Transcript Continuous Quality Improvement

Myriam Edwards MD
Geriatrician, Assistant Professor, and
Geriatric Medicine Fellowship
Program Director
Hurley Medical Center /
Michigan State University
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 by
Mark Ensberg, MD
Geriatric Education Center
Michigan State University
Family &
Friends
Spirituality
Activity &
Mobility
Independence
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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

www.alz.org
www.worriedaboutmemoryloss.com
www.dementiacoalition.org
PHQ - 2
Other Good
Questions
• Do you feel sad or blue?
• Have you lost interest in doing
things that you have enjoyed?
• What are you looking forward to?
• What do you do for enjoyment?

Masked depression
Denial of sadness
 Anxiety




Somatic Symptoms
Multiple other medical conditions
Depression and Memory Impairment
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
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 9
DIAGNOSIS IN OLDER PATIENTS IS
DIFFICULT BECAUSE THEY . . .
•
More often report somatic symptoms
•
Less often report depressed mood, guilt
•
Slide 10
May present with “masked” depression
cloaked in preoccupation with physical
concerns and complicated by overlap of
physical and emotional symptoms
DSM-IV DIAGNOSTIC CRITERIA
FOR MAJOR DEPRESSION

Gateway symptoms (must have 1)
•
•

Depressed mood
Loss of interest or pleasure (anhedonia)
Other symptoms
•
•
•
•
•
•
•
Slide 11
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
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 12
CLINICAL COURSE IN
MAJOR DEPRESSION

Recurrence, partial recovery, and
chronicity . . .
 disability
 use of health care resources
 morbidity and mortality
Slide 13
suicide
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
Slide 14

Ask & evaluate every
patient!

Get Up and Go

Look for signs of injury
Medi - cations
Chronic Risk Factors
Acute (short term) Risk Factors
Rehab (activity) Related Risk
Environmental Risk
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 18
Slide 18
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
Slide 19
Usually multifactorial
Slide 19
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)
•
•
Slide 20
Establish person’s comfortable gait speed; use
as both assessment and outcome measure
Remember that most gait disorders are
associated with underlying disease
Slide 20
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 21
Slide 21
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
•
Slide 22
Results are strongly associated with
functional independence in ADLs
Slide 22
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 23
Slide 23
EPIDEMIOLOGY OF FALLS
60
50
40
30
20
10
0
Community
LT Care
Each year 30%–40% of community-dwelling persons
aged ≥65, and about 50% of residents of long-termcare facilities, experience falls
Slide 24Slide 24
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 25Slide 25
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
•
Slide 26
Mortality highest in white men aged ≥85:
180 deaths/100,000 population
Slide 26
SEQUELAE OF FALLS
•
•
•
Slide 27
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 27
COSTS OF FALLS
•
 Emergency department visits
•
 Hospitalizations
•
Slide 28
Indirect cost from fall-related injuries like hip
fractures is substantial
Slide 28
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 29
Slide 29
CAUSES: MEDICATION USE

Specific classes, eg:





Slide 30
Benzodiazepines
Antidepressants
Antipsychotic drugs
Cardiac medications
Hypoglycemic agents

Recent medication dosage adjustments

Total number of medications
Slide 30

History

Brown Paper Bag Test
(Med Review)

Bladder Log / Diary

(PVR / Bladder Scan)
PREVALENCE OF UI
Slide 32

Affects 15%–30% of community-dwelling
older adults

Affects 60%-70% of residents of long-termcare institutions

Prevalence increases with age

Affects more women than men (2:1) until
age 80 (then 1:1)
IMPACT OF UI ON OLDER ADULTS

Morbidity
 Sleep
deprivation, falls with fractures,
sexual dysfunction
 Depression,
social withdrawal, impaired
quality of life
 Cellulitis,

Slide 33
pressure ulcers, UTIs
Costs: >$26 billion annually
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

Slide 34
Costs: >$26 billion annually
FACTORS CONTRIBUTING TO OR
CAUSING UI IN OLDER PERSONS
Comorbid disease
• Degenerative joint disease
• Sleep apnea
• Congestive heart failure
• Severe constipation
• Diabetes
Function and environment
• Impaired cognition
• Impaired mobility
• Inaccessible toilets
• Lack of caregivers
Slide 35
Neurological/Psychiatric
• Stroke
• Parkinson’s disease
• Normal pressure
hydrocephalus
• Dementias
• Depression
MEDICATIONS THAT CAN CAUSE
OR WORSEN UI
•
•
•
•
•
•
•
Alcohol
α-Adrenergic agonists
α-Adrenergic blockers
ACE inhibitors
Anticholinergics
Antipsychotics
Calcium-channel
blockers
• Cholinesterase inhibitors
Slide 36
•
•
•
•
•
•
•
•
Estrogen
GABAergic agents
Loop diuretics
Narcotic analgesics
NSAIDs
Sedative hypnotics
Thiazolidinediones
Tricyclic antidepressants
Delirium
Retention
Infection
Polyuria
Drugs
Restricted Mobility
Inflammation
Impaction
Pharmaceuticals





Urge
Stress
Overflow
Functional
Mixed
URGE INCONTINENCE
 Most
common type of UI in older persons
 Associated
with uninhibited bladder contractions,
called detrusor overactivity (DO)
 Signs

Slide 39
and symptoms:
Abrupt/compelling urgency, frequency, nocturia
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 40
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 41
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 42
MANAGEMENT OF UI: OVERVIEW

Goal: relieve the most bothersome aspect(s)

Stepped management strategy:
Behavioral
Lifestyle
Slide 43
Drugs
Surgery
ADDRESSING COMORBID
AND 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 44
BEHAVIORAL THERAPY

Bladder training and pelvic muscle exercise
(PME): effective for urge, stress, and mixed UI

Prompted voiding: cognitively impaired patients
Slide 45
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 46
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
Slide 47
Falls
Fuller, 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/to
olbox/pdfs/get_up_and_go_test.pdf
Urine Leakage
Urinary Incontinence Assessment in Older
Adults Part I – Transient Urinary Incontinence
http://www.hartfordign.org/publications/trythis/iss
ue11-1.pdf
Diagnostic Evaluation of Urinary Incontinence in
Geriatric Patients
http://www.aafp.org/afp/980600ap/weiss.html
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