Box 102.1 DIAGNOSTIC CRITERIA FOR MAJOR DEPRESSION*

TREATMENT

Effective therapy for mild to moderate depression usually involves use of antidepressants. Selective serotonin-reuptake inhibitors (SSRIs) are considered first-line treatment. Most SSRIs are equally effective, with gastrointestinal upset the most common adverse effect. Citalopram now has a maximum dose of 20 mg for patients >60 years old because of the risk of QT prolongation and torsades, and it should be avoided in patients with congenital QT syndrome or bradycardia. Fluoxetine (Prozac) should be avoided in older adults due to its long elimination half-life. Other antidepressants are available and their unique side effect profiles can be used to tailor medications to the individual needs. Mirtazapine (Remeron) is a serotonergic and noradrenergic antidepressant with potential beneficial side effects of sedation and appetite stimulation when used at low doses. Buproprion (Wellbutrin) can cause anxiety and insomnia and therefore may be useful in patients with fatigue or lethargy. Serotonin-norepinephrine reuptake inhibitors (SNRIs) such as duloxetine (Cymbalta) and venlafaxine (Effexor) are useful for patients with coexisting neuropathic pain, although SNRIs may be less well tolerated in frail older adults than SSRIs. Monotherapy is preferred in order to minimize side effects and drug interactions. Starting doses should be lower for older adults although full adult doses will usually be required for adequate response. Treatment response may take up to 12 weeks, although partial improvement will often be seen after 4 weeks of treatment. Antidepressant treatment should be continued for at least 6–12 months or longer to prevent recurrence. Other antidepressants such as tricyclic antidepressants and monoamine oxidase inhibitors are used less frequently due to their potential serious side effects of cardiac conduction defects, myocardial infarction, and orthostatic hypotension.

    Structured psychotherapy is another valid treatment option which studies show to be as effective as pharmacotherapy for mild to moderate depression. Psychotherapy is also useful in conjunction with pharmacotherapy in severe or chronic forms of depression.

    Electroconvulsive therapy (ECT) is effective for the treatment of severe depression in older adults resistant to other treatments or in patients at risk of serious harm due to psychotic features, suicidality, or severe malnutrition. Severe or persistent depression, the presence of mania or psychotic features, and suicidality are indications for referral to a psychiatrist.

URINARY INCONTINENCE

BACKGROUND

Urinary incontinence is a common and potentially disabling problem in older adults yet often goes unrecognized and untreated. Patients are often reluctant to mention this problem, and busy practitioners often do not inquire about it. Incontinence can lead to depression, anxiety, falls, skin infections, sleep disturbance, caregiver burden, and social isolation, and is a major reason for institutionalization.

EPIDEMIOLOGY

Up to 30% of those 65 and older are affected by urinary incontinence. The prevalence increases with age. Women are two to three times more likely to be affected until the age of 80, when men are just as likely to experience incontinence.

PATHOPHYSIOLOGY

Incontinence is often multifactorial. Changes in the lower urinary tract, central nervous system, cognition, mobility, and volume status all play a role in its development. The supporting muscles of the pelvic floor are often weakened by lack of estrogen, previous vaginal deliveries, or pelvic irradiation. These changes commonly result in detrusor muscle weakness, bladder overactivity, and bladder outlet obstruction. Disruption in the nervous system by stroke, Parkinson disease, or normal-pressure hydrocephalus, for example, can also lead to incontinence. Limited mobility, decreased manual dexterity, and cognitive dysfunction can lead to incontinence even in the absence of actual physiological abnormalities. Comorbidities including severe constipation, diabetes, and congestive heart failure also contribute.

CLINICAL PRESENTATION

There are four basic types of incontinence, although symptoms often overlap (see table 102.5).

    Urge incontinence is the most common and is also known as overactive bladder. It presents with the sudden need to urinate, often with leakage of moderate to large amounts of urine. Urinary frequency and nocturia are common. Men often have additional symptoms related to prostatic enlargement. Women with urge incontinence may also have symptoms of stress incontinence, which is referred to as mixed incontinence.

    Stress incontinence is characterized by leakage of urine with increased intra-abdominal pressure exacerbated by coughing, sneezing, position change, or exercise. It is more common in women and is often associated with weakened pelvic floor muscles.

    Overflow incontinence is seen with urinary retention due to detrusor muscle weakness or bladder outlet obstruction. Symptoms include decreased urinary output, weak stream, and hesitancy in addition to dribbling, frequency, and nocturia.

    Functional incontinence refers to the inability to reach the toilet in time. Causes include medications (e.g., diuretics), impaired mobility (e.g., arthritis and stroke), environmental obstacles, and psychiatric or cognitive disorders.

DIAGNOSIS

Because patients often do not report symptoms of urinary incontinence, care providers should screen for this disorder with routine questions directly inquiring about incontinence. A physical examination should include a pelvic examination to evaluate for anatomic or atrophic changes, a rectal examination to rule out impaction, and a neurological examination to rule out evidence of a focal neurological deficit. Mobility, cognition, and volume status should be assessed. Additional diagnostic tests should include a postvoid residual by bladder ultrasound and a urinalysis. Further urodynamic studies can be performed by a urologist or gynecologist when the diagnosis is unclear.

TREATMENT

Treatment options for incontinence depend on the type of incontinence as well as the preferences of the patient. Not all incontinence can be cured, but even a reduction in occurrence can greatly improve quality of life.

Stay updated, free articles. Join our Telegram channel

Join