What Causes Unusual Bed Wetting?
Institutional Geriatric care
Detailed Answer:
Hi,
Thank you for your query. I can understand your concerns.
It seems you are not satisfied with the institutional treatment given to you ,most likely due to lack of proper communication from nursing staff.
Conveen-sheath is often needed to prevent bed wetting (elderly men may not be able to communicate for urinal or visit toilet frequently un-assisted),even if the individual is not incontinent and it is quite hygienic but only thing it needs to be changed every 24-48 hours, to prevent UTI.
Decision to give IV fluids to elderly to correct dehydration is clinical and may be given oral fluids,if the patient is not vomiting or if otherwise oral intake is satisfactory.
He might be having bladder neck obstruction due to prostatic enlargement and had to be re-catheterized because of acute urinary retention (abdomen distended like a large beach ball).Urinary catheter is also fraught with increased risk of UTIs.
Bladder wash with urinary antiseptics are often given in patients with indwelling catheter for a long-term. Frequency is decided by urine analysis reports mainly.
Metformin is avoided to control diabetes ,if serum creatinine is >1.5 mg % in males to prevent complication of lactic acidosis .
Kindly give more details about his history so that I can help you better.
Regards
Dr. T.K. Biswas M.D. XXXXXXX
I guess I'll never know whether Dad's Conveen was changed frequently or not: I was at his bedside every single day except for one and luckily, that day, a friend of mine, who is a Sister, was on duty, but the conveen was never changed in front of me, obviously. I'll check to see if he remembers how often it was changed.
Dad is fully able to communicate and ALWAYS says if he needs the toilet, being used to lifting himself on and off his commode at home - he had developed amazing upper body strength to do this, but he liked the XXXXXXX it obviously offered him. When I first realised he had a Conveen, I was shocked, as initially I'd had no idea that it was effectively a condom with a bag attached! Had I known this, I'd naturally have queried it sooner, particularly as he was up and sitting in either the chair or in bed, whenever I visited (& I always stayed for a minimum of 3 hours). They knew & expected this, so a bottle was the obvious choice for Dad & possibly an overnight pad. A convene overnight perhaps, but not all the next day, when trying to recover from a UTI. They did adjust his diabetes meds, to take care of the extra strain on his kidneys & reduced the flow-rate of the fluids via canula to minimise heart-strain. (A v good doctor that day, but only there one out of the 13 days). He has a strong heart though, and incredibly good BP, at which the doctors are always astounded! In Oct 2007, he had a transurethral prostatectomy; enlarged but benign prostate. He's had Type 2 diabetes since 1995, when he was 72 and this has always been carefully managed with daily oral meds, though he did develop macular degeneration in 2011, registered sight-impaired 02 XXXXXXX 2013. In April 2008, he had his first knee replacement op and in November (SAME YEAR !!), he had the second one done! He had developed so much pain & loss of mobility in his legs by that time, that he's never walked since. A shortage of physiotherapists didn't help.
The acute urinary retention developed, all of a sudden, (having been passing water without issue) on the day we were taking him home from hospital nearly two weeks ago! He had been taking fluids orally, but the drip was only ever attached when I requested it, having noticed that it kept being taken away! The lack of consistency of rehydration via canula, however, coupled with the over-use of the conveen, I am convinced caused the catheter to have to be fitted, minutes before we took Dad home.
He regularly flows 'past' it in bed now unfortunately and is praying it'll be removed on Wednesday. Meanwhile, I'm sure he has another UTI, even though his fluid intake is optimal at present. He is not disoriented, but seems uncharacteristically tired. Even at nearly 92, he always had plenty of energy and enjoyed vibrant conversation.
I'll check his blood test results tomorrow and perhaps his urinalysis will be back by then.
You've been a huge help - please offer any other advice you can think of as I feel they are trying to convince Dad that it's "time to go". He continues to say he wants to live to at least 110 and has never been in low spirits despite lack of sight/mobility. Only this latest hospital 'treatment' has traumatised him (the hospital has been in the news a LOT recently e.g. - XXXX, yet his GP swooped in last week and got him to sign a DNR form, saying that "other patients had had crushed ribs from CPR!!" Dad is going to alter this directive, but it was unfair to suggest he made this decision when he was unusually tired and literally just returned from the hospital.
Sorry this is long, but I'm trying not to omit anything as I feel we will lose Dad before his birthday in 3 weeks if I don't fight for the treatment he is entitled to in this area. Many, many thanks for your assistance once again. Kind regards, XXXXXXX
Recurrent UTIs in elderly
Detailed Answer:
Hi,
Thank you for your query. I can understand your concerns.
One of the ways to prevent recurrent UTIs is to have adequate hydration oral mostly-if oral intake is poor IV fluids,which should be for short period though.
If your dad is fully alert and oriented, it is better to use urinal or the toilet should be close by-well lighted with high commode seat and hand rail to get up.
Diaper at night is also often in use in such situation (like leakage,urgency etc).
Condom cauterization,though better than indwelling catheter is not effective in acute retention.
Diabetes is often predisposing condition for recurrent UTIs but you have mentioned that his sugar is well controlled.
Poor bladder function, obstruction in urinary flow, and incomplete voiding are additional factors commonly found in patients with diabetes that increase the risk of UTI.
Let me know his blood test results and urinalysis report as available.
Regards
Dr. T.K. Biswas M.D. XXXXXXX
I'll have the blood test report and hopefully urinalysis tomorrow. I can understand why they've felt they should switch from Metformin to Gliclazide, but I am concerned about the Doxazosin and the Perindopril as he already has fairly low bp. I realise why he's been given them though. My biggest concern is that he was coerced into signing a DNR form and he would NEVER have done that if not feeling extremely "out of sorts". We are furious as a family. He doesn't really know why he agreed to it, he's told us, but he said he'd go with whatever the doctor said and she'd told him that his ribs may get broken by CPR.
He has very, very strong bones! Last time he damaged a bone was playing squash in 1961!!! If his heart stops or he has a stroke, while taking these meds (it'll be 2 weeks tomorrow), the forms now say DNR, so we'll lose him!
Thanks again XXXXXXX
Elderly patient and fruitful management
Detailed Answer:
Hi,
Thank you for your query. I can understand your concerns.
Doxazosin - a long-acting α-Blocker ,given in single daily dose is of benefit to elderly patient as first-line therapy with obstructive benign prostatic hyperplasia (BPH). Your dad had once acute retention of urine.
Perindopril an angiotensin-converting enzyme (ACE) inhibitor is antihypertensive and is also reno-protective in the long-run.
When any intervention is considered for a patient, the likelihood and magnitude of benefit that the patient can expect to gain must be balanced against the magnitude and likelihood of potential harms and possible risks to the patient.
Implementing these decisions can be particularly challenging
if the patient and/or their family wish to continue the ineffective intervention.
Cardiopulmonary resuscitation (CPR) can give rise to rib fracture even in otherwise healthy person. In older individual ,the risk is more ,because of osteopenia.
In one series as per literature,none of the terminally ill patients who had CPR performed survived.
One of the harms associated with unsuccessful CPR is prevention of a peaceful and dignified death,something that most patients and their relatives would wish for.
Decision not to attempt CPR (DNACPR) is ethical and is left to close relative to have the final say.
Regards
Dr. T.K. Biswas M.D. XXXXXXX