Continence and older adults Mark Weatherall University of Otago Wellington

2 Ageing of the population University of Otago Wellington N > 65% total population , , , ,091, ,353,

3 Ageing of the population University of Otago Wellington AgeMaleFemaleMaleFemale Mean life expectancy

4 Diseases, impairments, and activity limitations University of Otago Wellington Health related issuePrevalence: 45-54Prevalence: 75+ Any chronic condition General health related as Fair or Poor Chronic painful condition Use of GP in last 12 months Inpatient hospital care in last 12 months

5 Diseases, impairments, and activity limitations University of Otago Wellington DiseasePrevalence: 45-54Prevalence: 75+ Hypertension medication use Increased cholesterol Ischemic heart disease Congestive heart failure Stroke Arthritis Osteoporosis Diabetes Mood problems Anxiety problems4.03.3

6 Diseases, impairments, and activity limitations University of Otago Wellington Activity limitationAge 70-74Age 85+ % with limitation Housekeeping959 Shopping657 Bathing243 Mobility330

7 Diseases, impairments, and activity limitations University of Otago Wellington DisorderPercentage of subjects Heart failure31 Osteoarthritis26 Stroke22 Dementia22 Deafness14 Psychiatric illness14 Fracture of the proximal femur12 Cataract12 Ischemic heart disease11 Chronic obstructive lung disease10

8 Changes to urinary system Increased prevalence of detrusor over-activity Menopause and loss of trophic estrogen effects Decreased maximum bladder capacity Less efficient bladder emptying with higher post-void residual volumes Increased nocturnal urine production University of Otago Wellington

9 Continence and older age Medication use increases with age, loop diuretics increase rate of bladder filling, anti-cholinergics reduce bladder emptying Probably more mixed patterns of bladder and sphincter function University of Otago Wellington

10 Assessment: History Care with sensory impairments High prevalence of cognitive impairment especially in 85+ Around 30% of 85+ have moderate dementia, only half known In health care settings delirium very prevalent An supplementary history is usually useful University of Otago Wellington

11 Physical examination: General Principles Look beyond the urinary and abdominal system Especially hearing, eyesight, cognitive function Musculo-skeletal and nervous system Consider using screening instrument for cognitive function University of Otago Wellington

12 Investigations Still include MSU but very hard to interpret in older women with 20-30% prevalence of asymptomatic bacteruria Voided volume record but needs intact cognitive function Metabolic disorders more common University of Otago Wellington

13 Treatment General issues Balance therapeutic nihilism with hopeless optimism Very few very elderly in RCT’s of treatment so extrapolating results in younger healthier adults Altered pharmacokinetics (what the body does to the drug) such as reduced renal clearance, altered body fat/lean body mass Useful aphorism start low and go slow University of Otago Wellington

14 Treatment More likely to be on more drugs, may affect adherence, greater likelihood of drug interactions, Continence problems may be part of the clinical picture: MDT assessment, remediation and work-arounds Still candidates for surgical treatment, co-morbidities not age determine anaesthetic risk, higher prevalence of detrusor over-activity Cognitive function may interfere with pelvic floor muscle training and bladder retraining, consider scheduled toileting University of Otago Wellington

15 Conclusion Older adults can be challenging, frustrating, difficult and satisfying to diagnose and treat May have multiple problems and diagnoses People need careful individualised, likely multi- disciplinary, assessment and management University of Otago Wellington