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Urinary incontinence in frail older adults.

The proportion of Americans over age 65 years has more than tripled, from 4.1% in 1990 to 14.5% in 2014. Moreover, persons turning 65 years of age and older in 2014 had an additional 19.3 years added to their life expectancy. The number of persons 75 to 85 years of age is 17 times greater than in 1990, and the population 85 years of age or older is 50 times greater in size (Administration on Aging, Administration for Community Living, U.S. Department of Health and Human Services, 2015). One effect of the aging population is an increase in the number of frail older adults. Frailty is characterized by age-associated declines in physiologic reserve and function across multiple organ systems (Chamberlain et al., 2016). This clinically recognized syndrome is a major concern in the geriatric population and is associated with a number of adverse outcomes, including worsening disability and increased risk for hospitalization, nursing home admission, and death (Clegg, Young, Iliffe, Rikkert, & Rockwood, 2013).

The prevalence of urinary incontinence (UI) also increases with age. Among adults 65 years of age and older who responded to the National Health and Nutrition Examination Surveys during 2007-2010, 43% reported UI, with an estimated prevalence of moderate to severe incontinence of 24% (Gorina, Schappert, Bercovitz, Elgaddal, & Kramarow, 2014). No studies examining the prevalence of UI among frail older adults across care settings were identified. Studies have, however, examined the prevalence of UI in nursing homes and home health care; both settings included many older frail adults. Xu and Kane (2013) reported a prevalence rate of 65.8% in residents in all Medicare or Medicaid-licensed nursing homes in Minnesota. Two studies report the prevalence of UI in frail, homebound older adults, with rates at 40.2% to 51% (Gorina et al., 2014; Landi et al., 2003).

Frailty

Bandeen-Roche and colleagues (2015) assessed a nationally representative sample of adults 65 years of age and older for frailty using validated criteria. Fifteen percent of the subjects met the criteria for frailty, and 45.5% were prefrail. In this study, prefrail was defined as subjects who met some of their validated criteria for frailty. In the group 85 years of age and older, the percentage of those meeting the criteria for frailty increased to more than 30%. Frailty is widely recognized as an important geriatric syndrome. Frailty is a risk factor for a variety of negative health outcomes, including increased vulnerability to infections, falls, adverse drug reactions, and death. Despite a wide range of studies focused on frailty published each year, there is no clear consensus reporting the most effective method to assess for frailty (Butaet et al., 2015).

One general agreement unifying health professionals is that frailty is a multi-dimensional health problem and not synonymous with a disability. However, there is considerable variability in methods of frailty assessment. Two separate efforts attempted to achieve a consensus definition. Rodriguez-Manas and colleagues (2013) reported that the experts participating in their Delphi consensus project agreed on the multi-dimensional nature of frailty. The authors agreed it is distinct from disability, but there was no agreement on a specific set of clinical and biomarkers useful for diagnosis (Rodriquez-Manas et al., 2013). Morley et al. (2013) reported that a consensus meeting of experts from six international organizations defined frailty as "a medical syndrome with multiple causes and contributors characterized by diminished strength, endurance, and reduced physiologic function that increases an individual's vulnerability for developing increased dependency and/or death" (p. 393).

In a systematic review of frailty assessment instruments, Buta and colleagues (2015) identified 67 frailty instruments. Of the nine most commonly cited instruments, all included a measure of physical functioning. However, physical functioning was the only domain common to all nine. The most widely used measures are approaches based on deficits and physical phenotype models (Buta et al., 2015; Morley et al., 2013). The physical phenotype is based on the idea that critical mass of impairments or geriatric conditions adds up to the phenotype of frailty (Fried, Ferrucci, Darer, Williamson & Anderson, 2004). Based on this phenotype, frailty is a clinical syndrome consisting of three of more of the following conditions: unintentional weight loss, selfreported exhaustion, and weakness (often measured by grip strength); slow walking speed; and reduced physical activity (Fried et al., 2001). In their systematic review of frailty instruments, Buta et al. (2015) reported that the frailty phenotype is the most commonly used approach for assessing frailty. In contrast to the frailty phenotype, Guaraldi et al. (2015) proposed a deficit model that consists of summing an individual number of impairments and conditions to create a frailty index. These authors consider the deficits to include health variables, such as diagnosed conditions, signs and symptoms of disease, laboratory parameters, and self-report data. The rationale for this approach is that while an individual impairment or condition may result in relatively small deficits, the cumulative effect can be large.

UI and Frailty

Frailty and UI often co-exist, and there is evidence to suggest the relationship between frailty and incontinence may not be unidirectional (i.e., frailty leading to incontinence) (Wagg et al., 2013). Miles et al. (2001) examined the association between markers of frailty and a new onset UI in a sample of 2,600 older adults. The subjects who developed a new onset of UI during the two years they were followed were significantly more likely to be impaired in the markers of frailty used in this study. Berardelli et al. (2013) also examined the association between UI and frailty in older adults (n = 570). Controlling for the effects of age and sex, subjects with UI were 6.5 times more likely to be frail than those who were continent of urine. The investigators in both of these studies concluded that UI might be a marker of frailty.

In older adults age 65 years and older, both UI and frailty are considered geriatric syndromes. Geriatric syndromes are multifactorial, consisting of multiple interacting risk factors contributing to their etiology (Inouye, Studenski, Tinetti, & Kuchel, 2007). Common risk factors are older age and functional decline, mobility, and cognitive impairment. In addition, cerebral white matter lesions are common MRI findings in a number of geriatric syndromes and could represent a key common risk factor in the development of these syndromes (Kuo & Lipsitz, 2000). A number of studies are beginning to identify central nervous system (CNS) abnormalities in older adults with UI, including white matter lesions and altered central and peripheral neurotransmitter concentrations and actions (Wagg et al., 2013).

Multifactorial Etiology

In older adults age 65 years or older, frailty can adversely affect many functional requirements needed to maintain continence, including:

* Normal lower urinary tract function, including intact bladder function, normal sphincteric function, and normal pelvic floor function, with normal innervation from the peripheral and central nervous system.

* Adequate cognition needed to recognize the need to urinate with the capacity to find the toilet and with the ability to prevent urine leakage prior to reaching the toilet.

* Ability to communicate the need to void if unable to toilet independently.

* The functional ability necessary to get to the toilet (with or without assistance) and remove clothing.

* Ability to voluntarily initiate voiding when appropriate (Alexander, Shakespeare, Barradell, & Orme, 2015).

Wagg and colleagues (2013) conducted a number of systematic reviews related to UI in the frail elderly population for the 5th International Consultation on Incontinence. In addition to CNS changes, the authors identified a number of age-related changes contributing to UI in frail individuals. These include changes a) in bladder ultrastructure, such as muscle and axon degeneration; b) in bladder function, causing decreased capacity, decreased filling sensation, increased detrusor overactivity, decreased bladder contractile function, and increased residual urine; c) decreased closure pressure in the female urethra; d) prostate enlargement; e) decreased estrogen levels in women; f) increased nocturnal urine production; and g) altered immune function. A wide variety of factors outside of the lower urinary tract compound the effects of these age-related changes contributing to UI in the frail older adult population. These include many classes of medications, comorbid medical illnesses, neurologic and psychiatric disorders, functional impairments, and environmental factors (see Table 1) (Alexander et al., 2015; Wagg et al., 2013).

There is limited research describing the type of UI in frail elders. In a descriptive study of adults age 65 years and older receiving home care services in The Netherlands, the type of UI was based on medical record review (DuMoulin, Hamers, Ambergen, & Halfens, 2009). Of the 1,319 patients with UI, the type was diagnosed in 615 subjects. The most common diagnosis was functional UI (35.4%), followed by urge UI (33.4%), mixed UI (18.1%), and stress UI (13.1%). Functional incontinence is generally defined as involuntary urine loss resulting from the inability to toilet due to cognitive, functional, or mobility impairment in individuals with intact lower urinary tract function (Staskin et al., 2013). In an intervention study conducted by McDowell, Engberg, Rodriguez, Engberg, and Sereika (1996), the subject's UI type was based on a detailed urologic history. In this study, the most prevalent type of UI was mixed incontinence reported by 55.9% of the subjects (n = 90, all frail, elderly, and homebound) (McDowell et al., 1996). In another intervention study, Engberg and Sereika (2016) reported that 65.2% of homebound subjects (n = 93) reported mixed incontinence. None of the subjects in either study were classified as having functional incontinence. All subjects in both studies were cognitively intact as measured by a Mini Mental Examination (Folstein, Folstein, & McHugh, 1975) score of greater than 24. While cognitive impairment and functional or mobility issues contribute to UI in frail older adults, given the age-related changes in lower urinary tract function that characterize this population, one could argue that true functional incontinence is rare.

Assessment of UI In Frail Older Adults

Given the multifactorial nature of UI in frail older adults, the assessment of UI in this population must be comprehensive with the goal of identifying all potential contributing factors. Older adults with UI should be screened for frailty. The Vulnerable Elders Survey, a short selfreport frailty screening measure available to healthcare providers, is recommended as a possible tool by the Frailty Committee of the 5th International Consultation on Incontinence (Wagg et al., 2013). In addition, it is important to screen frail older adults for UI. Many people will not report this common health problem unless asked (Gibson & Wagg, 2014). Once UI is identified in frail older adults, assessment should include:

* A comprehensive assessment to identify comorbid conditions that may be contributing to UI (see Table 1) or that can affect treatment options.

* A targeted UI history to a) establish type and severity of incontinence; b) identify associated symptoms (urinary frequency and urgency, bothersome nocturia, enuresis, difficulty or incomplete bladder emptying, fecal incontinence, constipation, symptoms suggesting a urinary tract infection); c) assess toileting ability and access; d) determine the amount, type, and frequency of fluid intake; e) identify current or previous treatments for UI and their effectiveness and tolerability; and f) assess the impact of UI on personal and social life.

* A focused physical examination (abdominal, rectal, neurologic, pelvic, and mobility assessment) is recommended in most UI guidelines; however, high-quality evidence to support its value is lacking (Syan & Bucker, 2015).

* Determination of the individual's preferences in relation to treatments, as well as their outcome expectations.

* Additional diagnostic tests may be indicated (Wagg et al., 2013). These include urinalysis and culture when a UTI is suspected, cough stress test when stress UI is suspected, post-void residual urine when incomplete bladder emptying is suspected based on history or physical examination (suprapubic dullness after voiding), and urodynamic testing when results are likely to influence treatment decisions.

Management of UI

Many frail older adults have co-existing disabilities and comorbidities influencing responsiveness to interventions for UI. In addition, treatment of underlying comorbidities and/or impairments will often improve their UI. Managing UI in the frail elder population is aimed at identifying and treating comorbid conditions and/or impairments, which contribute to or cause UI (see Table 1) (Ouslander, 2000; Wagg et al., 2013). The aim of treatment needs to consider patients' level of frailty, comorbid conditions and/or impairments, and outcome expectations. While interventions will improve UI in most frail elders, complete continence may not be a realistic goal for those who are very frail. The Frailty Elderly Committee of the 3rd International Consultation on Incontinence introduced an alternate paradigm for treatment goals for frail elders and their caregivers (Wagg et al., 2013). Potential goals are:

* Independent continence: The patient is dry without the need for ongoing treatment.

* Dependent continence: The patient is dry with toileting assistance, behavioral treatment, and/or ongoing medication therapy.

* Contained incontinence: Urine is contained with pads or appliances (Wagg et al., 2013).

General Measures

Many clinicians recommend lifestyle interventions, such as weight loss, dietary modifications, eliminating select beverages, fluid management, and prevention/ treatment of constipation as part of the management of UI. The effectiveness of some lifestyle changes on UI are examined in clinical trials with varying evidence to support their effect (Imamura, Williams, Wells, & McGrother, 2015; Sun, Liu, & Jiao, 2016). Some of these lifestyle changes, such as weight loss, are not appropriate for many frail older adults, while others lack research examining their effects in the frail elderly population (Wagg et al., 2013).

Complete continence is not an achievable goal for all frail elders. The use of continence aids can enable them to perform their daily activities without fear of embarrassment. Absorbent pads are the most frequently used continence aid, and they are, unfortunately, often overused and misused. Absorbent pads can increase the risk for incontinence as well as urinary tract infections and skin irritation (Omli et al., 2010; Wagg et al., 2013). Research suggests that absorbent pads are the most frequent continence management approach in frail elders across all settings (Du Moulin et al., 2009; Omli et al., 2010; Roe et al., 2010; Wagg et al, 2008; Zisberg, 2011). Pads should not be a substituted for an active approach to the prevention, diagnosis, and treatment of UI in frail elders (Wagg et al., 2013).

Environmental Interventions

Environmental factors, such as accessibility to toilets and the availability of toileting assistance in a timely manner, are recognized risk factors for UI in the frail elderly population. Improving access to the toilet and providing toileting aids, such as grab bars and raised toilet seats, may improve UI in frail older adults with mobility and other functional impairments. Environmental cues, such as toilet visibility, better signage, and images, may be effective interventions in older adults with cognitive or visual-perceptual deficits (Wagg et al., 2013). The need for timely toileting assistance is an obvious but often neglected risk factor for UI in the care-dependent, frail elderly population across all care settings. For frail elders unable to toilet independently, the availability of toileting assistance is critical to the success of all other interventions for UI.

Behavioral Interventions

Their lack of side effects makes behavioral interventions the firstline treatment for frail elders. Voiding programs are designed for the frail elderly population with cognitive or physical impairments limiting their ability to actively participate in their self-care. These interventions require active caregiver participation and include prompted voiding, habit training, and scheduled (timed) toileting.

Prompted voiding. Prompted voiding combines regular prompts to toilet with positive feedback for appropriate toileting. The goal is to increase awareness for the need to urinate, leading to self-initiated toileting. Wagg and colleagues (2013) report that there is Level 1 research (designed from at least one randomized controlled trial) to support the short-term effectiveness of prompted voiding in treating daytime UI in frail elders in nursing homes and home care settings. To reduce caregiver burden associated with prompted voiding, the researchers recommend targeting this intervention to those most likely to benefit from prompted voiding. Individuals most likely to benefit from a prompted voiding program are those who are successful after a three-day trial. The intervention is continued only for those who achieve appropriate toileting rates (i.e., voids for greater than 66% of the prompts to toilet) or acceptable reductions in wet checks (i.e., less than 20% of checks are wet).

Habit training. Habit training matches the toileting schedule to the frail older adult's individual voiding pattern. This requires a baseline assessment (bladder diary/wet checks) to establish the frequency of continent and incontinent voids. The toileting schedule is then designed to pre-empt incontinent episodes. Wagg et al. (2015) concluded there is insufficient evidence to determine the effectiveness of habit training.

Scheduled (timed) toileting. Scheduled (timed) toileting is an intervention where the individual is toileted at fixed intervals without prompts or reinforcement for appropriate voiding. There is insufficient evidence to determine whether or not scheduled toileting decreases UI in frail elders (Wagg et al., 2015). The effect of combining regular toileting with an exercise intervention was examined in two randomized controlled trials (RCTs) included in a systematic review of conservative treatment of UI in frail elders (Stenzelius et al., 2015). In both studies, there was a significant reduction in incontinent episodes. When the weighted findings were combined, there was a moderate, but statistically significant, reduction in urine leakage.

Pelvic floor muscle training. Frail older adults with sufficient cognitive function to actively participate in their treatment may be candidates for pelvic floor muscle training (PFMT) or bladder training. There is limited research examining the effects of these interventions in frail elders. In a systematic review of conservative interventions for UI in frail community-dwelling older adults, Talley, Wyman, and Shamliyan (2011) identified three studies, only one an RCT, examining the effect of a multicomponent behavioral intervention that included PFMT and bladder training for incontinence in homebound older adults. All three reported significant reductions in incontinent episodes (75% to 80%) at the end of the intervention. Engberg and Sereika (2016) compared the effectiveness of PFMT in reducing UI in homebound and nonhomebound older adults. There was a significant reduction in UI in both groups, with no significant differences between them (a median 64.5% reduction in homebound subjects and 70.4% decrease in nonhomebound subjects).

Pharmacologic Treatment

Age-related changes in pharmacodynamics and pharmacokinetics, high levels of polypharmacy (with the potential for drugdrug interactions), high levels of comorbidities (with the potential for drug-disease interactions), and increased susceptibility to adverse drug effects (ADEs) are all causes for caution when initiating pharmacotherapy for UI in the frail elderly population. In general, there is a lack of high-quality evidence about the efficacy and safety of pharmacotherapy in frail older adults. Based on their systematic reviews of the literature, the Frailty Committee of the 5th International Consultation on Incontinence (Wagg et al., 2015) made the following recommendations for clinical practice related to pharmacotherapy for UI.

* Frail older adults should be considered for drug treatment only after all potentially remediable comorbid conditions/ factors are evaluated and addressed, and there is an appropriate trial of behavioral therapy and lifestyle interventions.

* Drug treatment should generally be avoided in individuals who make no attempt to toilet when assisted, become agitated when toileted, or are so impaired (functionally and cognitively) that there is no prospect for meaningful benefit.

* The major ADE of concern with antimuscarinic drugs is cognitive decline; however, evidence on its incidence and prevalence is scant. Actual incidence rates of cognitive decline with the drugs are difficult to estimate due to likely under-reporting, failure of clinical trials to report data related to this ADE, and/or the use of different measures lacking comparability across studies. The Mini-Mental State Examination (MMSE) and Alzheimer's Disease Assessment Scale--Cognitive (ADAS-Cog) do not seem to be sensitive to changes in cognition due to bladder antimuscarinics. Consequently, treatment decisions are often made on the basis of a global assessment of cognition during the clinical assessment, and if available, the caregiver's impression of changes in cognition. Bladder antimuscuranics as single agents are probably safe in cognitively intact older adults. However, in addition to the likely benefit from drug treatment, life expectancy and patient preferences, as well as their total anticholinergic load, need to be considered in treatment decisions.

* High doses (20 mg) of oxybutynin XL are associated with increased likelihood of cognitive impairment and should generally be avoided in older adults. Oxybutynin, even at low doses, is generally avoided in individuals at cognitive risk.

* Start other antimuscarinics at the lowest available dose and monitor the patient closely as the dose is slowly increased if needed to improve efficacy.

* Limit the overall exposure to antimuscaranics, especially when patients are also taking other drugs with anticholinergic properties, is an important consideration in treatment decisions.

* Monitor post-void residuals when frail older men who are unable to reliably report changes in lower urinary tract symptoms or have voiding difficulty are treated with antimuscarinics.

Mirabegon is a new selective [[beta].sub.3]-adrenoreceptor antagonist approved for the treatment of overactive bladder (urge UI). In studies of adults, mirabegon was associated with a low side effect profile. One concern associated with its use (and other drugs in this class) is the possible risk of adverse cardiovascular events (e.g., prolonged QT interval, tachycardia, and angina) (Balachandran & Duckett, 2015). After a systematic review of 16 studies examining the cardiovascular safety of mirabegron, Rosa et al. (2016) concluded that mirabegron appeared to be acceptable at therapeutic levels and is comparable to other antimuscarinic agents in adults. These authors caution, however, that because patients with poorly controlled hypertension, arrhythmias, and heart failure were excluded from the studies, there were no data reported on subjects' safety in these populations.

In a recent systematic review of the pharmacological treatment of UI in older adults and frail elders (Samuelsson et al., 2015), the authors concluded there were no published studies examining the effects of mirabegron in frail elderly subjects. There is a need for research to establish its efficacy, tolerability, and safety in this population. Given the lack of research in this population, as well as in patients with significant cardiovascular risk factors, especially common in frail elder subjects, the same caution recommended in relation to antimuscarinics seems appropriate when considering the use of mirabegron (Wagg et al., 2013). Therefore, it is important to carefully weigh the risk-benefit ratio prior to initiating treatment. Start at the lowest possible dose, and if needed, increase the dose slowly. It is most important to monitor for adverse effects, particularly cardiovascular effects.

Other Treatment Options

There is limited evidence on surgical treatments for UI in frail elders. The lack of evidence makes it difficult to make specific recommendations related to surgical treatments; however, age alone is not a contraindication to surgical treatment. Urodynamic evaluation is recommended prior to considering surgical treatment (Wagg et al., 2015). Injections of bulking agents for stress UI appears to provide only minor benefits, but age does not appear to affect the outcomes.

Conclusions

The prevalence of both UI and frailty increases with age. These two geriatric syndromes often co-exist and may share common risk factors. Older adults presenting with either syndrome should be assessed for the other. The etiology of UI in frail older adults is multifactorial and contributing factors extend beyond the lower urinary tract. Both assessment and treatment of UI in the population must take the many contributing factors into consideration.

The treatment of UI starts with the assessment, treatment, and re-evaluation of potentially treatable conditions. Lifestyle and behavioral interventions are recommended as the initial treatment for unresolved UI followed by consideration of a trial of pharmacotherapy in appropriately selected patients. The goals of treatment need to consider patients' level of frailty, comorbid conditions, and expectations. Complete continence may not be a realistic goal for some frail older individuals.

Nurses working in many clinical settings care for frail older adults. It is important to be aware that urinary incontinence is a common problem in this population and to include questions about bladder function is the assessment of frail individuals. The most appropriate firstline treatments for the majority of frail elders with UI are nursing interventions. It is important for nurses to be knowledgeable about these treatment options and to work with their frail patients and their families to identify the most appropriate option for each patient. Given the multiple factors that often contribute to incontinence in frail older adults, the best outcomes are generally achieved when interprofessional teams (e.g., nursing, medicine, physical therapy) work together to develop and implement treatment programs. It is also important for the nurse to be an active member of the team as care is planned and delivered to this patient population. While complete continence may not be a realistic goal for some frail elders, bladder function and the impact of UI on the quality of our patients' lives can be improved for almost all patients.

doi: 10.7257/1053-816X.2017.37.3.119

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Sandra Engberg and Hongjin Li

Sandra Engberg, PhD, CRNP, FAAN, is a Professor and the Associate Dean for Graduate Clinical Education, University of Pittsburgh School of Nursing, Pittsburgh, PA.

Hongjin Li, MS, RN, is a PhD Student, University of Pittsburgh School of Nursing, Pittsburgh, PA.
Table 1. Common Factors Outside the Age-Related Changes
in Lower Urinary Tract Iunction that Contribute to Urinary
Incontinence in Frail Elders

Factor                                     Examples

Medications              Diuretics, alpha adrenergic
                           agonists, alpha adrenergic antagonists,
                           anticholinergics, calcium channel blockers,
                           sedatives and hypnotics, ACE inhibitors,
                           opioid analgesics, and
                           cholinesterase inhibitors.
Medical                  Diabetes mellitus, heart failure,
  illnesses                degenerative joint disease,
                           chronic lung disease, and sleep apnea.
Neurologic and           Stroke, Parkinson's disease, normal
  psychiatric              pressure hydrocephalus,
  conditions               dementia, and depression.
Functional impairment    Physical, cognitive.
Disorders of the         Urinary tract infection, constipation/fecal
  lower urinary tract      impaction, prostatic hypertrophy.
  or surrounding
  structures
Environmental issues     Inaccessible toileting facilities,
                           unavailable caregivers to assist
                           with toileting, over and misuse of
                           continence aids (e.g., pads).
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Author:Engberg, Sandra; Li, Hongjin
Publication:Urologic Nursing
Date:May 1, 2017
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