What is the best approach to manage an older adult patient who has experienced a fall and has bladder control issues, potentially related to underlying conditions such as dementia, osteoporosis, or cardiovascular disease, and is taking medications like diuretics, sedatives, or anticholinergics?

Management of Falls with Bladder Control Issues in Older Adults

When an older adult presents with both falls and bladder control issues, immediately conduct a comprehensive medication review focusing on anticholinergics, diuretics, and sedatives, as these medications are frequently implicated in both conditions and represent the most readily reversible causes. 1

Immediate Assessment Priorities

Document the Fall Circumstances

• Assess for injuries first, then systematically examine potentially reversible causes including medications and environmental factors. 1
• Ask direct, specific questions rather than open-ended ones: "Did you feel dizzy?" or "Did you have difficulty walking?" rather than "What happened?" as patients often attribute falls to slipping or tripping when the true cause is medical. 2
• Falls may be the presenting symptom of acute illness including MI, stroke, GI bleeding, urinary tract infection, respiratory infection, or gallbladder infection. 2

Characterize the Bladder Control Problem

• Perform a focused history to identify the specific type of incontinence (urge, stress, overflow, functional) as each has different underlying causes and management strategies. 3
• Urinary incontinence is strongly associated with social isolation, depression, falls, and fractures, making it a high-priority quality of life issue despite being commonly unreported by patients. 1

Medication Review Algorithm

High-Risk Medications to Identify and Modify

Anticholinergic medications are particularly dangerous in older adults, causing dry mouth, constipation, urinary retention, blurred vision, cognitive impairment, and significantly increased fall risk. 4

• Review for bladder antimuscarinics (oxybutynin, tolterodine, solifenacin): 76% of serious falls or delirium episodes in dementia patients on these medications are followed by continued prescribing, representing a critical missed opportunity for deprescribing. 5
• In frail patients (those requiring support to walk, slow gait speed, difficulty rising from sitting, unexplained weight loss/weakness), use extreme caution with antimuscarinics and beta-3 agonists as they have a lower therapeutic index and higher adverse event profile. 1
• Identify other strong anticholinergics: 19% of patients on bladder antimuscarinics are concurrently on other anticholinergics, creating additive toxicity. 5
• Check for diuretics: 42% of patients on bladder antimuscarinics are also on diuretics, which can worsen urgency and increase fall risk through orthostatic hypotension. 5
• Identify sedatives and psychotropics: these medications increase fall risk and may cause urinary retention, particularly in elderly men with benign prostatic hypertrophy. 6

Medication Modification Strategy

If anticholinergics are identified, strongly consider discontinuation or dose reduction, as withdrawal of psychotropic medications has been shown in RCTs to significantly reduce fall risk. 1

• For patients on bladder antimuscarinics with inadequate symptom control or unacceptable side effects, consider switching to mirabegron (beta-3 agonist) which has similar efficacy but relatively lower adverse event profile. 1
• However, in frail patients with mobility deficits, cognitive impairment, or recent falls, behavioral strategies including prompted voiding and fluid management should be prioritized over pharmacologic management. 1

Identify Reversible Medical Causes

Laboratory and Diagnostic Workup

Order urinalysis and urine culture to identify urinary tract infection, which commonly presents as falls in the elderly and can cause or exacerbate incontinence. 3

• Prescribe antibiotics only if the patient has recent-onset dysuria PLUS at least one of: frequency, urgency, new incontinence, costovertebral angle tenderness, fever >37.8°C, rigors, or clear-cut delirium. 3
• Avoid treating asymptomatic bacteriuria, which is common colonization in elderly patients and does not require treatment. 3
• Check blood glucose and hemoglobin A1c to identify uncontrolled diabetes causing polyuria or neurogenic bladder. 3
• Screen for B12 deficiency, hypothyroidism, and depression as these can cause or exacerbate cognitive impairment that contributes to both falls and incontinence. 1

Physical Examination Focus

• Perform rectal examination to identify fecal impaction, which can cause both urinary incontinence and falls; if present, perform immediate disimpaction and establish a bowel regimen. 3
• Measure orthostatic blood pressure as autonomic insufficiency from diabetes or medications can cause both orthostatic hypotension (falls) and overflow incontinence. 1
• Conduct gait and balance evaluation, vision assessment, and cognitive screening as these are common modifiable risk factors for falls. 1

Multifactorial Intervention Components

Evidence-Based Fall Prevention Strategies

Implement a structured multifactorial intervention including: medication review and management, exercise programs, assessment of instrumental activities of daily living, orthostatic blood pressure measurement, vision assessment, gait and balance evaluation, cognitive evaluation, and assessment of environmental hazards. 1

• Five RCTs demonstrate that exercise programs can reduce fall rates in older adults. 1
• One RCT found that withdrawal of psychotropic medications significantly reduces fall risk. 1
• Home safety assessments have mixed evidence, with 2 RCTs showing benefit but 6 showing no significant reduction in falls. 1

Behavioral Management for Incontinence

For patients who cannot tolerate antimuscarinics or for whom pharmacologic management is inappropriate, implement prompted voiding schedules and fluid management (1.5-2L daily). 1, 3

• Recommend weight loss and exercise programs for obese patients as these improve both fall risk and incontinence. 3
• Establish timed voiding schedules to reduce urgency-related falls. 3

Special Considerations for Cognitive Impairment

If cognitive impairment is present (common in patients with diabetes and associated with faster cognitive decline), age-related brain changes in the bladder control network may predispose to urge incontinence independent of peripheral bladder pathology. 1, 7

• Screen for cognitive impairment using Montreal Cognitive Assessment, as unrecognized cognitive impairment interferes with ability to implement lifestyle modifications and medication adherence. 1
• Involve caregivers in diabetes education and incontinence management as this is critical for successful management in cognitively impaired patients. 1
• Review medications regularly in cognitively impaired patients as medications can affect cognitive function, creating a vicious cycle. 1

Critical Pitfalls to Avoid

• Do not continue bladder antimuscarinics after a serious fall or delirium episode without explicit reassessment of risks versus benefits. 5
• Do not combine multiple anticholinergic agents, as 19% of patients on bladder antimuscarinics are inappropriately on other anticholinergics. 5
• Do not prescribe antimuscarinics to patients on cholinesterase inhibitors for dementia (32% are inappropriately receiving both), as this represents pharmacologic antagonism. 5
• Do not attribute falls to "just slipping" without investigating underlying medical causes. 2
• Do not overlook that even mild anticholinergic effects (dry mouth, mild confusion) can reduce function, increase dependency, and negatively affect quality of life in ways that are often dismissed as "normal aging." 4

Follow-Up and Monitoring

Screen for falls and urinary incontinence at least annually, as both conditions are frequently unreported by patients and undetected by providers. 1, 3

• Document targeted symptoms when initiating any treatment to allow objective assessment of response. 1
• For patients deemed refractory to behavioral therapy (8-12 weeks) and at least one antimuscarinic trial (4-8 weeks), refer to appropriate specialist for consideration of third-line therapies. 1