2. Geriatric Urinary Incontinence Alexandra F. Suslow MD

3. % of Geriatric aged population s 1970 --->9.9% s 1984 -->11.5% s 1997 -- >13.1% s 2020 --> 20%

4. Life Expectancy s A child born in 1900--> <40 years s A child of the late 60’s--> 68.5 years s A child of the 90’s---> 72 years s A child of the Millenium--> >75 years

5. Reported prevalence of UI s 15-30% of community dwellers (ie” independent seniors”) s 30% of elderly in acute care s > 50% of long term care facilities (eg. NH)

6. DON’T ASK DON’T TELL

7. Myths and Facts s It is a normal part of aging s It is not a medical issue s “I’m not incontinent,I just have “accidents” s There is nothing to do about it s It’s just a minor inconvenience s It is abnormal at any age(other than infant) s It is a medical issue, like HTN or DM s Any involuntary loss is incontinence s Alleviation and occsl. cure are possible s THINK AGAIN!!!

8. Problems due to UI s Major Medical Problems s Major social issues s Major economic issues

9. Medical Issues s Pressure ulcers leading to infections and sepsis s Perineal rashes s Urosepsis s Increased risk of falls and fractures with subsequent increase of morbidity/mortality

10. Social issues s “ Cultural conditioning leading to stigmatization,social isolation, depression, and increased Psychological Morbidity” s (Umlauff et. all)

11. Economical Issues, general s Cost of Rx of associated symptoms (eg rashes and pressure sores) s Routine care costs( supplies,laundry) s Direct Medical Cost: Physician and Diagnostics

12. Economical Issues, Nursing Home s Marked increase in cost due to the increase in necessary nursing care (frequent changing of pt and linens) and due to increase utilization of supplies and ancilliary services s Estimated cost $3 billion

13. Breakdown of costs s Diagnostic/ medical $6.0 0.2% s Treatement surgical 1.2 0.04 s Treatement Pharmac. 0.7 0.02 s Routine care c catheter 104.7 3.2 s Routine care s catheter 19,061 58.4 s Sequelae (uti,falls etc) 15.71 4.8 s NH admissions due to UI 1087.7 33.3%

14. Total NH Cost Us$ 3.26 Billion (cost in 1987)

15. Cost in Community Dwellers s Estimated to be about $7 Billion, including costs of supplies, outpatient visits, short term hospitalizations etc.

16. GRAND TOTAL $10 billion. Adjusted to 1997-->$16 billion (more than cost of CABG/Dialysis combined)

18. Continence Determining Factors s Intact lower urinary tract anatomy and function s Adequate Mobility s Motivation s Mentation s Manual dexterity

19. Age Related Changes in LUT s Women: postmenopausal decrease in oestrogen leading to tissue atrophy,prolapse, changes in vaginal flora--->incr. risk of UTI s Men:Prostatic changes leading to urodynamic obstruction and the sequelae thereof

20. Age related changes cont’d changes in both genders s Changes in neurotransmittor balance and immune response. s Anatomic changes such as trabeculation, diverticulae, decreased elasticity s Involuntary detrussor contractions s Malnutrition, dehydration leading to fecal impaction and incr. risk of UTI

21. Medications s Diuretics--.polyuria,frequency,urgency s Anticholinergics:retention,impact. overflow s alpha-adrenergic blockers:urethral relax s alpha agonists,beta agonists, Ca channel Blockers:urinary retention s Ace inhibitors: cough exacerbation

22. Medications, cont’d s Narcotics: retention, impaction, sedation, delirium s Psychotropics: anticholinergic effect, sedation, rigidity s Lithium: polyuria,frequency s ETOH: polyuiria,urgency, sedation

23. Classification of UI s Transient incontinence s “Functional “ incontinence s Established incontinence --LUT causes

24. Transient Incontinence s D elirium s I nfection symptomatic UTI s A trophic urethritis s P harmacological agents

25. Side effects of Specific Meds s Anticholinergic agents s Frequent in prescription and OTC meds( antihistamines) s Causes overt and clinical retention---> faster attainment of capacity--> exacerbation of Detrussor overactivity s Aggravates leakage in stress inc. s Causes dry mouth-->polidypsia--> increase UOP

26. Side Effects of Specific Meds s Alpha adrenergic blockers s Found in many anti hypertensive meds s Block receptors in the bladder neck--> decreased tone-->agrravation of stress incontinence

27. Side Effects of Specific Meds s ACE INHIBITORS s Often prescribed for HTN, CHF s Tend to exacerbate chronic cough--> increase of stress incontinence

28. Transient Incontinence s D elirium s I nfection symptomatic UTI s A trophic urethritis s Pharmacological agents s Psychiatric causes s Excess UOP s Restricted mobility s Stool impaction

29. Established Incontinence: LUT causes of UI s Detrussor overactivity (“Urge Inc.”) s Stress incontinence s Overflow incontinence

30. Goals of the Work-up s R/o and treat transient causes s R/o uncommon causes : CNS,CA,stone s Determine the type of established UI

31. Complaints in Detrussor Overactivity s Presence or absence of “warning” s Frequency s Nocturia

32. Causes of Nocturia s Volume related:Excess intake, diuretic use, metabolic/endocrine, fluid overload, meds s LUT Related: detrussor instability,sensory urgency, prostatic changes

33. Only 22% of incontinent patients had pelvic/rectal exam preformed by their Doctor (Shame on us!!!)

34. Physical Exam s Baseline Exam (HEENT--->Extremities) s Expanded Neurological Exam s Stress Test s PVR s Urodynamic tests: cystometry s Cystoscopy

35. False Results of Stress test s False Pos: Urge during the test s False neg: –Stressor not strong enough –Bladder not full –Cystocele kinking the urethra

36. Management of Detrussor Overactivity s Bladder Retraining s Prompted Voiding s “ Just Say No” to Surgery s Pharmacological management

37. Drugs For DO s Others: Flavoxate, Ca chnl Blk, B-block/agonist s Imipramine s Doxepine s Anticholinergics Propantheline (Pro-Banthine) Dicyclomine (Bentyl) Oxybutinin (Ditropan) Tolterodine (Detrol)

38. Management of Stress Incontinence s Surgical s Pharmacological s Pelvic mm.Strengthening Kegel excercises Vaginal Cones Electric Stimulation

39. Surgical Interventions in Stress Incontinence s Perurethral injection of teflon s Artificial Sphincter s Colposuspension

40. Management of Overflow Incontinence s Blockage: Conservative Rx alpha antagonists 5-alpha reductase inhibitor Prostatectomy s Underactive Bladder: Decompression Catheterization Betanechol

41. Diapers and Pads s Protect Environment s Maintain comfort and dignity of patient

42. Special Thanks s The Lord: For everything s Pam S.: For her help (and patience) in the Library s Dr Houghton:For his help and advice for the presentation s Stacy and Julie: The Fairy Godmothers of the Residents s Dr Wells-Padron PharmD for the Nutrasweet s All who had to listen to the presentation over and over and over again