Understanding the Impact of Aging on Health: A Focus on Falls and Incontinence

Robert M. Blumm, MA, PA, PA~C Emeritus, DFAAPA

Understanding the Impact of Aging on Health: A Focus on Falls and Incontinence

April 1, 2024   |   PA

According to an article published in Tenderheart Health Outcomes, one in six Americans is 65 or older, representing 56 million citizens according to the 2020 census. These demographics underscore the necessity for geriatric care, highlighting the importance of falls and incontinence as significant health concerns. Falls, an increasing public health issue, are closely associated with incontinence, contributing to injuries that significantly affect the quality of life and mobility and can lead to surgery and hospital stays for complications such as hip fractures. As PAs and NPs, how can we utilize preventative medicine to reduce these risks significantly?

A Case Study Highlighting the Challenges in Geriatric Care

A case study that is relevant for any clinician treating age-related problems, particularly those with gastrointestinal etiology. A 70-year-old male with a history of type 2 DM and stage 3 B renal disease presents with a history of three episodes of uncontrollable explosive diarrhea on three occasions in the past eight months. He requested a consultation because the last incident occurred at a professional meeting, causing great embarrassment and concern.

The family history of GI carcinoma is negative; there is no abdominal pain and no rectal bleeding by history. On examination, there is minimal irritation of the anal region, most likely due to using Wet Ones after wiping after a bowel movement. There is one moderate size hemorrhoid which is reducible in the RLQ of the anus with no clot or bleeding. Anoscopy reveals a few minor internal hemorrhoids, which are non-contributary. The anal sphincter is weakened. Medications include semeglutides by injection once weekly over the past eight months. The abdomen is soft and non-tender in all four quadrants, and the RLQ has an appendectomy scar. The patient is considered a type 1 obese patient.

The initial diagnosis was constipation/diarrhea syndrome with the need to do a colon flush, take a light laxative daily, and start Kegel exercises four times daily, working up to ten contractions followed by fifteen seconds of rest and then repeating until a set of ten has been accomplished. A follow-up CT scan of the abdomen revealed two inguinal hernias, a few diverticula in the distal colon, and no evidence of other contributing factors. I would, in my differential diagnosis, consider a neurogenic sphincter problem related to the long-term DM and, more significantly, the possibility of a recognized reaction to the Semeglutide: perhaps reducing the strength or maintaining the same strength but changing it to once every two weeks. The patient has incorporated these ideas and products to fit his lifestyle, stopped his weekly injection for one month, and will check back with his endocrinologist. He has not had a repeat accident related to his bowel or bladder incontinence since his exam and treatment.

Linking Falls to Clinical Observations and Care Strategies

When do many falls occur? During the night, a patient will awaken from sleep to urinate or evacuate their bowels, and many of these patients are taking sleeping pills and antihistamines for sleep and, since the advent of legal THC gummies, are taking unknown quantities of these drugs with their melatonin. This represents a far greater occasion for sleepiness, unsteadiness, and dizziness as they begin the arduous journey to their bathrooms. Causative factors include drinking caffeinated drinks before the hour of sleep, drinking large amounts of water before bedtime, having nightcaps because they are in denial of being a senior citizen, as well as the drugs that are available to them. These factors may increase urinary output, BPH, UTI, DM, and cancer. Other medications, such as antidepressants, pain medication, diuretics as well as Vitamin D deficiency can lead to OAB. We need to desperately change the landscape for our patients and provide instruction sheets related to these issues and overall home safety. We must develop a treatment plan that is essential to the person before us and for this entire class of patients suffering from this modality. What can we do, and what should be our focus?

Preventative Measures to Enhance Patient Safety

The following list of preventive enhancements is suggested to alleviate the number of patients who have developed any of the associated problems, and it can be increased based on your imagination.

· Limit the consumption of alcoholic beverages and caffeinated drinks, such as coffee, tea, and sodas, after 5 PM or at least three hours before bedtime. This will lead to fewer excursions to the bathroom during the night and, therefore, less opportunity to fall.

· Reduce the use of all fluids and certain foods, such as gassy vegetables, spicy dinners, citrus juice, artificial sweeteners, and chocolate. These irritate the bladder and the colon, causing an exodus from the bed to the bathroom.

· Utilization of the toilet just before retiring creates an empty bladder or bowel, allowing for expansion and peristalsis during the night without making an urge. Urge incontinence can also be corrected with slight modification.

· Utilization of a padded sheet in bed or using a disposable diaper where they can feel confident that minor to moderate leakage will not soil their sheets or other bedding. This is especially useful in dealing with post-operative patients who cannot ambulate and could fall when using a bedside commode. It is essential to use the proper size that accommodates the patient's morphology. Proper absorbency is also necessary, and rather than purchasing stock supplies from a supermarket or pharmacy, research companies that take great care to fit their patients’ needs properly.

· Home safety includes proper lighting to walk from the bed to the bathroom, i.e., night and floor lighting. Include a small light in the bathroom so that your patient is not awakened from sleep by turning on an ample overhead light. Provide a walker, crutches, or wheelchair where needed, and install grab bars in the shower area and in the bathroom to make sitting and standing more accessible and safer. I would also consider a raised toilet seat to accommodate the patient's lack of strength or mobility, making it easier to sit and stand. I have seen, in orthopedics, hip fractures from a sleepy senior citizen who misses the perch and descends to the side of the toilet or the floor.

· Finally, general overall good health practices. As we age, there exists a decline in both muscle mass and bone density; these factors make for a patient with brittle bones. Developing a plan for daily ambulation, walking either outside or inside or at a gym, strengthens muscle, increases bone density, and improves overall balance and gait. For those who are available with assistance from a pool, many water aerobics can be practiced a couple of times a week with the aid of a trainer or caregiver. I encourage adult children to become involved in their parents' healthcare needs and reciprocate the care and love they received as children.

Concluding with the Role of Vigilance and the Importance of Malpractice Insurance

In closing, vigilance is always needed in this age group, and the care and diagnostic interventions that eliminate a perspective differential diagnosis. I have encountered a few surgeons in my history as a SPA who have said they have never had a post-operative complication. They wear arrogance on their sleeves because the more surgery you perform, the more incredible the opportunity for complications. A few PAs and NPs have also made this foolish statement. Time will prove that their arrogance will be rewarded with a blue sheet from a plaintiff’s attorney, which enumerates the basis of the litigation that has been initiated. I have received one of these in my years of practice, and the initial reaction is fear, doubt, confusion, and a mad rush to review the case to ascertain whether I missed something of significance. Only a small percentage of lawsuits against PAs and NPs are successful from the plaintiff’s charge, but the same psychological terror grabs the professional. Only then may they discover that their malpractice insurance has limitations and clauses that will deny them a successful defense. Also, depending on the company, one can get a lawyer who is not an expert in malpractice law and may have personal practices that aggravate your case because of arrogance or ignorance, which taints both the judge and the jury. I have seen this happen while attending a few instances of unfortunate physicians and PAs who were summarily found guilty. The goal of each of us is to purchase a personal liability insurance policy that has at least an A Best rating. In contrast, there exist companies that are AA Best Superior and will provide the most experienced legal professionals and occurrence policies that will remove the terror of our involvement and allow us the guidance to present a superior defense. Don’t look to save money on inferior products that will alter your outcome should you be required to go to a court of law.

Written For CM&F By Robert M. Blumm, PA, DFAAPA, PA-C Emeritus, CM&FClinical AdvisorUnderstanding the Impact of Aging