Martha Spencer, MD, FRCPC, Providence Health Care, Clinical Instructor, UBC (biography and disclosures)
Disclosures: Education grant from Pfizer to help support my incontinence fellowship in Edmonton, Grant from Pfizer ($10 000) to support start-up costs for the Geriatric Continence Clinic at SPH. Mitigating potential bias: Only published trial data is presented and recommendations are consistent with current practice patterns. No direct reference is made to products made by Pfizer in this article.
What I did before
Urinary incontinence (UI) is an important and often overlooked geriatric syndrome. Older patients present are often medically complex and may also have psychosocial and functional challenges that require thorough and time-consuming assessments. As such, seemingly less pressing issues such as urinary incontinence can get pushed aside. It was not until my fellowship in geriatric medicine that I began asking patients about UI as a routine question during my initial consult, but felt unsure of what I could do if the patient acknowledged the symptom. With so many other competing issues, I would often put it at the end of my issue list. I did not feel comfortable prescribing pharmacological treatment for UI due to their anticholinergic side effects and my lack of experience with these medications.
What changed my practice
After my training in Geriatric Medicine, I did an additional 5 months of fellowship training in geriatric urinary incontinence, which opened my eyes to the many medical causes and consequences of UI in this population. Although younger patients with incontinence are often managed surgically by urologists and gynecologists, geriatric patients may have medical comorbidities, functional impairment and medications as underlying causes of incontinence.
UI has been associated with falls, increased hospitalization rates and poorer quality of life in older adults and therefore deserves more attention from health care providers. 1, 2
What I do now
Older patients require a comprehensive medical and functional review to determine the cause of their UI. As with most geriatric syndrome, urinary incontinence is rarely caused by only one factor and therefore, taking the time to consider all aspects of a patient’s history is key. Additionally, a physical exam and some basic investigations are used to support the diagnoses.
Here are some pearls to consider when assessing an older adult for urinary incontinence:
1) Only about 50% of elderly patients seek help for UI and when they do, they are less likely to receive evidence-based care3. It must be reinforced to patients and health care providers alike that UI is NOT a normal part of aging!
2) Active case finding is important for all elderly patients, especially the frail. A simple question like “Do you have any problems with your bladder” is a great first step.
3) Take a thorough history to determine the type of incontinence. Urgency incontinence (UUI), is more prevalent in elderly patients4. Those with UUI may have coexisting stress incontinence and/or functional incontinence, defined as incontinence caused by problems outside the bladder, such as mobility and cognitive issues. Simple screening questions to identify the type of incontinence5 and a good functional/mobility history are key in making a diagnosis.
4) Always consider bother when assessing UI symptoms, both from the patient and caregiver’s point of view. Elderly patients are more likely to describe more severe and socially debilitating symptoms6, however some patients/caregivers may have developed acceptable strategies to manage their UI. Knowing how significant these symptoms are to the patient/caregiver may help guide the overall treatment plan.
5) Most older patients do not require complex investigations to determine the cause of their incontinence. Investigations that may be considered include simple blood tests such as GFR and serum glucose or HbA1C, a urinalysis to check for a urinary tract infection or glucosuria, and a post-void residual with a bladder scanner (bladder ultrasounds are available on most inpatient units, and if unavailable, a formal pelvic ultrasound can be requested). There is little evidence that invasive tests, such as urodynamic studies, are necessary in this population except for those going for surgery, those with complex neurological disorders, or those in whom the diagnosis remains uncertain after a thorough history and physical exam.
6) Non-pharmacological treatment should always be first line, especially in frail elderly patient who may have increased side effects and the potential for drug-drug interactions with pharmacological options. Nurse Continence Advisors are an invaluable resource for assessing patients for suitability for non-pharmacological therapy and instructing them how to properly perform these treatments. For cognitively intact older patients, pelvic floor muscle exercises and bladder retraining (during which the patient teaches themselves to lengthen the time between voids) can be very effective. In those who are cognitively impaired, timed voiding (when the patient is toileted at regular intervals) is a good strategy to improve continence. Weight loss is the only lifestyle intervention with good evidence as supported by the literature7, however should not be advised to those with are already of low body weight, or who are losing weight.
7) Pharmacological treatment should be considered in elderly patients with urgency incontinence on an individual basis, based on their medical, cognitive and functional status. There are two classes of medications available for urgency incontinence. The first is the antimuscarinics, which diminish detrusor muscle activity during the filling phase and reduce the strength of bladder contractions during the voiding phase. There is concern about using these medications in older patients due to the potential for anticholinergic side effects, particularly affecting cognition. Oxybutynin has high affinity for the M1 receptors, which are also found in the central nervous system. As such, it has been associated with impaired cognition in cognitively intact older adults, as well as higher rates of delirium and hospital admissions8. Newer antimuscarinics are available that have less affinity for the M1 receptor, and have properties that make them less able to penetrate into the central nervous system. Although these anticholinergics are still associated with side effects such as dry mouth, dry eyes and constipation that are often intolerable to patients, there is evidence to suggest that they do not significantly affect cognition in cognitively intact older patients9. New studies are emerging in high risk, vulnerable elderly patients, which also show no significant change in cognition10, however there is still limited evidence in those with dementia. Mirebegron, a selective beta-3 agonist, is the first of a second class of medications for overactive bladder, and acts to enhance bladder relaxation during the bladder filling phase. Preliminary data shows that Mirebegron is safe and effective in older adults11, however more studies are needed, particularly in the frail elderly population. In most provinces, including British Columbia, the only pharmacologic treatment that is covered under Pharmacare for overactive bladder is Oxybutynin, which poses a challenge for our frail elderly patients who should be offered safer first line therapy with a newer antimuscarinic or Mirebegron.12
Urinary incontinence is an important issue in the geriatric population that is often neglected and undervalued. The take-home point for all health providers is that urinary incontinence is NOT a normal part of aging, and that there are many effective, evidence-based treatments available. Case finding is key, and simply asking older patients about the presence of urinary incontinence opens up a dialogue about this important issue. So just ask!
- Brown JS, Vittinghoff E, Wyman JF et al. Urinary incontinence: does it increase risk for falls and fractures? Study of Osteoporotic Fractures Research Group. Journal of the American Geriatrics Society. 2000; 48:721–5. (View with CPSBC or UBC) DOI: 10.1111/j.1532-5415.2000.tb04744.x
- Thom DH, Haan MN, Van Den Eeden SK. Medically recognized urinary incontinence and risks of hospitalization, nursing home admission and mortality. Age and Ageing. 1997; 26:367–74. (View)
- Teunissen D, van Weel C, Lagro-Janssen T. Urinary incontinence in older people living in the community: examining help-seeking behaviour. British Journal of General Practice. 2005; 55:776–82. (View article and article corrections)
- Irwin DE, Milsom I, Hunskaar S et al. Population-based survey of urinary incontinence, overactive bladder, and other lower urinary tract symptoms in five countries: results of the EPIC study. European Urology 2006; 50:1306–14. (View with CPSBC or UBC) DOI: 1016/j.eururo.2006.09.019
- Holroyd-Leduc J, Tannenbaum C, Strauss S. The Rational Clinical Examination: What type of urinary incontinence does my female patient have? JAMA. 2008; 299;1446-1456. (View)
- Perry S, Shaw C, Assassa P et al. An epidemiological study to establish the prevalence of urinary symptoms and felt need in the community: the Leicestershire MRC Incontinence Study. Leicestershire MRC Incontinence Study Team. Journal of Public Health Medicine. 2000; 22:427–34. (View)
- Imamura M, Williams K, Wells M, McGrother C. Lifestyle interventions for the treatment of urinary incontinence in adults. Cochrane Database of Systematic Reviews. 2015:CD003505. (Request with CPSBC or view UBC ) DOI: 10.1002/14651858.CD003505.pub5
- Uusvaara J, Pitkala KH, Kautiainen H, et al. Association of anticholinergic drugs with hospitalization and mortality among older cardiovascular patients; a prospective study. Drugs and Aging. 2011; 28 (2);131-8 (Request with CPSBC or view UBC) DOI: 10.2165/11585060-000000000-00000
- Wagg A, Verdejo C, Molander U. Review of cognitive impairment with antimuscarinic agents in elderly patients with overactive bladder. International Journal of Clinical Practice. 2010; 64: 1279–86. (Request with CPSBC or UBC) DOI: 10.1111/j.1742-1241.2010.02449.x
- Dubeau CE, Kras SR, Griebling TL et al. Effect of fesoterodine in vulnerable elderly subjects with urgency incontinence: a double-blind, placebo controlled trial. Journal of Urology. 2014; 191:395-404 (Request with CPSBC or view UBC) DOI: 10.1016/j.juro.2013.08.027
- Bhide AA, Digesu GA, Fernando R, Khullar V. Mirabegron. A selective beta3 adrenoreceptor agonist for the treatment of overactive bladder. Journal of Research and Reports in Urology. 2012; 4:41–5. (View)
- Gibson W, Athanosopoulos A, Goldman H et al. Are we shortcoming frail older people when it comes to the pharmacological treatment of urgency urinary incontinence? International Journal of Clinical Practice. 2014;68(9):1165-73. (View with CPSBC or UBC) DOI: 10.1111/ijcp.12447