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Urinary incontinence in older adults
MEDICINE IN OLDER ADULTS
Urinary incontinence in older adults
Key points C
Urinary incontinence is not a diagnosis but has multiple underlying risk factors and potential contributing factors, akin to any geriatric syndrome
C
Where there is a dearth of data, there is no reason not to offer a frail older individual treatments that have proven efficacy in robust older persons
C
A systematic approach to urinary incontinence affords a symptomatic diagnosis of the most likely underlying causes in most cases, allowing a management plan to be formulated
C
There is accumulating evidence for the efficacy of treatment for incontinence in both robust and multimorbid older persons
Christina Shaw Adrian Wagg
Abstract Lower urinary tract symptoms and urinary incontinence are very common in the general population and increase in prevalence in association with age. Urinary incontinence in particular is still seldom discussed by patients, many of whom delay seeking healthcare for the condition. Urinary symptoms have a considerable impact on morbidity and quality of life. Older people encounter multiple barriers in gaining treatment for their problem and are unfortunately less likely to be given evidence-based treatment than younger people. Despite the increasing body of evidence for the effective management of the symptoms and conditions underlying incontinence, older people often fail to be assessed and treated for the condition. This article discusses the assessment and management of the main subtypes of incontinence likely to be encountered in generalist practice for both physiologically robust and more frail elderly individuals.
assumption that there is no available effective treatment. Therefore, in line with current guidelines, a case-finding question about bladder and bowel problems is recommended as part of all interactions between older adult patients and clinicians (see Wagg, 2015, in the further reading list) to overcome this and offer an appropriate assessment and management plan.
Keywords Assessment; frailty; overactive bladder; treatment; urinary incontinence
Definitions Several disorders result in urinary incontinence, but the majority is accounted for by stress UI (involuntary loss of urine on effort or physical exertion, or on sneezing/coughing) and urgency incontinence (involuntary loss of urine associated with urgency). A combination of the two is referred to as mixed UI. A closely related problem is that of overactive bladder (OAB), which is defined as urinary urgency, usually accompanied by frequency and nocturia, with or without urgency UI, in the absence of urinary tract infection or other obvious pathology. Other, less common but no less important, entities are nocturia (frequent nocturnal micturition), nocturnal enuresis (adult bedwetting) and ‘functional’ incontinence (incontinence caused by either physical or cognitive impairment, with no identifiable lower urinary tract disorder), all being associated with a considerable patient burden (Table 1). Age-related changes in the lower urinary tract can play a role in predisposing an older person to fail to maintain continence (Table 2). Several recent publications have demonstrated, using functional magnetic resonance imaging, that OAB is associated with changes in cerebral blood flow to certain areas of the brain. The amount of white matter changes (seen as areas of hyperintensity on MRI) may link several geriatric syndromes, including decline in cognition, mobility and continence. There is also increasing evidence that suppression of urinary urgency may require more subconscious effort in older persons, and that this may be related to the amount of white matter hyperintensities.
Introduction Urinary incontinence (UI), defined as the complaint of involuntary loss of urine, is a common and undertreated problem in older adults. Epidemiological studies show a positive association between age and both the accumulation of symptoms and the prevalence of UI and other lower urinary tract symptoms (LUTS). In the EPIC study, the prevalence of incontinence increased in men from 2.4% in those <39 years to 10.4% in those >60, and in women from 7.3% to 19.3%, respectively.1 With individuals living longer and older adults making up an increasing portion of the population, the impact of UI on society and on the healthcare system continues to increase. As with all the ‘geriatric giants’, UI is often the result of multiple risk factors and modifiers. Physiological, pathological and functional changes can result in a loss of continence. Older adults tend to not seek help from healthcare providers for a variety of reasons, including perceived stigma and social embarrassment, belief that UI is a normal part of ageing and an
Christina Shaw BSc is an Undergraduate Medical Student at the Division of Geriatric Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada. Competing interests: none declared. Adrian Wagg MBBS FRCP(Lond) FRCP(Edin) FHEA Capital Health Endowed Professor of Healthy Ageing, Division Director, Geriatric Medicine, University of Alberta, Edmonton, Alberta, Canada. Competing interests: he, or his institution has received support from Astellas, Pfizer, SCA, Duchesnay (Canada) for any of research, speaker fees or consultancy.
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Assessment History For most older adults, a systematic history allows a symptomatic diagnosis to be formulated (Table 3). A medication history and
1
Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Shaw C, Wagg A, Urinary incontinence in older adults, Medicine (2016), http://dx.doi.org/10.1016/ j.mpmed.2016.10.001
MEDICINE IN OLDER ADULTS
Common subtypes of UI Overactive bladder
Stress UI
Mixed UI
Voiding inefficiency
Functional incontinence
Urinary urgency, with or without urgency incontinence often with urinary frequency and nocturia
Urinary loss in association with exertion such as coughing, laughing or lifting
Symptoms of both urgency incontinence and exertional incontinence (take a careful history as ‘urgency’ or ‘precipitancy’ is often reported by women with stress UI only)
Incomplete emptying is not well reported by men, but more so by women. A large post-void residual volume without symptoms (recurrent urinary tract infections, frequency, dribble, upper tract involvement) does not need treatment (a 250-ml residual volume may be acceptable in older people)
Incontinence unrelated to an underlying disorder of lower urinary tract function, perhaps related to either physical or cognitive impairment
Table 1
Age-related changes in the lower urinary tract
Systematic history for continence in older persons
Decreased
C
Increased
C
Bladder capacity Sensation of filling Speed of contraction of detrusor Pelvic floor muscle bulk Sphincteric ‘resistance’ Urinary flow rate
Urinary frequency Prevalence of post-void residual volumes Outflow tract obstruction (men)
C C
C
C
Table 2
C C
physical examination are also necessary to exclude other diseases and diagnose or identify other factors or co-morbidities that may be adversely affecting the patient’s continence. A bladder diary of a minimum 3 days duration can be useful to provide an additional history; however, the benefits may not outweigh the considerable burden of achieving an accurate and complete diary. During the history, account should be taken of the impact the condition has on quality of life, patient’s and caregivers’ expectations and, depending on the treatment offered, the patient’s remaining life expectancy and functional level.
C
C C C C C C C C C
Co-morbidities Co-morbidities are common in the older adult population, and UI can be caused by, associated with or worsened by these. One study found UI to be independently associated with having at least one geriatric condition in 60% of study participants, at least two in 29% and at least three in 13%. These co-morbidities can be chronic diseases such as hypertension, congestive heart failure or arthritis. Diabetes mellitus can cause UI by multiple mechanisms leading to detrusor overactivity and culminating in diabetic cystopathy with incomplete bladder emptying or via poor glycaemic control causing osmotic diuresis and polyuria. Co-morbidities associated with UI also include depression and anxiety. Depression in older persons with UI may be underdiagnosed and undertreated, leading to an increased burden by
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Chief complaint Duration Treatment thus far, if any Storage symptoms: diurnal frequency, nocturnal frequency, nocturnal enuresis, urinary urgency, urgency incontinence, stress UI Voiding symptoms: hesitancy, straining, slow stream, intermittency, splitting or spraying Post-micturition symptoms: incomplete emptying, terminal dribble, post-micturition dribble Pads: type, number ‘Red flags’: haematuria, pain on micturition, dysuria (internal or external) Bowel habits: frequency, faecal urgency, faecal incontinence, acute change, laxative usage Sense of prolapse (women) Frequency of urinary tract infection Fluid intake volume (including caffeinated beverages, alcohol) Obstetric history (including instrumental deliveries) Gynaecological history Functional and cognitive state Impact of condition on quality of life Goals for treatment Assessment tools: bladder/bowel diary, validated conditionspecific questionnaires, quality-of-life assessment
Table 3
decreasing life satisfaction and self-rated health. Geriatric syndromes, such as falls, are also associated with urinary urgency and urgency UI. Data from nursing home residents suggest that older persons with urgency incontinence are significantly more burdened by multimorbidity than those without. UI is commonly associated with neurological conditions including Alzheimer’s disease, multi-infarct dementia (or a combination of these), stroke, dementia with Lewy bodies, Parkinson’s disease, normal pressure hydrocephalus, and multiple
2
Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Shaw C, Wagg A, Urinary incontinence in older adults, Medicine (2016), http://dx.doi.org/10.1016/ j.mpmed.2016.10.001
MEDICINE IN OLDER ADULTS
diagnosis.3 The use of antimuscarinic drugs for urgency UI and cholinesterase inhibitors for dementia does not appear to worsen cognition or cause delirium. Indeed, these can achieve positive continence outcomes if used carefully and with due regard to the necessity of dual prescribing.
system atrophy. UI manifests differently in different types of dementia: in Alzheimer’s disease UI is more frequently associated with the onset of severe cognitive decline, whereas in Lewy body dementia it precedes severe cognitive impairment. In a recent study, the prevalence of UI increased with decreasing mini-mental state examination scores. In any patient who presents with new-onset UI in association with gait disturbance and cognitive impairment, normal-pressure hydrocephalus should be ruled out as a potential cause.
Physical examination The initial step is to perform a relevant urogenital examination to assess for urogenital atrophy, prolapse, prostate size and masses, faecal loading and the presence of a palpable bladder. Dipstick urinalysis and ultrasound post-voiding residual volume should be carried out for all men, and for women if they complain of voiding symptoms. This should be done in association with a general physical examination that includes cognition, as well as examination for relevant neurological conditions including Parkinson’s disease, stroke, spinal stenosis, cauda equina syndrome and multiple system atrophy. Mobility and dexterity can be assessed when obtaining the routine dipstick urinalysis, by observing the patient preparing to collect a sample and returning for the physical examination.
Medications Polypharmacy is increasingly common in older adults, and some medications predispose an older person to incontinence. Although the list of medications that theoretically worsen incontinence is long (Table 4), there is little published evidence of the associations between these and incontinence. Evidence exists for diuretics, prostaglandin inhibitors, a-adrenoceptor blockers, selective serotonin reuptake inhibitors, cholinesterase inhibitors and systemic hormone replacement therapy. Medication lists should always be reviewed and potentially implicated medications discontinued, if feasible. Cholinesterase inhibitors for dementia are of particular relevance as their use appears to be associated with an increased risk of urinary urgency and urgency incontinence.2 Gliflozins can lead to an osmotic diuresis and predispose to incontinence and perhaps urinary tract infection. Prescribers should also be aware that many drugs have antimuscarinic effects and that there is a consequent total ‘antimuscarinic burden’ on the patient. In a number of epidemiological studies, this has been associated with cognitive decline and an increased incidence of dementia
Management Older adults, especially frail older persons, should not be denied any intervention that has proven utility in the care of community-dwelling, robust older adults for the treatment of UI (see Wagg, 2015, in the further reading list). Interventions should be employed with regard to the likely benefits, harms, and feasibility of the treatment, as well as to the expectations and concerns of the patient and their caregiver(s).
Medications that can worsen UI Medication
Potential or actual effect
a-Adrenoceptor antagonists Angiotensin-converting enzyme inhibitors Agents with antimuscarinic properties
Decrease smooth muscle tone in the urethra and can cause stress UI in women Cause cough that can worsen stress UI Can cause ineffective voiding and constipation that can contribute to incontinence. May cause cognitive impairment and reduce effective toileting ability (high dose, if cognitively at risk) Can cause constipation (verapamil) that can contribute to incontinence. Can cause dependent oedema (amlodipine, nifedipine), which can contribute to nocturnal polyuria Can cause urgency incontinence through cholinergic action Cause diuresis and incontinence Can cause polyuria due to a diabetes insipidus-like state Can cause constipation, confusion, and immobility e all of which can contribute to incontinence Can cause confusion, impaired mobility and incontinence Most have anticholinergic effects
Calcium channel blockers Cholinesterase inhibitors Diuretics Lithium Opioid analgesics Psychotropic drugs Sedatives, hypnotics, antipsychotics Histamine-1 receptor antagonists Selective serotonin reuptake inhibitors (sertraline identified) Gabapentin Non-steroidal anti-inflammatory agents Glitazones
Increase cholinergic transmission and can lead to urgency UI Can cause oedema, lead to polyuria while supine and worsen nocturia and night-time incontinence Can lead to an osmotic diuresis and predispose to incontinence and perhaps urinary tract infection
Table 4
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Please cite this article in press as: Shaw C, Wagg A, Urinary incontinence in older adults, Medicine (2016), http://dx.doi.org/10.1016/ j.mpmed.2016.10.001
MEDICINE IN OLDER ADULTS
Although these medications are undoubtedly of benefit to many people, their tolerability and perceived efficacy are still a problem. As a result, many patients stop their medication, and their use is associated with poor persistence rates in the community, although perhaps less so in older people.4 Many patients also stop their medications because of unrealistic expectations of the results of therapy, which should be modifiable by the healthcare provider. Suggestions that these medications lead to an increase in falls or widespread impairment in cognition, often used as justification for not using them, have largely been refuted. With cautious use, there is little reason not to try to control symptoms pharmacologically, and there is widespread evidence of benefit, even in ‘vulnerable’ elderly patients. Oxybutynin should, however, probably be avoided in older people at risk of cognitive impairment. More recently, the b3-adrenoceptor agonist mirabegron has been licensed in the UK for treatment of OAB. Early analysis of results in community-dwelling older people suggests benefit with acceptable safety (see Gibson and Wagg, 2014, in the further reading list). LUTS in older men, unless there is a complete absence of voiding symptoms, should initially be treated with an a-adrenoceptor antagonist, for example tamsulosin (those with a large prostate [>40 grams e the size of a golf ball] will also benefit from a 5-a-receptor antagonist such as finasteride or dutasteride). Where storage symptoms do not resolve, the addition of an antimuscarinic agent is recommended (see Lucas et al, 2013, in the further reading list). For stress UI, duloxetine is not recommended for use on the basis of cost-effectiveness (see Smith et al, 2013, in the further reading list). Its use is unfortunately also limited by a high incidence of nausea, leading to cessation of treatment. A recent systematic review and Delphi process specifically for LUTS drugs in older persons grades the appropriateness of each for its indication (see Oelke et al, 2015, in the further reading list).
Initial management Several general management strategies are applicable to all subtypes of UI but can have varying results depending on the particular circumstances. Management of fluid intake is important, aiming to achieve a balance between dehydration and excessive drinking, as well as avoiding alcohol and caffeine if identified as causative factors. Weight loss via dieting or medication can be beneficial but be difficult to achieve, especially in frail elderly individuals. Good diabetic control allows patients to manage the hyperglycaemic symptoms of osmotic diuresis and polyuria. Constipation management is also important. Once these strategies have been implemented, interventions can be used for certain subtypes of UI. For OAB or urgency efrequency syndrome, bladder retraining is the mainstay of conservative management. For stress and mixed incontinence, pelvic floor muscle therapy (Kegel exercises) is recommended. The benefit depends on adhering to the exercise regime, but patients may not return to baseline even with strict adherence. A 3-month supervised course involving at least 10 repetitions three times daily appears to be the minimum requirement. Pelvic floor muscle contractions can also be used to avoid an incontinence episode when confronted with urgency. For voiding inefficacy, double-voiding techniques can be effective. Behavioural management The following conservative management techniques are predominantly used in frail older persons: Prompted voiding e this involves prompts to use the lavatory with encouragement when prompting is successful. It is designed to increase patients self-initiating or requesting toileting and to decrease the number of UI episodes. Habit retraining e the incontinent person’s individual voiding pattern is identified, usually by means of a bladder diary. A schedule is then devised to pre-empt UI episodes. Timed voiding e the patient involves lavatory visits at fixed intervals, such as every 3 hours. It is considered a passive toileting programme. Combined prompted voiding and exercise therapy e functional intervention training involves direct care givers (nursing assistants / care aides) incorporating strengthening exercises into toileting routines. All techniques require active caregiver participation and considerable input. For the prompted voiding intervention, a 3day trial should be conducted in patients who might benefit. If there is <20% reduction in wet episodes, the intervention should be considered ineffective, and a reversion to ‘check and change’ of continence pads, the usual method of managing continence in dependent older persons, is required.
Surgical management If conservative and medical attempts to manage UI fail, there is good evidence for the efficacy of onabotulinumtoxin A injection into the bladder for refractory detrusor overactivity and OAB.5 The risk of large post-void residual urine volumes has been markedly reduced by the use of lower doses of toxin. Mid-urethral tapes for stress UI can be of benefit, although they appear less effective in older than younger women. De-obstructing surgical interventions (transurethral resection of prostate or alternative methods) should be used for outflow tract obstruction. Containment products (pads and appliances) An abundance of products is available for the management of UI. Current national guidelines recommend that these are used following an appropriate assessment, or are used in the interim period while definitive management is being arranged. The International Continence Society in collaboration with the International Consultation on Incontinence hosts a comprehensive online products directory, the Continence Product Advisor, for use by patients and caregivers, enabling them to gain advice on the suitability of different products (http://www. continenceproductadvisor.org/). Additionally, a more regionalspecific directory of most available UK products and appliances
Pharmacological management Urgency incontinence is the main cause of incontinence in older people. Antimuscarinic medications have remained the first line pharmacological treatment since the introduction of oxybutynin over 30 years ago. Since then, there has been refinement in the tolerability and adverse effect profiles of medications for OAB, but little additional efficacy over and above that reported with treatment with oxybutynin.
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MEDICINE IN OLDER ADULTS
is available online from PromoCon (http://www.disabledliving. co.uk/PromoCon/About). The first step in assessment should not be the provision of free pads. These should only be offered as part of a planned assessment and management plan, in accordance with current guidance. However, there should be recognition that, for many, containment forms an essential part of management regardless of efforts at cure. Intermittent catheterization may be required for older people with voiding symptoms, a significant post-void residual volume and detrusor failure, should de-obstructing surgery not be required or indicated. Many older people only need once- or twice-daily catheterization, which can be performed by some frail older persons themselves or by community services if this is impractical for the individual. Condom catheters can be preferable to pads for older men, but some may find them difficult to use. The use of indwelling urethral catheters is clinically indicated in a limited set of circumstances and should not be considered as a substitute for nursing care of older adults with incontinence. End-of-life catheterization can be used for comfort. The National Institute for Health and Care Excellence quality standard for UI states that active treatment is better than containment. A
long-term functional and cognitive outcomes. J Am Geriatr Soc 2008; 56: 847e53. 3 Lechevallier-Michel N, Molimard M, Dartigues JF, Fabrigoule C, glat A. Drugs with anticholinergic properties and Fourrier-Re cognitive performance in the elderly: results from the PAQUID Study. Br J Clin Pharmacol 2005; 59: 143e51. 4 Wagg A, Compion G, Fahey A, Siddiqui E. Persistence with prescribed antimuscarinic therapy for overactive bladder: a UK experience. BJU Int 2012; 110: 1767e74. 5 Schulte-Baukloh H, Weiss C, Stolze T, et al. Botulinum-A toxin detrusor and sphincter injection in treatment of overactive bladder syndrome: objective outcome and patient satisfaction. Eur Urol 2005; 48: 984e90. discussion 990. FURTHER READING Gibson W, Wagg A. New horizons: urinary incontinence in older people. Age Ageing 2014; 43: 157e63. Lucas MG, Bosch RJ, Burkhard FC, et al. European Association of Urology guidelines on assessment and nonsurgical management of urinary incontinence. Actas Urol Esp 2013; 37: 199e213. Oelke M, Becher K, Castro-Diaz D, et al. Appropriateness of oral drugs for long-term treatment of lower urinary tract symptoms in older persons: results of a systematic literature review and international consensus validation process (LUTS-FORTA 2014). Age Ageing 2015; 44: 745e55. Smith A, Bevan D, Douglas HR, James D. Management of urinary incontinence in women: summary of updated NICE guidance. BMJ 2013; 347: f5170. Wagg A, Gibson W, Ostaszkiewicz J, et al. Urinary incontinence in frail elderly persons: report from the 5th International Consultation on Incontinence. Neurourol Urodyn 2015; 34: 398e406.
KEY REFERENCES 1 Irwin DE, Milsom I, Hunskaar S, et al. Population-based survey of urinary incontinence, overactive bladder, and other lower urinary tract symptoms in five countries: results of the EPIC study. Eur Urol 2006; 50: 1306e14. discussion 1314e1315. 2 Sink KM, Thomas 3rd J, Xu H, Craig B, Kritchevsky S, Sands LP. Dual use of bladder anticholinergics and cholinesterase inhibitors:
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Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Shaw C, Wagg A, Urinary incontinence in older adults, Medicine (2016), http://dx.doi.org/10.1016/ j.mpmed.2016.10.001
Urinary incontinence in older adults
Key points C
Urinary incontinence is not a diagnosis but has multiple underlying risk factors and potential contributing factors, akin to any geriatric syndrome
C
Where there is a dearth of data, there is no reason not to offer a frail older individual treatments that have proven efficacy in robust older persons
C
A systematic approach to urinary incontinence affords a symptomatic diagnosis of the most likely underlying causes in most cases, allowing a management plan to be formulated
C
There is accumulating evidence for the efficacy of treatment for incontinence in both robust and multimorbid older persons
Christina Shaw Adrian Wagg
Abstract Lower urinary tract symptoms and urinary incontinence are very common in the general population and increase in prevalence in association with age. Urinary incontinence in particular is still seldom discussed by patients, many of whom delay seeking healthcare for the condition. Urinary symptoms have a considerable impact on morbidity and quality of life. Older people encounter multiple barriers in gaining treatment for their problem and are unfortunately less likely to be given evidence-based treatment than younger people. Despite the increasing body of evidence for the effective management of the symptoms and conditions underlying incontinence, older people often fail to be assessed and treated for the condition. This article discusses the assessment and management of the main subtypes of incontinence likely to be encountered in generalist practice for both physiologically robust and more frail elderly individuals.
assumption that there is no available effective treatment. Therefore, in line with current guidelines, a case-finding question about bladder and bowel problems is recommended as part of all interactions between older adult patients and clinicians (see Wagg, 2015, in the further reading list) to overcome this and offer an appropriate assessment and management plan.
Keywords Assessment; frailty; overactive bladder; treatment; urinary incontinence
Definitions Several disorders result in urinary incontinence, but the majority is accounted for by stress UI (involuntary loss of urine on effort or physical exertion, or on sneezing/coughing) and urgency incontinence (involuntary loss of urine associated with urgency). A combination of the two is referred to as mixed UI. A closely related problem is that of overactive bladder (OAB), which is defined as urinary urgency, usually accompanied by frequency and nocturia, with or without urgency UI, in the absence of urinary tract infection or other obvious pathology. Other, less common but no less important, entities are nocturia (frequent nocturnal micturition), nocturnal enuresis (adult bedwetting) and ‘functional’ incontinence (incontinence caused by either physical or cognitive impairment, with no identifiable lower urinary tract disorder), all being associated with a considerable patient burden (Table 1). Age-related changes in the lower urinary tract can play a role in predisposing an older person to fail to maintain continence (Table 2). Several recent publications have demonstrated, using functional magnetic resonance imaging, that OAB is associated with changes in cerebral blood flow to certain areas of the brain. The amount of white matter changes (seen as areas of hyperintensity on MRI) may link several geriatric syndromes, including decline in cognition, mobility and continence. There is also increasing evidence that suppression of urinary urgency may require more subconscious effort in older persons, and that this may be related to the amount of white matter hyperintensities.
Introduction Urinary incontinence (UI), defined as the complaint of involuntary loss of urine, is a common and undertreated problem in older adults. Epidemiological studies show a positive association between age and both the accumulation of symptoms and the prevalence of UI and other lower urinary tract symptoms (LUTS). In the EPIC study, the prevalence of incontinence increased in men from 2.4% in those <39 years to 10.4% in those >60, and in women from 7.3% to 19.3%, respectively.1 With individuals living longer and older adults making up an increasing portion of the population, the impact of UI on society and on the healthcare system continues to increase. As with all the ‘geriatric giants’, UI is often the result of multiple risk factors and modifiers. Physiological, pathological and functional changes can result in a loss of continence. Older adults tend to not seek help from healthcare providers for a variety of reasons, including perceived stigma and social embarrassment, belief that UI is a normal part of ageing and an
Christina Shaw BSc is an Undergraduate Medical Student at the Division of Geriatric Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada. Competing interests: none declared. Adrian Wagg MBBS FRCP(Lond) FRCP(Edin) FHEA Capital Health Endowed Professor of Healthy Ageing, Division Director, Geriatric Medicine, University of Alberta, Edmonton, Alberta, Canada. Competing interests: he, or his institution has received support from Astellas, Pfizer, SCA, Duchesnay (Canada) for any of research, speaker fees or consultancy.
MEDICINE --:-
Assessment History For most older adults, a systematic history allows a symptomatic diagnosis to be formulated (Table 3). A medication history and
1
Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Shaw C, Wagg A, Urinary incontinence in older adults, Medicine (2016), http://dx.doi.org/10.1016/ j.mpmed.2016.10.001
MEDICINE IN OLDER ADULTS
Common subtypes of UI Overactive bladder
Stress UI
Mixed UI
Voiding inefficiency
Functional incontinence
Urinary urgency, with or without urgency incontinence often with urinary frequency and nocturia
Urinary loss in association with exertion such as coughing, laughing or lifting
Symptoms of both urgency incontinence and exertional incontinence (take a careful history as ‘urgency’ or ‘precipitancy’ is often reported by women with stress UI only)
Incomplete emptying is not well reported by men, but more so by women. A large post-void residual volume without symptoms (recurrent urinary tract infections, frequency, dribble, upper tract involvement) does not need treatment (a 250-ml residual volume may be acceptable in older people)
Incontinence unrelated to an underlying disorder of lower urinary tract function, perhaps related to either physical or cognitive impairment
Table 1
Age-related changes in the lower urinary tract
Systematic history for continence in older persons
Decreased
C
Increased
C
Bladder capacity Sensation of filling Speed of contraction of detrusor Pelvic floor muscle bulk Sphincteric ‘resistance’ Urinary flow rate
Urinary frequency Prevalence of post-void residual volumes Outflow tract obstruction (men)
C C
C
C
Table 2
C C
physical examination are also necessary to exclude other diseases and diagnose or identify other factors or co-morbidities that may be adversely affecting the patient’s continence. A bladder diary of a minimum 3 days duration can be useful to provide an additional history; however, the benefits may not outweigh the considerable burden of achieving an accurate and complete diary. During the history, account should be taken of the impact the condition has on quality of life, patient’s and caregivers’ expectations and, depending on the treatment offered, the patient’s remaining life expectancy and functional level.
C
C C C C C C C C C
Co-morbidities Co-morbidities are common in the older adult population, and UI can be caused by, associated with or worsened by these. One study found UI to be independently associated with having at least one geriatric condition in 60% of study participants, at least two in 29% and at least three in 13%. These co-morbidities can be chronic diseases such as hypertension, congestive heart failure or arthritis. Diabetes mellitus can cause UI by multiple mechanisms leading to detrusor overactivity and culminating in diabetic cystopathy with incomplete bladder emptying or via poor glycaemic control causing osmotic diuresis and polyuria. Co-morbidities associated with UI also include depression and anxiety. Depression in older persons with UI may be underdiagnosed and undertreated, leading to an increased burden by
MEDICINE --:-
Chief complaint Duration Treatment thus far, if any Storage symptoms: diurnal frequency, nocturnal frequency, nocturnal enuresis, urinary urgency, urgency incontinence, stress UI Voiding symptoms: hesitancy, straining, slow stream, intermittency, splitting or spraying Post-micturition symptoms: incomplete emptying, terminal dribble, post-micturition dribble Pads: type, number ‘Red flags’: haematuria, pain on micturition, dysuria (internal or external) Bowel habits: frequency, faecal urgency, faecal incontinence, acute change, laxative usage Sense of prolapse (women) Frequency of urinary tract infection Fluid intake volume (including caffeinated beverages, alcohol) Obstetric history (including instrumental deliveries) Gynaecological history Functional and cognitive state Impact of condition on quality of life Goals for treatment Assessment tools: bladder/bowel diary, validated conditionspecific questionnaires, quality-of-life assessment
Table 3
decreasing life satisfaction and self-rated health. Geriatric syndromes, such as falls, are also associated with urinary urgency and urgency UI. Data from nursing home residents suggest that older persons with urgency incontinence are significantly more burdened by multimorbidity than those without. UI is commonly associated with neurological conditions including Alzheimer’s disease, multi-infarct dementia (or a combination of these), stroke, dementia with Lewy bodies, Parkinson’s disease, normal pressure hydrocephalus, and multiple
2
Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Shaw C, Wagg A, Urinary incontinence in older adults, Medicine (2016), http://dx.doi.org/10.1016/ j.mpmed.2016.10.001
MEDICINE IN OLDER ADULTS
diagnosis.3 The use of antimuscarinic drugs for urgency UI and cholinesterase inhibitors for dementia does not appear to worsen cognition or cause delirium. Indeed, these can achieve positive continence outcomes if used carefully and with due regard to the necessity of dual prescribing.
system atrophy. UI manifests differently in different types of dementia: in Alzheimer’s disease UI is more frequently associated with the onset of severe cognitive decline, whereas in Lewy body dementia it precedes severe cognitive impairment. In a recent study, the prevalence of UI increased with decreasing mini-mental state examination scores. In any patient who presents with new-onset UI in association with gait disturbance and cognitive impairment, normal-pressure hydrocephalus should be ruled out as a potential cause.
Physical examination The initial step is to perform a relevant urogenital examination to assess for urogenital atrophy, prolapse, prostate size and masses, faecal loading and the presence of a palpable bladder. Dipstick urinalysis and ultrasound post-voiding residual volume should be carried out for all men, and for women if they complain of voiding symptoms. This should be done in association with a general physical examination that includes cognition, as well as examination for relevant neurological conditions including Parkinson’s disease, stroke, spinal stenosis, cauda equina syndrome and multiple system atrophy. Mobility and dexterity can be assessed when obtaining the routine dipstick urinalysis, by observing the patient preparing to collect a sample and returning for the physical examination.
Medications Polypharmacy is increasingly common in older adults, and some medications predispose an older person to incontinence. Although the list of medications that theoretically worsen incontinence is long (Table 4), there is little published evidence of the associations between these and incontinence. Evidence exists for diuretics, prostaglandin inhibitors, a-adrenoceptor blockers, selective serotonin reuptake inhibitors, cholinesterase inhibitors and systemic hormone replacement therapy. Medication lists should always be reviewed and potentially implicated medications discontinued, if feasible. Cholinesterase inhibitors for dementia are of particular relevance as their use appears to be associated with an increased risk of urinary urgency and urgency incontinence.2 Gliflozins can lead to an osmotic diuresis and predispose to incontinence and perhaps urinary tract infection. Prescribers should also be aware that many drugs have antimuscarinic effects and that there is a consequent total ‘antimuscarinic burden’ on the patient. In a number of epidemiological studies, this has been associated with cognitive decline and an increased incidence of dementia
Management Older adults, especially frail older persons, should not be denied any intervention that has proven utility in the care of community-dwelling, robust older adults for the treatment of UI (see Wagg, 2015, in the further reading list). Interventions should be employed with regard to the likely benefits, harms, and feasibility of the treatment, as well as to the expectations and concerns of the patient and their caregiver(s).
Medications that can worsen UI Medication
Potential or actual effect
a-Adrenoceptor antagonists Angiotensin-converting enzyme inhibitors Agents with antimuscarinic properties
Decrease smooth muscle tone in the urethra and can cause stress UI in women Cause cough that can worsen stress UI Can cause ineffective voiding and constipation that can contribute to incontinence. May cause cognitive impairment and reduce effective toileting ability (high dose, if cognitively at risk) Can cause constipation (verapamil) that can contribute to incontinence. Can cause dependent oedema (amlodipine, nifedipine), which can contribute to nocturnal polyuria Can cause urgency incontinence through cholinergic action Cause diuresis and incontinence Can cause polyuria due to a diabetes insipidus-like state Can cause constipation, confusion, and immobility e all of which can contribute to incontinence Can cause confusion, impaired mobility and incontinence Most have anticholinergic effects
Calcium channel blockers Cholinesterase inhibitors Diuretics Lithium Opioid analgesics Psychotropic drugs Sedatives, hypnotics, antipsychotics Histamine-1 receptor antagonists Selective serotonin reuptake inhibitors (sertraline identified) Gabapentin Non-steroidal anti-inflammatory agents Glitazones
Increase cholinergic transmission and can lead to urgency UI Can cause oedema, lead to polyuria while supine and worsen nocturia and night-time incontinence Can lead to an osmotic diuresis and predispose to incontinence and perhaps urinary tract infection
Table 4
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Although these medications are undoubtedly of benefit to many people, their tolerability and perceived efficacy are still a problem. As a result, many patients stop their medication, and their use is associated with poor persistence rates in the community, although perhaps less so in older people.4 Many patients also stop their medications because of unrealistic expectations of the results of therapy, which should be modifiable by the healthcare provider. Suggestions that these medications lead to an increase in falls or widespread impairment in cognition, often used as justification for not using them, have largely been refuted. With cautious use, there is little reason not to try to control symptoms pharmacologically, and there is widespread evidence of benefit, even in ‘vulnerable’ elderly patients. Oxybutynin should, however, probably be avoided in older people at risk of cognitive impairment. More recently, the b3-adrenoceptor agonist mirabegron has been licensed in the UK for treatment of OAB. Early analysis of results in community-dwelling older people suggests benefit with acceptable safety (see Gibson and Wagg, 2014, in the further reading list). LUTS in older men, unless there is a complete absence of voiding symptoms, should initially be treated with an a-adrenoceptor antagonist, for example tamsulosin (those with a large prostate [>40 grams e the size of a golf ball] will also benefit from a 5-a-receptor antagonist such as finasteride or dutasteride). Where storage symptoms do not resolve, the addition of an antimuscarinic agent is recommended (see Lucas et al, 2013, in the further reading list). For stress UI, duloxetine is not recommended for use on the basis of cost-effectiveness (see Smith et al, 2013, in the further reading list). Its use is unfortunately also limited by a high incidence of nausea, leading to cessation of treatment. A recent systematic review and Delphi process specifically for LUTS drugs in older persons grades the appropriateness of each for its indication (see Oelke et al, 2015, in the further reading list).
Initial management Several general management strategies are applicable to all subtypes of UI but can have varying results depending on the particular circumstances. Management of fluid intake is important, aiming to achieve a balance between dehydration and excessive drinking, as well as avoiding alcohol and caffeine if identified as causative factors. Weight loss via dieting or medication can be beneficial but be difficult to achieve, especially in frail elderly individuals. Good diabetic control allows patients to manage the hyperglycaemic symptoms of osmotic diuresis and polyuria. Constipation management is also important. Once these strategies have been implemented, interventions can be used for certain subtypes of UI. For OAB or urgency efrequency syndrome, bladder retraining is the mainstay of conservative management. For stress and mixed incontinence, pelvic floor muscle therapy (Kegel exercises) is recommended. The benefit depends on adhering to the exercise regime, but patients may not return to baseline even with strict adherence. A 3-month supervised course involving at least 10 repetitions three times daily appears to be the minimum requirement. Pelvic floor muscle contractions can also be used to avoid an incontinence episode when confronted with urgency. For voiding inefficacy, double-voiding techniques can be effective. Behavioural management The following conservative management techniques are predominantly used in frail older persons: Prompted voiding e this involves prompts to use the lavatory with encouragement when prompting is successful. It is designed to increase patients self-initiating or requesting toileting and to decrease the number of UI episodes. Habit retraining e the incontinent person’s individual voiding pattern is identified, usually by means of a bladder diary. A schedule is then devised to pre-empt UI episodes. Timed voiding e the patient involves lavatory visits at fixed intervals, such as every 3 hours. It is considered a passive toileting programme. Combined prompted voiding and exercise therapy e functional intervention training involves direct care givers (nursing assistants / care aides) incorporating strengthening exercises into toileting routines. All techniques require active caregiver participation and considerable input. For the prompted voiding intervention, a 3day trial should be conducted in patients who might benefit. If there is <20% reduction in wet episodes, the intervention should be considered ineffective, and a reversion to ‘check and change’ of continence pads, the usual method of managing continence in dependent older persons, is required.
Surgical management If conservative and medical attempts to manage UI fail, there is good evidence for the efficacy of onabotulinumtoxin A injection into the bladder for refractory detrusor overactivity and OAB.5 The risk of large post-void residual urine volumes has been markedly reduced by the use of lower doses of toxin. Mid-urethral tapes for stress UI can be of benefit, although they appear less effective in older than younger women. De-obstructing surgical interventions (transurethral resection of prostate or alternative methods) should be used for outflow tract obstruction. Containment products (pads and appliances) An abundance of products is available for the management of UI. Current national guidelines recommend that these are used following an appropriate assessment, or are used in the interim period while definitive management is being arranged. The International Continence Society in collaboration with the International Consultation on Incontinence hosts a comprehensive online products directory, the Continence Product Advisor, for use by patients and caregivers, enabling them to gain advice on the suitability of different products (http://www. continenceproductadvisor.org/). Additionally, a more regionalspecific directory of most available UK products and appliances
Pharmacological management Urgency incontinence is the main cause of incontinence in older people. Antimuscarinic medications have remained the first line pharmacological treatment since the introduction of oxybutynin over 30 years ago. Since then, there has been refinement in the tolerability and adverse effect profiles of medications for OAB, but little additional efficacy over and above that reported with treatment with oxybutynin.
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is available online from PromoCon (http://www.disabledliving. co.uk/PromoCon/About). The first step in assessment should not be the provision of free pads. These should only be offered as part of a planned assessment and management plan, in accordance with current guidance. However, there should be recognition that, for many, containment forms an essential part of management regardless of efforts at cure. Intermittent catheterization may be required for older people with voiding symptoms, a significant post-void residual volume and detrusor failure, should de-obstructing surgery not be required or indicated. Many older people only need once- or twice-daily catheterization, which can be performed by some frail older persons themselves or by community services if this is impractical for the individual. Condom catheters can be preferable to pads for older men, but some may find them difficult to use. The use of indwelling urethral catheters is clinically indicated in a limited set of circumstances and should not be considered as a substitute for nursing care of older adults with incontinence. End-of-life catheterization can be used for comfort. The National Institute for Health and Care Excellence quality standard for UI states that active treatment is better than containment. A
long-term functional and cognitive outcomes. J Am Geriatr Soc 2008; 56: 847e53. 3 Lechevallier-Michel N, Molimard M, Dartigues JF, Fabrigoule C, glat A. Drugs with anticholinergic properties and Fourrier-Re cognitive performance in the elderly: results from the PAQUID Study. Br J Clin Pharmacol 2005; 59: 143e51. 4 Wagg A, Compion G, Fahey A, Siddiqui E. Persistence with prescribed antimuscarinic therapy for overactive bladder: a UK experience. BJU Int 2012; 110: 1767e74. 5 Schulte-Baukloh H, Weiss C, Stolze T, et al. Botulinum-A toxin detrusor and sphincter injection in treatment of overactive bladder syndrome: objective outcome and patient satisfaction. Eur Urol 2005; 48: 984e90. discussion 990. FURTHER READING Gibson W, Wagg A. New horizons: urinary incontinence in older people. Age Ageing 2014; 43: 157e63. Lucas MG, Bosch RJ, Burkhard FC, et al. European Association of Urology guidelines on assessment and nonsurgical management of urinary incontinence. Actas Urol Esp 2013; 37: 199e213. Oelke M, Becher K, Castro-Diaz D, et al. Appropriateness of oral drugs for long-term treatment of lower urinary tract symptoms in older persons: results of a systematic literature review and international consensus validation process (LUTS-FORTA 2014). Age Ageing 2015; 44: 745e55. Smith A, Bevan D, Douglas HR, James D. Management of urinary incontinence in women: summary of updated NICE guidance. BMJ 2013; 347: f5170. Wagg A, Gibson W, Ostaszkiewicz J, et al. Urinary incontinence in frail elderly persons: report from the 5th International Consultation on Incontinence. Neurourol Urodyn 2015; 34: 398e406.
KEY REFERENCES 1 Irwin DE, Milsom I, Hunskaar S, et al. Population-based survey of urinary incontinence, overactive bladder, and other lower urinary tract symptoms in five countries: results of the EPIC study. Eur Urol 2006; 50: 1306e14. discussion 1314e1315. 2 Sink KM, Thomas 3rd J, Xu H, Craig B, Kritchevsky S, Sands LP. Dual use of bladder anticholinergics and cholinesterase inhibitors:
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