What is the preferred medication for urge incontinence in an elderly female?

Preferred Medication for Urge Incontinence in Elderly Females

For elderly females with urge incontinence requiring pharmacotherapy after bladder training has failed, tolterodine or darifenacin are the optimal first-line medication choices due to their discontinuation rates being similar to placebo and superior tolerability profiles. 1

Treatment Algorithm

Step 1: Non-Pharmacologic Therapy First

• Bladder training must be initiated as first-line treatment before any medication is prescribed, as this has strong recommendation with moderate-quality evidence from the American College of Physicians 2
• If the patient is obese, concurrent weight loss and exercise should be implemented, as this effectively reduces urinary incontinence symptoms (strong recommendation, moderate-quality evidence) 2, 1

Step 2: Medication Selection When Bladder Training Fails

• First-line pharmacologic options: Tolterodine or Darifenacin 1

  • Both have discontinuation rates due to adverse effects that are not statistically different from placebo 1
  • High-quality evidence shows tolterodine achieves continence (NNTB 12) and improves urinary incontinence (NNTB 10) more than placebo 2
  • Darifenacin effectively improves urinary incontinence and quality of life in older women with comparable tolerability 1

• Second-line option: Solifenacin 1

  • Associated with the lowest risk for discontinuation due to adverse effects among antimuscarinics 1
  • High-quality evidence shows it achieves continence more than placebo (NNTB 9) regardless of age 2

• Alternative non-antimuscarinic: Mirabegron 1, 3

  • Beta-3 adrenergic agonist with a different mechanism of action 3
  • Lower anticholinergic side effects and lower risk of cognitive effects, particularly important in patients over 60 1
  • Starting dose is 25 mg orally once daily, may increase to 50 mg after 4-8 weeks 3

Step 3: Medications to Avoid in Elderly Females

Oxybutynin should be avoided as first-line therapy due to the following critical concerns:

• Highest discontinuation rate due to adverse effects among all antimuscarinics (NNTH 16 compared to placebo, NNTH 14 compared to tolterodine) 1, 2
• Associated with significant yet often unnoticed cognitive impairment in elderly patients 1
• Higher incidence of dry mouth, constipation, and cognitive impairment compared to other antimuscarinics 1
• Despite being effective (80.7% reduction in incontinence episodes in one study), the adverse effect profile makes it inappropriate for elderly patients 4

Fesoterodine should also be avoided due to poor tolerability:

• Has the worst tolerability profile with NNTH for adverse effects of only 7 1
• More adverse effects including dry mouth and headache compared to tolterodine (NNTH 11) 2

Special Considerations for Elderly Patients

Polypharmacy Assessment

• If the patient is taking ≥7 concomitant medications, avoid trospium and prefer tolterodine, darifenacin, or mirabegron 1
• Patients on ≥7 medications have increased risk of adverse effects with trospium 2

Monitoring Requirements

• Periodically monitor blood pressure, especially in hypertensive patients, as mirabegron can increase blood pressure 3
• Monitor for anticholinergic side effects: dry mouth, constipation, and blurred vision occur commonly with all antimuscarinics 2, 1
• Assess cognitive function, as antimuscarinics carry anticholinergic burden 1

Age-Related Evidence

• Moderate-quality evidence shows that age does not modify clinical outcomes associated with pharmacologic treatment 2
• High-quality evidence confirms that tolterodine, darifenacin, and solifenacin are effective in older women specifically 2, 1

Common Pitfalls to Avoid

• Do not prescribe systemic pharmacologic therapy for stress incontinence - the American College of Physicians strongly recommends against this (strong recommendation, low-quality evidence) 2
• Do not skip bladder training - pharmacologic treatment should only be used if bladder training was unsuccessful (strong recommendation, high-quality evidence) 2
• Do not use higher doses of solifenacin (10 mg vs 5 mg) without clear indication, as they do not decrease frequency of urinary incontinence episodes and are associated with increased adverse effects 2
• Do not prescribe oxybutynin as first-line despite its widespread availability and lower cost, as the adverse effect profile in elderly patients is unacceptable 1

Evidence Quality Summary

The American College of Physicians 2014 guideline provides the framework with high-quality evidence that pharmacologic treatment should follow failed bladder training 2. The choice of specific agent should be based on tolerability, adverse effect profile, ease of use, and cost 2. Among available options, tolterodine and darifenacin emerge as optimal choices based on their placebo-level discontinuation rates and proven efficacy in elderly populations 1.