Introduction
The decision to participate in the care of an elderly loved one can be a difficult one. It brings with it the responsibility of sensitive care for both a loved one's physical and emotional needs. Of all the issues that families must face together, few issues are as troubling for both caregivers and their family members as the problem of urinary incontinence.
Many older persons suffer with the inconvenience, embarrassment and adverse consequences of incontinence, unaware that many forms of incontinence are treatable. Understanding the various reasons for incontinence in elderly persons, and knowing what treatments are available, can allow a caregiver to help a loved one manage this problem.
What is Incontinence?
Urinary incontinence is the involuntary or uncontrollable loss of urine, and it is a common and difficult problem for aging adults. It is a problem that affects up to 30% of older persons living outside of hospitals or nursing homes, and is particularly common among elderly women. For those in nursing homes or other long term care facilities, the percentages are even greater. Incontinence can range from minor, occasional dribbling, to occasional unwanted loss of bladder control, to the complete inability to hold one's urine.
Despite its high prevalence, however, urinary incontinence is not a 'normal' part of aging. Incontinence represents a failure of the physical and mental processes that allow a person to hold their urine and to empty their bladder at an appropriate time.
The main components of the urinary system include the kidneys, which continuously produce urine; the bladder, a muscular sac which both holds the urine and contracts to expel urine when it is full; the urethra, a thin tube which drains the bladder to the outside; and the urinary sphincters, small muscles around the urethra that contract to block the passage of urine. Disruption on virtually any level of the urinary system can lead to incontinence.
Health
The brain and nervous system also play an important role in maintaining continence. The muscles of the bladder contract reflexively when the bladder is full. With 'potty training' in childhood, the brain learns how to override this automatic impulse, allowing a person to hold their urine until the appropriate time.
Acknowledging the Problem
Older men and women who suffer from urinary incontinence are at increased risk for certain complications, including urinary tract infections, falls and bed sores. Often the most incapacitating result of incontinence is the social isolation, embarrassment and loss of independence that many persons experience. Incontinent older persons, once active and independent, may live in fear of losing urinary control, and avoid spending extended time away from home. They are, in this way, prevented from participating in their usual activities. For caregivers of elderly persons, managing incontinence can be troubling. Those suffering with incontinence may be uncomfortable discussing the intimate details of their toileting habits, and may be reluctant to ask for help. Bed-bound elderly persons with incontinence need special, frequent attention to ensure that their skin stays clean and dry to prevent skin breakdown.
Under-Diagnosis
One of the major obstacles to improving the quality of life of persons with incontinence is its under-diagnosis. As an internist, I care for many elderly men and women who were initially reluctant to discuss incontinence with their doctors and their family. Either they were embarrassed, or they assumed their problem was a 'natural part of aging'. Some physical changes that occur with aging can lead to a predisposition to urinary incontinence, but inability to control the passage of urine should always be evaluated by a doctor.
Screening
Recently there has been increased awareness among physicians of the importance of screening for urinary incontinence. Screening involves a careful history and a full examination of the genital tract. Often physicians will ask a patient or that patient's caregiver to keep a voiding diary, or a record of daily urinations both voluntary and involuntary, in addition to the activities associated with incontinence. Identifying the correct cause of incontinence may lead to a treatment which will improve that patient's quality of life.
Causes and Treatments
Both physical and mental changes can lead to one's inability to hold urine. Many forms of incontinence are treatable. For those that are untreatable, there are absorbent pads, undergarments, or adult diapers. Understanding and recognizing the different types of incontinence is critical, and as a caregiver you can help your loved one's doctor make the correct diagnosis.
Stress Incontinence
Stress Incontinence is a very common form of incontinence in older women. It is defined as the involuntary loss of small amounts of urine when a person coughs, laughs, exercises or is startled. Stress Incontinence results from a natural muscle weakening in the floor of the pelvis which accompanies aging. Women who have had multiple vaginal deliveries are at increased risk. The diagnosis of stress incontinence is often made easily by reviewing the events that precipitate loss of urine. A doctor will often ask a patient to cough while standing, to observe if urine leaks out.
Treatment
The doctor's findings and the severity of symptoms, will determine treatment. If the patient's pelvic muscles have weakened significantly, and the bladder is bulging intothe vagina, surgery may be necessary. In less severe cases, stress incontinence can be treated with Kegel exercises, or exercises that strengthen the muscles of the pelvic floor. These exercises strengthen the pelvic muscles using repetitive contractions, not unlike weight training exercises in other muscle groups. The exercises involve contracting the pubococcygeal muscle, or the muscle used to hold back the flow of urine. This muscle can be identified by trying to stop the flow of urine halfway through urination, while seated on the toilet. Once a person appreciates what it feels like to contract this muscle, he or she can exercise by tightening to a count of three, relaxing, then tightening again. A typical regimen involves repeating this exercise 10 times, 5 times a day. In some cases a nurse specialist may be used to help a person learn to perform these exercises.
Urge Incontinence
35% of older persons with incontinence have what is called Urge Incontinence. 'Urgency' is the sudden feeling of having to urinate. This condition is also known as detrusor instability, named for the detrusor muscle in the bladder. For this population, the bladder tends to contract spontaneously when filled with only small amounts of urine, and some refer to it as 'overactive bladder'. Persons with urge incontinence will complain of frequent urination, frequent urination at night, bed-wetting, and sudden loss of urine.
Diagnosis
A doctor may be able to make a diagnosis of urge incontinence by taking a careful history. In some instances, a referral to a Urologist for special testing may be necessary. There are good behavioral and pharmacological treatments for this condition.
Behavioral Therapy Treatment
Because older persons may be particularly sensitive to side effects of the medicines used to treat urge incontinence, behavioral therapy should be tried first. Since the bladder is contracting at smaller volumes than it should, some people are able to avoid leakage by urinating frequently, preventing the bladder from filling to the point where it overacts. Toileting every hour is sometimes necessary, but many are able to 're-train' their bladder to tolerate larger amounts, by gradually increasing the intervals between urinations.
Pharmacological Treatment
If behavioral therapy is unsuccessful, or if an older person is unable to participate or cooperate with training, then medications may be tried. The goal of these medications is to relax the bladder muscle. Detrol and Ditropan are two commonly prescribed medications for urge incontinence. The side effects of these medicines include dry mouth, constipation and lightheadedness, although the newest, Detrol, may be better tolerated in elderly persons.
Overflow Incontinence
Overflow incontinence is a common cause of incontinence in men. It is the result of an overfilling of the bladder, usually due an obstruction of the urethra that prevents it from fully emptying during urination. Urine tends to spill, or overflow out of the full bladder, resulting in involuntary leakage. Persons with overflow incontinence will often describe a sensation that their bladder still contains urine after they've urinated.
The most common cause of urethral obstruction leading to overflow is an enlarged prostate, a condition extremely common in aging men. Women can develop overflow, however, particularly after bladder surgery, which can result in a narrowing of the urethra. Less commonly, overflow incontinence can result from a diminished nerve supply to the bladder, preventing it from contracting appropriately. This can occur in people with longstanding diabetes, multiple sclerosis, stroke, or spinal cord injury. It also occurs as a side effect of some medications.
Diagnosis
To diagnose overflow incontinence, doctors look for a large amount of urine left in the bladder after a person urinates, or the 'post-void residual'. To measure the post-void residual, a doctor or nurse inserts a catheter into the bladder after an attempt has been made to urinate. More than 150 mL of urine left in the bladder is considered abnormal and indicates possible overflow incontinence. Persons with a high post-void residual should be evaluated by a Urologist.
Treatment
Treatment of overflow depends on its cause. If it is a result of an enlarged prostate, surgery may be necessary to clear the obstruction. In those who have damage to the nerve supply of the bladder, intermittent catheterization may be necessary. This involves inserting a catheter to empty the bladder, usually several times a day. In most instances, people with overflow incontinence, or their caregivers, can be trained to do this easily and safely.
Functional Incontinence
Not all incontinence is the result of physical change. Incontinence resulting from causes not involving the urinary tract is called functional incontinence.
Mobility
Problems with mobility can be the cause of incontinence. A common scenario might involve a person with severe arthritis, who walks very slowly and spends most of his time in the living room, far away from the bathroom. Dementia, or what is commonly referred to as senility, can also be a contributor to incontinence. A person with advanced Alzheimer's, for example, who has difficulty communicating effectively, may leak urine or urinate inappropriately simply because he or she cannot communicate a need to be helped to the bathroom.
Medications
Medications can also play a role. Many medicines, including diuretics (used to increases urine output) and drugs with anticholinergic effects (as in many antihistamines), have side effects in the urinary tract and may cause or worsen incontinence. Other treatable medical conditions can cause or exacerbate incontinence as well, including urinary tract infections, severe constipation or atrophic vaginitis. Resolved treatment of the medical problem, in many instances, can restore normal continence.
Treatment
Treatment of functional incontinence is often simple. An appropriately place commode can allow someone with limited mobility to toilet without traveling far. For patients with Alzheimer's or other cognitive problems, prompted voiding is often a successful strategy. This involves helping your loved one to the bathroom at regular intervals and having them attempt to pass urine. If the intervals are frequent enough, their bladder will seldom fill to the point of contraction, thus minimizing accidents. Doctors are often able to substitute medications that have fewer side effects.
Summary
Urinary incontinence in the elderly is common and distressing, but often treatable. Although the elderly are at increased risk for incontinence, it is not a normal part of aging. An evaluation by a physician is an important first step. Once a cause is identified, behavior modification and optimization of underlying medical conditions may improve or eliminate incontinence. In other instances, medication or surgery may be indicated. As a last resort, unobtrusive and comfortable absorbent undergarments are available for both men and women. Although few older persons cherish the idea of adult 'diapers', they are often far easier to tolerate than expected and can mean the difference between freedom and isolation.
As a caregiver, it may be necessary for you to take the lead in addressing this problem. Help your loved one realize that this condition need not be a cause for shame, but rather should be viewed as a treatable medical problem. Help them keep an accurate voiding diary, as this can help a doctor identify the cause. Accompany them to the doctor, if necessary, to review the problem, and work together on the solution. Helping your loved one deal with their incontinence can improve the quality of life for both of you.
