Incontinence, the sleeping geriatric giant: challenges and solutions
Adrian Wagg
Key points
The prevalence of urinary incontinence increases in association with increasing age.
Behavioural and lifestyle interventions, including exercise, are effective in older people.
There is an increasing evidence base for pharmacological therapy of urgency incontinence in the elderly and frail elderly.
Surgical management for older men and women is associated with benefit but should be performed with due regard to potential benefits and harms, remaining life expectancy, and the expectations of both patient and, where relevant, caregiver.
Continence care should ideally be based around provision by specialist nurse practitioners working within a multiprofessional, integrated service.
1 Introduction
The maintenance of continence is a basic human function, partially dependent upon intact lower urinary tract function, but also on the necessary cerebral control, not only of urination but of social appropriateness of actions, mobility, and dexterity. Continence remains a little talked about subject for many older people and ‘bladder problems or weakness’ are often thought of as a necessary part of growing older. Urinary incontinence (UI) is certainly not a part of normal ageing although lower urinary tract symptoms are highly prevalent in later life. Urinary incontinence, in a similar fashion to other problems in late life, reflects a typical geriatric syndrome, with multiple risk and modulating factors acting together to produce an end effect. Thus, urinary incontinence is as much a diagnosis as is one of ‘falls’ or ‘delirium’, and effort needs to be made to identify the underlying factors which contribute to the problem. Such complexity should not be unduly daunting. Geriatricians are well used to the complexity paradigm in the context of falls and cognitive impairment; incontinence in older people is no different.
2 Prevalence and relation to age-associated changes in the brain
The prevalence of urinary incontinence increases with increasing age, affecting approximately 11% of men and 20% of women over the age of 60 (1). In addition to usual lower urinary tract pathology, incontinence in later life is perhaps dominated by an increasing inability to inhibit voiding in response to the sensation of urge to void. Investigation of older people with urgency has revealed an increased load of white matter hyperintensities in those with symptomatic urgency and difficulty in maintaining continence. These findings also link incontinence with cognitive and functional impairment, which may be a final common pathway in the generation of late-life geriatric syndromes (2).
3 Types of incontinence
3.1 Urgency and urgency incontinence
Urinary urgency is the hallmark symptom of overactive bladder (OAB), which for approximately a third of adults is associated with urgency urinary incontinence (3). The prevalence and incidence of urgency and urgency incontinence increases with age. In the EPIC (European Prospective Investigation into Cancer and Nutrition) study of adults over 40, based upon a structured telephone interview of more than 19,000 people, 19.1% (95% CI: 17.5–20.7) community-dwelling men and 18.3% (16.9–19.6) women over the age of 60 indicated that they had urinary urgency, and 2.5% (1.9–3.1) men and 2.5% (1.9–3.0) women indicated that they had urgency incontinence (1). More recently, reports from longitudinal studies in cohorts of men and women have illustrated the age-related increase in lower urinary tract symptoms, including urgency and urgency incontinence. In the study of women, 2,911 women responded to a self-administered postal questionnaire in 1991 and 1,408 of the women replied to the same survey in 2007. Over that time, the prevalence of UI, OAB, and nocturia increased by 13%, 9%, and 20%, respectively. The proportion of women with OAB and UUI increased from 6% to 16% (4). In men (5), 7,763 responded to a self-administered postal questionnaire in 1992, and 3,257 responded to the same survey in 2009. In a similar fashion, prevalence of UI and OAB increased (overall UI from 4.5% to 10.5%; OAB from 15.6% to 44.4%). The prevalence of nocturia, urgency, slow stream, hesitancy, incomplete emptying, postmicturition dribble, and daytime frequency also increased.
3.2 Stress urinary incontinence
Stress urinary incontinence (SUI), urinary loss which occurs on exertion or effort, appears to have its peak incidence in women in mid-life. In the EPIC study (1), 8.0% (95% CI: 7.1–9.0) of women over 60 had the condition. In men, the majority of SUI occurs following prostatic surgery, with rates varying depending upon the type of operation. Transurethral resection of the prostate is associated with rates of approximately 1% (6), whereas retropubic radical prostatectomy is associated with rates between 2% and 57% (7, 8), depending upon selection, definition, and time frame, but the proportion of men with SUI is generally more prevalent in the oldest groups. EPIC revealed a prevalence of 5.2% (95% CI: 4.2–6.1) in men over 60 years of age.
3.3 Mixed urinary incontinence
Although there are operational difficulties with the definition of mixed incontinence, particularly in cystometric terms, when regarded as urinary incontinence with symptoms of both urinary urgency incontinence and exertional incontinence, mixed incontinence is highly prevalent in primary care (9). To what extent this finding reflects uncertainty in history-taking (in that severe urethral sphincter incompetence can produce a feeling of precipitant urinary loss at pressure threshold or as urine enters the bladder neck and is reported as urgency), is unclear. Some epidemiological data suggest that mixed incontinence accounts for approximately one third of all cases of incontinence in women. Even so, mixed urinary incontinence accounted for only 4.1% of incontinence in women over 60 years of age in the EPIC study, probably highlighting the difficulty with the operational definition (1, 10).
3.4 Nocturnal enuresis
Whereas nocturia is extremely common in older people, nocturnal enuresis is less so. In a study of 3,884 community-dwelling men and women aged 65 to 79, nocturnal enuresis was reported by 2.1%, and was significantly higher among women (2.9%) than men (11). It is often accompanied by other associated lower urinary tract symptoms and complicated by associated co-morbid conditions or the effects of medications affecting sleep. Congestive heart failure, functional disability, depression, nocturnal polyuria, and use of hypnotics at least once per week have been associated with the condition. Adult-onset nocturnal enuresis without daytime symptoms in an older person without significant co-morbidity is a serious symptom. Usually it is a sign of significant urological pathology and should be thoroughly investigated (12).
3.5 Functional incontinence
Urinary incontinence in older people may be wholly unrelated to lower urinary tract abnormality. Successful toileting requires sufficient cognitive and physical function, including manual dexterity, to reach the toilet, undress, and void in a timely and socially appropriate fashion. For many frail older people, the burden of either physical or cognitive impairment renders this less likely. Incontinence in these situations is termed functional. There is little systematic evaluation or assessment of either the prevalence or management of this clinical entity. Much that is practised is as a result of received wisdom, involving lifestyle and behavioural techniques employed for the general management of incontinence in frail older people.
4 Voiding inefficiency
The finding of a post-voiding residual volume of urine is far from uncommon in an older population. In one survey of community-dwelling men and women over age 75, more than 10 ml of residual urine was found in 91 of the 92 men (median 90 ml; range 10–1502 ml) and in 44 of the 48 women (median 45 ml; range 0–180 ml) (13). In a study of men undergoing urological work-up, the finding of a post-void residual greater than 50 ml was 2.5 times greater for men with a prostate volume greater than 30 ml than in those with smaller prostates. Men with a post-void residual greater than 50 ml were about three times as likely to have subsequent acute urinary retention with catheterization during the subsequent three to four years (14). A separate study in older women found a residual volume of 100mL or more in up to 10% of older women, many of whom were asymptomatic. It appeared that the residual volume remitted over a two-year period (15). It is evident that there is a reduction in the contractile function of the bladder associated with ageing in both men and women. Probably this is due to a dampening of detrusor contractile force by the age-associated accumulation of surrounding connective tissue (16, 17). What constitutes a normal post-void residual in older people is still widely debated; the common concerns about recurrent urinary tract infection, incontinence, and upper renal tract damage are not well substantiated in otherwise normal older people, the risk of high pressures being low (18). There is no effective pharmacological therapy for ineffective voiding and, in the absence of outflow tract obstruction, no effective surgical intervention. Management consists of double voiding; if this proves ineffective then catheterization, either intermittent or indwelling, is the treatment of choice.
5 Quality of life and impact
The impact of incontinence in older people is often described in terms of its association with other conditions: UI is associated with an increased risk of falls and fracture, urinary tract infection, depression, and skin problems, and is an independent risk for institutionalization (19–21). In a large population-based observation study, UI (defined as use of pads) was independently associated with one other geriatric condition (of cognitive impairment, injurious falls, dizziness, vision impairment, or hearing impairment) in 60%, two or more conditions in 28%, and three or more in 13% (22). Associated conditions such as peripheral vascular disease, Parkinson’s disease (PD), diabetes mellitus, congestive heart failure, venous insufficiency and chronic lung disease, falls and contractures, recurrent infection and constipation have all been implicated in generating a predisposition to the development of UI (Table 8.1).
Table 8.1 Co-morbid medications associated with urinary incontinence in older people
| Conditions | Comments | Implications for Management |
|---|---|---|
Co-morbid medical illnesses Diabetes mellitus Degenerative joint disease Chronic pulmonary disease Congestive heart failure Lower extremity venous insufficiency Sleep apnoea | Poor control can cause polyuria and precipitate or exacerbate incontinence; also associated with increased likelihood of urgency incontinence and diabetic neuropathic bladder Can impair mobility and precipitate urgency UI Associated cough can worsen stress UI Increased night-time urine production can contribute to nocturia and UI May increase night-time urine production by increasing production of atrial natriuretic peptide | Better control of diabetes can reduce osmotic diuresis and associated polyuria, and improve incontinence Optimal pharmacologic and non-pharmacologic pain management can improve mobility and toileting ability Cough suppression can reduce stress incontinence and cough-induced urgency UI Optimizing pharmacologic management of congestive heart failure, sodium restriction, support stockings, leg elevation, and a late afternoon dose of a rapid-acting diuretic may reduce nocturnal polyuria and associated nocturia and night-time UI Diagnosis and treatment of sleep apnoea, usually with continuous positive airway pressure devices, may improve the condition and reduce nocturnal polyuria and associated nocturia and UI |
Severe constipation and faecal impaction | Associated with ‘double’ incontinence (urinary and faecal) | Appropriate use of stool softeners Adequate fluid intake and exercise Disimpaction if necessary |
Neurological and psychiatric conditions Stroke Parkinson’s disease Normal pressure hydrocephalus Dementia (Alzheimer’s, multi-infarct, others) Depression | Can precipitate urgency UI and less often urinary retention; also impairs mobility Associated with urgency UI; also causes impaired mobility and cognition in late stages Presents with UI, along with gait and cognitive impairments Associated with urgency UI; impaired cognition and apraxia interferes with toileting and hygiene May impair motivation to be continent; may also be a consequence of incontinence | UI after an acute stroke often resolves with rehabilitation; persistent UI should be further evaluated Regular toileting assistance essential for those with persistent mobility impairment Optimizing management may improve mobility and improve UI Regular toileting assistance essential for those with mobility and cognitive impairment in late stages Patients presenting with all three symptoms should be considered for brain imaging to rule out this condition, as it may improve with a ventricular-peritoneal shunt Regular toileting assistance essential for those with mobility and cognitive impairment in late stages Optimizing pharmacological and non-pharmacological management of depression may improve UI |
Medications | See Table 8.2 | Discontinuation or modification of drug regimen |
Functional impairments Impaired mobility Impaired cognition | Impaired cognition and/or mobility due to a variety of conditions listed above and others can interfere with the ability to toilet independently and precipitate UI | Regular toileting assistance essential for those with severe mobility and/or cognitive impairment |
Environmental factors Inaccessible toilets Unsafe toilet facilities Unavailable caregivers for toileting assistance | Frail, functionally impaired persons require accessible, safe toilet facilities, and in many cases human assistance in order to be continent | Environmental alterations may be helpful; supportive measures such as pads may be necessary if caregiver assistance is not regularly available |
Hypertension, congestive heart failure, arthritis, depression, and anxiety were associated with a higher prevalence of UI. A linear correlation (r = 0.81) was found between prevalence of UI and the number of co-morbid conditions (23). Moreover, incontinence has an impact on the quality of life and well-being of older people, leading to reduced socialization, associated with the severity of the incontinence, rather than the type, although other studies suggest that urgency incontinence has a greater impact than the other subtypes (24–26). There are also data to suggest a reduction in economic productivity and increased work absence for those with incontinence (27). While not immediately relevant, as the requirement for people to remain economically active until later in life increases, this is likely to become an important factor. The additional impact on informal caregivers of those with incontinence is also significant in terms of burden and reduced quality of life (28). The economic impact of some of those caregivers leaving the workforce to care for older people with incontinence has not been quantified. However, the additional costs associated with OAB and related incontinence in the UK has been estimated at €515 per year per patient, with nursing home continence care accounting for an additional €381 per year above that amount, the majority of this relating to containment products (29).
6 Evidence base for treatment
The evidence base for treatment of the elderly, specifically the frail elderly, lags behind that for community-dwelling adults. The difficulty of recruiting the elderly to clinical studies is well recognized (30) and is compounded by multiple exclusion criteria, meaning that the majority of older people become ineligible for study even if willing and able to participate. Despite the high prevalence of the condition and the increased severity experienced by older people, they tend to be excluded from treatment trials of pharmacotherapy and surgery. Data do however exist for conservative and prompted voiding and functional incidental training (exercise) in nursing home residents. The usefulness of this technique (and others like it) is limited by both the intensity of the intervention in relation to available staff time and perhaps more so recently by the changing demographics of those admitted to nursing home care, where 60% have a dementia diagnosis and 40% lose their mobility within six months of admission. The guidelines for care of frail older people within the International Consultation on Incontinence (published 2013) contains the most up-to-date synthesis of available evidence concerning conservative and behavioural interventions (31).
7 Treatment strategies for treating incontinence in the elderly
7.1 Lifestyle interventions
Several lifestyle interventions have been evaluated in healthier older women, including dieting and medication to help with weight loss, fluid selection (caffeine, alcohol, and volume), and constipation management. There are much fewer data in healthier older men and almost no data on frail older people (32). The international consultation on incontinence referred to earlier took the view that should there be evidence of efficacy for any intervention in a general population of older people, then it would seem unreasonable not to offer that intervention to the frail elderly, given that the intervention was feasible and congruent with the aims of management and expectations of that person (31). A trial of caffeine restriction, for example, may superficially result in little harm, but may adversely affect the hydration status of an older person for little perceived benefit.
7.2 Behavioural interventions
Behavioural interventions have been especially designed for frail older people with cognitive and physical impairments. Because these behavioural interventions have no side effects, they have been the mainstay of UI treatment in frail older people (33). The technique with the most evidence for its use is prompted voiding. Subjects are prompted to use the lavatory and encouraged with social reward when successfully toileted. This technique increases patient requests for toileting and self-initiated toileting, and decreases the number of UI episodes (34). A three-day trial during which the number of incontinent episodes should reduce by 20% would be considered successful. The second commonly used technique, habit retraining, requires the identification of the incontinent person’s individual toileting pattern and UI episodes, usually by means of a bladder diary. A toileting schedule is then devised to pre-empt them (35, 36). Timed voiding involves toileting at fixed intervals, such as every three hours. There is no patient education, reinforcement of behaviours, or attempt to re-establish normal voiding patterns (37).
7.3 Functional incidental training
Functional incidental training incorporates musculoskeletal strengthening exercises into toileting routines by nursing home care aides (nursing assistants) (38).
There is increasing evidence for the effectiveness of physical exercise as an intervention for urinary incontinence in populations in diverse settings. In a veterans nursing home population in the United States, the combination of prompted voiding and individualized, functionally oriented endurance and strengthening exercises offered four times per day, five days per week, for eight weeks was effective in significantly reducing urinary incontinence (39). An intervention which provided exercise and incontinence care every two hours from 8:00 a.m. to 4:30 p.m. (total of four daily care episodes) for five days a week over 32 weeks in a nursing home population was also found to be effective in significantly reducing incontinence (40). Similarly, a study of walking exercise for thirty minutes per day in a small group of cognitively impaired residents over four weeks resulted in a significant reduction in daytime incontinence episodes and an increase in gait speed and stamina (41). A 30-minute intervention conducted by allied health professionals three times weekly over eight weeks proved effective in increasing the number of subjects who achieved independent toileting but did not significantly reduce daily urine loss (42). In community-dwelling older people, a 30-minute evening walk proved effective in reducing nocturia, while also improving daytime urinary frequency, blood pressure, body weight, body fat ratio, triglycerides, total cholesterol, and sleep quality (43). Cognitive and functional impairment, common in frail elderly people, may preclude the use of some of these interventions. Additionally, the context in which care is provided needs to be considered (44–46). Many of these interventions are time-consuming and need effective staff engagement to deliver effectively (47). Although pelvic floor muscle training (PFMT) has not been studied extensively in frail older people, age and frailty alone should not preclude its use in patients with sufficient cognition to participate. An intervention involving information about urinary function combined with bladder training was effective among community-dwelling women aged between 55 and 80 years (48). The women were provided with the following information: slides and handouts about normal lower urinary tract anatomy and function; types of incontinence; effects of incontinence on lifestyle; healthy habits and self-care. The women were also given instruction and practice in bladder training and pelvic floor muscle training (PFMT), and how to incorporate these into everyday activities. The PFMT instructions—delivered via audiotape—suggested daily practice as well as bladder training if the intervoid interval was less than 3.5 hours. The fact that the programme was successful for this sample of women suggests it may be as well for older women who are frail.
7.4 Pharmacological therapy
The main target for pharmacological therapy of UI associated with storage symptoms is OAB/urgency-frequency syndrome. Here, antimuscarinic drugs are the mainstay of treatment. There is accumulating evidence—perhaps because of the increased severity of UI in older people, or because they are less successful with behavioural or lifestyle measures—that they are not only more likely to request drug therapy to control their OAB symptoms if medication is withdrawn (49), but are more likely to need higher doses of drug to achieve most benefit, particularly in the oldest old (>75 years) (50, 51). Additionally, older people appear to be more adherent to their therapy than the young (52).
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
