1. Continence Strategies: Towards Independence in the Elderly Karina So Clinical Nurse Consultant Urology / Continence Management Concord Hospital

2. Practical strategies Curative therapy for mild SI Symptom management for SI & UI Containment for severe and permanent Urinary incontinence Nocturnal incontinence Risk management on IDC/SPC/CISC Urge incontinence is associated with a modest increase in falls. Chiarelli et. Al.(2008) Urinary incontinence is associated with an increase in falls: a systematic review” Australia Journal of Physiotherapy 55: 89-95

3. Common Continence Problems in the elderly population Stress incontinence (SI) Urge incontinence (UI) Mixed incontinence Overflow incontinence Functional incontinence

4. Drugs that can cause urinary incontinence AgentMechanism of ActionType of Incontinence Antihypertensive Prazosin, Labetolol Sphincter relaxation Stress Incontinence Bladder relaxant Anticholinergics Tricyclic Antidepressants Promote incomplete emptying Overflow Incontinence Bladder Stimulant Caffeine, Cholinergics Enhance detrusor instability Urge Incontinence Sedative Antihistamines,antidepressants antipsychotics,Tranquilisers, Hypnotics Reduce awareness of bladder sensation Urge incontinence Miscellaneous Alcohol loop diuretics Lithium Lower inhibition Increase bladder filling, Polydipsia Urge incontinence

5. Stress Incontinence (SI) Mild SI - Curative therapy – Pelvic Floor Muscle Exercises – Behavioural modification – Review medication(s) – Healthy diet & maintain healthy wt. – Regulate fluid intake & healthy bowel habit

6. Real-time Ultrasound Scan Patient can watch pelvic floor muscles contract and relax as you retrain them (visual feedback on performance). It is a tool to encourage compliance. It does not measure PFM strength.

7. Moderate SI Symptom management – Mild SI care path – Intravaginal device – pessary ring, tampon, Contiform device. – Selection of continence products uridome

8. Symptom management SI Contiform! Penile clamp should be released every one to two hours to empty the bladder and prevent damage.

9. Severe and permanent SI Supportive care/ Risk Management –Containment –Social continence –Prevent skin problems, UTIs, odour control –Government Continence Aids schemes PADP CAAS/CAPS DVA – gold card

10. Management of Urge Incontinence Regulate fluid intake:amount,type, time. Bladder training strategies +/- medication Clothing- reduce layers, zipper/belt Medications – dose, time, route. Healthy diet, healthy bowel. Selection of appropriate continence aids Assess eligibility for Government schemes: PADP / CAAS/ DVA

11. Bladder Training therapy For mild-moderate sensory and motor urgency. Deferment strategies (take control) –Pelvic floor muscle contractions –Talk to your bladder –Tactile sensation/pressure – Distraction (think hard) Identify Optimal voiding time Frequency, volume & urgency diary

12. Drugs used to treat OAB Anticholinergics/Antimuscurinic Propantheline (Pro-banthine 15 - 30mg q.i.d.) Oxybutynin (Ditropan 5mg up to q.i.d.) –Oxytrol transdermal patch (3.9mg twice a week) Tolterodine (Detrusitol 1 - 2mg b.i.d.) Darifenacin (Enablex) Solifenacin (Vesicare 5 – 10mg daily)

13. Travel or bed time companion

14. Nocturnal incontinence Booster pad Pull up pants

15. Stricture therapy – patient specific Identify the optimal time for urethral dilatation before a reduction in urine flow. Select the size and type of firm catheter. Educate and support patient to perform regular self dilatation. Coude tip firm nelaton catheter

16. Management of Acute Urinary Retention Decompress the bladder using 100% silicone catheter size 14/16 Select the most appropriate drainage device – bag / valve Educate patient & carer on IDC care

17. Catheter size Balloon Size 12 FG 14 FG 16 FG 18 FG 20 FG 22 FG 24 FG 3 ml 5 ml 10 ml 20 ml 30 ml 60 ml Colour code

18. Catheter valve & leg bag

19. Management of Chronic Urinary Retention Prevent recurrent symptomatic UTI Identify high risk cases for urosepsis and prepare care plan –Use antibacterial soap for daily hygiene –If possible, high fluid intake > 2 litre/day –Prevent and correct constipation –Avoid trauma during catheter replacement procedure –Use catheter fixation device to avoid traction –Frequency of IDC or SPC replacement is individualised. –Periodic Urology review

20. Neurogenic bladder CISC +/- Anticholinergic Medication Queen Square Bladder Stimulator $75

21. Management of CISC Reduce Symptomatic UTI – assess CISC technique, frequency of CISC, equipment care, single use versus reusable catheter. Educate patient on monitoring of residual volume – bladder diary. Periodic urology review.

22. Class of laxatives/time to effect Bulk forming agentsOral, 48-72 hrs. Osmotic agents (sorbitol, lactulose,glyerol) Oral, 24-72 hrs. Osmotic agents (Macrogol or saline laxatives) Oral, 0.5 – 3 hrs. Stool softenersOral, 24 -72 hrs. StimulantOral, 6- 12 hrs.

23. Government Continence Aids Schemes NSW Health – Enable Health –PADP Federal Government Schemes –CAAS –CAPS from July 2010 –DVA for veterans with gold card

24. PADP Transition to Enable Health Website: www.health.nsw.gov.au/health-public- affairs/factsheets www.health.nsw.gov.au/health-public- affairs/factsheets One centralised body Office is based in Parramatta Transfer of PADP data in stages

25. Continence Aids Assistance Scheme (CAAS) CAAS is an Australian Government scheme offering assistance to eligible people who have permanent and severe incontinence. The scheme covers children aged 5 to 15 years, and adults over 64 years with permanent incontinence due to neurological conditions (Cat.A). The scheme also includes all causes of permanent incontinence, not just neurological causes, for those people who hold a pensioner concession card and their dependents (Cat.B). Website: www.intouchdirect.com.au The National Continence Helpline 1800 330 066

26. Continence Aids Payment Scheme (CAPS) As of July 2010 ….. Clients can receive a one off payment of up to $489.95 to purchase their own products. Can nominate the payment goes to an agency/ supplier. CAPS payment is exempted as income. Contact Medicare Australia Office for information 132 011

27. Role of Medicare Australia As of July 2010.. Respond to enquires about CAPS. Receive and process CAPS applications. Make payments directly into a CAPS client’s nominated bank account or nominated provider’s account. Send statements regarding the payment to clients. Supply CAPS Application form