Incontinence in Older Adults: Going Beyond the Bladder Catherine E. DuBeau, MD Clinical Chief of Geriatric Medicine Professor of Medicine UMass Medical.

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