Presented by Grace Smith CNC Latrobe Regional Hospital Continence Clinic
Better understand the true effects of aging on the lower urinary tract / bladder Consider other factors that may contribute to urinary incontinence (not just in the elderly) and hopefully consider proactive strategies. Debunk the Myth!!
RESNICK, 2014
Urine storage reflexes Voiding reflexes. Fowler C.J, Griffiths D, & de Groat W.C (2008)
Bladder continuously filled with urine at rate 1-2ml per minute 1st sensation to empty bladder is felt when approximately half full Voiding can be delayed until bladder is full, and place and time convenient Normal bladder emptying average volume 300-500 ml every 3-4 hours
Container (Bladder) Urgency or urge incontinence = too much squeeze (bladder spasms / possible leakage) - OAB Impaired contractility = not enough squeeze (incomplete or poor emptying) Detrusor hyperactivity with Impaired Contractility (DHIC) Closure (Pelvic floor / Sphincter / Urethra) Stress incontinence = not enough closure BPH/ Prolapse/ blockage = too much closure A combination of Container and closure issues (mixed UI)
This is only looking at OAB and SUI / UUI / MUI does not include other e.g. DSD or DHIC
1 in 3 women who have had a baby Increased risk babies > 4 kg more than 3 pregnancies instrumentation during delivery and prolonged labour 1 in 6 women who have not had babies 1 in 10 men Female athletes are three times more likely than other women to experience urinary incontinence (incidence of urinary leakage varies between sports, with 80 per cent of trampolinists, 67 per cent of gymnasts, 50 per cent of tennis players, 40 per cent of aerobics participants)
Age Males Females 15-19 2% 11% 20-24 5% 18% 25-29 5% 18% 30-34 4% 40% 35-39 4% 40% 40-44 6% 44% 45-49 6% 44% 50-54 17% 55% 55-59 17% 55% 60-64 13% 48% 65-69 13% 48% 70-74 26% 40% 75-79 26% 40% 80+ 30% 41% 47% of Australians with urinary incontinence living in the community are aged under 50. (Deloitte Access Economics 2011) Hawthorne (2006)
Cost > $ 2 billion a year in continence aids Continence issues can often be prevented with appropriate screening, assessment, prevention and management strategies, resulting in better quality of care and life. The monetary value of the disease burden from incontinence is $16.7 billion in 2010 for community dwelling individuals and $7.1 billion for residents in aged care facilities.
Aging is a known to be associated with decline in nearly every physiological system including the lower urinary tract not necessarily urinary incontinence There are very few studies focused on the pathophysiological mechanisms underling symptoms of the aging bladder and on bladder function (Siroky, 2004)
frequency of Bladder contractions Detrusor overactivity F.U.N sensation of bladder filling delayed urge Awareness is not registered re fullness until later in filling cycle shorter warning period in bladder muscle effectiveness Decrease in bladder elasticity (compliance and capacity) as collagen fibres in the aging bladder cross-link and stiffen to incomplete emptying residuals F.U.N
A reduced bladder capacity????? Increase in uninhibited contractions, Decreased urinary flow rate, Diminished urethral pressure profile (particularly in women), Increased post void residual urine volume???. The aging bladder specifically may be described as manifesting detrusor overactivity, impaired contractility, or a combination of both (Siroky, 2004) Urine production at night has been shown to increase with age although overall urine production and daytime micturition remain relatively unchanged
1. Decreased kidney size and weight with loss of functional glomeruli lead to decreased renal function - kidneys no longer concentrate urine as effectively as they once could. 2. There is the added change to vascular and cardiac function / BP Therefore more water is lost through voiding.
Arginine vasopressin (AVP) - insufficient circulating levels during the night time Atrial natriuretic peptide (ANP) and brain natriuretic peptide with age water- and sodium-conserving mechanisms urine production Impaired cardiac function with congestive heart failure, venous stasis, oedema - Fluid retention in the feet and legs is independently correlated with nocturia
the complaint that an individual has to wake one or more times to void each void preceded and followed by sleep" (International Continence Society (ICS)) Nocturia increases in prevalence from 10% at the age of 50 to 50% to as high as 77.1 and 93% in elderly men and women respectively (Osman & Chapple 2013)
Obstructive sleep apnoea (OSA) increases in prevalence with aging - probable underlying mechanism is from increased ANP levels induced by the negative intrathoracic pressures generated in OSA leading to Nocturnal polyuria
Not all are age related but certainly more prevalent in the susceptible aging body
F.U.N F.U.N F.U.N.S / dexterity https://farm9.staticflickr.com/8065/8263119014_4c2428b903.jpg
Continence requires that the urethral pressure exceeds the intravesical pressure at all times except during micturition Increased urethral closure pressure - Increased urethral cell maturation atrophy occurs when oestrogen is lowered below level for endometrial proliferation - Increased blood flow the vessels serve as a hydraulic sphincter to augment other continence mechanisms. - In the postmenopausal state, this vascular plexus becomes flat and ineffective. -Increased α-adrenergic receptor sensitivity in urethral smooth muscle (increasing urethral resistance) Improved abdominal pressure transmission to proximal urethra Stimulate peri-urethral collagen production (affecting elasticity and thickness) Improved neuronal control of micturition Increased sensory threshold of the bladder Reduced incidence of urinary tract infection (Henn, 2013)
http://www.bcmj.org/sites/default/files/bcmj_55vol2_incontinence_table2.jpg
D I A P P E R s / dexterity F.U.N S https://farm9.staticflickr.com/8065/8263119014_4c2428b903.jpg
Obesity 20-70% increase in UI with every 5 unit increase in body mass index : (Subak et al. (2009) Bowels Caffeine / Alcohol Dehydration in elderly Respiratory disease Smoking Poorly controlled Diabetes
Enlarged prostate progressively produces bladder outlet obstruction mild cases - detrusor is able to compensate for increased outlet resistance by increasing bladder contraction strength. significant outlet obstruction can cause: decreased flow, hesitancy, difficulty initiating urine stream, prolonged voiding, post micturition dribble and obstructed urinary output Persistent in BC DU Ongoing Bladder Hypotonia. Prostate Surgery (SUI)
Good bladder and bowel habits Educate, educate educate Improve Defecation dynamics Review birthing practices Commence PF health at an early age Reduce palliative approach - be proactive Improve knowledge and reinforce accountability for exercise therapist
Treat underlying causes or contributing factors (such as urinary tract infections, constipation, medications, delirium and lack of toilet access) Promote adequate oral hydration and fibre intake. Where appropriate - Document bowel actions using a bowel chart such as the Bristol Stool Chart Monitor the use of medications that may cause constipation, (such as opiates) or urinary incontinence. Orientate the person to their new physical environment, with special attention to locating the call bell and where the bathroom is Provide clear signage for toilets. Ensure the that they can access the toilet (if unable to independently access the toilet, ensure access to their call bell). Provide adequate lighting and luminous signage to toilets at night. Provide optimal privacy for urinary and faecal elimination. Discourage the use of known bladder irritants (such as coffee, alcohol, soft drinks). Minimise the use of indwelling catheters. Minimise the use of restraints (including bed rails) Ensure gait aids are within reach at all times when the person is cognitively intact and independent with mobility. Limit the use of continence pads 'just in case', especially large ones that may reduce a patient's ability to self toilet. http://www.health.vic.gov.au/older/toolkit/08continence/index.htm
Bladder habits and dysfunctions at one stage of life may affect bladder health in subsequent stages. Many of the factors that negatively impact bladder health at all ages may be modifiable, Healthy bladder habits may prevent or reverse bladder dysfunctions that can occur naturally or in response to life events Ellsworth et al,2013,
Age does not cause urinary incontinence However Age-related changes although they may put people at higher risk of urinary incontinence. Ignorance along with failure to be proactive Are the major contributors to UI
RESNICK 2014
Questions?
Buckley BS & Lapitan MCM 2010. Prevalence of urinary incontinence in men, women, and children - current evidence: findings of the Fourth International Consultation on Incontinence. The Journal of Urology 76: 265-270 Ellsworth, P; Marschall-Kehrel, D; King, S; Lukacz, E (2013) Bladder health across the life course. International Journal of Clinical Practice, May; 67 (5): 397-406. Fonda D (1999) Nocturia: A Disease or Normal Aging? BJU International 84(Suppl.1):13 15 Fowler C.J, Griffiths D, & de Groat W.C (2008) The neural control of micturition Nat Rev Neurosci. June ; 9(6): 453 466 Henn EW (2010 / 2013) Menopause and its effect on the female lower urinary tract S Afr Pharm J Vol 80 No 5 Mathias H, Pfisterer D, Griffiths D, Werner S, & Resnick N (2006) The Effect of Age on Lower Urinary Tract Function: A study in women JAGS 54:405-412
Nadir I Osman, Christopher R Chapple (2013) Focus on Nocturia in the Elderly Aging Health. 9(4):389-402. Pinkerton, J (2010) Vaginal impact of menopauserelated oestrogen deficiency OBG Management Vol. 22, No. 11 Resnick N,M MD (2014) Geriatric urinary Incontinence Strickland, R. (2014) Reasons for Not Seeking Care For Urinary Incontinence in Older Community Dwelling Women: A Contemporary Review. Urologic Nursing. 34: 63 68. Best Care for Older People Everywhere - Toolkit (2014) http://www.health.vic.gov.au/older/toolkit/08continence/ind ex.htm