In seniors, urinary incontinence (UI) is not only a common condition, but also a disruption in terms of functionality, quality of life, and the potential to disable.1,2 It may adversely affect physical health, psychological well-being, social status, and the costs of health care.3 This condition may affect not only frail elderly individuals residing in nursing facilities, but also active seniors residing in the community and hospitalized geriatric patients as well. Furthermore, regardless of the setting, UI can affect individuals across the spectrum of cognitive function, from those with good function to those with dementia and other neurologically degenerative diseases.
It is possible to cure or significantly improve UI, especially in individuals who have functional mobility and mental capacity.3 When not curable, management of UI aims to improve patient comfort, provide helpful strategies for patients and caregivers, and minimize the costs of caring for this condition.3 While medications can improve UI, this column will focus on eliminating reversible causes (TABLE 1), implementing lifestyle strategies, and discussing products to be considered as an integral component of the comprehensive management of this condition.
Resources for the Pharmacist provides links to
recently published literature from the Agency for Healthcare Research
and Quality regarding systematic reviews of the benefits and harms of
pharmacologic interventions, as well as nonsurgical treatments, for UI.
UI: Definition, Prevalence, and Risk Factors
When involuntary leakage of urine is sufficient and frequent enough to constitute a social and/or health problem, it is labeled as urinary incontinence (TABLE 1).2 Severity of this condition ranges from occasional episodes of dribbling small amounts of urine to the continuous leakage of urine with concomitant fecal incontinence.3 Risk factors for UI include older age, female gender, increased body mass index, and limited physical activity.4
Approximately 33% of women aged 65 years and over and 15% to 20% of men aged 65 years and over experience UI to some degree. 2,5 It is estimated that among seniors who reside in the community, 5% to 10% have UI (more than weekly and/or with use of urinary protection pads) as compared to approximately 60% to 80% of seniors in many long-term-care facilities.2 The condition is more common among women than men until after 85 years of age, when there is no difference in prevalence based on gender.5
Of note, while UI is particularly disabling and distressing in the elderly, women in reproductive and early postmenopausal years may also experience this condition and suffer unnecessarily.6 In women, stress incontinence (TABLE 1) occurs largely because of complications of childbirth and the development of menopausal atrophic urethritis (TABLE 1)—thinning of the estrogen-dependent lining of the outer urethra.6,7 Typically, UI is more severe in obese people secondary to pressure from abdominal contents on the top of the bladder.7 Despite available treatment regimens, stress incontinence is usually suffered in silence.1 In men, stress incontinence may occur as a consequence of prostate surgery owing to postprostatectomy sphincter weakness.3
The potential adverse-effect categories of UI include: 1) physical health, such as skin rashes/ulcers, recurrent urinary tract infections, and falls; 2) psychological health, such as isolation, depression, and loss of independence; 3) social consequences, such as caregiver burden; and 4) economic burden, such as the costs of laundry, supplies, caregiving/housekeepers, and health care management of complications.2,4
Pharmacists in all practice settings can help improve the lives of seniors by identifying reversible causes (TABLE 1), including those that are medication related, and by recommending strategies to help manage UI, including products that can help patients remain social and engaged without fear of embarrassment. Patients can also be guided on how to respond to questions their physician may ask (e.g., “Do episodes of UI occur with laughing, coughing, sneezing, or bending? Does there appear to be a relationship between taking certain medications or drinking alcohol or caffeinated beverages?”) to help determine the type, severity, and cause of UI and develop an appropriate treatment plan (see Resources for the Patient).
Classification of UI
UI is often differentiated by its causes, and classified either as transient or potentially reversible, or as having established or persistent causes. TABLE 1 outlines the categories of transient causes of UI using the mnemonic, DIAPPERS.4 Once transient causes have been exposed and appropriately managed, causes of established UI should be addressed.4
Medications That Can Cause or Worsen UI
Medications that can cause or worsen UI are addressed in TABLE 1; additionally, pharmacists can provide patients with a handout that discusses, in lay terms, drugs known to cause UI and categorizes them into four groups: 1) high blood pressure drugs; 2) antidepressants; 3) diuretics; and 4) sleeping pills (see Resources for the Patient).
Updated Beers Criteria: The recently published American Geriatrics Society (AGS) Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults addresses8
• A list of anticholinergic medications, including a group of antimuscarinics used for UI (darifenacin, fesoterodine, flavoxate, oxybutynin, solifenacin, tolterodine, trospium), to be avoided in older adults.8 The list is compiled from drugs rated as having strong anticholinergic properties in the Anticholinergic Risk Scale, Anticholinergic Drug Scale, and Anticholinergic Burden Scale.8 These agents are reported as having the potential to exacerbate constipation and should ultimately be avoided; alternatives should be considered if constipation develops, unless there are no other alternatives available.8
• Stress or mixed UI with regard to aggravation of UI secondary to alpha-blockers (e.g., doxazosin, prazosin, terazosin); the recommendation is to avoid these in women.8
• UI (all types in women) with regard to aggravation of incontinence secondary to oral and transdermal estrogen (excludes intravaginal estrogen); recommendation is to avoid in women.8 Estrogen applied locally (intravaginally), helps maintain vaginal and urethral tissue even when relatively small doses are used.6,9 Resolution of urinary symptoms is often achieved by applying a small dab of estrogen cream locally to the urethra.6
Strategies and Products to Help Manage UI
TABLE 1 and Resources for the Patient discuss strategies (including Kegel exercises, scheduled toileting, and medication modification) and products (incontinence pads, pessary, urinal) used in the management of UI that are important both in conjunction with medication therapy and as alternatives to pharmacologic therapy when medications should be avoided. Of note, female patients who do not respond to behavioral or pharmaceutical therapy should be referred to a urogynecologist or urologist.4 Male patients with urinary obstruction who are refractory to medical or pharmaceutical therapy should be referred to a urologist.4 A discussion on UI beyond the scope of this column may be found in online Reference 7.
Tips for Traveling Seniors
UI may prevent seniors from visiting overnight with family and friends or traveling for business or pleasure. Embarrassment associated with wetting sheets and disposing of incontinence pads is often the culprit.10 Pharmacists dispensing medications for UI and/or providing medication consultations may find it helpful to provide seniors with a handout for UI products to make overnight travel amenable (see Resources for the Patient).
Some examples of these products and tips for encouraging the freedom of travel in patients with UI include:10
• Packing a bag for emergencies that includes incontinence pads, bed pads, odor neutralizer spray, disposable plastic bags, and extra slacks, preferably black
• Carrying UI products in a purse; having disposable bags available to discard soiled incontinence pads; trying the use of a tampon (to help prevent leaks caused by stress incontinence by putting pressure on the urethra)
• Practicing Kegel exercises (see Resources for the Patient) to tighten pelvic muscles to prevent leaks
• Reducing coffee intake
• Minimizing water and other beverages when planning a long car trip while at the same time drinking enough to avoid dehydration
• Minimizing alcohol, which acts as a diuretic, and spicy and high-acid foods, which can irritate the bladder and exacerbate problems with urge incontinence
• Using a properly fitted removable pessary for stress incontinence (e.g., secondary to childbirth) to help support pelvic organs
• If warranted, medications for UI initiated 1 to 2 days prior to an overnight stay10
Conclusion
Pharmacists can contribute to the appropriate and compassionate management of UI by identifying transient causes of UI—including those that are medication-related—and providing recommendations regarding medications, strategies, and products that can improve functionality, independence, and quality of life.
REFERENCES
1. Cooper TK, Smith OM. Gynecologic disorders in the elderly. In: Fillit HM, Rockwood K, Woodhouse K, eds. Brocklehurst’s Textbook of Geriatric Medicine and Gerontology. 7th ed. Philadelphia, PA: Saunders Elsevier; 2010:716-725.
2. Kane RL, Ouslander JG, Abrass IB. Essentials of Clinical Geriatrics. 5th ed. New York, NY: McGraw-Hill, Inc; 2004:173-218.
3. Johnson TM, Ouslander JG. Incontinence. In: Halter JB, Ouslander JG, Tinetti ME, et al, eds. Hazzard’s Geriatric Medicine and Gerontology. 6th ed. New York, NY: McGraw-Hill; 2009:718-730.
4. Johnston CB, Harper GM, Landefeld CS. Geriatric disorders. In: McPhee SJ, Papadakis MA, Rabow MW, eds. 2011 Current Medical Diagnosis & Treatment. 50th ed. New York, NY: McGraw Hill Medical; 2011:70-72.
5. Beers MH, Jones TV, Berkwits M, et al, eds. The Merck Manual of Health & Aging. Whitehouse Station, NJ: Merck Research Laboratories; 2004:768-778.
6. Northrup C. The Wisdom of Menopause. New York: Bantam Books; 2001:129-130,161-162, 265-266.
7. Urinary incontinence. www.merckmanuals.com. Fully
Revised August 2007/Modified March 2008.
www.merckmanuals.com/professional/genitourinary_disorders/voiding_disorders/urinary_incontinence.html.
Accessed May 17, 2012.
8. American Geriatrics Society (AGS) Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. JAGS. 2012. www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf. Accessed March 9, 2012.
9. Zagaria ME. Urogenital symptoms of menopause: atrophic vaginitis and atrophic urethritis. US Pharm. 2011;36(9):22-26.
10. Davis JL. When you’re a guest with incontinence.
WebMD.com. Reviewed July 29, 2009.
www.webmd.com/urinary-incontinence-oab/features/when-you-are-a-guest-with-incontinence.
Accessed April 30, 2012.
11. Foon R, Toozs-Hobson P. Overactive bladder. Obstet Gynaecol Reprod Med. 2007;17:255-360.
12. Dorland’s Pocket Medical Dictionary. 28th ed. Philadelphia, PA: Elsevier Saunders; 2009.
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