Sonya Lytwynec, RegN, BScN,
Hassan Razvi, MD, FRCSC,
Southwestern Ontario Regional Geriatric Program: Continence Outreach

Overflow urinary incontinence is one of five types of incontinence.¹ The assessment and therapeutic interventions associated with overflow incontinence are reviewed in the fourth article of a five-part series on urinary incontinence. The first article in this series provided an overview of the prevalence, types, and treatment of incontinence in the frail elderly.

Overflow incontinence is defined as the involuntary loss of urine associated with over-distension of the bladder.² It is reported to comprise up to 30% of diagnoses in a geriatric continence clinic.³ Aging is associated with several physiologic and anatomic changes to the urinary tract which may predispose the older person to overflow incontinence. Both bladder outlet obstruction and detrusor muscle weakness may manifest alone or in combination as overflow incontinence. It has been estimated that up to 60% of men between 70 and 87 years of age develop clinical symptoms of benign prostatic hypertrophy (BPH).¹ BPH is the most common cause of voiding dysfunction in elderly males and may first present as urinary retention and overflow incontinence. Overflow incontinence occurs less often in women, but may develop following pelvic surgery or as a result of pelvic organ prolapse.

Shechar Dworski, BSc

As the North American geriatric population steadily increases, a greater emphasis is being placed on primary prevention in the form of screening and counseling, to avoid onset and/or advancement of disease. Treatment of advanced disease often requires much more invasive and time-intensive procedures, and is more stressful and risky for the patient. The periodic health exam is an opportune setting for a primary care physician to screen asymptomatic elderly patients for diseases commonly associated with aging or with a high-risk group. The physician's role is moving from treatment to prevention in our current social climate, since early detection often reduces onset and progression of disease, or at least reduces complications and increases survival rates.

Unlike their younger counterparts and the stronger elderly, when frail elderly become ill, early symptoms of chronic disease are rarely specific and localized ones. Instead, older patients usually manifest nonspecific symptoms, which quickly lead to loss of function. This creates dependency in a previously independent older person without giving any clues as to the cause of the problem. The functional expressions of disease include cessation or reduction of eating and drinking, dizziness, urinary incontinence, falling, weight loss, acute confusion, failure to thrive, and new onset or worsening of previous dementias.

Roger YM Wong, BMSc, MD, FRCPC,
Division of Geriatric Medicine, Department of Medicine,
University of British Columbia, Vancouver, BC

For many adults age 65 years or above, their point of entry into the health care system often begins with an office visit to their family practitioners. In some instances, proper assessment of these elderly patients may become quite a daunting task for the primary care physician in a busy office. Two common barriers to conducting a comprehensive geriatric assessment (CGA) in the office setting include the lack of a systematic approach to screen for common geriatric problems, and more importantly, the paucity of time. The challenge therefore becomes how one can assess a frail older patient with multiple medical and functional problems quickly and effectively. This article will highlight some simple ways to incorporate important concepts of geriatric assessment into one's busy outpatient practice.

CGA and health promotion

The United Nations has declared 1999 as the Year of the Older Person. CGA is one of the ways to promote healthy living in the older adult. Simply defined, CGA refers to the multi-faceted approach of diagnosing and managing complex physical, psychological and functional problems.

Margaret Grant, MD,
Geriatric Medicine Resident, University of Toronto, Toronto, Ontario

Definition and Prevalence

In response to the confusion surrounding the existence of multiple definitions of orthostatic hypertension (OH), a consensus statement was developed to standardize the meaning of this medical condition. OH is defined as a reduction of systolic blood pressure (BP) of at least 20 mm Hg, or a reduction of diastolic BP of at least 10 mm Hg within 3 minutes of standing or lying on a tilt table at an angle of at least 60 degrees.¹ The prevalence of OH in the elderly ranges from 5 to 33 %.^2-4 This variability may be the result of different definitions used and the range of populations considered, from frail older nursing home patients to healthy older people living in the community. The prevalence of OH can be as high as 50% in frail older nursing home patients.²

In a study by Ooi et al., which looked at nursing home patients' BP taken at 8 different times, OH was found to be variable depending on the time of day, with a higher prevalence just before breakfast.

Eleanor Brownridge, RD, FDC

The nutrition priorities of the elderly (over age 75) go against the grain of mainstream nutrition messages believes Dr. Katherine Gray-Donald, Associate Professor at the School of Dietetics and Human Nutrition, McGill University in Montreal. "These people shouldn't be worrying about fat and cholesterol. Rather than tons of vegetables and fruit and skim milk, they need omelettes, milk shakes and cream soups."

"We've been able to show that for the homebound elderly declining body weight is a predictor of mortality," says Dr. Gray-Donald. "People who lose weight die sooner."

Moreover, a recent 5-year mortality study of 4300 nonsmoking men and women, aged 65 to 100 years, indicated that being overweight later in life does not pose a significant health risk.¹ Rather the risks associated with significant weight loss should be the primary concern.

Traditionally physicians have asked patients: "Have you unintentionally lost ten pounds or more in the past year?" But even intentional weight loss in an elderly person suggests nutrition problems. Because of low energy needs, it is very difficult for an elderly person to lose weight by dieting and still maintain adequate nutritional status.

By the time a 10-pound weight loss has occurred it may be too late to reverse muscle deterioration. Dr.

Anna Liachenko, BSc, MSc

A large body of observational evidence suggested that estrogen replacement therapy (ERT) after menopause decreases a women's lifetime risk of death from myocardial infarction by 35 to 50 percent and increases life expectancy by 2 to 3 years. However, a recent major clinical trial concluded that estrogen plus progestin therapy did not decrease the overall risk of myocardial infarction and coronary death among postmenopausal women with previous heart disease. The main question raised by the results of the trial is whether doctors should change their prescribing patterns and which patient populations will be affected. While there is no simple answer, it is important to consider the issues involved such as, How serious were the limitations of the observational research? Did the trial look at the right group of patients? How far can we extrapolate the results? And what are the future implications?

The Heart and Estrogen/progestin Replacement Study (HERS) trial was a randomized, blinded, placebo-controlled trial designed to test the efficacy and safety of hormone replacement therapy (HRT, estrogen plus progestin) on secondary prevention of heart disease. The trial involved 2763 postmenopausal women with established coronary artery disease. In the HRT group, the rate of coronary events increased by 50% in the first year of the trial and subsequently decreased by 40% in the forth and fifth years, yielding no significant effect overall.

Rhonda L. Witte, BSc

Skin--we clean it, shave it, cream it and tan it, all with a common goal--to preserve our youthful image. Not only does it help our general appearance, but it also feeds our self-image, making us "feel" younger. In a society where younger parallels attractiveness, we find ourselves constantly in search of new remedies to prevent our skin from aging . On the other hand, aging is a sign of wisdom and the more signs we have, the better we look. Can't we just age without looking older? And is what we consider to be aging of the skin really due to the aging process itself?

Cutaneous aging is a result of both intrinsic and extrinsic events. Intrinsic aging, also referred to as chronological aging, occurs independently of environmental influences. The changes seen with intrinsic aging occur in sun-protected areas. It is this characteristic that sets it apart from extrinsic aging which occurs as a result of environmental effects on the skin, the most important of which is exposure to sunlight.^1,2 The term "photoaging" refers to the age-related cutaneous changes resulting from exposure to sunlight and accounts for the majority of changes generally associated with appearance.

Michele Kohli, BSc, MSc

The persistence of influenza in the North American population has not been completely explained by epidemiologists.¹ During the last influenza season (1997-98), there were 5,148 laboratory confirmed cases of influenza in Canada (see Table 1).² The elderly population, those aged 65 years and above, are particularly susceptible to this disease. Over 95% of the deaths caused by influenza occur in this age group, in part, because of the higher prevalence of congestive heart failure and lung disease.¹ Last year, the occurrence of influenza peaked between January and March.² When the prevalence of influenza is high in a population, patients presenting with a febrile respiratory illness along with symptoms such as myalgia, headache, sore throat and cough are often diagnosed as having influenza.¹ However, the gold standard for diagnosis is laboratory detection of the virus in nasopharyngeal swabs.¹ The genes of the influenza virus mutate frequently, causing the antigenic molecules of the virus to change, resulting in the emergence of new viral sub-types. This process is known as antigenic drift. When human and swine or avian strains of influenza A recombine, the resulting new subtypes can cause pandemics.

Michelle Durkin, BSc

The skin is the largest organ of the body and the most visible. Ironically its importance in health promotion can be easily overlooked, especially in elderly patients. Because the skin is the first line of defense against infection, disease, and injury, proper skin care is always important. As the skin ages, however, the importance of its care increases, because structural changes occur which are responsible for compromised skin functioning (see Table 1) and a transformation in appearance (see related article on the aging skin: Wrinkles, Age-spots and Spider Veins Primary Aesthetic Concerns).