Incontinence in Older Adults: Going Beyond the Bladder

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

2. 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 • She didn’t mention any incontinence so she must not find it bothersome • All of the above • None of the above

3. 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

4. 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

5. 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

6. 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+

7. What causes UI? • Inability tostoreurine at low pressure • Uninhibed bladder contractions • Insufficient urethral closure • Inability toemptybladder in timely and effective manner • Inefficient bladder contraction • Urethral or bladder outlet blockage

8. 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

9. “Bladder Symptoms”  Bladder Condition Other determinants of continence: Environment Mentation Manual dexterity Medical conditions and medications Mobility

10. Comorbid Disease Diabetes Congestive heart failure Degenerative joint disease Sleep apnea Severe constipation Function and Environment Impaired cognition Impaired mobility Inaccessible toilets Lack of caregivers Factors that Cause or Worsen UI • Neurological / Psychiatric • Stroke • Parkinson’s disease • Dementia (advanced) • Depression (severe) Ouslander JG. NEJM 2004; 350:786

11. Medications that Cause or Worsen UI Medical conditions ACEI - cough Causing edema - Nifedipine Amlodipine “Glitazones” NSAIDs/COX2 Gabapentin Pregabalin Causing constipation Mentation Sedative hypnotics Benzos Anticholinergics • LUT function •  Bladder contractility • Anticholinergics • Calcium blockers •  Sphincter tone • Alpha agonist • Sphincter tone Alpha blocker Diuretics Mobility Antipsychotics

12. 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....

13. 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....

14. 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....

15. 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 urgency? Without physical activity or without a sense of urgency? Stress Urge Mixed Other Brown JS et al. Ann Intern Med 2006:144: 715 

16. Now evidence thattreatment of these does not decrease UI • 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

17. Urethra • 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 Rectocele Cystocele Hymenal ring Split speculum

18. 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

19. Stepwise UI Treatment Behavioral Drugs Surgery Lifestyle Urge Urge Urge Urge (severe) Stress Stress Stress Mixed Mixed Mixed Mixed

20. 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)

21. 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 • Caffeine and diuretic beverages • Fluid intake • Constipation • Weight loss • Smoking Lifestyle Subak LL et al. Internatl Urogynecol J 2002; 13:40 Brown JS et al. Diabetes Care 2006; 29:385

22. Bladder training Pelvic muscle exercises Use in combination for both urge and stress UI Behavioral

23. Normal Stress Incontinence Urethra Supporting fascia deSouza NM et al. Radiology 2002;225:433

24. Key Regions in Bladder Control Insula Pons Anterior Cingulate Gyrus Periaqueductal Grey Prefrontal Cortex Kavia R et al, J Comp Neurol 2005; 493:27

25. Antimuscarinics for urge and mixed UI New agents Stress UI? Drugs

26. Current antimuscarinics • Oxybutynin • Oxybutynin 2.5-5 mg bid-qid • Oxybutynin XL 5-20 mg daily • Oxytrol patch 3.9 mg 2x/week and Gelnique  gel • Tolterodine • Detrol 1-2 mg bid • Detrol LA 2-4 mg daily • Fesoterodine • Toviaz 4–8 mg daily • Trospium chloride • Sanctura20 mg bid • Sanctura XR 60 mg daily • Darifenacin • Enablex 7.5-15 mg daily • Solifenacin • Vesicare 5-10 mg daily

27. 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) • Dry mouth: oxybutynin worst • Constipation: darifenacin, solifenacin • Least: Oxytrol patch (but rash in 15%) No Major Differences All decrease UI ~70%, ~25% cure rate Tolerability Adverse effects Efficacy 4th International Consultation on Incontinence, 2008 Chapple C et al, Eur Urol 2005 Shamliyan TA et al, Ann Int Med 2008

28. Burch Colposuspension Urethral Sling ME Albo et al. NEJM 2007, 356: 214

29. Injectables - Collagen Short term efficacy, best for stress UI due to inadequate sphincter closure Not effective in post-prostatectomy UI

30. 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