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

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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

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