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Geriatric Urinary Incontinence

Geriatric Urinary Incontinence. Alexandra F. Suslow MD. % of Geriatric aged population. 1970 --->9.9% 1984 -->11.5% 1997 -- >13.1% 2020 --> 20%. Life Expectancy. A child born in 1900--> <40 years A child of the late 60’s--> 68.5 years A child of the 90’s---> 72 years

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Geriatric Urinary Incontinence

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  1. Geriatric Urinary Incontinence Alexandra F. Suslow MD

  2. % of Geriatric aged population • 1970 --->9.9% • 1984 -->11.5% • 1997 -- >13.1% • 2020 --> 20%

  3. Life Expectancy • A child born in 1900--> <40 years • A child of the late 60’s--> 68.5 years • A child of the 90’s---> 72 years • A child of the Millenium--> >75 years

  4. Reported prevalence of UI • 15-30% of community dwellers (ie” independent seniors”) • 30% of elderly in acute care • > 50% of long term care facilities (eg. NH)

  5. DON’T ASKDON’T TELL

  6. It is a normal part of aging It is not a medical issue “I’m not incontinent,I just have “accidents” There is nothing to do about it It’s just a minor inconvenience It is abnormal at any age(other than infant) It is a medical issue, like HTN or DM Any involuntary loss is incontinence Alleviation and occsl. cure are possible THINK AGAIN!!! Myths and Facts

  7. Problems due to UI • Major Medical Problems • Major social issues • Major economic issues

  8. Medical Issues • Pressure ulcers leading to infections and sepsis • Perineal rashes • Urosepsis • Increased risk of falls and fractures with subsequent increase of morbidity/mortality

  9. Social issues • “ Cultural conditioning leading to stigmatization,social isolation, depression, and increased Psychological Morbidity” • (Umlauff et. all)

  10. Economical Issues, general • Cost of Rx of associated symptoms (eg rashes and pressure sores) • Routine care costs( supplies,laundry) • Direct Medical Cost: Physician and Diagnostics

  11. Economical Issues, Nursing Home • Marked increase in cost due to the increase in necessary nursing care (frequent changing of pt and linens) and due to increase utilization of supplies and ancilliary services • Estimated cost $3 billion

  12. Breakdown of costs • Diagnostic/ medical $6.0 0.2% • Treatement surgical 1.2 0.04 • Treatement Pharmac. 0.7 0.02 • Routine care c catheter 104.7 3.2 • Routine care s catheter 19,061 58.4 • Sequelae (uti,falls etc) 15.71 4.8 • NH admissions due to UI 1087.7 33.3%

  13. Total NH Cost Us$ 3.26 Billion (cost in 1987)

  14. Cost in Community Dwellers • Estimated to be about $7 Billion, including costs of supplies, outpatient visits, short term hospitalizations etc.

  15. GRAND TOTAL • $10 billion . • Adjusted to 1997-->$16 billion • (more than cost of CABG/Dialysis combined)

  16. Continence Determining Factors • Intact lower urinary tract anatomy and function • Adequate Mobility • Motivation • Mentation • Manual dexterity

  17. Age Related Changes in LUT • Women: postmenopausal decrease in oestrogen leading to tissue atrophy,prolapse, changes in vaginal flora--->incr. risk of UTI • Men:Prostatic changes leading to urodynamic obstruction and the sequelae thereof

  18. Age related changes cont’dchanges in both genders • Changes in neurotransmittor balance and immune response. • Anatomic changes such as trabeculation, diverticulae, decreased elasticity • Involuntary detrussor contractions • Malnutrition, dehydration leading to fecal impaction and incr. risk of UTI

  19. Medications • Diuretics--.polyuria,frequency,urgency • Anticholinergics:retention,impact. overflow • alpha-adrenergic blockers:urethral relax • alpha agonists,beta agonists, Ca channel Blockers:urinary retention • Ace inhibitors: cough exacerbation

  20. Medications, cont’d • Narcotics: retention, impaction, sedation, delirium • Psychotropics: anticholinergic effect, sedation, rigidity • Lithium: polyuria,frequency • ETOH: polyuiria,urgency, sedation

  21. Classification of UI • Transient incontinence • “Functional “ incontinence • Established incontinence --LUT causes

  22. Transient Incontinence • D elirium • I nfection symptomatic UTI • A trophic urethritis • P harmacological agents

  23. Side effects of Specific Meds • Anticholinergic agents • Frequent in prescription and OTC meds( antihistamines) • Causes overt and clinical retention---> faster attainment of capacity--> exacerbation of Detrussor overactivity • Aggravates leakage in stress inc. • Causes dry mouth-->polidypsia--> increase UOP

  24. Side Effects of Specific Meds • Alpha adrenergic blockers • Found in many anti hypertensive meds • Block receptors in the bladder neck--> decreased tone-->agrravation of stress incontinence

  25. Side Effects of Specific Meds • ACE INHIBITORS • Often prescribed for HTN, CHF • Tend to exacerbate chronic cough--> increase of stress incontinence

  26. Transient Incontinence • D elirium • I nfection symptomatic UTI • A trophic urethritis • Pharmacological agents • Psychiatric causes • Excess UOP • Restricted mobility • Stool impaction

  27. Established Incontinence:LUT causes of UI • Detrussor overactivity (“Urge Inc.”) • Stress incontinence • Overflow incontinence

  28. Goals of the Work-up • R/o and treat transient causes • R/o uncommon causes : CNS,CA,stone • Determine the type of established UI

  29. Complaints in Detrussor Overactivity • Presence or absence of “warning” • Frequency • Nocturia

  30. Causes of Nocturia • Volume related:Excess intake, diuretic use, metabolic/endocrine, fluid overload, meds • LUT Related: detrussor instability,sensory urgency, prostatic changes

  31. Only 22% of incontinent patients had pelvic/rectal exam preformed by their Doctor (Shame on us!!!)

  32. Physical Exam • Baseline Exam (HEENT--->Extremities) • Expanded Neurological Exam • Stress Test • PVR • Urodynamic tests: cystometry • Cystoscopy

  33. False Results of Stress test • False Pos: Urge during the test • False neg: • Stressor not strong enough • Bladder not full • Cystocele kinking the urethra

  34. Management of Detrussor Overactivity • Bladder Retraining • Prompted Voiding • “ Just Say No” to Surgery • Pharmacological management

  35. Drugs For DO • Others: Flavoxate, Ca chnl Blk, B-block/agonist • Imipramine • Doxepine • Anticholinergics • Propantheline (Pro-Banthine) • Dicyclomine (Bentyl) • Oxybutinin (Ditropan) • Tolterodine (Detrol)

  36. Management of Stress Incontinence • Surgical • Pharmacological • Pelvic mm.Strengthening • Kegel excercises • Vaginal Cones • Electric Stimulation

  37. Surgical Interventions in Stress Incontinence • Perurethral injection of teflon • Artificial Sphincter • Colposuspension

  38. Management of Overflow Incontinence • Blockage: • Conservative Rx • alpha antagonists • 5-alpha reductase inhibitor • Prostatectomy • Underactive Bladder: • Decompression • Catheterization • Betanechol

  39. Diapers and Pads • Protect Environment • Maintain comfort and dignity of patient

  40. Special Thanks • The Lord: For everything • Pam S.: For her help (and patience) in the Library • Dr Houghton:For his help and advice for the presentation • Stacy and Julie: The Fairy Godmothers of the Residents • Dr Wells-Padron PharmD for the Nutrasweet • All who had to listen to the presentation over and over and over again

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