U i I ti i Old Urinary Incontinence in Older Adults

Di K N Di K N DNP FAAN BCB PMDDiane K. Newman, Diane K. Newman, DNP, FAAN, BCB-PMD

CoCo--Director, Penn Center for Continence and Pelvic HealthDirector, Penn Center for Continence and Pelvic HealthDivision of Urology, University of Pennsylvania Health System Division of Urology, University of Pennsylvania Health System

Adjunct Associate Professor of Urology in Surgery j gy g yResearch Investigator SeniorResearch Investigator SeniorPerelman School of Medicine, University of Pennsylvania Philadelphia, Pennsylvania Philadelphia, Pennsylvania p , yp , y

Prevalence of UI in CommunityPrevalence of UI in Community--Dwelling Dwelling W b A W b A Women by Age Women by Age (N=27,936; Norway)(N=27,936; Norway)

45Hannestad 2000

30354045

ge

202530

cent

ag

51015

Per

c

05

Total 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+

Ageg

Prevalence of UI in American Men by Age Prevalence of UI in American Men by Age (N=21,590)(N=21,590)y gy g

Diokno et al., 200735

25

30

15

20

5

10

0

5

18-24 yrs 35-44 yrs 45-54 yrs 55-64 yrs 65-74 yrs 75+ yrsy y y y y y

Prevalence of UI in American Women and Men Prevalence of UI in American Women and Men Age 65+ by Frequency Age 65+ by Frequency (National Health and Nutrition Examination Survey)(National Health and Nutrition Examination Survey)

4040

3535

4040WomenWomenMenMen

2525

3030

1515

2020

55

1010

Anger et al., 2006Anger et al., 2006

00OverallOverall Every DayEvery Day Few/WeekFew/Week Few/MonthFew/Month

Urinary Incontinence:Urinary Incontinence:Unwanted leakage of urine Unwanted leakage of urine Unwanted leakage of urine Unwanted leakage of urine

•• TypesTypesTypesTypes–– UrgencyUrgency –– urine loss on the way to urine loss on the way to

toilet following urgencytoilet following urgencyg g yg g y•• Overactive bladderOveractive bladder

–– Urgency Urgency -- intense/sudden desire to voidintense/sudden desire to voidFrequency Frequency >8 voids/24 hours>8 voids/24 hours–– Frequency Frequency -- >8 voids/24 hours>8 voids/24 hours

–– NocturiaNocturia -- awakening (2 or more) at awakening (2 or more) at night to voidnight to void

StSt i l k ith ti it i l k ith ti it –– StressStress --urine leakage with activity urine leakage with activity such as coughing or laughingsuch as coughing or laughing

Prevalence of UI Types in American Women Prevalence of UI Types in American Women (37 studies)(37 studies)(37 studies)(37 studies)

3535

3030

3535

StressStress UrgeUrge MixedMixed

2020

2525

1010

1515

55

1010

001919--44 yrs44 yrs 4545--64 yrs64 yrs 65+ yrs65+ yrs 80+ yrs80+ yrs

Prevention of Urinary and Fecal Incontinence in Adults, December 2007; Evidence Report/Technology Assessment, Number 161Prevention of Urinary and Fecal Incontinence in Adults, December 2007; Evidence Report/Technology Assessment, Number 161

Pooled prevalence of UI in Community Pooled prevalence of UI in Community Women by TypeWomen by TypeWomen by TypeWomen by Type

Age group Stress Urge Mixed

19‐44 years 12 8% 4 9% 7 1%19 44 years 12.8% 4.9% 7.1%

45‐64 years 21.8% 10.2% 12.7%

65 and older 16.1% 12.2% 16.8%

Adapted from Shamliyan et al 2007

Pooled prevalence of UI in Community Pooled prevalence of UI in Community Men by TypeMen by TypeMen by TypeMen by Type

Age Group Stress UI Urge UI Mixed UI

19‐44 years .74% 3.09% .70%

45‐64 years 3.78% 7.75% 1.53%

65 and over 2.67% 11.70% 6.13%

80 and over ‐‐‐ 18.18% 9.4%

Adapted from Shamliyan et al 2007

US Prevalence of Overactive Bladder US Prevalence of Overactive Bladder by Age and Genderby Age and Genderby Age and Genderby Age and Gender

30

35MenWomen

20

25Women

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10

15

Per

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0

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P

Stewart WF, Van Rooyen JB, Cundiff GW, Abrams P, Herzog AR, Corey R, Hunt TL., Wein, AJ (2003) Prevalence and burden of overactive bladder in the United States. World J Urol. May;20(6):327-36

018-24 25-34 35-44 45-54 55-64 65-74 75+

Age

Prevalence and burden of overactive bladder in the United States. World J Urol. May;20(6):327 36

Overall Prevalence of UI in the Nursing Home Overall Prevalence of UI in the Nursing Home Population (Men & Women)Population (Men & Women)p ( )p ( )United StatesUnited States

100100

8080

9090

77%77% 74%74%

5050

6060

7070

92 9344%44%

62%62%

49%49%55%55%

3030

4040

5050 19 1944%44%

23%23%

1010

2020

95,91

1

5,758

29,64

5

380

2,014

839

457

00PalmerPalmer19911991

BorrieBorrie19921992

Peet.Peet.19951995

BrandeisBrandeis19971997

AggazottiAggazotti20002000

AdelmannAdelmann20042004

NelsonNelson20052005

JumadilovaJumadilova20052005

BoyingtonBoyington20072007

Urinary Incontinence in the ElderlyUrinary Incontinence in the Elderlyy yy y

• In older adults, especially those who are frail, UI is considered to be a geriatric syndrome, because many of its risk factors are not directly related to the genitourinary tract

• Geriatric syndromes have been defined as:– multifactoral health conditions that occur when the accumulated effects of

impairments in multiple systems render an older person vulnerable to situational challenges

b f d ff b l ll k• Large numbers of different baseline as well as precipitating risk factors may interact with each other in influencing the ability of an older individual to remain continent in the face of common daily challengeschallenges

DuBeau, CE, Kuchel, GA, Johnson, T, Palmer, MH, Wagg, A (2009) Incontinence in the frail elderly. In P. Abrams, L. Cardozo, S. Khoury, & A. Wein (Eds.), Incontinence: Proceedings from the Fourth International Consultation on Incontinence. (pp. 961-1024). Plymouth, UK: Health Publications, Ltd.

Continence in the ElderlyContinence in the ElderlyRisk factorsRisk factors

Memory (impaired?)motivation

EnvironmentRisk factorsRisk factors

motivation

Medical

Mobility

conditions(neurologic

diti )MobilityPoor upper Poor upper and lower and lower extremity extremity strengthstrength

Manual d t it

conditions)

strengthstrength dexterity

Incontinence and FrailtyIncontinence and Frailtyyy•• Systematic review that included Systematic review that included

epidemiological studies from an variety of epidemiological studies from an variety of epidemiological studies from an variety of epidemiological studies from an variety of developed countries (developed countries (ShamliyanShamliyan et al 2007)et al 2007)

•• Findings: Findings: gg–– prevalence of UI, FI, and combined incontinence prevalence of UI, FI, and combined incontinence

increased with age and functional dependency increased with age and functional dependency –– cognitive impairment limitations in daily cognitive impairment limitations in daily cognitive impairment, limitations in daily cognitive impairment, limitations in daily

activities, and prolonged institutionalization in activities, and prolonged institutionalization in NH were associated with a higher risk of NH were associated with a higher risk of incontinenceincontinenceincontinenceincontinence

–– among community dwelling adults, stroke, among community dwelling adults, stroke, diabetes, obesity, poor general health, and diabetes, obesity, poor general health, and comorbiditiescomorbidities were associated with UI and FIwere associated with UI and FIcomorbiditiescomorbidities were associated with UI and FIwere associated with UI and FI

LUTS and frailty LUTS and frailty yy Incontinence is not part of the normal aging Incontinence is not part of the normal aging

processprocessprocessprocess–– That said, there is an That said, there is an prevalence of continence issues with increasing age prevalence of continence issues with increasing age

Incidence and prevalence of OAB symptoms Incidence and prevalence of OAB symptoms (f i ti (f i ti (frequency, urgency, urgency incontinence (frequency, urgency, urgency incontinence and and nocturianocturia) increase with increasing age ) increase with increasing age ((KoelblKoelbl 2009)2009)

Li k t d f ti f f t l/li bi t d l i i th f t l Li k t d f ti f f t l/li bi t d l i i th f t l –– Links to dysfunction of prefrontal/limbic system and lesions in the frontal Links to dysfunction of prefrontal/limbic system and lesions in the frontal region of the brain (Griffiths & region of the brain (Griffiths & TadicTadic 2008; Zhang, Yu & Wang 2010). 2008; Zhang, Yu & Wang 2010).

–– In men, also associated with urethral obstruction (In men, also associated with urethral obstruction (KrissovichKrissovich 2006)2006)

Urinary incontinence Urinary incontinence may be a marker frailty may be a marker frailty Urinary incontinence Urinary incontinence may be a marker frailty may be a marker frailty in older persons in older persons ((DubeauDubeau et al 2009; Eustace et al 2007; Holroydet al 2009; Eustace et al 2007; Holroyd--Leduc, 2004).Leduc, 2004).

How does frailty make UI worseHow does frailty make UI worseyy

Decreased mobility Decreased mobility –– Difficulty reaching the toilet (mobility, Difficulty reaching the toilet (mobility,

environment)environment)ConstipationConstipation–– ConstipationConstipation

–– Poor fluid intakePoor fluid intake–– Decreased strength of PFM?Decreased strength of PFM?–– Decreased strength of PFM?Decreased strength of PFM?

Difficulty with manual dexterityDifficulty with manual dexterity PolypharmacyPolypharmacy PolypharmacyPolypharmacy

–– anticholinergic burdenanticholinergic burden–– sedationsedationsedationsedation

UI and Cognitive impairmentUI and Cognitive impairmentg pg p Delirium is often multifactoral in etiology Delirium is often multifactoral in etiology

(R b t l 2009 Wh t k 2006)(R b t l 2009 Wh t k 2006)(Reuben et al., 2009; Whytock, 2006)(Reuben et al., 2009; Whytock, 2006)–– Urinary tract infection and medications Urinary tract infection and medications

common causescommon causescommon causescommon causes Delirium interferes with awareness of Delirium interferes with awareness of

surrounding and ability to care for oneself surrounding and ability to care for oneself surrounding and ability to care for oneself. surrounding and ability to care for oneself. –– One of the factors to be considered in older One of the factors to be considered in older

adults with acute onset urinary incontinenceadults with acute onset urinary incontinenceyy–– A previously functionally independent A previously functionally independent

community dwelling older adult might community dwelling older adult might b dd l d d t b dd l d d t become suddenly dependent become suddenly dependent

UI and Cognitive impairmentUI and Cognitive impairmentg pg p Dementia affects many domains of Dementia affects many domains of

cognitioncognition Interferes with ability to carryout normal Interferes with ability to carryout normal y yy y

ADLs ADLs -- including toileting. including toileting. Dementias are neurological conditions Dementias are neurological conditions gg

that can impair cortical inhibition of the that can impair cortical inhibition of the bladder and lead to bladder and lead to neurogenicneurogenic detrusordetrusorggoveractivityoveractivity

(Dubeau et. al., 2009; Eustace et. al. 2007; Krissovich, 2006)

Second Cause of Second Cause of Institutionalization in the ElderlyInstitutionalization in the Elderly

Does UI predict NH placement?Does UI predict NH placement?p pp p Studies are inconclusive.Studies are inconclusive. N= 5986 HMO members, aged 65 years and N= 5986 HMO members, aged 65 years and

older (US)older (US)–– adjusted risk of admission to a nursing facility adjusted risk of admission to a nursing facility

2.0 times greater for incontinent women and 3.2 2.0 times greater for incontinent women and 3.2 times greater for incontinent men times greater for incontinent men (Th t l 1997)(Th t l 1997)times greater for incontinent men times greater for incontinent men (Thom et al 1997)(Thom et al 1997)

N= 4,646 PACE participants 55 years and N= 4,646 PACE participants 55 years and older (US)older (US)older (US)older (US)–– Bowel incontinence independent predictor of Bowel incontinence independent predictor of

institutionalization, but not UI institutionalization, but not UI (Freidman et al 2005)(Freidman et al 2005) institutionalization, but not UI institutionalization, but not UI (Freidman et al 2005)(Freidman et al 2005). .

Does UI predict NH placement?Does UI predict NH placement?p pp p N= 6,506 community dwelling aged 70 and older N= 6,506 community dwelling aged 70 and older

(US) (US) (US) (US) Overall UI not to be a strong independent risk factor Overall UI not to be a strong independent risk factor

for NH placementfor NH placement However in subgroups with higher levels of caregiver However in subgroups with higher levels of caregiver However, in subgroups with higher levels of caregiver However, in subgroups with higher levels of caregiver

burden (baseline ADL dependence, visual burden (baseline ADL dependence, visual impairment, high BMI, previous smoking history) it impairment, high BMI, previous smoking history) it was was (Holroyd(Holroyd--Leduc et al 2004). Leduc et al 2004). was was (Holroyd(Holroyd Leduc et al 2004). Leduc et al 2004).

Systematic review of US studies of predictors of NH Systematic review of US studies of predictors of NH admission for people with dementia N=39,526admission for people with dementia N=39,526p pp p Incontinence NOT a consistent predictor of NH Incontinence NOT a consistent predictor of NH

admissionadmission Caregiver stress the most significant predictor Caregiver stress the most significant predictor ((GauglerGaugler et et g g pg g p (( gg

al 2009)al 2009)

Does UI predict NH placement?Does UI predict NH placement?p pp p

UI alone does not predict NH placement UI alone does not predict NH placement U a o e does ot p ed ct N p ace e t U a o e does ot p ed ct N p ace e t for frail older adults, but may be one for frail older adults, but may be one factor that adds to caregiver burden and factor that adds to caregiver burden and ggstressstress

UI & CaregivingUI & CaregivingSignificant BurdenSignificant BurdenCurrent ResearchCurrent ResearchCurrent ResearchCurrent Research

The effect of urinary incontinence on the The effect of urinary incontinence on the emotional health of spouses, in general, emotional health of spouses, in general,

d l i i ti l hd l i i ti l hand spousal caregivers, in particular has and spousal caregivers, in particular has been relatively neglected.been relatively neglected.

Fultz N.H. (2005), The impact of own and spouse’s urinary incontinence on depressive symptoms, Social Science andFultz N.H. (2005), The impact of own and spouse s urinary incontinence on depressive symptoms, Social Science and Medicine, 60, 2537-2548.Cassells C and Watt E (2003) The impact of incontinence on older spousal caregivers (2003), Journal of Advanced Nursing, Issues and Innovations in Nursing Practice, 42(6), 607-616.

Informal Informal CaregivingCaregiving: : Limited ResearchLimited ResearchLimited ResearchLimited Research

•• Large number of informal caregivers providing Large number of informal caregivers providing g g p gg g p gcare to prevent and/or manage incontinence (an care to prevent and/or manage incontinence (an estimated 10 and 7 million respectively)estimated 10 and 7 million respectively)

Li it d h i i th i t f Li it d h i i th i t f –– Limited research examining the impact of Limited research examining the impact of incontinence on caregiver burden incontinence on caregiver burden

–– Most studies focused on urinary incontinence alone or in Most studies focused on urinary incontinence alone or in combination with fecal incontinencecombination with fecal incontinence•• Little research examining the impact of only fecal incontinence Little research examining the impact of only fecal incontinence

–– The majority of care recipients had dementiaThe majority of care recipients had dementia–– Methodologies variedMethodologies varied

Impact of UI on Other Measures of Impact of UI on Other Measures of Caregivers Impact/Burden: U S StudiesCaregivers Impact/Burden: U S StudiesCaregivers Impact/Burden: U.S. StudiesCaregivers Impact/Burden: U.S. Studies

•• UI management rated as third most UI management rated as third most ggtroublesome troublesome caregivingcaregiving task (behind a lack task (behind a lack of time for their own needs and managing of time for their own needs and managing care recipient emotional/ behavioral care recipient emotional/ behavioral p /p /problems)problems)

•• 30% of caregivers did not feel prepared to 30% of caregivers did not feel prepared to deal with UIdeal with UIdeal with UIdeal with UI

Colling J, Owen TR, McCreedy M, Newman D . The effects of a continence program on frail community-dwelling elderly persons. .Urol Nurs. 2003 Apr;23(2):117-22, 127-31

Impact of Urinary Incontinence on Impact of Urinary Incontinence on Caregiver Burden: U S StudiesCaregiver Burden: U S StudiesCaregiver Burden: U.S. StudiesCaregiver Burden: U.S. Studies•• Examined caregiver burden in persons caring for Examined caregiver burden in persons caring for g p gg p g

cognitively impaired care recipients with UI; cognitively impaired care recipients with UI; caregivers reported that UI caregivers reported that UI –– Was sometimes a burdenWas sometimes a burdenWas sometimes a burdenWas sometimes a burden–– Frequently had a negative impact on themFrequently had a negative impact on them

•• Some/great deal of strain reported Some/great deal of strain reported UIUI l d d l d d 56%56%–– UIUI--related odor related odor –– 56%56%

–– Toileting Toileting –– 55%55%–– Changing pad/clothing Changing pad/clothing –– 53%53%g g p / gg g p / g–– UIUI--related costs (pads/briefs) related costs (pads/briefs) –– 53%53%–– Wet clothing Wet clothing –– 50%50%–– Changing bed linen Changing bed linen –– 44%44%–– Changing bed linen Changing bed linen –– 44%44%

EngbergEngberg et al., 2002et al., 2002

Impact of UI on Indirect Measures of Impact of UI on Indirect Measures of Caregivers Burden: U S StudiesCaregivers Burden: U S StudiesCaregivers Burden: U.S. StudiesCaregivers Burden: U.S. Studies

•• Caregivers of early stroke Caregivers of early stroke survivors rated managing survivors rated managing g gg gUI as the second most UI as the second most common problem and the common problem and the

di i bl di i blmost distressing problemmost distressing problem

Grant JS, Glandon GL, Elliott TR, Giger JN, Weaver M. Caregiving problems and feelings expereinced by family caregivers of stroke survivors the first month after discahrge. Int J Rehabil Res. 2004 Jun;27(2):105-11

Impact of UI on Other Measures of Impact of UI on Other Measures of Caregivers Impact/Burden: U S StudiesCaregivers Impact/Burden: U S StudiesCaregivers Impact/Burden: U.S. StudiesCaregivers Impact/Burden: U.S. Studies

•• Associated with increased adjusted Associated with increased adjusted jjcaregivingcaregiving hours/week relative to caring for hours/week relative to caring for persons who were continentpersons who were continentWh h i i h Wh h i i h •• When the incontinence was severe enough to When the incontinence was severe enough to require pad/garments, the hours were even require pad/garments, the hours were even higher higher higher higher

•• In the In the U. S., U. S., national financial annual costs of national financial annual costs of more than $6 billion for incontinencemore than $6 billion for incontinence--related related informal care has been estimatedinformal care has been estimated

Langa K.M. et al (2002), Informal Caregivers Time and Costs for Urinary Incontinence in Older Individuals in Langa K.M. et al (2002), Informal Caregivers Time and Costs for Urinary Incontinence in Older Individuals in the United States, Journal of the American Geriatrics Society, April, 50(4), 733the United States, Journal of the American Geriatrics Society, April, 50(4), 733--737.737.

Falls and UIFalls and UI Among community dwelling older adults, Among community dwelling older adults,

t LUTS h b i t d ith t LUTS h b i t d ith storage LUTS have been associated with storage LUTS have been associated with increased fall risk increased fall risk

((VoaklanderVoaklander et al 2006; et al 2006; TakazawaTakazawa & & ArisawaArisawa, 2005; Tromp et al 1998; Tromp et al 2001) , 2005; Tromp et al 1998; Tromp et al 2001)

Type of UI may be a factor Type of UI may be a factor ––community studiescommunity studiescommunity studiescommunity studies

–– N=6,049 older women, UUI weekly or more N=6,049 older women, UUI weekly or more was associated with falls risk (OR = 1.26) and was associated with falls risk (OR = 1.26) and f t SUI t f t SUI t fractures, SUI was not fractures, SUI was not (Brown et al 2000)(Brown et al 2000)

A f il ld th ith i d A f il ld th ith i d –– Among frail older women, those with mixed Among frail older women, those with mixed UI 3.05 times more likely to fall, SUI and UUI UI 3.05 times more likely to fall, SUI and UUI alone not associated with falls alone not associated with falls ((TakazawaTakazawa et al 2005)et al 2005)alone not associated with falls alone not associated with falls ((TakazawaTakazawa et al, 2005)et al, 2005)

Type of UIType of UIypyp Chiarelli et al (2009) conducted a Chiarelli et al (2009) conducted a

systematic review to examine the systematic review to examine the association of UI and falls in community association of UI and falls in community elderselders–– 9 studies, data from N=15,679 pooled9 studies, data from N=15,679 pooled

•• UUI UUI –– OR for falls 1.94OR for falls 1.94•• SUI SUI –– OR for falls 1.11OR for falls 1.11•• Mixed UI Mixed UI –– OR for falls 1.92OR for falls 1.92

OAB symptoms and falls OAB symptoms and falls y py p Urinary urgency and UUI both fall risk factors in a Urinary urgency and UUI both fall risk factors in a

Finish study of 1016 adults 70 years and older. Finish study of 1016 adults 70 years and older. ((LuukinenLuukineny yy y ((1996)1996)

NOBLE survey (n= 397 cases and 522 controls), those NOBLE survey (n= 397 cases and 522 controls), those with OAB increased risk of injury related to a fall (OR = with OAB increased risk of injury related to a fall (OR = 2 26) 2 26) 2.26). 2.26). (Wagner 2002) (Wagner 2002)

N= 405 Taiwanese community seniors, N= 405 Taiwanese community seniors, urinary frequency or UUI were factors that urinary frequency or UUI were factors that y q yy q ypredicted falls predicted falls ((HuiHui--Chi 2004)Chi 2004)

NocturiaNocturia episodes at least twice nightly episodes at least twice nightly i ifi tl i ifi tl ii k f f ll (OR 1 84) i k k f f ll (OR 1 84) i k significantly significantly ririsk of falls (OR = 1.84), risk sk of falls (OR = 1.84), risk

increased in those reporting more than three increased in those reporting more than three episodes (OR = 2.15) episodes (OR = 2.15) (Stewart et al 1992)(Stewart et al 1992)p ( )p ( )

The current status:The current status: Despite the link between LUTS and falls in Despite the link between LUTS and falls in

it d lli ld d lt f it d lli ld d lt f community dwelling older adults, few community dwelling older adults, few intervention studies to reduce falls have intervention studies to reduce falls have included urinary symptomsincluded urinary symptomsincluded urinary symptomsincluded urinary symptoms

Both the NICE Guidelines (UK) (2004) and Both the NICE Guidelines (UK) (2004) and Both the NICE Guidelines (UK) (2004) and Both the NICE Guidelines (UK) (2004) and AGS/BGS (2011) revised falls guidelines AGS/BGS (2011) revised falls guidelines suggest including continence assessment as a suggest including continence assessment as a part of falls risk assessment, there is not part of falls risk assessment, there is not enough research from which to develop enough research from which to develop evidence based interventions evidence based interventions evidence based interventions. evidence based interventions.

Research gap: Is balance and gait affected by Research gap: Is balance and gait affected by LUTS? LUTS? LUTS? LUTS?

Earlier explanations of the association between falls Earlier explanations of the association between falls d UI t d d t b i li ti (d UI t d d t b i li ti ( li i i ) li i i )and UI tended to be simplistic (and UI tended to be simplistic (egeg. slipping on urine). slipping on urine)

Literature has been emerging that supports a much Literature has been emerging that supports a much more complex relationshipmore complex relationship Wolf (2000) suggested that divided attention may play a Wolf (2000) suggested that divided attention may play a

role in falls risk in someone focused on trying to urgently role in falls risk in someone focused on trying to urgently reach the bathroom reach the bathroom L kL k t l (2000) t d i f it d b l t l (2000) t d i f it d b l LemackLemack et al (2000) reported worsening of gait and balance et al (2000) reported worsening of gait and balance disturbances in PD patients when urinary symptoms also disturbances in PD patients when urinary symptoms also present present -- involvement of spinal and higher level cognitive involvement of spinal and higher level cognitive functions?functions?

Smith et al (2008) reported changes in balance in midSmith et al (2008) reported changes in balance in mid--life life women with comparing empty with full bladder stateswomen with comparing empty with full bladder states

Addressing the research gapAddressing the research gapg g pg g p Pilot studies examining gait and balance Pilot studies examining gait and balance

changes related to bladder symptoms changes related to bladder symptoms among competent community based among competent community based older older adults adults with OAB now under way at several with OAB now under way at several centrescentres Data relating to frail older adults is Data relating to frail older adults is

lacking, but may be an important avenue lacking, but may be an important avenue g y pg y pto pursue in future falls prevention to pursue in future falls prevention studiesstudies

Continence Assessment of Continence Assessment of Community Frail Older AdultsCommunity Frail Older AdultsCommunity Frail Older AdultsCommunity Frail Older AdultsInterdisciplinary Assessment: Interdisciplinary Assessment: Functional assessment (mobility, manual Functional assessment (mobility, manual

dexterity, activities of daily living)dexterity, activities of daily living) Cognitive assessmentCognitive assessment Home environment assessmentHome environment assessmentHome environment assessmentHome environment assessment Medication reviewMedication review Bladder diaryBladder diary Bladder diaryBladder diary

–– Caregiver can assist if neededCaregiver can assist if needed

AssessmentAssessment

Those experiencing or at risk for falls should Those experiencing or at risk for falls should have a Falls Assessment which have a Falls Assessment which includesincludesassessment of continence and other urinary assessment of continence and other urinary symptoms (NICE, 2004; symptoms (NICE, 2004; Panel on Prevention Panel on Prevention of Falls in Older Persons 2011)of Falls in Older Persons 2011)of Falls in Older Persons, 2011)of Falls in Older Persons, 2011)

Little evidence this occursLittle evidence this occurs Little evidence this occursLittle evidence this occurs Access to continence services may be limited Access to continence services may be limited

in some jurisdictionsin some jurisdictionsin some jurisdictionsin some jurisdictions

Assessment and InterventionsAssessment and InterventionsRecommended in the International Recommended in the International

Consultation on Incontinence algorithm Consultation on Incontinence algorithm on assessment and management of on assessment and management of incontinence in frail elders incontinence in frail elders (Dubeau et.al., 2009)(Dubeau et.al., 2009)

Basic Basic AssessmentAssessmentBasic Basic AssessmentAssessment Active case finding for UI should be done in all

older persons (Grade A)older persons (Grade A).

Screening for frailty is possible (Grade A) and d (G d C)encouraged (Grade C).

The basic assessment of UI should focus on identification of potentially treatable conditions and factors that may cause or worsen UI, contribute to its burden, and impact management decisions (Grades A C)decisions (Grades A-C).

DuBeau CE Kuchel GA Johnson T Palmer MH Wagg A (2009) Incontinence in the frail elderly In P Abrams L Cardozo SDuBeau, CE, Kuchel, GA, Johnson, T, Palmer, MH, Wagg, A (2009) Incontinence in the frail elderly. In P. Abrams, L. Cardozo, S. Khoury, & A. Wein (Eds.), Incontinence: Proceedings from the Fourth International Consultation on Incontinence. (pp. 961-1024).Plymouth, UK: Health Publications, Ltd.

Factors in Management of UI in AdultsFactors in Management of UI in Adults

Behavioral treatmentBehavioral treatment Behavioral treatmentBehavioral treatment–– Availability and willingness of caregiversAvailability and willingness of caregivers

Drug treatmentDrug treatmentAA l d d ff d h dll d d ff d h dl–– AgeAge--related differences in drug handlingrelated differences in drug handling

–– DrugDrug--drug, drugdrug, drug--disease interactionsdisease interactions–– Adverse effects, especially cognitiveAdverse effects, especially cognitive–– CountryCountry--specific guidelines, formulariesspecific guidelines, formularies

SurgerySurgery–– Nihilism and small number of studiesNihilism and small number of studies

Estimating costs and benefitEstimating costs and benefit–– Importance of “intangibles,” reimbursementImportance of “intangibles,” reimbursement

Two Broad Categories of Behavioral Two Broad Categories of Behavioral StrategiesStrategiesStrategiesStrategies

Patient DependentPatient Dependent Patient DependentPatient Dependent–– Pelvic muscle exercises, Pelvic muscle exercises, bladder training, bladder training,

fluid managementfluid managementfluid managementfluid management–– Requires ability to learn and retain new skillsRequires ability to learn and retain new skills

Caregiver DependentCaregiver DependentCaregiver DependentCaregiver Dependent–– Scheduled voiding, Scheduled voiding, timed voiding, and timed voiding, and

prompted voidingprompted voidingp p gp p g–– Requires someone to assist the residentRequires someone to assist the resident

Johnson,TJohnson,T 2002, JAMDA2002, JAMDA

Problems that Can Impact Continence Problems that Can Impact Continence StatusStatusStatusStatus

Not able toNot able to::Not able toNot able to::–– Identify the urge to voidIdentify the urge to void

Remember how to respond to the urgeRemember how to respond to the urge–– Remember how to respond to the urgeRemember how to respond to the urge–– Remember where the toilet is locatedRemember where the toilet is located

To sit on the toiletTo sit on the toilet–– To sit on the toiletTo sit on the toilet–– To communicate the need for assistanceTo communicate the need for assistance

To understand verbal reminders for toiletingTo understand verbal reminders for toileting–– To understand verbal reminders for toiletingTo understand verbal reminders for toileting

Jirovec 1986Jirovec 1986

InterventionsInterventions Alter environment Alter environment –– remove obstacle course!remove obstacle course! Equipment Equipment

•• Mobility and bathroom equipmentMobility and bathroom equipment•• Commode by bedsideCommode by bedside•• Easy off clothingEasy off clothing

Timed toileting/prompted voiding initially Timed toileting/prompted voiding initially Timed toileting/prompted voiding initially, Timed toileting/prompted voiding initially, possibly followed by bladder trainingpossibly followed by bladder training

Potential burden on caregiver?Potential burden on caregiver?–– Potential burden on caregiver?Potential burden on caregiver? Containment products Containment products

Fl id t Fl id t d ti d ti Fluid management Fluid management –– may need promptingmay need prompting

InterventionsInterventions

Pelvic floor muscle exercises?Pelvic floor muscle exercises?–– Some evidence that older community based Some evidence that older community based yy

women can benefit from PFME women can benefit from PFME (e.g. Perrin et al 2005) (e.g. Perrin et al 2005)

–– Studies in the physically/cognitively frail are Studies in the physically/cognitively frail are not availablenot available•• Those with cognitive impairment may not be able Those with cognitive impairment may not be able

to undertake thisto undertake thisto undertake thisto undertake this•• Further research with physically frail individuals Further research with physically frail individuals

is neededis needed

SummarySummaryyy Incontinence is an issue that is often Incontinence is an issue that is often

experienced by older community dwelling experienced by older community dwelling -- and may be more problematic in those and may be more problematic in those with cognitive or physical frailtywith cognitive or physical frailty Incontinence and other LUTS are linked to Incontinence and other LUTS are linked to

cognitive impairment and falls cognitive impairment and falls Assessment and management of UI in frail Assessment and management of UI in frail gg

community dwelling older adults can be community dwelling older adults can be improvedimprovedpp