DUBAI, UAE (UroToday.com) - Ms. Eustice opened her lecture by discussing the effect of aging on UI in women.
Vecchioli-Scaldazza & Morosetti (2010) evaluated the effect on aging by using urodynamics (UDS) to look at incidence of detrusor overactivity (DO), types of UI, pelvic organ prolapse (POP), BMI, and anorectal disorders. 84 women with UI underwent full urogynecological workups and UDS. There were 2 age groups (< 65 > 65). Results in the > 65 group indicated that urgency and mixed UI were most prevalent. There was increased bladder sensation but decreased bladder capacity and increased DO. There was a reduction in MUCP and a higher BMI was observed in older patients.[ref: Vecchioli-Scaldazza & Morosetti (2010) Effect of aging on urinary incontinence in woman Arch Ital Urol Androl. 82(3); 167-71]
But of interest to clinicians is “who are the frail elderly"? as there does not appear to be a clear definition. They are >65 and may be homebound or institutionalized. They will have lost physiologic reserve and have a clinical syndrome that includes weight loss, exhaustion, weak grip strength, slow gait speed and reduced physical activity. UI maybe an early indicator of frailty as it can be a marker. Baztan, et al. (2005) studied 205 patients admitted to a rehab unit and found that UI was associated with increased mortality or long-term care at 6 months.
Baztan, JJ et al. (2005) New onset urinary incontinence and rehabilitation outcomes in frail older patients. Age and Ageing; 34 1: 1-4
Holroyd-Leduc JM, et al. (2004) Urinary incontinence and its association with death, nursing home admission, and functional decline 52 712-718
Miles TP, et al. (2001) New-onset incontinence and markers of frailty: data from Hispanic established populations for epidemiologic studies of the elderly The Journals of Gerontology 56A M19-M24
David Fonda, a geriatrician from Australia developed the following Paradigm for Continence which is useful for determining the different phases of UI management for the frail elderly:
Recognising the particular characteristics of this group requires a positive attitude and approach from the clinician. In terms of outcome – a shift from dependent incontinence to independent may be unrealistic – Fonda illustrates this well as there may be a prevailing belief that continence cannot be achieved and therefore may not receive adequate attention. Implementing achievable treatment or management strategies may help to reduce avoidance. Thom, et al. (1997) suggests that women with incontinence are twice as likely to be admitted to a care home and men three times as likely.
[ref: Fonda, D. & Abrams, P. (2006) Cure sometimes, help always—a “continence paradigm” for all ages and conditions. Neurourology & Urodynamics 25, 290-292.]
Understanding the effects of aging on the LUT in frail elders is hampered due to lack of research. Shimanouchi studied 249 frail elders – found that women had a higher tendency towards severe UI than men (average age 79.5). Madersbacher et al. (1998) postulated that reporting of symptoms was comparable between men and women. Resnick challenged the concept of normality and the LUT = 56 volunteers – 65-101 were investigated urodynamicially. Frailty diminishes an individual’s ability to compensate for age-related changes in the lower urinary tract/bowel that an age-matched contemporary who is fit and well might achieve.
[ref: Shimanouchi S, et al. (2000) Home care for the frail elderly based on urinary incontinence level Public Health Nursing 17(6):468-473.]
Nocturnal frequency / polyuria is an extremely difficult problem to treat as it is multifactorial in nature. Interventions may be targeted at any of the individual elements and include rational fluid intake, adjustment of medication exacerbating polyuria, such as calcium channel blockers. Administration of early evening furosemide, daytime recumbently and the use of DDAVP has been shown to be efficacious in some patients. Intractable UI should not be identified as such until non-invasive therapies have been tried. Ouslander (2000) suggests that labelling UI in this way becomes a ‘self-fulfilling prophecy.’ Failure to treat reversible causes is an indicator of poor care.
[refs: Landi, F, et al. (2003) Potentially reversible risk factors and urinary incontinence in frail older people living in the community, Age and Ageing 32(2): 194-199.
Ouslander, JG (2000) Intractable incontinence in the elderly, BJU International; 85(Suppl 3): 72-78.]
Bathrooms and toilets are considered the most challenging aspects of self-care and this is where supportive OT intervention can be successful.
[refs: Gitlin LN, Miller KS & Boyce A (1999) Bathroom modifications for frail elderly renters: outcomes of a community-based program Technology and Disability; 10: 141-149.
Ouslander JG & Johnson TM (2004) Continence care for frail older adults: it is time to go beyond assessing quality J A Med Directors Assoc; 5(3): 213-216.
Achieving continence requires a positive attitude from both the sufferer and health professionals, and contributes to the elimination of denial and secrecy on the part of the older person.
[refs: Mitteness LS and Barker JC (1995) Stigmatizing a ‘normal’ condition: urinary incontinence in later life Medical Anthropology Quarterly 9(2) 188-210.
Robinson JP (2000) Managing urinary incontinence in the nursing home: residents’ perspective Journal of Advanced Nursing 31(1) 68-77.]
Assessment of the patient with UI should include screening to allow early diagnosis - simple investigations that include a 24-hour bladder diary, urine test, and bladder scan. Options for treatment include lifestyle measures, bladder retraining, and medication. Screening the elder patient for environmental issues is important, including screeing for restricted mobility, impaired dexterity, impaired vision, cognitive impairment, difficulty accessing the toilet, and the need for assistance.
So key points for practice include:
- Becoming frail may be a clinical syndrome
- Inability to compensate for these factors can lead to urinary and fecal incontinence
- Common conditions include DHIC, nocturia and constipation
- Treatment of asymptomatic bacteriuria is not appropriate
- Frail elders should not be excluded from treatment or management strategies
- Always investigate and treat the reversible causes of incontinence first
- Behavioural interventions can be successful and pharmacotherapy is useful in carefully selected frail elders
- Watch for adverse events and drug interactions when prescribing medication
- Inter-professional working is fundamental
Presented by Sharon Eustice, RN, Nurse Consultant at the 7th Pan Arab Continence Society (PACS) Annual Meeting - February 3 - 5, 2011 - Dubai, United Arab Emirates
Reported for UroToday by Diane K. Newman, RNC, MSN, CRNP, FAAN and Continence Nurse Practitioner Specialist - University of Pennsylvania Medical Center.
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