NR601 final

Geriatric depression scale

A commonly used scale is the 15-item version of the Geriatric Depression Scale (GDS). The GDS is unique in that it does not emphasize physical symptoms of depression (e.g., sleep and appetite changes) but focuses on psychological factors to suggest the presence of depression. A score of ≥5 suggests a need for further evaluation. The GDS can be administered in 5 to 10 minutes or can be given to the patient to fill out.

McGeer criteria

Acute dysuria OR Fever >37.9 Celsius plus one of the following: Urgency Frequency Suprapubic pain Gross hematuria Costovertebral angle tenderness Urinary incontinence

Combination Therapy: Alpha-Blockers and Anticholinergic Medications

Anticholinergic agents (e.g., oxybutynin, tolterodine) inhibit muscarinic receptors in the detrusor muscle and relieve irritative voiding symptoms. Commonly used for overactive bladder, the use of anticholinergics was discouraged in patients with BPH because of concerns of causing urinary retention

Depression and comorbidities

Both stroke and heart disease have a strong correlation with depression. Treatment of comorbid depression with antidepressants can significantly improve morbidity and mortality.

SSRI and hyponatremia

Checking serum sodium after 2 weeks can be considered in patients starting an SSRI who have additional risk factors or who are taking other medications associated with antidiuretic hormone secretion (e.g., thiazides, nonsteroidal antiinflammatory drugs [NSAIDs])

Hearing loss and dizziness

Classical hearing loss patterns in dizziness are as follows: low frequency, fluctuating is typical of Ménière disease; low frequency, unilateral, gradually decreasing suggests eighth nerve tumor.

Urgency

Compelling, often sudden need to void that is difficult to defer.

Frequency

Complaint of needing to void too often during the day, as defined by the patient

SNRIs

SNRIs (duloxetine, venlafaxine, desvenlafaxine) inhibit the synaptic reuptake of both norepinephrine and serotonin. Although there is no conclusive evidence that the SNRIs are any more efficacious than SSRIs in treating depression in older adults,123,124 this class does offer distinct benefits for chronic pain conditions with or without comorbid depression.125 Venlafaxine predominantly affects serotonin uptake at doses <150 mg daily, and accordingly at those doses its side effects are typical of SSRIs.126 Duloxetine has a more balanced effect on both serotonin and norepinephrine at clinically relevant doses and is indicated for a number of pain indications, including fibromyalgia, neuropathic pain associated with diabetic peripheral neuropathy, and chronic musculoskeletal pain

SSRI's

SSRIs are among the most commonly prescribed drugs in medicine. SSRIs are generally well tolerated although they have both common and less well-known side effects that are important to consider when prescribing for older adults. With a majority of serotonin receptors being located in the gut, the most common initial side effects of SSRIs tend to be gastrointestinal (GI) and transient. A temporary decrease in initial dosing minimizes GI side effects for most patients while serotonin receptors in the gut are downregulated. Later emerging GI side effects include constipation with paroxetine and diarrhea with sertraline. The latter can be quite persistent with an onset that is delayed enough that it is often poorly recognized as a cause. In addition, SSRIs can have an activating effect when initially prescribed, which may result in insomnia or jitteriness. Changes in dose and time of administration are usually sufficient to address these issues

Intermittent stream

Sensation that the bladder is not empty after voiding.

Primary Skin and Soft Tissue Infection Management and Treatment

Some experts recommend that all community-associated primary SSTIs be treated with clindamycin, a drug that treats many CA-MRSA strains, as well as β-hemolytic streptococci. Others note that the risk for CA-MRSA is increased if the primary SSTI has evidence for abscess formation or drainage when compared with cellulitis alone. In that instance, a β-lactam antibiotic is recommended for cellulitis alone and clindamycin or trimethoprim-sulfamethoxazole when abscesses or drainage are present. Still others note that the choice of antibiotic has little impact on CA-MRSA and surgical incision and drainage is most important For treatment directed against methicillin-sensitive S. aureus and streptococci, oral treatments with first-generation cephalosporins (cephalexin) and antistaphylococcal penicillins (dicloxacillin, amoxicillin-clavulanate) are appropriate. For penicillin-allergic patients, clindamycin or a quinolone with activity against streptococci (moxifloxacin) can be used. For severe bacterial SSTIs, empiric treatment should be directed against MRSA until results of cultures are known; vancomycin, daptomycin, tigecycline, or oral linezolid could be considered

UI surgery

Surgical interventions for stress incontinence​ include: midurethral mesh sling​ Surgical interventions for urgency incontinence include: sacral neuromodulation​: implanted electrode connected to a stimulator

Overactive bladder

Symptom syndrome (not a specific pathologic condition) consisting of urgency, frequency, and nocturia, with or without urge incontinence.

Symptomatic UTI

Symptoms of lower UTI or cystitis include suprapubic pain, dysuria, frequency, and urgency. Flank pain and fever are more typical of upper tract infection or pyelonephritis

BPH assessment

The digital rectal examination (DRE) is an essential assessment for BPH and is used to assess prostate size, contour, and presence of abnormal nodules The International Prostate Symptom Score (IPSS) Links to an external site., is a validated questionnaire that measures the severity of lower urinary tract symptoms (LUTS). A score of 7 or less indicates mild symptoms, 8 to 19 indicates moderate symptoms and 20 to 35 indicates severe symptoms. Although it indicates prostatic issues, it is not a diagnostic tool for BPH.

UI surgery

The most commonly used procedures are colposuspension (Burch operation) and slings (synthetic mesh, or autologous or cadaveric fascia, placed at the proximal or midurethra).

Benign Prostate Disease

The prostate is divided into four lobes. The anterior lobe lies in front of the urethra and consists of fibromuscular tissue. The median lobe is situated between the two ejaculatory ducts and the urethra. The right and left lateral lobes make up the bulk of the prostate and are separated by the prostatic urethra. The posterior lobe is the medial part of the lateral lobes and can be palpated through the rectum during digital rectal examination (DRE

Loeb criteria

Three of the following: Fever >38 Celsius New/increased burning, frequency, urgency New flank or suprapubic pain Change in character of urine New or worsening mental status changes

Asymptomatic Bacteriuria

treatment of asymptomatic bacteriuria does not permanently eradicate the organism and, with rare exception, no benefit of treatment for the older adult has been demonstrated in terms of improved wellbeing, relief of chronic symptoms, or survival. Treatment of "dirty urine" in the older adult population with asymptomatic bacteriuria is not beneficial. Uncomplicated UTI requires that the woman be healthy without diabetes and immunosuppression Use of nitrofurantoin may be limited in older adults because of contraindications in patients with renal insufficiency (creatinine clearance <40 cc/min). Fosfomycin and nitrofurantoin are not indicated for pyelonephritis

Delirium symptoms

• Acute change in mental status • Fluctuating course • Attention disturbance • Memory disturbance • Orientation disturbance • Perceptual disturbance • Thought disturbance • Sleep disturbance • Consciousness disturbance • Speech disturbance • Psychomotor activity disturbance

Chronic Bacterial Prostatitis

A 4- to 6-week course of oral fluoroquinolones may be prescribed after the initial diagnosis in chronic bacterial prostatitis if infection is strongly suspected. Herbal extracts or phosphodiesterase-5 inhibitors when combined with antibiotics may improve symptoms and quality of life. When chronic bacterial prostatitis is caused by Trichomonas vaginalis, a 14-day course of metronidazole has been shown effective CP/CPPS is the most common type of prostatitis with long-lasting, difficult-to-resolve symptoms for which patients will access multiple providers. Nonmedication approaches, alpha-blockers, anticholinergics, antibiotics, and combinations of these therapies improve symptoms

Criteria for identifying a manic episode

A distinct period of time (at least 7 days) where a person's mood becomes persistently elevated, expansive, and/or irritable. During this time the patient also displays at least three of the following symptoms: a. Inflated self-esteem and grandiosity—Patient may start challenging authority at the workplace. May become suspicious that others are talking about or plotting against him or her. b. Decrease in need for sleep—Patient may sleep for only 3 hours per night without experiencing any tiredness during the day. Make sure to ask about daytime naps to rule out underlying sleep disorder. c. Increase in distractibility—Patient may have difficulty focusing on one task at a time. d. Increase in goal-directed activity—Patient may take on multiple projects at once. e. Impulsivity—Patient may partake in risky behaviors without considering the consequences. f. Rapid thinking or racing thoughts—Patient may have multiple unrelated thoughts at the same time and find it difficult to express these thoughts to others. g. Talkativity—Patient finds oneself speaking rapidly, often forcing others to interrupt

Criteria for Skin and Soft Tissue Infection

A. Cellulitis/soft tissue/wound infection At least one of the following criteria present: 1. Pus present at a wound, skin, or soft tissue site 2. New or increasing presence of at least four of the following signs/symptoms subcriteria: a. Heat at the affected site b. Redness at the affected site c. Swelling at the affected site d. Tenderness or pain at the affected site e. Serous drainage at the affected site f. One constitutional criterion More than one patient with streptococcal skin infection from the same serogroup (e.g., A, B, C, G) in a healthcare institution may suggest an outbreak For wound infections related to surgical procedures use the Centers for Disease Control and Prevention's National Healthcare Safety Network Surgical Site Infection criteria Presence of organisms cultured from the surface (e.g., superficial swab culture) of a wound is not sufficient evidence that the wound is infected B. Scabies Both criteria 1 and 2 present: 1. A maculopapular and/or itching rash 2. At least one of the following subcriteria: a. Physician diagnosis b. Laboratory confirmation (scraping or biopsy) c. Epidemiologic linkage to a case of scabies with laboratory confirmation Care must be taken to rule out rashes related to skin irritation, allergic reactions, eczema, and other noninfectious skin conditions An epidemiologic linkage to a case can be considered if there is evidence of geographic proximity, temporal relationship to the onset of symptoms, or evidence of common source of exposure (e.g., shared caregiver) C. Fungal oral/perioral and skin infections Oral candidiasis: Both criteria 1 and 2 present: 1. Presence of raised white patches on inflamed mucosa, or plaques on oral mucosa 2. A medical or dental provider diagnosis Fungal skin infection: Both criteria 1 and 2 present: 1. Characteristic ras

Criteria for Gastrointestinal Infection

A. Gastroenteritis At least one of the following criteria present: 1. Diarrhea, three or more liquid or watery stools above what is normal for the resident within a 24-hour period 2. Vomiting, two or more episodes in a 24-hour period 3. Both of the following signs/symptoms subcriteria present: a. A stool specimen positive for a pathogen (such as Salmonella, Shigella, Escherichia coli O157:H7, Campylobacter species, rotavirus) b. At least one of the following GI subcriteria present: i. Nausea ii. Vomiting iii. Abdominal pain or tenderness iv. Diarrhea Care must be taken to exclude noninfectious causes of symptoms. For instance, new medications may cause diarrhea, nausea, or vomiting; initiation of new enteral feeding may be associated with diarrhea; nausea or vomiting may be associated with gallbladder disease Presence of new gastrointestinal (GI) symptoms in a single resident may prompt enhanced surveillance for additional cases In the presence of an outbreak, stool specimens should be sent to confirm the presence of norovirus, or other pathogens (such as rotavirus or E. coli O157:H7) B. Norovirus gastroenteritis: Both criteria 1 and 2 present: 1. At least one of the following GI subcriteria present: a. Diarrhea, three or more liquid or watery stools above what is normal for the resident within a 24-hour period b. Vomiting, two or more episodes in a 24-hour period 2. A stool specimen positive for detection of norovirus either by electron microscopy, enzyme immunoassay, or a molecular diagnostic test such as polymerase chain reaction (PCR) In the presence of an outbreak, stool specimens should be sent to confirm the presence of norovirus, or other pathogens (such as rotavirus or E. coli O157:H7) In the absence of laboratory confirmation, an outbreak (two or more cases occurring in the long-term ca

Criteria for Lower Respiratory Tract Infection

A. Influenza-like illness: Both criteria 1 and 2 present: 1. Fever 2. At least three of the following symptom subcriteria (a-f) present: a. Chills b. New headache or eye pain c. Myalgias or body aches d. Malaise or loss of appetite e. Sore throat f. New or increased dry cough B. Pneumonia: All criteria 1-3 present: 1. Interpretation of a chest radiograph as demonstrating pneumonia or the presence of a new infiltrate 2. At least one of the following respiratory subcriteria (a-f): a. New or increased cough b. New or increased sputum production c. O2 saturation <94% on room air or a reduction in O2 saturation of >3% from baseline d. New or changed lung examination abnormalities e. Pleuritic chest pain f. Respiratory rate of 25/min 3. At least one constitutional criterion C. Lower respiratory tract (bronchitis or tracheobronchitis): All criteria 1-3 present: 1. Chest radiograph not performed, or negative for pneumonia or new infiltrate 2. At least two of the respiratory criteria (B. 2. a-f) listed earlier 3. At least one constitutional criterion If criteria for influenza-like illness and another upper or lower respiratory tract infection (LRTI) are met at the same time, only the diagnosis of influenza-like illness should be recorded Because of increasing uncertainty surrounding the timing of the start of influenza season, the peak of influenza activity, and the length of the season, "seasonality" is no longer a criterion to define influenza-like illness For both pneumonia and LRTIs, presence of underlying conditions that could mimic a respiratory tract infection presentation (e.g., congestive heart failure or interstitial lung diseases) should be excluded by a review of clinical records and an assessment of presenting symptoms and signs

Criteria for Urinary Tract Infection

A. Without an indwelling catheter: Both criteria 1 and 2 present: 1. At least one of the following signs/symptoms subcriteria (a-c) present: a. Acute dysuria or acute pain, swelling, or tenderness of the testes, epididymis, or prostate b. Fever or leukocytosis and At least one of the following localizing urinary tract subcriteria: i. Acute costovertebral angle pain or tenderness ii. Suprapubic pain iii. Gross hematuria iv. New or marked increase in incontinence v. New or marked increase in urgency vi. New or marked increase in frequency c. In the absence of fever or leukocytosis, then at least two or more of the following localizing urinary tract subcriteria: i. Suprapubic pain ii. Gross hematuria iii. New or marked increase in incontinence iv. New or marked increase in urgency v. New or marked increase in frequency A urinary tract infection (UTI) should be diagnosed when there are localizing genitourinary signs and symptoms and a positive urine culture A diagnosis of urinary infection can be made without localizing symptoms if a blood culture isolate is the same as the organism isolated from the urine, and there is no alternate site of infection In the absence of a clear alternate source, fever or rigors with a positive urine culture in the noncatheterized resident or acute confusion in the catheterized resident will often be treated as urinary tract infection However, evidence suggests most of these episodes are likely not from a urinary source Pyuria does not differentiate symptomatic UTI from asymptomatic bacteriuria Absence of pyuria in diagnostic tests excludes symptomatic UTI in residents of long-term care facilities 2. One of the following microbiologic subcriteria: a. ≥105 cfu/mL of no more than two species of microorganisms in a voided urine b. ≥102 cfu/mL of any number

Menopause symptom management

Although menopause is a natural part of aging, symptoms may have a negative impact on well-being. The body will adjust to hormone changes and symptoms typically ease after a couple of years. In the meantime, however, there are ways to management the symptoms. Hot flashes and night sweats​ Avoid triggers- spicy foods, hot drinks, alcohol, and caffeine​ Maintain a cool environment, layer clothing​ Increase exercise Vaginal dryness​ Vaginal estrogen​ Vaginal moisturizer​ Lubricants during sex Mood changes​ Selective serotonin reuptake inhibitors (SSRIs) Osteoporosis​ Calcium and vitamin D supplements​ Bone density scans

Benign Paroxysmal Positional Vertigo

BPPV is the most common vestibular disorder in older persons, occurring in up to 40% of patients experiencing dizziness. It is characterized by intense vertigo lasting a minute or so after movement. It often comes in bouts lasting for days to weeks, occurring several times in a several week period, and then not recurring for months to years. There is usually a latent period of 5 to 10 seconds between change in position and the onset of dizziness and nystagmus. The dizziness tends to subside once the position is resolved.7 The patient may experience tinnitus but does not experience hearing loss. It is a specific variety of vertigo characterized by fatigable nystagmus with a short latency period that can be best observed when the Dix-Hallpike maneuver is performed. Patients with BPPV typically present with brief episodes of vertigo associated with a change in head position, such as when turning over in bed or straightening up after bending over. Some 20 to 60 seconds of rotational dizziness after sitting the patient rapidly from a supine position with the head turned 30 degrees to one side or the other is the classic response. Rotational nystagmus is often seen at that time as well. Extending the neck to look and reach up may also produce symptoms in patients with BPPV

UI behavioral therapies

Behavioral therapies include bladder training and pelvic muscle exercises; both are useful for urgency and stress incontinence. ​ Bladder training includes frequent voiding (i.e., every 2 hours) along with visualization and muscle contractions to help control urgency. As training progresses, the time between voluntary voids is increased. The training process may take several weeks (Mazur-Bialy et al., 2020)​. Pelvic muscle exercises, or Kegels, help to strengthen the pelvic floor. Exercises may be done throughout the day, with a goal of three sets of 10-12 per day. Exercises may begin to improve incontinence within a month. Prompted voiding may decrease incontinence episodes in cognitively impaired clients. The caregiver should prompt the client to report the need to void throughout the day and assist in toileting every 2-3 hours

Minimally Invasive Treatment for Refractory Urge Urinary Incontinence

Botulinum toxin: Injection in detrusor during cystoscopy: Can reduce UI with a slightly higher cure compared with antimuscarinics, although with a greater risk of urinary retention. Patients must be willing to do self-catheterization because of the risk of urinary retention Optimal dosing for specific patient groups such as older women is uncertain Sacral nerve modulation Percutaneous implantation of a trial electrode at the S3 sacral root, which is connected to an external stimulator. Patients responding to the trial have a permanent lead with a pacemaker-like energy source implanted Anticipated newer MRI-compatible models will end need to explant stimulators before imaging Percutaneous tibial nerve stimulation66 Very small trials only66 Patients unlikely to see efficacy before 6 weeks of treatment Limited coverage by insurance

Combination Therapy: Alpha-Blockers and 5-Alpha-Reductase Inhibitors

Combinations of doxazosin and finasteride, as well as tamsulosin and dutasteride, have been studied.21,22 When used together over several years, the combination of alpha-adrenergic antagonists with 5-alpha-reductase inhibitors has been shown to be safe and to reduce clinical progression of BPH better than either agent alone

Nocturia

Complaint of waking at night one or more times to void. If these voids are associated with UI, the term nocturnal enuresis may be used

Community-Acquired Pneumonia Severity of Illness Score (CURB-65 Criteria

Confusion Disoriented person, place, time Uremia ≥20 mg/dL Respiratory rate >30 breaths/minute Low Blood pressure Systolic/diastolic 90/60 mmHg Age ≥65 years Increased age

Beta-3 Agonists

Currently, mirabegron (Myrbetriq 25-50 mg once daily) is the only beta-3 receptor agonist approved in the United States for treatment of urge UI (LOE = B for efficacy Mirabegron can increase blood pressure; persons with hypertension should have periodic blood pressure checks while on mirabegron, and mirabegron should not be used in patients with severe uncontrolled hypertension

MCI and AD pharmacotherapy

Currently, only two classes of medications are approved by the US Food and Drug Administration for treatment of AD: cholinesterase inhibitors (including donepezil, galantamine, and rivastigmine) and the N-methyl-D-aspartate (NMDA) receptor inhibitor, memantine. The benefits from these medicines are typically small, and vary according to the cause of dementia and illness stage. All of these agents carry the risk of clinically significant adverse effects. Cholinesterase inhibitors may cause gastrointestinal distress and weight loss, urinary urgency, bradycardia, syncope, and sleep disturbances (including vivid, troublesome dreams). Memantine has fewer side effects but is associated with dizziness and possibly hallucinations and increased agitation. Thus clinicians, patients, and family caregivers need to carefully weigh the benefits and risks of pharmacotherapy and monitor carefully for adverse effects. There was a small advantage of titrating therapy from 5 mg to 10 mg daily. Patients experienced higher rates of side effects but no additional clinical benefit at 23 mg per day

Treatment of Woman With Uncomplicated Urinary Tract Infection

Cystitis Pyelonephritis Able to tolerate medication Absence of: • pyelonephritis symptoms • fever, flank pain • allergy history Obtain a urine culture Hospitalized—give IV dose initially • ceftriaxone • aminoglycoside • quinolone (unless resistance >10%) First-Line Oral Treatment Options First-Line Oral Treatment Options Nitrofurantoin 100 mg BID × 5 daysa TMP/SMZ DS BID × 3 days (avoid if prior UTI in 3 months, or 20% resistance to sulfas in the community) Fosfomycin 3 gm single dosea (lower efficacy) Pivmecillinam 400 mg BID × 5 daysa (lower efficacy) Ciprofloxacin 500 mg BID × 7 days Levofloxacin 750 mg QD × 7 days TMP/SMZ DS BID × 14 days β-lactam 10-14 days (less efficacious) Second-Line Treatment Oral Options Quinolones Topical estrogen use may reduce recurrent episodes of UTI in healthy older women by normalizing vaginal pH and restoring normal flora. Cranberry juice may reduce significant bacteriuria in older women by inhibiting binding of gram-negative bacilli to uroepithelial cells. Prophylaxis with postcoital or once-daily low doses of trimethoprim-sulfamethoxazole, quinolones, or nitrofurantoin may be considered on older women, as well as younger women with uncomplicated and recurrent UTI

Women decreased libido

Decreased libido without identifiable cause may respond to flibanserin, the first FDA-approved medication for female sexual dysfunction Flibanserin is a centrally acting serotonergic agent, and daily use results in small increases in sexual desire and sexual activity. However, daily use and frequent side effects (somnolence, dizziness) limit its utility. Bupropion may be a better option for women with sexual dysfunction who strongly desire pharmacologic intervention. Although not FDA approved for female sexual dysfunction, the mechanism of action is similar to flibanserin, the side-effect profile is well known, long-term safety data are available, and a low-cost generic is available. A third option for low libido is bremelanotide, a melanocortin receptor agonist, recently approved by the FDA for use in premenopausal women. However, it must be injected subcutaneously about 45 minutes before anticipated sexual activity and frequently causes nausea (40%) and/or headache (11%). Decreased libido may respond to testosterone, but no androgen preparation is approved by the FDA for hypoactive sexual desire disorder in women

ED diagnostic testing

Diagnostic testing such as hemoglobin A1c, thyroid function studies, and lipid panel may reveal the underlying cause (Ma et al., 2021). All men with ED should have at least two morning serum total testosterone tests to identify testosterone deficiency

Hesitancy

Difficulty in initiating voiding, resulting in a delay in the onset of voiding after the individual feels ready to pass urine.

Disequilibrium

Disequilibrium is a feeling that a fall is imminent and is characterized by unsteadiness or imbalance that occurs only when erect and primarily involves the trunk and lower extremities rather than the head; the sensation disappears when sitting or lying

Moderate dementia

During the intermediate stage of illness, which corresponds to a CDR score of 2 or an MMSE of 12 to 19, patients will typically experience worsening memory loss and executive function. Difficulty with use of language will emerge, including problems with reading and writing, as well as communicating needs effectively. People at this stage of illness will have difficulty learning new things or coping with new situations, and may lack the ability to think logically, leading to irritation or angry outbursts. They may display impulsive behaviors, leading to safety challenges, such as wandering, risky driving, or unsafe gun handling. Difficulties in carrying out multistep tasks, such as dressing or bathing, will occur, even though the physical ability to complete each task component is preserved, and this will result in gradual dependence on others for performance of ADLs and IADLs. Symptoms such as hallucinations, delusions, or paranoia may emerge.16 The middle stage is a time when caregiver burden may be particularly problematic; however, with appropriate support, caregivers and people living with dementia may be supported in the home, without the need to transition to residential long-term care.17 Patients with moderate dementia will generally remain verbal, recognize close family members, and may still be able to reminisce about distant memories and enjoy pleasant events.

Electroconvulsive Therapy

ECT is highly effective and can be particularly beneficial for patients with active suicidal ideation and psychotic depression. It has the lowest incidence of mortality among all procedures performed under general anesthesia. There are no absolute contraindications to the use of ECT. It has been shown to be more efficacious in LLD than in the general adult population. It results in more immediate response in symptoms and may be effective for those patients experiencing significant disability from their depressive symptoms. ECT is also a useful alternative for frail older patients who may have multiple comorbid conditions and who are unable to tolerate antidepressant treatment. However, it should be noted that even after acute treatment and symptom improvement, there is an 85% chance of relapse in the first 6 months if the patient is not provided adjunctive maintenance pharmacotherapy. Therefore ECT is best seen as an acute intervention to hasten response. Primary side effects experienced by the older population are short-term memory loss and a possible increase in incidence of falls, particularly in nursing home patients

Evaluation of neurocognitive dysfunction

Evaluation of cognitive dysfunction includes a thorough history, including medication review, functional status, and collateral history from a trusted family member or friend, a complete physical examination, and an objective measure of cognitive function. Laboratory workup includes thyroid-stimulating hormone (TSH), vitamin B12, HIV, and Syphilis serologies if risk factors are present. Neuroimaging

ED follow up

Follow-up visits 6-8 weeks after initiating medical treatment are recommended. Treatment failure for at least four sexual attempts is indicated before changing medications or treatment modality. Referrals to urology or endocrinology are warranted for complicated cases or treatment failure

Driving and AD

Formal driving assessments by occupational therapy and/or local departments of motor vehicles may help make a determination that patients can no longer safely drive. Providers should be familiar with their state-specific reporting laws for suspected impaired driving

BPPV treatment

Fortunately, BPPV usually resolves spontaneously. The Epley maneuver or canalith repositioning procedure can speed resolution. The success rate for this treatment is about 90%.15 If symptom control is required before the patient can obtain this treatment, a patient may trial meclizine, valium, or promethazine, but caution should be practiced in using these sedating drugs for older adults because they tend to cause dizziness between BPPV episodes and increase postural instability and falls risk. Acute

GSM Evaluation and Treatment

GSM includes genital dryness, burning, and irritation associated with diminished lubrication, as well as pain on penetration Vaginal gels or moisturizers are first-line therapy for GSM topical estrogen therapy is still considered first-line therapy for symptoms of GSM, but estrogen therapy has little direct effect on libido or sexual satisfaction deep dyspareunia is a cardinal symptom of endometriosis

Selective Serotonin Reuptake Inhibitor Side Effects in Older Adults

Gastrointestinal upset • Jitteriness • Hyponatremia • Drug-drug interactions (because of effects on CYP450 liver enzymes) • Gastrointestinal bleeding • Extrapyramidal side effects (tremors, parkinsonism, bruxism

Testosterone blood tests

Ideally, blood should be obtained in the morning to account for circadian rhythm and the result carefully interpreted. For example, a serum total testosterone concentration less than 200 ng/dL in a symptomatic man strongly suggests hypogonadism that will likely respond to treatment. A serum total testosterone concentration between 200 and 300 ng/dL in a symptomatic man likely also represents hypogonadism, but response to treatment is less predictable.

SSRI safety

If a patient is on a blood thinner such as warfarin, it is recommended that the patient's international normalized ratio be checked more frequently during the start of treatment and at dose changes Use of SSRIs can occasionally result in the induction or exacerbation of neurologic symptoms, including parkinsonism, dyskinesias, akathisia, and bruxism The new FDA dosing guidelines call for a maximum dose of 40 mg per day in individuals up to age 65 years and a per-day maximum of 20 mg in those age >65 years. The FDA also suggests more frequent electrocardiogram (ECG) monitoring in patients with heart failure or bradyarrhythmia, or who are on concomitant medications that prolong the QT interval

Pneumonia vaccine

If a person received the Pneumovax before turning 65 years, it should be repeated once after the age of 65 years Prevnar is now only recommended for high-risk persons such as those with asplenia or cochlear implants

Mild dementia

In the early stage of illness, also described as "mild" dementia, which is associated with a CDR score of 1 or an MMSE of 20 to 26, patients typically experience symptoms associated with poor memory, such as forgetting key events, repetitive questioning, and misplacing familiar objects. Impaired judgment may lead to safety risks or vulnerability to scams or financial exploitation. Impairments in executive function may lead to difficulty following directions, managing complex tasks such as paying bills, and may also result in a loss of spontaneity or sense of initiative. One of the hallmarks of AD is a lack of insight into loss of abilities (anosognosia), which can result in the person seeming defensive or indifferent to his or her level of impairment and its consequences However, during this stage of dementia, individuals are generally still able to maintain their basic ADLs and some instrumental ADLs (IADLs). Many people with mild dementia continue to live independently or with minimal support. Individuals may retain capacity to provide consent for simple medical procedures, assign a healthcare power of attorney, participate in advanced care planning, and work with their family or lawyers to address their financial and legal affairs.

Immunizations Recommended for Older Adults

Influenza inactive (IIV), or recombinant (RIV) 1 dose annually Tetanus, diphtheria, pertussis (TDAP) 1 dose after age 65 years then Td every 10 years Varicella recombinant (Shingrix) 2 doses 2-5 months apart. Give to those who had zoster Pneumococcal 1 dose of PPSV23 (Polysaccharide, Pneumovax); consider 1 dose PCV 13 in high-risk patients Hepatitis A/hepatitis B Only if high risk, and at least once

Novel treatments

Intranasal (IN) esketamine was approved by the FDA in 2019 for TRD when used in conjunction with a traditional oral antidepressant.142 Studies support IN esketamine as a potential fast-acting and effective treatment in depressed patients.143 In the geriatric population, clinical trials show the use of IN esketamine is safe and effective. Studies in older adults with TRD revealed significant reduction of depressive symptoms with only mild to moderate side effects, similar to those found in the general adult population

Clinical manifestations

LUTS are divided into three groups: storage, voiding, and postmicturition symptoms. Storage (irritative) symptoms include increased daytime frequency (voiding too often during the day), nocturia (to wake at night one or more times to void), urgency (sudden urge to urinate that is difficult to defer), incontinence (complaint of any involuntary leakage of urine), and bladder sensation (defined by five categories: normal, increased, reduced, absent, and nonspecific). Voiding (obstructive) symptoms are experienced during the voiding phase and include a slow stream (perception of reduced urine flow), splitting or spraying (character of stream), intermittent stream (urine flow that starts and stops), hesitancy (difficulty in initiating micturition), straining (muscular effort used to initiate, maintain, or improve the urinary stream), and terminal dribble (prolonged final part of micturition, when flow has slowed to a trickle/dribble)

ED lab testing

Laboratory evaluations should target relevant comorbid conditions, such as diabetes mellitus and vascular disease or disorders suggested by the physical examination. The measurement of serum testosterone should be considered, especially in men with low libido. An at-home therapeutic trial of a phosphodiesterase inhibitor (sildenafil or vardenafil) is considered first-line evaluation and treatment.23 The initial dose should be low (sildenafil 25-50 mg or vardenafil 5-10 mg) in men suspected of having neurogenic ED

Severe dementia

Late-stage dementia, CDR of 3 or MMSE less than 12, may last 1 year or longer. During the late stage of dementia, individuals lose the ability to communicate verbally, may develop sleep dysregulation, and will lose other motor functions that can result in mealtime difficulties, dysphagia, and weight loss. In addition, patients will gradually lose their desire to eat or drink, which is often distressing for family members. Dysmobility, affecting balance, walking, and ability to transfer, will occur, and many people eventually become bedridden. Dysmobility can also result in functional incontinence.16 The combination of incontinence and dysmobility greatly increases risk for development of pressure ulcers and the need for an increased level of care. Patients will gradually experience a complete loss of language, and may only be able to communicate with facial expressions, such as grimacing or smiling. Death from severe dementia typically results from malnutrition or infections because of aspiration pneumonia or pressure ulcers

Urge incontinence

Leakage preceded by/associated with urgency. Common precipitants include running water, hand washing, going out in the cold, even the sight of the garage or trying to unlock the door when returning home. The need to "rush to the toilet" and length of time one can forestall an urgency episode are less useful symptoms because they reflect cognition, mobility, toilet availability, and sphincter control, as well as bladder function

Stress incontinence

Leakage with effort, exertion, sneezing, or coughing. Leakage may be provoked by minimal or no activity when there is severe sphincter damage. Leakage coincident with cough, laugh, sneeze, or physical activity suggests failure of sphincter mechanisms. Leakage that occurs seconds after the activity, especially if difficult to stop, suggests a cough-induced uninhibited detrusor contraction.

Atypical Pneumonia

Legionella pneumophila, other Legionella species, Chlamydophila (Chlamydia) pneumoniae, and Mycoplasma pneumoniae may cause atypical pneumonitis in older adults. Legionella occurs predominantly in older persons with underlying illness. Parainfluenza, respiratory syncytial virus (RSV), rhinovirus, metapneumovirus, coronaviruses, influenza, and adenovirus are increasingly recognized as causes of atypical pneumonia in older adults

UI lifestyle modifications

Lifestyle interventions include weight loss, reducing consumption of caffeine and alcohol, decreasing fluid intake before bed, and smoking cessation.

Lifestyle Interventions and Self-Management

Lifestyle modifications address avoiding caffeine and alcohol and the timing of fluid intake, such as avoiding fluids 2 hours before bedtime if bothersome nocturia is present. Dietary factors may also include avoiding bladder irritants, such as carbonated beverages and artificial sweeteners.4 Bladder diaries document urinary frequency, volume, and circumstances surrounding urinary symptoms and can assist individuals in identifying lifestyle contributors. Behavioral interventions address voiding habits, replacing maladaptive behaviors with more healthful approaches. For example, patients with urgency may void at inappropriately short intervals to stay ahead of the urge and as a result diminish bladder capacity

Medicare B covered vaccines

Medicare Part B covers vaccines to prevent influenza and pneumonia, as well as hepatitis B if the patient is at medium to high risk for this disease. No copay is associated with these vaccines. All other vaccines are covered under Medicare Part D; this includes the vaccine for zoster.

Benign Prostatic Hyperplasia: Management

Men with mild to moderate symptoms may be satisfied with lifestyle modification only. Both medical and surgical treatments are also available, with medication the usual first approach. Indications for surgical treatment include patient preference, dissatisfaction with medication, and refractory urinary retention. Complications from prostatic obstruction, including renal dysfunction, bladder stones, recurrent urinary tract infections, and hematuria, are also managed surgically

UI MIP

Minimally invasive procedures may be considered for clients who have urgency incontinence that does not respond to behavioral interventions or medications. Referral to urology is appropriate for clients seeking minimally invasive procedures or surgery.​ Procedures for urgency incontinence​ include: onabotulinumtoxinA bladder injections​ instilled in office via cystoscope​ percutaneous tibial nerve stimulation​ electrical stimulation via acupuncture needle​ weekly appointments for 3 months​ ​Procedures for stress incontinence​ include: urethral bulking​ botulinum toxin injections

Defintions for Severe Pneumonia

Minor criteria • Severe tachypnea ≥30 breaths per minute • Hypoxemia PaO2/FIO2 ratio ≤250 • Multilobar infiltrates • Confusion/disorientation • Hypotension requiring aggressive fluid resuscitation • Leukopenia <4 • 000 white blood cells/mL • Thrombocytopenia <100,000 platelets/mL • Uremia—blood urea nitrogen >20 mg/dL • Hypothermia—temperature <36° C Major criteria • Septic shock requiring vasopressors • Respiratory failure requiring mechanical ventilation

Dizziness

Multisensory or multifactorial dizziness is the most common cause of chronic dizziness in older persons A brain that has insufficient information to be confident of where it is in space generates a sensation of dizziness. This can be caused by reduced sensory inputs or impairment of their integration. Well-described anatomic and physiologic changes associated with aging that make older adults susceptible to dizziness include a reduction in sensory receptors located in the inner ear (semicircular canals, saccule, and utricle), proprioceptive end organs, and retina. Vision and visual-vestibular reflexes are known to decline with advancing age. Because adults rely heavily on vision to compensate for vestibular and postural control deficits, a decline in vision contributes significantly to dizziness and subsequent imbalance in older individuals

Straining

Muscular effort either to initiate, maintain, or improve the urinary stream

Near syncope

Near syncope is a feeling that the person is about to pass out. This is distinguished from, but etiologically quite similar to, syncope, the medical term applied when the patient actually faints or blacks out (i.e., has a sudden and temporary loss of consciousness, with spontaneous recovery), because of insufficient oxygen delivery to the brain (via hypotension or other mechanisms). In contrast, patients with presyncope or near-syncope can remember manifestations (e.g., dizziness, blurred vision, weakness, the fall). When a patient complains of the feeling of being about to pass out, we typically think of something cardiovascular in nature. If it happens with standing, we think of postural hypotension, possibly from drugs, acute illness, or a vasovagal phenomena. If it happens while sitting or lying down, a cardiac arrhythmia may be involved.

Hormone replacement therapy

Nonhormone therapies provide sufficient relief for most women with mild symptoms (North American Menopause Society, n. d. b.). Hormone replacement therapy (HRT) may be indicated for more severe symptoms and helps to prevent bone loss. There are two types of HRT: estrogen-only (ET) or estrogen plus progestin (EPT). EPT is indicated for women who have not had a hysterectomy to help prevent uterine cancer. HRT is delivered systemically (e.g., oral tablets, patches, injections) or locally (e. g., creams, vaginal rings); the lowest effective dose should be prescribed for the shortest amount of time to minimize risks. Risks include stroke, blood clots, and breast cancer. Each woman should be assessed individually, and the benefits should outweigh the risks Selective estrogen receptor modulators (SERMs) block or activate estrogen receptors in certain areas of the body and is an alternative treatment for women with a history of breast cancer or those with concerns about using HRT (North American Menopause Society, n. d. c.)

Older adults and suicide

Older patients with depression and suicidal ideation are more likely to turn to their PCP than to seek treatment from a mental health specialist. Antidepressants significantly decrease suicidal ideation or gestures in older depressed patients

Other depressants

Other options for treatment of depression in older adults include bupropion, which is mechanistically unique among antidepressants and the only agent with an additional indication for smoking cessation.127 Bupropion has the additional benefits of having no sexual side effects, minimal weight gain potential, and negligible GI bleeding risk. On the other hand, it can be too activating for some patients, does not appear to be as effective for anxiety disorders, and has a moderate inhibitory effect on CYP2D6. Mirtazapine, also devoid of sexual side effects, is an alpha-2 antagonist and indirectly increases serotonin and norepinephrine transmission. It is also a potent inhibitor of histamine (H1) receptors, with subsequent effects on sleep and appetite. Sedation is greatest at lower doses (<15 mg daily) and is offset at higher doses by increased noradrenergic activity. Unlike the antidepressant effect, the impact on sleep is immediate, and, if not excessive, can provide for improved patient adherence. In one RCT, mirtazapine showed more pronounced improvement in depression when compared with paroxetine in the first few weeks of treatment, likely because of its effects on sleep, which is a major component of depression rating scales.128 With both mirtazapine and bupropion, there is little information on long-term use and further study is needed.

Slow stream

Perception of reduced urine flow, usually compared with previous performance

UI medications

Pharmacologic therapy is not approved for stress incontinence but may be prescribed for the management of urgency incontinence or overactive bladder and includes:​ Antimuscarinic medications: oxybutynin (Ditropan), tolterodine (Detrol)​ monitor for anticholinergic adverse effects​ drugs interact with drugs that induce CYP2D6​ the American Geriatrics Society 2019 Beers Criteria recommends avoiding antimuscarinics in clients with dementia or cognitive impairment​ ​Beta-3 Agonist: mirabegron (Myrbetriq)​ interacts with drugs that induce CYP2D6​ potential adverse effect: increased BP​

Phosphodiesterase-5 Inhibitors

Phosphodiesterase-5 inhibitors, initially approved for the treatment of erectile dysfunction, have been studied for the treatment of LUTS. Compared with placebo, the daily use of sildenafil, tadalafil, or vardenafil demonstrated improvement in both erectile function and IPSS scores

Postmenopausal bleeding

Postmenopausal bleeding is genital tract bleeding in a woman who is not on HRT or non-cyclical bleeding in a menopausal woman on HRT. The most common cause of postmenopausal bleeding is benign vaginal atrophy. Atrophy is easily recognized on physical exam by the presence of a thin, pale vaginal epithelium along with narrowing of the introitus. Subjectively, the client will complain of dyspareunia and possibly post-coital bleeding. Other conditions cause postmenopausal bleeding Vaginal atrophy -Local or systemic estrogen Endometrial atrophy​ -Short course of systemic estrogen Endometrial polyps -Surgical removal Uterine fibroids -Surgical removal Endometrial hyperplasia -Medical management to prevent the progression to endometrial cancer including systemic progesterones or hormonal intrauterine device (IUD) to thin uterine lining Cancers (endometrial, ovarian, cervical, vaginal) -Total hysterectomy -Radiation Genitourinary syndrome of menopause (GSM) is a new term to describe vulvovaginal atrophy, atrophic vaginitis, or urogenital atrophy due to estrogen deficiency and is characterized by a broad spectrum of signs and symptoms

Mixed continence

Presence of both urgency and stress UI symptoms. Patients vary in the predominance, severity, and/or bother of urge versus stress leakage

Complete Blood Count and infection

Presence of leukocytosis, neutrophilia, and left shift may be useful if present when evaluating the older adult patient with suspected infection (neutrophilia is present with >14,000 leukocytes/mm3; left shift is present with >6% bands or ≥1500 bands/mm3)

Treatment of Erectile Dysfunction

Sildenafil is a phosphodiesterase inhibitor that potentiates the penile response to sexual stimulation. It improves the rigidity and duration of erection. It is taken 1 hour before sexual activity and has little effect until sexual stimulation occurs. Vardenafil is a more potent and specific phosphodiesterase inhibitor. A lower effective dose and better adverse-event profile (no effect on color vision) make vardenafil a reasonable option. Tadalafil is a longer-acting phosphodiesterase inhibitor with an adverse-event profile similar to that of vardenafil but with the added potential problem of muscle pain. Avanafil (approved in 2016) has a more rapid onset of action; it is taken 30 minutes before sexual activity. All four of these agents are contraindicated for concomitant use with nitrate medications, because the combination can produce fatal hypotension Intracavernous injection of drugs, such as papaverine, phentolamine, and alprostadil, is effective in producing erections (LOE = A)26 but used much less frequently since oral therapy has become available. Alprostadil, the only agent approved by the FDA for intracavernosal injection, produces erections that last 40 to 60 minutes

Post void dribbling

Small amounts/drops of urine after voiding has stopped. More common in men.

Antibiotic Resistance

Some strains of gram-negative bacilli, particularly Escherichia coli and Klebsiella pneumoniae, have become increasingly resistant to β-lactam antibiotics. Dependence on the carbapenems (imipenem, meropenem, ertapenem) as the last resort to treat severe gram-negative infections is greatly threatened by the emergence of carbapenemase-producing strains In general, treatment of asymptomatic colonization with these bacteria will not permanently eradicate the organism, prevent infections, or improve patient outcomes.

Testosterone supplementation

Testosterone supplementation increases libido and can improve ED in men with hypogonadism (LOE = B). In patients with convincing symptoms of low libido, check morning fasting total testosterone level. For diagnosis of hypogonadism, levels should be less than 200 ng/dL Possible adverse events associated with testosterone include polycythemia, prostate enlargement, and fluid retention. It is important to obtain a baseline prostate-specific antigen level before beginning therapy. If prostate-specific antigen or hematocrit increases with testosterone therapy, it usually does so within the first 6 months. Therefore these levels should be checked every 3 months during the first year of therapy.

5-Alpha-Reductase Inhibitors

The enzyme 5-alpha-reductase is required for the conversion of testosterone to the more active dihydrotestosterone. Finasteride and dutasteride are inhibitors of 5-alpha-reductase and reduce tissue levels of dihydrotestosterone, thus reducing prostate gland size, the static component of urethral obstruction. Improvements in LUTS scores and urine flow rates may not be evident for up to 6 months Side effects are primarily sexual and include decreased libido, erectile dysfunction, and ejaculation dysfunction These medications are not to be handled by pregnant women because of the possibility of absorption and subsequent risk to a male fetus

Alpha-Blockers

The five long-acting alpha-1 selective blockers, namely terazosin, doxazosin, tamsulosin, alfuzosin, and silodosin, are approved by the US Food and Drug Administration (FDA) for the treatment of symptomatic LUTS arising from BPH and are considered to have equal clinical effectiveness.13 All five of these medications have the convenience of once-daily dosing. Side effect profiles are generally similar except that alfuzosin appears less likely to cause ejaculatory dysfunction. Terazosin and doxazosin are less costly, older, generic options but require dose titration and blood pressure monitoring

Antidepressant prescribing

The general rule is to begin treatment at a low dose (e.g., start with 50% of the target dose) and titrate after 4 to 7 days to minimize initial side effects. Although the target dose for many older patients is lower than for younger adults, it is crucial to monitor the patient for both medication intolerance and improvement of depressive symptoms. If the patient reports no side effects with the initial dose, yet does not show any improvement of depression, then it is prudent to continue increasing the antidepressant until a trial of the maximum tolerable dose of the medication is achieved. Although susceptibility to side effects is a concern on initiation of an antidepressant, once older adult patients have been established on a tolerable dose of the medication, they have a rate of discontinuation with continued treatment similar to that of the general adult population A patient who has responded to antidepressant treatment should be continued on treatment for approximately 1 year for a first depressive episode. After a second or third episode, however, it has been recommended to extend treatment after reaching remission, with some patients requiring lifelong treatment

Alpha-Blockers

The two main pharmacologic approaches are alpha-adrenergic antagonist and 5-alpha-reductase inhibitor therapy. Anticholinergic agents may be used when irritative symptoms of LUTS predominate. Alpha-adrenergic antagonists, or alpha-blockers, are directed at the dynamic component of urethral obstruction. Smooth muscle of the prostate and bladder neck has a resting tone mediated by alpha-adrenergic innervation. Alpha-blockers relax the smooth muscle in the hyperplastic prostate tissue, prostate capsule, and bladder neck, thus decreasing resistance to urinary flow. Of the two major alpha-adrenergic receptors, alpha-1 receptors predominate in the prostate. Alpha-blockade development for BPH therapy progressed from a selective alpha-1 agent (e.g., prazosin) to long-acting selective alpha-1 agents (terazosin, doxazosin) that allowed once-a-day dosing but still required blood pressure monitoring and dose titration to reduce orthostatic hypotension The most common adverse events of alpha-1 agents are dizziness, mild asthenia (fatigue or weakness), and abnormal ejaculation. For patients undergoing cataract surgery, intraoperative floppy iris syndrome (IFIS) is a potential risk of all alpha-blockers. IFIS is characterized by sudden intraoperative iris prolapse and pupil constriction and may result in surgical complications, such as iris damage, torn lens capsules, and vitreous prolapse

Management and Treatment

Therapy directed against atypical bacteria, such as macrolides and doxycycline, should also be given if the patient is not being treated with a fluroquinolone For severe pneumonia, a patient should also receive treatment for MRSA (vancomycin or linezolid) or Pseudomonas with an antipseudomonal penicillin (piperacillin-tazobactam), cephalosporin (cefepime or ceftazidime), or carbapenem (imipenem or meropenem) pending results of sputum, blood cultures, and nasal MRSA polymerase chain reaction

second generation antipsychotics

There has been increasing use of second-generation antipsychotic (SGA) augmentation in depression of all age groups, although there are few high-quality studies of SGA augmentation in LLD, and most are limited by small sample size. High dropout rates have been identified because of adverse effects, including sedation, dizziness, constipation, and orthostatic hypotension.135 In 2005 the FDA issued a black box warning advising that all SGAs were associated with excess mortality in older patients, including an increased risk for sudden cardiac death, as well as cerebrovascular adverse events in older patients with dementia.136 In terms of SGA selection, aripiprazole and quetiapine have the most supportive evidence currently. Studies of aripiprazole have shown decreased depressive symptoms and increased remission rates in older patients.136-140 Quetiapine has been shown to be effective in achieving higher remission and response rates when used as monotherapy in LLD, suggesting promise as a safe augmenting agent. In these trials, aripiprazole and quetiapine were well tolerated. The most common adverse effects were akathisia with aripiprazole and somnolence with quetiapine. However, when SGAs are used, clinicians must continue to closely monitor for side effects, including extrapyramidal symptoms and drug-induced parkinsonism

RTMS

This treatment does not require anesthesia and can be performed on an outpatient basis. The only absolute contraindication of rTMS is the presence of implants or ferromagnetic devices in or near the head, and the most serious, although rare, adverse event is seizure, occurring in <1 in 10,000 patients.157 For the rTMS procedure, the patient is seated while magnetic pulses are used to stimulate the brain to induce change in mood. The procedure is typically prescribed as a total course of pulses delivered in 30- to 40-minute sessions daily over a period of 4 to 6 weeks. The patient is not sedated and can converse during treatments. Of the dozens of randomized rTMS trials in major depression, few have included older adults. Of those studying older adults, findings were variable in terms of rTMS efficacy; however, safety and tolerability have been demonstrated, and more studies are needed.158 Given that the strength of the magnetic field falls off rapidly with distance and that many older adults have significant brain atrophy and white matter burden, this treatment modality may require higher doses in older patients than those used in younger adults for efficacy.

Surgical Therapy

Transurethral resection of the prostate (TURP), in use for over 90 years, is the standard of care to which other BPH surgical treatments are compared Usually performed under spinal anesthesia, TURP involves passage of an endoscope through the urethra to surgically remove the inner portion of the prostate. Long-term complications can include retrograde ejaculation, bladder neck contracture, and erectile dysfunction. One unique complication of TURP is TUR syndrome, a dilutional hyponatremia resulting from systemic absorption of irrigant solution. The development of a bipolar generator (bipolar TURP) to replace the conventional monopolar TURP allows the use of isotonic irrigating fluids and eliminates the risk of electrolyte disturbance.32 Transurethral incision of the prostate (TUIP) is an endoscopic procedure via the urethra to make one or two cuts in the prostate and prostate capsule, relieving urethral constriction. Limited to use in small prostate glands (<30 g), TUIP results in lower rates of retrograde ejaculation but higher rates of requiring secondary procedures

TCA antidepressants

Tricyclic antidepressants (TCAs) have been extensively studied, and there are numerous trials showing efficacy. However, TCAs have many safety issues and have a higher incidence of side effects particularly in older patients, the most prominent of which are various anticholinergic effects and cardiac effects, including increased heart rate, slowing of cardiac conduction, and orthostatic hypotension. ECGs should be monitored before and during TCA use, and careful measurement of orthostatic blood pressure is mandatory. The two TCAs with the best safety profile for older patients are the secondary amines nortriptyline and desipramine. Both of these drugs can be measured in the blood stream, and nortriptyline has a therapeutic window that can guide dosing Although TCAs are safe to use in older adults, it is important to monitor pulse, orthostatic blood pressure, cardiac conduction, and anticholinergic side effects.

Causes of Sexual Dysfunction in Older Men

Vascular disease Gradual onset Vascular risk factors: diabetes mellitus, hypertension, hyperlipidemia, tobacco use Neurologic disease (e.g., radiation therapy, spinal cord injury, autonomic dysfunction, surgical procedures) Gradual onset (unless postsurgical) Neurologic risk factors: diabetes mellitus; history of pelvic injury, surgery, or irradiation; spinal injury or surgery; Parkinson disease; multiple sclerosis; alcoholism Loss of bulbocavernosus reflex Medications (e.g., anticholinergics, antihypertensives, cimetidine, antidepressants) Sudden onset Lack of sleep-associated erections or lack of erections with masturbation Temporal association with a new medication Psychogenic (e.g., relationship conflicts, performance anxiety, childhood sexual abuse, fear of sexually transmitted diseases, "widower syndrome") Sudden onset Sleep-associated erections or erections with masturbation are preserved Hypogonadism Gradual onset Decreased libido more than erectile dysfunction Small testes, gynecomastia Low serum testosterone concentration Endocrine (e.g., hypothyroidism, hyperthyroidism, hyperprolactinemia) Rare, <5% of cases of erectile dysfunction

Vertigo

Vertigo is a sensation in which patients feel that their environment is moving. Although the sensation is often rotational, patients also may feel as though they are falling. It is usually episodic, begins abruptly, and is often associated with nausea or vomiting

Psychostimulants

When the aforementioned treatments fail, psychostimulants are sometimes considered for monotherapy or adjunctive therapy in depressed older adult patients. One benefit with psychostimulants is that response to treatment is seen relatively quickly (i.e., within days). This may be helpful in cases where time to response is critical, such as with patients in rehabilitation programs or in end-of-life care. Trials, however, have been relatively short in total treatment time and number of patients treated.129 Subsequently, long-term efficacy with this class of medications is unknown. There are several studies showing psychostimulants improving particular symptoms that may be seen with older depressed patients, such as apathy, fatigue, impaired executive functioning, and even gait dysfunction with a decreased incidence of falls.129 However, these improvements do not necessarily correlate with overall improvement in depression and trials primarily included patients with comorbid medical conditions and hypoactive delirium. A 16-week double-blind, placebo-controlled RCT of 143 depressed older patients comparing combined treatment with citalopram and methylphenidate with either drug alone found that combined treatment led to more improvement in mood, as well as a higher rate of remission compared with either drug alone.130 Precautionary measures when using psychostimulants include taking a thorough cardiac history because there is limited data about safe use of stimulants in older adults; however, recent reports of use in younger adults have been largely reassuring. Blood pressure and heart rate should be monitored regularly because both can be increased by psychostimulant use.

Zostavax

Zostavax can be used when there is a Shingrix allergy, if a patient prefers the Zostavax, or the patient wishes an immediate vaccination and Shingrix is unavailable. The vaccination is recommended even if a patient is unsure about having chickenpox in the past

Complicated UTI

appropriate management requires obtaining a urine sample for culture and antimicrobial susceptibilities because their infecting organisms and treatment responses are not predictable Follow-up samples of urine for culture should be obtained only if symptoms of infection persist or recur to verify if a secondary infection with a new organism resistant to therapy has emerged during treatment Recurrent UTI with the same organism should prompt a search for anatomic defects that can be remediated

Desmopressin

desmopressin should not be used to treat nocturia in older, especially frailer, patients because of the risk of hyponatremia

UI pharmacotherapy

duloxetine is effective in reducing stress UI (LOE = A)42 but is not approved for this indication in the United States Vaginal topical estrogen (cream, vaginal tablet, or slow-release ring) (LOE = B)46 is helpful for uncomfortable vaginal atrophy and may decrease recurrent urinary tract infections.

Antimuscarinics

established efficacy are oxybutynin, tolterodine, fesoterodine, trospium, darifenacin, and solifenacin