Urinary Incontinence in Frail Older Adults

Sandra Engberg; Hongjin Li

Disclosures

Urol Nurs. 2017;37(3):119-125. 

In This Article

Management of UI

Many frail older adults have co-existing disabilities and comorbidities influencing responsiveness to interventions for UI. In addition, treatment of underlying comorbidities and/or impairments will often improve their UI. Managing UI in the frail elder population is aimed at identifying and treating comorbid conditions and/or impairments, which contribute to or cause UI (see Table 1) (Ous lander, 2000; Wagg et al., 2013). The aim of treatment needs to consider patients' level of frailty, comorbid conditions and/or impairments, and outcome expectations. While interventions will improve UI in most frail elders, complete continence may not be a realistic goal for those who are very frail. The Frailty Elderly Committee of the 3rd Inter national Consultation on Incontinence introduced an alternate paradigm for treatment goals for frail elders and their caregivers (Wagg et al., 2013). Potential goals are:

  • Independent continence: The patient is dry without the need for ongoing treatment.

  • Dependent continence: The patient is dry with toileting assistance, behavioral treatment, and/or ongoing medication therapy.

  • Contained incontinence: Urine is contained with pads or appliances (Wagg et al., 2013).

General Measures

Many clinicians recommend lifestyle interventions, such as weight loss, dietary modifications, eliminating select beverages, fluid management, and prevention/treatment of constipation as part of the management of UI. The effectiveness of some lifestyle changes on UI are examined in clinical trials with varying evidence to support their effect (Imamura, Williams, Wells, & McGrother, 2015; Sun, Liu, & Jiao, 2016). Some of these lifestyle changes, such as weight loss, are not appropriate for many frail older adults, while others lack research examining their effects in the frail elderly population (Wagg et al., 2013). Complete continence is not an achievable goal for all frail elders. The use of continence aids can enable them to perform their daily activities without fear of embarrassment. Absorbent pads are the most frequently used continence aid, and they are, unfortunately, often overused and misused. Absorbent pads can increase the risk for incontinence as well as urinary tract infections and skin irritation (Omli et al., 2010; Wagg et al., 2013). Research suggests that absorbent pads are the most frequent continence management approach in frail elders across all settings (Du Moulin et al., 2009; Omli et al., 2010; Roe et al., 2010; Wagg et al, 2008; Zisberg, 2011). Pads should not be a substituted for an active approach to the prevention, diagnosis, and treatment of UI in frail elders (Wagg et al., 2013).

Environmental Interventions

Environmental factors, such as accessibility to toilets and the availability of toileting assistance in a timely manner, are recognized risk factors for UI in the frail elderly population. Improving access to the toilet and providing toileting aids, such as grab bars and raised toilet seats, may improve UI in frail older adults with mobility and other functional impairments. Environmental cues, such as toilet visibility, better signage, and images, may be effective interventions in older adults with cognitive or visual-perceptual deficits (Wagg et al., 2013). The need for timely toileting assistance is an obvious but often neglected risk factor for UI in the care-dependent, frail elderly population across all care settings. For frail elders unable to toilet independently, the availability of toileting assistance is critical to the success of all other interventions for UI.

Behavioral Interventions

Their lack of side effects makes behavioral interventions the firstline treatment for frail elders. Voiding programs are designed for the frail elderly population with cognitive or physical impairments limiting their ability to actively participate in their self-care. These interventions require active caregiver participation and include prompted voiding, habit training, and scheduled (timed) toileting.

Prompted voiding. Prompted voiding combines regular prompts to toilet with positive feedback for appropriate toileting. The goal is to increase awareness for the need to urinate, leading to self-initiated toileting. Wagg and colleagues (2013) report that there is Level 1 research (designed from at least one randomized controlled trial) to support the short-term effectiveness of prompted voiding in treating daytime UI in frail elders in nursing homes and home care settings. To reduce caregiver burden associated with prompted voiding, the researchers recommend targeting this intervention to those most likely to benefit from prompted voiding. Individuals most likely to benefit from a prompted voiding program are those who are successful after a three-day trial. The intervention is continued only for those who achieve appropriate toileting rates (i.e., voids for greater than 66% of the prompts to toilet) or acceptable reductions in wet checks (i.e., less than 20% of checks are wet).

Habit training. Habit training matches the toileting schedule to the frail older adult's individual voiding pattern. This requires a baseline assessment (bladder diary/wet checks) to establish the frequency of continent and incontinent voids. The toileting schedule is then designed to pre-empt incontinent episodes. Wagg et al. (2015) concluded there is insufficient evidence to determine the effectiveness of habit training.

Scheduled (timed) toileting. Scheduled (timed) toileting is an intervention where the individual is toileted at fixed intervals without prompts or reinforcement for appropriate voiding. There is insufficient evidence to determine whether or not scheduled toileting decreases UI in frail elders (Wagg et al., 2015). The effect of combining regular toileting with an exercise intervention was examined in two randomized controlled trials (RCTs) included in a systematic review of conservative treatment of UI in frail elders (Stenzelius et al., 2015). In both studies, there was a significant reduction in incontinent episodes. When the weighted findings were combined, there was a moderate, but statistically significant, reduction in urine leakage.

Pelvic floor muscle training. Frail older adults with sufficient cognitive function to actively participate in their treatment may be candidates for pelvic floor muscle training (PFMT) or bladder training. There is limited research examining the effects of these interventions in frail elders. In a systematic review of conservative interventions for UI in frail community-dwelling older adults, Talley, Wyman, and Shamliyan (2011) identified three studies, only one an RCT, examining the effect of a multicomponent behavioral intervention that included PFMT and bladder training for incontinence in homebound older adults. All three reported significant reductions in incontinent episodes (75% to 80%) at the end of the intervention. Engberg and Sereika (2016) compared the effectiveness of PFMT in reducing UI in homebound and nonhomebound older adults. There was a significant reduction in UI in both groups, with no significant differences between them (a median 64.5% reduction in homebound subjects and 70.4% decrease in nonhomebound subjects).

Pharmacologic Treatment

Age-related changes in pharmacodynamics and pharmacokinetics, high levels of polypharmacy (with the potential for drugdrug interactions), high levels of comorbidities (with the potential for drug-disease interactions), and increased susceptibility to adverse drug effects (ADEs) are all causes for caution when initiating pharmacotherapy for UI in the frail elderly population. In general, there is a lack of high-quality evidence about the efficacy and safety of pharmacotherapy in frail older adults. Based on their systematic reviews of the literature, the Frailty Committee of the 5th International Consultation on Incontinence (Wagg et al., 2015) made the following recommendations for clinical practice related to pharmacotherapy for UI.

  • Frail older adults should be considered for drug treatment only after all potentially remediable comorbid conditions/factors are evaluated and addressed, and there is an appropriate trial of behavioral therapy and lifestyle interventions.

  • Drug treatment should generally be avoided in individuals who make no attempt to toilet when assisted, become agitated when toileted, or are so impaired (functionally and cognitively) that there is no prospect for meaningful benefit.

  • The major ADE of concern with antimuscarinic drugs is cognitive decline; however, evidence on its incidence and prevalence is scant. Actual incidence rates of cognitive decline with the drugs are difficult to estimate due to likely under-reporting, failure of clinical trials to report data related to this ADE, and/or the use of different measures lacking comparability across studies. The Mini-Mental State Examination (MMSE) and Alzheimer's Disease Assessment Scale – Cognitive (ADAS-Cog) do not seem to be sensitive to changes in cognition due to bladder antimuscarinics. Consequently, treatment decisions are often made on the basis of a global assessment of cognition during the clinical assessment, and if available, the caregiver's impression of changes in cognition. Bladder antimuscuranics as single agents are probably safe in cognitively intact older adults. However, in addition to the likely benefit from drug treatment, life expectancy and patient preferences, as well as their total anticholinergic load, need to be considered in treatment decisions.

  • High doses (20 mg) of oxybutynin XL are associated with increased likelihood of cognitive impairment and should generally be avoided in older adults. Oxybutynin, even at low doses, is generally avoided in individuals at cognitive risk.

  • Start other antimuscarinics at the lowest available dose and monitor the patient closely as the dose is slowly increased if needed to improve efficacy.

  • Limit the overall exposure to antimuscaranics, especially when patients are also taking other drugs with anticholinergic properties, is an important consideration in treatment decisions.

  • Monitor post-void residuals when frail older men who are unable to reliably report changes in lower urinary tract symptoms or have voiding difficulty are treated with anti-muscarinics.

Mirabegon is a new selective β3-adrenoreceptor antagonist approved for the treatment of overactive bladder (urge UI). In studies of adults, mirabegon was associated with a low side effect profile. One concern associated with its use (and other drugs in this class) is the possible risk of adverse cardiovascular events (e.g., prolonged QT interval, tachy cardia, and angina) (Bala-chandran & Duckett, 2015). After a systematic review of 16 studies examining the cardiovascular safety of mirabegron, Rosa et al. (2016) concluded that mirabegron appeared to be acceptable at therapeutic levels and is comparable to other antimuscarinic agents in adults. These authors caution, however, that because patients with poorly controlled hypertension, arrhythmias, and heart failure were excluded from the studies, there were no data reported on subjects' safety in these populations.

In a recent systematic review of the pharmacological treatment of UI in older adults and frail elders (Samuelsson et al., 2015), the authors concluded there were no published studies examining the effects of mirabegron in frail elderly subjects. There is a need for research to establish its efficacy, tolerability, and safety in this population. Given the lack of research in this population, as well as in patients with significant cardiovascular risk factors, especially common in frail elder subjects, the same caution recommended in relation to anti-muscarinics seems appropriate when considering the use of mirabegron (Wagg et al., 2013). Therefore, it is important to carefully weigh the risk-benefit ratio prior to initiating treatment. Start at the lowest possible dose, and if needed, increase the dose slowly. It is most important to monitor for adverse effects, particularly cardiovascular effects.

Other Treatment Options

There is limited evidence on surgical treatments for UI in frail elders. The lack of evidence makes it difficult to make specific recommendations related to surgical treatments; however, age alone is not a contraindication to surgical treatment. Urodynamic evaluation is recommended prior to considering surgical treatment (Wagg et al., 2015). Injections of bulking agents for stress UI appears to provide only minor benefits, but age does not appear to affect the outcomes.

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