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Diane Newman: Well, I've been treating individuals with incontinence since 1986. I've been at Penn for 23 years. I know how frustrating a problem is, but I love my practice because it's so rewarding when people get better, so I'm really hopeful that I'm going to be able to share with you some things that you can do with a loved one or friend, whoever, who may have some memory issues with dementia. Let's just start though. I want you to understand about the bladder, because really, to start helping these individuals, you need to understand what we're talking about as far as anatomy and that, but basically the bladder is a muscle. It is on the lower urinary tract. It holds urine that the kidneys make, and it fills very slowly. It actually is flat like a pancake. As it fills with urine, it rises up to the abdomen, up to the belly button, almost like a football. Basically, as a muscle, it can expand or it can shrink, and that's really important when we talk about bladder symptoms such as incontinence.

I like this slide because it shows you the side view of a man and a woman. What's important about this is the fact that we have an upper and lower urinary tract. The upper urinary tract is the kidneys and the ureters. The kidneys, of course, get all the waste from our blood and get rid of it so that we don't get sick in that, and the ureters, I always say, are like a cooked number 11 spaghetti noodle. They're very thin, but they are the vehicle to get the urine down to the bladder. When we talk about incontinence, we're talking about the lower urinary tract, and that's the bladder and the urethra, which is a tube that goes from the bladder to the outside, which is how the urine comes out. What's different though is men and women. Men have a long urethra and us women have a short one.

It's believed that women have more urinary tract infections because that urethra is so short that the bacteria just doesn't have that far to travel up into our bladder to get it infected, but it's important that we realize the importance of the length of that urethra. Now, when do you have to go to the bathroom? Well, usually the first sensation to go is when your bladder is about half full, which is about two cups. If it can expand, it can go to four cups, it can go to 13 ounces, but it's really healthy to urinate about every three to four hours. I say that because a lot of people that I see go to the bathroom every two hours and you may be dealing with a loved one who has to go even more frequently. But as we get older, we do have to go more frequently and that those kidneys may be producing more urine because of other problems that we have, such as heart problems, blood pressure problems, and that where more urine is produced. That's why we tend to see, as we age, we're going to the bathroom more frequently.

This is a very important side, is that it's important to understand that urination, or voiding, or what my patients call peeing basically is really controlled by your brain and your nerves because your brain tells you when you have to go to the bathroom. Once we were all toilet-trained, we knew what that sensation meant. If you have any problem with your brain or the nerves in your spinal cord, you're going to have problems with your bladder. We see that with individuals who have Parkinson's, we see that with individuals who have MS, any neurologic problem. If they have a spinal cord injury, you may be incontinent, you may be losing urine, or basically you cannot urinate, so it's very important to understand that with dementia and memory loss, we lose the understanding of what to do with that urge, what to do with that bladder.

It's really because of the changes in the brain, so it's important to understand that why we're seeing this condition more in older individuals is because of what we call neurologic changes, changes in the brain and the nerves. Now, urinary incontinence, my patients don't come and say to me, "Well, I have urinary incontinence." They use terms like, "My bladder leaks. I had an accident, I peed on myself. I wet myself. I don't have any more control of my bladder." But basically, incontinence is when a person leaks or loses urine when they don't want to, and that's what the definition of urinary incontinence is. There are several different types. We have urgency incontinence, and this usually occurs after urgency. Usually, what we hear is people leak urine on the way to the bathroom. You may be dealing with someone about that now, who leaks, cannot make it to the bathroom.

This is part of overactive bladder, which is when someone has urgency, they can't control and they rush to the bathroom and don't make it. Stress incontinence is urine leakage with activity such as coughing, laughing, sneezing, or with effort, or what I'll hear someone say, "When I pick up my grandkids, I leak a little bit. When I bend over, when I'm gardening, when I go to stand up, I leak urine." That's stress incontinence. We tend to see that in younger individuals usually after pregnancy. About one out of three women after having a child will leak urine, and that's called stress incontinence. It's episodic, so it doesn't occur all the time. With stress incontinence, there are small amounts of urine leakage. Usually, it's drops. With urgency incontinence, it can be the entire bladder volume, whatever is in that bladder.

What we see with older adults though is mixed symptoms, so it's a combination of urgent and stress incontinence, and that tends to be what I see in older individuals. These are the other symptoms that we see: urgency. Urgency is not the desire to go to the bathroom. Urgency is sudden. It comes on very suddenly. I hear in Philly, "Oh, honey. When I got to go, I got to go. I don't know I'm going to go, I don't know it's going to come on." What happens is we develop these behaviors or habits where we're going more frequently because we're worried about when that urgency is going to come and we fear that we're going to leak urine. That's what you see as far as frequency. We may have to get up at night to urinate and some people may be bed wetters where they wet the bed because they're not aware that they have to go.

This is an important slide because aging is not the cause of urinary incontinence, but there are a lot of associated problems that can cause bladder dysfunction, memory changes, impaired mobility, frailty, even heart disease, because what happens with heart disease is we have these fluid shifts and that may cause us to have more urine in our bladder and we can't control it. Even though aging doesn't cause incontinence, it can affect the bladder. These are some terms we see with that older adult. Functional, which means that the bladder is okay, but because I'm slow now, I don't know, maybe I had a stroke, I can't make it to the bathroom as quickly, or again, memory changes that may cause me to have incontinence. But most of what we've seen in an older adult is multifactorial where it's outside the bladder, medications may be causing it. I'll give you a list of medications that can affect the bladder. Something else may be related and causing the incontinence.

What we know about it is that it's not normal, it's common. It affects both men and women. You should not be ashamed about it. We can do something about it. Sometimes just healthy bladder habits can improve the problem, but I have to stress to you that this is really a problem for women across the lifespan. We start to see incontinence with women in the childbearing years, and then we go through menopause. With aging men, we tended to see older men who have this problem. These next two slides just show you that prevalence. As you can see, that first error is in the menopausal years, we realized that in order to keep the bladder healthy and the tissue in that area healthy, we need estrogen, the hormone estrogen. When we go through menopause, we lose that estrogen hormone. That makes that area frail and irritable and that's when we start to see bladder symptoms, and then as we age.

In men, this pattern is a little different. As you can see, it's not that common in younger men, it's only with aging men, and that's because of their prostate gland, which is at the base of the bladder, and that can be enlarged causing issues with bladder symptoms or it could be they may have prostate cancer. If we do something to the prostate, it can cause incontinence and bladder dysfunction, but it really does impact quality of life. We've seen an association with depression, anxiety. It really affects self-esteem. People are embarrassed, they're shameful. They won't tell it. What I find a lot in older adults is that they don't want to tell their children. They'll hide it because they're worried about the fact that, "Oh, if they find out, they're going to move me maybe out of my home." Really, it's really something that people are very ashamed of and really internalize and don't let people know, especially their loved ones.

We know that we have a lot more data now in younger women where it does impact work productivity, the lack of being able to go to the bathroom when you want to. You may be in a job where you only get one or two breaks during your eight or 10-hour shift. Well, you may have to go more frequently, so it really can affect work. Now, I told you that it's not normal for aging, because you're older that you have a problem, but there are changes in the bladder that are important. Number one, you produce most of your urine at night. By that, I mean when you're flat. Because we start to develop high blood pressure, some cardiac insufficiency, we have fluid that goes to what we call extracellular places; that's why you'll see swelling in legs, because during the day, the person's upright, maybe sitting in a chair, and the fluid goes to the external. The lowest area of gravity, it's in our legs.

When you're flat, you diurese, which means your kidneys produce more urine because that fluid's shifting back through the body, so you produce more urine at night. That's probably the worst time because you're asleep and you don't want to fall to get up to go to the bathroom. The bladder doesn't hold as much. It's not as efficient with really holding that urine. When we urinate, there may be a little bit more left. I hear all the time, "Well, Diane, I think I'm done, and then I go to get off the toilet or I have to go back again." A couple ounces is normal, so that may happen. It becomes overactive, so like I said, it just wants to empty when it wants to, and then sometimes it doesn't give me a warning, and because, functionally, we're not as fast at walking in that, we have less time to get to the bathroom.

What is a real concern, and I am actually doing some research in this area that's supported by NIH, is that falls are directly related to us going to the bathroom, and we have more and more data. The data was first on women who were breaking hips, breaking knees, large bones. They found out that when that occurred, the event that triggered the fall was walking to the bathroom usually at night. We now have data in men. This is getting a lot more interest at the Medicare level because it's costing so much money repairing these bones, so we really are at risk. Incontinence and urgency frequency can really place a person at risk for falls, and this is a real concern. I'm sure it's a concern if you're dealing with someone. Like I said, there are certain medications that can worsen bladder problems, and a lot of people that I see that are older are on many of these medications.

A diuretic, which is a water pill, if you're producing urine, you're going to have to go pee more often. That makes sense, doesn't it? But there are other medications. A lot of medications we take over the counter. Cold remedies can actually affect the bladder. Pain, because you don't know you have to go because you're taking those signals out of your brain with some pain medication, so there's really a lot. We also feel that some of the medications we're taking to improve our memory actually has an adverse effect on our bladder. I mean, sometimes I just work with people on what medications they are taking. Can we change the class of medications because of the impact on the bladder? That's something that I really recommend that people do talk to their provider about whether that medication, especially if you have someone who started on a new medication and you're starting to notice worsening bladder problems or new bladder problems like incontinence, it can be related to the medication.

This is some of the quotes that I hear. "You just get used to it," as far as caring for someone. The more often you do it, it becomes a routine. Caregiving is not easy when you have someone with incontinence. I want to stress to you, I don't know any of you that are dealing with this, what the data has shown is that incontinence, urinary incontinence specifically, is the second leading cause of institutionalization of the elderly. By the way, the main cause is Alzheimer's, memory changes. But when you do survey data of caregivers, and this was done I think at the University of Pittsburgh, they surveyed caregivers of older adults, and they found out that incontinence was the number one reason why they would look for placement. "If mom wet the chairs, if mom wet the bed, I just can't deal with it anymore." They look for movement into a more skilled facility of care.

There is drug therapy for incontinence, specifically for overactive bladder, urgency, frequency, and urgency incontinence. These are all the medications. I think they can be appropriately used. I will stress to you though, there's one agent called Ditropan or oxybutynin that I see prescribed a lot in older adults. This actually can worsen memory, and I try not to prescribe it to my older patients. You may want to look at medications, because this tends to be the first medication providers will go to because, I hate to say, it's cheap, it's generic. The newer medications down the bottom, Myrbetriq and Gemtesa, are a different class. They may be better, and I do recommend that if you even have someone in their 90s, I do prescribe Myrbetriq or Gemtesa. These can help with overactive bladder. What they do is they relax the bladder so you're not given that overactivity, giving you more time to get to the bathroom, so these can be very helpful.

But like I say, you want to consider concerns with some of the ones on that first list. The chart on the top on the left and the chart on the right are something we call antimuscarinics. They're anticholinergics, and they can affect memory. If you have a provider who wants to prescribe a drug for your loved one or whoever you're caring for, you want to say to them, "Is it going to have a negative effect on their memory? Their memory right now may not be good." Please be understanding that these drugs can have an effect because they go into the brain. It can affect memory. I want to give you some practical things to do though that might help. Number one, how much is someone drinking? Too much can cause problems, too little can result in concentrating urine causing problems.

I have people do diaries, almost like you do a food diary. How much are you drinking? Really, it should be normal, and there are actually fluid charts online that you can get and put in the person's weight to find out how much they should be drinking. You also want to space the fluid throughout the day and then not maybe after supper, because if you drink in the evening hours, you're going to get up to pee during the night. That's just a given when you drink those fluids, but you don't want to restrict someone because that can lead to some other problems like dehydration. Diet really does impact the bladder, and I'm giving you some things that do. One is caffeine. A lot of people need their coffee, their tea, sodas, chocolate. Easter's just in two days. A lot of chocolate, milk chocolate has caffeine. We are really a caffeinated society. This sounds simple, but I cannot stress to you enough that if you cut down on caffeinated products, you will see urinary symptoms improve.

We also see it in artificial sweeteners like Equal. We also see it in tomato-based products like spaghetti, tomato-based, or Mexican, spicy foods. Alcohol, you may want to have a couple of glasses of wine with dinner. You're probably going to have to get up to urinate at night. I have a handout on this. If you want, I can email the group here as far as some of the handouts I use if you want to provide them. It's a whole page about things in the diet. A lot of my patients will say, "Well, Diane, you took away everything I like. What's left?" Really, it's not to take away and restrict you. It's to find out does something worsen the symptoms so that you can make a decision whether, I don't know, you drink that extra cup of coffee or whatever, so I think this can be very helpful.

As far as during the night, like I said, you want to stop drinking after dinner. Maybe if you end dinner at 7:00, you don't want to be drinking after that before you go to bed because you're going to get up to pee. I have a lot of my patients tell me, "Well, I like that water jug next to my bed because I'm dry during the night." Well, if you're going to drink, you're going to have to get up. Cut out maybe that coffee or tea with dinner so you're not having caffeine. You may have it in the morning but not in the evening. If you have swelling, if you have some congestive heart failure or high blood pressure and you notice swelling at the end of the day, then you know that fluid's going to get back to those kidneys during the night.

I'm a big believer in support stockings, not the heavy thick things you get in the hospital, but go to a pharmacy and get some nice support stockings. Wear them during the day. Elevate your legs, put them on a pillow, watch TV, put them on a recliner during that late afternoon. That will cause that fluid to get back through the kidneys. The other thing is if you're taking a water pill, this is a little hint I tell individuals, so if you take that diuretic, a lot of people say, "Well, I take it once a day and it's always in the morning." Well, if you take the water pill in the morning, it's going to work over the next six hours. That's what we call half-life. Well, that's great. You get rid of that extra fluid maybe by 2:00 in the afternoon, then it starts to accumulate again. What happens? You're going to have to get rid of it during the night. I suggest, and a lot of geriatricians will suggest, that you take the water pill in the afternoon.

If it's a once-a-day water pill, take it at 3:00 or 4:00, so you get rid of that fluid during those evening hours and then you'll be a little bit better during the night where you won't have that extra fluid on board. This is, I think, one of my most important slides, your bowels. I didn't show you a picture, but right behind the bladder in women is the vagina. In men, it's the rectum, and then behind our vagina is our rectum. If you have hard stool that sits there because you have constipation and you have to strain or take a laxative to get that stool out, that puts pressure on the bladder. What's it going to cause? It's going to cause you to go to the bathroom more frequently. It may even cause you to leak urine. Bowels have such a relationship. We call it the pelvic area. That rectum sits down there, the bladder sits down there, the vagina sits down there, the uterus and the prostate, and in men, the urethra.

Well, it's all a tight area there, so if you have hard stool coming down that's sitting around, it's going to put pressure on the bladder. Sometimes, when I have someone who has constipation, I stop there and work with them on a bowel regimen. If you have someone who cannot get the stool out because the rectal valve, we have a rectal valve there, it's called the sphincter, it sometimes gets weaker as we age, a suppository is really good, but I really... Setting a time to have your bowel movement every day is important. People will tell me, "Well, coffee makes me move my bowels." We tend to move our bowels in the morning, because during the night, we're at rest and that stool moves through... It's called a gastrocolic reflex. The stool moves through the colon and then dumps into the rectum so we feel like we have to have a bowel movement in the morning. Warm temperature fluid will stimulate the bowels to move. That's why maybe coffee stimulates somewhat and move.

It's not actually what's in the coffee. It's probably the temperature, also maybe why warm oatmeal also stimulates. Having something warm in the morning, I tell my patients to do warm water with lemon or something that will stimulate the bowel. Also, they've shown in children who have spina bifida that if you put [inaudible 00:21:20] and you give them something warm to drink, and then you put them on the toilet, you can have it train the bowel to move in the morning. It may be something that you consider with your loved one or whoever you're caring for. You can inhibit the bowel movement. What happens though is that that stool just sits there and gets harder and harder, so you may want to come up with a set time to move your bowels. You have to train the bowel, so that's a really important thing to remember.

Toileting programs do work. This is what we call scheduled toileting. This was actually researched way back in the '70s in, actually, England, in the United Kingdom and London hospitals. They called it bladder drill. What they did is they took individuals to the toilet every two hours. Wow, they found out, hey, they were able to make that person empty their bladder, but also they didn't have as much incontinence because they caught the person before the incontinence was going to occur. You can do this, you can get into a program. I've done some research where we've really shown that older individuals, all of us go to the bathroom at the same time really every day. If you start to see a pattern, you can, what we call, toilet that individual every two hours. This is actually very helpful in someone who has memory loss. You'd be surprised.

Also, if they have mobility issues, taking them to the bathroom. Don't wait until they say, "It's so strong, I can't hold it," or they leak. You're only having incontinence. But like I said, tracking someone's habits, and that's why I really do recommend a diary. Again, I can send you a sample diary. You just maybe try to track someone's habits for the day to see if you see any patterns. You'd be surprised. It's just like a food diary that people do for weight loss. You start to see patterns of what someone's eating or when someone's peeing. Prompted voiding actually has quite a bit of research mostly in the nursing home environment. It's a combination of scheduled toileting, but you prompt the person. Nurses are really good at this. We take someone to the bathroom, we turn on water, and then we say, "Okay. Now, I'm going to give you some privacy. I want you to go to the bathroom." That's called prompting.

They've shown that if you do that, you recreate. Remember, we need to recreate what that habit is. Women sitting to go to the bathroom, we relax the whole pelvic area and we urinate. Men tend to stand, but men can also sit to urinate. But this really does work, and the research has been in individuals who have memory loss. Now, if you can try someone on this, and what the research has shown is positive reinforcement. I don't want to get it down to how we toilet train kids but... I don't know if any of you have toilet trained a child, but it is like, "Oh my goodness, you went in the bathroom. This is wonderful." I toilet trained my kid with M&Ms. They got a reward for the behavior that I wanted, which was going in the toilet, so there is some positive reinforcement as part of prompted voiding, but this has some of the best research as far as this technique working.

I want to stress to you that the research is also in those who have Alzheimer's and that this does work. For someone who knows they have to go to the bathroom, and this is retraining, so if you have someone who will say to you, "Oh, I knew I had to go but I can't make it there," or, "Oh, it just happened," but they know they have to go, we can teach them techniques to inhibit the urge, we call it. They have to be able to do that. They have to have some sensation of that urge sensation. One of the things is don't rush to the bathroom. Hurrying them along, that anxiety worsens. I teach them how to control urgency.

Again, I have a handout on this, and I do recommend... Again, I can share all this with you if this will be helpful. But as a program, where you teach them how to get rid of the urge before they walk to the bathroom, if you can get rid of the urge, that gives you more time. I'll give you the analogy of the nurse. I always tell this kind of story. Okay, we do this. We do this when we're younger without even thinking about it. The nurse is handing out medications. She's an hour behind. A patient falls out of bed on the floor and she has to go to the bathroom. She felt the urge to pee. What does she do? "Well, oh my goodness, I'm behind. Let me go help them get this poor patient back in bed." What happened to the urine in the bladder?

It didn't just disintegrate, go away. She inhibited the urge. What was that? There were three messages to her brain. "I'm behind in meds. I got to help that person off the floor. I got to pee." She threw the urge message out with something more important. Nurses are notorious, they keep doing that throughout their shift, and then all of a sudden at the end of the shift, sometimes... I mean, my daughter does 12-hour shifts, then they go pee. That's not good. You shouldn't hold urine for 8, 10, 12 hours. We actually call that nurse's bladder, but you can delay voiding. Well, that's what bladder training is, and this does work. I really want to stress this. I do this every day in my practice, and I find this to be really, really helpful.