Lectures

Question 1

Frailty definition & adverse outcomes (6)

Answer 1

A syndrome characterised by decreased reserve
and resistance to stressors, resulting from
cumulative decline across multiple physiologic
systems, and causing vulnerability to adverse
outcomes (disability, morbidity, falls,
hospitalisation, institutionalisation, death).

Question 2

Frailty phenotype (5), prevalence/incidence

Answer 2

• Changes in grip strength; exhaustion/fatigue; less physically active; slow gait; unintentional weight loss
• Prevalence 6.9%, 4 year incidence 7.2%

Question 3

Causes of frailty (primary, secondary) leading to 3 factors causing the clinical syndrome of frailty

Answer 3

Primary causes: Changes in gene expression, oxidative DNA damage, telomere shortening
Secondary causes: Depression, cancer, CHF, chronic infection
All the above result in: Neuroendocrine dysregulation, immune dysfunction, sarcopenia - leading to frailty

Question 4

Working approach: domains for assessment of frailty (7)

Answer 4

– Nutrition
– Mobility
– Activity
– Strength
– Endurance
– Cognition
– Mood

• Balance between assets and deficits will determine the consequences for an individual
• Dynamic nature
• Early and late life factors contribute
• Adaptability, physical environment & social resources are important determinants of the impact of frailty.

Question 5

Risk factors for frailty (10)

Answer 5

• Age, low education
• 30 year cumulative predictors: heavy drinking, cigarette, physical inactivity, depression, poor perceived health, 2 or more chronic symptoms, 1 or more chronic conditions, social isolation

Question 6

Frailty - debate whether it is a syndrome or not (collection of factors leading to worse outcomes compared to the sum of the individual components) - what’s the point?

Answer 6

Frailty research and debate has opened new
horizons in understanding of the aging process and
potential to identify vulnerable older adults and
prevent/delay adverse consequences

Question 7

Frailty is a syndrome that identifies:

Answer 7

A physiologic syndrome characterized by vulnerability to adverse outcomes such as disability, increased morbidity, hospitalization, mortality…

Question 8

Mechanisms of urinary incontinence and corresponding clinical types (6)

Answer 8

Detrusor Overactivity - Urge Incontinence
Detrusor Underactivity - Overflow Incontinence
Outlet Incompetence - Stress Incontinence
Outlet Obstruction - Overflow Incontinence/BPH Sx
Unrelated to underlying bladder pathology - Functional Incontinence, Transient Incontinence
Mixed - the most common! Mostly urge and stress

Question 9

Potentially reversible causes of urinary incontinence (acronym)

Answer 9

Delirium
Infection (UTI, pneumonia...)
Atrophy (urethral, vag)
Psychological
Pharmacology (Diuretics, BZD, 
Excess urination (XS caffeine)
Restricted Mobility (=functional incont - can't get to bathroom in time)
Stool impaction

Question 10

Physical exam for urinary incontinence

Answer 10

Neurologic Examination:
Cognitive Assessment
Perineal Sensation
Sacral Reflexes
Voluntary Contraction of Anal Sphincter
Lower Extremity Exam (strength, tone, DTRs, Long Tract Signs)
Mobility/Gait

Urogenital Exam:
Rectal exam (impaction and tone)
Pelvic exam
– Urogenital atrophy
– Pelvic floor muscle strength (digital vaginal exam)
Test for stress leakage (in upright position)
Post-void residual volume

Question 11

Post-void residual volume: Normal and abnormal values

Answer 11

-By in-and-out catheterization or bladder ultrasound.

PVR 400-450 ml is diagnostic of overflow UI.

Question 12

Detrusor Hyperactivity with Impaired Contractility (DHIC): Definition and why is it important?

Answer 12

• Bladder unstable but weakened: found in >1/3 of incontinent institutionalized elderly individuals.
• Important clinical implications because these individuals are at risk for urinary retention on bladder relaxant medications.

Question 13

DDx Stress incontinence

Answer 13

1. Genuine Stress Incontinence (GSI)
   – due to decreased urethral tone or due to internal sphincter deficiency and anatomical deviation of the bladder neck
   – In women commonly seen as a result of traumatic
   birth injury, inherited collagen disorders
   – In men, post-prostatectomy
2. Pelvic floor muscle weakness (external sphincter deficiency)
   – Due to sarcopenia, obesity, or recurrent straining

Question 14

DDx Urge incontinence

Answer 14

1. Age-related/idiopathic
2. Due to damage to central inhibitory tracts:
   – Frontal CVA, Parkinson’s, tumour, normal pressure hydrocephalus
3. Due to local bladder irritation:
   – Stone, polyp, cancer, cystitis
4. BPH
5. Weak pelvic floor muscles combined with excessive consumption of caffeinated beverages (usually in association with gait impairments)

Question 15

DDx Overflow incontinence

Answer 15

1. Bladder outlet obstruction:
   – In men: BPH, prostate ca, urethral stricture post-TURP or post-radiation.
   – In women: large cystocele or prolapse, stricture post surgery or radiation.
2. Detrusor underactive:
   – Spinal cord injury, spinal metastases, spinal stenosis
   – Anticholinergic medications.

Question 16

Tx Stress Incontinence

Answer 16

1. Behavioral: Weight loss if overweight, fluid modification, Kegel Exercises
2. Physiotherapy (pelvic floor muscle training) & Biofeedback
3. Medical: alpha-agonists, duloxetine.
4. Surgical: collagen injections, TVT (trans-vaginal tape), suspensions

Question 17

Tx Urge incontinence

Answer 17

1. Behavioral: Kegel Exercises, PFMT, Prompted Voiding, Bladder Retraining,
2. Medical: “antispasmodics”
   – mode of action: direct muscle relaxants, anti-cholinergic
   or both
   – oxybutinin (Ditropan) (M1) or tolterodine (Detrol) (M2) in short or long-acting forms reduce UI episodes by 20-60%.
   – Solifenacin (Vesicare) and trospium chloride (Trosec) are new anti-muscarinic (M3 & M4) alternatives shown to be equally or more effective than oxybutinin and tolterodine.
   – Alpha-antagonists (Flomax) if BPH suspected in men

Question 18

Tx Overflow incontinence

Answer 18

1. Treat the underlying cause.
2. If PVR is >400 ml, bladder must be decompressed with an indwelling catheter. Attempt to wean with in-and-out catheterizations.

Question 19

Cure rate in elderly for urinary incontinence

Answer 19

Cures can be obtained in over 30% of frail elderly

with UI. Significant improvements are obtained in another 30%.

Question 20

In Canada, 1 out of 5 older adults living at home is mistreated or has been mistreated at least once since becoming an older adult. T/F

Answer 20

False - Prevalence of elder abuse is 1% -18% (3.2%- to 4%)

Question 21

Most common types of elder abuse (2)

Answer 21

Psychological, financial (more than physical)

Question 22

Older adults are more at risk of elder abuse if they are living with someone else than if they are living alone. T/F

Answer 22

True - often abuser is caregiver.

Question 23

Older men are as likely as older women of being mistreated. T/F

Answer 23

True

Question 24

Rate of reporting of elder abuse?

Answer 24

From only 1/15 cases to 1/6 cases are reported.

Question 25

Fragility fractures represent ____% of all fractures in men and women over 50

Answer 25

80%

Question 26

Fracture risk assessment tools? Apply to which populations?

Answer 26

CAROC (Canada), FRAX (WHO) - apply to untreated men and women over age 50

Question 27

CAROC levels and what each represent (3) Based on which criteria? (3) Other criteria that will increase risk level? (2)

Answer 27

Low risk: Fracture risk 20% CAROC based on: Age, sex, bone density T-score at femoral neck Criteria for "bumping up" to next level: Prior fragility fracture after age 40, or recent prolonged glucocorticoid use (if both present: automatically high)

Question 28

FRAX uses the same criteria as CAROC as well as: (5) | FRAX and CAROC give the same risk assessment __% of the time.

Answer 28

BMI, parental hip fracture, rheumatoid arthritis, current smoking, alcohol intake; femoral neck bone density is an optional input. FRAX and CAROC give same risk assessment 90% of the time.

Question 29

Clinical approach to osteoporosis: risk factors for fracture

Answer 29

``` Fracture after age 40 Parental hip fracture Current steroid use Current smoking High EtOH Hx of rheumatoid arthritis Hx of falls ```

Question 30

Clinical approach to osteoporosis: what to look for on physical exam (3), labs and tests (2)

Answer 30

Height measurement: if lost 2cm or more since last visit, may indicate compression # Weight: if lost >10% of body weight since age 25, indicates higher risk Get up and go test: If can't get out of chair without using arm rests, they are at higher risk for falls Labs: rule out secondary causes: 25-OH VitD after pt has been on VitD for 3 months (takes 3 months for level to plateau) DXA (Dual-energy X-ray absorptiometry, for measuring bone mineral density) for everyone above age 65 and between 50-65 if risk factors exist.

Question 31

Osteoporosis: Management

Answer 31

Exercise (supervised if indicated/prev #) Calcium 1200 mg/day (from diet and supplements) Vit D: 50yrs: 800-2000 IU/day If at high risk or if had prev hip for spine #, consider pharmacoTx

Question 32

4 questions to ask yourself when seeing a patient who has fallen.

Answer 32

1. What caused the fall(s)? 2. Have there been other falls? 3. Does this patient have an occult medical illness contributing to the fall(s)? 4. What can i do to prevent further falls?