Fixing the Leaking Tap – Incontinence in Elderly

Urinary incontinence is a prevalent problem among the elderly. 

We evaluate the contributing factors leading to incontinence which help in determining targetted and individualised treatment for better care and results.

Urinary incontinence, which involves the involuntary discharging of urine, is a major problem among the elderly, affecting up to one third of community-dwelling or acutely hospitalised elderly people and half of the elderly in nursing homes. Although the prevalence of incontinence increases with age, urinary incontinence is abnormal and not part of the ageing process.

There are treatment options available, and management may differ from those for a younger person.

Evaluating Causes of Incontinence

Among the elderly, incontinence may be transient and often multifactorial. The mnemonic “DIAPPERS” is useful in evaluating possible causes of transient incontinence.

The mnemonic DIAPPERS represents:

  • Delirium,
  • Infection (symptomatic),
  • Atrophic vaginitis,
  • Pharmaceuticals (long-acting sedative, calcium channel blockers, ACE-inhibitors etc),
  • Psychological,
  • Excess urine output (diuretics, diabetes mellitus),
  • Reduced mobility (hip fractures, deconditioning), and
  • Stool impaction (opioid medication). Care should be taken to avoid any overtreatment of asymptomatic bacteriuria.

If incontinence persists despite the elimination of possible transient causes, other established causes of urinary incontinence, similar to younger individuals, have to be evaluated and managed.

There are several types of urinary incontinence. Among the elderly, urinary leakage is a common occurrence due to underlying involuntary detrusor contractions. These abnormal bladder contractions may be secondary to normal ageing or central nervous system lesions (i.e., old strokes). Patients with this type of incontinence often report the need to rush to the bathroom, and among the elderly, the patient wets himself/herself, sometimes unknowingly.

Stress urinary incontinence, is leakage of urine on straining such as with coughing or sneezing. It is a common cause of incontinence especially among older women. It can also occur with elderly men who have previously had prostate surgery. Some people have mixed urinary incontinence, with a combination of both symptoms mentioned.

Overflow incontinence is a term to describe urine leakage associated with urinary retention. In some patients with neurological conditions or poorly controlled diabetes mellitus, neurological control in bladder storage and emptying is affected, hence resulting in “overflow” incontinence, in which bladder distension of the stored urine leaks out beyond a certain capacity. This type of leakage may also occur in older men with bladder outlet obstruction, often due to an enlarged prostate.

Among the elderly, cognitive impairment and/or physical immobility can contribute to incontinence, but incontinence is not inevitable with dementia or impaired physical function. The aim of evaluation should be to identify and treat any serious underlying cause, assess the patient’s clinical state, environment and support, and plan realistic individualised treatment targets.

 

Targeted physical and neurological examination is essential, as well as functional status and existing medical conditions. Evidence of dementia, delirium, stroke, Parkinson’s disease and neuropathy have important impact on the course of management. Fecal impaction and anal tone are useful, although many neurologically intact elderly people are unable to volitionally contract the anal sphincter. Presence of atrophic vaginitis or pelvic organ prolapse among elderly women, and prostate size for men are relevant clinical findings that can help to guide effective management.

The range of contributing factors to incontinence in an older patient are broader. A bladder diary is a useful tool in symptom evaluation. A typical bladder diary records the 24 hour, daytime and night-time frequency and amount of voided volumes, leakages and fluid intake over a period of three days. This provides information on the functional bladder capacity and severity of symptoms. It can also indicate possible systemic conditions (i.e., predominantly nocturia in a patient with congestive cardiac failure).

Some elderly patients, especially those with cognitive or visual impairment may not be able to keep a bladder diary, and caregiver assistance will be required.

Urinalysis, renal function, electrolytes and post-void residual volume are useful points for investigation among the elderly exhibiting incontinence, and will guide subsequent tests. Interpretation of creatinine levels has to take into account the age-related reduction of muscle mass.

Treatment Options

Treatment of incontinence among the elderly has to be individualised, and the successful treatment is often multifactorial, addressing factors beyond the urinary tract. Contributing factors should be treated first (e.g. urinary tract infection, fecal impaction, atrophic vaginitis, heart failure), with appropriate fluid management and review of current medications.

For urgency incontinence due to underlying detrusor overactivity, anticholinergics may be tried, with careful monitoring of potentially decreased bladder emptying leading to acute urinary retention, blurring of vision and cognitive impairment. Although the elderly are more vulnerable to any potential side effects of medication, many controlled trials have shown that anticholinergics prove effective and can be safely used with the elderly, with care for early review, and monitoring of post-void residual volumes.

The most common cause of stress incontinence in older women is urethral hypermobility. Healthy weight loss if obese, and pelvic floor muscle exercise for the cognitively in-tact and motivated can be helpful for this condition.

Age per se is not a contraindication to surgery for treatment of urinary incontinence. In well-selected patients, many incontinence surgical procedures can be done as day surgery, under regional anaesthesia. These include periurethral bulking injections, mid-urethral sling or artificial urinary sphincter for stress incontinence, and intravesical botulinium toxin A injections for detrusor overactivity incontinence.

For men with incontinence due to an enlarged prostate causing bladder outlet obstruction, treatment options range from medication to transurethral resection of prostate (TURP) which can be done under regional anaesthesia.

If surgery is contemplated, urodynamic testing should be considered pre-operatively after empirical treatment has failed. For frail patients possessing overflow incontinence and who are unfit for surgery, the option of intermittent catheterisation or long-term indwelling catheter with regular changes are realistic options. It is important that the principles of catheter care be taught to both patients and caregivers.

Geriatric urinary incontinence can be treated or managed satisfactorily, with careful evaluation and monitoring of treatment effects.


 

Dr Sharon Yeo 

Dr Sharon Yeo is a Consultant in the Department of Urology in Tan Tock Seng Hospital (TTSH) and a Clinical Lecturer with the Yong Loo Lin School of Medicine at the National University of Singapore (NUS). Dr Yeo obtained her medical degree and Master of Medicine (Surgery) at NUS and is a member of the Royal College of Physicians and Surgeons of Glasgow, UK.

She received the Ministry of Health Manpower Development Plan (HMDP) award and completed a Fellowship in Female Urology, Neuro-urology, Urodynamics and Reconstructive Surgery at the Bristol Urological Institute, UK. Dr Yeo leads the new multidisciplinary Pelvic Floor Service in TTSH for Voiding Dysfunction and Incontinence and the Urology service at AMKThye Hua Kwan Hospital.