Causes of Transient Incontinence. Geriatrics: Urinary Incontinence, Dementia, and Delirium. Classification of Established Incontinence

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1 Causes of Transient Geriatrics: Urinary, Dementia, and Delirium Carla Zeilmann, PharmD, BCPS St. Louis College of Pharmacy Therapeutics 3 Fall 2003 D delirium I infection A atrophic urethritis and vaginitis P pharmaceuticals and alcohol P psychiatric disorders E excessive urine output R restricted mobility S stool impaction Urinary Definitions Transient Established Detrusor muscle Postvoiding residual volume Classification of Established Outlet Obstruction (overflow) Outlet Incompetence (stress) Detrusor Overactivity (urge) Detrusor Underactivity (neurogenic) Functional Outlet Obstruction AKA Overflow incontinence Symptoms include trouble starting stream of urine, poor urinary stream, nocturia, feeling of incompletely emptying the bladder Causes include BPH in men

2 Outlet Incompetence AKA Stress incontinence Symptoms include loss of small amounts of urine when intraabdominal pressure increases Causes include pelvic floor weakness in women Functional Symptoms are a loss of urine due to impaired functional abilities Causes include mobility, cognition, or manual dexterity problems Detrusor Overactivity AKA Urge incontinence Symptoms include a frequent desire to void, involuntary voiding, and leakage of small amounts of urine Causes include involuntary bladder contractions Diagnosis of Look for and eliminate causes of transient incontinence If incontinence persists, classify type of established incontinence Use history, lab, and physical exam Detrusor Underactivity AKA Neurogenic bladder Symptoms are similar to overflow incontinence Causes include nerve injury or diabetic neuropathy Please write down something* that needs clarification. *something about this lecture so far

3 Non-pharmacologic Therapy for Timing of fluid intake Bladder retraining Strengthening exercises Diapers, bedpads, bedside commode, urinal Catheters Surgery Detrusor Overactivity (Urge) oxybutynin tolterodine anticholinergics calcium channel blockers diltiazem mg/d verapamil mg/d nifedipine mg/d Outlet Obstruction (BPH) prazosin, doxazosin, terazosin tamsulosin, alfuzosin finasteride, dutasteride saw palmetto Detrusor Underactivity (Neurogenic) bethanechol Outlet Incompetence (Stress) estrogen alpha agonists Summary of Treatment Options for Type of Non-Pharmacologic Therapy Pharmacologic Therapy Overflow Bladder retraining Timing of fluid intake Diapers, catheters Surgery α-antagonists 5 α-reductase inhibitors Stress Urge Neurogenic Functional Bladder retraining, diapers Kegel s exercises Surgery for prolapse or bladder neck suspension Bladder retraining, diapers Timing of fluid intake Strengthening exercises Bladder retraining, diapers Timing of fluid intake Decompress bladder X10-14 days with a catheter Environmental modifications Improve functional status topical estrogen α-agonists anticholinergics bethanechol none

4 Questions? Diagnosis of Dementia DSM-IV Criteria Both of the following: Memory impairment One or more: aphasia, apraxia, agnosia, executive functioning Cause impairment of social/occupational functioning, significant decline Course of decline is gradual and continual Not due to delirium Dementia Dementia decline in cognitive function not due to impaired consciousness no acute disorders that can cause reversible cognitive impairment Cognitive functioning learn and retain information, handle complex tasks, reasoning ability, spatial ability and orientation, language, behavior Diagnosis of Dementia Alzheimer's disease the most common cause of dementia diagnosis of exclusion Multi-infarct dementia second most common cause of dementia stepwise presentation focal neurologic deficits some cognitive domains remain intact Causes of Dementia Primary dementia Vascular dementia Dementia with Lewy body disease Dementia due to toxic ingestion Dementia due to infection Dementia due to structural abnormalities Potentially reversible causes Treatment of Dementia Treatment for cognitive disturbances (Alzheimer s disease only) Treatment of behavioral disturbances (all causes of dementia)

5 Alzheimer s Disease Types of Behavior Problems Disruptive Physically dangerous Psychological Psychotic Alzheimer s Disease Non-pharmacologic Management for Non-Cognitive Symptoms Behavior = communication Remove triggers of behavior problem Frustration at not being able to finish tasks Anxiety about being bathed, dressed or toileted Restraints Too much/too little mental stimulation New surroundings/change in routine Treatment for Cognitive Disturbances Donepezil - Aricept Rivastigmine - Exelon Galantamine - Reminyl Tacrine Cognex Memantine Ebixa (not yet on market) Triggers, continued Inadequate supervision Possible offending medications Unsafe environment Unmet physical needs Sensory impairment Caregiver anger, frustration or fear

6 Pharmacologic Management for Non-Cognitive Symptoms To be used only if non-pharm therapy fails to achieve goals for behavior management Disruptive antiepileptics, propranolol, sedative/hypnotics Psychological antidepressants, antianxiety medications Psychotic - antipsychotics Delirium an acute confusional state associated with an underlying physical condition acute onset, fluctuating course impaired attention altered levels of consciousness Mini-case Causes of Delirium AJ is a 87 yo male admitted to the nursing home because his family can no longer leave him home alone, and they have to work. He is diagnosed only with mild AD. At bedtime, he becomes very combative. During the day, he is very quiet and withdrawn, and cries frequently. D E L I R I U M drugs electrolyte and physiologic abnormalities lack of drugs infection reduced sensory input intracranial problems urinary retention and fecal impaction myocardial problems Mini-case Should we treat his mild AD? Donepezil 5 mg qd Should we treat his combative behavior? Trazodone 25 mg hs or zolpidem 5 mg hs Should we treat his depression? Sertraline 25 mg qd Drugs That Can Cause Delirium Sedative hypnotics Antidepressants Anticholinergics Opioids Low potency antipsychotics Anticonvulsants Antiparkinsonian agents H2 blockers

7 Diagnosis of Delirium DSM-IV Criteria Disturbance of consciousness Change in cognition Develops over a short time and fluctuates Due to a general medical condition, intoxication, withdrawal, multiple problems Rule out causes of DELIRIUM with history, physical, and lab findings Treatment of Delirium Three principles: Identify and treat the underlying acute disorder Remove contributing factors Control disruptive behaviors Non-pharmacologic therapy is the same as for dementia Treatment of Delirium Pharmacologic therapy for agitation: risperidone haloperidol lorazepam