The Pharmacy Guild of Australia NSW Branch

1. The Pharmacy Guild of Australia NSW Branch INCONTINENCE For Aged Care Staff

2. The Pharmacy Guild of Australia NSW Branch INCONTINENCE Involuntary loss of urine or stool in sufficient amount or frequency to constitute a social and or health problem. A heterogeneous condition that ranges in severity from dribbling small amounts of urine to continuous urinary incontinence with concomitant faecal incontinence. Prevalence increases with age, but it is not part of the normal aging

3. The Pharmacy Guild of Australia NSW Branch The statistics Incontinence occurs in approximately 50% of nursing home residents 25-30% of community dwelling older women 10-15% of community dwelling older men. 545,000 or 2.8% of the Australian adult population have severe incontinence. 128,800 of the total live in �care accomodation�; requiring assistance including frequent leakage events and assistance due to mobility limitation

4. The Pharmacy Guild of Australia NSW Branch Urge-common in elderly Stress Overflow Functional TYPES OF INCONTINENCE URGE INCONTINENCE is usually due to detrusor muscle overactivity with leakage of urine because the bladder is perceived to be full. This common in the elderly; it occurs as an isolated event or secondary to local factors, e.g. bladder infection or stones, or to central factors, e.g. stroke, dementia or Parkinson�s Disease. STRESS INCONTINENCE occurs when the intra-abdominal pressure is increased, e.g. after a cough or sneeze and there is a weak pelvic floor or urethral sphincter. It is common in women after childbirth. OVERFLOW INCONTINENCE occurs with leakage of urine from a full distended bladder. It occurs commonly in men with prostatic obstruction, following spinal cord injury or in women with cystoceles or after gynaecological surgery. FUNCTIONAL INCONTINENCE. Passage of urine occurs owing to inability to get to a toilet because of disability, e.g. stroke, trauma, the unavailability of toilet facilities or dementia URGE INCONTINENCE is usually due to detrusor muscle overactivity with leakage of urine because the bladder is perceived to be full. This common in the elderly; it occurs as an isolated event or secondary to local factors, e.g. bladder infection or stones, or to central factors, e.g. stroke, dementia or Parkinson�s Disease. STRESS INCONTINENCE occurs when the intra-abdominal pressure is increased, e.g. after a cough or sneeze and there is a weak pelvic floor or urethral sphincter. It is common in women after childbirth. OVERFLOW INCONTINENCE occurs with leakage of urine from a full distended bladder. It occurs commonly in men with prostatic obstruction, following spinal cord injury or in women with cystoceles or after gynaecological surgery. FUNCTIONAL INCONTINENCE. Passage of urine occurs owing to inability to get to a toilet because of disability, e.g. stroke, trauma, the unavailability of toilet facilities or dementia

5. The Pharmacy Guild of Australia NSW Branch Physical examination form local problems, e.g. prostatic enlargement in men, gynaecological disorders in women, and for central problems, eg neurological disorders or dementia Urine analysis, e.g. glycosuria and culture for UTI Treatment of contributing causes, e.g. constipation, drug therapy, other co-existing disease MANAGEMENT

6. The Pharmacy Guild of Australia NSW Branch Urge Incontinence bladder training anti-muscarinics, eg oxybutynin, fenosteride Stress incontinence pelvic floor exercises Overflow removal of obstruction Functional improve facilities regular urine voiding absorbent padding. MANAGEMENT (cont)

7. The Pharmacy Guild of Australia NSW Branch Medications can be a common cause of incontinence Alpha-blockers (eg�prazosin) Diuretics Sedatives Calcium channel blockers Sympathomimetic decongestants (eg�pseudoephedrine) Anticholinergics (doxepin, hyoscine, ipratropium, benztropine, chlorpromazine, imipramine, amitriptyline) MEDICATIONS THAT CAN CONTRIBUTE TO INCONTINENCE

8. The Pharmacy Guild of Australia NSW Branch Urgency incontinence due to increased activity of the detrusor smooth muscle may be worsened by poor mobility, resulting in patients not reaching the toilet in time by urinary tract infection. For symptomatic control, use: oxybutynin URGE INCONTINENCE

9. The Pharmacy Guild of Australia NSW Branch DOSE: Elderly, start with 2.5�mg at night and increase slowly if necessary. (AMH 2008) 5 mg orally, 2 or 3 times daily (decrease dose in the elderly or debilitated to 2.5 mg twice daily, maximum (eTG) ADVERSE EFFECTS: cognitive dysfunction confusion, hallucinations, anxiety, paranoia OXYBUTYNIN(Ditropan)

10. The Pharmacy Guild of Australia NSW Branch DOSE Adult, initially, 5�mg once daily; if necessary, increase dose to 10�mg once daily. Do not exceed 5�mg daily in people with moderate hepatic impairment, creatinine clearance <30�ml/minute or taking potent CYP3A4 inhibitors (eg�itraconazole, ketoconazole, ritonavir). Counselling: Swallow tablet whole; do not crush or chew Adverse Effects: anticholinergic eg dry mouth, urinary retention, constipation SOLIFENACIN (Vesicare)

11. The Pharmacy Guild of Australia NSW Branch May respond to: prazosin 0.5 mg orally, twice daily, increasing to 2 mg, twice daily, if tolerated �OR � amitriptyline 25 mg orally, at night, increasing to 100 mg daily, if tolerated STRESS INCONTINENCE

12. The Pharmacy Guild of Australia NSW Branch Relax smooth muscle in the bladder neck and prostate, decreasing resistance to urinary flow. DOSE: 0.5�mg twice daily for 3�7�days, then increase according to clinical response up to 2�mg twice daily dose must be adjusted according to individual response if treatment is interrupted for several days, restart and titrate dosage as if starting for the first time stop if there is no benefit after 4�6�weeks of maximal treatment Adverse Effects first dose hypotension is common with the selective alpha-blockers; it is most serious in the elderly and in patients with fluid depletion or who are taking diuretics PRAZOSIN (Minipress, Pressin)

13. The Pharmacy Guild of Australia NSW Branch Relax smooth muscle in the bladder neck and prostate, decreasing resistance to urinary flow. DOSE: 400�mg once daily, in the morning. Counselling: Swallow whole, with or after food Adverse Effects: postural hypotension, dizziness, priapism, TAMSULOSIN (Flomaxtra)

14. The Pharmacy Guild of Australia NSW Branch In terminal illness (eg due to complete sphincter dysfunction from spinal cord compression) can be managed with absorbent padding or an indwelling catheter. Involvement of a urologist or continence clinical nurse consultant can be helpful OTHER FORMS OF INCONTINENCE

15. The Pharmacy Guild of Australia NSW Branch BPH is the most common prostatic disorder; can cause urinary obstruction with symptoms such as hesitancy, dribbling after urination, nocturia, frequency and urgency and may culminate in urinary retention. Neither the presence or absence of residual urine nor the size of the prostate are related to symptom severity, degree of obstruction or treatment outcome. BENIGN PROSTATIC HYPERTROPHY

16. The Pharmacy Guild of Australia NSW Branch Exclude prostate cancer, UTI and renal failure. Differentiate nocturia from polyuria (use a fluid balance diary). Heart failure may cause nocturia. Consider using a scoring system to assess symptoms and monitor progress, eg�International Prostate Symptom Score, Mild symptoms, not causing undue discomfort, where surgery is not indicated, do not need active treatment, but �watchful waiting� with periodic reassessment. BPH � Before starting treatment

17. The Pharmacy Guild of Australia NSW Branch Reduces prostate size but appears to be effective only if the prostate is significantly enlarged (>40�cm3). Full clinical response may take 6�months or more. Generally well tolerated, although may cause sexual dysfunction. Less cost effective than selective alpha-blockers. Drug Handling: Women who are or may become pregnant should not handle broken or crushed tablets without gloves (ADEC category�X) FINASTERIDE (PROSCAR)

18. The Pharmacy Guild of Australia NSW Branch Management of UTI in the elderly can be difficult. Sometimes over prescribing of antibiotics, with associated risk of adverse effects and development of resistance. Key messages include: Asymptomatic bacteriuria is common in the elderly. Cloudy or malodorous urine in a patient without symptoms or signs does not require investigation or treatment. Elderly patients with signs and symptoms of sepsis require urgent treatment. URINARY TRACT INFECTION

19. The Pharmacy Guild of Australia NSW Branch http://www.continence.org.au/site/index.cfm International Prostate Score www.usrf.org/questionnaires/AUA_SymptomScore.html Therapeutic Guidelines Australian Medicines Handbook eMIMS REFERENCES