Neurourology and Urodynamics

Urinary Incontinence in Frail Elderly Persons: Report From the 5th International Consultation on Incontinence Adrian Wagg,1* William Gibson,2 Joan Ostaszkiewicz,3** Theodore Johnson III,4 Alayne Markland,5 Mary H. Palmer,6 George Kuchel,7 George Szonyi,8 and Ruth Kirschner-Hermanns9 1

University of Alberta, Edmonton, Alberta, Canada Division of Geriatric Medicine, University of Alberta, Edmonton, Alberta, Canada 3 Deakin University, Melbourne, Australia 4 Emory University, Atlanta, Georgia 5 Geriatric Medicine, University of Birmingham Center for Aging, Birmingham, Alabama 6 The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 7 Division of Geriatrics, University of Connecticut Health Center, Farmington, Connecticut 8 Royal Prince Alfred Hospital Balmain, NSW, Australia 9 Department of Neuro-Urology, University Hospital Bonn, Bonn, Germany 2

Background: Evidence based guidelines for the management of frail older persons with urinary incontinence are rare. Those produced by the International Consultation on Incontinence represent an authoritative set of recommendations spanning all aspects of management. Aims: To update the recommendations of the 4th ICI. Materials and Methods: A series of systematic reviews and evidence updates were performed by members of the working group in order to update the 2009 recommendations. The resulting guidelines were presented at the 2012 meeting of the European Associatioon of Urology. Results: Along with the revision of the treatment algorithm and accompanying text. There have been significant advances in several areas including pharmacological treatment of overactive bladder. Discussion: The committee continue to notes the relative paucity of data concerning frail older persons and draw attention to knowledge # 2014 Wiley Periodicals, Inc. gaps in this area. Neurourol. Urodynam. Key words: behavioral management; frail older persons; older people; overactive bladder; stress urinary incontinence; urinary incontinence; urinary retention INTRODUCTION

As the population ages, the numbers of older people with lower urinary tract symptoms (LUTS) and urinary incontinence (UI) will significantly increase, as will the associated cost of their care, even if the observed improvement in physical function among older people, with increases in disease-free life and decline in disability amongst those in early old age, are maintained.1,2 This population is characterized by people ranging from functionally independent centenarians to bed bound, cognitively and physically impaired people in their sixties. The healthier, robust older person is phenotypically and physiologically similar to someone in middle age, and as such information relating to their assessment and treatment is not covered in this report. There is a continued dearth of Level 1 evidence for interventions in the frail older person and there remains a systematic failure to include older people in clinical trials.3 Intervention studies and outcome measures need to be broaderbased, incorporate a range of settings, caregivers, models of care, and appropriate outcome goals for the frail elderly population.4 This summary will concentrate of that which has developed since the report of the 4th International Consultation,5 although the recommendations are based on all the available evidence.5 FRAILTY AND UI/LUTS

We defined the frail elderly as those over the age of 65 with a clinical presentation or phenotype combining impairments in physical activity, mobility, balance, muscle strength, motor processing, cognition, nutrition, and endurance including feelings of fatigue and exhaustion.6–8 The relationship between UI and frailty is not unidirectional. Incident UI in those over age 65 #

2014 Wiley Periodicals, Inc.

has been associated with a twofold increased risk of impairment in both personal and instrumental activities of daily living, and poor performance on three physical measures, suggesting that incident UI may be an early marker of the onset of frailty.9 URINARY INCONTINENCE (UI) AS A GERIATRIC SYNDROME

Many of the risk factors for UI or LUTS in the frail are not directly related to the genitourinary tract.10,11 As such, large numbers of baseline as well as precipitating risk factors may interact with each other in influencing the ability of an older individual to remain continent of urine in the face of common daily challenges. Multifactorial complexity has greatly complicated the development of a pathophysiological framework for the study of common geriatric syndromes.10 However, given that common risk factors are shared by different geriatric syndromes, they may present potential targets for intervention. Recent functional magnetic resonance imaging (fMRI) studies have identified areas within the central nervous system

Christopher Chapple led the peer-review process as the Associate Editor responsible for the paper. Conflict of interest: Dr. Wagg has Received monies for consultancy, speaker fees, and research from Astellas Pharma, Pfizer Corp, SCA, and Watson Pharma.

Correction added on June 14, 2014, after first online publication: the third author, Joan Ostaszkiewicz, was included.
Correspondence to: Adrian Wagg, Department of Medicine, University of Alberta, 1-116 Clinical Sciences Building, 11350 83 Avenue, Edmonton, Alberta, Canada. E-mail: [email protected] Received 27 February 2014; Accepted 6 March 2014 Published online in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/nau.22602

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that are particularly relevant to urinary urgency, and failure of activation within orbitofrontal regions may contribute to an older individual’s decreased ability to suppress urgency.12–14 Connectivity pathways within the right insula and anterior cingulate gyrus may also play a role in maintaining continence,13,14 supporting the concept that declines in connectivity15 and coordination16 between different brain regions represent early critical events in ageing. ASSESSMENT OF THE FRAIL OLDER PATIENT WITH INCONTINENCE

Recommendations for the assessment of frail older people with incontinence are summarized in the algorithm (Fig. 1). Since the last consultation,5 the European Association of Urology has published guidelines on UI which include those for frail older men and women. These are largely based on the findings of the 4th ICI.17 The National Institute for Clinical Excellence (NICE) guidelines in the UK were revised in 2013 and now include specific recommendations for the management of UI in the frail elderly.18 The US government sets minimum quality standards for UI assessment and management in longterm care, but these standards, along with basic fundamental principles of UI, are poorly understood by long-term staff.12 Two groups, the US Assessing Care of Vulnerable Elders (ACOVE) project and the UK Clinical Effectiveness and Evaluation Unit, have developed quality performance measures for UI care in frail older people, using structured literature and expert

Fig. 1. Management algorithm.

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panel review.19–23 It should be borne in mind that multiple diagnoses can co-exist, and due consideration given to mixed UI, combining urge and stress elements, and detrusor hyperactivity with impaired contractility (DHIC).24 COMPONENTS

The essential first step is to actively case find in the frail elderly, as the condition is generally under-reported. Up to half of those with UI will not report this fact to anyone.25 The second is to identify treatable, potentially reversible conditions and other factors that can cause or contribute to UI. Amelioration may improve UI directly, make UI more amenable to other interventions, and overall improve the patient’s (and caregivers’) quality of life.26 The common, treatable, potentially reversible conditions that can contribute to UI in frail older people can be defined by the mnemonic DIPPERS (see algorithm). Strong consideration should be given to the potential to over-treat asymptomatic bacteriuria as infection because of the potential adverse outcomes from unwarranted antibiotic treatment.27 FACTORS IN MANAGEMENT

Many frail older people will have co-existing disability and comorbidity, both of which can influence the clinical presentation and assessment of UI, as well as responsiveness to interventions. Frail older people may realize additive benefits in domains other than UI from UI treatment that is aimed at

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underlying comorbidity and impairment. Even ‘‘intractable’’ UI is amenable to interventions that may improve the patient’s urinary and bowel function and quality of life.28 The 3rd ICI paradigm of dependent continence (dependent upon ongoing assistance, behavioral treatment and/or medication) or independent continence (cured without the need for ongoing treatment) also defined ‘‘contained incontinence’’ which should be possible by use of appropriate products such as pads, catheters, and appliances thus providing ‘‘social continence’’ or ‘‘accepted incontinence.’’29,30 The balance between the degrees of continence achieved may vary as UI severity changes, and is dependent upon patient and caregiver preferences. Many people with cognitive impairment can still express their views and treatment preferences.31,32 MEASURING THE BENEFITS AND EFFECTIVENESS OF TREATMENT

Outcome research indicates that patients value quality of life, and that this encompasses many domains beside UI, and is not dependent on complete dryness. New approaches and tools to assess UI-specific quality of life in cognitively-impaired frail elderly are needed, as well as better understanding of the interaction between functional impairment and the impact of UI.33 TREATMENT OF URINARY INCONTINENCE IN THE FRAIL ELDERLY Lifestyle Interventions

Several lifestyle interventions have been evaluated in healthier older and younger women, including dieting and medication to help with weight loss, dietary modification, fluid selection and management, and constipation management. Although many health care professionals advocate lifestyle interventions to treat UI,34–37 there are no data on these interventions for the frail elderly. Some of these interventions may be inappropriate for or impractical to use in frail older people, for example weight loss, yet advanced age alone should not preclude use of lifestyle interventions if assessment warrants this. Two very small older trials and one recent small RCT38 raise the possibility that increasing fluid intake in incontinent frail elderly people may actually decrease UI.39,40 Behavioral Interventions

Behavioral interventions have been especially designed for frail older people with cognitive and physical impairments that may affect their ability to learn new behaviors or to actively

participate in self-care activities. They have been the mainstay of UI treatment in the frail elderly.41

 Prompted voiding, involving prompts to toilet with contingent social approval, is designed to increase patient requests for toileting and self-initiated toileting, and decrease the number of UI episodes.42  Habit retraining, requires the identification of the incontinent person’s individual toileting pattern, including UI episodes, usually by means of a bladder diary. A toileting schedule is then devised to pre-empt UI episodes.43,44  Timed voiding (scheduled toileting, routine toileting, and fixed toileting) involves toileting an individual at fixed intervals, no attempts are made at patient education or reinforcement of behaviors, or to re-establish voiding patterns.41,45  Combined toileting and exercise therapy incorporates strengthening exercises into toileting routines.46 Another combination intervention, administered by occupational or physical therapist, involves toileting and mobility skills.47 Cognitive and functional impairments may preclude the use of some of these interventions. Staff buy-in for the intervention is considered an important component to behavioral interventions.48–51 Consideration of organizational and social factors is considered important to implementation of evidence-based practices.52 Pelvic floor muscle rehabilitation has not been studied extensively in frail older people but this should not preclude their use in appropriate patients with sufficient cognition to participate.53,54 Combined behavioral modification programmes involving pelvic floor muscle exercises, bladder training, and information about lifestyle modifications that prevented UI in community-dwelling older women aged between 55 and 80 years,55 could be effective in some frail older women. There is insufficient evidence to determine if timed voiding improves continence (Level 4).56 Studies repeatedly show that, with the conclusion of a research trial, persistence with the intervention is rarely maintained. Outcome evaluation is usually limited to ‘‘wet checks’’ and not UI, and no studies report cure or patient-based outcomes. No studies reported impact on caregivers. There is little focus on night-time UI; little consideration as to the psychological impact of toileting programmes on patients and caregivers, and no long-term follow up.41,57 Many studies excluded frail older adults with terminal illness, inability to respond to a one-step command, or poor language ability.58–61 The frequency of the intervention varied across studies as well,

TABLE I. Summary of Evidence for Behavioral Interventions Prompted voiding is effective in the short-term treatment of daytime UI in nursing home residents and home-care clients when caregivers comply with the protocol Prompted voiding is ineffective and should not be used for people who need the assistance of more than one person to transfer; these people should be managed with ‘‘check and change.’’ Prompted voiding should not be continued in eligible people who have less than a 20% reduction in wet checks or toilet successfully less than two-thirds of the time after a 3-day trial; these people should be managed with ‘‘check and change.’’ Interventions combining toileting and exercise, decrease wet checks, and improve endurance in nursing home residents, including those with psychiatric disease Interventions combining prompted voiding, exercise, fluid, and food intake interventions improve UI frequency and appropriate toileting It is uncertain whether habit retraining reduces UI in frail older people It is uncertain whether timed voiding reduces UI in frail older people There are no proven interventions to reduce night-time UI in frail older people There are no proven interventions to reduce the incidence of UI in hospitalized frail older people

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Level 1 Level 1 Level 1 Level 1 Level 1 Level Level Level Level

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with toileting conducted every 2 hr over 12-, 14-, and 24-hr schedules.42 Evidence statements are shown in Table I. Recommendations for Practice

 Frailty, not age, should guide treatment decisions.  Family, caregivers, or residential and/or nursing staff dealing



  

with different levels of UI (mild, moderate, catheter managed) have different educational needs and require different levels of support. Interventions to support family caregivers of individuals with UI may need to be adapted to suit formal carers or staff in long-term care so that they accommodate the organizational context. A one-size fits all approach will not accommodate the diverse needs of older people in long term residential care Interventions or approaches to caring for an individual with UI and cognitive impairment need to be tailored to the person’s unique abilities and disabilities. Interventions for UI should be theory-based, multi-component, interdisciplinary, and person-centred. Pharmacological Treatment

Frail people with UI should be considered for drug treatment only following a comprehensive evaluation of remediable causative factors, and an evaluation for and trial of appropriate behavioral therapy and lifestyle interventions. Drug treatment should not generally be used for people who make no attempt to toilet when aided, become agitated with toileting, or are so functionally and cognitively impaired that there is no prospect of meaningful benefit. Even so, a recent study of US nursing home residents suggested that only a small proportion of incontinent residents potentially suitable for drug therapy ever received it.62 Since the last ICI we located a further 13 randomized placebo controlled trials (RCTs) of antimuscarinic medication involving subjects over the age of 80. There have been two large studies of older people, one in Europe and one in the US; the latter targeted at frail older people identified by the VES-13.63,64 For most studies it was impossible to identify whether subjects were frail, except where the study was performed in an institutional environment, in which it is reasonable to assume a high prevalence of functional and cognitive impairment. Age-stratified analyses of CNS outcomes from trials in adults aged 65 and older with overactive bladder were found in only eight publications.65 Explicit, concurrent behavioral therapy was used in most nursing home studies, yet may have occurred in many others although these are usually specifically prohibited in trials managed by the pharmaceutical industry. Combination therapy and high comorbidity could have attenuated differences between drug and placebo, and make it difficult to compare results directly with studies in healthy older and younger people. Outcomes in care home studies were universally assessed by UI frequency (pad-weighing, bladder diaries, and wet-checks), and none reported quality of life outcomes. No reversible causes other than UTI were addressed prior to entry or randomization in most studies. The recent studies of antimuscarinics for frail elderly people are summarized in Table II. There are no new studies since the last ICI of tolterodine, and none specifically in the frail elderly for trospium chloride or mirabegron. Evidence statements are shown in Table III. Recommendations for Practice

 A global assessment of the cognitive and ‘‘at risk’’ status of the patient should be undertaken. Unfortunately, the miniNeurourology and Urodynamics DOI 10.1002/nau

mental state examination (MMSE) and Alzheimer’s disease assessment scale—cognitive (ADAS-Cog) seem to be insensitive to change in cognitive impairment due to bladder antimuscarinics.66,67 Patients that might be at risk of impaired cognition have been well described.68 Treatment may necessarily depend upon a global assessment of cognition during the clinical assessment and, if possible, a carer’s impression of change. In addition to the likely benefit from drug treatment, considering the life expectancy and wishes of the patient, account should be taken of total anticholinergic load. There is evidence of cognitive safety of these drugs, for the most part in cognitively intact older adults, and therefore, prescribing bladder antimuscarinics as single agents is, on the whole, probably safe.  Those studies using high doses (20 mg) of oxybutynin XL are associated with an increased likelihood of causing cognitive impairment, which may not be readily apparent to either the patient or the clinician. This drug should probably be avoided in the elderly at high doses, and in those at cognitive risk at even low dose. The other antimuscarinics should be initiated carefully, at the lowest dose for tolerability, with dose increases where indicated for efficacy, and reviewed early.  The length of exposure to anticholinergics seems to be important, studies suggest a lack of decline in those with established dementia69,70 but with exposures of at least 2 years, there is a reported increase in mortality.71–73 Consideration should be given to limiting the overall exposure of antimuscarinics, particularly if given concurrently with other drugs with anticholinergic properties. Issues in Drug Treatment

A major antimuscarinic adverse drug effect (ADE) of concern in frail adults is cognitive decline, yet there are few data about its incidence or prevalence. Cognitive effects may be underdetected because they are clinically subtle, neither asked about nor reported by the patient, mistaken for age-related diseases and ageing, or because of the high rates of drop out in longitudinal studies.68,74 People with pre-existing cognitive impairment (especially from conditions known to affect central cholinergic pathways) may be at greater risk for this ADE although there are some data to suggest that those with established dementia may not experience cognitive decline following therapy with anticholinergic agents.70 Actual incidence rates of cognitive impairment with antimuscarinic agents for UI are difficult to estimate because of probable under-reporting,62 the different measures used across studies, failure to specify the measure in published trials, the use of proxy measures (such as quantitative EEG), and differences in psychometrics and clinical relevance of self-report, physiologic, and performance measures of cognition. Sink et al.66 found a 50% faster rate of cognitive decline in patients taking both a bladder antimuscarinic (specifically oxybutynin or tolterodine) in combination with an acetylcholinesterase inhibitor (AChI) compared to those taking an AChI alone, but no change in ADAS-Cog score. This contrasts to the work of Lu and Tune,75 who, in a small study of patients with Alzheimer’s disease, found that MMSE scores were significantly worse after 2 years in those taking bladder antimuscarinics with AChI than an AChI alone. Xerostomia is common in older people.76 Antimuscarinics frequently exacerbate this condition, leading to concerns about deteriorating dental health.77 Meta-analyses of bladder antimuscarinics show minor variations in the incidence of dry mouth from clinical trials, with oxybutynin associated with the highest prevalence.78 A recent sub-group analysis of a

Urinary Incontinence in Frail Elderly Persons TABLE II. Trials of Bladder Antimuscarinics Since the 4th ICI Drug

Design

Setting and patients

Results

Minassian 200794

Prospective randomized 12-week, open-label study to investigate the effectiveness of extended release versus immediate release oxybutynin

Community-dwelling female population over the age of 65

Sand 200795

Randomized, open-label, assessing health-related quality-of-life (HRQoL), and safety with oxybutynintransdermal system (OXY-TDS)

Community-based study of 2878 participants aged 18 years who had been given a diagnosis of OAB.

Lackner 201196

Efficacy of oral extendedrelease oxybutynin for urge urinary incontinence

4-week trial in 50 older female nursing home residents with mild to severe cognitive impairment.

Solifenacin

Herschorn et al.79

Randomized, multicentre, prospective, double-blind, double-dummy study to compare the incidence, and severity of dry mouth and other adverse events in patients 65 years and >65

132 subjects with 1 urgency episode per 24 hr, with or without urgency incontinence, and 8 micturitions per 24 hr for 3 months.

Darifenacin

Chapple 200797

RCT assessing efficacy, tolerability, safety, and quality of life in 400 subjects mean age 72 years

Randomized (2:1) to 12 weeks of doubleblind treatment with darifenacin 7.5 mg once daily for 2 weeks, then optional titration to 15 mg daily or placebo with sham titration

Fesoterodine

Wagg et al.64

RCT, efficacy, and PRO comparing fesoterodine to placebo

794 community dwelling men and women >65 (1/3 > 75)

DuBeau et al.63,98

12 week double blind, placebo controlled study

562 people of mean age 75 years fulfilling definition of vulnerable elderly

72 women (23%) were enrolled over 34 months (33 in the immediate release group, and 39 in the extended release group). The study was stopped prematurely There were clinically meaningful and statistically significant improvements in 9 of 10 domains in KHQ at the study end; the greatest improvements were in incontinence impact (13.5), symptom severity (12.4), and role limitations (13.3). Both groups achieved a significant median decrease in mean urinary incontinence episodes and urinary frequency at 4 weeks (P ¼ 0.01–0.05). Incidence and severity of dry mouth and other adverse events with solifenacin were similar between younger and older patients. solifenacin 5 mg/day was associated with fewer episodes and lower severity of dry mouth, and a lower discontinuation rate Mean urgency urinary incontinence episodes decreased significantly with both darifenacin (88.6%) and placebo (77.9%; P > 0.05), QoL assessments revealed significant improvements with darifenacin versus placebo Improvement in urgency episodes (1.92 vs. 3.47, P < 0.001), micturitions (0.93 vs. 1.91, P < 0.001), nocturnal micturition (0.27 vs. 0.51, P ¼ 0.003), severe urgency episodes (1.55, 2.40, P < 0.001), and incontinence pad use. The response on the treatment benefit scale, OAB-S, PPBC, and UPS significantly greater in fesoterodine group Mean reductions in UUI episodes at week 12 versus placebo 0.65 (0.21), P < 0.0018) and 24 hr micturition frequency 0.84 (0.23), P < 0.0003)

Oxybutynin

Study

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5

Comments

No age stratification, not obviously a frail element to the study sample

No between group differences in any outcome

Adverse events were evaluated in subgroups of patients 65 years and >65 years. No stratification otherwise

Unsure re ‘‘frailty’’ of sample

Community dwelling sample, including very elderly, no assessment of frailty, largely cognitively intact

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TABLE III. Summary of Evidence for Pharmacological Management Short-term treatment with oxybutynin-IR has small to moderate efficacy in reducing urinary frequency and urgency UI when added to behavioral therapy in long-term care residents. Low dose oxybutynin-ER does not cause delirium in cognitively impaired nursing home residents Oxybutynin-IR has been associated with cognitive adverse effects in people with dementia and/or Parkinson’s disease, and The incidence and prevalence of this are unknown Oxybutynin has been associated with tachycardia but not associated with QTc prolongation or ventricular arrhythmia. Oxybutynin is less effective in people with impaired orientation, cerebral cortical under-perfusion, and reduced bladder sensation Oxybutynin is less well tolerated than solifenacin in older people Fesoterodine is effective in ameliorating the symptoms of OAB in frail older people, identified by VES-13 There is insufficient evidence to determine the efficacy, tolerability, and safety of the following agents in the frail elderly Intravesical oxybutynin Transdermal oxybutynin Trospium Tolterodine Darifenacin Solifenacin Mirabegron Duloxetine Oral and topical oestrogen Tolterodine is associated with cognitive impairment and tachycardia, and The incidence and prevalence of this are unknown. Solifenacin (5 mg/day) is associated with no impairment of cognition in older people with mild cognitive impairment versus placebo.

randomized controlled trial of solifenacin, 5 mg/day, versus oxybutynin 5 mg thrice daily, examined the tolerability of both drugs in subjects under and over the age of 65 years; dry mouth was more common and more severe with oxybutynin.79 In those over 75 years of age, dry mouth was more common in those treated with 8 versus 4 mg daily of fesoterodine.80 The incidence of decreased visual accommodation has been specifically evaluated only in young healthy volunteers.81 Drug trials typically report only ‘‘blurred vision,’’ without further characterization. Increased post-void residual volume (PVR) as an ADE is seldom reported in clinical trials of antimuscarinics for UI or OAB. When it has been reported, the magnitude of increase is likely of little clinical significance. The incidence of acute urinary retention with antimuscarinics in general is low, less than one percent even in men, but it has not been systematically evaluated in the frail elderly. PVR

Level 2 Level 1 Level 3 Level 4 Level 3/2 Level 2 Level 2 Level 1 Level 4

Level 3 Level 4 Level 2

should be monitored in frail older men treated with antimuscarinics who may not reliably report change in LUTS or voiding difficulty. The majority of men with clinically relevant outlet obstruction are excluded from treatment trials and the results of these should be viewed in that light. Surgical Treatment in the Frail Elderly

Despite ongoing reports concerning the aetiology and pathophysiology of UI in older people, information on surgical management of the frail elderly is scarce.82,83 The outcomes of anti-incontinence surgery in frail elderly patients may be affected by inherent co-morbidities, as well as impaired bladder and pelvic floor function. There are still very few studies of gynaecological surgery in older frail women, surgical treatment for post-prostatectomy UI in frail men, and minimally invasive

TABLE IV. Summary of Evidence for Surgical Treatments No studies were identified regarding gynaecological surgery in institutionalized elderly women. Exogenous administration of oestrogen is ineffective in promoting wound healing after gynaecological surgery in older women. Injection of bulking agents for SUI appears to give minor benefit in women, however, the technique is minimally invasive and age does not appear to correlate with outcomes. No studies were identified that evaluate functional or quality of life outcomes after UI surgery in frail older people Risks of morbidity and mortality for frail patients undergoing anti-UI procedures are similar to those of other major non-cardiac surgical procedures. Surgical mortality risks are still low in elderly people, and when deaths do occur, they are often due to cardiac or cancer complications. Operative mortality is inconsistently associated with increased age, and many studies do not uniformly control for comorbid conditions. Patient-controlled analgesia provides adequate pain control and sedation and increased patient satisfaction compared with standard fixed-dose and time-administered medications in cognitively intact geriatric patients. Choice of agent for patient-controlled analgesia may affect postoperative cognition. Some case series and waitlist-controlled trials suggest that minimally invasive surgical approaches may be useful in older adults, yet these trials may have little to do with whether surgical treatments are appropriate in the frail elderly

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Level 4 Level 3 Level 3 Level 4 Level 2 Level 2–3 Levels 2–3 Level 2 Level 3 Level 3

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TABLE V. Summary of Evidence for the Management of Nocturia Late afternoon administration of a diuretic may reduce nocturia in people with lower extremity venous insufficiency or congestive heart failure unresponsive to other interventions. If OAB, DO, and/or urgency UI is felt to be a major contributor to nocturia, antimuscarinic agents should be considered. If nocturia is due to insomnia alone, then a very-short acting sedative hypnotic may be considered. DDAVP should not be used in frail elderly because of the risk of hyponatraemia.

procedures, or peri-operative care (including prevention of common postoperative complications) in urological and gynaecological patients. With the advent of newer ‘‘minimally invasive’’ procedures, there has come some use in older, albeit, not frail patients. Injection of bulking agents in women appears to be as effective, or ineffective, in older women as in younger patients.84 Most published reports examining outcomes of tension-free vaginal tape (TVT) in the elderly population are limited by short term follow-up, small patient groups, and confounding variables.85–87 No specific conclusions can be drawn regarding surgical treatment of UI in frail men. For evidence statements see Table IV. Recommendations for Practice

(a) Age alone is not a contraindication to surgical treatment of UI (Grade C). (b) Urodynamic evaluation should be done before considering surgical treatment of UI in frail older people (Grade B). (c) Preoperative risk should be stratified using established indices (Grade A). (d) Ensure adequate post-operative nutrition, especially in patients who cannot take oral feeding or who become delirious (Grade C). (e) Programmes to prevent post-operative delirium should be utilized (Grade A) along with proactive use of established measures to diagnose delirium (Grade A). (f) Pain assessment in cognitively impaired people should use measures specially-designed for this population (Grade B). (g) Proactive preventative approaches to hospitalization-related functional impairment should be used (Grade A). Nocturia in the Older Adult

The International Continence Society definition of nocturia88 is problematic for several reasons. While a single episode of awakening to urinate would be considered nocturia, patients are more likely to be experience significant bother and have decreased quality of life, or consult a provider about nocturia if they have three or more episodes.89,90 Additionally, waking needing to void and then not being able to get back to sleep is not, by definition, nocturia, but is bothersome.91,92 As with UI, there are limited data on optimal diagnostic assessment, and therefore recommendations are generally based on expert opinion.88,93 The evidence base regarding treatment, particularly with respect to the frail, is somewhat thin. The treatment literature regarding vasopressin and its analogues is robust, yet use of the therapy in the older patient continues to be limited because of the side effect of hyponatraemia. The evidence is summarized in Table V. Recommendations for Management

 Nocturia investigations should be carried out utilizing both frequency-volume charts and validated questionnaires capturing QoL and bother related specifically to nocturia Neurourology and Urodynamics DOI 10.1002/nau

Level 2 Level 3 Level 3 Level 1

CONCLUSION

In conclusion, there remains a dearth of high-quality evidence to guide the investigation and management of UI and LUTS in both the community-dwelling and institutionalized frail elderly. Clinicians need to use their judgment when extrapolating the evidence for management of LUTS/UI in younger people and pay due regard to the potential benefits and risks in the frail, while also seeking and paying attention to the views of both the patient and their caregivers. REFERENCES 1. Baltes PB, Smith J. New frontiers in the future of aging: From successful aging of the young old to the dilemmas of the fourth age. Gerontology 2003;49: 123–35. 2. Martin LG, Schoeni RF, Andreski PM. Trends in health of older adults in the United States: Past, present, future. Demography 2010;47:S17–40. 3. McMurdo ME, Roberts H, Parker S., et al. Improving recruitment of older people to research through good practice. Age Ageing 2011;40:659–65. 4. Fonda D, Resnick NM, Colling J, et al. Outcome measures for research of lower urinary tract dysfunction in frail older people. Neurourol Urodyn 1998;17: 273–81. 5. DuBeau CE, Kuchel GA, Johnson T, II. et al. Incontinence in the frail elderly: Report from the 4th International Consultation on Incontinence. Neurourol Urodyn 2010;29:165–78. 6. Ferrucci L, Guralnik JM, Studenski S, et al. Designing randomized, controlled trials aimed at preventing or delaying functional decline and disability in frail, older persons: A consensus report. J Am Geriatr Soc 2004;52:625–34. 7. Fried L, Tangen C, Walston J, et al. Frailty in older adults: Evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001;56:M146–56. 8. Health, United States. 2003. With Chartbook on Trends in the Health of Americans. (Accessed June 11, 2004, at http://www.cdc.gov/nchs/products/ pubs/pubd/hus/highlits.pdf) 9. Thom DH, Haan MN, Van Den Eeden SK. Medically recognized urinary incontinence and risks of hospitalization, nursing home admission and mortality. Age Ageing 1997;26:367–74. 10. Inouye SK, Studenski S, Tinetti ME, et al. Geriatric syndromes: Clinical, research, and policy implications of a core geriatric concept. J Am Geriatr Soc 2007;55:780–91. 11. DuBeau CE. Beyond the bladder: Management of urinary incontinence in older women. Clin Obstet Gynecol 2007;50:720–34. 12. Griffiths D, Derbyshire S, Stenger A, et al. Brain control of normal and overactive bladder. J Urol 2005;174:1862–7. 13. Tadic SD, Griffiths D, Schaefer W, et al. Abnormal connections in the supraspinal bladder control network in women with urge urinary incontinence. Neuroimage 2008;39:1647–53. 14. Griffiths D, Tadic SD. Bladder control, urgency, and urge incontinence: Evidence from functional brain imaging. Neurourol Urodyn 2008;27:476–8. 15. Hof PR, Morrison JH. The aging brain: Morphomolecular senescence of cortical circuits. Trends Neurosci 2004;27:607–13. 16. Andrews-Hanna JR, Snyder AZ, Vincent JL, et al. Disruption of large-scale brain systems in advanced aging. Neuron 2007;56:924–35. 17. Schroder A, Abrams P, Andersson K-E, et al. Guidelines on urinary incontinence: European Association of Urology; 2010. 18. Urinary Incontinence in Women. 2013. (Accessed at http://guidance.nice.org. uk/CG171/NICEGuidance/pdf/English.) 19. Fung CH, Spencer B, Eslami M, et al. Quality indicators for the screening and care of urinary incontinence in vulnerable elders. J Am Geriatr Soc 2007;55: S443–9. 20. Schnelle JF, Smith RL. Quality indicators for the management of urinary incontinence in vulnerable community-dwelling elders. Ann Intern Med 2001;135:752–8. 21. Wagg A, Potter J, Peel P, et al. National audit of continence care for older people: Management of urinary incontinence. Age Ageing 2008;37:39–44. 22. Wagg A, Mian S, Lowe D, et al. National audit of continence care for older people: Results of a pilot study
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