Annals for Educators - 4 September 2018
Authors: Christine Laine
Journal: Annals of Internal Medicine (2018)

Web Exclusives4 September 2018Annals for Educators - 4 September 2018FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201809040 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsScreening for Urinary Incontinence in Women: A Systematic Review for the Women's Preventive Services InitiativeScreening for Urinary Incontinence in Women: A Recommendation From the Women's Preventive Services InitiativeThis systematic review evaluated the evidence for screening for urinary incontinence in women and provided background for the recommendations made by the Women's Preventive Services Initiative.Use these papers to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners how common urinary incontinence is among adult women. In what ways may it manifest? What are the possible causes, and how should incontinence be evaluated? Use the information in DynaMed Plus: Urinary Incontinence in Women, a benefit of your ACP membership. Are women who are concerned about urinary incontinence hesitant to raise the issue with their physicians?Review the findings of this systematic review. Do your learners recommend screening for urinary incontinence? What did the Women's Preventive Services Initiative recommend, and why?What are the requirements for disease screening to be effective?What potential challenges and problems are there with screening for urinary incontinence as recommended here? Use the accompanying editorial to help frame your discussion. Risks and Benefits of Marijuana Use. A National Survey of U.S. AdultsAlthough evidence is limited regarding the potential health benefits and safety of marijuana, legal access to it is increasing and marijuana products are being aggressively marketed to the public. This nationally representative U.S. survey evaluated public perceptions about the health benefits and risks of marijuana use.Use this paper to:Ask your learners whether they believe marijuana is beneficial for any medical conditions. Are there any risks?What is known about marijuana's benefits and harms? Look at the results of recent systematic reviews that evaluated its use for chronic pain and posttraumatic stress disorder and the risks to respiratory and cardiovascular health. Ask your learners whether they ask patients about marijuana use. Should they?Why do your learners think the public seems to have a favorable view of the benefits of marijuana despite the lack of evidence? Why might this matter?In the Clinic: Parkinson DiseaseParkinson disease is the second most common neurodegenerative disorder after Alzheimer disease, affecting 1% of persons older than 65 years and 3% of those older than 80 years. It has long been recognized as a motor system disorder but also has significant nonmotor symptoms affecting sensory, emotional, cognitive, and autonomic functions. Are your learners prepared to recognize, evaluate, and treat patients with Parkinson disease?Use this review to:Ask your learners what symptoms should prompt consideration of Parkinson disease. What questions should be asked? What should be looked for on physical examination?How is the diagnosis made?What is the differential diagnosis, and what testing should be considered?When should drug therapy be started, and how? Should your learners do this, or should all patients see a specialist?What drugs are used to treat Parkinson disease, and what are the potential side effects and adverse reactions?What are the nonmotor symptoms of Parkinson disease? How should they be managed?What is the prognosis of a patient with Parkinson disease? How would your learners discuss the prognosis with a patient and her or his family? What information should be provided, and what questions should be asked?Humanism and ProfessionalismOn Being a Patient: Michael's Testimonial“As I was losing control of my body because of my ALS, this decision was the one last element of control I had over my life. For that to be taken away fills me with great anxiety, because now I do not know how this is going to play out.”Use this essay to:Listen to an audio recording of the testimonial, read by Dr. Michael LaCombe. Ask your learners if they have ever talked to patients with terminal illnesses about their concerns regarding their eventual death. What did they learn?Go to the bedside! Are there patients on your service who would be willing to discuss their thoughts about dying with your team, and perhaps would even appreciate it?Do your learners believe that patients with terminal illnesses should have the option of determining when their lives will end?Do your learners believe that physicians should be allowed to assist patients who wish to determine the timing of their death?Why does the author emphasize in the opening paragraph that the word “option” is very important? Why might such an option be important to a patient even if she or he does not exercise it?On Being a Doctor: Is This How It's Supposed to Be?Dr. Maldonado is surprised when, following what seemed a normal office visit with a new patient, she was asked, “Is this how it's supposed to be?”Use this essay to:Listen to an audio recording, read by Dr. Virginia Hood. Ask your learners whether they have sufficient time for patient appointments. If not, why not? Are all of the pressures external, or are we at fault as well?How long are your learners' scheduled outpatient appointments? How long will they likely be after residency? Will your learners be able to negotiate the amount of time for patient appointments when discussing a job with a potential employer? What would your learners be willing to sacrifice to have more time at each patient appointment?What can we do as individuals and as a profession to address the problems raised in this essay?Teaching Scholarship OpportunityHerbert S. Waxman Chief Resident Teaching ScholarshipAll chief residents who are members of ACP are eligible to apply for a Herbert S. Waxman Chief Resident Teaching Scholarship. Waxman Scholars assist in teaching popular workshops under the guidance and mentorship of expert faculty in the Clinical Skills Center at ACP's annual Internal Medicine Meeting. The scholarship includes the cost of meeting registration, travel, and accommodations for the ACP Internal Medicine Meeting 2019, to be held April 11–13 in Philadelphia, Pennsylvania.This is an opportunity to build your CV and gain valuable experience teaching a workshop.The submission deadline for applications is September 28, 2018. Don't miss it— click here to complete your application! MKSAP 17 QuestionAn 86-year-old woman is evaluated for increasing urinary incontinence. The patient has dementia and lives with her daughter, who is her primary caregiver. She previously had occasional urinary incontinence but now needs to wear a diaper. Her daughter is concerned about mild skin irritation she has noticed on the patient's buttocks. In addition to dementia, the patient has osteoarthritis and hypothyroidism. Medications are levothyroxine and as-needed acetaminophen.On physical examination, vital signs are normal. BMI is 21. The patient is confused but cooperative. She appears frail and uses a walker for balance when standing and ambulating. Cardiopulmonary examination is normal. The abdomen shows no tenderness or suprapubic fullness. Erythema is present around the groin and buttocks, but no pressure ulcers are seen.Urinalysis is normal.Which of the following is the most appropriate management?A. Antimuscarinic agentB. Pelvic floor muscle trainingC. Prompted voidingD. Transdermal estradiolCorrect AnswerC. Prompted voidingEducational ObjectiveManage functional incontinence in a frail older woman.CritiqueBehavioral therapy utilizing prompted voiding is the most appropriate management of this patient. This patient's incontinence may be due to multiple factors, including structural and functional causes complicated by her cognitive impairment and decreased mobility. Prompted voiding involves regularly asking the patient to report on incontinence, asking the patient if he or she needs to void, providing assistance with access to the bathroom, and praising the patient for continence. This technique has been shown to reduce urinary incontinence in older patients who have caregivers capable of working with them, such as this one, as well as those residing in assisted-care facilities. This intervention is also usually timed so that prompted voiding occurs before accumulation of a large volume of urine in the bladder, reducing the likelihood that incontinence will occur. With active and consistent caregiver involvement, timed and prompted voiding can help achieve improved bladder control.Antimuscarinic agents are used to decrease urgency, frequency, or incontinence in overactive bladder with urge incontinence. Adverse effects are common, however, including constipation, dry mouth, dizziness, and confusion, and older patients are at greatest risk for adverse consequences. Therefore, an antimuscarinic agent would not be an appropriate therapeutic choice in this older patient with cognitive impairment.Pelvic floor muscle training is effective in reducing incontinence but requires active participation by the patient. Although training is implemented by physical therapists or advanced practice nurses, both pelvic floor muscle and bladder training require intact cognition and the ability to self-manage and self-sustain a training regimen and are therefore unlikely to be effective in this patient with dementia.Systemic estrogen therapy has not been shown to alleviate urinary incontinence and may worsen symptoms. It is also associated with increased cardiovascular risks when initiated in women more than 10 years post-menopause.Attention to skin care and use of absorptive products with frequent changes are extremely important in preventing skin breakdown in older patients with incontinence. A review of modifiable factors is also helpful, including medication use, mobility issues, weight reduction, and caffeine reduction.Key PointBehavioral therapy utilizing prompted voiding has been shown to reduce urinary incontinence in older patients with dementia.BibliographyMarkland AD, Vaughan CP, Johnson TM 2nd, Burgio KL, Goode PS. Incontinence. Med Clin North Am. 2011 May;95(3):539-54.Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Associate Dean of Graduate Medical Education and Affiliations, Thomas Jefferson University. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 4 September 2018Volume 169, Issue 5Page: ED5KeywordsBladderCaregiversDementiaHealth surveysIncontinenceMarijuanaMusclesParkinson diseaseSystematic reviewsUrinary incontinence ePublished: 4 September 2018 Issue Published: 4 September 2018 Copyright & PermissionsCopyright © 2018 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...