geriatric urinary incontinence & overactive bladder

Geriatric Urinary Incontinence &Overactive Bladder

Joseph G. Ouslander, M.D.Professor of Medicine and Nursing

Director, Division of Geriatric Medicine and GerontologyChief Medical Officer,

Wesley Woods Center of Emory UniversityDirector, Emory Center for Health in Aging

Research Scientist, Birmingham/Atlanta VA GRECC

Geriatric Urinary Incontinence &Overactive Bladder (OAB)

Prevalence & impacts Pathophysiology Diagnostic evaluation Management

An Update

Geriatric Urinary IncontinencePrevalence

34%

12%22%

5%

70%

40%

0%10%20%30%40%

50%60%70%80%

Ever Daily Ever Daily

Community (General)Community

(Frail)/Acute Hospital

N H

Women Men

Overactive Bladder Overactive Bladder (OAB)(OAB)

Urinary Frequency >8 voids/24 hrs

Nocturia awakening at night to void

Urgency, with or without urge incontinence

Overactive BladderPrevalence

17%16%

WomenMen

Milsom et al: BJU International, 87:760, 2001

Telephone survey of 16,776 adults age 40+

Overactive BladderPrevalence

9%

31%

3%

42%

0%5%

10%15%20%25%30%35%40%45%50%

Age 40-44 Age 75+ Age 40-44 Age 75+

Women Men

05

10152025303540

Chronic

sinusit

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Allergic

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High choles

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Chronic

bronchitis

Diabete

s

Arthriti

s

Heart d

iseas

eAsth

maInco

ntinen

ceUlce

r

Top Chronic Conditions in the U.S.M

illio

ns

OAB

OAB: “Dry” vs “Wet” (Urge Incontinence)

Wet(37%)Dry

(63%)OAB

Adapted from Stewart W et al. ICI 2001

Spectrum of OAB and Urinary Incontinence

z• Urgency• Frequency• Nocturia

Stress UI Mixed Urge UI

OABOAB

Incontinence

Impact of UI & OAB on Quality of Life

Quality of Life

OccupationalDecreased productivityAbsence from work

SocialLimited travel and activity around toilet availability

Social isolation

Psychological Fear and anxietyLoss of self-esteemDepressionSexual

Avoidance of sexual contact and intimacy

PhysicalDiscomfort, odorFalls and injuries

Adverse Consequences of UI & OAB

87 Y.O. woman living at home, with minimal assistance from family

Incontinent rushing to the toilet at 2 a.m., slipped and fell in urine

Sustained a hip fracture Now confined to a wheelchair

and required admission to a nursing home

Urge Incontinence, Falls, and Fractures

• 6,049 women, mean age 78.5• 25% reported urge UI (at least weekly)• Followed for 3 yrs• 55% reported falls, 8.5% fractures• Odds ratios for urge UI and

Falls: 1.26 Non-spine fracture: 1.34

Brown et al: JAGS 48: 721 – 725, 2000

PredisposeGenderRacial

NeurologicAnatomicCollagenMuscularCultural

Environmental

InciteChildbirth

Nerve damageMuscle damage

RadiationTissue disruptionRadical surgery

InterveneBehavioral

PharmacologicDevicesSurgical

DecompensateAging

DementiaDebilityDisease

EnvironmentMedications

ConstipationOccupationRecreation

ObesitySurgery

Lung diseaseSmoking

Menstrual cycleInfection

MedicationsFluid intake

DietToilet habitsMenopause

Promote

Abrams P, Wein A. Urology. 1997:50(suppl 6A):16.

Geriatric Urinary Incontinence and OABMulti-factorial

Pathophysiology

Drugs/Other Conditions

Urinary

Tract Neurological

Functional/Behavioral

Geriatric Urinary Incontinence & OAB

Geriatric Urinary Incontinence & OAB

Lower urinary tract Bladder pathology (infection, tumor, etc) Detrusor overactivity Women – atrophic urethritis, sphincter

weakness Men – prostate enlargement Urinary retention

• Obstruction• Impaired bladder contractility

Pathophysiology

100Volume

Blad

der p

ress

ure

200 40030000

100 Involuntarybladder contractions

Normal voluntary void

Geriatric Urinary Incontinence & OABDetrusor Overactivity

DHIC

% b

ladd

er e

mpt

ying

DH0

20

40

60

80

100

Resnick, Yalla JAMA 1987;148:3076

Geriatric Urinary Incontinence & OABDHIC

Pathophysiology of Detrusor Overactivity

Neurogenic Myogenic Combination Unknown

Sphincter Weakness

Geriatric Urinary Incontinence & OAB

Neurological Brain

• Stroke, dementia, Parkinson’s Spinal cord

• Injury, compression, multiple sclerosis Peripheral innervation

• Diabetic neuropathy

PathophysiologyGeriatric Urinary Incontinence & OAB

Functional/Behavioral Mobility impairment Dementia Fluid intake

• Amount and timing• Caffeine, alcohol

Bowel habits/constipation Psychological (anxiety)

Pathophysiology

Geriatric Urinary Incontinence & OAB

Other Conditions Diabetes (polyuria) Volume overload (polyuria, nocturia)

• Congestive heart failure• Venous insufficiency with edema

Sleep disorders (nocturia)• Sleep apnea• Periodic leg movements

PathophysiologyGeriatric Urinary Incontinence & OAB

Requirements for Continence

Adequate: Lower urinary tract function Mental function Mobility, Dexterity Environment Motivation (patients, caregivers)

Reversible Causes (“DRIP”)

D elirium

R estricted mobility, R etention

I nfection, I nflammation, I mpaction

P olyuria, P harmaceuticals

Geriatric Urinary Incontinence & OAB

Drugs

Diuretics Narcotics Anticholinergics Psychotropics Cholinesterase inhibitors Alpha adrenergic drugs

Overflow

Urge Stress

Functional

Persistent Incontinence

History (Bladder Diary in selected patients) Physical exam Cough test for stress incontinence Non-invasive flow rate (helpful in men) Measurement of voided and post-void

residual volumes Urinalysis

Diagnostic Assessment

Geriatric Urinary Incontinence & OAB

History Most bothersome symptom (s) Treatment preferences and goals Medical history for relevant conditions and

medications Onset and duration of symptoms Prior treatment and response Characterization of symptoms

Overactive bladder Stress incontinence Voiding difficulty Other (pain, hematuria)

Bowel habits Fluid intake

Physical Exam Cardiovascular Abdominal Neurological Perineal skin condition External genitalia Pelvic exam

Atrophic vaginitis Pelvic prolapse

Rectal exam Sphincter control Prostate

Post-Void Residual Determination

Diabetics Neurological conditions (e.g. post acute stroke, multiple sclerosis, spinal cord injury) Men (especially those who have not had a TUR) Anticholinergics and narcotics History of urinary retention or

elevated PVR

Urinalysis

Infection Sterile hematuria Glucosuria

Examples of criteria for further evaluation Recurrent UTI Recent pelvic surgery Severe pelvic prolapse Sterile hematuria Urinary retention Failure to respond to initial therapy,

and desire for further improvement

Geriatric Urinary Incontinence and OAB

Management of Geriatric Incontinence and OAB

Reversible causes Supportive

measures Education Environmental Toilet substitutes Catheters Garments/pads

Behavioral interventions

Pharmacologic therapy

Surgical interventions

Devices

Modify fluid intakeModify drug regimens (if feasible)Reduce volume overload (for nocturia)

e.g. take furosemide in late afternoon in patients with nocturia and edema

Treat: Infection (new onset or worsening symptoms)ConstipationAtrophic vaginitis (topical estrogen)

Treat Reversible Causes

Management of Geriatric Incontinence and OAB

EducationEnvironmental

Clear well-lit path to toiletBedside commodes, urinals

CathetersFor skin problems, retention, palliative

care/patient preference

Garments/pads

Supportive Measures

Management of Geriatric Incontinence and OAB

Chronic Indwelling Catheters

Significant, irreversible retention Skin lesions/surgical wounds Patient comfort/preference

Appropriate indications

Management of Geriatric Incontinence and OAB

Undergarments and PadsNonspecificFoster dependencyExpensive

Management of Geriatric Incontinence and OAB

Stress incontinence• Periurethral injections• Bladder neck suspension• Sling procedure• Artificial sphincter

Urge incontinence• Implantable stimulators• Augmentation cystoplasty

Surgical Interventions

Management of Geriatric Incontinence and OAB

Behavioral Interventions “Bladder Training”

• Education• Urge suppression techniques• Pelvic muscle rehabilitation

With and without biofeedback Toileting programs

• Prompted voiding (and others)

Pelvic Muscle ExercisesLocate pelvic muscles

Repeat in setsof up to 10

3-4 times/day, and use in

everyday life

Relax completely for

at least 10 seconds

Squeeze muscles tightly for up to

10 seconds

Burgio et al: JAMA 280: 1995, 1998

Management of Geriatric Incontinence and OABBehavioral vs. Drug Treatment

0

5

10

15

20

Baseline 2 4 6 8

Time, wk

Acc

iden

ts p

er W

eek,

No.

Behavioral Drug Control

Much betterBetterAble to wear fewer padsCompletely satisfiedContinue treatment Wants another treatment

Management of Geriatric Incontinence and OAB

Behavior

742676789714

513156495876

273934284376

Drug ControlPatient Perceptions

Burgio et al: JAMA 280: 1995, 1998

Behavioral vs. Drug Treatment

Prompted Voiding

Protocol• Opportunity (prompt) to

toilet every 2 hours• Toileting assistance if

requested• Social interaction and

verbal feedback• Encourage fluid intake

Prompted Voiding

Reduces severity by half 25%-40% of frail nursing

home patients respond well UI episodes decrease

from 3 or 4 per day to 1 or fewer

Responsive patients can be identified during a 3-day trial

Efficacy in Research Studies

Ouslander JG et al. JAMA 273:1366-70

Management of Geriatric Incontinence and OAB

Drug Therapy

Lower Urinary Tract Cholinergic and Adrenergic Receptors

Detrusor muscle (M)

Trigone ()Bladder neck ()

Urethra ()

Μ=muscarinic =1-adrenergic

Motor Innervation of the BladderNeurotransmitter: Acetylcholine

Receptors: Muscarinic

Pelvic Nerve Contraction

Ouslander J. N Engl J Med. 2004;350:786-799

Motor Innervation of the Bladder

Ouslander J. N Engl J Med. 2004;350:786-799

Sensory Innervation of the Bladder

Drug Therapy for Stress Incontinence

Limited efficacy Two basic approaches:

Estrogen to strengthen periurethral tissues (not effective by itself)

Alpha adrenergic drugs to increase urethral smooth muscle tone (no drugs are FDA approved for this indication)

Pseudoephedrine (“Sudafed”) Duloxitene (“Cymbalta”)

Drug Therapy for Urge UI and OAB

Antimuscarinic/Anticholinergics -Blockers

• Men with concomitant benign prostatic enlargement

Estrogen (topical)• May be a helpful adjunct for women with

severe vaginal atrophy and atrophic vaginitis DDAVP (Off label in the U.S.)

• Carefully selected patients with primary complaint of nocturia

Drug Therapy for Urge UI and OAB

Darifenacin (“Enablex”) Oxybutynin (“Ditropan”)

• IR • ER (“ XL”)• Patch (“Oxytrol”)

Solifenacin (“Vesicare”) Tolterodine (“Detrol”)

• IR• Long-acting (“LA”)

Trospium (“Sanctura”)

Drug Therapy for UI and OAB

Several factors influence the decision to use pharmacologic therapy:

Degree and bother of symptoms

Patient/family preference

Risk for side effects/co-morbidity

Responsiveness to behavioral interventions

Cost

Drug Therapy for Urge UI and OAB

Anticholinergics: meta-analysis• 32 trials; most double-blind; 6,800 subjects• Significant effects on:

Incontinence and voiding frequencyCure/improvementBladder capacity

• Modest clinical efficacy vs. placebo• Measured over short time periods

Herbison P, et al. BMJ. 2003;326:841-844

Drug Therapy for Urge UI and OAB

Efficacy ~ 60 - 70% reduction in urge UI ~ 30 - 50% placebo effect

Efficacy is similar in elderly vs. younger Adverse events

Dry mouth ~ 20-25% (~ 5% “severe”) Others – less common

Iris/Ciliary Body = Blurred VisionLacrimal Gland = Dry Eyes

Salivary Glands = Dry Mouth

Heart = Tachycardia

Stomach = GERD

Colon = Constipation

Bladder = Retention

CNS

Potential Side Effects of Antimuscarinic Drugs

SomnolenceImpaired Cognition

Antimuscarinics and Cognition

• Antimuscarinic drugs used for the bladder can theoretically cause cognitive impairment

• ACh is a pivotal mediator of short-term memory and cognition

• Cholinergic system involvement in Alzheimer’s disease has been clearly established

• Of the 5 muscarinic receptors M1 appears most involved in memory and learning

Antimuscarinic Drugs and Cognition

Tolterodine

Oxybutynin,Solifenacin

Trospium

• Low lipophilicity• Charged• Relatively “bulky”

• High lipophilicity,• Neutral• Relatively “small”

• Relatively “bulky”• Highly polar

+

Vasculature CNSBBB

++++

++ +

+

++++

++++

++

++

++

++

++

+

Darifenacin • Lipophilic, small• “M3 selective”

Summary1. UI and OAB are common conditions in the geriatric

population, and are associated with considerable morbidity and cost

2. The pathophysiology is multifactorial, and many potentially reversible factors can contribute

3. All patients should have a basic diagnostic assessment, and selected patients should be referred for further evaluation

4. A variety of treatment options are available; behavioral interventions and drug therapy for urge UI and OAB are most commonly prescribed

5. Treatment should be guided by patient preference, their most bothersome symptoms, and the pathophysiology felt to underlie these symptoms