Incontinence in Older Adults Going Beyond the Bladder老年人超越膀胱失禁

1、Incontinence in Older Adults:Going Beyond the Bladder,Catherine E. DuBeau, MD Clinical Chief of Geriatric Medicine Professor of Medicine UMass Medical School,JG is 76 yo woman who comes in for routine follow up of HTN, hyperlipidemia, osteoporosis, and some mild memory problems (she doesnt drive but

2、 still lives independently). She complains of constipation. When you go to examine her, you notice she is wearing “pull-ups.” This suggests:,a. The results of having 6 children b. She is likely developing dementia and leakage is common with that condition She didnt mention any incontinence so she mu

3、st not find it bothersome All of the above None of the above,What is Incontinence?,82 yo, unpredictable sudden urgency with leakage that wets through to her clothing 76 yo, after surgery for prostate cancer leaks large drops with coughing, golfing 87 yo, with end-stage dementia, bed-bound in a nursi

4、ng home, with no bladder or bowel control 72 yo, leaks when playing tennis and jogging,In a survey of patients with at least one episode of incontinence weekly: Half never sought care Only 60% those who sought care recalled receiving any treatment Of those who did receive treatment, 50% reported mod

5、erate to great frustration with ongoing urinary leakage,Harris SS et al. J Urol 2007,Incontinence A classic geriatric condition,Hannestad YS, et al. Norwegian EPINCOT Study. J Clin Epidem 2000;53:1150,Severity = Frequency x Amount,Large leakage at least weekly,The Impact of Incontinence,Psychosocial

6、 Decreased quality of life Worry and coping Depression Nursing home placement Medical consequences Falls and fractures Skin infections UTIs Economic costs $26 billion per year $3,600 annually per person age 65+,What causes UI?,Inability to store urine at low pressure Uninhibed bladder contractions I

7、nsufficient urethral closure Inability to empty bladder in timely and effective manner Inefficient bladder contraction Urethral or bladder outlet blockage,Physiological changes in the LUT with age,Bladder decreased contraction strength Urethra (women) decreased smooth and striated muscle density, de

8、creased vascular density and flow Vagina, pelvic floor no change Prostate hyperplasia and hypertrophy These changes alone do not cause UI, but increase the vulnerability to develop UI when other stressors occur,“Bladder Symptoms” Bladder Condition,Medical conditions and medications,Other determinant

9、s of continence:,Mobility,Mentation,Manual dexterity,Environment,Factors that Cause or Worsen UI,Comorbid Disease Diabetes Congestive heart failure Degenerative joint disease Sleep apnea Severe constipation,Neurological / Psychiatric Stroke Parkinsons disease Dementia (advanced) Depression (severe),

10、Function and Environment Impaired cognition Impaired mobility Inaccessible toilets Lack of caregivers,Ouslander JG. NEJM 2004; 350:786,Mentation Sedative hypnotics Benzos Anticholinergics,Mobility Antipsychotics,Medications that Cause or Worsen UI,Medical conditions ACEI - cough Causing edema - Nife

11、dipine Amlodipine “Glitazones” NSAIDs/COX2 Gabapentin Pregabalin Causing constipation,LUT function Bladder contractility Anticholinergics Calcium blockers Sphincter tone Alpha agonist Sphincter tone Alpha blocker Diuretics,A Prescribing Cascade leading to UI,77 yo woman with urgency; gets amlodipine

12、 for HTN,Edema, constipation, impaired bladder emptying,Nocturia, urgency, some UI,Urge incontinence!,Add antimuscarinic, constipation,Add laxative.,The Prescribing Cascade,77 yo woman with urgency; gets nifepine for HTN,Edema, constipation, impaired bladder emptying,Nocturia, urgency, some UI,Add a

13、ntimuscarinic, constipation,Add laxative.,Urge incontinence!,The Prescribing Cascade,77 yo woman with urgency; gets nifepine for HTN,Edema, constipation, impaired bladder emptying,Nocturia, urgency, some UI,Add antimuscarinic, constipation,Add laxative.,Urge incontinence!,Brown JS et al. Ann Intern

14、Med2006:144: 715,In the past 3 months, have you ever leaked urine, even a small amount?,Yes,Did you leak urine most often when you were: When you were performing some physical activity, such as coughing sneezing; lifting or exercising? When you had the urge or feeling you needed to empty your bladde

15、r, and could not get to the bathroom fast enough? About equally as often with physical activity as with a sense of urgency? Without physical activity or without a sense of urgency?,Stress,Urge,Other,Mixed,Beginning an Incontinence Assessment,Evaluation for the cause of UI DIAPPERS mnemonic Delirium

16、Infection Atrophic vaginitis Pharmaceuticals Psychological condition Excess urine output Reduced mobility Stool impaction Physical exam Rectal examination for fecal loading or impaction (Grade C) Functional assessment (mobility, transfers, manual dexterity, ability to successfully toilet) (Grade A)

17、Screening test for depression (Grade B) Cognitive assessment (to assist in planning management, Grade C),DuBeau CE et al, Incontinence in Frail Elderly, 4th International Consultation on Incontinence, 2008,Characterize the type of UI Physical exam Rectal exam impaction, prostate nodules (not size) P

18、elvic exam pelvic organ prolapse Cough stress test (full bladder, upright) Confirm stress symptoms Post-voiding residual volume not necessary in initial evaluation,Rectocele,Cystocele,Split speculum,Hymenal ring,Importance of Treatment Goals,82 yo, unpredictable sudden urgency with leakage that wets

19、 through to her clothing Decreased costs of pull-ups, go out without worry about visible leakage or smell; occasional urgency tolerable 76 yo, after surgery for prostate cancer leaks large drops with coughing, golfing No leakage 87 yo, with end-stage dementia, bed-bound in a nursing home, with no bl

20、adder or bowel control Prevention of skin breakdown, dignity, comfort 72 yo, leaks when playing tennis and jogging Ability to be active without worry; avoid surgery,Stepwise UI Treatment,Lifestyle,Behavioral,Surgery,Drugs,Urge Urge Urge Urge (severe),Stress Stress Stress,Mixed Mixed Mixed Mixed,Indi

21、cations for immediate referral,Hematuria Pelvic pain Acute onset of UI Complex neurological disease other than dementia Pt desires surgery for stress UI Marked pelvic floor prolapse Dysuria, pain, frequent small voids (possible interstitial cystitis),Lifestyle,Caffeine and diuretic beverages Fluid i

22、ntake Constipation Weight loss Smoking,Subak LL et al. Internatl Urogynecol J 2002; 13:40 Brown JS et al. Diabetes Care 2006; 29:385,Behavioral,Bladder training Pelvic muscle exercises,Use in combination for both urge and stress UI,deSouza NM et al. Radiology 2002;225:433,Normal,Stress Incontinence,

23、Supporting fascia,Urethra,Kavia R et al, J Comp Neurol 2005; 493:27,Periaqueductal Grey,Key Regions in Bladder Control,Prefrontal Cortex,Anterior Cingulate Gyrus,Pons,Insula,Drugs,Antimuscarinics for urge and mixed UI New agents Stress UI?,Current antimuscarinics,Oxybutynin Oxybutynin 2.5-5 mg bid-q

24、id Oxybutynin XL 5-20 mg daily Oxytrol patch 3.9 mg 2x/week and Gelnique gel Tolterodine Detrol 1-2 mg bid Detrol LA 2-4 mg daily Fesoterodine Toviaz 48 mg daily Trospium chloride Sanctura 20 mg bid Sanctura XR 60 mg daily Darifenacin Enablex 7.5-15 mg daily Solifenacin Vesicare 5-10 mg daily,Choosing an Antimuscarinic,Efficacy,Tolerability Adverse effects,No Major Differences All decrease UI 70%, 25% cure rate,4th International Consultation on Incontinence, 2008 Chapple C et al, Eu