Urinary Incontinence

Key Points

• Incontinence is a common medical problem in the elderly population, affecting up to 30% of women and 15% of men.

• Older women are more likely to have urge and stress incontinence, and older men are more likely to experience overflow and urge incontinence.

• Acute episodes of incontinence are more likely the result of underlying medical conditions (e.g., infection, hyperglycemia) or new medications (e.g., diuretics).

Table 4-14 Principles of Rational Drug Prescribing for Elderly Patients

Table 4-13 Medication Question Checklist

1. Is there a clear indication for this medication?

2. Is it working?

3. Are there side effects?

4. Is the patient taking the medication routinely?

5. Does the medication need lab monitoring?

6. Is it still needed?

1. Periodically update and review the medication list.

2. Work with the community pharmacist.

3. Educate the patient about the medication.

4. Consider an adverse drug event (ADE) as a cause of any new patient symptom.

5. Simplify the medication regimen.

6. Start one medication at a time, at lowest possible dose.

• Specific health risks, including depression and falls, have been linked to urinary incontinence in the elderly patient.

• History, physical examination, urinalysis, and postvoid residual assessment are the key elements in categorization of incontinence.

• In the majority of patients, incontinence can be diagnosed and treated by the primary care provider.

• Treatment options for incontinence include behavior modification, pelvic floor exercises, pharmacologic agents, vaginal pessaries, periurethral bulking agents, and surgical procedures.

• Systemic hormone replacement therapy may exacerbate incontinence.

Urinary incontinence, defined as involuntary leakage of urine, affects 25% to 30% of all adults in their lifetime. The estimated prevalence of urinary incontinence in people over 65 years of age ranges from 35% in community-dwelling individuals to more than 60% for those who reside in long-term care facilities (Goode et al., 2008; Song and Bae, 2007; Tennstedt et al., 2008). Incontinence not only increases in prevalence with age, but also is considered part of a geriatric syndrome. Within the younger population a specific condition of the lower urinary tract or its neurologic control is often the cause of urinary incontinence. In older persons, however, incontinence is often secondary to physiologic age-related changes, comorbidities, medications, and functional impairments.

In 2000 the estimated total cost of urinary incontinence in the United States was $16.3 billion, with $12.4 billion spent on incontinence care for women alone. Routine incontinence care represented the largest expenditure (Hu et al., 2004). Women spend almost $750 annually out of pocket for incontinence management, have significantly decreased quality of life, and are willing to pay almost $1400 per year for a cure. The annual costs of incontinence care are greater than annual direct costs for breast, ovarian, cervical, and uterine cancer treatments combined (Subak et al., 2006, 2008; Wilson et al., 2001).

Urinary incontinence is associated with increased morbidity and mortality. Studies have demonstrated an association between urinary incontinence and worsening in overall function. Health-related quality-of-life measurements have been found to decline in individuals with urinary incontinence (DuBeau et al., 2009; Ko et al., 2005; Teunissen et al., 2006). This decline has been seen in those living independently, in assisted-living facilities, and in long-term care environments (DuBeau et al., 2006).

Specific health risks linked to urinary incontinence include depression, social isolation, urinary tract infections, pressure ulcers, falls and fractures, decreased sexual activity, sleep deprivation, and increased caregiver stress (Brown et al., 2000; Griebling, 2006; Ory et al., 1986; Spector, 1994). Urinary incontinence is also found to be a common reason for institutionalization of the elderly patient (Holroyd-Leduc et al., 2004).

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