Gastrointestinal, Renal, and Genitourinary Disorders
Gastrointestinal Issues
Constipation is common and often multifactorial: opioids, anticholinergics, calcium channel blockers, low fluid and fiber intake, immobility. Treat with osmotic agents (polyethylene glycol) and stimulant laxatives; avoid chronic stimulant overuse concerns only when truly indicated. Proton pump inhibitors should be reviewed periodically - long-term use is linked to Clostridioides difficile infection, hypomagnesemia, fractures, and B12 deficiency - and deprescribed when the indication has passed. Gastroesophageal reflux may present atypically with cough or hoarseness.
Renal Function
Older adults have reduced renal reserve and are vulnerable to acute kidney injury from dehydration, NSAIDs, contrast, and the triple whammy. Dose renally cleared drugs by estimated clearance. Avoid nephrotoxins where possible, and monitor potassium and creatinine after starting ACE inhibitors, ARBs, or diuretics.
Urinary Tract and Incontinence
Asymptomatic bacteriuria is common in older adults and should not be treated except in pregnancy or before urologic procedures; treating it drives resistance and C. difficile. Distinguish transient causes of incontinence (delirium, infection, medications, retention, stool impaction) from established types: stress, urge, overflow, functional. Urge incontinence responds to bladder training and antimuscarinics or beta-3 agonists, but antimuscarinics worsen cognition and retention - mirabegron may be preferable in frail patients, with blood pressure monitoring. Benign prostatic hyperplasia is treated with alpha blockers (watch orthostasis) and 5-alpha reductase inhibitors.
Traps
Stems that culture a asymptomatic patient and then treat are testing stewardship. Another trap is attributing incontinence to age rather than evaluating for retention or impaction.
Rule of Thumb
Before labeling incontinence as chronic, screen for the transient causes and review medications; before treating a positive urine culture, ask whether the patient has symptoms.