INCONTINENCE

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INCONTINENCE

• For Aged Care Staff

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INCONTINENCE

• Involuntary loss of urine or stool in sufficient
  amount or frequency to constitute a social and or
  health problem.
• A heterogeneous condition that ranges in severity
  from dribbling small amounts of urine to
  continuous urinary incontinence with concomitant
  faecal incontinence.
• Prevalence increases with age, but it is not part
  of the normal aging

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The statistics

• Incontinence occurs in
• approximately 50 of nursing home residents
• 25-30 of community dwelling older women
• 10-15 of community dwelling older men.
• 545,000 or 2.8 of the Australian adult
  population have severe incontinence.
• 128,800 of the total live in care accomodation
  requiring assistance including frequent leakage
  events and assistance due to mobility limitation

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TYPES OF INCONTINENCE

• Urge-common in elderly
• Stress
• Overflow
• Functional

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MANAGEMENT

• Physical examination form local problems, e.g.
  prostatic enlargement in men, gynaecological
  disorders in women, and for central problems, eg
  neurological disorders or dementia
• Urine analysis, e.g. glycosuria and culture for
  UTI
• Treatment of contributing causes, e.g.
  constipation, drug therapy, other co-existing
  disease

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MANAGEMENT (cont)

• Urge Incontinence
• bladder training
• anti-muscarinics, eg oxybutynin, fenosteride
• Stress incontinence
• pelvic floor exercises
• Overflow
• removal of obstruction
• Functional
• improve facilities
• regular urine voiding
• absorbent padding.

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MEDICATIONS THAT CAN CONTRIBUTE TO INCONTINENCE

• Medications can be a common cause of incontinence
• Alpha-blockers (eg prazosin)
• Diuretics
• Sedatives
• Calcium channel blockers
• Sympathomimetic decongestants (eg pseudoephedrine)
  
• Anticholinergics (doxepin, hyoscine, ipratropium,
  benztropine, chlorpromazine, imipramine,
  amitriptyline)

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URGE INCONTINENCE

• Urgency incontinence due to increased activity of
  the detrusor smooth muscle may be worsened by
• poor mobility, resulting in patients not reaching
  the toilet in time
• by urinary tract infection.
• For symptomatic control, use
• oxybutynin

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OXYBUTYNIN(Ditropan)

• DOSE
• Elderly, start with 2.5 mg at night and increase
  slowly if necessary. (AMH 2008)
• 5 mg orally, 2 or 3 times daily (decrease dose in
  the elderly or debilitated to 2.5 mg twice daily,
  maximum (eTG)
• ADVERSE EFFECTS cognitive dysfunction
• confusion, hallucinations, anxiety, paranoia

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SOLIFENACIN (Vesicare)

• DOSE
• Adult, initially, 5 mg once daily if necessary,
  increase dose to 10 mg once daily.
• Do not exceed 5 mg daily in people with moderate
  hepatic impairment, creatinine clearance
  lt30 ml/minute or taking potent CYP3A4 inhibitors
  (eg itraconazole, ketoconazole, ritonavir).
• Counselling
• Swallow tablet whole do not crush or chew
• Adverse Effects anticholinergic eg dry mouth,
  urinary retention, constipation

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STRESS INCONTINENCE

• May respond to
• prazosin 0.5 mg orally, twice daily, increasing
  to 2 mg, twice daily, if tolerated
•  OR
•  
• amitriptyline 25 mg orally, at night, increasing
  to 100 mg daily, if tolerated

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PRAZOSIN (Minipress, Pressin)

• Relax smooth muscle in the bladder neck and
  prostate, decreasing resistance to urinary flow.
• DOSE
• 0.5 mg twice daily for 37 days, then increase
  according to clinical response up to 2 mg twice
  daily
• dose must be adjusted according to individual
  response
• if treatment is interrupted for several days,
  restart and titrate dosage as if starting for the
  first time
• stop if there is no benefit after 46 weeks of
  maximal treatment
• Adverse Effects
• first dose hypotension is common with the
  selective alpha-blockers it is most serious in
  the elderly and in patients with fluid depletion
  or who are taking diuretics

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TAMSULOSIN (Flomaxtra)

• Relax smooth muscle in the bladder neck and
  prostate, decreasing resistance to urinary flow.
• DOSE 400 mg once daily, in the morning.
• Counselling Swallow whole, with or after food
• Adverse Effects postural hypotension, dizziness,
  priapism,

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OTHER FORMS OF INCONTINENCE

• In terminal illness (eg due to complete sphincter
  dysfunction from spinal cord compression) can be
  managed with absorbent padding or an indwelling
  catheter.
• Involvement of a urologist or continence clinical
  nurse consultant can be helpful

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BENIGN PROSTATIC HYPERTROPHY

• BPH is the most common prostatic disorder can
  cause urinary obstruction with symptoms such as
  hesitancy, dribbling after urination, nocturia,
  frequency and urgency and may culminate in
  urinary retention.
• Neither the presence or absence of residual urine
  nor the size of the prostate are related to
  symptom severity, degree of obstruction or
  treatment outcome.

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BPH Before starting treatment

• Exclude prostate cancer, UTI and renal failure.
• Differentiate nocturia from polyuria (use a fluid
  balance diary). Heart failure may cause nocturia.
• Consider using a scoring system to assess
  symptoms and monitor progress, eg International
  Prostate Symptom Score,
• Mild symptoms, not causing undue discomfort,
  where surgery is not indicated, do not need
  active treatment, but watchful waiting with
  periodic reassessment.

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FINASTERIDE (PROSCAR)

• Reduces prostate size but appears to be effective
  only if the prostate is significantly enlarged
  (gt40 cm3). Full clinical response may take
  6 months or more. Generally well tolerated,
  although may cause sexual dysfunction. Less cost
  effective than selective alpha-blockers.
• Drug Handling Women who are or may become
  pregnant should not handle broken or crushed
  tablets without gloves (ADEC category X)

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URINARY TRACT INFECTION

• Management of UTI in the elderly can be
  difficult. Sometimes over prescribing of
  antibiotics, with associated risk of adverse
  effects and development of resistance.
• Key messages include
• Asymptomatic bacteriuria is common in the
  elderly.
• Cloudy or malodorous urine in a patient without
  symptoms or signs does not require investigation
  or treatment.
• Elderly patients with signs and symptoms of
  sepsis require urgent treatment.

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REFERENCES

• http//www.continence.org.au/site/index.cfm
• International Prostate Score www.usrf.org/question
  naires/AUA_SymptomScore.html
• Therapeutic Guidelines
• Australian Medicines Handbook
• eMIMS