Common Medical Issues in the Elderly:

Assessing Current Care Options

From the Edmund G. Beacham 36th Annual Current Topics in Geriatrics, presented by the
Johns Hopkins University School of Medicine

Educational Objectives

The goals of this program are to improve antibiotic therapy in the elderly and the management of incontinence in this population. After hearing and assimilating this program, the clinician will be able to:

1.   Name the factors to be considered when prescribing antibiotics to people older than 50 yr of age.

2.   Explain why multidrug-resistant tuberculosis is spreading so rapidly.

3.   Describe strategies for preventing the spread of infectious disease among hospitalized elderly patients.

4.   List the most common types of urinary incontinence.

5.   Instruct patients in behavioral methods for managing incontinence, including maintenance of a voiding diary, prompted voiding, bladder retraining, and pelvic floor exercises.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the fol­lowing has been disclosed: Dr. Greenough has received funding from CERA Products, Merck and Co, the Hart­ford Foundation, Ventria, and Acambis-Sanofi Pasteur. Dr. Burton and the planning committee reported nothing to disclose.

Acknowledgements

This program was recorded at the Edmund G. Beacham 36th Annual Current Topics in Geriatrics, held February 12-14, 2009, in Towson, MD, and sponsored by the Johns Hopkins University School of Medicine, Division of Geriatric Medicine and Gerontology, and jointly sponsored by the Institute for Johns Hopkins Nursing. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Antimicrobials in the Elderly: Is Now the Beginning of the End?

William B. Greenough III, MD, Professor of Medicine, Johns Hopkins University School of Medicine, Balti­more, MD

Special considerations in elderly: infections more serious and take higher toll than in younger populations; 75% of deaths from diarrheal disease are in patients >50 yr of age

Tuberculosis: resistance to antimicrobial therapy emerging; in today’s world, must consider risk of global spread; >1 billion people currently colonized with Mycobacterium tuberculosis (MTB); 10 million new cases occur annu­ally; »50% of those highly infectious; causes 2 to 3 million deaths annually

New challenge: multidrug resistance arising from widespread insufficient duration of antimicrobial treatment; new highly virulent strains causing more aggressive disease (example  —  M tuberculosis W-Beijing); over past decade, resistance in United States has risen from 2% to 9%

How bacteria fight back: proliferate every 30 to 60 min; quickly adapt to surrounding conditions, including pres­ence of broad-spectrum antimicrobials; MTB resistance to penicillin developed almost concurrently with its large-scale use in 1940s; similar pattern seen with other antibiotics; currently, no new nontoxic antibiotics against resistant gram-negative bacteria in pipeline; pathogens generally not aggressive, except in frail elderly people; several antibiotics still effective against gram-positive organisms, but often toxic

Diseases created with antibiotics: Clostridium difficile infection; »2.5 million cases thought to occur annually; causes »11,000 deaths annually; more virulent strains now appearing

What clinicians can do: urge researchers to develop proper tools for bedside diagnosis and treatment; tried and true methods for controlling infectious diseases  —  hand washing; quarantine (isolate infected hospital patients)

New approaches: new vaccines; more knowledge of bacterial toxins and how to prevent their action; restoration of normal flora; rapid diagnosis (within 1-2 hr); and reorientation of health care system to favor prevention of noso­comial infections

New vaccines: research on tuberculosis vaccines still in infancy; probably will not appear for another decade; 2 vaccines against C difficile now under investigation; probably not available for another 5 yr, but important in ge­riatric population; varicella vaccine for preventing shingles in elderly also under developedment; good vaccine against pneumococcus needed for geriatric patients

Receptor blockade: involves blocking target site of bacterial toxin; in field study conducted in Bangladesh, speaker and colleagues administered B subunit of Vibrio cholerae to patients at high risk for cholera; this blocked intesti­nal receptors of cholera toxin, and patients did not get sick when exposed to organism

Biotherapies: none shown clinically important

Cultures: current system of waiting several days for laboratory to grow cultures antiquated; gene amplification also “a really dull tool in terms of 21st century technology”

Real-time polymerase chain reaction (RT-PCR) technology: measures bacterial DNA; in recent study conducted by speaker and colleagues, identified >50% of specimens deemed negative in quantitative cultures; more sensitive way of identifying organisms that are difficult to culture; takes »30 min; uses heat-resistant enzymes to amplify target bacterial DNA and thus permit detection and identification; clinicians should persuade administrators and researchers to “bring it to the bedside”

Reorientation of health care system: more emphasis on caring for elderly patients at home instead of in hospital; as­sociated with better outcomes and lower risk for delirium

Questions and answers

Screening for C difficile colonization before appearance of active disease: when patients admitted to long-term care facility, surveillance and knowing where infection located important for control; speaker does surveillance on all new patients and determines whether infection or colonization present; hand washing, masks, and gowns only practical ways of controlling infection in most long-term care facilities

Alternatives to broad-spectrum antibiotics for nursing home patients who present to emergency department: rapid diagnostics only practical solution; too risky to delay treatment of frail elderly person even for 24 hr; puts clini­cian “between a rock and a hard place”

Probiotics: may have rare but dangerous side effects in elderly patients; Stonyfield Farm yogurt contains Lactoba­cillus reuteri, which has been shown to prevent diarrhea in pediatric patients; however, no research yet performed in elderly patients; caution advised with over-the-counter products

Urinary Incontinence in the Elderly

John Burton, MD, Professor, Department of Medicine, Division of Geriatric Medicine and Gerontology, and Director, Geriatric Education Center, Johns Hopkins University, Baltimore

Prevalence: affects 15% to 25% of active, healthy, community-dwelling women >65 yr of age; often “the straw that breaks the camel’s back,” leading to nursing home placement or need for home nursing care; physical effects in­clude sores, cellulitis, infections, falls and fractures from slipping, and sleep disturbance; social withdrawal biggest problem, leading to isolation

“Don’t ask, don’t tell”: health professionals do not ask about incontinence, and patients do not talk about it; many patients assume incontinence part of normal aging

Patient evaluation: takes 5 to 10 min to define type of incontinence, rule out dangerous precipitating events such as bladder tumors, and determine severity and impact on patient’s life; if necessary, make special appointment to focus on that issue alone

Most common types of incontinence: urge, stress, overflow, and functional

Urge incontinence: also called detrusor overactivity, detrusor instability, or detrusor hyperreflexia; most common cause of urinary incontinence in elderly population; characterized by sudden sense of urgency, usually followed by flood of urine, although small urinary losses also possible

Stress incontinence: predominates in younger women, but also common among older people; usually associated with urologic etiology such as childbirth or urologic procedure; characterized by loss of small volume of urine associated with increased abdominal pressure; results from loss of tone in tissues surrounding urethra

Mixed incontinence: almost always combination of urge and stress incontinence; most common pattern; pure urge or stress incontinence extremely rare among elderly people; one type often predominates; focusing on dominant type “can be extremely helpful”

Overflow incontinence: should be part of initial evaluation; accounts for 10% to 15% of urinary incontinence in  el­derly; causes include atonic bladder due to diabetes or certain drugs; outlet obstruction from tumor or prostatism; symptoms are nonspecific, subtle, and may resemble stress or urge incontinence; include reduced urinary stream (often subtle, may go unnoticed); feeling of incomplete voiding (unreliable sign); more frequent voiding of smaller amounts (good indicator); continuous dribbling (end-stage condition; medical emergency); leakage with­out warning

Functional incontinence: patient unable or unwilling to reach toilet in time; associated conditions such as dementia, arthritis, or Parkinson’s disease could make using toilet difficult; cause may be nosocomial (using intravenous [IV] hydration while restraining patient to keep IV line in place)

Physical examination: keep focused and limited; evaluate patient’s general neurologic function (cognitive impair­ment makes treatment difficult); if patient normal cognitively, examine abdomen for masses, pelvic region for atro­phy or prolapse; also check vaginal area for masses and assess urethral sphincter function; rule out rectal impaction or constipation and check function of anal sphincter (innervation similar to that of urethral sphincter)

Management: behavioral therapy should be first choice, with pharmacologic treatment secondary

Behavioral therapy: prompted voiding  —  void according to a schedule, rather than waiting for urge; idea to “keep the tank at a low level”; bladder retraining –controlling bladder capacity and urge; involves teaching patient to recognize urge and postpone voiding, by voiding at certain intervals that are lengthened each week; pelvic muscle rehabilitation  —  teach patient to identify pelvic floor muscles and how to control them; many patients do not know how to tighten sphincter, (may tighten abdomen as well); have patient tighten anal or urinary sphincter first for count of 3, then 4, then 5, and so on, until she(he) can hold at least for count of 7 to 8; may require 4 to 5 ses­sions with nurse; basic principles  —  lump stress and urge incontinence together when counseling patient; have patient keep voiding diary (available online); good information available through major search engines; other good resources include Simon Foundation and National Institutes of Health; efficacy  —  evidence suggests 80% of patients improve; 10% to 15% cured

Physiology of micturition: complex; involves brain and spinal cord and multiple reflexes involving sympathetic, parasympathetic, and somatic nervous systems; cholinergic, adrenergic, and calcium channel receptors; implication  —  almost any medication may exacerbate incontinence

Pharmacologic therapy: oxybutynin and tolterodine used most frequently; oxybutynin currently on Beers’ Drugs To Be Avoided in the Elderly list because newer drugs thought to have fewer side effects; evidence now shows little difference between oxybutynin and newer compounds (should be removed from list); both agents provide 30% to 40% improvement, particularly with urge or mixed incontinence (less with pure stress incontinence); start with low dose and increase slowly; possible side effects include dryness of mouth, constipation, and cognitive changes; drug treatment of stress incontinence  —  modest benefits achieved with tricyclic antidepressants; estrogen has no benefit and should not be used (may exacerbate incontinence); true drug benefits often difficult to determine because stud­ies usually small and company-sponsored; controlled-release forms associated with slightly fewer side effects

Suggested Reading

Bernal G: Fighting female incontinence. Rehab Manag 21:34, 2008; Blumberg HM: Needed: new and better tools to combat latent tuberculosis infection. Ann Intern Med 149:761, 2008; Burgio EL et al: Behavioral therapy to en­able women with urge incontinence to discontinue drug treatment: a randomized trial. Ann Intern Med 149:161, 2008; Carr LK: Overactive bladder. Can J Urol 15Suppl1:32, 2008; Dobson R: Singles vaccination is likely to be cost ef­fective at age 65 or 70. BMJ 338:b944, 2009; DuBeau CE: Therapeutic/pharmacologic approaches to urinary incon­tinence in older adults. Clin Pharmacol Ther 85:98, 2009; Fink HA et al: Treatment interventions in nursing home residents with urinary incontinence: a systematic review of randomized trials. Mayo Clin Proc  83:1332, 2008; Kelly CP, LaMont JT: Clostridium difficile  —  more difficult than ever. N Engl J Med 359:1932, 2008; Lauti M et al: An­ticholinergic drugs, bladder retraining and their combination for urge urinary incontinence: a pilot randomised trial. Int Urogynecol J Pelvic Floor Dysfunct 19:1533, 2008; Shah NS et al: Extensively drug-resistant tuberculosis in the United States, 1993-2007. JAMA 300:2153, 2008; Zanni GR, Wick JY: Treating tuberculosis in older adults. Con­sult Pharm 23:844, 2008.