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  • in reply to: Session 03: Subtypes of Dementia #4168

    During the discussion, someone mentioned Electroconvulsive Therapy (ECT) as an option to manage the verbal outbursts (responsive behaviours) for a person with Parkinson’s Corticobasal Syndrome type dementia. Dr. Cindy Grief, a geriatric psychiatrist, did some research and had the following to say regarding ECT as treatment:

    There’s some emerging evidence for ECT used for treating agitation in dementia. It’s safe in Parkinson’s disease and there are cases for its use in PD + anxiety and depression. I have not found any evidence for specific conditions like FTD perse. There’s a case report for the treatment of frontotemporal dementia plus bipolar disorder. Bottom line is that the best evidence for FTD is Trazodone. ECT is last line option. There are just case reviews and case series. So probably worth a try if medicationss haven’t worked. No RCTs.

    in reply to: Session 5 – Advance Care Planning #3303

    There were several questions that were not answered during the session due to limited time. Thankfully our speakers graciously sent us their answers for you to review:

    Q: what is the difference between a Will and the Advanced Directives?

    A: The terms “living will” and “advance directive” are used interchangeably and mean the same thing – they are however terms used in the U.S., but not legal terms here in Ontario, though often used. Both terms are synonymous and refer to care and treatment wishes expressed (verbally and/or in writing) by a capable person projected into a future time of incapacity to express one’s wishes. In Ontario such wishes may or may not be included in a legal power of attorney for treatment document.

    in reply to: Spring 2019 ECHO Care of Elderly – Session 2: Frailty #3191

    Hello Learning Partners,

    Some of you had questions during the Frailty Session regarding Whey Protein use in the elderly. Our librarian found a few resources that you can find in our clinical resources:
    1) A whey protein-based multi-ingredient nutritional supplement stimulates gains in lean body mass and strength in healthy older men- A randomized controlled trial

    2) Whey protein ingestion in elderly results in greater muscle protein accrual than ingestion of its constituent essential amino acid content.

    in reply to: Fall 2018 ECHO Care of the Elderly: Welcome Page #1500

    Hi Crystal – glad you enjoyed the first session! Based on your role, it sounds like the ECHO Care of the Elderly program is a great match for you!

    in reply to: Fall 2018 ECHO Care of the Elderly: Welcome Page #1480

    Hi Ewa and welcome!


    Hi Athina,

    Please see some comments below gathered from our team:

    PART 1:
    Wow. That’s an interesting question. I’m not actually clear on this, but a boating license is not issued by MTO the same way that a license to drive a car is, correct? That is a pleasure craft operator’s licence and i doubt that MTO would be regulating them. They are issued differently (mostly by taking an online course?) and it is usually the coast guard or local peace officers who patrol the waterways and regulate motorcraft operation.
    If someone is concerned about on the water safety, I’d be asking to see their pleasure boat operator’s license and proceed from there. No one is allowed on the waterways in Ontario without one.


    PART 2:
    I agree that it is not MTO that deals with other licenses such as boating or flying aircraft.

    I think that it is important to ask patients about other forms transportation and that it is fair to say if you believe they are unsafe to drive a motor vehicle that they are likely also unsafe to drive a boat or fly a plane. I am not aware of reporting regulations for boats and planes, and, unfortunately, I am not clear who you would report concerns to.

    in reply to: Physical and ivestigation in incontinence #1084

    Hi Jose,

    Here is some information gathered from our Hub team:

    PART 1:
    As a Continence Advisor, the physical exam IS part of the assessment. I normally start with a pre and post void bladder scan just to rule out any retention issues first. With the physical exam, I, nor do many of my colleagues use a speculum. What we are mainly looking for are atrophic changes, irritation, drainage etc. I will assess pelvic muscle tone by asking patients to tighten their rectum. Asking the patient to cough will allow to see whether there is any loss of urine (stress) or any presence of pelvic organ prolapse, cystocele, or rectocele. I do not do the Q-tip test. By not using a speculum, it is less invasive and normally accepted by most patients.

    I do agree that for many elderly women, they have not had physical exam in several years but often it will prove their symptoms by actually “seeing” what is going on. Vaginal atrophy can be seen on inspection of perineum and thus is very likely impacting on bladder tissues as well. Many women might not realize they have a prolapse at all. I think imaging will depend on what symptoms are present but agree that obesity is difficult to obtain a bladder scan accurately.

    Changes in fluid, caffeine, hygiene and toileting are all what I would normally review and change BEFORE looking at any medication. Sometimes they are not needed when the above are corrected.

    Hope this helps…..I am open to feedback anytime!

    PART 2:
    With respect to the physical examination not all women presenting with incontinence need a pelvic examination prior to initiating behavioral or medical therapy as long as the symptoms allow the clinician to differentiate between stress versus urgency incontinence and there is no systemic or other evidence of pelvic pathology.

    Women with atypical symptoms, diagnostic uncertainty, or failure of initial treatment strategies should undergo pelvic examination with special attention to evaluate for pelvic floor muscle integrity, vaginal atrophy, pelvic masses, and advanced pelvic organ prolapse beyond the hymen.
    stress test — Confirmation of the diagnosis of stress urinary incontinence (SUI) includes visualizing leakage of urine from the urethra during a urinary stress test (also referred to as a cough stress test or cough test). Instantaneous leakage with cough suggests SUI. Delayed leakage suggests detrusor overactivity incontinence, especially if there is a large flow of leakage that is difficult for the patient to stop.

    The urinary stress test consists of having a patient with a full bladder Valsalva (tense her abdominal muscles) or cough
    Assessing urethral mobility — Urethral hypermobility (also referred to as bladder neck hypermobility) is present in most women who have primary SUI. In our practice, we no longer formally test for urethral hypermobility, since the presence or absence of hypermobility does not appear to change management. Historically, the urethral cotton swab test (Q-tip test) was the most common test used to evaluate urethral mobility for gynecologists. However, the cotton swab test has questionable test-retest and interobserver reliability. It is not possible to assess the accuracy of this and other tests of urethral hypermobility, since there is no accepted gold standard.
    Postvoid residual volume — Measurement of the postvoid residual volume (PVR) is performed to exclude overflow incontinence or other types of voiding dysfunction. To measure the PVR, the patient is asked to start with a full bladder and void as she normally would (without additional effort to fully empty the bladder). The residual urine in the bladder is measured either by catheterization or bladder sonography. Normally, women should be able to void at least 80 percent of the total bladder volume and have residual urine less than 50 cc immediately after voiding. In general, a PVR of greater than 200 cc may be suggestive of voiding dysfunction or detrusor weakness; the range of normal values for PVR and treatment options remains controversial (these values may vary in elderly women or those with advanced pelvic organ prolapse).

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