Preparing for the “Tsunami of Older Adults”

Two of the numerous geriatrics offerings at this year’s ACP convention were part of a series entitled “Modifying Your Office Practice for the Tsunami of Older Adults.” This eminently apropos title was actually something of a theme for the convention as a whole. This year, only 3 clinical categories boasted more offerings than geriatrics. In 2009, 6 categories offered more courses-and in 2008, geriatrics was not even listed as a separate category in the convention program! Clearly, primary care physicians are beginning to feel the impact of the baby boomers’ coming of age.
          Among ACP 2010’s many useful offerings-which ranged from cardiovascular disease in patients over 80 to how best to care for hospitalized seniors-those in the series “Modifying Your Office Practice for the Tsunami of Older Adults” were particularly intriguing. These 2 workshops, one on managing urinary incontinence and the other on managing memory loss, focused on concrete, practical steps physicians could take to improve patient care in these areas. The presenters/facilitators-Hollis Day, MD, Lisa Granville, MD, Bree Johnston, MD, and Gail Sullivan, MD, MPH-chose the small-group workshop format because they were especially interested in changing physician behavior and they felt this format was best able to achieve that goal. They divided the attendees up into 3 smaller groups, which discussed relevant case vignettes on the 2 topics. 
          Tips on managing urinary incontinence. Because urinary incontinence is still “in the closet” to some degree, it is common for patients to mention it (if they do so at all) in a “one more thing, Doc” manner at the very end of their visit. Attendees shared strategies for being more proactive and preventing such last-minute broachings of the topic. These ranged from including incontinence on the pre-visit questionnaire to putting posters about incontinence in patient bathrooms and exam rooms. 
          One of a number of useful tools the workshop facilitators provided was a good sample voiding diary that attendees could download and use with patients. To boost compliance with completion of the diary, it was suggested that clinicians ensure that patients understand its importance and usefulness.
          The facilitator who led this reporter’s small group (Lisa Granville, MD) stressed the importance of thoroughly ruling out transient causes of urinary incontinence, and the various categories of these were reviewed. “People often overlook bladder irritants,” she noted. These include such things as artificial sweeteners, carbonated beverages, citrus juice, and concentration of the urine.
          Although the pros and cons of using a catheter versus an ultrasound machine to measure post-void residual urine were discussed at some length (both are equally accurate, it turns out), the facilitator mentioned that physicians are not obligated to do urodynamic studies before prescribing medications. 
          However, it was emphasized that the medications available to treat urinary incontinence have many side effects, and that these are especially pronounced in the elderly. Thus, the workshop included much discussion of how to effectively teach Kegel exercises-which, when done correctly, have out-performed medication in studies. Also, Kegels can be of benefit in urge as well as stress incontinence. The importance of holding the contractions of the pelvic floor muscles (rather than simply doing many quickly released contractions) was stressed. Also of note: it is no longer recommended to help patients identify the proper muscle action by having them interrupt their flow as they void; this approach can result in unwanted associations.
Situations in which referral to a urologist is warranted were discussed. Among these are hematuria not in the presence of an infection, unclear diagnosis, and the presumed correct intervention not producing the expected result.
          The workshop reviewed the billing codes that can be used for management of urinary incontinence. The facilitator pointed out that the counseling code is appropriate for this condition, since management requires a lot of sharing of information.
          Tips on managing memory loss. This workshop centered around 4 video clips of patient-physician interactions : one featuring a patient with normal age-associated memory loss, one a patient with signs of early dementia, one a patient with delirium, and the last a patient with more advanced dementia. The discussions that followed the video clips elicited a number of the issues involved in caring for patients with memory impairment-and useful tips on how better to handle some of these.
          The importance of early screening was stressed. “Early dementia can be subtle,” the facilitator (Dr Granville again) noted. “You need to scratch to expose it.” Early screening for dementia has a number of potential benefits. It can help ensure patient safety, can alert the physician to any need for assistance with medication management-and it may unearth a cause for memory deficits that is fixable, such as medication side effects.
          Attendees reviewed various aspects of using 2 of the most common screening tools: the Mini-Cog and the Mini Mental State Examination (MMSE). The facilitator pointed out that when administering the Mini-Cog, it is important to ask the patient to draw a clock that shows a time of 10 minutes after 11:00. Depicting this time is a better test of abstract thinking than the depiction of, for example, 10 minutes before 2:00 (a time that some clinicians ask for).
          When administering the MMSE to a patient with no math skills and limited spelling skills (which would make it impossible to test him or her with successive subtraction of 7’s or with spelling W-O-R-L-D backward), the facilitator noted that you can usually ask the patient to spell his name backward. It is important to encourage patients while administering the test, to ensure that they don’t get discouraged and fail to complete it. The MMSE is not usually sensitive enough to detect dementia in patients who are quite intellectually developed. For these patients, neuropsychological testing is usually required. 
          On the question of whether to include scanning in a screen for dementia, the facilitator noted that although neurologists and psychiatrists typically do this, it is not always necessary. The settings in which scanning is warranted include memory loss of recent onset, onset at a younger age, rapid decline, and associated neurological symptoms.
          A screen for memory loss also should include a focused history taking. Good areas to probe include what, specifically, the patient tends to forget; whether anyone else has noticed that there is a problem; and of course, what medications he is taking. The point was made that dementia cannot be diagnosed unless depression and delirium have been ruled out; time was devoted to differentiating between dementia and delirium.
          With regard to managing more advanced dementia, the importance of good communication skills was emphasized. Approaches such as speaking slowly and directly to the patient, breaking down instructions into single steps, responding to feelings more than to facts, and having familiar people around to provide reassurance are all strategies that can help alleviate patient agitation.
          Fall prevention-and more. The case-based, workshop-style presentations used at the 2 sessions described above are also available online, for CME credit, at www.sgim.org/cme. In addition, the Web site offers a third module, on fall prevention, and an extensive collection of useful resources and references.