MD FRCPC Providence Health Care Clinical Instructor UBC An introductory module for clinicians This module is part of the sfCare approach PowerPoint Presentation 85 x 11 Poster Patient Handout ID: 928852
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Slide1
Urinary
Incontinence
Dr. Martha Spencer
, MD, FRCPC
Providence Health CareClinical Instructor, UBC
An introductory module for clinicians
Slide2This module is part of the sfCare approach
PowerPoint Presentation
8.5 x 11 Poster
Patient Handout
Slide3Objectives
Objectives
What
is urinary incontinence?
Prevalence and impactCauses How to treat
Case study
Summary
Senior
friendly
a
pproach
Questions
Distinguish between the types of urinary incontinence
Identify the negative effects that urinary incontinence can have on older adults
Recognize the factors that can lead to urinary incontinence
Describe interventions to treat urinary incontinence
Apply a senior friendly approach to
treating urinary incontinence
Slide4What is urinary incontinence (UI)?
There are different types of UI:
Urgency incontinenceStress incontinence
Functional incontinenceOverflow incontinence
Involuntary loss of bladder control causing the release of urine.
Objectives
What is urinary incontinence?
Prevalence and impact
Causes
How
to
treat
Case
study
Summary
Senior
friendly
a
pproach
Questions
Slide5How common is UI?
Up to
50% of older Canadians have urinary incontinence…
ObjectivesWhat is urinary incontinence?
Prevalence and impactCauses How to
treatCase study
Summary
Senior
friendly
a
pproach
Questions
Slide6UI is underdiagnosed and undertreated
Embarrassment at sharing this issue with their healthcare provider
Not speaking to a primary care provider about their symptoms due to the belief that it is a normal part of agingHealthcare providers and older adults may
feel as though other health issues take priorityInadequate assessment in frail older adults
Yet, UI is underdiagnosed and undertreated in older adults. Why?
Roe B et al 2011.
J Advanced Nursing
,
67
(2),
228-250
Cdn Continence
Foundation, Cameron Institute. Incontinence: The Canadian Perspective. December 2014.
Santos CRDS 2011
Neurology
and urodynamics
,
30
(8), 1473-1479ObjectivesWhat is urinary incontinence?Prevalence and impactCauses How to treat
Case studySummarySenior friendly approachQuestions
Slide7UI is not adequately assessed
Only 24-48% of patients received UI assessments
(Georgio et al, 2001)Abrams et al. Incontinence. 5th International Consultation on Incontinence. 5th Edition, 2013.
In older adults in residential
care, there is a quality gap:
Most patient do not have relevant physical examinations
Only 55% of patients with dementia/UI had care plans
(Pringle-Specht et al, 2002)
Rectal
15%
Pelvic
2%
(Watson et al, 2003)
In
community-dwelling older adults
t
he
type of UI is only diagnosed in 48% of
cases
(Du Moulin
et al,
2009)ObjectivesWhat is urinary incontinence?
Prevalence and impact
Causes
How
to
treat
Case
study
Summary
Senior
friendly
a
pproach
Questions
Slide8The importance of UI
Mandl, M., Halfens, R. J., & Lohrmann, C. (2015). Incontinence care in nursing homes: a cross‐sectional study. Journal of advanced nursing, 71(9), 2142-2152.
UI can have negative effects on older adults, including…
Objectives
What is urinary incontinence?
Prevalence and impact
Causes
How
to
treat
Case
study
Summary
Senior
friendly
a
pproach
Questions
Problems with taking
medication
New or worsening symptoms or
conditions
Decline in
mobility
Impairments
in
oral
intake
Self-reported decrease in overall
health
Decline in functional and self-care
abilities
Decline
in ability to perform ADLs
Hygienic/skin problems
Reduced
self-esteem
, depression, social
isolation
Slide9Causes of UI
Objectives
What is urinary incontinence?
Prevalence and impactCauses
How to treatCase study
SummarySenior
friendly approach
Questions
Slide10Some conditions that can cause UI
Sleep
disordered
breathing
ObesityChronic lung disease
ConstipationDiffuse Lewy body disease
Dementia
Parkinson’s disease
Recurrent infection
Stroke
Congestive heart failure
Peripheral vascular disease
Diabetes mellitus
Venous insufficiency
Normal Pressure Hydrocephalus
Falls and contractures
Objectives
What is urinary incontinence?
Prevalence and impact
Causes
How
to treatCase study
Summary
Senior
friendly
a
pproach
Questions
Slide11Some medications that can cause UI
Medications
Effects on Continence
Alpha adrenergic antagonists
smooth
muscle tone in the urethra
May
precipitate stress urinary incontinence in women
Angiotensin converting enzyme inhibitors
Can cause
cough
and exacerbate
UI
Anticholinergics
May
urinary
retention
Constipation
that can contribute to UIMay impair cognition
and
reduce effective toileting ability
Abrams et al. Incontinence.
5
th
International Consultation
on Incontinence.
5
th
Edition, 2013.
Objectives
What is urinary incontinence?
Prevalence and impact
Causes
How
to
treat
Case
study
Summary
Senior
friendly
a
pproach
Questions
Slide12Some
medications that can cause UI (cont.)
Medications
Effects on Continence
Calcium channel blockers
May
urinary retention
Constipation
Dependent edema
which can contribute to nocturnal polyuria
Cholinesterase inhibitors
bladder contractility
-
urgency
UI
Diuretics
Diuresis
and precipitate UI
Lithium
Polyuria due to diabetes insipidus
Opioid analgesics
Urinary retention
Constipation
Confusion
Immobility
All
of which can contribute to UI
Abrams et al. Incontinence
. 5
th
International Consultation
on Incontinence.
5
th
Edition, 2013.
Objectives
What is urinary incontinence?
Prevalence and impact
Causes
How
to
treat
Case
study
Summary
Senior
friendly
a
pproach
Questions
Slide13Some
medications that can cause UI (cont.)
Medications
Effects on Continence
Psychotropic
drugs:
sedatives
,
hypnotics
,
antipsychotics
,
histamine
1
receptor
antagonists
Confusion
and impaired mobility
Anticholinergic effects
ConfusionSedative serotonin re-uptake inhibitors
cholinergic transmission and may lead to urinary UIOthersGabapentin, glitazones, non-steroidal anti-inflammatory agents
Edema
nocturnal
polyuria
and
night-time UI
Abrams et al. Incontinence.
5
th
International Consultation
on Incontinence.
5
th
Edition, 2013.
Objectives
What is urinary incontinence?
Prevalence and impact
Causes
How
to
treat
Case
study
Summary
Senior
friendly
a
pproach
Questions
Slide14How to treat UI
Lifestyle interventions
Behavioral interventions
Pharmacological treatment
Objectives
What is urinary incontinence?
Prevalence and impact
Causes
How to treat
Case
study
Summary
Senior
friendly
a
pproach
Questions
Slide15Lifestyle
11 trials, with 6000 participants looked at
Weight loss
interventions -
4
trials
Decreasing fluid intake - 3 trials
Decreasing caffeine - 3 trials
Eliminating soy - 1 trial
Imamura
M et al Cochrane
Database of Systematic Reviews 2015, Issue
12
Authors’ conclusion:
Evidence
for the effect of weight loss on urinary incontinence is building and should be a research
priority
. Generally, there was insufficient evidence to inform practice reliably about whether lifestyle interventions are helpful in the treatment of urinary incontinence.
Cochrane review (2015) of lifestyle interventions for the treatment of urinary incontinence in adults
How to treat UI
Objectives
What is urinary incontinence?Prevalence and impactCauses How to treatCase study
Summary
Senior
friendly
a
pproach
Questions
Slide16Abrams et al. (2017). Incontinence, 6th International Consultation on Incontinence.
Physical activity
Non-RCT data suggests that moderate exercise may decrease
UI/overactive bladder
symptoms
SmokingUI/overactive bladder symptoms may improve with smoking abstinence
CaffeineReduction in caffeine intake recommended, but evidence limited (small RCT with n=14, cross-sectional data based on self-report)
How to treat UI
Lifestyle
Lifestyle (cont.)
While evidence is lacking about the efficacy of lifestyle interventions, the following are recommended:
Objectives
What is urinary incontinence?
Prevalence and impact
Causes
How to treat
Case
study
Summary
Senior
friendly
a
pproach
Questions
Slide17Abrams et al. (2017). Incontinence, 6th International Consultation on Incontinence.
Hydration
Best possible intervention= increasing hydration
6-8 cups of total fluid/dayhelps to prevent concentrated urine that can irritate the inner lining of the bladder (epithelium)
Constipation
Small observational trials show association between chronic straining and UIHow to treat UI
Lifestyle
Lifestyle (cont.)
While evidence is lacking about the efficacy of lifestyle interventions, the following are recommended:
Objectives
What is urinary incontinence?
Prevalence and impact
Causes
How to treat
Case
study
Summary
Senior
friendly
a
pproach
Questions
Slide18Abrams et al. (2017). Incontinence, 6th International Consultation on Incontinence.
Pelvic floor muscle
training (PFMT)
(PFMT)
Effective as a stand-alone treatment, as part of a multi-component strategyCombination of drug therapy + PFMT more effective than either treatment aloneSupervised PFMT should be offered as a first-line conservative therapy for women of all ages with UI (Level 1 evidence, Grade A recommendation)
How to treat UI
Behavioural Interventions
Objectives
What is urinary incontinence?
Prevalence and impact
Causes
How to treat
Case
study
Summary
Senior
friendly
a
pproach
Questions
Slide19Abrams et al. (2017). Incontinence, 6th International Consultation on Incontinence.
How to treat UI
Behavioural Interventions
Scheduled Voiding Regimes
Bladder
training
Should be recommended as a first-line conservative therapy for UI in women
Start
with 1hr intervals and increase by
15-30 min
intervals until q2-3hr voiding intervals achieved
Consider self-monitoring with diary/log
Importance of supervising
healthcare provider
(
e.g.
nurse continence advisor)
Consider different
strategy
if no improvement after 3 weeks
Timed
voiding
No high quality evidence to support efficacy in cognitively intact women
Objectives
What is urinary incontinence?
Prevalence and impact
Causes
How to treat
Case
study
Summary
Senior
friendly
a
pproach
Questions
Slide20Abrams et al. (2017). Incontinence, 6th International Consultation on Incontinence.
For most, consider 6-8 weeks trial of non-pharmacological treatment prior to drug therapy.
Consider starting on drug therapy earlier if:
Few
medications Cognitively intact Significant reduction in patient’s quality of life
Age <65 years old (more evidence about adverse effects, fewer adverse effects)Few comorbidities
How to treat UI
Pharmacological treatment
Objectives
What is urinary incontinence?
Prevalence and impact
Causes
How to treat
Case
study
Summary
Senior
friendly
a
pproach
Questions
Slide21Case study: Mrs. S
Mrs. S is an 84 year old female, widowed, living alone in an apartment, and has been
experiencing urinary incontinence for 5 years.
Frequency - 10x/day, 4x/night
Leakage with urgency
Occasional leaking with cough, getting out of chair
No hesitancy, intermittency or sensation of
incomplete
emptying
4-5 pads/day,
1-2 pads/night
No dysuria, hematuria or
recurrent UTI
Soft BM q 1-2 days
Drinks 6 cups of water, 2 cups of tea, 1 cup of coffee/day
Symptoms
Objectives
What is urinary incontinence?
Prevalence and impact
Causes
How to treatCase studySummary
Senior friendly approachQuestions
Slide22Case study: Mrs. S
PMHx
Type 2 diabetes
Hypertension
Chronic venous insufficiencyChronic pain due to osteoarthritis
in hands and kneesFalls x 2 in past year
Medications
Metformin 1g po bid
Amlodipine
10mg po
daily
Furosemide
20mg po
bid
Celecoxib 100mg
po
bid
Gabapentin 100mg
po
tid
Lorazepam 0.5mg po qhs
What’s going through your mind?ObjectivesWhat is urinary incontinence?Prevalence and impactCauses How to treat
Case study
Summary
Senior
friendly
a
pproach
Questions
Slide23Case study: Mrs. S
What type of urinary incontinence does Mrs. S have?
Objectives
What is urinary incontinence?
Prevalence and impactCauses How to treat
Case studySummarySenior
friendly approach
Questions
Slide24Case study: Mrs. S
Multifactorial Incontinence
Stress Incontinence
+
Functional Incontinence
Urgency Incontinence
+
Frequency-
10x/day, 4x/night
Leakage with urgency
Occasional leaking with cough, getting out of chair
No hesitancy, intermittency or sensation of
incomplete emptying
Arthritis pain in hands and knees
Objectives
What is urinary incontinence?
Prevalence and impact
Causes
How to treat
Case study
Summary
Senior
friendly
a
pproach
Questions
Slide25Case study: Mrs. S
Furosemide = urinary urgency and frequency
Polyuria due to excessive fluid consumption and caffeinated beverages
Poorly controlled type 2 diabetes
with glucosuriaWeak pelvic floor muscles
Arthritis, slow gait, orthostatic hypotension
Urgency
Stress
Functional
Causes of Mrs. S’s multifactorial
i
ncontinence
Nocturia:
Fluid redistribution from pedal edema
V
enous
insufficiency
NSAIDS
, calcium channel blockers, Gabapentin
Enuresis
Co-administration of Lorazepam and Lasix at night
Objectives
What is urinary incontinence?
Prevalence and impact
Causes
How to treat
Case study
Summary
Senior
friendly
a
pproach
Questions
Slide26Case study: Mrs. S
Trial caffeine reduction
Physical
exercise - to increase gait speed and decrease falls risk
Referral to pelvic floor muscle physiotherapistInstruction and self-management tools for bladder training
Taper Lasix, taper Lorazepam
Replace NSAID with AcetaminophenReplace Amlodipine with Ramipril (lower dose)
Add Gliclizide ER 30mg po daily to optimize
diabetes control
Lifestyle
Behavioural
Medication Review
Evidence-based conservative management for Mrs. S includes:
Objectives
What is urinary incontinence?
Prevalence and impact
Causes
How to treat
Case study
Summary
Senior
friendly
a
pproach
Questions
Slide27Summary
Urinary incontinence is not a normal part of aging!
There are different types of urinary incontinenceIt is possible to manage urinary incontinence with a variety of
non-pharmacological strategies
ObjectivesWhat is urinary incontinence?Prevalence and impactCauses
How to treatCase study
SummarySenior
friendly
a
pproach
Questions
Slide28The senior friendly approach
Ask leaders to remove barriers to care, and provide education for staff, patients and caregivers.
Address incontinence as a health issue just as you would for adults of all ages.
Avoid using briefs without assessing the cause of urinary incontinence.
Ensure your organization’s washrooms are not only accessible, but also senior friendly.
How all healthcare providers can address
urinary incontinence using a senior friendly care approach
Organizational Support
Emotional &
Behavioural
Environment
Ethics in Clinical Care and Research
Physical Environment
Processes
of Care
Organizational Support
Ethics in Clinical Care and Research
Processes
of Care
Emotional &
Behavioural Environment
Physical Environment
Objectives
What is urinary incontinence?
Prevalence and impact
Causes
How to treat
Case study
Summary
Senior friendly approach
Questions
Slide29What do you already do in your daily work that relates to continence management?
What is one thing you can do differently as a result of reviewing this module?
Share an example of a strategy you have used to broach the topic of incontinence with your patients?
Discussion questions
Objectives
What is urinary incontinence?Prevalence and impact
Causes How to treat
Case study
Summary
Senior
friendly
a
pproach
Questions
Slide30The sfCare Learning Series received support from the Regional Geriatric Programs of Ontario, through funding provided by the Ministry of Health and Long-Term Care.
V1 July 2019