Specialist Shares Helpful Facts
F. Katz, M.D., is director of The Center for Healthy Living in
Teaneck, New Jersey. An internist specializing in the care of the
elderly, Dr. Katz is associated with PMR, the Physical Medicine and
Rehabilitation Center, P.A., of Englewood, New Jersey. PMR is devoted to
the diagnosis and treatment of medical problems related to pain and
disability, and its multidisciplinary treatment teams provide
comprehensive care for sports, spine, orthopedic, and neuromuscular
conditions. For more information, click on
Today we are delighted to present short articles by Dr. Katz on three
topics of great importance to many older adults: chronic pain, urinary
incontinence, and sleep problems.
Pain is an objectionable sensory and
emotional experience. Older people often have numerous sources of
pain stemming from multiple medical conditions. Acute pain from trauma,
infection, or musculoskeletal injury may be superimposed upon chronic
pain from arthritis, osteoporosis, cancer, and bone diseases. The
perception of pain is strongly inter-related to other conditions; pain
may aggravate, or be the manifestation of depression, decreased
socialization, sleep disturbances, and impaired ambulation. Pain may be
especially difficult to recognize in individuals with cognitive deficits
who neither comprehend pain nor effectively communicate its presence.
Listening carefully to the patient or
getting input from a caretaker can provide the most accurate evidence of
the existence and intensity of pain, as pain is often intermittent and
variable. Interdisciplinary assessment by physicians, nurses, and
therapist allows for the development of a treatment plan that addresses
multiple sources of pain and provides various modalities for treatment.
One of the best tools of evaluation is simply asking the patient to rate
the pain on a scale of 0 to 10. Pain should not be accepted as a
natural consequence of aging.
Medications play a central role in the
treatment of pain. In older patients in particular, the challenge of
using medications to provide adequate pain relief while avoiding
potential side effects is paramount. Many patients with mild to moderate
pain respond to around-the-clock Tylenol. The maximum recommended dose
is 2 extra strength tablets four times a day. If this fails, NSAID
treatment (Motrin and others) or COX-2 treatment (Celebrex and others)
may be beneficial.
The use of opioid medications (Codeine
and others) has become more acceptable. Many older people erroneously
fear that they will develop an addiction. Use of chronic opioids to
relieve true pain is not an addiction. Of concern, however, are the
potential sedating effects and concurrent increased risk of falling. The
importance of starting at a low dose and tapering up to control the pain
cannot be overemphasized.
Non-pharmacological strategies alone,
or in combination with medications, should bean integral part of the
treatment plan. Regular participation in exercise, physical and
occupational therapy, massage, and acupuncture are all effective.
Patient education, along with learning cognitive and behavioral coping
strategies, can help modify factors such as helplessness and low
self-esteem which have been shown to increase pain and disability.
Effective pain management for all older
adults is our goal. A systematic approach to recognize, treat, reassess,
and modify treatment to meet the needs of each individual should be
available to all older adults in all treatment settings.
Urological Issues in the Elderly
One of the most problematic issues
of getting older is seeking help for embarrassing medical issues.
Urination is often a problem -- whether it is that one cannot make it to
the bathroom on time, or it takes too much time and effort to pass
Urinary incontinence is characterized
by leakage of urine that is not under voluntary control. In other words,
it happens at any time and in any location. It is a very prevalent
problem affecting 15 to 30 percent of aged people in the community and
over 50 percent residing in long term care. Urinary incontinence can
cause skin infections, falls with fractures, sleep deprivation, social
withdrawal, and depression. Urinary incontinence impairs quality of
Urinary incontinence is a geriatric
syndrome caused by a multitude of factors, and frequently there is
treatment available to either cure the problem or at least reduce the
frequency and severity of accidents. Sometimes the cause of incontinence
is obvious as in the individual with a gait abnormality who cannot make
it to the bathroom on time. In other instances, a comprehensive
evaluation is required to unmask the cause.
Inability to pass urine is seen in a
variety of circumstances, but is most common in elderly men secondary to
a condition called benign prostatic hypertrophy. This condition is seen
in 90 percent of men by age 85 and is easily diagnosed on physical
examination and confirmed with ultrasound. There are many treatment
The Good and the Bad About Sleep
It is well known that lack of sleep
can lead to irritability, depression, decreased performance, and
cognitive impairment. More importantly, insomnia leads to daytime
somnolence which can increase the risk of falls, hip and vertebral
fractures, and motor vehicle accidents. Treatment of insomnia should
begin with behavioral recommendations geared toward decreasing the time
it takes to fall asleep (sleep onset) and increasing the amount of time
remaining asleep (sleep maintenance). When these measures are not
successful, we often turn to medications
For any treatment recommendation, the
physician must evaluate the benefits versus the risk. This problem is
amplified when there are multiple medical problems and medications that
may interact and exacerbate both the desired treatment effect and side
effects. The best approach is to start with the lowest dose of the
chosen medication and to modify the dose or change treatment depending
upon whether the desired effect is achieved and whether the side effects
are acceptable. Below is a chart of commonly used medications for
-- Usual dose is 7.5-30 mg. Mainly used for sleep-maintenance insomnia.
Side effects include drowsiness, dizziness, and incoordination. It is
-- Usual dose is 5-10 mg. Mainly used for sleep-onset insomnia. Side
effects include drowsiness, dizziness, and amnesia. Newer version,
Ambien CR, may be better for sleep maintenance.
-- Usual dose is 1-3 mg. Mainly used ofr sleep-maintenance insomnia.
Side effects include unpleasant taste, dry mouth, drowsiness, and
-- Usual dose is 5-20 mg. Used for sleep onset and maintenance. Side
effect is mostly drowsiness.
-- Usual dose is 8 mg. Mainly used ofr sleep-onset insomnia. Side
effects are drowsiness and dizziness. Probably is the least effective
but the safest.
-- Usual dose to treat insomnia is 25-75 mg. Side effects include
dizziness, dry mouth, and headache. Considered by many geriatricians to
be one of the safest choices.
Always speak to your physician after
starting a new medication if you are experiencing any new symptoms.