What are the guidelines for managing Overactive Bladder (OAB) in geriatric patients?

Management of Overactive Bladder in Geriatric Patients

For geriatric patients with overactive bladder (OAB), a stepwise approach beginning with behavioral therapies as first-line treatment, followed by beta-3 adrenergic agonists as preferred pharmacologic options, is recommended due to their lower cognitive risk profile compared to antimuscarinic medications. 1

Initial Evaluation

• Comprehensive medical history focusing on bladder symptoms (urgency, frequency, nocturia, with or without incontinence) is essential for diagnosis and treatment planning 1
• Physical examination to identify contributing factors such as pelvic organ prolapse or enlarged prostate 1
• Urinalysis to exclude urinary tract infection and hematuria 1
• Post-void residual measurement in patients with risk factors (emptying symptoms, history of retention, neurologic disorders, prior incontinence surgery) 1

First-Line Treatment: Behavioral Therapies

• Behavioral therapies should be offered to all geriatric patients with OAB due to their excellent safety profile and lack of drug interactions 1
• Bladder training, including timed voiding and gradual extension of voiding intervals 1
• Fluid management with appropriate timing and potentially reducing fluid intake, especially in the evening 2, 1
• Dietary modifications to avoid bladder irritants (caffeine, alcohol, spicy foods) 1, 3
• Physical activity and exercise to improve overall bladder function 1
• Pelvic floor muscle training for urge suppression and improved control 1

Second-Line Treatment: Pharmacologic Options

Beta-3 Adrenergic Agonists (Preferred)

• Mirabegron is the preferred pharmacologic option for geriatric patients due to lower cognitive risk 1, 4
• FDA-approved for treatment of OAB in adults with symptoms of urge urinary incontinence, urgency, and urinary frequency 4
• Effective in treating OAB symptoms within 4-8 weeks 4
• Caution needed when used with CYP2D6 substrates (thioridazine, flecainide, propafenone) 4

Antimuscarinic Medications (Use with Caution)

• Should be used with caution in geriatric patients due to risk of cognitive impairment 1, 5
• Options include darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, and trospium 1
• Contraindicated or use with extreme caution in patients with:
  • Narrow-angle glaucoma 1
  • Impaired gastric emptying 1
  • History of urinary retention 1
  • Cognitive impairment 1, 5
• Post-void residual >250-300 mL warrants caution when using antimuscarinics 1
• Trospium may be preferred among antimuscarinics for elderly patients as it does not cross the blood-brain barrier and has lower risk of cognitive effects 5

Combination Approaches

• Behavioral therapies may be combined with pharmacologic management for enhanced effectiveness 1
• Initiating behavioral and drug therapy simultaneously may improve outcomes in frequency, voided volume, and symptom distress 1

Treatment Monitoring and Adjustments

• Allow adequate trial periods (8-12 weeks) to determine efficacy before changing therapies 1
• If inadequate symptom control or unacceptable adverse events occur with one medication, consider:
  • Dose modification 1
  • Switching to a different antimuscarinic 1
  • Switching to a beta-3 adrenergic agonist 1
• Annual follow-up is recommended to assess treatment efficacy and detect any changes in symptoms 2

Third-Line Treatment Options for Refractory OAB

• Intradetrusor onabotulinumtoxinA injections for patients who fail behavioral and pharmacologic interventions 1, 3
• Peripheral tibial nerve stimulation (PTNS) as an option for refractory cases 1, 6
• Sacral neuromodulation (SNS) for patients who fail conservative treatments 1, 3

Special Considerations for Geriatric Patients

• Higher prevalence of OAB in elderly population with significant impact on quality of life 3, 7
• Increased risk of falls related to nighttime lavatory trips 7
• Polypharmacy concerns and drug interactions 5
• Altered drug metabolism and clearance due to age-related physiological changes 5
• Cognitive function assessment before initiating antimuscarinic therapy 5, 7
• Vulnerable elderly patients (aged ≥65 years at increased risk of functional decline) may benefit from intervention to limit functional deterioration 7

Incontinence Management Strategies

• Absorbent products, barrier creams, and external collection devices can be discussed as management strategies for patients with urgency urinary incontinence 1
• These strategies manage symptoms but do not treat the underlying condition 1