According to an article published in Tenderheart Health Outcomes, one in six Americans are age 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 major health concerns. Falls, an increasing public health issue, are closely associated with incontinence, contributing to injuries that significantly affect quality of life, mobility, and can lead to surgery and hospital stays for complications such as hip fractures. How can we, as PAs and NPs, utilize preventative medicine to significantly reduce these risks?
A Case Study Highlighting the Challenges in Geriatric Care
A case study which is relevant for any clinician treating age related problems and 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 took place while 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 at the conclusion of 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 small 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 with an appendectomy scar in the RLQ. 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 was performed and 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, antihistamines for sleep and, since the advent of legal THC gummies, are taking unknown quantities of these drugs with their melatonin. This, of course, 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 prior to 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 as well as to overall home safety. It is incumbent on us to develop a treatment plan that is both essential to the person before us as well as this 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 are suggested to alleviate the number of patients that have developed any of the associated problems and can be increased based on your imagination.
· Limit utilization of any type of alcoholic beverage and caffeinated drinks, such as coffee, tea and sodas after 5 PM or at least three hours prior to bedtime. This will lead to less excursions to the bathroom during the night and, therefore, less opportunity to have a fall.
· Reduce the use of all fluids and certain foods such as gassy vegetables, spicy dinners, citrus juice, artificial sweeteners, and chocolate, all of which irritate both 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 and allows for expansion and peristalsis during the night without creating an urge. Urge incontinence can also be corrected with small modification.
· Utilization of a padded sheet in bed or using a disposable diaper where they can feel confident that small 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 who could fall when using a bedside commode. It is important to use the proper size that accommodates the morphology of the patient. Proper absorbency is also important and, rather than purchasing stock supplies from a supermarket or pharmacy, perform research into companies that take great care to properly fit their patients’ needs.
· Home safety includes proper lighting to walk from the bed to the bathroom, i.e. night lights, floor lighting. Include a small light in the bathroom so that your patient is not awakened from sleep by turning on a large overhead light. Provide a walker, crutches or wheelchair where needed and installation of grab bars, not only in the shower area, but in the bathroom to make sitting and standing both easier and safer. I would also consider a raised toilet seat to accommodate for the lack of strength or mobility of the patient, 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 to the floor.
· Finally, general overall good health practices. As we decline in 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 which strengthens muscle; therefore, increasing bone density and the ability to have better overall balance and gait. For those that have availability with assistance to a pool, there are many water aerobics that can be practiced a couple of times a week with assistance of a trainer or caregiver. I encourage adult children to become involved in their parent’s health care needs to reciprocate for the care and the love that they received as children.
Concluding with the Role of Vigilance and the Importance of Malpractice Insurance
In closing, vigilance is always needed in both this age group and the care and diagnostic interventions that eliminate a perspective differential diagnosis. I have encountered a few surgeons in my history of being a SPA who have said that they have never had a post operative complication. They are wearing their arrogance on their sleeves because, the more surgery you perform, the greater opportunity for complications. There are a few PAs and NPs who 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 nonetheless the same psychological terror grabs the professional. It is only then that they may 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 will both aggravate your case because of arrogance or ignorance and both the judge, and the jury are tainted by this. I have personally seen this happen while attending a few cases 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 whereas 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&F Clinical Advisor
