Health and Fitness Information for Mature Adults 

May 2, 2008              

Table of Contents

  • Medical Specialist Shares Helpful Facts (Introduction to special issue)

  • Chronic Pain (Medications and non-pharmacological strategies)

  • Urological Issues in the Elderly (Prevalence and causes)

  • The Good and the Bad About Sleep Medications (They're not all the same)

Medical Specialist Shares Helpful Facts

Terri 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.

Chronic Pain

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 urine.

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 life.

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 options.

The Good and the Bad About Sleep Medications

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 insomnia:

Restoril -- Usual dose is 7.5-30 mg. Mainly used for sleep-maintenance insomnia. Side effects include drowsiness, dizziness, and incoordination. It is addictive.

Ambien -- 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.

Lunesta -- Usual dose is 1-3 mg. Mainly used ofr sleep-maintenance insomnia. Side effects include unpleasant taste, dry mouth, drowsiness, and dizziness.

Sonata -- Usual dose is 5-20 mg. Used for sleep onset and maintenance. Side effect is mostly drowsiness.

Rozerem -- 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.

Trazodone -- 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.

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