REVIEW
Management of urinary
incontinence in frail elderly
women
Leanne Alexander
Kathleen Shakespeare
Victoria Barradell
Susan Orme
Abstract
Urinary incontinence (UI) is defined by the International Continence Soci-
ety as any involuntary leakage of urine. It is a common clinical problem,
and its incidence increases with age. It is a particular problem in the frail
elderly, who can sometimes pose a diagnostic and therapeutic challenge
by virtue of their complexity. UI is a major cause of disability and depen-
dency and adversely affects the psychological and physical health of the
older person. However, treatment can lead to significant improvements.
Keywords cognitive impairment; elderly; frail; urinary incontinence
Introduction
Urinary incontinence (UI) is defined by the International Conti-
nence Society as any involuntary leakage of urine. It is a common
clinical problem, and incidence increases with age. Estimations
of prevalence vary according to the definitions used, but is
thought to be around 15e30% in the ambulant community
dwelling elderly, rising to between 50 and 80% in those in long-
term care.
Normal ageing is not a cause of urinary incontinence,
although age related changes in lower urinary tract function can
predispose older people to UI which is then exacerbated by
comorbidities. UI is a major cause of disability and dependency
significantly increasing the risk of care home placement and
adversely affects the psychological, physical and social well
being of older people. It also predisposes to carer negativity and
stress, which itself is a major factor in placement for institutional
care.
The frail elderly have traditionally been under treated due to
fears over the side effects of the medications, under reporting of
symptoms, and low expectations of treatment outcomes by both
Leanne Alexander MBChB (Hons) BA (Hons) MRCP DGM is a Speciality Doctor in
Geriatric Medicine at Barnsley Hospital NHS Foundation Trust, UK.
Conflicts of interest: none declared.
Kathleen Shakespeare MBChB MRCP is a Consultant in Geriatric Medicine,
Chesterfield Royal Infirmary, UK. Conflicts of interest: none declared.
Victoria Barradell MBChB MRCP is a Consultant in Geriatric Medicine at
Doncaster and Bassetlaw Trust, UK. Conflicts of interest: none declared.
Susan Orme BMBS (Hons) BMedSci FRCP is a Consultant in Geriatric Medicine
at Barnsley Hospital NHS Foundation Trust Hospital, Barnsley, UK.
Conflicts of interest: none declared.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 25:3
patients and doctors. However, significant improvements can be
achieved with correct assessment and treatment. The following
forms a framework to aid the management of this challenging
group of patients.
Prevalence
A 1993 MORI poll in the UK showed a lifetime prevalence of UI at
all ages of 6.6% in men, and 14% in women with approximately
3.9 million sufferers in the UK alone. Prevalence continues to
increase as a consequence of an ageing population with resource
implications for the NHS and social care. The true prevalence of
UI is difficult to accurately estimate as many sufferers never seek
due to embarrassment, lack of awareness of treatment options,
and the myth that UI is a normal consequence of ageing.
Estimations also vary widely according to the definition used,
but a review of the literature suggests a prevalence of 15e30%
for community dwelling older people. All studies report a higher
incidence of UI among care home residents in the range of 50
e80% because UI is associated with older age, frailty, cognitive
impairment, limited mobility leading to a greater level of de-
pendency. All of these factors are more prevalent amongst those
in long-term care.
The severity of UI has been defined in various ways, but
mostly according to the frequency of urine loss. The general
prevalence of severe urinary incontinence (weekly or more) in all
age groups is thought to be between 3 and 7%. The Newcastle
85þ cohort study in 2009 reported an overall incidence of severe
UI in 21%, commoner in women.
Associated factors
UI is associated with other co-morbidities and can contribute
significantly towards declining functional status and poor quality
of life. It is also associated with substantially increased risk of
admission to twenty-four hour care. Incontinence in this context
may be functional and treatment should be modified accordingly.
A list of some of the major conditions contributing to UI can be
found in Table 1. Appropriate treatment of the conditions listed is
a necessary part of continence management in this patient group.
The more common medications associated with exacerbations
of UI are listed in Box 1. In particular diuretics increase the
volume of urine produced. Changing to a loop diuretic with a
longer half-life such as torasemide can make some improvement
in incontinence associated with diuretic timing.
Medication review is therefore essential with particular
reference to drugs that contribute towards incomplete bladder
emptying or cause constipation.
Conditions caused by urinary incontinence
UI is generally thought to be a predictor of adverse outcomes in
older people. Those with UI have a greater mortality, but
generally also have more significant comorbidities, which may
partly explain this association. There is no universally agreed
definition of frailty but it is thought of as a multi-system syn-
drome of impaired mobility, fatigue, muscle strength, and bal-
ance. Common conditions caused by UI are listed in Table 2.
75 Ó 2015 Elsevier Ltd. All rights reserved.
 REVIEW

Conditions contributing to urinary incontinence

Condition Type of incontinence Notes

Dementia Urge incontinence Causes UI by variety of mechanisms:

Functional incontinence a) Decreased motivation and initiative to
go to the toilet
b) Social disinhibition
c) Decreased executive function
d) Immobility or gait disturbance
e) Severe autonomic failure (Lewy Body
Dementia)
Stroke Urge incontinence Varying effects on bladder and bowel function,
Functional incontinence mobility and functional ability to toilet
Occasionally urinary retention UI post stroke often improves over time
Poor prognostic indicator for those in whom it
persists
Parkinson’s Disease Functional incontinence Also autonomic failure in “Parkinson’s Plus”
Urge incontinence syndromes
Delirium Delirium can be associated with detrusor
underactivity or bladder outflow
obstruction causing urinary retention
(“cystocerebral syndrome”) as well as
infection causing UI
Normal Pressure Hydrocephalus Incontinence, gait and cognitive deficits
Potentially reversible with VP shunt
Anxiety and Depression Can result from incontinence
Less motivation to stay continent
Can also cause mildly impaired cognition
Arthritis Functional incontinence
Urge incontinence
Diabetes Functional incontinence Polyuria in poorly controlled DM
Peripheral neuropathy
Autonomic neuropathy
Increased susceptibility to UTI
Peripheral oedema (heart failure, venous Nocturia Reabsorption of peripheral oedema causing
insufficiency, medications) Nocturnal polyuria increased circulating volume and increased
Nocturnal enuresis nocturnal urine production
Increased ANP levels secondary to
myocardial stretch from increased
circulating volume may also contribute to
increased nocturnal urine production
Constipation and faecal impaction Combined faecal and urinary incontinence Outflow tract obstruction causing urge
Urge incontinence incontinence from detrusor overactivity
Urinary retention Straining can result in weakened pelvic
floor muscles
COPD Stress incontinence Cough can exacerbate stress incontinence

Table 1

How is continence maintained? 4. Sufficient mobility and manual dexterity to remove clothing,
5. Ability to voluntarily initiate micturition at the appropriate
Maintaining continence is a complex process, and depends on:
time.
1. An intact bladder, sphincter, and pelvic floor function with
The frontal cortex is responsible for voluntary control of
normal innervation,
micturition with the sensation of a full bladder as well as external
2. An ability to communicate the need to go to the toilet if
sphincter contraction and relaxation. The motor cortex controls
immobile,
bladder motor function, as well as the ability to mobilize to the
3. Adequate cognition to know how to find the toilet and to
toilet, bypassing any environmental hazards en route. All of
keep continence until on the toilet,
these processes can be affected by inter-current illness.

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 REVIEW

Urethral changes
Drugs that Cause or Exacerbate Urinary Incontinence Ageing results in increased collagen deposition in the urethra,
and loss of circular smooth muscle in the urethral sphincter. This
C Alcohol results in decreased urethral closing pressure.
C Alpha adrenergic agonists e.g. midodrine, pseudoephedrine
C Alpha blockers e.g. doxazosin, tamsulosin Vaginal changes
C ACE inhibitors e.g. ramipril, lisinopril Post menopausal atrophy can cause loss of lactobacilli leading to
C Caffeine colonization with pathogens such as Escherichia coli, enterococci
C Cholinesterase inhibitors e.g. donepezil, rivastigmine etc, as well as atrophic vaginitis.
C Diuretics e.g. bendrofluazide, furosemide, bumetanide
C Anticholinergic drugs Other changes
C Oral oestrogen therapies e.g. HRT Ageing causes reduced pituitary production of antidiuretic hor-
C Opioids e.g. codeine, morphine, tramadol mone (ADH) reducing urine-concentrating ability. Nocturia is
C Sedatives and hypnotics e.g. benzodiazepines, zopiclone also more common due to reversed diurnal urine production
through increased production of atrial natriuretic peptide (ANP).
Box 1 This acts on the kidney to produce greater volumes of more
dilute urine at night. Nocturnal urine production can also be
Age related changes affecting the urinary tract
increased by peripheral oedema re-entering the circulation at
Multiple age related changes occur in the lower urinary tract as night whilst lying in bed.
well as age-associated co-morbidities that are linked with UI. Changes in the immune system related to age can lead to an
increased likelihood of UTI. Practical problems with maintaining
Bladder changes anal and vulval hygiene may also contribute.
Collagen deposition within the bladder wall results in a reduction
in functional bladder capacity and lower urinary flow rates
What are the symptoms and subtypes of UI?
through a reduction in bladder elasticity. Decreased innervation
results in less cholinergic transmission and a reduced sensation Overactive bladder (OAB) is defined as urgency that occurs with
of bladder filling so that the first sensation of needing to void is or without urge UI, usually with frequency and nocturia, and in
closer to the functional bladder capacity, giving less time to get to the absence of other pathology. OAB that occurs with urge UI is
the toilet and void appropriately. known as ‘OAB wet’. OAB that occurs without urge UI is known
as ‘OAB dry’. OAB is the most common cause of UI in the elderly.
Residual volume In the elderly these are most commonly cerebrovascular or
A residual volume of more than 100 ml is indicative of incom- neurodegenerative in origin. Several studies have reported a link
plete bladder emptying in younger person but in the elderly up to between larger numbers of white matter lesions and worsening
200 ml can be considered normal. Very large residual volumes UUI symptoms.
(>300 ml) are associated with increased risk of upper urinary
tract dilatation and renal impairment. . Stress incontinence
Stress urinary incontinence (SUI) is the complaint of involuntary
leakage of small amounts of urine on effort or exertion, sneezing
Conditions caused by urinary incontinence or coughing. It is more common after the menopause.
Condition Notes
Incontinence due to incomplete bladder emptying
Depression and Also reduced quality of life and social Is usually secondary to an underactive bladder, or a bladder
anxiety isolation outflow obstruction, and tends to cause a continuous loss of
Falls and fractures Falls and fractures can result from UI, small amounts of urine. Causes include spinal cord lesions (MS,
especially UUI and OAB cord compression), peripheral nerve lesions (e.g. diabetic
Nocturia Nocturia can result in daytime sleepiness, neuropathies) and constipation. Constipation is the most
and have an adverse effect on cognition. It prevalent cause of this in hospital inpatients and long-term care
is associated with an increased falls risk of settings.
between 10% and 21% with two or more
Mixed incontinence
voids per night, as well as an increased
This is a combination of OAB and SUI symptoms. Treatment
fracture risk and nocturnal enuresis
initially should be aimed at the predominant symptom.
Pressure areas UI is an important feature in the
development of pressure areas, and slows
Functional incontinence
their healing. Can also cause skin rashes
Functional incontinence is a general term to describe the
and dermatitis
factors outside the lower urinary tract that contribute to UI,
Urinary tract infection UTI is associated with chronic urinary
including mobility, environmental factors, medications
retention, as well as indwelling catheters
and other co-morbidities. There are a variety of ways to
and condom drainage systems
manage mobility and continence that are discussed later in this
Table 2 article.

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 REVIEW

Nocturia assessment of functional ability and social circumstances in

The International Continence Society defines nocturia as having order to enable comprehensive holistic management (Box 2). In
to wake one or more times to void urine at night. Nocturnal patients with cognitive impairment some history should be eli-
polyuria is defined as producing more than 35% of total daily cited from the carer if possible.
urine output at night. Incidence increases with age and usually
>50% men and women over the age of 60 will have nocturia. By Examination
the age of 80, the majority of women will have symptoms. See Box 3.

Investigation
Assessment of frail older patients with UI Investigations should include baseline blood tests as well as a
History bladder diary. NICE guidelines recommend the use of bladder
A comprehensive history is the most important part of any diaries over a minimum of three days in order to initially assess
assessment of a frail older patient and should include a thorough anyone with UI. Fluid intake, voiding times and quantities, and
episodes of urinary incontinence are recorded. This can be done
History taking either by the patient or a carer, and is a useful tool in identifying
the cause of the UI but is not always possible to achieve in the
Urinary symptoms frail. In the setting of severe cognitive or functional impairment,
C Storage e any urgency, frequency or nocturia symptoms a modified diary, where the number of voids, episodes of UI and
C What is the flow of urine like? number of drinks consumed gives some useful information.
C Any urinary leakage, amount lost, and its precipitants. Urinalysis and a post-void bladder scan are also indicated.
C Distress caused and current coping strategies.
C Haematuria/UTI symptoms? Specialist investigation
Urodynamics: frail older women may be considered more suit-
able for conservative management and so urodynamics may be
Bowels unnecessary. A functional assessment of walking and undressing
C Constipation symptoms? Is the patient taking any treatment for will usually be of more diagnostic value in this patient group.
this?
C Straining (can weaken pelvic floor muscles) Management
C Presence and frequency of any faecal incontinence General measures and lifestyle modifications: the management
of UI requires a multidisciplinary approach. This is of particular
importance in the frail. National guidelines such as the NICE
Fluid intake
guidelines for the management of UI tend to focus on younger
C Caffeine intake
fitter patients, although recommendations are now included for
C Alcohol intake
frailer adults. NICE clinical guidelines on UI in neurological
C Volume and timing of drinks in comparison to symptoms
disease focus on incontinence in patients with multiple sclerosis,
Parkinson’s disease, dementia and stroke which may be appli-
PMHx cable to some of the frail elderly patients.
C Previous urological/renal problems, haematuria or recurrent UTI Factors such as the aetiology of incontinence, mobility, co-
C Previous pelvic surgery morbidities, anaesthetic risk, potential side effects and patient
C Details of pregnancies, mode of delivery and birth weight of choice all need to be considered.
children
C Other co-morbidities contributing to UI Conservative measures: certain conservative measures apply to
C Any cognitive impairment? all aetiologies of UI and it is important to give simple advice first.
Hygiene e advise washing daily and after every accident
using unscented soap or baby wipes paying attention to adequate
DHx
C Sedatives and hypnotics
C Anti-muscarinics
Examination
C Diuretics and timing of diuretics
C Constipating medications (opiates, calcium channel blockers)
C Record BMI
C Assess general mobility
SHx C Test for cognitive impairment with AMT. If score<8/10, consider
C General functional status and ability to perform activities of daily MMSE (Score <27 is abnormal)
living C Abdominal examination and PR
C Mobility C External genitalia
C Access to toilets/continence aids C PV examination if indicated
C Impact on quality of life e incontinence questionnaire (ICIQ) C Neurological exam e especially legs and for signs of unrecog-
C Availability of carers around timing of symptoms nized Parkinsonism

Box 2 Box 3

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 25:3 78 Ó 2015 Elsevier Ltd. All rights reserved.
 REVIEW
drying. Advise loose fitting clothes to reduce the risk of skin
damage from soiling.
Fluid, caffeine and alcohol intake e advise drinking 2e3
pints of fluid a day. Less than this can exacerbate irritable
bladders and more will increase the volume or urine production.
Advise avoiding caffeine (switch to decaffeinated tea and coffee if
possible) and excess alcohol as both have a diuretic effect and
can exacerbate incontinence.
Weight loss e obesity carries an increased risk of SI and UUI,
and in these cases weight reduction and education programmes
can help especially in those with a body mass index greater than
30 kg/m2.
Smoking e whilst stopping smoking has no direct effect on
urinary incontinence, persistent cough contributes to stress in-
continence and stopping smoking may reduce this.
Reversible causes e see Box 4.
Medication review e medication review is essential (Box 5).
Environmental interventions e difficulty in accessing toilet
facilities is a potentially major factor in incontinence in the frail.
This is known as functional incontinence and usually co-exists
with other forms of incontinence. In many, poor mobility may
be a contributing factor but environment also plays a part.
Occupational therapists assess functional difficulties and prob-
lems with home environment. They may be able to provide
downstairs commodes, and adjust lighting and flooring. Clothing
that is elasticated or with Velcro fastening can be used to aid
rapid removal. It is important to consider such factors in hospi-
tals and care homes in addition to patients’ own residences
because a change in a frail person’s environment can exacerbate
any UI.
Containment devices e many frail elderly will require the use
of devices to contain urine to preserve dignity when incontinent.
A wide range of absorbent pads is available. Pads can be worn
next to the skin or as absorbent sheets for beds. Body worn pads
are superior to sheets as they are less likely to wrinkle and cause
pressure damage and less likely to affect pressure relieving
mattresses. Such devices are not treatments in themselves, but
are used in addition to other therapies or as a long-term man-
agement strategy in those with refractory symptoms despite
treatment. The patient and carer preferences should be consid-
ered when choosing containment products.
Catheters e the indications for catheterization include
chronic urinary retention where medical management has failed
and surgery is thought to be inappropriate, pressure sores or
wounds prone to urinary contamination.
The different methods of catheterization include intermittent
catheterization (either by patient or carer), long term urethral
Reversible causes of urinary incontinence
C Constipation
C Metabolic disturbance e.g. hypercalcaemia, hyperglycaemia
C Urinary tract infection
C Delirium and acute confusional states
C Atrophic vaginitis
C Medications (see Box 1)
C Restricted mobility
Box 4
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 25:3
Side effects of anticholinergic medication
CNS
C Sedation
C Cognitive impairment
C Delirium
Gastrointestinal
C Dry Mouth
C Constipation
Ophthalmic
C Mydriasis (Glaucoma)
C Impaired accommodation (blurred vision)
CVS
C Arrhythmia
C Tachycardia
C Orthostatic intolerance
Urinary
C Retention
Box 5
catheterization, or supra-pubic catheter. Intermittent catheteri-
zation and supra-pubic catheterization have lower risks of uri-
nary tract infection and also have less impact on sexual function.
It is important that in any patient requiring catheterization that
patients and carers are counselled regarding the indications,
complications and care.
Specific measures
Stress incontinence (SI)
Conservative
Pelvic floor exercises and vaginal cones e both of these
techniques though demonstrated to be highly efficacious in
younger women are likely to be less effective in certain groups of
frail elderly as patients must have adequate higher mental
functions and sufficient motivation.
Bladder training and habit retraining e bladder training
aims to gradually increase the intervals between each void. It
utilizes scheduled voiding when awake, and relaxation tech-
niques to suppress the sensation of urgency in the time between
voids. It can be very effective in those with normal cognitive
function.
Prompted voiding and scheduled toileting e in those
with cognitive impairment who do not have the cognitive ca-
pacity to comply with behavioural interventions, timed voiding
and prompted voiding can reduce the risk of UI. Prompted
voiding involves asking patients at regular intervals whether
they would like to go to the toilet. It is carer and patient
dependent and requires a moderate degree of remaining
cognition.
Timed toileting is carer dependent and may be more appro-
priate in those with severe cognitive impairment. Both of these
79 Ó 2015 Elsevier Ltd. All rights reserved.

techniques aim to reduce incontinent episodes but do not affect
bladder function and they may increase the workload for carers.
They are only effective for daytime incontinence.
Pharmacological therapy
Serotonin and noradrenaline reuptake inhibitors (Dulox-
etine) e SNRI’s have been shown in a recent Cochrane review to
improve quality of life in patients with UI although it has little
impact on the numbers cured. The inhibition of serotonin and
noradrenaline reuptake specifically in the sacral spinal cord in-
creases the tone of the sphincter through parasympathetic inhi-
bition and improves urethral closure. Side effects are significant.
At present duloxetine is recommended should pelvic floor ther-
apy be unsuccessful and the patient prefer to avoid surgery.
Whilst this is a common situation in the frail elderly, side effects
of duloxetine may limit its use in this group. NICE suggest it may
be considered as a second line treatment for those unsuitable for
surgery.
Oestrogen therapy: around the menopause withdrawal of oes-
trogen may result in a reduction of periurethral pressure. Theo-
retically replacing this oestrogen locally will reduce SI. There is
some evidence that topical oestrogens may improve incontinence
for the duration of treatment but the effect is modest and only
small proportions of women benefit. NICE recommend its use in
OAB patients who are post menopausal with vaginal atrophy. It
also has a role in the prevention of recurrent urinary tract
infection and local symptoms in women with atrophic vaginitis.
Urge incontinence/overactive bladder
Conservative measures: as above.
Pharmacological Rx
Anticholinergic therapy e anticholinergic drugs used in UUI
act on smooth muscle receptors of which there are 5 types: M1
eM5. Type M2 causes bladder relaxation during filling and M3
mediates bladder contraction, therefore the interaction between
these receptors contributes to the symptoms of overactive
bladder.
Type M1 is found the in hippocampus and forebrain and plays
an important role in memory and cognition.
It is the presence of muscarinic receptors in other organs that
causes the extensive side effects found with anticholinergic
Drugs with anticholinergic side effects
Antiemetics Hyoscine, cyclizine, prochlorperazine
Antiparkinsonian Procyclidine, trihexyphenidyl
medication
Antispasmodic Oxybutynin, trospium, tolterodine, solifenacin
Antiarrhythmic Disopyramide, procainamide, quinidine
Antihistamine Chlorpheniramine
Antidepressants Amitriptyline, imipramine, doxepine,
nortriptyline
Antipsychotics Chlorpromazine, dozapine, fluphenazine,
thioridazine
Table 3
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 25:3
REVIEW
agents (Table 3). Use of other drugs with anticholinergic prop-
erties (e.g. tricyclic antidepressants, antipsychotics, ranitidine,
ACE inhibitors and bronchodilators) is common in the elderly
and concomitant use increases the risk of anticholinergic side
effects. The side effect profiles of available drugs govern choice
of agent in the frail. It is recommended that use of such drugs be
reviewed early and frequently. NICE state that oxybutynin, an
antimuscarinic, is contraindicated in the frail elderly; it is asso-
ciated with acute confusion in this patient group. Fesoterodine
has a good evidence base for use in the elderly and similarly
solifenacin. They are generally well tolerated. Artificial saliva
and osmotic laxative can be prescribed at the out set of treatment
to counteract common side effects of dry mouth and con-
stipation, therefore improving treatment compliance and
success.
B3-adrenoceptor agonist e mirabegron is a novel drug in
treatment of OAB. It is a b3 adrenoceptor agonist and reduces
smooth muscle contractility in the bladder. B3 adrenoceptors are
concentrated in the urinary bladder hence there are less systemic
side effects of treatment. It is currently a third line treatment for
OAB in NICE guidelines and should be used when antimuscarinic
drugs are contraindicated or clinically ineffective. The main
contraindication is uncontrolled hypertension. Care should be
taken if the patient is on digoxin.
Desmopressin e desmopressin is an analogue of vasopressin
that reduces water excretion from the kidneys. Taken at night it
may reduce symptoms in those with troublesome nocturia.
However, due to increasing evidence of hyponatraemic electro-
lyte disturbance and interaction with other medications, this
should not be used in the frail elderly unless all alternatives have
been considered and treatment is supervised by daily U&E
measurement in the first week. This is an off licence treatment
and requires informed consent from the patient.
Surgical therapies: details about specific surgical intervention
are beyond the scope of this article however it is important to
consider the appropriateness of surgery in the elderly. Experi-
enced surgeons and anaesthetists should make any decisions
regarding surgery.
Frailty has been shown to independently predict post-
operative complications, length of stay and discharge to care
homes. However, it is important not to discount such manage-
ment purely on the basis of age and ‘physiological age’ is an
increasingly common concept in modern surgery within the
ageing population.
In patients with prolapse causing stress incontinence, pes-
saries or surgery can be considered. The use of pessaries in the
frail elderly is often well tolerated and if effective may avoid the
need for surgery.
Botulinum Toxin A therapy e evidence suggests an
improvement in symptoms of UUI. Unfortunately all research has
been in patients under the age of 80 years old the majority. It is
difficult therefore to extrapolate this data to the frail elderly
population. There is a risk of incomplete bladder emptying after
the procedure and the patient needs to demonstrate a willingness
and ability to perform intermittent Self Catherisation. However,
this is a feasible treatment option if this criteria is met. In practice
however it tends to be the younger aged who consider this a
viable treatment option.
80 Ó 2015 Elsevier Ltd. All rights reserved.
 REVIEW
Incontinence associated with incomplete bladder emptying
Medication review is essential as anticholinergic medications can
increase incomplete bladder emptying and should be avoided.
Constipation should be avoided. Specific treatment depends on
the cause.
Urinary incontinence and cognitive impairment
The incidence of dementia rises substantially after the age of 75,
and UI in the cognitively impaired can range from 11% in an
outpatient setting to 90% in care homes. Dementia can cause UI
by a variety of mechanisms ranging from decreased motivation
and initiative to go to the toilet, social disinhibition, decreased
executive function, immobility or gait disturbance or even severe
autonomic failure.
In Alzheimer’s disease UI presents an average of 6.5
years after dementia onset. However in Lewy Body Dementia
UI presents sooner after dementia onset (3.2 yrs) and in
vascular dementia UI can precede dementia onset by 5 years or
more.
Managing UI in the patient with cognitive impairment pre-
sents a challenge. Patients are often difficult to assess as they
may not be able to give an accurate history and may not comply
with examination or investigations. Patients with dementia tend
to have other major comorbidities and may be on medications
that cause UI. They are more likely to be susceptible to the side
effects of drugs, particularly anticholinergics and may be on
other drugs that interact with medications for UI. Patients may be
difficult to nurse, may pull out catheters and pads putting sig-
nificant strain on carers. However, the benefits of any improve-
ment in continence in this patient group cannot be
underestimated.
Methods such as prompted and timed toileting are effective
and avoiding constipation is important. A medication review is
vital in these patients. Anticholinergic drugs can be considered
but use with care (see Box 5 and Table 3). NICE clinical guideline
on Urinary incontinence in neurological disease provides advise
for patients with dementia.
Anticholinergics and cognitive impairment
There has been concern that interaction of anticholinergic drugs
with M1 receptors in the brain can cause problems with atten-
tion, concentration, memory, and visuospatial awareness. The
most recent NICE guidelines have stated that oxybutynin is
contraindicated in the frail elderly because of this effect, this has
long been known to clinicians.
The concern that all antimuscarinics have this effect
has been addressed in the literature on OAB. Recently, the
SOFIA trial studied the efficacy, tolerability and safety of feso-
terodine, an anticholinergic, in 794 individuals over the age of
65, thus providing robust data in the elderly age group. It was a
prospective, randomized, double blind, placebo controlled
multicentre trial that investigated the effect of fesoterodine on
the symptoms of OAB and specifically examined
cognitive function. The trial established that fesoterodine
reduced OAB symptoms and that there was no significant
reduction in cognitive function demonstrated by monitoring of
the MMSE.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 25:3
There was a meta-analysis of the effects of antimuscarinics on
health-related quality of life, which includes cognition, in over-
active bladder treatment by Khuller et al 2006, which showed
that treatment of OAB with anticholinergics compared with pla-
cebo had statistically significant differences in favour of anti-
muscarinic therapy. It provided evidence that antimuscarinics
provide health related quality of life benefits to patients with
OAB.
Conclusion
Chronological age is no indicator of frailty. Treatment options in
the biologically young cognitively intact female should not differ
from those of the chronologically young.
The frail older woman is disproportionately more disadvan-
taged by UI. It can affect both social and domiciliary functioning
and negatively impact on their relationship with their carers. The
supposition that the frail female will inevitably be incontinent
and that nothing can be done to alleviate her symptoms is a
myth.
The importance of comprehensive medical and multidisci-
plinary assessment cannot be overemphasized. Goal setting that
is realistic and perhaps based on improvement rather than ab-
solute cure can be more appropriate in this group. Assessment of
functional status, carer availability and cognition allows these
goals to be tailored to the needs of the individual. Avoidance of
constipation, appropriate medication review, promotion of hy-
giene and availability of appropriate aids and containment
products can help frail older women maintain social activity and
to remain in their preferred environment. A
FURTHER READING
1 Abrams P, Cardozo L, Fall M. The standardisation of terminology of
lower urinary tract function: report from the Standardisation Sub-
committee of the International Continence Society. Neurourol Urodyn
2002; 21: 167e78.
2 National Institute for Health and Clinical Excellence. Urinary inconti-
nence: the management of urinary incontinence in women. (Clinical
guideline 171). 2013, http://www.nice.org.uk/Guidance/CG171.
3 Wagg A, Potter J, Peel P, Irwin P, Lowe D, Pearson M. National audit of
continence care for older people: management of urinary inconti-
nence. Age Ageing 2008; 37: 39e44.
4 DuBeau C, Kuchel G, Johnson T, Palmer M, Wagg A. Incontinence in
the frail elderly: report from the 4th International Consultation on
Incontinence. Neurourol Urodyn 2010; 29: 165e78.
5 Thirugnanasothy S. Managing urinary incontinence in older people.
BMJ 2010; 341: 339e43.
6 Collerton J, Davies K, Jagger C. Health and disease in 85 year olds:
baseline findings from the Newcastle 85þ cohort study. BMJ 2009;
339.
7 Durrant J, Snape J. Urinary incontinence in nursing homes for older
people. Age Ageing 2003; 32: 12e8.
8 Wagg A, Cardozo L, Chapple C, et al. Overactive bladder syndrome in
older people. BJU Int 2007; 99: 502e9.
9 Sakakibara R, Tomoyuki U, Yamanashi T, Kishi M. Dementia and lower
urinary dysfunction : with reference to anticholinergic use in elderly
population. Int J Urol 2008; 15: 778e88.
81 Ó 2015 Elsevier Ltd. All rights reserved.
 REVIEW
10 Wagg A, Verdejo C, Molander U. Review of cognitive impairment with
antimuscarinic agents in elderly patients with overactive bladder. Int J
Clin Pract Aug 2010; 64: 1279e86.
11 Technology appraisal 290. NICE Mirabegron for treating symptoms of
overactive bladder. 2013. London: NICE, http://www.nice.org.uk/
Guidance/ta290.
12 NICE Urinary Incontinence in Neurological Disease. Management of
lower urinary tract dysfunction in neurological disease. Issued:
August 2012. NICE clinical guideline 148. http://www.nice.org.uk/
guidance/cg148.
13 Wagg A, Khullar V, Marschall-Kehrel D. Flexible-dose fesoterodine in
elderly adults with overactive bladder: results of the randomized,
double-blind, placebo-controlled study of fesoterodine in an aging
population trial. J Am Geriatr Soc 2013; 61: 185e93.
14 Khullar V, Chapple C, Gabriel Z, Dooley JA. The effects of anti-
muscarinics on health-related quality of life in overactive bladder: a
systematic review and meta-analysis. Urology 2006; 68(suppl 2):
38e48.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 25:3
Practice points
C Urinary incontinence is not a normal feature of ageing.
C A full history and examination including functional and cognitive
status should be performed as part of the assessment.
C The impact of medication on continence should always be
considered.
C Physiologically young elderly patients should be considered for
surgical intervention if conservative management fails.
C Timed toileting can be of use in managing UI even in the frail
cognitively impaired elderly.
C It is important to exclude and to treat constipation in the frail.
C When considering treatment with an antimuscarinic total anti-
cholinergic drug load should be considered.
C Refer to NICE clinical guideline 171 urinary incontinence in
Women and NICE clinical guideline 148 urinary incontinence in
neurological disease for best practice.
82 Ó 2015 Elsevier Ltd. All rights reserved.