Urinary Incontinence in Frail Older Adults

Sandra Engberg; Hongjin Li

Disclosures

Urol Nurs. 2017;37(3):119-125. 

In This Article

Multifactorial Etiology

In older adults age 65 years or older, frailty can adversely affect many functional requirements needed to maintain continence, including:

  • Normal lower urinary tract function, including intact bladder function, normal sphincteric function, and normal pelvic floor function, with normal innervation from the peripheral and central nervous system.

  • Adequate cognition needed to recognize the need to urinate with the capacity to find the toilet and with the ability to prevent urine leakage prior to reaching the toilet.

  • Ability to communicate the need to void if unable to toilet independently.

  • The functional ability necessary to get to the toilet (with or without assistance) and remove clothing.

  • Ability to voluntarily initiate voiding when appropriate (Alexander, Shakespeare, Barra-dell, & Orme, 2015).

Wagg and colleagues (2013) conducted a number of systematic reviews related to UI in the frail elderly population for the 5th International Consultation on Incontinence. In addition to CNS changes, the authors identified a number of age-related changes contributing to UI in frail individuals. These include changes a) in bladder ultrastructure, such as muscle and axon degeneration; b) in bladder function, causing decreased capacity, decreased filling sensation, increased detrusor overactivity, decreased bladder contractile function, and increased residual urine; c) decreased closure pressure in the female urethra; d) prostate enlargement; e) decreased estrogen levels in women; f) increased nocturnal urine production; and g) altered immune function. A wide variety of factors outside of the lower urinary tract compound the effects of these age-related changes contributing to UI in the frail older adult population. These include many classes of medications, comorbid medical illnesses, neurologic and psychiatric disorders, functional impairments, and environmental factors (see Table 1) (Alexander et al., 2015; Wagg et al., 2013).

There is limited research describing the type of UI in frail elders. In a descriptive study of adults age 65 years and older receiving home care services in The Netherlands, the type of UI was based on medical record review (DuMoulin, Hamers, Ambergen, & Halfens, 2009). Of the 1,319 patients with UI, the type was diagnosed in 615 subjects. The most common diagnosis was functional UI (35.4%), followed by urge UI (33.4%), mixed UI (18.1%), and stress UI (13.1%). Functional incontinence is generally defined as involuntary urine loss resulting from the inability to toilet due to cognitive, functional, or mobility impairment in individuals with intact lower urinary tract function (Staskin et al., 2013). In an intervention study conducted by McDowell, Engberg, Rodriguez, Engberg, and Sereika (1996), the subject's UI type was based on a detailed urologic history. In this study, the most prevalent type of UI was mixed incontinence reported by 55.9% of the subjects (n = 90, all frail, elderly, and homebound) (McDowell et al., 1996). In another intervention study, Engberg and Sereika (2016) reported that 65.2% of homebound subjects (n = 93) reported mixed incontinence. None of the subjects in either study were classified as having functional incontinence. All subjects in both studies were cognitively intact as measured by a Mini Mental Examination (Folstein, Folstein, & McHugh, 1975) score of greater than 24. While cognitive impairment and functional or mobility issues contribute to UI in frail older adults, given the age-related changes in lower urinary tract function that characterize this population, one could argue that true functional incontinence is rare.

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