R4 Geriatric Medicine Handout Dec. 29th, 2008 This handout is a collection of geriatric medicine pearls.

It should be taken as a guideline and not as the letter of the law. Nor should it be taken as a complete syllabus of geriatric content. Strategies for studying and presenting may be embedded in the sections. They are simply the opinion of author and should be taken as such. You may hear contradictory information... Table of Contents Page Osteoporosis 2 Dementia 5 Functional inquiry 9 Falls assessment 10 Parkinsonism 12 Urinary incontinence 14 Osteoporosis Physical Exam Osteoporosis lends itself to an OSCE station because it was a recent JAMA RCE article (JAMA 2004 Vol. 292, No.23). The following is merely a suggested approach. The important thing is to have an organized approach to any station. For physical exam stations some people take a vitals then head-totoe strategy in hopes of not forgetting anything. This is important for scenarios in which the patient could potentially be unstable (not that they are for physical exam scenarios). For osteoporosis I suggest a strategy that proves you know the evidence behind the physical exam followed by a search for secondary causes of osteoporosis. Reminders: 1. Listen closely to the question you are being asked. If the examiner says assess for osteoporosis this means you may want to clarify if they want a focused history of the problem. For osteoporosis this might include: - a history of back pain - previous fragility fractures (which is diagnostic of osteoporosis) - reported height loss > 6 cm - reported humped back (JAMA RCE) - menopausal status - PMHx of thyroid disease, hypogonadism, bowel disease including celiac disease and bowel resection - Meds including: cumulative steroid use, anticonvulants, heparin, glitazones - lactose intolerance/milk allergy - smoking history

If the examiner says, examine this patient... you will not gain any points for interviewing the patient and you will be redirected to focus on the physical exam findings. Another potential variation on physical exam stations is to be asked to look for etiology rather than the actual condition: i.e. Examine this man for secondary causes of osteoporosis without examining for osteoporosis. In this case it would be appropriate to focus on findings consistent with: - GI disease: scars from bowel resections, malnutrition, vitamin deficiencies, extra-intestinal findings of IBD - Endocrine disease: hyperthyroidism, hypogonadism - Renal disease: excoriations from purities, asterixis, edema/HTN 2. Describe what you are doing as you are performing the manoeuvre. Dont say I would..., instead state it in real time, I am.... When appropriate you can phrase this as a description for the patient, especially if there are directions the patient must follow. 3. It is important to know what exam manoeuvres increase or decrease the likelihood of a given diagnosis but it is apparently not necessary to quote the specific likelihood ratio numbers. Introduction: One of the important things to formulate in your mind is your 15 second summary of how you are going to organize any physical exam or history OSCE station. The following, again, is a suggestion:

My approach to osteoporosis is to initially focus on the exam manoeuvres found to increase the
likelihood of osteoporosis in women summarized in the JAMA RCE series including, WORTH: weight, occiput-wall distance, rib-pelvis distance, tooth count and self-reported humped back. Time permitting I will then assess for other physical exam findings supportive of the diagnosis of osteoporosis or suggestive of a secondary cause for osteoporosis.

WORTH
W weight To the patient: I am measuring your weight today in kg as a weight less than 51 kg has been found to significantly increase the likelihood of osteoporosis (PLH 7.3) . Look around for a scale which may be available as a prop in the room. Following weight, I am now measuring your height in metres. How tall were you at your tallest? SOGC guidelines from 2006 summarized that a historical height loss greater than 6 cm or a prospective height loss greater than 2 cm has level IA evidence to recommend further imaging for vertebral compression fracture. The BMI can be calculated from the (weight in kg)/(height in m) squared. Currently BMI has not been found to significantly effect the likelihood of diagnosing osteoporosis. O occiput-wall distance Please stand with your back to this wall and your heals touching the wall. Dont tilt your head back, just look forward comfortably, the line from the corner of your eye to the superior attachment of the ear parallel to the floor. Any distance between the back of the head (occipital prominence) and the wall is a

positive sign. This has been found to significantly increase the likelihood of a diagnosis of osteoporosis (PLR 4.6). R rib-pelvis distance Please stand straight with your arms stretched out straight in front of you at 90 degrees. I am standing behind you and placing my fingers in the space between the inferior margin of the ribs and the superior edge of the pelvis in the mid-axillary line. Two or fewer finger breadths significantly increases the likelihood of osteoporosis (PLR 3.8). T teeth I am counting your teeth as some studies have found that a total tooth count of <20 can increase the likelihood low bone mineral density. (PLR 1 3.4) **dont focus on this exam finding. H self-reported humped back This is technically a history finding. It can be mentioned in passing as the PLR in one study was 3.0 and it was mentioned in the JAMA RCE in the Box titled Physical Examination Manoeuvres Suggesting Presence of Osteoporosis or Spinal Fracture. Evidence does not currently support the use of grip strength, hand skin-fold or armspan-height difference in the examination for osteoporosis. Additional examination (dependent on the question being asked): A. In patient with back pain after a fall: Back MSk exam Inspection for swelling, erythema, atrophy, deformity, scars (SEADS). Swelling and erythema would be unlikely. Atrophy could occur in the context of chronic back pain especially if there are associated neurologic signs. The focus should be on deformity. Inspect anteriorly, laterally and posteriorly. Comment of deviations from normal cervical lordosis, thoracic kyphosis and lumbar lordosis. Palpation over spine while standing or prone. Thumping along the spine helps to identify possible infection/mets. ROM c-spine flexion/extension/lateral flexion (ear to shoulder)/rotation (look over shoulder) - l-spine flexion (touch toes)/extension (bend backwards)/lateral flexion(slide your hands down your leg) - t-spine rotation (sit down, cross your arms and turn upper body to look over shoulder) Neurologic exam (assuming mid or lower back pain) Motor a. Strength: hip flexion, knee extension, knee flexion, foot dorsiflexion b. tone Reflexes - knee, ankle, plantar bilaterally Sensory pin prick (use a sharp toothpick), light touch (cotton ball), vibration (start distally), proprioception

B. In asymptomatic patient (i.e. looking for secondary causes): H&N: uveitis (IBD), thyroid (goiter/nodule, ocular findings associated with Graves disease), glossitis/bleeding gums (malabsorption/malnutrition) Resp: signs of cystic fibrosis (hyperinflation, clubbing...) CV: tachycardia, irreg. HR (both hyperthyroidism) Ab: scars from bowel resection, ascites (renal failure) GU: testicular atrophy (say you would do) Skin: jaundice (bowel disease or CRF), excoriations from pruritus, erythema nodosa/pyoderma gangrenosum (IBD), decreased hair distribution (hypogonadism) MSk: active joints

Dementia Dementia could easily be a scenario that goes something like this: A 75 year old woman and her daughter present to your office. The daughter wonders if her mother if her mother has Alzheimers disease. Outline your approach to this patient. Preamble Having assured myself that the patient is stable, my approach to the assessment for dementia is to identify abnormalities in short term memory and one other area of cognition that is effecting functioning then move on to attempting to determine the specific dementia etiology. I will assess the patient and ask the daughter to contribute with collateral as appropriate. History Symptoms: (need STM impairment and one other area of impairment) i. short term memory symptoms repetitive questions ii. agnosia inability to recognize people or objects iii. aphasia word finding problems, difficulty finishing sentences iv. executive dysfunction difficulty planning complex tasks such as change in ability to cook a meal for family, difficulty organizing taxed Associated symptoms: hallucinations, strokes/neurological deficits, parkinsonism, gait changes, urinary symptoms Risk factors: family history of dementia, history of strokes/TIAs, level of education (higher is protective), head trauma Behavioural and psychological symptoms of dementia (BPSD): paranoia, agitation, violence Safety questions: Fires in the kitchen? Wandering and getting lost? Accidents while driving? Leaving the house unlocked? Mood symptoms (Depression is in the differential): decreased enjoyment, decreased interest (i.e. in grandchildren), decreased sleep, decreased appetite, rule-out suicidal ideation Functional inquiry: IADLs = telephone, shopping, cooking, banking, laundry, cleaning, driving/transportation, medications ADLs = bathing, dressing, toileting, eating, ambulation

PMHx/Meds/Allergies/FHx/SoHx Cognitive assessment Be able to do an MMSE (supported by JAMA RCE series) Physical Exam Vital: include postural BP, comment on HR as treatment can cause bradycardia Head to toe: pallor, jaundice, hypoxia, murmurs/irreg HR (increase risk of CVA), abdomen for liver, neuro exam for focal signs as well as signs of Parkinsons disease (rigidity/bradykinesia/postural instability/ tremor/glabellar tap), GAIT exam (vascular wide-based magnetic gait vs. Parkinsonian narrow-based shuffling gait) Investigations Bloodwork: CBC, lytes, Ur, Cr, Ca/Mg/PO4, TSH, VitB12, VRDL, +/- HIV test CT: if sudden onset (less than 1 yr), if headache, nausea, vomitting, focal neuro signs, gait changes and urinary symptoms (rule out NPH), young DDx - below are classic findings but they are not pathoneumonic Reversible: a. hypothyroidism weight gain, slowing, skin/hair changes, bradycardia b. VitB12 deficiency decreased lower extremity reflexes, decreased proprioception, angular stomatitis, glossitis, optic disc atrophy c. normal pressure hydrocephalus (NPH) wide based gait/falls, urinary incontinence Degenerative: a. Alzheimers Disease prominent STM, gradual smooth progression, no comorbids b. Vascular Dementia hx of strokes/TIAs, focal neuro signs, wide-based magnetic gait c. Parkinsons Dementia PD diagnosed years prior to dementia d. Lewy Body Dementia visual hallucinations, PD symptoms early, fluctuations, exquisite sensitivity to neuroleptics (worsens PD) e. Mixed Dementia - AD with hx of CVA or CT evidence f. Frontotemporal prominent apathy, personality change, disinhibited behavior Treatment 1. Nonpharmacologic future planning: power of attorney, will, care-giver support, wander guard - daily routine - safety: unplug/disable stove, consider formal driving assessment or removal of license 2. Pharmacologic - cholinesterase inhibitors: in mild moderate dementia. Serious side effects include upper GI bleeding IN THE PRESENCE OF AN ACTIVE PEPTIC ULCER, bradycardia (consider ECG). Common side effects include GI intolderance (nausea/dyspepsia) - memantine: in moderate to severe dementia. Can be used in combination.

Hypothetical MCQ about memory: - remember when studying for MCQs, they are often peoples recollections and not exact. Understanding the big points should help you pick the correct answer. Some questions are simply too vague to be sure the answer is correct. - the most normal change in MEMORY is decreased free recall. Should correct with prompting. - another normal change in COGNITION is a decreased ability to learn new skills - the changes are normal if they are not progressive and do not affect daily function UTD quote: The normal cognitive decline associated with aging consists primarily of mild changes in memory and the rate of information processing, which are not progressive and do not affect daily function. In a study of 161 communitydwelling, cognitively normal individuals ages 62 to 100 years, learning or acquisition performance declined uniformly with increasing age. In contrast, delayed recall or forgetting remained relatively stable. Similarly, a second report found that aging was associated with a decline in the acquisition and early retrieval of new information but not in memory retention. Source: UTD v14.2 1. What is the most normal change in memory in the elderly? a. Loss of anterograde memory b. Loss of short-term memory abnormal and classic for early AD c. Loss of immediate recall and recognition if this is free recall then this is normal d. Loss of recall of facts 2. Which of the following is an abnormal finding with respect to memory in the elderly? a. Decreased registration and immediate recall b. Decreased long term memory most abnormal but certainly not the most common c. Decreased free recall - can be a normal change in aging d. Decreased ability to immediately name faces - unclear if this means agnosia 3. What is a normal manifestation of cognitive decline in the elderly? a. decreased registration and recall b. decreased recall with prompting (cueing) normal memory changes CAN be prompted c. decreased free recall d. decreased long-term memory e. reduced retrieval of learned skills learning NEW skills can be reduced (not retrieval) 4. Old guy with progressive memory loss. Previous MI, HTN, DM, no peripheral pulses, bilat carotid bruits. Which test will lead to diagnosis? a. psychometric testing - can confirm cognitive changes but cant confirm etiology (can suggest etiology) b. CSF analysis

c. EEG d. CT head would identify infarcts and vascular changes but is non-specific e. carotid Dopplers 5. Female in her 60s with sudden onset of memory loss. Keeps asking where are we? What are we doing? No loss of consciousness or head trauma. Lasts for 8 hours with no recollection of the events. What is the Cause? a. Complex partial seizures b. Wernickes encephalopathy c. Transient global amnesia CLASSIC (if alternating LOC and fluctuations with medical illness, think delirium) d. B12 deficiency 6. 67 yo woman brought by her husband with a 6 month history of deteriorating memory. Unable to do her own banking. Had difficulty short-term memory on mini mental exam. What is the most likely Dx i: a. Alzheimers disease gave you STM and executive dysfunction plus functional change b. Lewy Body Dementia c. Multi-infarct dementia 7. Old man brings in wife with gradual onset word finding difficulties, vagueness, and cant do finances. Normal except MMSE shows disorientation and cant get 3 word recall. Diagnosis? a. Alzheimers b. Normal memory loss with aging c. Vascular dementia d. Lewy Body dementia e. Depression Functional Inquiry

75 year old woman is being discharged from hospital. Please discuss with the patient all the issues
related to her discharge with respect to ADLs and IADLs. *pre-admission functioning predicts function after discharge *obtain collateral history (i.e. state you would!) History Where were you living prior to admission? Where you getting any supports from the health unit? Did you have friends or family who helped? How? Would you mind if I called them to ask them a few questions? IADLs - Did you have any difficulty using the telephone before admission? - Did you cook for yourself prior to admission? If no, did you when you were younger? - Did you clean for yourself? If no...

- Did you do your own laundry? Was it downstairs? - Did you do your own shopping? - Did you drive? If no, how did you get to appointments? - Did you manage your own medications? Were they blister-packed? - Did you do your own banking? ADLs - Did you bath or shower? Did you need any help? Did you fear falling? - Did you have any trouble making it to the bathroom? Any accidents? - Did you need any help dressing? Even with the buttons? - Did you need any help eating, for example cutting meat? - Did you use a cane, walking or wheelchair prior to coming to hospital? Changes from baseline Have you noticed any changes since you have been in hospital? Can you think of any additional help you will need at home? Consult the multidisciplinary team I am going to talk to your physiotherapist and occupational therapist to see if they have identified any help you may need at home... Falls assessment This could be a: i. scenario ii. focused history and physical iii. physical exam station

As per the JAMA RCE series, my approach to a falls assessment is to assess:

History of falls (PLR 2.3 3.8) Orthostatic blood pressure Gait and Balance Medication review ADL/IADL assessment Cognitive assessment History HPI: When was your last fall? Please describe it. Was it inside or outside? (inside higher risk) Was it in the middle of the night? Where you on your way to the washroom? Did you faint or black-out? (very different approach see syncope) PMHx: list, ask specifically about Parkinsons disease, history of stroke with remaining deficit, heart conditions/arrhythmias/pacemakers, diabetes (enquire about

peripheral neuropathy and amputations) Meds: Did you bring your medications or do you have a list? - psychotropic medications such as benzodiazapines, phenothiazide and antidepressants can increase the likelihood (PLR 28!!) Functional inquiry: ADL/IADL Cognitive assessment Screening MMSE (dementia PLR 1&) Physical exam I would do a complete physical examination but will focus on the components I would emphasize in a falls assessment. Vitals: full set of vitals including O2sat, HR and especially a postural set of vital signs from lying to standing at 1 and 3 minutes. A significant postural drop is 20 mmHg systolic or 10 mmHg diastolic. A lack of compensatory increase in HR suggests a beta-blocker or autonomic failure (i.e. Parkinsons Disease or DM) Visual acuity: Snellen chart Gait: Timed get up and Go (TUG) Ask patient to rise from a chair (ideally without arms), instructing them not to use their arms, walk 10 feet (3m), turn around, walk back to the chair and sit down. Time this using your watch. - a TUG > 10 sec has PLR or 2.0 - being unable to rise from a chair without using the arms has a PLR 4.3 in men - for gait comment on Initiation Step height Step length Step symmetry Stability Stance width Arm swing En bloc turning (having to take mini-steps) Balance: ***always ensure you are in a position to safely catch patient if they appear to be ready to fall. If you consider the patient too high a risk of falling, state that and do not put them at risk!! 1. Sitting static balance any instability while sitting 2. Sitting dynamic balance any instability sitting while reaching or when given a small shove on the sternum 3. Standing balance a) Feet comfortably apart give small nudge to sternum or pull from behind (Being prepared to catch them!!) b) One foot in front of the other (tandem) c) Standing on one foot (each side) 4. Walking balance ability to tandem walk

Remainder of the physical exam: volume status, head and neck, complete cardiovascular (heart sounds, bruits...), MSk, complete neuro for focal deficits and signs of Parkinsons disease Parkinsons Disease Perform a focused history and physical exam for Parkinsons disease.

Parkinsons disease is characterized by tremor, rigidity, bradykinesia and postural instability. The JAMA
RCE series summarized findings on history and physical that increase the likelihood of Parkinsons disease. History Complete history including... Symptoms: (JAMA RCE in bold) - tremor? Resting vs intention? Asymmetrical? Limbs vs head/voice? - rigidity? Stiffness? - bradykinesia? - poor balance? Falls? Walking aid? - shuffling gait? - change in writing? (micrographia) - difficulty turning in bed? - difficulty raising out of a chair? - trouble opening jars? - visual hallucinations? Vivid dreams (REM behavioural sleep disorder)? PMHx: CVAs? Meds: specifically antipsychotics/metaclopramide? FHx: PD? Physical Exam Complete physical exam including... Vitals: postural BP, HR Tremor: observe while collecting history, observe in opposite hand when testing for bradykinesia or with concentration Rigidity: I am rotating the wrist while asking the patient to go limp like a rag doll. I am testing for cogwheeling at the elbows with my thumb over the bicepts tendon. With the patient lying in bed I am elevating the limp leg at the knee and noting any decreased relaxation of the legs as they come to the horizontal. Bradykinesia: I am asking the patient to touch the thumb to the index finger in a nice big movement as fast as possible. I am asking the patient to pretend to play the piano with both hands. I am asking the patient to twiddle one forearm around the other. I am asking the patient to stomp one heal up and down in a nice big movement.

Postural Instability: I am asking the patient to stand. While standing behind the patient I am bracing myself to catch him/her. I am warning the patient then tugging gently backwards towards myself. If the patient has to take a step backward for stability this is positive for postural instability. Gait assessment: I am asking the patient to walk for approximately 10 feet then turn around noting any narrowing of the base, decreased arm swing and any en bloc turn. I am now asking the patient to walk heal to toe as was described in the JAMA RCE to increase likelihood of PD if present Glabella tap: I am asking the patient to sit on the bed. I am tapping between the eyebrows without bringing my hand into the line of sight. I am counting the number of taps before the blink reflex is extinguished. Greater than 10 blinks is an abnormal glabella tap. Time permitting: I am assessing for impaired vertical gaze which might suggest a supranuclear palsy. I am assessing cognition which could suggest Parkinsons dementia if the PD is longstanding or suggest a diagnosis of Lewy Body dementia. Finally I will finish the other components of a full history and physical exam.

BOTTOM LINE: JAMA 2003;289:347-353. Does this patient have Parkinson disease? Features on history for RULING IN Parkinson disease + LR Classic symptoms Tremor Rigidity and bradykinesia Postural Instability (loss of balance) Shuffling while walking Micrographia 1.4 17 4.5 1.6 6.6 3.3 15 2.8 5.9

New symptoms
Trouble turning in bed Difficulty rising from chair 13 1.9 5.2

Trouble opening jars

6.1

Features on history for RULING OUT Parkinson disease - LR Rigidity and bradykinesia Tremor 0.12 0.24 0.6

Physical Exam Signs for RULING IN Parkinson disease Sign Rigidity and bradykinesia Glabellar tap Difficulty walking heel to toe LR+ 4.5 4.5 2.9

Chronic Urinary Incontinence Female patient - effects up to 55% of women - the DDx includes: stress incontinence, urge incontinence, mixed (stress + urge), overflow incontinence, functional incontinence (cognitive, dexterity, mobility) - prevalence: Young women - stress incontinence is most common Older women urge incontinence becomes more prevalent Potential scenario A 70 year old woman presents to your office complaining of urinary incontinence of many years duration that is being to embarrass her. Approach As per the JAMA RCE (March 2008), the likelihood of correctly identifying the subtype of urinary incontinence IN WOMEN is increased by a history, physical examination and stress test.| History I would perform a complete history focusing on... Symptoms: Acute vs. Chronic if acute pursue UTI work-up... Chronic

Do you have ANY involuntary loss of urine? (defines incontinence) Stress incontinence Do you lose rine during sudden physical exertion, lifting, coughing or sneezing?, small volumes of urine? Urge incontinence* (JAMA RCE) Do you experience such a strong and sudden urge to void that you leak before reaching the toilet?, large volume of loss? Social impact: How do you cope with the leakage?, do you limit your outings due to leakage? PMHx: gynaecological/obstetrical history, DM, CVA, dementia, PD, arthritis Meds: current list including diuretics, anticholinergic meds, sedatives Allergies: Functional inquiry: Do you use a walking aid? Do you use furniture to stabilize yourself? Do you find buttons/zippers difficult? Do you have history of getting lost? Do you wear glasses? Lifestyle: How much coffee/caffeinated beverages do you drink? How much exercise do you get? How much EtOH do you drink? Do you smoke? Physical Exam I would perform a complete physical exam focusing on... Vitals: orthostatic drop and HR for autonomic dysfunction and hypertensive dieresis Routine Resp/CV/GI Neuro: focusing on deep tendon reflexes and peripheral sensation (vibrarion and light touch) GU: - With the patients consent I would do an external genital exam for any prolapsed. - Rectal exam for stool impaction, sensation and strength of voluntary anal contraction - Stress test*(JAMA RCE) I would ask the patient the patient to cough while in the lithotomy position or standing. Any leakage of urine is a positive test. Investigations - Routine lab work including fasting blood sugar, urinalysis, urine C&S. - Post void residual volume There is insufficient evidence that a post-void residual volume helps to differentiate types of urinary incontinence IN WOMEN but is important in older women with urge incontinence and women on anticholinergic medications. (JAMA RCE 2008) Management Nonpharmacologic: 1. Lifestyle adequate fluid intake ~ 2L/day, avoid caffeine/aspartame/EtOH, decrease evening fluid intake, manage constipation, decrease smoking, treat cough 2. Bladder training = gradually increasing the time between timed voiding - small effect size but positive effect for urge and stress 3. Pelvic muscle training (Kegel exercises requires teaching to be

done right) self-reported improvement for stress and mixed 4. Prompted voiding timed reminders to void - especially helpful for cognitively impaired Pharmacologic: 1. Anticholinergic antimuscarinic specifically i.e. oxybutinin (Ditropan) - inhibits uncontrolled bladder contractions and relaxation of urethra - useful in urge +/- stress incontinence - NOT FOR OVERFLOW INCONTINENCE - extreme caution in the elderly 2. Estrogen improves bladder relaxation and sphincter tone - try topical Referral: - subtype unclear after assessment - history/evidence of prolapsed or prior obs/gyne surgery or trauma - incomplete response to treatment and patient interested in surgical options - hematuria, elevated post-void residual volume, recurrent/symptomatic UTIs Hypothetic MCQs about incontinence 1. Elderly patient with incontinence. The most common cause: a) increased detrusor activity - results in urge incontinence, frequently quoted as being the most common b) decreased detrusor activity c) stress incontinence d) functional incontinence Answer D (or A) Aging leads to many factors that predispose to urinary incontinence: detrusor overactivity, decreased bladder capacity, decreased flow rate, increased post void residual volume, prostate hypertrophy and outlet obstruction in men, and change in diurnal fluid excretion. These factors do not necessarily result in urinary incontinence, and incontinence is not a part of "normal" aging. Functional incontinence: mobility/cognitive impediments to continence (30-50% of cases in elders!) Urge incontinence: involuntary leaking preceded immediately by urgency due to uninhibited bladder contractions of detrusor overactivity (more common with increasing age) Stress incontinence: involuntary leaking on exertion Mixed incontinence (usually women): urgency and with exertion Overflow incontinence (usually men): continuous leakage associated with incomplete bladder emptying due to impaired detrusor contractility or bladder outlet obstruction

Source: UTD v14.2

2. Terminal cancer. Mets to spine. On morphine. Good pain control. On lactulose. Incontinent of stool. ? mechanism? a. Overflow incontinence

3. Elderly person in hospital with incontinence, what is best test? a. urinalysis plus culture and sensitivity always think UTI in acute incontinence b. cystogram c. post void residuals d. urodynamics 4. A 72 woman who is POD 4 post L THR has incontinence of urine that is worse with coughing or change in position. What is the best next test? a. Post-void residual - ordinarily cough would be stress but post-op think overflow b. Pelvic ultrasound c. Urodynamic studies d. Serum creatinine 5. Elderly diabetic with regular frequent urinary incontinence and noctural incontinence without urgency. Next best test: a. Post void residual may have an atonic bladder associated with autonomic neuropathy b. Urine urinalysis plus C&S depends if this is an acute change c. Serum glucose could contribute to incontinence if high, reversible therefore worth testing early d. Cystoscopy e. Urinary flow studies likely diagnostic but not the next best test

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