Memory  Alzheimer’s disease. and increased in mortality  Assessment: o Mini-Mental State examination form  Epidemiology of Delirium o Most often identified in hospitalized patients o Independent risk factors  Psychoactive medications  Severe illness  Cognitive impairment (Dementia  Vision impairment  High ratio of BUN to creatinine. Insomnia  Circadian rhythm disturbance.

   Disorganized or erratic though processes  Increased psychomotor activity o Hypoalertness and hyperalertness o Fluctuations in behavior and level of cognition throughout the day  Sundowning Protocol targeted to risk factors o Delirium can be prevented in patients who are at risk for the disorder o TABLE !(to be given later) o Elder life program  Patients at risk for incidence of delirium were identified for further care o Optimize cognitive function(reorientation and therapeutic activities) o Prevent sleep deprivation (relaxation and noise reduction) o Avoid immobility (ambulation and exercises o Improve vision( Visual aids and illumination) o Improve hearing( hearing devices) o Treat Dehydration (Volume replacement or repletion) Prevention and Management of Delirium o Increased Socialization  Placement of a patient in a room near the nurses’ station for greater observation and socialization  Social visits with family members.5-1.0mg given orally or IM q 6-8 hours  Control agitation o Higher doses or more frequent administration (e.. or hired sitter  The avoidance of physical restraints  Promotion of normal sleep cycles  Noise control and dim lighting at night o Pharmacotherapy  Patients with bothersome symptoms o Haloperidol.DOC  O. a caregiver. every 30 minutes) may be needed.  Adverse effects of Haldol o EPS o Dystonic reaction .g.

0mg give orally or parenteral  Urinary Incontinence  Involuntary loss of urine of sufficient severity to be a social or health problem  Never a consequence of normal aging  It is always treatable and often curable  Sources of social embarrassment for older patients o Loss of self-esteem o Loss of physical independence o Increases risk for institutionalization  Epidemiology o 10-15% in women 65 y/o o >25% men and women >85 y/o o 50in nursing home residents and frail homebound  Acute incontinence o Sudden in onset o Associated with an acute illness (Infection or delirium) Iatrogenic event (Polypharmacy or restricted mobility) o UTI is the most commonly recognized cause of transient incontinence in ambulatory patients o Hospitalized patients  Delirium or acute confusion  Excessive infusions of IV fluids  Metabolic disorders. such as hyperglycemia with glycosuria o Four basic types of established urinary incontinence  Stress  Urge  Overflow  Functional Incontinence  TABLE 4  Often caused by combination of two or more of the subtypes of incontinence  Classified as mixed incontinence o Medical history-key to diagnosis  Includes a description of :  Onset  Duration  Characteristics of incontinence . Severe anxiety and sleep disturbance o Lorazepam. in doses of 0.5-1.

o o o  Frequency  Timing  Quantity of episodes  Precipitants of incontinence  Exercise.5-5. w/c helps patient identify pelvis floor muscle exercises  Men  Anatomical-> intrinsic sphincter deficiency resulting from trauma to the bladder outlet o Most commonly secondary to prostatectomy  Tx w/ periutheral injections Urge Incontinent  Frail elderly  Behavioral and environmental interventions are most effectives  Urinals. 2. or onset of acute diseases. walkers or wheelchairs for patient with impaired ambulation  Intractable incontinenceabsorbent undergarments or adult diapers Combined stress and urged  Responsive to behavioral modification ( RX treatment (oxybutynin Cl.  Medical History  Record or diary of incontinent episodes recorded for 7 days o Continence record for nursing home residents  Reliable measure of the frequency of incontent episode  Provides clues to the etiology and severity Stress Incontince  Female outpatients  Behavioral interventions (anorectal biofeedback. bedside commodes. previous surgery. or other external collecting devices may help  Canes.0mg) and a placebo  Women >55y/o  Toileting schedule may be effective  Patients should be encouraged to urinate at regular intervals and before physical exertion .

 Risk factors and etiology o Fecal Incontinence is most often a result of fecal impaction  Factors that contribute o Disordered muscle integrity  Anal sphincter and external anal( major location of problem) o Decreased rectal sensation or compliance  Can be due to sexual promiscuities such as anal sex o Declining mental function o Loss of physical mobility  Likely  Constipation causes o Diet low in fiber o DHN o Immobility o Medications . assistive devices and pharmacologic interventions o Oxybutynine (Driptane) Fecal Incontinence  Continuous or recurrent uncontrolled passage of fecal material for at least 1 month  Acute and chronic fecal incontinence occur commonly in elderly patients with co-morbid conditions  Often a socially embarrassing and incapacitating problem  Epidemiology o 50% of patients in nursing homes o 30% of elderly patients in hospitals  Constipation is often associated with incontinence.  Urinary Incontinence  Involuntary loss of urine of sufficient severity to be a social or health problem  Source of embarrassment for older patients o Loss of self-esteem o Loss of physical independence o Increases risk for institutionalization  Never a consequence of normal aging  It is always treatable and often curable  Incontinence can be managed through exercise. particularly in patients with fecal impactions. toileting. schedules.

g.g.g Tap water) are often sufficient to treat constipation  Fecal disimpaction can be performed manually with an anesthetic lubricant or by mineral oil enemas  High Fiber diet o High fiber diet or given fiber supplements (Psyllium or methylcellulose) o Together with liquids to stimulate peristalsis o If associated with hard stools. anorectal and neurologic function. senna and bisacodyl)  Hyperosmolar laxatives ( e. lactulose) o Dependency is a known complications  Rectal suppositories (e. Diagnostic Evaluation o Medical history and physical examination o Evaluation of fecal continence includes a careful review of the patient’s cognitive status. fiber and fluids should be introduce gradually o This is the best alternative  Suppositories and Enemas o Intermittent use of glycerin or bisacodyl suppositories is warranted if rectosigmoid outlet delay or difficult passage of a soft stool is the primary concern o Patients is unable to retain a suppository can be treated with periodic enemas or hyperosmolar solutions  Compress the gluteal area Fall and gait disturbance  .g glycerin and bisacodyl)  Enemas (e. and a rectal examination o Fecal impaction is suggested by the passage of watery stools laden with mucus  Prevention o Assessment of risk factors o Common approaches to prevention  Changes in the diet  Increased physical activity  Judicious use of laxatives and enemas  Surgical correction in patients with anatomic abnormalities  Laxatives o Prescribed with patients with incontinence resulting from constipation  Stimulate laxative (e.

Risk factor o Intrinsic risk factors  Lower extremity weakness  Physical assessment for muscle strength makes use of the four quadrants and scored over 5  Poor grip strength  Gail and balance deficits  Impaired performance of daily activities  Visual impairment  Cognitive impairment  Depression o Extrinsic risk factors  Poly pharmacy. vasodilators. hip fracture  be immobile loss of functional independence Often lead to an older person’s loss of functional independence and a fear of failing.use of 4 or more prescription drugs  Environmental impediments  Poor lighting  Loose carpets  Absence of bathroom safety equipment Diagnostic Evaluation o Medical History o Physical examination o Review of risk factors. floor or other lower levels Common and potentially preventable causes of morbidity and mortality in elderly adults Falls can be associated with syncopal or presyncopal episodes(sudden loss of consciousness can be From cardiac arrhythmias(v-fib).g. medications (e. postural hypotension.unintentional coming to rest on the ground.        Accidental falls. or postprandial(after eating) hypotension< d/t to the blood supply shifting to the stomach>) Epidemiology o 1/3 in the community of >65 years old o Half of persons 80 y/o > o Half of these individuals who fall experience multiple falls Accounts for serious injuries that include hip fractures and soft tissue trauma o Physical assessment with those hip fracture Changes in the color of the skin. adrenergic blockers) .

a decreased risk of fall with injury. balance and gait(cerebellar test)) Help identify patients at risk. mental status(to assess use MSE) . tubes.  Screening instruments (vision ( use of snellen’s chart) . and weight machines were used under therapist supervision o Immobility  Prolonged bed rest produces many physiologic changes  Decreases in blood volume and cardiac output  Orthostatic hypotension  Hypoxemia  Muscle atrophy  Generalized weakness  Hospitalized elderly patients. and improved balance o Resistive exercises  Effectiveness of both low-intensity and progressive high-intensity resistive exercise  Bands.enhances balance and body awareness when combined with balanced training  Studied in a randomized trial o Therapist-conducted exercise  Home visits of women >80  Made by PT or physiotherapist  41% reduction in self-reported falls in 1 year. immobility increases the risk for functional dependency  Immobile risk for pressure ulcer development o . Diagnostic Evaluation o Observation of the patient’s balance and gait is the most useful aspect of the examination Prevention and management o Multicomponent interventions o Interventions is basically prevention of risk factors o Balance and strengthening exercise  Tai chi. pulleys.

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