Download Incontinence in Older Adults: Going Beyond the Bladder

Incontinence in Older Adults:
Going Beyond the Bladder
Catherine E. DuBeau, MD
Clinical Chief of Geriatric Medicine
Professor of Medicine
UMass 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 children
b. She is likely developing dementia and leakage is
common with that condition
c. She didn’t mention any incontinence so she
must not find it bothersome
d. All of the above
e. 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
Severity = Frequency x Amount
Large leakage at least weekly
Hannestad YS, et al. Norwegian EPINCOT Study. J Clin
Epidem 2000;53:1150
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
Other determinants of
continence:
Environment
Mentation
Manual dexterity
Medical conditions and
medications
Mobility
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
Medications that Cause or Worsen UI
Medical conditions
Mentation
ACEI - cough
Causing edema Nifedipine
Amlodipine
“Glitazones”
NSAIDs/COX2
Gabapentin
Pregabalin
Causing constipation
Sedative hypnotics
Benzos
Anticholinergics
Mobility
Antipsychotics
LUT function
 Bladder contractility
Anticholinergics
Calcium blockers
 Sphincter tone
Alpha agonist
 Sphincter tone
Alpha blocker
Diuretics
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....
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....
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....
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
Stress
Urge
Mixed
urgency?
Without physical activity or without a sense of urgency?
Other
Brown JS et al. Ann Intern Med 2006:144: 715
Evaluation for the cause of UI
• DIAPPERS mnemonic
–
–
–
–
–
–
–
–
Delirium
[Infection]
[Atrophic vaginitis]
Pharmaceuticals
Psychological condition
Excess urine output
Reduced mobility
Stool impaction
Now evidence that
treatment of these does
not decrease UI
– 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
Characterize the type of UI – Physical exam
– Rectal exam – impaction, prostate nodules (not size)
– Pelvic exam – pelvic organ prolapse
Urethra
Cystocele
Rectocele
Hymenal ring
Split speculum
– Cough stress test (full bladder, upright)
• Confirm stress symptoms
– Post-voiding residual volume – not necessary in initial
evaluation
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
Stepwise UI Treatment
Lifestyle
Urge
Stress
Mixed
Behavioral
Urge
Stress
Mixed
Drugs
Urge
Mixed
Surgery
Urge (severe)
Stress
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 beverages
Fluid intake
60% UI reduction (IQR
Constipation
30% to 89%) with large
Weight loss
(16 kg) weight loss via
liquid diet
Smoking
30% decrease in odds
for stress UI with 3.5 kg
loss
Subak LL et al. Internatl Urogynecol J 2002; 13:40
Brown JS et al. Diabetes Care 2006; 29:385
Behavioral
Bladder training
Pelvic muscle exercises
Use in combination for
both urge and stress UI
Normal
Stress Incontinence
Urethra
Supporting fascia
deSouza NM et al. Radiology 2002;225:433
Key Regions in Bladder Control
Insula
Anterior
Cingulate
Gyrus
Pons
Periaqueductal Grey
Prefrontal Cortex
Kavia R et al, J Comp Neurol 2005; 493:27
Antimuscarinics for
urge and mixed UI
Drugs
New agents
Stress UI?
Current antimuscarinics
1.
Oxybutynin
–
–
–
2.
Oxybutynin 2.5-5 mg bid-qid
Oxybutynin XL 5-20 mg daily
Oxytrol patch 3.9 mg 2x/week and Gelnique  gel
Tolterodine
–
–
3.
Detrol 1-2 mg bid
Detrol LA 2-4 mg daily
Fesoterodine
–
4.
Toviaz 4–8 mg daily
Trospium chloride
–
–
5.
Sanctura 20 mg bid
Sanctura XR 60 mg daily
Darifenacin
–
6.
Enablex 7.5-15 mg daily
Solifenacin
–
Vesicare 5-10 mg daily
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)
No Major Differences
All decrease UI ~70%,
~25% cure rate
Efficacy
• Dry mouth: oxybutynin worst
• Constipation: darifenacin, solifenacin
• Least: Oxytrol patch (but rash in 15%)
Tolerability
Adverse effects
4th International Consultation on Incontinence, 2008
Chapple C et al, Eur Urol 2005
Shamliyan TA et al, Ann Int Med 2008
Burch Colposuspension
Urethral Sling
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 postprostatectomy 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