Incontinence and falls: geriatric giants, hand in hand. Disclosures. Objectives

Transcription

1 The 9 th Annual Dr. Gerald Zetter Memorial Lectureship (Geriatric Grand Rounds) Thursday, September 18, 28 12: noon Dr. Bill Black Auditorium Glenrose Rehabilitation Hospital Incontinence and falls: geriatric giants, hand in hand In keeping with Glenrose Rehabilitation Hospital policy, speakers participating in this event have been asked to disclose to the audience any involvement with industry or other organizations that may potentially influence the presentation of the educational material. Disclosure will be done both verbally and using a slide or handout. Visit web sites: for handouts, poster, schedule, subscription: for on-demand archive of previous presentations: Dr. Gerald Zetter Memorial Lecture Adrian Wagg Senior Lecturer in Geriatric Medicine University College London, UK Disclosures Consultant Astellas, Pfizer, Boehringer-Ingelheim, UCB Pharma Lecturer Ardana, Astellas, Boehringer-Ingelheim, Pfizer, UCB Pharma, SCA Research Astellas, Boehringer-Ingelheim, Pfizer, UCB Pharma Objectives To understand the association between falls and urinary incontinence To demonstrate an understanding of the underlying factors which might lead an elderly person to fall To understand the range of interventions which might be employed to reduce falls 1

2 Incontinence Instability Immobility The Geriatric Giants Intellectual decline Isaacs B. The challenge of Geriatric Medicine. Oxford Medical Publications, Oxford 1992 % (95%CI) Symptom prevalence and age Women < >6 age group European Urology Volume 5, Issue 6, December 26, Pages Nocturia ( 2 times/night) Urgency Frequency UUI Symptom prevalence and age Falls, like bladder problems are common in the elderly % (95%CI) Men < >6 3 Age group European Urology Volume 5, Issue 6, December 26, Pages Nocturia ( 2 times/night) Urgency Frequency UUI The fit elderly are less likely to fall Recurrence is 6-7% in a year % falls/yr 2

3 prevalence of falls and urinary incontinence in men and women over and under the age of 65 years as a percentage of total UK population % 1 5 men<65 men>65 women<65 women>65 falls urinary incontinence Falls affect: 3-4% of the elderly population in the community 3-6% in nursing homes 25% of external injuries admitted to Accident and Emergency 6 th leading cause of death in the elderly Although only 5 per cent of falls result in fracture the total annual cost of these fractures to the NHS has been calculated as 1.7billion Significant loss of independence and quality of life (Cooper 1993). 5% of falls have a mechanical cause Minor soft tissue injuries (3-5%) Hip fractures (1%) other fractures (3-5%) serious soft tissue injuries (5%) Frequent Causes of Falls in Elderly 2% 2% 5% 5% 5% accidents medication acute illness lower extremity weakness gait disorders 3

4 Falls more common in women Fractures more common in women Hip fracture associated with significant mortality 24% all cause mortality at 3/12 for women >75 Vertebral fracture also associated with increased mortality in older women RR: 8.64 vs younger women Falls & Death Leading cause of death from injury in >65yr olds Almost half of deaths follow hip fracture A marker of an increased risk of death Patients with incontinence post operation for hip fracture do worse in terms of functional ADL & mortality They are more likely to be institutionalised post fracture They are more likely to be cognitively impaired Falls affecting lives Doubles length of hospital stay Greater functional decline in ADL s Greater risk for institutionalisation- fear Loss of sense of independence 4

5 Risk Factors for Falls Chronic Illnesses Physical deficits cognitive impairment reduced vision problems rising from chair foot problems neurological changes impaired hearing Others environmental hazards risky behaviours Dementia Stroke Parkinson s s Disease Other neuromuscular disease Arthritis Diabetes Heart disease and hypertension Co-morbidities & continence Other common conditions of the elderly which may be linked to incontinence include: Peripheral vascular disease, Parkinson s disease, diabetes mellitus, congestive heart failure, venous insufficiency and chronic lung disease, falls and contractures, recurrent infection and constipation Health care needs assessment. The epidemiologically based needs assessment reviews. Medications Multi-medication or new one in last 2 weeks long-acting hypnotics- anxiolytics tricyclic antidepressants antipsychotics antiparkinsonian drugs insulin other cardiac, diuretic, or antihypertensive drugs 5

6 Many drugs predisposing to incontinence also may predispose to falls Diuretics Calcium channel antagonists Antimuscarinics (incl. Antihistamines, antispasmodics, anti-parkinsonian agents) Alpha adrenoreceptor agonists Non Steroidal Anti-Inflammatory Drugs Benzodiazepines and antipsychotics The elderly are more prone to postural instability Musculoskeletal factors decline in muscle strength reduced bone density arthritis Neurological factors cerebrovascular disease Parkinson s s disease Dementia Environmental factors environmental design Medication polypharmacy The elderly get less time to get to the lavatory There is a decreased sensation of bladder filling in association with age. Maximum & functional bladder capacity fall There is a greater urinary frequency Saito M, Kondo A, Kato T, Yamada Y. Frequency-volume charts: Comparison of frequency between elderly and adult patients. Br J Urol 1993; 72: : Sensation Bladder capacity at first desire to void as a proportion of maximum bladder capacity in association with age Age Age group 6

7 2 Can t t hold on Maximum bladder capacity by decade of life (median and 95% CI) The interval was (median and 95%CI) 5 (4 5) and 3 (3 5) minutes in older men. The intervals were statistically significantly different (W= , p<.1) Young R1 R2 Old Woo W.W, Wagg A. Int Urogyn J 22 Volume (ml) n= n=185 n=332 n=262 n=184 n=199 n=13 n= Age group Collas DM, Malone-Lee JG. Ageassociated changes in detrusor sensory function in women with lower urinary tract symptoms. Int Urogynecol J 1996; 7: Elderly people also get up more at night to void In 6 8 year olds Loss of renal concentrating ability Kirkland JL, Lye M, Banerjee AK. Patterns of urine flow and electrolyte excretion in healthy elderly people. Brit Med J 1983; 287: Loss of diurnal ADH / ANP secretion Asplund R, Aberg H. Diurnal variation in the levels of antidiuretic hormone in the elderly J Intern Med 1993; 229: 131 Increase in GFR when supine Bing M H, Moller L A, Jennum P, Mortensen S, Lose G THE PREVALENCE AND BOTHERSOMENESS OF NOCTURIA IN WOMEN AND MEN AGED 6-8 YEARS. 7

8 Physiological changes which predispose to increased nocturnal urinary frequency Increased 24h urine volume output Increased urinary frequency Reduction in the ability of the kidney to concentrate urine Delayed diuresis in response to a fluid load Alteration in the circadian rhythm of ADH secretion Increased level of Na secretion by night Risk for falls & fracture associated with incontinence Weekly or more frequent urge incontinence associated with an increased risk of falling or fracture: OR: 1.26 (95% CI ) FALLS OR: 1.34 (95% CI ) FRACTURE Brown JS, Vittinghoff E, Wyman JF, Stone KL, Nevitt MC, Ensrud KE, Grady D. J Am Geriatr Soc 2;48: Risk for falls & fracture associated with incontinence Stress incontinence not associated with increased risk? Patients with early a.m. urgency or precipitancy -physiology Relationship with nocturnal frequency? Risk for falls & fracture associated with incontinence Increasing dependence,falling and urinary incontinence share underlying risk factors impairment of arm and leg function sensory impairment affective impairment. All combine to reduce compensatory ability Tinetti ME, Inouye SK, Gill TM, Doucette JT. JAMA 1995; 273:

9 Risk for falls & fracture associated with incontinence in stroke patients Incontinence associated with 2.3 times ( ) relative risk of falls in rehab 2% of falls occurred during visits to toilet or bathroom. Non-syncopal falls in the home 85% of falls occur in the home Environmental modification may help No association found between hazards in the home and non-syncopal falls- even when balance, sensory impairment and cognition taken into account more complex relationship likely Krug EG et al. Am J Public Health 2;9: Tutuarima JA et al. Stroke 1997; 28: Environmental Hazards Ground surfaces Furniture Lighting esp at night Bathroom: difficult access, flooring Alcohol Difficult to remove clothing Other... Role for the OT Targeted Intervention PROFET ( ) Participants (n=184) Aged 65+, presented in A+E with a fall. Received TI treatment or Usual Care. At 12 month follow up TI group had: Reduction in No. of falls OR.39 (95% CI.23-.6),.6), (p=.2) 9

10 Targeted Intervention Yale FICSIT trial ( ). Participants (n=31) age 7+; greater than one risk factor for falls. received TI or usual care. At 12 month follow up TI group had: 3 % reduction fall. $2 reduction in mean health care cost. Multi Disciplinary Team Social worker Community Nurse Occupational Therapist Physiotherapist Limitations of evidence Only associations identified Is incontinence a cause of falls - attractive hypothesis of loss of compensatory ability in the elderly supported by physiological mechanisms supported by community data Is incontinence merely a marker of functional dependence? supported by Tinetti supported by stroke data Conclusions Bladder symptoms -common Falls - common There may be a causal relationship there is some supporting evidence also associated with marked functional impairment Efficacy of intervention in continence status upon fall frequency needs to be proven 1