What can we do about comorbidities? Adrian Wagg Capital Health Professor of Healthy Ageing

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1 What can we do about comorbidities? Adrian Wagg Capital Health Professor of Healthy Ageing

2 What characterizes older persons? Well they re older than you regardless of your age Positive illusion Youthful identity View of life stages occurring later when one is in middle age and later life age denial Middle aged and older adults maintain age identities 20% more youthful than their actual age Gana K et al. Aging & Mental Health 2004;8:58-64 Taylor SE. Psychological Bulletin 1988;103: Rubin DC. Psychological Bulletin and review 2006;13:

3 What s a medically complex older patient? Multimorbidity (Co-existence of 2 or more chronic medical conditions) Between , prevalence of 3 or more conditions increased by 60% 4 or more conditions increased by 300% Associated with increased healthcare utilisation lower health related quality of life increased disability, morbidity and mortality

4 Multimorbidity BMC Public Health (2015) 15:415

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6 ANNALS OF FAMILY MEDICINE VOL. 10, NO. 2 MARCH/APRIL 2012 The rise of multimorbidity Prevalence of multimorbidity (defined as 2 diseases) reported in primary care settings

7 Multi-morbidity s profile Lancet 2007; 370:

8 UI as a Geriatric Syndrome Multiple risk factors, across multiple organ systems and domains Young Elderly RF 1 RF 2 UI UI Modulating factor Tinetti et al11995; Inouye et al, 2007

9 Co-morbid conditions 65+ yrs in primary care n=2612, men=826 women= *Others(Primary Care) Alcohol related disease 2, Other renal impairment or disease 92, Other gynaecological 0 disease or disorder 24, Other gastroenterological disease or disorder 108, Non-specific and other malignancies 37, Other problems related to childbirth 1, Delirium 9, Haematological disorders 21, Retention of urine 5, Mental health diagnoses 32, Other urological surgery or disease 39, Learning disability 8, Other endocrine disease or disorder 41, Other respiratory disease or disorder *Others(Primary 100, Other Care) Alcohol related disease 2, Other renal impairment or disease 92, Other gynaecological disease or disorder 24, Other gastroenterological disease or disorder 108, Non-specific and cardiac disease or disorder other 90, malignancies Other 37, Other problems related to childbirth 1, Delirium 9, Haematological disorders 21, vascular (non-cardiac) disease Retention or disorder of urine 5, Mental health diagnoses 32, Other urological surgery or disease 39, Learning disability 22, Other musculoskeletal 8, disease Other endocrine disease or disorder 41, Other respiratory disease or disorder 100, Other cardiac disease including fracture & Osteoporosis or disorder 198, 90, Other vascular (non-cardiac) disease or disorder 22, Other musculoskeletal disease including fracture & Osteoporosis 198, Others 74 Others 74 20

10 Distribution of co-morbid conditions Hospitals (n=2011) primary care (n=1786) 0 Wagg, A et al 2011 RCP NACC

11 Consultant pharmacist 2015;30: Prevalent disease in residents with UI/ OAB compared with a matched cohort without UI/OAB

12 Medically complex patients in trials % Distribution of co-existing conditions in patients >65y participating in all trials of fesoterodine Wagg et al 2016, in press

13 Associated conditions and UI peripheral vascular disease diabetes mellitus congestive heart failure venous insufficiency chronic lung disease falls and contractures Sleep disordered breathing stroke Dementia Diffuse Lewy body disease Parkinson s disease Normal Pressure Hydrocephalus recurrent infection Constipation Obesity Ouslander, J.G. and J.F. Schnelle, Incontinence in the nursing home. Ann Intern Med, (6): p McGrother C, Donaldson M. Continence in Health Care Needs Assessment

14 Associated conditions and UI peripheral vascular disease diabetes mellitus congestive heart failure venous insufficiency chronic lung disease falls and contractures Sleep disordered breathing stroke Dementia Diffuse Lewy body disease Parkinson s disease Normal Pressure Hydrocephalus recurrent infection Constipation Obesity Ouslander, J.G. and J.F. Schnelle, Incontinence in the nursing home. Ann Intern Med, (6): p McGrother C, Donaldson M. Continence in Health Care Needs Assessment

15 The bladder in PD In PD patients diagnosed according to modern criteria, the prevalence of urinary symptoms 27% to 39% using validated questionnaires PD patients report significantly more symptoms than healthy controls.

16 The bladder in PD Correlation with neurological disability, and to stage of disease J Neurol Neurosurg Psychiatry 2000;68: Auton Neurosci 2001;92: bladder symptoms only correlate with age. Arq Neuropsiquiatr 2003;61: Age Ageing 1995;24:

17 The bladder in PD Increased rate of voiding dysfunction, measured by IPSS, related to severity of disease and age rather than duration

18 PD medication and the bladder detrusor overactivity improved after administration of apomorphine and levodopa Neurourol Urodyn 1993;12: in subjects with on off phenomena, detrusor overactivity lessened with levodopa in some and worsened in others. Br J Urol 1985;57: in advanced PD, levodopa exacerbated detrusor overactivity in the filling phase, but also improved bladder emptying Mov Disord 2003;18: The unpredictable effect of medication is not related to stage of disease age presence or absence of symptoms Mov Disord 2002;17(Suppl. 5):S218.

19 Stroke and bladder control Incontinence associated with any lesion except for occipital lobe anteromedial region, frontal lobe primarily identified Sakakibara R et al J neurol Sci 1996;137: cortical+subcortical strokes 5.3 times more likely to be associated with incontinence Gelber DA. et al. Stroke 1993;24: Size of stroke more important than location?

20 Factors leading to incontinence Site of cerebral lesion Motor impairment Reduction in conscious level Cognitive impairment Speech impairment Female sex Gelber DA. et al. Stroke 1993;24: Borrie MJ et al. Age Ageing 1986;15:177-81

21 Effect on outcome 52% dead at 6/12 compared with 7% continent stroke survivors Nakayama H et al Stroke 1997;28: Incontinent 30 day post stroke survivors 3.9 times more likely to die within 1 year and 2 times within 5 years Hankey G et al. Stroke 2000;31: Anderson C et al Stroke 1994;25:

22 Effect on outcome II Increased disability best predictor of severe / moderate 3/12. OR: 5.4(95%CI: ) Taub NA et al. Stroke 1994;25:352-7 Poor outcome in terms of function mobility discharge destination Brittain KR et al Stroke 1998;29:524-8 Kalra L et al. Postgrad Med J 1993;69:33-36.

23 Effect on outcome III Predicts recovery of limb strength and ADL Barer DH. Age Ageing 1989;18: Presence of incontinence better predictor of recovery at four weeks than predictive scoring Prescott R et al. Stroke 1982;13: Residents of institutional care with incontinence more likely to be stroke sufferers Chiang L. et al. J Amer Geriatr Soc 2000;48:

24 Associated morbidity Conflicting data on increase in associated depression. In the elderly, and in women,positive association. Robinson G et al. Br J Psychiatr 1984;144: Vetter NJ et al Lancet 1981;2:

25 Underlying diagnosis Few studies have performed urodynamic studies in stroke patients No specific type of incontinence associated with stroke Detrusor hyperreflexia commonest lesion, 50-82% Feder M et al. Euro Neurol 1987;27: Acontractile bladder in 17-25% Linsenmeyer TA. et al. Neurol Rehabil 1992;2:23-6. Outflow tract obstruction common Tsuchida S et al. Urology 1983;21:

26 Management Strategies Few studies have reported on treatment scheduled voiding programmes appear effective medication for urge incontinence less so Gelber DA. Et al. Stroke 1993;24: A four month programme of PFMT appeared effective at six months FU in women with UI Tibaek S, Gard G, Jensen R Int Urogynecol J Pelvic Floor Dysfunct Mar;18(3): No systematic attempt to assess treatment efficacy in this group.

27 Does exercise help? 3/12, twice weekly exercise to increase the muscle strength, walking ability, and pelvic floor muscle. UI affected 66.7% at baseline to 23.3% after intervention risk of at least monthly urinary incontinence decreased with increasing quintiles of moderate physical activity Increasing levels of total physical activity were significantly associated with a reduced risk of UI (top versus bottom quintile ) OR 0.81, 95% confidence interval [CI] ; Walking, was related to 26% lower risk of developing UI (top versus bottom quintile, OR 0.74, 95% CI Arch Gerontol Geriatr Mar 6. J Urol. 2008;179: Obstet Gynecol Mar;109(3):721-7

28 Exercise and combined interventions Older Japanese women one hourly, twice weekly intervention over three months muscle strength, stability and walking and pelvic floor muscle strength statistically significant decrease in incontinence and an increase in maximum walking speed. The same group, examining the use of a similar intervention for its effect on stress urinary incontinence found a significant reduction in BMI in the intervention group, probably adding to its benefit Kim, H., et al., EffectiveneJ Am Geriatr Soc, (12): p Kim, H.,Yoshida, H, Suzuki,T. syndrome: Arch Gerontol Geriatr Mar 6

29 Nursing home residents prompted voiding and individualized, functionally oriented endurance and strength-training exercises four times per day, 5 days per week, 8 weeks Significant reduction in UI episodes exercise and incontinence care to improve skin health every 2 hours from 8:00 a.m. to 4:30 p.m. (total of four daily care episodes) 5 days a week for 32 weeks effective in reducing incontinence No effect on skin health Ouslander, J.G., et al., J Am Geriatr Soc, (7): p Bates-Jensen, B.M., et al., J Am Geriatr Soc, (3): p

30 Nursing homes cognitively impaired residents walking exercise for thirty minutes per day four weeks significant reduction in daytime incontinence episodes increase in gait speed and stamina NH residents thrice weekly, 30 minute intervention 8 weeks Increase in the number of subjects who achieved independent toileting a non-significant reduction in daily urine loss Jirovec, M.M.Int J Nurs Stud, (2): p van Houten, P., W. Achterberg, and M. Ribbe, Gerontology, (4): p

31 Nocturia 30 minute evening walk effective in reducing nocturia, improved daytime urinary frequency Reduced blood pressure, body weight, body fat ratio, triglycerides, total cholesterol Increased sleep quality Sugaya, K., et al. Biomed Res, (2): p

32 So, what to do? Recognise the conditions which might be impairing the woman s ability to toilet successfully Think wider than simply LUTS and incontinence Mobility Dexterity Cognition Sight Environment

33 So, what to do? OT referral? Easy to read signs Contrasting colours for toilet seat and toilet Don t leave white porcelain objects around the house!

34 Products:

35 What matters to older patients? Having an assessment in a private room (91%) Having good channels of communication between all professionals who deal with my bladder/bowel condition (87%) Being assessed by someone who is friendly, understanding and reassuring (87%). Being able to have a full assessment of my problem if I mention it (85%) Having a service that can easily link me to specialists or other services (83%) Having equipment such as pads delivered on time to where I live (83%) Being able to choose from a full range of good quality, reliable, and properly fitting pads, knickers and other products irrespective of cost (83%) Patient Mar 1;3(1):11-23

36 Getting regular updates about bladder and bowel conditions, services and equipment free of charge in a form I can understand (76%) Being able to fully understand my condition and what the future holds for me (74%) Whenever possible, being given a choice of treatments by continence specialists (74%) Getting hold of a local expert for advice and or treatment when I need it (67%) Being involved in a full discussion about care and treatment face-to-face (67%) Patient Mar 1;3(1):11-23

37 Multi-disciplinary care for older people

38 What multi-professional care does your service offer?

39 Barriers to better care Patient assessment and continence promotion regardless of age, rather than pad provision Improving attitudes towards continence and older people rapid and appropriate patient referral pathways strengthened inter-service collaborations investment in service capacity higher profile of UI within medical and nurse training Orrell A BMJ Open 2013;3:e doi: /bmjopen

40 Service delivery model PLoS One Aug 14;9(8):e doi: /journal.pone

41 Service delivery model Evidence suggests that this part of the service model is crucial poorly done, both in primary and secondary care where done well, is largely because of local champions PLoS One Aug 14;9(8):e doi: /journal.pone

42 Recommendations 1.Develop robust referral pathways to ensure patients receive timely, equitable and effective care 2. Use continence nurse specialists for initial assessment and treatment, where available Can manage and treat incontinence more effectively than primary care physicians Where not possible, focus on training existing healthcare professionals

43 Recommendations 3.Use a case co-ordinator to ensure a patient-centred approach Accompanies service user along care pathway Single point of contact to ensure smooth delivery of care 4. Promote use of self-management tools or techniques Patients & caregivers may prefer active role in treatment decision-making Providing information on managing incontinence can lessen demand

44 Recommendations 5. Specialists should play a key role in quality governance, training and dissemination of best practice Should have well-defined roles separate to those providing initial assessment and treatment... HOWEVER, hold key insights and knowledge in the areas of quality governance, training and dissemination of best practice 6. Use a comprehensive standardised assessment of user, product, and usagerelated factors to assess needs with regards to containment products Use standardised assessment of following factors as per international standard (ISO 15621: 2011):User related factors; Product-related factors; Usage-related factors Needs of each patient must be reassesed periodically

45 Recommendations 7. Technology should enable self-care, connect patients and caregivers, and enable providers to monitor progress and troubleshoot problems Technology can: Fill gaps where resources and manpower are lacking Connect patients, caregivers and health care professionals Overcome embarrassment and stigma for patients visiting their doctor 8. For payers: in order to provide the highest quality continence care, ensure care standards are incentivised Transparency on outcome indicators can motivate improved performance Financial incentives linked to outcomes can also motivate powerfully Operational performance measures can indicate level of efficiency

46 Recommendations 9. Establish accredited programmes of training Recommend establishment of certificate in continence care nursing Where there is a shortage of nurses, set up accredited training programmes for other health and social care professionals 46

47 But team approach needed: recognising the additional factors which predispose older people to toileting unsuccessfully The integrated continence service is still a desirable concept Treating comorbidities Medication review Pragmatic treatments Appropriate use of therapies nt_data/file/198033/national_service_framework_for_older_peopl e.pdf