Urinary Incontinence in the Elderly

Essentials

• Urinary incontinence in an elderly person has an effect on the patient's and his/her family's quality of life as well as on health care costs. It increases the risk of falls and the need for long-term institutional care.
• The patient is often too embarrassed to seek appropriate help.
• Various treatment options that either cure or at least ease the situation are available to manage urinary incontinence in an elderly person.

Prevalence and types

• More common in women and in those living in round-the-clock care
  • Among individuals aged over 70 years, over half of women and about a quarter of men suffer from troublesome urinary incontinence.
• Urge incontinence
  • Characterised by a sudden urge to urinate (urgency)
  • Part of overactive bladder syndrome, the other symptoms of which include urinary urgency without incontinence, urinary frequency and nocturia
  • The most common type in men. The underlying cause is often the increased resistance to urine flow in the outflow tract caused by benign prostatic hyperplasia (BPH).
• Stress incontinence
  • Involuntary loss of urine during physical exertion or strain
  • Common in women
  • Rare in men, mostly seen as a complication of prostate surgery
• Mixed incontinence
  • A combination of urge and stress incontinence
  • The most common type in women
• Overflow incontinence
  • Incontinence caused by either acute or chronic urinary retention

Changes connected with aging

• Women
  • Atrophy of urogenital mucous membranes
  • Weakening of the pelvic floor supporting structures
  • Urethral shortening
• Men
  • Benign prostatic hyperplasia Benign Prostatic Hyperplasia.
• Men and women
  • Detrusor hyperactivity with impaired contractile function
  • The functional volume of the bladder decreases leading to an increased volume of residual urine.
  • Tthe ability of the kidneys to concentrate urine decreases.
  • The volume of urine excreted during the night (nocturnal polyuria) increases in relation to the volume excreted during the day.

Factors associated with urinary incontinence in the elderly

• Neurological diseases
  • Memory disturbances
  • Cerebrovascular disease and the so-called white matter changes in the deep parts of the brain
  • Parkinson's disease
  • One component in the triad of symptoms in the normal pressure hydrocephalus (NPH)
• Other chronic diseases
  • Type 2 diabetes
  • Cardiac insufficiency (fluid retention, diuretics)
  • Lung disease (cough)
  • Musculoskeletal disease (e.g. spinal stenosis)
• Depression and depressive symptoms
  • Cause or consequence?
• Intestinal symptoms
  • Constipation
  • Faecal incontinence
• Reduced mobility and functional capacity
• Frailty syndrome
• Delirium
• Acute urinary tract infection
  • Moreover, asymptomatic bacteriuria is very common in an elderly person and requires no management.
• Medication
  • Diuretics
  • Antipsychotic drugs with anticholinergic properties
  • Analgesics acting on the central nervous system
  • Hypnotics and sedatives
  • Acetylcholinesterase inhibitors used in Alzheimer's disease

Treatment

• Investigations and treatment are decided on according to the cause(s) and type of incontinence.
• In cases where the patient has a memory disease, several comorbidities or a medication consisting of a variety of drugs, the emphasis of management should be on a holistic approach and rehabilitation.

Rehabilitation aspects

• The maintenance and promotion of mobility and functional capacity improve bladder control.
• Speedy and effective rehabilitation should be provided after an acute illness or surgery using appropriate mobility aids.
• An indwelling catheter should be removed as soon as possible in order to preserve bladder control and to avoid catheter-induced infections and other complications.
• It must be ensured that the patient has an obstacle-free and safe route (e.g. adequate lighting etc.) to the toilet or commode both at home and in residential care.

Incontinence protection

• High quality incontinence pads that are changed sufficiently frequently
• Various collection bags are available for men
• It may be more difficult for elderly men to accept the use of incontinence pads, and they should be given particular attention during counselling and education.

Other points of importance

• Listen to the wishes of the patient and his/her family
• Observe the mood of the incontinent patient and prescribe, if necessary, antidepressants.
• Treat constipation Obstipation in the Adult.
• Review all medication.
• In persons with a memory disorder, consider also other possible aetiological factors of urinary incontinence than the memory disorder.

Referral criteria

• Suspicion of urinary obstruction (e.g. a prolapse in women and prostate problems in men)
• Severe symptoms
• No results are achieved with conservative treatment
• Postoperative complications