Re: Frailty, Cognitive Impairment, and Functional Disability in Older Women with Female Pelvic Floor Dysfunction

Urological Survey Geriatrics Re: Frailty, Cognitive Impairment, and Functional Disability in Older Women with Female Pelvic Floor Dysfunction E. A. Erekson, T. R. Fried, D. K. Martin, T. J. Rutherford, K. Strohbehn and J. P. Bynum Department of Obstetrics and Gynecology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire Int Urogynecol J 2015; 26: 823e830. doi: 10.1007/s00192-014-2596-2

Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25516232 Editorial Comment: Changes in functional status commonly occur with aging and are often associated with underlying comorbidities. Frailty is a complex geriatric syndrome that is typically the result of multiple contributory etiological factors.1 Frailty has been associated with numerous negative health outcomes, including loss of independence of basic activities of daily living (ADLs) and more advanced instrumental ADLs (IADLs). Similarly cognitive impairment has been identified as a risk factor for functional deterioration in geriatric patients. To date, there have been relatively few studies examining the epidemiology of these issues in geriatric patients undergoing urological surgery or other treatments. This cross-sectional study examined the prevalence of these conditions in a series of 150 older women who were undergoing initial evaluation of pelvic floor dysfunction and prolapse at a single tertiary medical center. Standard validated instruments were used to operationally define frailty, cognitive impairment, and ADL and IADL status. Prevalence of frailty was 16%, cognitive impairment with likely dementia was 21.3% and loss of independence of at least 1 ADL or IADL was 30.7%. Following initial consultation 46% of women chose surgical therapy for their prolapse. Unfortunately the study was not designed to follow clinical outcomes in this cohort. It would be interesting to see whether these factors influenced the results of surgical or nonsurgical therapies. The results document that these conditions may be more prevalent in the clinical population than one might assume and deserve specific attention by clinicians guiding therapy. Tomas L. Griebling, MD, MPH 1. Fried LP, Tangen CM, Walston J et al: Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001; 56: M146.

Re: Functional Status in Older Women Diagnosed with Pelvic Organ Prolapse T. V. Sanses, N. K. Schiltz, B. M. Couri, S. T. Mahajan, H. E. Richter, D. F. Warner, J. Guralnik and S. M. Koroukian University of Maryland School of Medicine, Baltimore, Maryland, Case Western Reserve University, University Hospitals Case Medical Center and Cleveland Clinic, Cleveland, Ohio, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, and University of Nebraska-Lincoln, Lincoln, Nebraska Am J Obstet Gynecol 2016; 214: 613.e1ee7. doi: 10.1016/j.ajog.2015.11.038

Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26704893 Editorial Comment: Although the incidence and prevalence of functional impairment increase with advancing age, this condition should not be viewed as an inevitable part of growing older. A variety of 0022-5347/17/1975-0001/0 THE JOURNAL OF UROLOGY® Ó 2017 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION

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parameters can be measured that document functional status, including muscle strength, mobility, and basic and instrumental activities of daily living. To date, there has been little epidemiological research on these issues in urological patients. These authors examined national data from the Health and Retirement Study and Medicare files in 890 women 65 years old or older diagnosed with pelvic organ prolapse. As noted in the abstract, the data revealed relatively high rates of functional impairment for the multiple variables analyzed. Rates of functional impairment were also highly correlated with self-reported health status. Unfortunately this study focused only on physical limitations and did not include analysis of cognitive impairment, which can be an important aspect of functional decline in older adults. It would be interesting to see how these issues influence results. As the authors note, the implications of functional limitations on subsequent clinical outcomes are unknown and are a topic of great interest to clinicians who work with older adults. Tomas L. Griebling, MD, MPH

Suggested Reading Greer JA, Northington GM, Harvie HS et al: Functional status and postoperative morbidity in older women with prolapse. J Urol 2013; 190: 948.

Re: Impact of Anticholinergic Load on Bladder Function J. F. De La Cruz, C. Kisby, J. M. Wu and E. J. Geller Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, University of North Carolina, Chapel Hill, North Carolina Int Urogynecol J 2015; 26: 545e549. doi: 10.1007/s00192-014-2548-x

Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25335752 Editorial Comment: Use of anticholinergic medications can lead to several negative clinical issues in geriatric patients. Examples include delirium, dry mouth, dry eyes and constipation. Urinary retention has long been considered a major risk of anticholinergic use in older adults, although strong evidence-based data are lacking in the literature. These authors sought to identify associations between the amount and strength of anticholinergic load in geriatric patients and urinary retention and other functional bladder parameters measured by urodynamics. A validated scale of anticholinergic potential was used to categorize all medications, which yielded a sum score for each subject. Analysis compared these scores with high vs low overall anticholinergic load. Interestingly there were no overall differences between groups regarding either post-void residual volume or other measured bladder parameters. However, sensitivity analysis showed differences in those with a very high anticholinergic risk score compared to the lowest level group. Although additional research will be necessary to corroborate these findings, the results continue to support recommendations for avoidance of high dose anticholinergic medications in the geriatric population. This caution is particularly important because many of the medications commonly used to treat overactive bladder in this population have anticholinergic properties. This factor should be considered in the context of total anticholinergic burden when prescribed in this potentially vulnerable geriatric population. Tomas L. Griebling, MD, MPH

Re: In Geriatric Patients, Delirium Symptoms are Related to the Anticholinergic Burden M. Naja, J. Zmudka, S. Hannat, S. Liabeuf, J. M. Serot and P. Jouanny Department of Geriatric Medicine and Clinical Research Center, Amiens University Medical Center, Amiens and Department of Geriatric Medicine, Dijon University Medical Center, Dijon, France Geriatr Gerontol Int 2016; 16: 424e431. doi: 10.1111/ggi.12485

Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25952295 Editorial Comment: Polypharmacy and certain types of medications have been identified as risk factors for delirium in elderly patients. Anticholinergic medications have traditionally been

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considered a potential etiological factor for delirium in this population. Numerous medications have anticholinergic properties that range in strength from mild to strong. This study was designed to assess associations between degree of medication use and delirium outcomes. Previously validated measures of cumulative anticholinergic load and delirium were used to operationally define these variables. The authors examined a cohort of 102 patients 75 years old or older (mean  SD 86.3  5.8 years) admitted to a single acute care geriatric unit in France. Prevalence of preadmission anticholinergic use was high, at 51.6%. Daily rates of delirium symptoms were also high, ranging from 34.8% to 60%. This finding is reflective of the fluctuating course associated with delirium. Development of the condition was directly associated with a substantial increase in mortality and length of hospital stay, as well as loss of functional independence and poorer health status at discharge home. Greater levels of anticholinergic burden were correlated with increased incidence of delirium. These data support the widely held belief regarding the associations between anticholinergic medications and delirium in older adults. Clinicians who prescribe anticholinergic medications to geriatric patients should be aware of this issue and the potential for deleterious side effects in this elderly population.1 Tomas L. Griebling, MD, MPH 1. Hanlon JT, Schmader KE, Ruby CM et al: Suboptimal prescribing in older inpatients and outpatients. J Am Geriatr Soc 2001; 49: 200.

Re: Delirium is Not Associated with Anticholinergic Burden or Polypharmacy in Older Patients on Admission to an Acute Hospital: An Observational Case Control Study H. C. Moorey, S. Zaidman and T. A. Jackson Institute of Inflammation and Ageing, and College of Medical and Dental Sciences, University of Birmingham and Department of Geriatric Medicine, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, United Kingdom BMC Geriatr 2016; 16: 162. doi: 10.1186/s12877-016-0336-9

Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/27655289 Editorial Comment: Delirium and polypharmacy are common syndromes seen in older adults, and both can have serious clinical consequences. Use of anticholinergic medications in elderly patients is also common, and extensive research has linked their use with possible increased risk of delirium. Several validated instruments to quantify the degree of anticholinergic burden have been developed but to date their routine use in clinical care has been relatively limited. This study evaluated these scales in relation to polypharmacy and delirium in a group of 125 elderly patients with delirium and a comparison group of 122 without delirium. Standard measures were used to define delirium and polypharmacy. Interestingly there was no observed association between either of the anticholinergic burden scales and these other conditions. These results contradict most other literature on the topic. Use of acetylcholinesterase inhibitors, drugs that increase functional acetylcholine levels, was associated with increased delirium. However, this finding could be a covariate effect because these drugs are used to treat dementia, which is a recognized risk factor for delirium. The study findings must be interpreted with caution and may actually be more reflective of the sensitivity and usefulness of the anticholinergic burden scales themselves. The results should not be construed to imply that polypharmacy and anticholinergics are not important factors in the development of these potentially serious geriatric syndromes.1 Tomas L. Griebling, MD, MPH 1. American Geriatrics Society 2012 Beers Criteria Update Expert Panel: American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2012; 60: 616.

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Re: Natural History of Pessary Use in Women Aged 65e74 versus 75 Years and Older with Pelvic Organ Prolapse: A 12-Year Study S. Ramsay, L. M. Tu and C. Tannenbaum Centre Hospitalier Universitaire de Sherbrooke, Faculte´ de Me´decine et des Sciences de la Sante´ de l’Universite´ de Sherbrooke, Sherbrooke and Centre de Recherche de l’Institut Universitaire de Ge´riatrie de Montre´al, Faculty of Medicine, Universite´ de Montre´al, Montreal, Quebec, Canada Int Urogynecol J 2016; 27: 1201e1207. doi: 10.1007/s00192-016-2970-3

Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26872647 Editorial Comment: Pelvic organ prolapse is an extremely common condition, particularly in postmenopausal older women. Treatment options typically depend on type and degree of prolapse and levels of symptomatic bother. The most common treatments include observation, pessary placement and surgical reconstruction. Patients are often counseled about and choose their options based on prolapse severity and bother associated with symptoms. Pessary insertion is frequently considered a viable option for elderly women who do not desire surgery or are not good surgical candidates due to comorbidities. The authors examined factors associated with either success or discontinuation of pessary use in a cohort of 304 consecutive women 65 years old or older seen at a single tertiary clinical center in Canada. Subjects were followed through time, and long-term use was defined as 1 year or more. Overall 63% of women had successful initial placement, and the cumulative probabilities of continued use at 1 year were 87.5% in women 65 to 74 years old and 80.8% in those 75 years old or older. These probability rates decreased with time, with 62.1% of younger and 37.8% of older subjects still using a pessary at 5 years. Those with posterior vaginal compartment prolapse (rectocele) or a history of hysterectomy or vaginal reconstructive surgery were less likely to experience successful placement. Patients using a pessary must be carefully followed for potential risk of vaginal tissue erosion, which was seen in 19.3% of this cohort. The risk of erosion was higher in the women 75 years old or older compared to younger women (HR 3.2, 95% CI 1.6e6.3). These findings can help clinicians identify factors that may be predictive of successful or unsuccessful pessary use in elderly women with pelvic organ prolapse. In turn, this information may help guide recommendations for individual therapy. Tomas L. Griebling, MD, MPH