URINARY INCONTINENCE

IN OLDER ADULTS

Done by \ - Ahmed Abdullah Saad Mofleh

- Osama Naji AL- Burihi

Supervised by \ Dr. Khaled AL- Sayani

Goals of Presentation:
 Discuss the prevalence and significance of urinary
incontinence (UI) in older adults
 Identify risk factors and common causes of UI
 Review assessment, diagnosis and treatment
options related to the management of UI
 Discuss the challenges of UI in older adults with
dementia
 Discuss informal caregiver supportive approaches
and key factors in product selection—from a
clinical perspective
Prevalence of UI in Older
Adults
About 2 million suffer from this silent epidemic

 30 - 60% community-dwelling older women

 10 - 35% community-dwelling older men

 Over 50% institutionalized older adults

 Prevalence increases with age and disability

(Anger et al, 2006; Melville et al, 2005; Vaughan, et al. 2011)
Types of UI
 UI is simply defined as loss of urine of any amount (Abrams, 2002)

 Urge- hits suddenly without warning, no holding time, leak on the

way to the bathroom
 Stress- no urgency, occurs with activity (i.e. exercise, coughing,
laughing, sneezing)and more common in women.
 Overflow- mechanical forces (physical movement) on an
over- distended bladder (can be from Benign Prostate
Hypertrophy or Diabetes)
 Functional- leak as a result of functional limitations (i.e. mobility
problems, arthritis, stroke)
Causes of UI
 Abnormal changes in urinary system
 Loss of mental ability
 Physical disability (immobility)
 Infection
 Uncontrolled or undiagnosed medical condition
(diabetes, estrogen depletion)
 Constipation
 Side effect of medication (diuretics,
anticholinergics)
Causes Mnemonic - DIAPERS
 Delirium
 Infection of the bladder or urethra
 Atrophic vaginitis
 Pharmaceuticals, including alcohol, caffeine and
artificial sweeteners
 Excess excretion
 Restricted mobility
 Stool impaction
Burdens of UI in Older
Adults
 Depression

 Decreased quality of life (QOL)

*UI has a stronger influence on psychological QOL
than cancer, diabetes and arthritis (Hawkins et al., 2011)

 Emotional health (isolation)

 Major indication for nursing home placement

*The annual nursing home admissions in the US
related to UI is estimated at $6 billion (Morrison, 2006)
Case Study 1- Work
Up
 70 y/o female
 Has a strong urge to urinate and leaks on the way to
the bathroom
 Leaks a little when she coughs or sneezes hard

 What type of UI do you think she is experiencing?

UI Evaluation Should Include
 Focused History
 Physical Examination
 Functional Assessment
 Urinalysis
 Post-void residual urine volume

*Urinary Incontinence Evaluation Form

 Click on or copy and paste the link below to access

the UI Evaluation Form

 http://www.gericareonline.net/tools/eng/urinary/attachments/UI_Tool_3_Evaluation.pdf
 Focused UI History…
Type
 Do you leak urine during physical activity such as coughing,
sneezing, lifting, or exercising?
 Do you get the urge to go and can’t make it without leaking?
Onset & Duration
Severity
 Frequency of leakage
 Need for absorbent products
 Degree of bother to the patient

Symptom Progression
 Better, worse, about the same?
 Focused UI History…
Lower Urinary Tracts Symptoms
 Urgency, frequency, nocturia, dysuria, weak stream, straining to
void, etc.
 AUA-7 (American Urological Association Symptom Inventory-7;
a 7-
item screening tool for UI) (Svatek et al., 2005)
Constipation
Fluid Intake & Bladder Irritants
 Type (caffeine, ETOH, artificial sweeteners)
 Volume
 Timing

Previous Treatments
 Affects on UI
Medical & Surgical History &
Physical Examination
Brief Neurological Exam
 Medical, neurological  Gait
history  Lower extremity strength
 Genitourinary surgeries & reflexes
 Medications, including
 Cogwheel rigidity
 Sphincter tone &
OTC
voluntary
 Habits (tobacco use,
ETOH) Rectal & Pelvic Exam
 Pelvic floor muscle
strength
Vaginal atrophy Prostate

 enlargement
Skin

Functional Assessment

 Brief cognitive assessment (MMSE, Clock

Draw, Mini-cog, MOCHA)

 ADL and IADLs (toileting dependency)

 Physical mobility (manual dexterity, history of

falls)
Urinalysis and Post Void Residual
 Urinalysis to rule out infection

 Post void residual (PVR) to measure amount

of urine left in bladder after voiding

 Ultrasound or catheter

 Acute UI or suspected retention

Case Study 1- Work
Up70 y/o female


 Has a strong urge to urinate and leaks on the way to the bathroom.
 Leaks a little when she coughs or sneezes hard

 Work up
 Hx: No meds including OTC; drinks only
 water
 Physical: unremarkable
 UA: normal
 Cognition: Mini-Cognitive exam is negative
 Function: lives alone, toilets independently
PVR: 35 mL
 Diagnosis? Mixed (Stress and Urge Incontinence)
 Treatment Options?
 Treatment Options
 Pelvic floor muscle exercises (Kegels)
 Instruction w/home practice

 Biofeedback, electrical stimulation

 Self monitoring (bladder diaries)

 Lifestyle Changes
 Gradual caffeine reduction/elimination

 Weight loss

 Fluid management

 Bladder Training
 Medications Antimuscarinics, Alpha-adrenergic antagonists
(selective vs. non-selective), 5-alpha reductase inhibitors
Pelvic Floor Muscle Exercises
(Kegels)

“Squeeze like you’re trying to hold back gas”

 Urge UI Suppression –
“Freeze & Squeeze”
When the urge strikes… Treatment for Urge Incontinence in Women

100

80
81%

Stop and stay still

60
 68%
40
39%
 Squeeze pelvic floor muscles 20

 Relax rest of body Behavioral Drug Control

 Concentrate on suppressing urge

 Wait until the urge subsides
 Walk to bathroom at normal pace
(Markland et al., 2011)
Stress UI Strategy –
“Squeeze before you Sneeze”
 For stress UI squeeze pelvic floor muscles
before sneezing, coughing, or lifting
UI Product Selection – Key
Factors
 Gender (boxers vs. briefs)
 Volume of leakages
 Cost & budget
 Availability of products
 Timing of leakages (day vs. night)
 Mobility & function
 Quality of Life (caregiver & care-recipient)
 Maintain dignity
 Case Study 2 – Product Selection
 Mr. B has a history of Parkinson’s disease and is experiencing UI

 Function and Cognition – Although Mr. B’ Parkinson’s disease

is somewhat advanced he is still able (cognitively and functionally) to
participate in his care and manage his leakages independently.
 Age – not a concern in this case.
 Cost – not a concern in this case.
 Pre-existing Caregiver Burden – Mr. B’s wife is experiencing
significant burden in caring for him.
 Priority of Goals – managing leakages overnight.
 Etiology of Condition – abnormal changes in urinary system
 Additional Social Support - daughter
Case Study 2 - Product Selection
 The volume of leakages was important to consider because certain
products are better equipped in managing certain types of leakages.
Recommend the smallest or least intrusive product available that
can appropriately manage the condition.
 Since Mr B. is a male there are external urinary devices available and
with the help of the nursing staff we were able to train him on
applying it and caring for it himself.
 Cost & budget were not an issue for this couple, but it should
always be considered.
 Dignity Mr. B was very clear that he would not wear pads or briefs
of any kind.
 After months of working with Mr. and Mrs. B, they were able to take
an overnight trip to visit their daughter without incident.
Diagnostic evaluations

 Urinalysis and urine culture .

 Residual urine measurement.
 Vaginal and anal examination.
 Urodynamic studies .
 Serum electrolytes, calcium levels and BUN/creatinine levels.
 Spinal MRI .
 Ultrasonography.

 Cystourethrography.
 Intravenous pyelography (IVP).
 Fluoroscopy and video urodynamic
 Uroflowmetery, cystometer and urethral pressure profilometery (UPP) .
 Electromyography (EMG)
Management of urinary incontinence
1. Behavioural techniques :-
 Bladder control training.
 Scheduled toilet trips .
 Biofeedback.
 Pelvic floor muscle exercises.
 Fluid and diet management
2. Drug therapy :-
 Anticholinergic agent ,
 Antispasmodics ,
 Topical estrogen ,
 Tricyclic antidepressants ,
 Alpha- adrenergic blockers , Alpha – adrenergic agonists.
3.Medical devices :-
 Urethral inserts.
 Pessaries .
 Catheters.
 Clamps and compression rings for man .
 Electrical stimulation devices
Continue ….
4. Surgical treatment for urinary incontinence
 Artificial
urinary sphincter.
 Sling procedures.
 Bladder neck suspension
 Laparoscopic bladder suspension procedure
 Retro pubic colposuspension
 Bladder augmentation
 Neuromodulation
 Physiotherapy management

PT assessment :- Subjective information

 Pelvic floor muscle function and strength :-

 0 - no contraction
 1 - flicker
 2 - weak squeeze, no lift
 3 - fair squeeze, definite lift
 4 - good squeeze with lift
 5 - strong squeeze with a lift
 Palpation -
Mnemonics :- PERFECT
• P – power .
• E - endurance, the time (in seconds) that a maximum contraction
can be sustained.
• R - repetition, the number of repetitions of a maximum voluntary
contraction.
• F - fast contractions, the number of fast (one second) maximum
contractions.
• ECT - every contraction timed, reminds the therapist to continually
overload the muscle activity for strengthening.
 PT management

PFMT (pelvic floor muscles training) also known as kegel Exercises.

Electrical stimulation.
Pre - operation :
• Keep lungs clear of fluid and prevent chest infection.
• Chest physiotherapy (Breathing exercises).
• Help maintain muscles tone and promote the return of blood in veins to
heart.
• Limb physiotherapy (Circulatory exercises)
• Bed mobility
 Continue….

• Post - operation
• Clear lungs and prevent chest infection .
• Support abdomen with soft pillow , take 4 to 5 deep slow breaths then 1
deep cough.
• Reduce muscle weakness and pain on the incision site o posterior basal
and lower costal breathing, concentrating on the affected side .
• Improve coughing, chest expansion, breathing pattern .
 Continue…….
• Patient education ,
• Posture awareness
• Advice patient to continue exercises as taught
• Improve muscle tone and promote the return of blood in veins to heart
- Circulatory exercise.
• Progression for bed mobility
• Ambulate patient around bed site
• Patient education Posture awareness Continue, exercising 3x/day Avoid
heavy weight lifting
When to refer to a specialist…
 Most UI can be treated by primary care providers

 Consider referral for:

 recurrent urinary tract infections
 post void residual > 200 mL
 pelvic pain w/ UI
 hematuria (asymptomatic)
 UI with new neurologic
symptoms

(Vaughan et al. , 2011)

 A Discussion About Dementia
and Urinary Incontinence
 Nicole Davis-is an Adult and Gerontological
Nurse Practitioner with expertise in urinary
incontinence, the needs of the aging, and using
Telehealth to support family caregivers.
 Ms. Davis will talk about her experience in
Nicole Davis
MSN, ANP-BC, GNP-BC caring for older adults with UI and dementia
and supporting family caregivers.
 Ms. Davis addresses the prevalence and
challenges of UI in dementia and the key role
of family caregivers.
 Click on or copy and paste the weblink below to listen
to the podcast: https://gsu.sharestream.net/ssdcms/i.do?
u=893776aba2ac41f
Conclusion
 UI is not an inevitable part of aging

 UI is amenable to treatment in many cases and can be

managed by primary care providers

 Behavioral treatments are effective options for older

adults with UI

 Consider family caregiver burden and needs related to

the management of UI
References
 Abrams, P., Cardozo, L., Fall, M., Griffiths, D., Rosier, P., Ulmsten, U.,…Wein, A. (2002). The standardisation of
terminology of lower urinary tract function: Report from the Standardisation Sub-committee of the International Continence
Society. Neurourology and Urodynamics, 21(2), 167-178.
 Anger, J., Saigal, C., & Litwin, M. (2006). The prevalence of urinary incontinence among community dwelling adult
women: Results from the National Health and Nutrition Examination Survey. The Journal of Urology, 175(2), 601-604.
 Gotoh, M., Matsukawa, Y., Yoskikawa, Y., Funahashi, Y., Kato, M., & Hattori, R. (2009). Impact of urinary incontinence on
the psychological burden of family caregivers. Neurourology and Urodynamics, 28(6), 492-496. doi: 10.1002/nau.20675
 Hawkins, K., Pernarelli, J., Ozminkowski, R., Bai, M., Gaston, S., Hommer, C.,...Yeh, C. (2011). The prevalence of urinary
incontinence and its burden on the quality of life among older adults with Medicare supplement insurance. Quality of Life
Research, 20(5), 723-732. doi: 10.1007/s11136-010-9808-0
 Markland, A. D., Vaughan, C. P., Johnson, T. M. 2nd, Burgio, K. L., & Goode, P.S. (2011). Incontinence. Medical Clinics of
North America, 95(3), 539–554. doi: 10.1016/j.mcna.2011.02.006
 Melville, J., Katon, W., Delaney, K., & Newton, K. (2005). Urinary incontinence in US women: A population-based study.
Archives of Internal Medicine, 165(5), 537-542.
 Morrison, A., & Levy, R. (2006). Fraction of nursing home admissions attributable to urinary incontinence. Value in Health
(Wiley-Blackwell), 9(4), 272-274.
 Svatek, R., Roche, V., Thornberg, J., & Zimmern, P. (2005). Normative values for the American Urological Association
Symptom Index (AUA-7) and short form Urogenital Distress Inventory (UDI-6) in patients 65 and older presenting for non-
urological care. Neurourology And Urodynamics, 24(7), 606-610.
 Vaughan, C., Goode, P., Burgio, K., & Markland, A. (2011). Urinary incontinence in older adults. The Mount Sinai Journal
of Medicine, 78(4), 558-570. doi: 10.1002/msj.20276