Incontinence in Older Adults: Going Beyond the Bladder

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Incontinence in Older AdultsGoing Beyond the
Bladder

• Catherine E. DuBeau, MD
• Clinical Chief of Geriatric Medicine
• Professor of Medicine
• UMass Medical School

2

• JG is 76 yo woman who comes in for routine follow
  up of HTN, hyperlipidemia, osteoporosis, and some
  mild memory problems (she doesnt 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 children
• b. She is likely developing dementia and leakage
  is common with that condition
• She didnt mention any incontinence so she must
  not find it bothersome
• All of the above
• None of the above

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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

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• 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
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Incontinence A classic geriatric condition
Severity Frequency x Amount
Large leakage at least weekly
Hannestad YS, et al. Norwegian EPINCOT Study.
J Clin Epidem 2000531150
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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

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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

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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

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Bladder Symptoms ? Bladder Condition
Other determinants of continence
Environment
Mentation
Manual dexterity
Medical conditions and medications
Mobility
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Factors that Cause or Worsen UI

• Comorbid Disease
• Diabetes
• Congestive heart failure
• Degenerative joint disease
• Sleep apnea
• Severe constipation

• Neurological / Psychiatric
• Stroke
• Parkinsons disease
• Dementia (advanced)
• Depression (severe)

• Function and Environment
• Impaired cognition
• Impaired mobility
• Inaccessible toilets
• Lack of caregivers

Ouslander JG. NEJM 2004 350786
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Medications that Cause or Worsen UI
Medical conditions ACEI - cough Causing edema -
Nifedipine Amlodipine Glitazones
NSAIDs/COX2 Gabapentin Pregabalin Causing
constipation
Mentation Sedative hypnotics Benzos Anticholinergi
cs

• LUT function
• ? Bladder contractility
• Anticholinergics
• Calcium blockers
• ? Sphincter tone
• Alpha agonist
• Sphincter tone
• Alpha blocker
• Diuretics

Mobility Antipsychotics
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A Prescribing Cascade leading to UI
77 yo woman with urgency gets amlodipine for HTN
Edema, constipation, impaired bladder emptying
Nocturia, ? urgency, some UI
Urge incontinence!
Add antimuscarinic
? constipation
Add laxative....
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The Prescribing Cascade
77 yo woman with urgency gets nifepine for HTN
Edema, constipation, impaired bladder emptying
Nocturia, ? urgency, some UI
Urge incontinence!
Add antimuscarinic
? constipation
Add laxative....
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The Prescribing Cascade
77 yo woman with urgency gets nifepine for HTN
Edema, constipation, impaired bladder emptying
Nocturia, ? urgency, some UI
Urge incontinence!
Add antimuscarinic
? constipation
Add laxative....
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Beginning an Incontinence Assessment
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
Mixed
Other
Brown JS et al. Ann Intern Med 2006144 715 
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• 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
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• 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

Rectocele
Cystocele
Hymenal ring
Split speculum
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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 jogging
• Ability to be active without worry avoid surgery

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Stepwise UI Treatment
Behavioral
Surgery
Drugs
Lifestyle
Urge Urge Urge Urge (severe)
Stress Stress Stress
Mixed Mixed Mixed Mixed
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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)

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Caffeine and diuretic beverages Fluid
intake Constipation Weight loss Smoking
Lifestyle
Subak LL et al. Internatl Urogynecol J 2002
1340 Brown JS et al. Diabetes Care 2006 29385
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Bladder training Pelvic muscle exercises
Use in combination for both urge and stress UI
Behavioral
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Normal
Stress Incontinence
Urethra
Supporting fascia
deSouza NM et al. Radiology 2002225433
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Key Regions in Bladder Control
Insula
Pons
Anterior Cingulate Gyrus
Periaqueductal Grey
Prefrontal Cortex
Kavia R et al, J Comp Neurol 2005 49327
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Antimuscarinics for urge and mixed UI New
agents Stress UI?
Drugs
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Current antimuscarinics

• Oxybutynin
• Oxybutynin 2.5-5 mg bid-qid
• Oxybutynin XL 5-20 mg daily
• Oxytrol? patch 3.9 mg 2x/week and Gelnique ? gel
• Tolterodine
• Detrol? 1-2 mg bid
• Detrol LA? 2-4 mg daily
• Fesoterodine
• Toviaz? 48 mg daily
• Trospium chloride
• Sanctura? 20 mg bid
• Sanctura? XR 60 mg daily
• Darifenacin
• Enablex? 7.5-15 mg daily
• Solifenacin
• Vesicare? 5-10 mg daily

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Choosing an Antimuscarinic

• 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)

• Dry mouth oxybutynin worst
• Constipation darifenacin, solifenacin
• Least Oxytrol patch (but rash in 15)

No Major Differences All decrease UI 70, 25
cure rate
Tolerability Adverse effects
Efficacy
4th International Consultation on Incontinence,
2008 Chapple C et al, Eur Urol 2005 Shamliyan TA
et al, Ann Int Med 2008
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Burch Colposuspension
Urethral Sling
ME Albo et al. NEJM 2007, 356 214
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Injectables - Collagen
Short term efficacy, best for stress UI due to
inadequate sphincter closure Not effective in
post-prostatectomy UI
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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