INCONTINENCE IN THE ELDERLY PATIENT

Incontinence in the elderly patient
Prevalence
UI increases markedly with advancing age affecting 10 - 20% of women and 7 - 10% of men >65 years old and living at home. This figure escalates if older people are institutionalized.
Prevalence for both sexes: residential home 25%; nursing home 40%; long-stay hospital ward 50 - 70%.

Transient causes of UI (DIAPPERS)
- Delirium
- Infection
- Atrophic vaginitis or urethritis
- Pharmaceuticals (opiates and calcium antagonists cause urinary retention and constipation; anticholinergics cause increased PVR and retention; α adrenergic antagonists cause reduced urethral resistance in women)
- Psychological problems depression; neurosis; anxiety
- Excess fluid input or output (diuretics; CCF; nocturnal polyuria)
- Restricted mobility
- Stool impaction (constipation)

Established UI
This is unrelated to comorbid illness and persists over time. There are several types including UUI, SUI, and incontinence associated with impaired bladder emptying (due to underactive bladder, urethral or bladder outlet obstruction). In addition, functional incontinence is associated with factors outside of the urinary tract such as permanent immobility, cognitive impairment, and environmental changes.
History
Seek out any transient causes and correct before arranging complex assessment and investigation. This can immediately improve function and quality of life, and may be sufficient to restore continence, even if there is coexisting urinary tract dysfunction. Elicit full drug history; comorbid conditions; psychological, cognitive, functional, social, and environmental status.

Examination
Include mini-mental state evaluation (OHCM) and direct observation of patient dexterity and mobility (Barthel Index). Include abdominal assessment (distended bladder), DRE (impacted faeces), vulval inspection (pelvic organ prolapse; atrophic vaginitis), and neurological testing.

Investigations
Measure serum creatinine; frequency volume chart; bladder ultrasound for post-void residual volume; urinalysis (screen for infection, haematuria, glycosuria); evaluation of the home environment and assess need for modifications (occupational therapist and district nurse visits); urodynamics if simple measures fail to work.

Management
Conservative
Biofeedback, electrical stimulation of pelvic floor, and behavioural methods are appropriate only if cognition intact. Pelvic floor exercises (good results if used in conjunction with anticholinergics). Treat any vaginitis (0.01% estriol cream topically). Absorbent appliances include bed pads and body worn pad products (disposable or re-useable); body worn external urine collection devices (close fitting penile sheath/convene); pessary for POP; indwelling catheters where UI is due to obstruction or no alternative intervention suitable.

Surgery
In women, consider colposuspension, periurethral bulking agents, and surgery for pelvic organ prolapse.
In men, sphincter incompetence can be treated with injection of bulking agents, fascial sling with needle suspension or bone anchoring sling, and artificial urinary sphincter.