From the Guidelines
For elderly patients with incontinence, a comprehensive approach is recommended, prioritizing non-pharmacologic therapies and absorbent products, as supported by the most recent guideline from the American Urological Association 1.
Key Components of Incontinence Management
- Start with absorbent products like adult briefs, pull-up underwear, or bed pads based on the severity and type of incontinence.
- Implement a scheduled toileting program every 2-3 hours during waking hours.
- Pelvic floor exercises (Kegel exercises), performed 3 sets of 10 contractions daily, can strengthen relevant muscles.
- Maintain good skin care with gentle cleansing using pH-balanced products after each episode, followed by moisture barrier creams containing zinc oxide or dimethicone to prevent skin breakdown.
- Ensure adequate fluid intake (1.5-2 liters daily) but reduce evening fluids after 6 PM.
- Consider using a bedside commode or urinal for nighttime needs.
Pharmacologic Therapies
- Medications such as oxybutynin (2.5-5mg twice daily), tolterodine (2-4mg daily), or mirabegron (25-50mg daily) may help reduce urgency and frequency, as suggested by earlier guidelines 2, 3.
- However, the choice of pharmacologic agent should be based on tolerability, adverse effect profile, ease of use, and cost of medication, considering the patient's individual needs and potential for adverse effects 3, 4.
Importance of Regular Reassessment
Regular reassessment is crucial as the patient's needs may change over time, and adjustments to the treatment plan may be necessary to optimize outcomes and minimize adverse effects, as emphasized in the guideline 1.
From the FDA Drug Label
CLINICAL STUDIES Tolterodine tartrate tablets were evaluated for the treatment of overactive bladder with symptoms of urge urinary incontinence, urgency, and frequency in four randomized, double-blind, placebo-controlled, 12-week studies. The efficacy endpoints for study 007 (see Table 3) included the change from baseline for: Number of incontinence episodes per week Number of micturitions per 24 hours (averaged over 7 days) Volume of urine voided per micturition (averaged over 2 days)
The treatment for incontinence in an elderly patient may include tolterodine.
- Tolterodine has been evaluated for the treatment of overactive bladder with symptoms of urge urinary incontinence, urgency, and frequency.
- The efficacy endpoints included the change from baseline for number of incontinence episodes per week.
- The study results demonstrated that tolterodine was associated with a statistically significant reduction in incontinence episodes compared to placebo 5.
Geriatric Use Clinical studies of oxybutynin chloride did not include sufficient numbers of subjects age 65 and over to determine whether they respond differently from younger patients Other reported clinical experience has not identified differences in responses between healthy elderly and younger patients; however, a lower initial starting dose of 2.5 mg given 2 or 3 times a day has been recommended for the frail elderly due to a prolongation of the elimination half-life from 2-3 hours to 5 hours.
Alternatively, oxybutynin may also be considered for the treatment of incontinence in elderly patients.
- A lower initial starting dose of 2.5 mg given 2 or 3 times a day has been recommended for the frail elderly due to a prolongation of the elimination half-life.
- Dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy 6.
From the Research
Non-Pharmacological Interventions for Urinary Incontinence in Elderly Patients
- Non-pharmacological therapies are desirable in elderly patients with urinary incontinence, as they can reduce the risk of adverse effects associated with medications 7.
- Group exercise therapy and behavioral therapy have been shown to be beneficial in reducing episodes of incontinence in older women, with a mean reduction of 1.07 and 0.74 episodes per day, respectively 7.
- Simple conservative measures, such as education around fluid intake, weight loss, managing constipation, and pelvic floor exercises, can make a significant impact on managing incontinence in elderly patients 8.
Types of Urinary Incontinence and Treatment Approaches
- Urinary incontinence can be grouped into several types, including stress incontinence, urgency incontinence, overflow incontinence, functional incontinence, and mixed urinary incontinence 9.
- Nonsurgical treatments, including behavioral therapies, pelvic floor muscle exercise, and other treatments, are available and can be successful for many older women 9.
- Behavioral therapy, toilet training, and physiotherapeutic interventions are indispensable modules in the multifaceted approach to improve continence in frail elderly patients 10.
Pelvic Floor Muscle Exercise and Training
- Pelvic floor muscle exercise (PFME) is defined as exercise to improve pelvic floor muscle strength, power, endurance, relaxation, or a combination of these parameters 11.
- PFME has been recommended as first-line treatment for urinary incontinence, particularly stress urinary incontinence, and can provide urethral support to prevent urine leakage and suppress urgency 11.
- Clinicians and physical therapists should understand pelvic floor muscle anatomy, evaluation, regimen, and instruct patients how to train the muscles properly to effectively use PFME as a behavioral therapy for urinary incontinence 11.