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+
Urinary incontinence is a widespread problem and an estimated 13 million American men and women suffer from it. The condition affects 15% to 35% of the elderly population living at home, and is present in more than half of the 1.5 million nursing home residents in the United States.1 Even though 50% of nursing home residents suffer from the condition, only a small percentage are being actively treated.
Urinary incontinence increases the risk of hospitalization and admission to long-term care facilities2 and has been associated with loss of independence and other deleterious effects on quality of life.3 It affects the physical and emotional well-being of millions of American men and women.1
The total cost of urinary incontinence was estimated at $26 billion in 1995, and $3600 annually per person older than 65 years.4
We need to make sure that we are not missing the opportunity to treat this condition merely because some people think it is a “normal” consequence of aging or because of concerns about cost of therapy.
1. Clinical Practice Guidelines: Urinary Incontinence in Adults: Acute and Chronic Management. Rockville, Md: US Dept of Health and Human Services, Agency for Health Care Policy and Research; 1996:5. AHCPR publication
2. Thom DH, Haan MN, Van Den Eeden SK. Medically recognized urinary incontinence and risks of hospitalization, nursing home admission, and mortality. Age Ageing. 1997;26:
3. Lenderking WR, Nackley JF, Anderson RB, Testa MA. A review of the quality-of-life aspects of urinary urge incontinence. Pharmacoeconomics. 1996;9:11-23.
4. Wagner TH, Hu T-W. Economic costs of urinary incontinence in Urology ;51:

7. Inability to store urine at low pressure
What causes UI?
Inability to store urine at low pressure
Uninhibed bladder contractions
Insufficient urethral closure
Inability to empty bladder 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. Factors that Cause or Worsen UI
Comorbid Disease
Diabetes
Congestive heart failure
Degenerative joint disease
Sleep apnea
Severe constipation
Neurological / Psychiatric
Stroke
Parkinson’s disease
Dementia (advanced)
Depression (severe)
Function and Environment
Impaired cognition
Impaired mobility
Inaccessible toilets
Lack of caregivers
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. 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)
Now evidence that treatment of these does not decrease UI
DuBeau CE et al, Incontinence in Frail Elderly, 4th International Consultation on Incontinence, 2008

17. 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
Urethra
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. Caffeine and diuretic beverages Fluid intake Constipation Weight loss
Smoking
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
Lifestyle
Subak LL et al. Internatl Urogynecol J 2002; 13:40
Brown JS et al. Diabetes Care 2006; 29:385

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

23. Normal Stress Incontinence Supporting fascia Urethra
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 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 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