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Urinary Incontinence

Urinary Incontinence. An introductory module for clinicians. Dr. Martha Spencer , MD, FRCPC Providence Health Care Clinical Instructor, UBC. This module is part of the sfCare approach. Patient Handout. 8.5 x 11 Poster. PowerPoint Presentation. Objectives.

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Urinary Incontinence

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  1. Urinary Incontinence An introductory module for clinicians Dr. Martha Spencer, MD, FRCPC Providence Health Care Clinical Instructor, UBC

  2. This module is part of the sfCare approach Patient Handout 8.5 x 11 Poster PowerPoint Presentation

  3. Objectives Distinguish between the types of urinary incontinence Identify the negative effects that urinary incontinence can have on older adults Recognize the factors that can lead to urinary incontinence Describe interventions to treat urinary incontinence Apply a senior friendly approach to treating urinary incontinence Objectives What is urinary incontinence? Prevalence and impact Causes How to treat Case study Summary Senior friendly approach Questions

  4. What is urinary incontinence (UI)? Involuntary loss of bladder control causing the release of urine. Objectives What is urinary incontinence? Prevalence and impact Causes How to treat Case study Summary Senior friendly approach Questions • There are different types of UI: • Urgency incontinence • Stress incontinence • Functional incontinence • Overflow incontinence

  5. How common is UI? Up to 50% of older Canadians have urinary incontinence… Objectives What is urinary incontinence? Prevalence and impact Causes How to treat Case study Summary Senior friendly approach Questions

  6. UI is underdiagnosed and undertreated Yet, UI is underdiagnosed and undertreated in older adults. Why? Objectives What is urinary incontinence? Prevalence and impact Causes How to treat Case study Summary Senior friendly approach Questions • Embarrassment at sharing this issue with their healthcare provider • Not speaking to a primary care provider about their symptoms due to the belief that it is a normal part of aging • Healthcare providers and older adults may feel as though other health issues take priority • Inadequate assessment in frail older adults Roe B et al 2011. J Advanced Nursing, 67(2), 228-250 Cdn Continence Foundation, Cameron Institute. Incontinence: The Canadian Perspective. December 2014. Santos CRDS 2011Neurology and urodynamics, 30(8), 1473-1479

  7. UI is not adequately assessed In community-dwelling older adults the type of UI is only diagnosed in 48% of cases (Du Moulin et al, 2009) Objectives What is urinary incontinence? Prevalence and impact Causes How to treat Case study Summary Senior friendly approach Questions In older adults in residential care, there is a quality gap: Only 55% of patients with dementia/UI had care plans (Pringle-Specht et al, 2002) Most patient do not have relevant physical examinations Only 24-48% of patients received UI assessments (Georgio et al, 2001) Rectal 15% Pelvic 2% (Watson et al, 2003) Abrams et al. Incontinence. 5th International Consultation on Incontinence. 5th Edition, 2013.

  8. The importance of UI UI can have negative effects on older adults, including… • Problems with taking medication • New or worsening symptoms or conditions • Decline in mobility • Impairments in oral intake • Self-reported decrease in overall health • Decline in functional and self-care abilities • Decline in ability to perform ADLs • Hygienic/skin problems • Reduced self-esteem, depression, social isolation Objectives What is urinary incontinence? Prevalence and impact Causes How to treat Case study Summary Senior friendly approach Questions Mandl, M., Halfens, R. J., & Lohrmann, C. (2015). Incontinence care in nursing homes: a cross‐sectional study. Journal of advanced nursing, 71(9), 2142-2152.

  9. Causes of UI Objectives What is urinary incontinence? Prevalence and impact Causes How to treat Case study Summary Senior friendly approach Questions

  10. Some conditions that can cause UI • Stroke • Congestive heart failure • Peripheral vascular disease • Diabetes mellitus • Venous insufficiency • Normal Pressure Hydrocephalus • Falls and contractures • Sleep disordered breathing • Obesity • Chronic lung disease • Constipation • Diffuse Lewy body disease • Dementia • Parkinson’s disease • Recurrent infection Objectives What is urinary incontinence? Prevalence and impact Causes How to treat Case study Summary Senior friendly approach Questions

  11. Some medications that can cause UI Objectives What is urinary incontinence? Prevalence and impact Causes How to treat Case study Summary Senior friendly approach Questions Abrams et al. Incontinence. 5thInternational Consultation on Incontinence. 5th Edition, 2013.

  12. Some medications that can cause UI (cont.) Objectives What is urinary incontinence? Prevalence and impact Causes How to treat Case study Summary Senior friendly approach Questions Abrams et al. Incontinence. 5thInternational Consultation on Incontinence. 5th Edition, 2013.

  13. Some medications that can cause UI (cont.) Objectives What is urinary incontinence? Prevalence and impact Causes How to treat Case study Summary Senior friendly approach Questions Abrams et al. Incontinence. 5thInternational Consultation on Incontinence. 5th Edition, 2013.

  14. How to treat UI Objectives What is urinary incontinence? Prevalence and impact Causes How to treat Case study Summary Senior friendly approach Questions Lifestyle interventions Behavioral interventions Pharmacological treatment

  15. How to treat UI Lifestyle Cochrane review (2015) of lifestyle interventions for the treatment of urinary incontinence in adults Objectives What is urinary incontinence? Prevalence and impact Causes How to treat Case study Summary Senior friendly approach Questions • 11 trials, with 6000 participants looked at • Weight loss interventions - 4 trials • Decreasing fluid intake - 3 trials • Decreasing caffeine - 3 trials • Eliminating soy - 1 trial Authors’ conclusion: Evidence for the effect of weight loss on urinary incontinence is building and should be a research priority. Generally, there was insufficient evidence to inform practice reliably about whether lifestyle interventions are helpful in the treatment of urinary incontinence. Imamura M et al Cochrane Database of Systematic Reviews 2015, Issue 12

  16. How to treat UI Lifestyle (cont.) Lifestyle While evidence is lacking about the efficacy of lifestyle interventions, the following are recommended: Objectives What is urinary incontinence? Prevalence and impact Causes How to treat Case study Summary Senior friendly approach Questions Caffeine Reduction in caffeine intake recommended, but evidence limited (small RCT with n=14, cross-sectional data based on self-report) Physical activity Non-RCT data suggests that moderate exercise may decrease UI/overactive bladder symptoms Smoking UI/overactive bladder symptoms may improve with smoking abstinence Abrams et al. (2017). Incontinence, 6th International Consultation on Incontinence.

  17. How to treat UI Lifestyle (cont.) Lifestyle While evidence is lacking about the efficacy of lifestyle interventions, the following are recommended: Objectives What is urinary incontinence? Prevalence and impact Causes How to treat Case study Summary Senior friendly approach Questions Constipation Small observational trials show association between chronic straining and UI • Hydration • Best possible intervention= increasing hydration • 6-8 cups of total fluid/day • helps to prevent concentrated urine that can irritate the inner lining of the bladder (epithelium) Abrams et al. (2017). Incontinence, 6th International Consultation on Incontinence.

  18. How to treat UI Behavioural Interventions Objectives What is urinary incontinence? Prevalence and impact Causes How to treat Case study Summary Senior friendly approach Questions Pelvic floor muscle training (PFMT) (PFMT) • Effective as a stand-alone treatment, as part of a multi-component strategy • Combination of drug therapy + PFMT more effective than either treatment alone • Supervised PFMT should be offered as a first-line conservative therapy for women of all ages with UI (Level 1 evidence, Grade A recommendation) Abrams et al. (2017). Incontinence, 6th International Consultation on Incontinence.

  19. How to treat UI Behavioural Interventions Scheduled Voiding Regimes Objectives What is urinary incontinence? Prevalence and impact Causes How to treat Case study Summary Senior friendly approach Questions • Bladder training • Should be recommended as a first-line conservative therapy for UI in women • Start with 1hr intervals and increase by 15-30 min intervals until q2-3hr voiding intervals achieved • Consider self-monitoring with diary/log • Importance of supervising healthcare provider (e.g. nurse continence advisor) • Consider different strategy if no improvement after 3 weeks • Timed voiding • No high quality evidence to support efficacy in cognitively intact women Abrams et al. (2017). Incontinence, 6th International Consultation on Incontinence.

  20. How to treat UI Pharmacological treatment Objectives What is urinary incontinence? Prevalence and impact Causes How to treat Case study Summary Senior friendly approach Questions For most, consider 6-8 weeks trial of non-pharmacological treatment prior to drug therapy. • Consider starting on drug therapy earlier if: • Few medications • Cognitively intact • Significant reduction in patient’s quality of life • Age <65 years old (more evidence about adverse effects, fewer adverse effects) • Few comorbidities Abrams et al. (2017). Incontinence, 6th International Consultation on Incontinence.

  21. Case study: Mrs. S Symptoms • Frequency - 10x/day, 4x/night • Leakage with urgency • Occasional leaking with cough, getting out of chair • No hesitancy, intermittency or sensation of incomplete emptying • 4-5 pads/day, 1-2 pads/night • No dysuria, hematuria or recurrent UTI • Soft BM q 1-2 days • Drinks 6 cups of water, 2 cups of tea, 1 cup of coffee/day Objectives What is urinary incontinence? Prevalence and impact Causes How to treat Case study Summary Senior friendly approach Questions • Mrs. S is an 84 year old female, widowed, living alone in an apartment, and has been experiencing urinary incontinence for 5 years.

  22. Case study: Mrs. S Objectives What is urinary incontinence? Prevalence and impact Causes How to treat Case study Summary Senior friendly approach Questions Medications PMHx • Metformin 1g po bid • Amlodipine 10mg po daily • Furosemide 20mg po bid • Celecoxib 100mg po bid • Gabapentin 100mg po tid • Lorazepam 0.5mg po qhs • Type 2 diabetes • Hypertension • Chronic venous insufficiency • Chronic pain due to osteoarthritis in hands and knees • Falls x 2 in past year What’s going through your mind?

  23. Case study: Mrs. S Objectives What is urinary incontinence? Prevalence and impact Causes How to treat Case study Summary Senior friendly approach Questions What type of urinary incontinence does Mrs. S have?

  24. Case study: Mrs. S Objectives What is urinary incontinence? Prevalence and impact Causes How to treat Case study Summary Senior friendly approach Questions Multifactorial Incontinence • Frequency- 10x/day, 4x/night • Leakage with urgency • Occasional leaking with cough, getting out of chair • No hesitancy, intermittency or sensation of incomplete emptying • Arthritis pain in hands and knees Urgency Incontinence + Stress Incontinence + Functional Incontinence

  25. Case study: Mrs. S Causes of Mrs. S’s multifactorial incontinence Objectives What is urinary incontinence? Prevalence and impact Causes How to treat Case study Summary Senior friendly approach Questions Stress Functional Urgency • Nocturia: • Fluid redistribution from pedal edema • Venous insufficiency • NSAIDS, calcium channel blockers, Gabapentin • Enuresis • Co-administration of Lorazepam and Lasix at night • Arthritis, slow gait, orthostatic hypotension • Furosemide = urinary urgency and frequency • Polyuria due to excessive fluid consumption and caffeinated beverages • Poorly controlled type 2 diabeteswith glucosuria • Weak pelvic floor muscles

  26. Case study: Mrs. S Evidence-based conservative management for Mrs. S includes: Objectives What is urinary incontinence? Prevalence and impact Causes How to treat Case study Summary Senior friendly approach Questions Behavioural Medication Review Lifestyle • Taper Lasix, taper Lorazepam • Replace NSAID with Acetaminophen • Replace Amlodipine with Ramipril (lower dose) • Add Gliclizide ER 30mg po daily to optimize diabetes control • Trial caffeine reduction • Physical exercise - to increase gait speed and decrease falls risk • Referral to pelvic floor muscle physiotherapist • Instruction and self-management tools for bladder training

  27. Summary Objectives What is urinary incontinence? Prevalence and impact Causes How to treat Case study Summary Senior friendly approach Questions • Urinary incontinence is not a normal part of aging! • There are different types of urinary incontinence • It is possible to manage urinary incontinence with a variety of non-pharmacological strategies

  28. The senior friendly approach How all healthcare providers can address urinary incontinence using a senior friendly care approach Objectives What is urinary incontinence? Prevalence and impact Causes How to treat Case study Summary Senior friendly approach Questions Ask leaders to remove barriers to care, and provide education for staff, patients and caregivers. Organizational Support Organizational Support Emotional & Behavioural Environment Address incontinence as a health issue just as you would for adults of all ages. Emotional & Behavioural Environment Processes of Care Processes of Care Ethics in Clinical Care and Research Avoid using briefs without assessing the cause of urinary incontinence. Ethics in Clinical Care and Research Physical Environment Ensure your organization’s washrooms are not only accessible, but also senior friendly. Physical Environment

  29. Discussion questions Objectives What is urinary incontinence? Prevalence and impact Causes How to treat Case study Summary Senior friendly approach Questions • What do you already do in your daily work that relates to continence management? • What is one thing you can do differently as a result of reviewing this module? • Share an example of a strategy you have used to broach the topic of incontinence with your patients?

  30. The sfCare Learning Series received support from the Regional Geriatric Programs of Ontario, through funding provided by the Ministry of Health and Long-Term Care. V1 July 2019

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