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Particular beverages can aggravate the lower urinary tract symptoms in older adults. Alcohol, caffeine, and highly acidic citrus fruits and drinks are considered direct

Table 4-17 "Red Flag" Criteria for Referral of Older Patient with Incontinence to Subspecialist

Significant uterine, bladder, or rectal prolapse

Surgery or radiation involving lower urinary tract within past 6 months Two or more symptomatic urinary infections in past 6 months More than five red blood cells per high-power field (>5 RBCs/hpf) on repeated urinalysis in the absence of infection Postvoid residual volume greater than 200 mL

Marked prostatic enlargement, prominent asymmetry, or induration of bladder lobes

Persistent symptoms after appropriate trials of behavioral or drug therapy bladder-irritants and may worsen incontinence symptoms. Alcohol has diuretic properties, causing increased urinary frequency. Weight loss may be beneficial for some patients, in particular women with stress incontinence. Nocturia is a common complaint for many elderly patients with multifac-torial causes (Sugaya et al., 2008). Minimizing late-afternoon and evening fluid intake may decrease nocturnal episodes for some patients. Reduced production of antidiuretic hormone has been seen in patients with obstructive sleep apnea. Treatment of the sleep apnea may help reduce nocturia symptoms (Kujuba and Aboseif, 2008).

In older patients with symptoms of urinary urgency, timed voiding is often suggested. Many patients experience symptoms only when the bladder is full, so voiding more frequently will reduce the amount of bladder distention and the sense of urinary urgency. Older patients with cognitive or mobility impairments will often need assisted-toileting programs. Providing physical assistance in going to the toilet on a regular basis can reduce incontinence episodes (van Houten et al., 2007). Some patients benefit from bladder retraining, in which they are taught to delay voiding at progressively longer intervals (Wallace et al., 2004). Bladder retraining can take months and has the most benefit for patients with urge incontinence and those with mixed incontinence when combined with pelvic floor exercises (Tuenis-sen et al., 2004). The patient is encouraged to focus on the sensations in the pelvis, complete pelvic floor contractions and wait until the urgency sensation subsides before proceeding to the toilet.

Pelvic floor muscle (Kegel) exercises remain one of the mainstays of behavioral therapy in the treatment of urinary incontinence. The exercises involve repetitive contractions and relaxations of the pelvic floor muscles. They have been found effective in stress, urge, and mixed incontinence (Hay-Smith and Dumoulin, 2006). A simply way to teach women to identify and isolate the pelvic floor muscles is by having the patient squeeze the examiner's finger during vaginal examination. Squeezing the examiner's finger by contracting the anal sphincter during a rectal exam can help both men and women isolate the pelvic floor muscles.

Pessaries in many different forms have been used for hundreds of years for the treatment of pelvic organ prolapse and urinary incontinence in women. The support offered by the pessary helps in correcting the angles and contacts between adjacent organs, thus minimizing bladder irritation and spontaneous contractions that lead to incontinence. Pessaries come in a variety of shapes and sizes and must be individually fitted for each patient by their health provider. Routine cleaning and care by either the patient or, in many cases, their provider is required. In many women, pessaries offer the advantage of avoiding surgery while providing functional support.

Many older adults with urinary incontinence use some type of pad or undergarment to help with their urinary incontinence. Although these products play an important role in the management of incontinence symptoms, patients should be encouraged to seek other types of treatment if appropriate. The cost of these products can be significant and is not covered by Medicare or most other insurance plans. However, it is important to realize that these absorbent products can help older adults maintain their functional independence and participate in their preferred activities.

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Sleep Apnea

Sleep Apnea

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