Incontinence in Older Adults: Going Beyond the Bladder Catherine E. DuBeau, MD Clinical Chief of...
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Transcript of Incontinence in Older Adults: Going Beyond the Bladder Catherine E. DuBeau, MD Clinical Chief of...
Incontinence in Older Adults:Going Beyond the Bladder
Catherine E. DuBeau, MDClinical Chief of Geriatric Medicine
Professor of MedicineUMass Medical School
JG is 76 yo woman who comes in for routine follow up of HTN, hyperlipidemia, osteoporosis, and some mild memory problems (she doesn’t drive but still lives independently). She complains of constipation. When you go to examine her, you notice she is wearing “pull-ups.” This suggests:
a. The results of having 6 childrenb. She is likely developing dementia and leakage is
common with that conditionc. She didn’t mention any incontinence so she
must not find it bothersomed. All of the abovee. None of the above
What is Incontinence?
82 yo, unpredictable sudden urgency with leakage that wets through to her clothing
76 yo, after surgery for prostate cancer leaks large drops with coughing, golfing
87 yo, with end-stage dementia, bed-bound in a nursing home, with no bladder or bowel control
72 yo, leaks when playing tennis and jogging
In a survey of patients with at least one episode of incontinence weekly:– Half never sought care– Only 60% those who sought care recalled receiving
any treatment– Of those who did receive treatment, 50% reported
moderate to great frustration with ongoing urinary leakage
Harris SS et al. J Urol 2007
Incontinence – A classic geriatric condition
Hannestad YS, et al. Norwegian EPINCOT Study. J Clin Epidem 2000;53:1150
Severity = Frequency x Amount
Large leakage at least weekly
The Impact of Incontinence
• Psychosocial– Decreased quality of life– Worry and coping– Depression– Nursing home placement
• Medical consequences– Falls and fractures– Skin infections– UTIs
• Economic costs– $26 billion per year– $3,600 annually per person age 65+
What causes UI?
• Inability to store urine at low pressure– Uninhibed bladder contractions– Insufficient urethral closure
• Inability to empty bladder in timely and effective manner– Inefficient bladder contraction– Urethral or bladder outlet blockage
Physiological changes in the LUT with age
• Bladder – decreased contraction strength• Urethra (women) – decreased smooth and striated
muscle density, decreased vascular density and flow• Vagina, pelvic floor – no change• Prostate – hyperplasia and hypertrophy
These changes alone do not cause UI, but increase the vulnerability to develop UI when other stressors occur
“Bladder Symptoms” Bladder Condition
Medical conditions and medications
Other determinants of continence:
Mobility
MentationManual dexterity
Environment
Factors that Cause or Worsen UI
Comorbid Disease• Diabetes• Congestive heart failure• Degenerative joint disease• Sleep apnea• Severe constipation
Neurological / Psychiatric• Stroke• Parkinson’s disease• Dementia (advanced)• Depression (severe)
Function and Environment• Impaired cognition• Impaired mobility• Inaccessible toilets• Lack of caregivers
Ouslander JG. NEJM 2004; 350:786
MentationSedative hypnoticsBenzosAnticholinergics
MobilityAntipsychotics
Medications that Cause or Worsen UI
Medical conditionsACEI - coughCausing edema - Nifedipine Amlodipine “Glitazones” NSAIDs/COX2 Gabapentin PregabalinCausing constipation
LUT function Bladder contractility Anticholinergics Calcium blockers Sphincter tone Alpha agonist Sphincter tone Alpha blockerDiuretics
A Prescribing Cascade leading to UI
77 yo woman with urgency; gets amlodipine for HTN
Edema, constipation, impaired bladder emptyingNocturia, urgency, some UI
Urge incontinence!
Add antimuscarinic
constipation Add laxative....
The Prescribing Cascade
77 yo woman with urgency; gets nifepine for HTN
Edema, constipation, impaired bladder emptyingNocturia, urgency, some UI
Add antimuscarinic
constipation Add laxative....
Urge incontinence!
The Prescribing Cascade
77 yo woman with urgency; gets nifepine for HTN
Edema, constipation, impaired bladder emptyingNocturia, urgency, some UI
Add antimuscarinic
constipation Add laxative....
Urge incontinence!
Brown JS et al. Ann Intern Med 2006:144: 715
In the past 3 months, have you ever leaked urine, even a small amount?
Yes
Did you leak urine most often when you were:
When you were performing some physical activity, such as coughing sneezing; lifting or exercising?
When you had the urge or feeling you needed to empty your bladder, and could not get to the bathroom fast enough?
About equally as often with physical activity as with a sense of
urgency? Without physical activity or without a sense of urgency?
Stress
Urge
Other
Mixed
Beginning an Incontinence Assessment
Evaluation for the cause of UI• DIAPPERS mnemonic
– Delirium– [Infection]– [Atrophic vaginitis]– Pharmaceuticals– Psychological condition– Excess urine output– Reduced mobility– Stool impaction
– Physical exam• Rectal examination for fecal loading or impaction (Grade C)
• Functional assessment (mobility, transfers, manual dexterity, ability to successfully toilet) (Grade A)
• Screening test for depression (Grade B)
• Cognitive assessment (to assist in planning management, Grade C)
DuBeau CE et al, Incontinence in Frail Elderly, 4th International Consultation on Incontinence, 2008
Now evidence that treatment of these does not decrease UI
Characterize the type of UI – Physical exam– Rectal exam – impaction, prostate nodules (not size)– Pelvic exam – pelvic organ prolapse
– Cough stress test (full bladder, upright)• Confirm stress symptoms
– Post-voiding residual volume – not necessary in initial evaluation
RectoceleCystocele
Split speculum
Hymenal ring
Urethra
Importance of Treatment Goals
82 yo, unpredictable sudden urgency with leakage that wets through to her clothing
Decreased costs of pull-ups, go out without worry about visible leakage or smell; occasional urgency tolerable
76 yo, after surgery for prostate cancer leaks large drops with coughing, golfing
No leakage
87 yo, with end-stage dementia, bed-bound in a nursing home, with no bladder or bowel control
Prevention of skin breakdown, dignity, comfort
72 yo, leaks when playing tennis and joggingAbility to be active without worry; avoid surgery
Stepwise UI Treatment
Lifestyle Behavioral SurgeryDrugs
Urge Urge Urge Urge (severe)Stress Stress StressMixed Mixed Mixed Mixed
Indications for immediate referral
• Hematuria
• Pelvic pain
• Acute onset of UI
• Complex neurological disease other than dementia
• Pt desires surgery for stress UI
• Marked pelvic floor prolapse
• Dysuria, pain, frequent small voids (possible interstitial cystitis)
Lifestyle
Caffeine and diuretic beveragesFluid intakeConstipationWeight lossSmoking
Subak LL et al. Internatl Urogynecol J 2002; 13:40Brown JS et al. Diabetes Care 2006; 29:385
60% UI reduction (IQR 30% to 89%) with large (16 kg) weight loss via liquid diet
30% decrease in odds for stress UI with 3.5 kg loss
Behavioral
Bladder trainingPelvic muscle exercisesUse in combination for both urge and stress UI
deSouza NM et al. Radiology 2002;225:433
Normal Stress Incontinence
Supporting fascia
Urethra
Kavia R et al, J Comp Neurol 2005; 493:27
Periaqueductal Grey
Key Regions in Bladder Control
Prefrontal Cortex
Anterior Cingulate Gyrus
Pons
Insula
Drugs
Antimuscarinics for urge and mixed UI
New agents
Stress UI?
Current antimuscarinics
1. Oxybutynin– Oxybutynin 2.5-5 mg bid-qid– Oxybutynin XL 5-20 mg daily– Oxytrol patch 3.9 mg 2x/week and Gelnique gel
2. Tolterodine– Detrol 1-2 mg bid– Detrol LA 2-4 mg daily
3. Fesoterodine– Toviaz 4–8 mg daily
4. Trospium chloride– Sanctura 20 mg bid– Sanctura XR 60 mg daily
5. Darifenacin– Enablex 7.5-15 mg daily
6. Solifenacin1. Vesicare 5-10 mg daily
Choosing an Antimuscarinic
EfficacyTolerability
Adverse effects
No Major Differences
All decrease UI ~70%, ~25% cure rate
4th International Consultation on Incontinence, 2008
Chapple C et al, Eur Urol 2005
Shamliyan TA et al, Ann Int Med 2008
• Dry mouth: oxybutynin worst
• Constipation: darifenacin, solifenacin
• Least: Oxytrol patch (but rash in 15%)
• Cost (variable)• Dose size and escalation (oxybutnin XL widest range)• Once daily vs other dosing (extended release forms)• Timing with other meds, meals (trospium: empty stomach)• Drug-drug interactions• Drug-disease interactions (trospium – renal clearance)
Urethral Sling
Burch Colposuspension
ME Albo et al. NEJM 2007, 356: 214
Injectables - Collagen
Short term efficacy, best for stress UI due to inadequate sphincter closure
Not effective in post-prostatectomy UI
Take Homes
• Continence depends on more than the lower urinary tract
• Office based history and physical
• Use behavioral treatment first
• Drugs for urge incontinence differ more in tolerability than efficacy