Geriatric Urinary Incontinence

Alexandra F. Suslow MD

% of Geriatric aged population

1970 --->9.9% 1984 -->11.5% 1997 -- >13.1% 2020 --> 20%

Life Expectancy

A child born in 1900--> <40 years A child of the late 60’s--> 68.5 years A child of the 90’s---> 72 years A child of the Millenium--> >75 years

Reported prevalence of UI

15-30% of community dwellers (ie” independent seniors”)

30% of elderly in acute care > 50% of long term care facilities (eg.

NH)

DON’T ASKDON’T TELL

Myths and Facts

It is a normal part of aging

It is not a medical issue

“I’m not incontinent,I just have “accidents”

There is nothing to do about it

It’s just a minor inconvenience

It is abnormal at any age(other than infant)

It is a medical issue, like HTN or DM

Any involuntary loss is incontinence

Alleviation and occsl. cure are possible

THINK AGAIN!!!

Problems due to UI

Major Medical Problems Major social issues Major economic issues

Medical Issues

Pressure ulcers leading to infections and sepsis

Perineal rashes Urosepsis Increased risk of falls and fractures

with subsequent increase of morbidity/mortality

Social issues

“ Cultural conditioning leading to stigmatization,social isolation, depression, and increased Psychological Morbidity”

(Umlauff et. all)

Economical Issues, general

Cost of Rx of associated symptoms (eg rashes and pressure sores)

Routine care costs( supplies,laundry) Direct Medical Cost: Physician and

Diagnostics

Economical Issues, Nursing Home

Marked increase in cost due to the increase in necessary nursing care (frequent changing of pt and linens) and due to increase utilization of supplies and ancilliary services

Estimated cost $3 billion

Breakdown of costs

Diagnostic/ medical $6.0 0.2% Treatement surgical 1.2 0.04 Treatement Pharmac. 0.7 0.02 Routine care c catheter 104.7 3.2 Routine care s catheter 19,061 58.4 Sequelae (uti,falls etc) 15.71 4.8 NH admissions due to UI 1087.7 33.3%

Total NH Cost

Us$ 3.26 Billion

(cost in 1987)

Cost in Community Dwellers

Estimated to be about $7 Billion, including costs of supplies, outpatient visits, short term hospitalizations etc.

GRAND TOTAL

• $10 billion .• Adjusted to 1997-->$16 billion• (more than cost of CABG/Dialysis combined)

Continence Determining Factors

Intact lower urinary tract anatomy and function

Adequate Mobility Motivation Mentation Manual dexterity

Age Related Changes in LUT

Women: postmenopausal decrease in oestrogen leading to tissue atrophy,prolapse, changes in vaginal flora--->incr. risk of UTI

Men:Prostatic changes leading to urodynamic obstruction and the sequelae thereof

Age related changes cont’dchanges in both genders

Changes in neurotransmittor balance and immune response.

Anatomic changes such as trabeculation, diverticulae, decreased elasticity

Involuntary detrussor contractions Malnutrition, dehydration leading to fecal

impaction and incr. risk of UTI

Medications

Diuretics--.polyuria,frequency,urgency Anticholinergics:retention,impact.

overflow alpha-adrenergic blockers:urethral

relax alpha agonists,beta agonists, Ca

channel Blockers:urinary retention Ace inhibitors: cough exacerbation

Medications, cont’d

Narcotics: retention, impaction, sedation, delirium

Psychotropics: anticholinergic effect, sedation, rigidity

Lithium: polyuria,frequency ETOH: polyuiria,urgency, sedation

Classification of UI

Transient incontinence “Functional “ incontinence Established incontinence --LUT causes

Transient Incontinence

D elirium I nfection symptomatic UTIA trophic urethritisP harmacological agents

Side effects of Specific Meds

Anticholinergic agents Frequent in prescription and OTC

meds( antihistamines) Causes overt and clinical retention---> faster

attainment of capacity--> exacerbation of Detrussor overactivity

Aggravates leakage in stress inc. Causes dry mouth-->polidypsia--> increase

UOP

Side Effects of Specific Meds

Alpha adrenergic blockers Found in many anti hypertensive meds Block receptors in the bladder neck-->

decreased tone-->agrravation of stress incontinence

Side Effects of Specific Meds

ACE INHIBITORS Often prescribed for HTN, CHF Tend to exacerbate chronic cough-->

increase of stress incontinence

Transient Incontinence

D elirium I nfection symptomatic UTIA trophic urethritisPharmacological agentsPsychiatric causesExcess UOPRestricted mobilityStool impaction

Established Incontinence:LUT causes of UI

Detrussor overactivity (“Urge Inc.”) Stress incontinence Overflow incontinence

Goals of the Work-up

R/o and treat transient causes R/o uncommon causes : CNS,CA,stone Determine the type of established UI

Complaints in Detrussor Overactivity

Presence or absence of “warning” Frequency Nocturia

Causes of Nocturia

Volume related:Excess intake, diuretic use, metabolic/endocrine, fluid overload, meds

LUT Related: detrussor instability,sensory urgency, prostatic changes

Only 22% of incontinent patients had pelvic/rectal exam preformed

by their Doctor

(Shame on us!!!)

Physical Exam

Baseline Exam (HEENT--->Extremities) Expanded Neurological Exam Stress Test PVR Urodynamic tests: cystometry Cystoscopy

False Results of Stress test

False Pos: Urge during the test False neg:

– Stressor not strong enough– Bladder not full– Cystocele kinking the urethra

Management of Detrussor Overactivity

Bladder Retraining Prompted Voiding “ Just Say No” to Surgery Pharmacological management

Drugs For DO

Others: Flavoxate, Ca chnl Blk, B-block/agonist Imipramine Doxepine Anticholinergics

• Propantheline (Pro-Banthine)• Dicyclomine (Bentyl)• Oxybutinin (Ditropan)• Tolterodine (Detrol)

Management of Stress Incontinence

Surgical Pharmacological Pelvic mm.Strengthening

• Kegel excercises

• Vaginal Cones

• Electric Stimulation

Surgical Interventions in Stress Incontinence

Perurethral injection of teflon Artificial Sphincter Colposuspension

Management of Overflow Incontinence

Blockage:• Conservative Rx• alpha antagonists• 5-alpha reductase inhibitor• Prostatectomy

Underactive Bladder:• Decompression• Catheterization• Betanechol

Diapers and Pads

Protect Environment Maintain comfort and dignity of patient

Special Thanks

The Lord: For everything Pam S.: For her help (and patience) in the Library Dr Houghton:For his help and advice for the

presentation Stacy and Julie: The Fairy Godmothers of the

Residents Dr Wells-Padron PharmD for the Nutrasweet All who had to listen to the presentation over and

over and over again