What is the recommended treatment approach for urinary symptoms in patients with dementia using Gemtesa (vibegron)?

Gemtesa (Vibegron) for Urinary Symptoms in Patients with Dementia

Beta-3 adrenergic agonists like Gemtesa (vibegron) are preferred over antimuscarinic medications for treating urinary symptoms in patients with dementia due to their favorable cognitive safety profile. 1

Treatment Algorithm for Urinary Symptoms in Dementia

First-Line Approach

1. Behavioral interventions

   • Timed and prompted voiding schedules
   • Caregiver education on toileting assistance
   • Environmental modifications (clear path to bathroom, adequate lighting)
   • Adequate fluid intake management

2. If behavioral approaches are insufficient:

   • Add Gemtesa (vibegron) 75mg once daily as the preferred pharmacological option

Rationale for Choosing Gemtesa in Dementia

• The 2024 AUA/SUFU guidelines strongly recommend beta-3 agonists over antimuscarinic medications in patients with cognitive impairment 1
• Antimuscarinic medications are associated with increased risk of dementia and cognitive decline, with evidence suggesting a cumulative and dose-dependent relationship 1
• Gemtesa does not have the anticholinergic effects that can worsen cognitive function in patients with dementia 2

Safety Considerations with Gemtesa

Monitoring Requirements

• Watch for signs of urinary retention, particularly in:
  • Patients with bladder outlet obstruction
  • Patients taking concurrent muscarinic antagonist medications 2

Adverse Effects to Monitor

• Headache (4.0%)
• Nasopharyngitis (2.8%)
• Diarrhea (2.2%)
• Nausea (2.2%)
• Upper respiratory tract infection (2.0%) 2

Contraindications

• Known hypersensitivity to vibegron or components of Gemtesa 2

Special Considerations in Dementia Patients

Medication Management

• Minimize exposure to medications with anticholinergic properties as recommended by the Canadian Consensus Conference on Diagnosis and Treatment of Dementia (100% consensus) 1
• Perform multidimensional health assessment for older adults, including medication review, to identify reversible conditions and rationalize medication use 1

Functional Assessment

• Consider the patient's ability to:
  • Recognize the need to void
  • Locate and reach the toilet
  • Manage clothing for toileting
  • Transfer to toilet safely

Caution with Antimuscarinic Alternatives

• Oxybutynin has been shown to have significant adverse cognitive effects 3
• Limited data support the cognitive safety of trospium, solifenacin, darifenacin, and fesoterodine in dementia patients 3

Common Pitfalls to Avoid

1. Misattributing delirium to UTI without proper assessment

   • Delirium in dementia patients is often incorrectly attributed to UTI without adequate evidence 1
   • Assess for other causes of mental status changes before assuming UTI 1

2. Overreliance on pharmacological management alone

   • Behavioral interventions should be maintained even when medications are added 1
   • Combined approaches are more effective than medication alone 3

3. Failure to reassess medication effectiveness

   • Monitor response to therapy and discontinue if no improvement is observed 1
   • Consider alternative approaches if urinary symptoms persist

4. Ignoring the impact of functional impairment

   • Urinary incontinence in dementia often results from both cognitive impairment and urological dysfunction 4
   • Address environmental and functional barriers to continence

By following this approach, clinicians can effectively manage urinary symptoms in patients with dementia while minimizing the risk of cognitive decline associated with antimuscarinic medications.