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Urinary incontinence affects a large percentage of persons over age 65 and predisposes them to social isolation, depression, and premature nursing home placement. Transient incontinence may be precipitated by such factors as delirium, infection, atrophic vaginitis/urethritis, medication use, and restricted mobility. Persistent incontinence may be of the urge, stress, overflow, or functional type. The patient history and simple tests such as bedside urodynamics generally isolate the cause. In this first part of a two-part article, we discuss the primary care evaluation of the older patient with urinary incontinence. In part 2 (page 37), we discuss a primary care management strategy.
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PMID:Urinary incontinence in the aged, Part 1: Patient evaluation. 159 66

Urinary incontinence (UI) is now recognized as a prevalent, physically and emotionally disruptive, and costly health problem in the geriatric population. Because incontinence may be a manifestation of a subacute or reversible process within or outside of the lower urinary tract, and because effective treatment is available, it is important for primary care physicians to identify and appropriately assess incontinence in their geriatric patients. The initial evaluation of an incontinent geriatric patients. The initial evaluation of an incontinent geriatric patient includes a targeted history and physical examination, urinalysis, and simple tests of lower urinary tract function. Potentially reversible conditions that may be causing or contributing to the incontinence, such as delirium and urinary tract infection (UTI), should be identified and managed. Patients who may benefit from further testing, including urologic or gynecologic examination and/or complex urodynamic tests, should be identified and referred. Several therapeutic modalities can be used to treat geriatric UI. Behavioral therapies are noninvasive and effective, both in functional community-dwelling geriatric patients and in functionally impaired nursing home residents. Behavioral therapies include bladder training, pelvic muscle exercises, biofeedback, scheduled toileting, habit training, and prompted voiding. Pharmacologic therapy is often used in conjunction with behavioral therapy. For stress incontinence, alpha-adrenergic drugs are used and can be combined with topical or oral estrogen therapy in women. For urge incontinence, pharmacologic treatment involves drugs with anticholinergic and direct bladder muscle relaxant properties. Pharmacologic therapy for overflow incontinence is generally not effective on a long-term basis. Surgical treatment is indicated when a pathologic lesion such as a tumor is diagnosed, or when anatomic obstruction is believed to be the cause of the patient's symptoms. Surgical treatment of stress incontinence can be highly effective in properly selected women. Nonspecific, supportive treatments are also important in managing geriatric UI. Education for patients and caregivers is critical for the success of most therapies. Environmental manipulations and the appropriate use of toilet substitutes are especially important in frail, functionally impaired patients. Highly absorbent adult undergarments are helpful for managing many patients, but should not be used as the initial response to incontinence, and are best used in conjunction with more specific treatment whenever possible. Chronic indwelling catheterization should only be used to manage incontinence when it is associated with clinically significant urinary retention, skin conditions that cannot heal because of incontinence, or severe illness that makes the catheter the most comfortable method of management.(ABSTRACT TRUNCATED AT 400 WORDS)
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PMID:Geriatric urinary incontinence. 173 88

A comprehensive evaluation of incontinence using office-based techniques may discover reversible problems such as delirium, urinary infections, vaginitis, depression, drug effects, endocrinologic causes, immobility, or impaction. Treatment of these causes may alleviate incontinence. Bedside urodynamics are a sensitive, specific, and useful office-based technique that can identify detrusor instability, overflow incontinence, or stress incontinence. Low urinary flow rate, difficulty with catheterization, slow bladder filling or severe urgency, bladder capacity over 600 ml, and post-void residual over 150 ml need referral. Patients with hematuria, recurrent infections, recent surgery or pelvic irradiation, and pelvic or prostatic masses also need further evaluation. A number of medical and behavioral therapies are available for stress incontinence and detrusor instability that can substantially reduce incontinence, but most patients with overflow have more complicated problems requiring further evaluation, surgery, or long-term bladder drainage.
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PMID:Practical management of urinary incontinence. 268 69

Evaluation of 1 million incontinent American nursing home residents is hampered by both failure to detect incontinence and logistical barriers to diagnostic testing. The nationally mandated Minimum Data Set (MDS) and Resident Assessment Protocol (RAP) were devised to address these deficiencies. Although both instruments are also used in at least 18 other countries, neither has been evaluated. Our goal was to determine the reliability of the MDS and the accuracy of the RAP in predicting the lower urinary tract cause of incontinence. We determined interrater reliability for the 13 MDS items related to urinary incontinence in 123 randomly selected residents of 13 nursing homes in 5 states; forms were completed blindly by 2 nurses from each facility who were trained for a day. The RAP was assessed in 102 representative institutionalized women by blinded evaluation of its diagnostic accuracy compared with the multichannel videourodynamic criterion standard. For the MDS, interrater reliability for incontinence of all grades was excellent (weighted kappa correlation coefficient = 0.90), although reliability was greater at the extremes of measurement than for incontinence of intermediate severity. With the exception of delirium, correlations for the 11 MDS items related to incontinence were 0.65-0.96; for 6 items, correlations were > or = 0.8. The diagnostic accuracy of the RAP, successfully administered to 80% of women, was 70%. The accuracy of the nearly identical algorithm that formed the basis for the RAP was 84%. Importantly, serious misclassifications were not observed for either the RAP or the algorithm. Although its definitions should be modified slightly, the MDS appears to be feasible and reliable when administered by trained staff. In women, the diagnostic accuracy and safety of the RAP are good-particularly when administered as instructed-but the original, sex-specific algorithm is preferable. Together, the MDS and modified RAP provide a useful, stepwise, and non-urodynamically based strategy to guide evaluation and therapy of incontinence in this setting.
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PMID:Evaluating a national assessment strategy for urinary incontinence in nursing home residents: reliability of the minimum data set and validity of the resident assessment protocol. 891 12

A 74-year-old man became delirious 2 days after beginning oral therapy with methazolamide. The delirium was manifested by intermittent psychosis, incontinence of bowel and bladder, lethargy, and disorientation. These symptoms continued for 25 days despite many changes in his drug regimen, and complete laboratory, urologic, and neurologic work-ups. The symptoms resolved completely within 1 week of discontinuing methazolamide. This is the first case reported of delirium associated with methazolamide not accompanied by a metabolic imbalance.
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PMID:Methazolamide-induced delirium. 908 35

Legionella is a frequent etiologic agent in the development of both nosocomial and community acquired pneumonias. Involvement of the nervous system is common in Legionella infections. We present a case of Legionnaires' disease which illustrates distinctive neurologic findings including delirium and cerebellar dysfunction. Furthermore, this paper reviews the neurological and psychiatric features of 609 Legionella infected patients with involvement of the nervous system. The most common signs were disorientation (58%), headache (52.4%), and somnolence (39.7%). Less frequent or rare were: cerebellar dysfunction (11.2%), hallucinations (8.4%), agitation or stupor (4.1%), affective disorders (3.1%), peripheral neuropathy (2.8%), pyramidal disturbances (2.1%), memory loss (1.6%), seizures (1.5%), cranial nerve palsies (1.5%), incontinence (0.7%), and extrapyramidal disturbances (0.3%). Cranial CT scans, cerebrospinal fluid findings, and nerve and muscle biopsies were usually unremarkable. Neuropathologic examinations failed to demonstrate specific characteristics. Hyponatremia and serum CPK level elevation were present in up to 89% and 50% of patients, respectively. Prognosis of disturbances of the nervous system was mainly good. We conclude that in the presence of definite neurological findings, pulmonary infection, hyponatremia, and CPK elevation Legionella infection should be considered.
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PMID:[Neurologic and psychiatric symptoms of legionella infection. Case report and overview of the clinical spectrum]. 927 65

A 42-year-old man came to our emergency room hyperthermic (oral temperature, 42.4 degrees C), diaphoretic, and delirious. Other findings included labile blood pressure, sinus tachycardia (heart rate, 138/min), tachypnea (respiratory rate 34/min), muscle rigidity, and incontinence. Two days earlier, he had gone to a local clinic with complaints of abdominal pain, nausea, and vomiting. Promethazine was prescribed, and this was the patient's only medication on admission. Laboratory studies showed leukocytosis, hypernatremia, metabolic acidosis, elevated creatinine phosphokinase level, elevated transaminase levels, azotemia, hyperkalemia, hyperphosphatemia, hypocalcemia, and myoglobulinuria. The clinical and laboratory findings were characteristic of the neuroleptic malignant syndrome, with promethazine as the offending agent.
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PMID:Neuroleptic malignant syndrome due to promethazine. 1054 78

Is the patient going to die of cancer or with cancer? Is the patient going to suffer pain and disability due to cancer? Is the patient able to tolerate aggressive life-prolonging treatment? This paper tries to reply to the fundamentals of these questions by introducing the multidimensional assessment that evaluates areas where age-related changes are more likely. Chronologic age cannot be used to predict the degree of comorbidity and of functional deterioration of the single individual up to age 85 at least. Assessment of aging includes health, functional status, nutrition, cognition, socio-economic and emotion evaluations. This multidisciplinary assessment is referred to as comprehensive geriatric assessment (CGA). The risk of comorbid conditions increases with age and may result in underdiagnosis: in older patients, new symptoms may not be clearly recognized by the patient and may be dismissed by practitioners as manifestations of preexisting conditions. A meaningful assessment of comorbidity may be obtained with a comorbidity index. The Charlson scale and the Chronic Illness Rating Scale - Geriatric (CIRS-G), have enjoyed the widest acceptance. The Instrumental Activities of Daily Living (IADL) and the Activities of Daily Living (ADL) are the most sensitive assessment of function in older individuals. IADLs include shopping, managing finances, housekeeping, laundry, meal preparation, ability to use transportation and telephone and ability to take medications: in simple words, the IADLs are those skills a person needs to live independently. ADLs include feeding, grooming, transferring, toileting and are the skills necessary for basic living. Though a correlation exists among comorbidity, performance status, ADL and IADL, this correlation is not strong enough to be reflected in a single parameter. The Folstein Mini Mental Status (MMS), is the instrument of most frequent use to screen older individuals for dementia. The main problem with the MMS is lack of sensitivity to early stages of dementia. The Geriatric Depression Scale (GDS), a simple tool that can be completed by most patients at home, doubles the rate of detection of depression. The Mini Nutritional assessment is very sensitive to screen older persons for malnutrition. The risk of polypharmacy increases with age and partly results from the fact that older patients visit different practitioners. A CGA should also include evaluation of the so called Geriatric Syndromes like delirium, incontinence, osteoporosis, all of which represent a hallmark of frailty. The CGA may help the management of older individuals with cancer in at least three areas: detection of frailty, treatment of unsuspected conditions, removal of social barrier to treatment.
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PMID:The application of the principles of geriatrics to the management of the older person with cancer. 1096 Jul 97

The mnemonic DEEP-IN stands for a series of easy-to-administer, office-based screening tests designed to streamline initial assessment of the geriatric patient. These screens can quickly identify signs of delirium, dementia, depression, and adverse drug effects; vision and hearing deficits; risk for future impairments in activities of daily living; incontinence, and malnutrition. The author developed the mnemonic from personal experience and from an evidence-based application of validated geriatric and geropsychiatric studies.
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PMID:Functional assessment. Easy-to-use screening tools speed initial office work-up. 1150 59

Older individuals are at risk for adverse events in all settings where cancer is treated. Common geriatric syndromes can complicate cancer therapy, and thus, increase patient morbidity and the costs of care. Furthermore, cancer treatment can worsen geriatric syndromes. It is often difficult to determine whether declining health is a result of cancer treatment or the patient's underlying disease. Baseline assessment of multiple factors may facilitate detection of a decline in the patient's health status, which may be remediable. Geriatric syndromes may substantially affect quality of life and are also important in the prognosis and outcome of cancer therapy. This article reviews the assessment of cognitive syndromes (dementia and delirium), vision and hearing impairment, gait and balance difficulties, malnutrition, incontinence, depression, osteoporosis, sleep disorders, environmental and social issues, and functional decline. Although there are many geriatric domains and many focused assessment tools, assessment does not need to be time-consuming. Streamlined assessment tools have been developed; they are brief, inexpensive, and easily administered, and they may be valuable to the oncologist. Staff such as nurses, social workers, or office personnel could perform these assessments and minimize the impact on the physician's time.
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PMID:Geriatric syndromes and assessment in older cancer patients. 1178 Jul 1


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