UNIT 4: COMMON DISORDERS IN THE AGING 4.7 GERIATRIC SYNDROMES: URINARY INCONTINENCE

Urinary continence is a basic function that should keep healthy elderly, regardless of age. It is important to stress that urinary incontinence is not a normal phenomenon of aging.

Urinary incontinence can be defined as "any urine leakage that cause discomfort to the patient" (Abrams P, 2002). It is part of geriatric syndromes, constituting a cause of disability and impaired quality of life.

The prevalence of urinary incontinence is higher in women, and it depends on the level of care: 30% in community, hospital 30%, chronic residential units or 50%. Among the risk factors for urinary incontinence in women include diabetes mellitus, lack of estrogen and high BMI restitution. Additionally, cognitive impairment increases its effects, although not a risk factor (Thüroff JW, 2011).

In the initial evaluation is recommended to ask:

- You lose urine when you do not like? Do you have you problems with your bladder, unintentionally gets wet? Or do you have small leaks of urine upon exertion, such as laughing or sneezing?

Also in the initial assessment must be excluded concomitant urinary incontinence causes acute (<4 weeks duration) such as urinary tract infection, diabetes, vaginal atrophy, fecal impaction, polypharmacy, etc. (PS Yim, 1996)

The impact generated by this health problem can be many and varied. Not directly depend on the severity of the leak. Influence of individual factors (age, sex, comorbidity, functional status, lifestyle), as well as the type of incontinence (especially emergency).

Importantly, the impact can affect different areas of the patient: (JS Brown, 2000).

- Medical: urinary tract infections, skin ulcers, infections, ulcers, falls, fractures, urinary tract infections

- Psychological: loss of self-esteem, anxiety, depression, isolation

- Social isolation, greater need for family support, greater need for health resources, increased risk of institutionalization, dependence on the caregiver ycarga

- Economic: increased costs of care and complications

Estrogen deficiency is a common cause of nocturia and urinary incontinence in women, so it is necessary to systematically investigate this deficiency before considering other therapies.

Before a diagnosis of stress urinary incontinence or urgency should indicate pelvic floor exercises and bladder training (RCOG Press at the Royal College of Obstetricians and Gynaecologist, 2006). Shipping should be considered if espcial (Thüroff JW, 2011):

- Frail elderly

- Added significant factors: hematuria, pain, etc..

- Coexisting disease: functional impairment, dementia

- Initial response to insufficient treatment

The following segment is about an incontinence nurse at Fremantle Hospital in Western Australia.

REFERENCES:

• Treaty of geriatrics for residents. Spanish Society of Geriatrics and Gerontology. [Home Site] [accessed May 18, 2013] Available at: http://www.segg.es/tratadogeriatria/main.html

• Clinical Practice Guideline: Assessment Comprehensive Geriatric Gerontological Ambulatory Elderly. Mexico: Ministry of Health, 2011. Available at: http://sgm.issste.gob.mx/medica/medica_documentacion/guias_autorizadas/Geriatr%C3%ADa/IMSS-491-11-valoraci%C3%B3n%20geronto-geriatrica/IMSS-491-11-GER%20Valoraci%C3%B3n%20geronto%20geriatrica.pdf

UNIT 4: COMMON DISORDERS IN THE AGING 4.6 GERIATRIC SYNDROMES: CONSTIPATION

Constipation is a symptom, not a disease. It can be defined as the decrease of the number of times depositional (<3 times per week) or evacuating dry feces too slim. It is associated with hard consistency of stool.

It represents a major geriatric syndrome because of its prevalence, its serious complications and their significant impact on the quality of life of elderly. It affects mostly females. Only 5% of the elderly have fewer than 3 bowel movements a week, though more than 1/4 of those over 60 years meet other criteria for constipation. Approximately 80% of the institutionalized elderly are constipated.

Causes of constipation in the elderly are multiple and, in many cases, several causes coexist simultaneously. This should be taken into account when considering a diagnosis and treatment. Although most people suffering from constipation due to unsuitable lifestyle habits such as:

• A sedentary lifestyle

• A diet low in fiber.

• Drugs that decrease or slow down bowel motility.

• Emotional disturbances.

Constipation can also be secondary to diseases such as: structural colon lesions, postsurgical changes, metabolic disorders, neurological disorders, etc.

The symptoms experienced by people who suffer constipation are:

- Bloating.

- Abdominal pain.

- Pain on defecation.

- Changes in behavior.

The Recommendations and advice that we give the patient are:

• Increase fluid intake (if not contraindicated).

• A diet rich in fiber, increase your intake of fruits, vegetables and whole grains. And reduce food consumption astringent food.

• Avoid a sedentary lifestyle and exercise appropriate to the patient.

• Avoid drugs that slow or slow peristalsis.
 • Encourage the person intimacy when defecation.

• Administer laxatives (by prescription).

• Establishment of schedules defecation, intestinal rehabilitation.

• Encourage the practice of exercises that promote or strengthen pelvic muscles, like Kegel exercises.

• Control the number and shape of stools, great importance in geriatric institutionalized people with dependence.

From the point of view is also recommended nursing identify drugs that cause constipation, such as calcium antagonists, tricyclic antidepressants, antimuscarinic bladder and opiates.

The easier and cheaper treatment will be to implement changes in individual lifestyles. So it is necessary make a proper health education and prevention to patients.

REFERENCES:

• Treaty of geriatrics for residents. Spanish Society of Geriatrics and Gerontology. [Home Site] [accessed May 18, 2013] Available at: http://www.segg.es/tratadogeriatria/main.html

• From the Key Benito J A. Horsemen Anes M. Management of constipation in older people. Bulletin of Nursing in Primary Care of Talavera de la Reina, 2008. Available at: http://gaptalavera.sescam.jccm.es/web1/gaptalavera/prof_enfermeria/boletines/boletin_enfermeria6_2008.pdf

• Clinical Practice Guideline: Assessment Comprehensive Geriatric Gerontological Ambulatory Elderly. Mexico: Ministry of Health, 2011. Available at: http://sgm.issste.gob.mx/medica/medica_documentacion/guias_autorizadas/Geriatr%C3%ADa/IMSS-491-11-valoraci%C3%B3n%20geronto-geriatrica/IMSS-491-11-GER%20Valoraci%C3%B3n%20geronto%20geriatrica.pdf

UNIT 4: COMMON DISORDERS IN THE AGING 4.5 GERIATRIC SYNDROMES: FALLS AND INESTABILITY

The elderly has an increased risk of falling. Specifically, 20% of population over age 65 have some type of limitation in activities of daily living to facilitate falls (Cuesta-Triana F, 2001). In most cases occurs at home environment and many of these are produced by an inaccurate adjustment of the home environment.



The fall is multifactorial in origin, relevant in the elderly and may be a manifestation of disease. A fall can generate functional dependency, creating a vicious cycle, and which in turn relates to more falls (Tinetti ME, 2010). It can lead to a loss of independence in the elderly, generating a high health spending. This risk will result in the patient immobility, can worse the medical history or even the appearance of new diseases that may worsen the picture, and even the elderly can die.

It is therefore essential the fall risk assessment and all elderly person must be evaluated considering factors for falls risk presented (Scott V, 2007)

From the nurse’s point of view there are necessary implement security strategies in the elderly to reduce the incidence of falls and their complications. This requires identifying the population at risk and implement nursing interventions that are effective for the prevention of falls.
First it is important to identify the risk factors. It has been identified about 400 risk factors. The most common are:
- Weakness (sarcopenia)
- Gait disturbance
- Limitation of mobility
- Visual deficit
- Cognitive impairment
- Type 2 Diabetes Mellitus
- Sex female
- Functional dependence
- Drugs with sedative effect
- Orthostatic Hypotension
- Environmental factors: low visibility, bathrooms without bearing support, etc. (Masud T, 2001)

Downton Scale is useful for carrying out a risk assessment.

The first preventive measure is to inform patients and their caregivers about the existence of risk. From there work and collaborate in modifying home environments that can be dangerous, without compromising the functional independence of the elderly.
Usually, the patient with a fall, suffering a sharp process is revealed as a precipitating factor. Eg urinariom infection respiratory tract, anemia, angina, etc. (Kallin K, 2002).

After the fall, only 41% of elderly go to a medical service and more than half of them, have more than one fall per year.
To prevent a fall is necessary to know the risk factors, the characteristics of the fall and the patient's environment.
So when there is a fall, we must make appropriate records, performing a systematic assessment in the elderly, noting incidents, causes that led to the fall, and record the treatment and care that had to apply. Assess the factors related to the fall and notify relatives. And then make appropriate monitoring in the elderly for abnormalities produced as a result of the fall.

It is important to advise the elderly on existing measures and appropriate technical assistance to him, and informer the patient about economic aid that the health system provides.

REFERENCES :

• Treaty of geriatrics for residents. Spanish Society of Geriatrics and Gerontology. [Home Site] [accessed May 18, 2013] Available at: http://www.segg.es/tratadogeriatria/main.html

• Clinical Practice Guideline: Assessment Comprehensive Geriatric Gerontological Ambulatory Elderly. Mexico: Ministry of Health, 2011. Available at: http://sgm.issste.gob.mx/medica/medica_documentacion/guias_autorizadas/Geriatr%C3%ADa/IMSS-491-11-valoraci%C3%B3n%20geronto-geriatrica/IMSS-491-11-GER%20Valoraci%C3%B3n%20geronto%20geriatrica.pdf

UNIT 4: COMMON DISORDERS IN THE AGING 4.4 GERIATRIC SYNDROMES: DEMENTIA AND DELIRIUM

Dementia is the progressive loss of cognitive function due to brain damage or brain disorders attributable beyond the normal aging. It is an age-related disease. It is a decline of higher functions: memory (in relation to the previous level of the patients),etc. And later, add psychological and behavioral changes, resulting in progressive disability the patient.

The geriatric syndrome of dementia must meet the following characteristics:

- Provide a level of normal consciousness.

- Be acquired and persistent over time.

- Affect different functions.

- Be of sufficient intensity to have an impact on personal functioning, or social work.

Dementias are Alzheimer's, Parkinson's disease, Huntington's disease and may also be secondary to metabolic processes, endocrine drugs, psychiatric diseases, toxic, etc.

Delirium is a syndrome characterized by acute onset with fluctuating course, with attention disorders, changes in alertness. Is multifactorial in origin and is an indicator of long hospital stay, increased morbidity and mortality. It is common in the elderly, especially elderly frail and dementia (Burns A, 2004). Mortality associated with delirium (25-33%) is as high as that associated with acute myocardial infarction or sepsis. (Ionuye SK, 1994) 

There are several factors of delirium: (Ionuye SK, 2007)

- Psychotropic drugs, opioids, diuretics, anticholinergic effect, etc.

- Fluid and electrolyte imbalance.

- Surgical Procedures.

- General anesthesia.

- Hypoxia.

- Neurological disorders.

- Use of benzodiazepines.

- Pain and Sleep Deprivation.

- Physical restrictions.

- Using tubes and catheters in general.

By detecting delirium in the elderly, they should get the precipitating causes and recommended referral to an emergency department for comprehensive assessment. (Francis J, 2011) The Confusion Assessment Method (CAM) is used for the rapid identification of delirium (Wei LA, 2008). It is recommended to ask the primary caregiver if the patient has had recent changes in behavior or consciousness. If the answer is yes, it would conduct an assessment using the CAM for the detection of delirium (Wei LA, 2008)

Therefore, the patient with loss of cognitive functions will present:

- Memory problems: often the first to appear. Limiting intellectual and social activities.

- Speech disturbances: decreases the ability to communicate orally and writing.

- Impairment of spatial orientation: become disoriented easily, even at home. They keep objects which will hardly be found.

- Inability to perform certain tasks: the end is manifest in the simplest tasks, such as greeting.

- Disorders of personality and behavior: agitation, etc.

- Changes: hallucinations, neurological disorders, anxiety, depressive features, motor incoordination, etc.

REFERENCES

-Treaty for geriatric residents. Spanish Society of Geriatrics and Gerontology. [Home Site] [accessed May 18, 2013] Available at: http://www.segg.es/tratadogeriatria/main.html

- Clinical Practice Guideline: Assessment Comprehensive Geriatric Gerontological Ambulatory Elderly. Mexico: Ministry of Health, 2011. Available at: http://sgm.issste.gob.mx/medica/medica_documentacion/guias_autorizadas/Geriatr%C3%ADa/IMSS-491-11-valoraci%C3%B3n%20geronto-geriatrica/IMSS-491-11-GER%20Valoraci%C3%B3n%20geronto%20geriatrica.pdf

UNIT 4: COMMON DISORDERS IN THE AGING 4.3 GERIATRIC SYNDROMES: IMMOBILITY

Immobility is the decreased ability to perform activities of daily living and it is caused by impairment of motor functions.

Immobility syndrome is the common pathway of disease presentation. It is generated by a series of pathophysiological changes in multiple systems, conditioned by immobility and disuse. Cause is multifactorial, potentially reversible and preventable.

Decreasing physical functionality is a known consequence of aging. Older adults show a large deterioration in motor skills due to the reduction in strength and muscle volume, decreased speed and skill of the march, leading to concomitant motor impairment and disability (AS Buchman, 2009).

Immobility syndrome prevention

1) Primary: The best preventive measure is to keep the degree of mobility. Several studies agree that physical exercise as the main factor preventing immobility. The benefits of exercise do not decrease with age. Improving muscle strength and therefore improves ambulation, increases bone mass, improving hyperglycemia, lowers blood triglyceride levels and increase HDL cholesterol, etc. It also reduces anxiety and depressive symptoms. It is recommended starting the exercise 2 or 3 days a week to reach 5.

Healthy elderly subjects are divided into two groups: <75 years: moderate exercise to high intensity aerobic and resistance, and in> 75 years moderate effort exercises.

2) Secondary prevention: Once detected the clinic may include a number of changes in the environment that encourage commuting and encourage the maintenance of autonomy. These measures include: avoiding architectural barriers, maintain the sensory, technical adjustments, encourage independence. On a practical level should be taken into account:

a. Doors: amplitude, weight, easy to open or close.

b. Rooms and corridors: amplitude, if accurate mobilization wheelchairs, etc.

c. Furniture: remove furniture that may interfere with ambulation, and place them as help or support point.

d. Railings: for support.

e. Lighting: adequate, with switches in accessible and comfortable.

f. Floors: carpet removal, cables or cords. Slip resistant surfaces and ramps instead of stairs.

g. WC: Using grab bars, lifts the toilet bowl, bathtub non-slip surface, easy entry and exit from the tub by seats.

h. Personal Hygiene: adaptations in the sponge, combs and brushes, care of the folds, mouth and dentures.

i. Dress: replacing zippers and Velcro buttons, garment open in front and slip resistant soles in shoes. To dress the lower body will be easier to do in supine starting with the extremity disabilities.

j. Chairs: solid, heavy, high back and arms.

k. Bedding: preferably height adjustable cushions person or use

3) Tertiary prevention: treatment of complications such as joint contractures, stiffness, muscle atrophy, osteoporosis, etc. It starts with postural control involves body alignment body symmetrically avoiding antalgic postures. Includes repositioning every two hours initially.

Technical aids: canes (support the 15.20% of total body weight), crutches, walkers, wheelchairs, etc..

RESOURCES:

Treaty for geriatric residents. Spanish Society of Geriatrics and Gerontology. 
[Home Site] [accessed May 18, 2013] Available at: http://www.segg.es/tratadogeriatria/main.html