Fourth International Consultation On Incontinence (ICI) - Frail Elderly Committee Highlights

Main Category: Urology / Nephrology
Article Date: 25 Jul 2008 - 2:00 PDT

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PARIS, FRANCE (UroToday.com) - Dr. DuBeau began by thanking David Fonda, who chaired this committee for the previous consultation and whose work provided the basis for this committee's endeavors. Dr. DuBeau noted that definitions of "frailty" exist, but for the purposes of this discussion "Frail Elderly" are essentially the vulnerable elderly. Healthy elderly are those 65 years or older, community dwelling, and persons with minimal or well-managed co-morbidities. She presented Level 2 evidence regarding the definition of "Frail Elderly", which includes those with multiple chronic medical conditions, polypharmacy, needing assistance with ADLs, and those at high risk for hospitalization. Many are homebound or institutionalized. She addressed how UI differs in the frail elderly compared to the rest of the adult population. Older patients have multiple risk factors for UI and there may be a significant burden on caregivers and institutions. Treatments, in addition to standard conservative therapies and pharmacological interventions, must often take a "system-level" approach in institutionalized patients to develop care models and appropriate strategies to reduce the burden of UI.

Dr. DuBeau presented new data that has been published since the previous consultation. With respect to age-related changes in the genito-urinary system, there is Level 2 evidence for decreased detrusor contractile function, functional capacity and urinary flow rate in older patients. In the female urethra, there is decreased vascular density and blood flow, decreased sphincteric muscle mass, and decreased sensation (Level 2-3). There is Level 3 evidence that there are no significant age-related changes to the vagina and pelvic floor. For men, benign prostatic hyperplasia and prostate cancer are, of course, more prevalent with aging, and there is also new information regarding the role of inflammation and prostatic infarction in precipitating acute urinary retention (Level 3). Levels of evidence were presented for non-LUT factors involved in UI, including comorbid conditions (Level 2), CNS white matter signal abnormalities (Level 4), depression (Level 3), cholinesterase inhibitors (Level 3), and functional impairments (Level 1). UI is also a significant risk factor for falls in the elderly (Level 1).

Several changes were highlighted in the assessment of UI in the Frail Elderly, including a Grade A recommendation for a functional assessment, a Grade B for depression screening and a Grade C for dipstick urinalysis. With respect of measurement of PVR, a Grade C recommendation was given for its use in patients at risk for high PVRs, including those with diabetes, a history of urinary retention, constipation and a previous history of urodynamic obstruction or decreased contractility. Treatment of asymptomatic bacteruria/pyuria was given a Grade D recommendation, and Dr. DuBeau noted that the criteria for diagnosing UTIs in nursing home patients are neither sensitive nor specific.

With respect to management of UI, Dr. DuBeau cited several considerations in the frail elderly. Life expectancy should be taken into account when evaluating potential treatments and providers need to be aware of several issues regarding medications, including changes in pharmacokinetics, polypharmacy and risks and consequences of adverse events. Regarding new data, Dr. DuBeau cited a paucity of new studies regarding the frail elderly. There were two new studies on oxybutynin ER, but the details were not discussed. There were two single-center studies on slings in older patients; the study from the Urinary Incontinence Treatment Network is in press. Two points were made with respect to nocturia in the frail elderly: Evaluation should focus on the underlying cause (nocturnal polyuria, sleep apnea), and treatment with desmopressin has a high risk of causing dilutional hyponatremia in this population (Grade A).

Dr. DuBeau concluded by highlighting the changes in the algorithm for "Management of Urinary Incontinence in Frail Older Persons" since the previous consultation. In the well-known "DIAPPERS" acronym, atrophic vaginitis is deleted and the potential harm of treatment of asymptomatic bacteruria was added. In the evaluation section, digital rectal examination and "wet checks" were added and the specification for mid-stream urine was deleted. Specific patients recommended for PVR checks was also added. Estrogen treatment was removed from the SUI and UUI categories for treatment, and the word "cautious" was removed as a modifier for anticholinergic therapy for UUI. Double voiding was removed as a recommendation for patients with elevated PVRs, and an exact cut-off value of PVR requiring catheter decompression was deleted. Finally, prior to specialist referral for treatment failures, the primary care physician should reassess for contributing functional impairments and comorbidities.

Catherine DuBeau, MD, Committee Chair

Moderated by Joachim W. Thüroff, MD, and Masaru Murai, MD, at the Fourth International Consultation on Incontinence (ICI) - July 5 - 8, 2008. Palais des Congres, Paris, France.

Written by William Jaffe, MD, a Contributing Editor with UroToday.com

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