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