Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

PR4152 Multi-Morbidity > IC3 Geriatric Syndrome > Flashcards

IC3 Geriatric Syndrome Flashcards

1
Q

Is frailty associated with age?

A

Frailty may not definitely be in an elderly (not a must), not a physiological aging but pathological aging

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What are the components of the Fried Frailty Tool (not used in clinical setting)?
What is the different scorings and what do they suggest?

A
  1. Weak [Poor hand grip strength, difficulty walking up 1 flight of stairs]
  2. Slow walking [>6-7 secs to walk 10 feet]
  3. Low physical activity
  4. Weight loss [5% or more weight loss in the last year]
  5. Exhaustion [positive answer to whether they feel fatigued when performing daily activities]

[1-2 characteristics> pre-frail, 3 or more> frail]

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What are the different categories of the clinical frailty scale (CFS)?

A
  • CFS 1-9
  • CFS 1-3 = robust healthy elderly
  • CFS 4 = pre-frail (mild frailty), functionally Independent (iADL & bADL), but symptoms of chronic illnesses are affecting activity tolerance
  • Physical fitness, e.g. have HF cant walk for long. 1 fall can push them into CFS 5 or 6
  • CFS 5 = Need assistance for all or some of the iADLs
  • ​​Need help to get grocery or see drs
  • CFS 6 = Need assistance for all outside activities (iADL) and some of the bADLs (e.g. dressing, eating, ambulating, toileting, hygiene, bathing)
  • CFS 7 = Clinically stable but FULLY dependent (iADL & bADL) for personal care (but not yet dying)
  • CFS 8 = Nearing end of life (dying) and FULLY dependent for personal care
  • CFS 9 = Terminally ill (<6 months) but not severely frail
  • ​​Usually cancer patient , can be functionally independent, but terminally ill can be well today but can go tmr
    *
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

How to intervene for frailty?

A
  1. Physical Exercise/Occupational Therapy
  • Resistant exercise to strengthen the muscle, not heavy lifting
  1. Nutritional Intake, with Oral Nutritional Supplement (Milk Feeds) if necessary
  • Medication side effects [Appetite, anticholinergics, sense of taste, sedation]
  • Depression
  • Access to food
  • ​​No money or ability to purchase the food that they need
  • ?Feeding assisted
  • Function is poor to feed themselves, so patient might not eat
  • Chewing/Swallowing
  • Consistency is not right, so choke or have chewing or swallowing difficulties
  • Unnecessary dietary restriction
  • Want to encourage them to eat, so don’t restrict as much as possible
  1. Medication Review
  • DRPs affecting ability to take part in Physiotherapy/Occupational therapy and adequate Nutritional Intake
  • Vitamin D supplementation
  • ​​For bone, muscle and immune system
  • If vit D less than 10mg/L, assoc with dysfunctional immune system
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Is frailty reversible?

A

Yes. Frailty is not a terminal illness, in the early stage of frailty can still reverse it.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is the cause of falling?

A

Multifactorial

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What are the rippling effects of a fall event?

A
  • Pain, fracture, traumatic brain injury
  • Concern about falling (vs fear of falling) –> deconditioning
  • Functional decline
  • Reduced Quality of Life/Functional dependency
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What are the 3 questions to be asked when patient had a fall event?
And if yes to all 3 what does it mean?

A
  1. Fell in the past 12 months?
  2. Feel unsteady?
  3. Any concerns about falling?

high risk of future falls
Then need to evaluate further and stratify future risk by evaluating the 5 things

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What is inside the framework of multidomain fall risk assessment by AGS?

A
  1. History of falls
  2. Medications
  3. Gait, balance, and mobility
  4. Visual acuity
  5. Other neurological impairments
  6. Muscle strength
  7. Heart rate and rhythm
  8. Postural hypotension
  9. Feet and footwear
  10. Environmental hazards
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What are the mechanism of drugs that leads to increase risk of falls?

A
  • Sedation
  • Orthostatic hypotension (OH)
  • Anticholinergics
  • Hypoglycemia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What is the main mechanism of anticholinergics and benzodiazepines in causing patients to fall?

A
  1. Anticholinergic can lead to falls because they can cause
  • Drowsiness (not main mechanism)
  • Blurred vision (not main mechanism)
  • Confusion, delirium
  • But don’t need to be confused or delirium for u to fall
  • Anticholinergic can slow down reaction time,
  1. Benzodiazepine, those taking long term
  • People using it can develop to the side effects of sedation, but that doesn’t mean that those who use it long term that don’t have sedation are not at high risk of falls
  • This is because their reaction time is slower
  • Long term benzo, sometimes cannot tolerate without on any benzo so just cut down the dose to bare minimum
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What are the STOPFall medications?

A
  1. Anticholinergics e.g. muscle relaxants
  2. Sedative antihistamines
  3. Benzodiazepines
  4. Opioids
  5. Antidepressants
  6. Anti-epileptics
  7. Hypoglycemics
  8. Alpha adrenergic blockers for HTN
  9. Alpha adrenergic blockers for BPH e.g. terazosin
  10. Oversensitive bladder and incontinence medications
  11. Vasodilators for CVD
  12. diuretics
  13. antipsychotics
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Which Geriatric syndrome is the most self-reported to doctors?

A

Dizziness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What are the rippling effects of dizziness?

A
  1. Potentially serious etiologies [Stroke, Myocardial infarction, Traumatic Brain Injury, Infection like pneumonia
  2. Increased risk of fall
  3. Increased risk of deconditioning
  • React to fear of falling by not walking much or going out, thus they become deconditioned
  • Their legs “disappear”, their muscles in the lower limb shrinks and become weak
  1. Reduced Quality of life
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What are the type of dizziness?

A
  1. Vertigo
  • Objects spinning
  • OR Objects are not spinning but they themselves are moving
  1. Pre-syncopal dizziness
  • Associated with change in body posture e.g. from sitting to lying to standing
  • Due to postural hypotension
  • Dizziness with the feeling of faint
  1. Dysequilibrium
  • Sense of lightheadedness or unsteadiness when walking about
  1. Unspecified dizziness
  • Can’t tell what’s wrong with the unsteadiness or dizziness
  • Can’t categorize them into 1 so have more than 1 type of dizziness
  • Older adults can have more than one type of dizziness > GS
  • Not enough to determine cause(s).
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

How to tell the difference between vertigo and pre-syncopal dizziness?

A
  • Sometimes both description could overlap a bit
  • But we can differentiate them:
  • E.g. patients with benign paroxysmal positional vertigo (BPPV), may get up and experience vertigo
  • but for patient with dizziness associated with postural hypotension, when they get back they will have dizziness but when they sit down or lie down the dizziness will disappear but for those with BPPV will not disappear
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

For most patients with dizziness, how long does it last?
Thus, what should we do?

A
  • 45% experienced dizziness of only up to 1 min¹¹
  • This last point is very important because when using oral meds, takes time to dissolve and absorbed into the system and be transported to site of action, about 0.5-1hr to exert its effect
  • If dizziness is not frequent and is transient, doesn’t make sense to put the patient at risk of ADR since the patients may not derive benefits from the meds
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What is the TiTraTE appraoch to evaluate dizziness?

A
  1. Timing
  2. Triggers
  3. Targeted examination
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

When do we treat dizziness symptomatically?

A

only if vestibular symptoms are prolonged (>30 mins) + most of the treatment are on the Beer’s list

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

If we do need to treat dizziness symptomatically, what are some of the possible options?

A
  1. Antihistamine
  2. Phenothiazines
  3. Anticholinergics
  4. Benzodiazepine
  5. Antidopaminergic
  6. Calcium channel antagonists
  7. Histamine analogues
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Which anticholinergic medicines can be used to treat dizziness symptomatically?
What are the issues with giving anticholinergics?

A
  • ?Side effects
  • Must remember the anticholinergic side effects
  • Very impt when providing care to elderly
  • Side effects: Confusion, delirium, sedation, blurred vision, dry mouth, urinary retention, constipation, dry skin need to remember and understand how these ADR will change the patient’s behaviour and functional status
  • First Gen Antihistamine
  • Diphenhydramine/Dimenhydrinate/Meclizine
  • Anticholinergic
  • Scopolamine (hyoscine hydrobromide), How about hyoscine butylbromide?
  • Hyoscine Butylbromide is buscopan → Doesn’t cross BBB as easily as scopolamine so not for dizziness but for anti-spasmodic agent for cramps
  • Phenothiazine
  • Prochlorperazine/Promethazine
  • Additional Antidopaminergic effects. ?Contraindications
  • Promethazine → Besides strong anticholinergic effects, it has strong anti-dopaminergic effects so should avoid procodin (codeine and promethazine) in patients with Parkinsonism/Parkinson’s Disease, will worsen movement disorder
    *
22
Q

What are some benzodiazepines that can be used to treat dizziness?
Which population is it more for?
How long should you use it for?
What are the issues with BZDs?

A
  • More for younger patients not geri patients by ENT specialists
  • ​​Lorazepam/Diazepam/Clonazepam
  • More sedating
  • Fall risk
  • Use Short term: a few days
  • If use for long term, can worsen cognitive functions and increase risk of depression
  • So not good for long term
  • Even if tolerant to ADR but will increase risk of fall since it can slow down reaction thus increase risk of fall
23
Q

What are the anti-dopaminergic drugs that can be used to treat dizziness? Who should avoid them?

A
  • Parkinsonism, DLB and Parkinson’s disease, or Parkinson’s disease dementia should avoid this
  • Metoclopramide and promethazine
  • ?Contraindications
  • alternative: ondansetron (or domperidone but be careful of ATc prolongation)
  • Less for dizziness and more for nausea and vomiting
24
Q

What are the calcium channel antagonist that can be used to treat dizziness?
What are the issues with this medication?

A
  • Flunarizine but not commonly used in public institutions
  • High dose use for peripheral vascular disease in other countries but not in Singapore, but can give rise to ADR and very sedating
  • Cinnarizine (Very common)
  • ?Increasing circulation in the cochlear
  • Sedating
  • Weight gain due to antihistaminergic effect
  • Caution in patients with Parkinsonism
  • Careful when taking long term, look out for parkinsonism,
  • Increase risk of movement disorder in patients with existing parkinsonism
25
Q

What histamine analogue can be used to treat dizziness?
What are the issues with this medication?

A

Betahistine

  • Use commonly among geri patients
  • Type 3 Histamine Receptor antagonist; Partial agonist at H1 receptor; negligible agonism at H2 receptor
  • Well tolerated
  • Per Lexicomp: Use with caution in Asthma
  • Act on histamine receptor and cause bronchospasm, thus if given Betahistine and have asthma, see if they experience worsening of asthma control
  • Per Lexicomp: Contraindicated if active or history of Peptic Ulcer Disease
  • Use H2RA for dyspepsia
  • So betahistine can cause problem/worsening of gastric problems in patients with active or hx of PUD
26
Q

Which geriatric syndrome is a geriatric medical emergency?

A

Delirium

27
Q

What are the delirium subtypes? What are the characteristics of each subtype?

A
  1. Hyperactive delirium
  • Easy to pick up
  • Agitation (e.g. resisting care, climbing out of bed, pulling out IV plug/catheter, etc)
  • Inattention
  • Psychosis (delusions/hallucinations)
  • Onset –> Develops over hours or days
  1. Hypoactive delirium
  • Difficult to identify, may not be sleepy or not responding to call, but they are very slow in responding
  • Slow response
  • Increased sedation
28
Q

What are the risk factors of delirium?

A

**1. Age 65 yrs or older
**
2. Cognitive impairment (Past/Present) and/or Dementia

  • If patient have hx of delirium, the chance of them having delirium in the future is higher
  • If have underlying dementia, the chance of them having dementia is higher

3.** Current hip fracture
**
* Strong risk factor
* For those patients with hip fracture, want to avoid meds that will increase risk of patient developing delirium (because pain and inflammation compounded with stress and repair causes inflammatory chemicals to be systematically released throughout the body during the surgical procedure)

**4. Severe illness
**
* Delirium affect younger patients too
* But the degree of insult needed to cause us to develop delirium will be much higher and only see that in ICU when patient is very sick
* Becos of the diff populations, the guidelines to treat agitation in ICU, the dose of meds is very high and use IV haloperidol which is not recommended in geriatric patients in general ward
* If we become critical care Pharmacists and work in ICU and ask to cover general ward, don’t apply the ICU dose in general ward patients
*

29
Q

What tool is used to detect delirium in Singapore?
What are the components in the tool?
Can it detect both hyperactive and hypoactive delirium?

A

4AT for detection of Delirium

  1. Level of Alertness
  2. Abbreviated Mental Test 4 (AMT4) [DOB, Age, Place, Current Year]
  3. Attention [Dec>Nov>…] vs [30 -3 -3 -3 -3….]
  4. Acuity

Website: www.the4at.com

Can detect both hyperactive and hypoactive delirium

30
Q

What are the common causes of delirium?

A

I WATCH DEATH

  1. Infection
  2. Withdrawal (alcohol, barbiturates, benzodiazepines)
  3. Acute metabolic disorder (electrolyte imbalance, hepatic or renal failure)
  4. Trauma (head injury, post-operative)
  5. CNS Pathology (stroke, hemorrhage, tumor, seizure disorders, Parkinson’s)
  6. Hypoxia (anemia, HF, pulmonary embolus)
  7. Deficiencies (vitamin B12, folic acid, thiamine)
  • never seen delirium improve when replace the patients with vit B12 but it’s still impt to replace vit B12 if they are deficient
  1. Endocrinopathies (thyroid, glucose, parathyroid, adrenal)
  2. Acute vascular (shock, vasculitis, hypertensive encephalopathy)
  3. Toxins, substance use, medication (alcohol, anesthetics, anticholinergics, narcotics)
  • anticholinergics though is to help with bradycardia, when removed to abruptly it will cause tachycardia because they have increase level of anxiety which cause /increase in heart beating
  1. Heavy metals (arsenic, lead, mercury)
31
Q

When do you use diphenhydramine while patient has delirium?

A

When patient has a severe allergic reaction. Other than that, should avoid all anticholinergics

32
Q

When patient is delirious, and have BZD / Z-drugs on, what should you do?

A

Taper the drugs slowly, do not abruptly withdraw

33
Q

If have delirium and on famotidine, what should you do?

A
  • change to PPI if not CI
  • If not possible, then use famotidine at renally adjusted doses
  • famotidine cannot be used long term as will cause tachyphylaxis
34
Q

What are the drugs that cause delirium?

A
  1. Analgesics [Opioids, esp pethidine]
  2. Antimicrobials [Fluoroquinolone, Cefepime]
  3. Anticholinergics
  4. Corticosteroids –> can cause insomnia, confusion
  5. Dopamine agonists –> antidopaminergic, high impulse control disorder
  6. propantheline (antimuscarinic and antispasmodic
  7. H2RA
  8. Hypoglycemics
  9. Hypnotics/sedatives
  10. Anticonvulsants –> especially levetiracetam
  11. Antidepressants [Mirtazapine/SSRI/TCAs]
  12. Cardiovascular drugs [Digoxin]
  13. Muscle relaxant
  14. Lithium
35
Q

What is the 1st line approach of delirium?

A

Prevention

  • Sensory functions optimisations
  • Hydration/nutrition
  • Bowel movement/urination
  • Early mobility
  • Pain control
  • Medication review
  • Social interaction with loved ones
  • Reorientation with clock/calendar/proper lighting
  • Conducive environment
  • Promote good sleep
  • Address infection/hypoxia
36
Q

What line is the use of pharmacotherapy for agitation in delirium?
What are the pharmacotherapy?

A
  • This is a last resort since antipsychotics used in patients with dementia increases risk of stroke and mortality and risk of BPD?? so don’t want to use as first line, even if use, must monitor and cut down dose and stop when the situation allow us to do that
  1. We usually use quetiapine (has D2 and 5HT2 antagonism) since it’s suitable for all sort of patient regardless of risk of neuroleptic sensitivity reaction e.g. those with DLB, PDD
  • But delirium don’t need such a high dose of 100mg unless have underlying psychiatric condition such as schizophrenia but then we would use other antipsychotics since quetiapine at this dose don’t have that much antidopaminergic effect and can’t bring agitation under control compared to higher dose of other antipsychotics
  1. Olanzapine PO (orodispersible), 1.25-2.5mg , up to 10mg/day
  • Olanzapine is the safest in terms of cardiac toxicities
  1. Haloperidol 0.3-1 mg BD, up to 5mg/day
  • Contraindications: Prolonged QTc, Parkinsonism [including DLB/PDD]
  1. Lorazepam 0.5-1mg
  • 1st line for alcohol / BZD withdrawal
  • QTc is prolonged and bad, and dr is not comfortable to use antipsychotics then will use benzodiazepine like lorazepam
37
Q

How to treat hypoactive delirium?

A
  • Don’t treat with any drugs but want to withdraw as many CNS suppressant as much as possible and want to treat underlying cause e.g. infection /stroke
  • If stroke then have to wait it out, by the time you detect the stroke we might exceed the window to give thrombolytics
  • Don’t know since when they become like that so can’t determine the window to apply thrombolytic so just wait it out
38
Q

What are the prerequisites for urinary continence?

A
  • Normally functioning lower urinary tracts
  • Adequate physical and cognitive functions to use toilets
39
Q

What happens during the bladder filling phase and bladder voiding phase (Which systems are activated?)

A

Bladder filling phase

  • Sympathetic Nervous System activated/ Parasympathetic Nervous System blocked
  • > activate β-3 adrenergic receptor > Bladder detrusor relaxation
  • > activate ⍺-1 adrenergic receptor > tightening of Bladder outlet/urethra
  • Want the bladder be relaxed and the outlet to be tightly closed
  • ​​Want the norepinephrine to act on the adrenergic receptors
  • Phenylephrine (have anticholinergic effects) will cause tightening of outlet and thus cause urinary retention

Bladder voiding phase

  • Sympathetic Nervous System blocked/ Parasympathetic Nervous System activated
  • > Activate M3 receptor in the bladder> bladder contraction
  • Acetylcholine will act on the entry receptors and cause bladder contraction
40
Q

What are the types of UI?

A
  1. Stress
  2. Urge
  3. Overflow
  4. Functional
41
Q

What is stress UI?

A

Definition: Involuntary loss of urine (small amounts) with increasing intra-abdominal pressure (e.g. coughing, laughing, exercise)
Common Causes: weak pelvic floor muscles (childbirth, pregnancy, menopause), bladder outlet or urethral sphincter weakness, post-urologic surgery

  • Common among post menopausal women,
  • don’t have tight pelvic floor muscles urethra, so cant keep the urine in the bladder and will leak out
  • Esp those who have given birth multiple times
  • Happens after menopause, after losing oestrogen, will affect the integrity and strength of the muscles
  • Men will not really have stress UI, unless have undergone prostatectomy → prostate prevents men from getting stress UI since the prostate act as a valve that prevents leakage
42
Q

What is urge UI?

A

Definition: Leakage of urine (can be large volumes) because of inability to delay voiding after sensation of bladder fullness is perceived
Common Causes: Detrusor overactivity, either isolated or associated with one or more of the following: local genitourinary conditions e.g. tumours, stones, diverticula, outflow obstruction; or CNS disorder e.g. stroke, parkinsonism, dementia, spinal cord injury

  • Common among men and women
  • Associated with detrusor muscle overactivity
  • For men, it could be secondary to the inability to empty out the urine properly, so stretching of bladder overtime cause the bladder to be overly sensitive
  • Or serious causes like tumour, diverticula etc.
  • Thus 1 of the work up for UI esp. urge UI is urinalysis to see if have blood in urine
43
Q

What is overflow UI?

A

Definition: Leakage of urine (small amounts) caused by either mechanical forces on an overdistended bladder (resulting in stress leakage) or other effects of urinary retention on bladder and sphincter function (contributing to urge leakage)
Common Causes: anatomic obstruction by prostate, stricture, cystocele; acontractile bladder associated with diabetes or spinal cord injury; neurogenic associated with multiple sclerosis or other spinal cord lesions; medication effect

  • Cause by obstruction to outflow e.g. men with benign prostatic hyperplasia / hypertrophy
  • Caused by patients with underactive bladder e.g. neurogenic bladder, can’t contract properly, due to some form of neurolytic disorder
44
Q

What is functional UI?

A

Definition: Urinary accidents associated with the inability to toilet because of impairment of cognitive and or physical functioning, psychological unwillingness, or environmental barriers
Common Causes: Severe dementia or other neurologic disorder; psychological factors such as depression and hostility

  • Not something wrong with the urinary tract but more of not good body or brain
  • E.g. Osteoarthritis, amputation can’t reach the toilet on time to be continent
  • Delirious, depress or demented
  • They are not motivated if serially depressed, or demented then don’t know the urge and don’t know what to do
45
Q

What is the mneumonics for finding the cause of UI?

A

DIAPPERS
1. Delirium
2. Infection
3. Atrophic vaginitis
4. Pharmacueticals
5. Psychological disorders esp. depression
6. Excessive ruine output e.g. hypoglycemia
7. Reduced mobility (e.g. functional incontinence) or reversible (e.g. drug-induced) urinary retention
8. Stool impaction

46
Q

What are the drugs that can relax bladder muscles or tighten the outlet?

A
  1. Opioids
  • Tighten urethra so can cause urinary retention
  • Most of the time opioids causing these type of problems, patient must have risk factors, Using opioids itself is not a CI, but it’s about addressing other risk factors, opioids cause UI in those patients who are constipated or not moving or dose is too high
  1. ACEi is due to cough, so might be a problem for those with stress UI
  2. Phenylephrine only used in ICU
  3. Alpha blockers can relax the bladder outlet and cause voiding of urine, this worsens for women with stress UI
  4. Hardly use antiarrhythmic
  5. Disopyramide has strong anticholinergic effect
  6. Flecainide are not for those patients with structural heart disease, and usually elderly in the geri wards have structural disease so not commonly used in elderly, normally used in much younger patients
  7. **Duloxetine (SNRIs) **can be used for stress ulcer, can strengthen the urethra so increase urinary retention
  8. TCA and typical antipsychotics they act as anticholinergics, alpha blockers, antihistamine
  9. Anticholinergics will cause UI, but Alpha blockers are suppose to help but then Alpha blockers cause OH and not helping with the urine but Anticholinergics is causing UI
  10. Estrogen
  • Don’t want to give to elderly women with stress UI becos will worsen it but topical estrogen might help
  1. **Beta 3 agonist **
  • can cause relaxation of bladder, so can cause worsening of urinary retention, if have untreated BPH or underactive bladder because can relax the muscle
  1. Caffeine
  • Diuretic, and Irritant so not good for those with overactive bladder, should avoid caffeine, becos can stimulate the bladder detrusor muscle and cause it to contract easily
47
Q

What drugs worsen UI?

A
  1. CCB,
  • When use CCB e.g. nifedipine and amlodipine, (selective dilate arteries without any effects on veins, unlike ACEi and ARBs that dilates both the veins and arteries
  • So when dilate the arteries without the veins, this will increase hydrostatic pressure in capillary, will push the water out so more water will go into the interstitial space. Thus at night when sleep, without the effect of gravity, the water will go back into the intravascular space so the intravascular volume will expand, this will stop anti-diuretic hormone and more water will be excreted as urine
    Thus cause nocturia urinary incontinence
  • Some patients on CCB complained of peripheral edema, dr will give frusemide, not going to be effective becos the problem is not increase water or Sodium retention but it’s becos of the selective vasodilating effect on the arteries
  • So a better way is to give something that dilates the veins if there are still indication to reduce BP then give ACEi and ARBs that dilate the veins or cut down dose of CCB
  • Functional implications of peripheral edema? Mild pitting edema, means each leg have 500-1L extra water in the leg, walking will not be easy esp for frail patients, will impact their mobility so don’t add therapeutics but cut down and replace with sth else
  • Drug side effects is a diagnosis of exclusion work with dr to see if it’s the case becos patient might have DVT
  • Patient was taking nifedipine for decades but then later have bilateral swelling and coincided with the triple therapy, becos clarithromycin inhibit CYP3A4 from metabolising nifedipine, thus have peripheral edema
  1. gabapentin,
  2. pregabalin,
  3. thiazolidinediones
47
Q

How to manage UI in general?

A

1st line: Non-pharm

  1. Bladder retraining (only if cognitive function is good)
  2. Kegel’s pelvic floor muscle exercise (for stress and urge UI)
  3. Time voiding (for those functionally dependent)
  4. Continence pad
48
Q

How to manage stress UI?

A
  1. Kegel’s exercise
  2. Topical estrogen [may take up to 3 months for action onset, need counselling], the monograph says that within 2-3 weeks can see effect
  • Estrogen thickens and strengthens the genitourinary tract
  1. Duloxetine, esp if depression present but not for patients with crcl <30 ml/min → But not seen used in sg
  2. Surgery/Devices
  • Surgery are not advisable for most elderly patient who are frail
49
Q

How to manage urge UI?

A
  1. Kegel’s exercise
  2. Treat BPH [men]
  3. Topical estrogen [delayed onset]
  4. β-3 adrenergic receptor agonist
  • mirabegron, vibegron
  • Want to cause the detrusor muscles to relax so that it would keep contracting due to it being over sensitive
  1. Antimuscarinic agents
  • anticholinergic side effects
  • prefer M3-selective agents such as solifenacin and darifenacin (is M3 selective than solifenacin)
  • helps bladder detrusor muscles to relax
  1. Botulinum toxin injection
  • Prevent muscles from moving for a limited time
  1. Sacral nerve stimulation etc
50
Q

How to manage overflow UI?

A

Bladder outlet obstruction

  • treat BPH

Bladder underactivity

  • men: bethanechol (stimulates muscarinic receptor)
  • women: bethanechol + clean intermittent cathetirization (CIC)

PR4152 Multi-Morbidity (7 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions