RCP-SoPW 2019 – Incontinence is often a tipping point into full-time care for elderly

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by Rachel Pugh

Managing urinary incontinence (UI) is as important a factor in keeping elderly people living independently in their own homes as retaining mobility but it is frequently underplayed by the medical profession.

Dr Rhian Morse, consultant in geriatric and general medicine at University Hospital of Wales, made this point at the joint conference in Cardiff of the Royal College of Physicians/Society of Physicians in Wales. She explained that urinary incontinence often becomes the tipping point for elderly people into long-term care in her talk focusing on urinary incontinence.

She said: “Tackling incontinence is a case where potentially a small improvement can produce a very large gain.”

Describing UI as a complex multi-factorial combination of acquired disease, age-related physiology and external influences such as environment or drugs, Morse highlighted the following:

*  Its management costs the NHS 3-4% of its annual spending

*  More than 30% of fit women over 65 living independently suffer from it, which increased to 70% of people in long-term care

*  UI is often associated with other conditions such as Parkinson’s Disease (60% of patients), diabetes (80% higher risk), obesity (pelvic floor dysfunction four times more likely) dementia with falls have very high incidence of incontinence, stroke (non-resumption of continence within 48-72 hours is a high risk factor for mortality and morbidity)

*  UI is associated with low mood, social isolation, mobility impairment, poor functional improvement from acute illness, urinary tract infections (UTI), skin infections, falls and fractures, need for long-term care.

Said Morse: “it’s common to hear patients say that they will not go and stay with family at Christmas because of fear of incontinence.” Morse said tackling it required a multi-pronged approach to tease out all the component issues

Studies show that ‘the abnormal is normal’ (1) and that even very fit 70-80 year old men show evidence of unstable contraction, decreased bladder capacity (from around 600ml to 300ml), reduced bladder sensation allowing less time to reach the lavatory, slower speed of detrusor contraction and duration of bladder contraction and greater residual volume. Nocturia and nocturnal polyuria are significant problems because of the increased risk of falls. An 80 year-old can be producing a litre of urine at night, which equates to 3-4 visits to the toilet per night with a bladder size reduced to 300ml.

Investigations for incontinence include a measurement of the post void residue, a mid-stream specimen of urine (MSU) to check for infection and a bladder chart.

Behavioural approaches to nocturnal polyuria include looking at fluid intake, use of compression stockings, daytime recumbency, diuretics and possible use of desmopressin.

Current pharmacological agents for overactive bladder (OAB) include anti-muscarinic agents such as toltorodine and solifenacin. Despite the risk they pose of cognitive effects, Morse considers them worth trying if they prevent patients from having to go into a care home. The Beta 3 Agonist, Mirabegron, is also worth considering. (2)

Recurrent UTIs can underlie incontinence. Morse said such infections should receive specialist investigation, in the case of males aged more than 16 years, people with recurrent upper UTIs and lower UTIs where underlying cause is unknown, pregnant women, children and young people under 16 in line with UTI guidelines for under 16 and people with suspected cancer in line with NICE guidelines. (3)

More needs to be done to improve the physical environment for people too, such as providing appropriate padding, regular toileting/access to toilet /access to bottles, call bells and staffing.

“We need to be asking ourselves whether the environment is part of the challenge,” said Morse