1. Continence in the very aged Mark Weatherall University of Otago, Wellington

2. 2 Introduction Very advanced aged usually means aged over 85 years 2006 census 56,667 over age 85, of 495,600 over age 65 (11.4%) Medium projections are by 2031 156,300 over age 85, of 1,079,600 (14.5%) University of Otago, Wellington

3. 3 General consequences Increased prevalence and incidence of disease, impairment, and activity limitation Limitations of current knowledge from cohort effect and cross-sectional studies It is possible that older people in 25 years will be fitter and have less disease than the current cohort University of Otago, Wellington

4. 4 Some diseases and related consequences University of Otago, Wellington Prevalence/Incidence in >85 years Continence consequences Dementia>25%Detrusor over-activity, difficulty finding and using toilets Stroke5-10%Detrusor over-activity, mobility and dexterity, cognitive problems Parkinson’s Disease2-3%Mobility and dexterity, cognitive problems Hypertension50-70%Medication use CHF5-10%Medication use, mobility limitation, changed urine production

5. 5 Some diseases and related consequences University of Otago, Wellington Prevalence/Incidence in >85 years Continence consequences COPD10-20%Cough and stress incontinence, mobility limitations Osteoarthritis>50%Mobility and dexterity limitations, lumbar spine involvement and continence nerves Osteoporosis>50%Mobility and dexterity after fractures Diabetes15-20%Excess urine production, continence nerve damage

6. 6 Common Impairments University of Otago, Wellington Vision and hearing impairments are very common Indirect consequences, navigating and using toilets, hearing health care advice Cognitive impairment affects practical abilities, planning toileting, locating toilets, using toilets including undressing Associated diseases lead to detrusor over-activity

7. 7 Common Activity Limitations University of Otago, Wellington Mobility limitation and falls very common About 40% of over 85’s fall each year Decreased mobility means decreased speed of access to toilets Advanced activities often affected such as shopping, housework, bathing. Flow on effects: Access product, laundry, skin care

8. 8 Lower urinary tract changes with age University of Otago, Wellington Increased prevalence of detrusor over-activity Bladder outflow obstruction from prostate disease leads to urinary symptoms, possibly reduced bladder emptying and detrusor over-activity Decreases urethral sphincter function in women Decreased bladder capacity, increased residual urine, increased nocturnal urine production

9. 9 Social consequences University of Otago, Wellington 75% of over aged 85 live in private dwellings although many people live alone 25% of over aged 85 live in residential care, continence problems affect more than half Older adults with activity limitation are very reliant on family members: Informal carers

10. 10 UI: Prevalence and type University of Otago, Wellington Overall about 40% have some UI, probably more detrusor over-activity than younger people Mixed problems common e.g. detrusor over- activity and reduced detrusor muscle contraction strength Men and women more likely to have had lower urinary tract surgery

11. 11 Assessment University of Otago, Wellington Careful individual assessment, older adults are a very diverse group Impairments and activities of daily living, especially cognitive function, dexterity, and mobility Try and define the lower urinary tract problem Bowel function, close anatomical relationship

12. 12 Management University of Otago, Wellington Impairments/Activities of daily living, may need multi-disciplinary approach Cognitive function determines the range of management strategies e.g. bladder retraining versus scheduled toileting Treatment of lower urinary tract

13. 13 Management University of Otago, Wellington Difficulties with medication e.g. anti-cholinergic agents with dry mouth, cognitive impairment, constipation Importance of social continence

14. 14 Conclusions University of Otago, Wellington A growing proportion of our patients Challenging to assess and manage Rewarding to improve the quality of life