BERKELEY, CA (UroToday.com) - Choosing the right approach in treating complex elderly patients is not always an easy task. This is even more challenging when the condition, which leads to bothersome and disabling symptoms, does not have any curative treatment options.
The case of urinary incontinence (i.e., urge or mixed incontinence) in elderly patients admitted for long-term care (e.g., nursing homes) is a good example to describe the complexity of this decision process. Choosing between behavioral interventions, medication (i.e., bladder antimuscarinics (BAM)), surgery, diapers, or combinations of these can be very challenging. Randomized controlled trials (RCTs) showed that combining behavioral interventions (i.e., prompted voiding, scheduled toileting) with BAM leads to better bladder control than either behavioral interventions or medication alone.[1, 2, 3] However, preferences related to treatment choices differ between patients, their families, and caregivers in the long-term care facility.[4, 5] Patients might prefer medication because they consider prompted voiding embarrassing and “fostering dependence.”[4] In the regular care setting of a long-term care facility, the health care provider is faced with making a clinical decision about treatment for a particular patient while incorporating patient and family preferences and concerns into the existing scientific evidence.
Consider the following scenario: a health care provider in a nursing home facility is faced with the decision of treating a patient, Mr. Smith, an 85-year-old man with bothersome urge incontinence and cognitive impairment. Mr. Smith also has a history of hypertension, congestive heart failure, and stroke. Mr. Smith is already taking medications to treat these medical conditions and he insists on getting a BAM for his urinary symptoms. Based on the evidence from RCTs, the provider understands the value of starting his patient on a BAM to help control his urinary symptoms. However, she also knows that patients enrolled in RCTs evaluating BAM are not necessarily similar to Mr. Smith. RCTs predominantly enroll younger individuals, mostly women who are in good health; the trials aimed at elderly populations excluded patients similar to Mr. Smith, with comorbidities or poor functional status (cognitive performance, mobility). Where should she look for the evidence to guide her treatment decision for Mr. Smith? Methodologically sound research, using data from patients treated in regular long-term care settings, could provide the best evidence by evaluating the experience that patients like Mr. Smith had when treated with BAM.
We conducted a study among elderly residents of Veterans Affairs Community Living Centers with the purpose of evaluating risks and benefits associated with initiation of a BAM in the regular long-term care setting.[6] The mandatory periodic assessments conducted in these nursing homes, combined with pharmacy and hospital data, allowed us to determine the impact of starting a patient like Mr. Smith on a BAM. Patients treated for urinary incontinence in our study looked very different from those typically enrolled in RCTs. They were older (mean age 80 years, with a little over 20% of the users being 85 and older), male (almost 96%), with multiple comorbidities and on multiple medications. Almost half of them had mild to severe cognitive impairment or limitations in mobility and several experienced falls in the recent past. What did we find? Should we treat these patients for bothersome urinary incontinence symptoms with a BAM? Our study cannot fully answer this complex question. Our results, however, suggest that oxybutynin immediate-release, a nonselective BAM with central nervous system penetration, should be avoided in patients like Mr. Smith because of the risk of hip fracture. The number needed to treat for one patient to get improvement in symptoms was about the same as the number needed to harm by causing a hip fracture. This risk-benefit balance is clearly unacceptable given all the negative consequences of hip fracture, including an increased mortality risk.[7] What is left unanswered? Our study could not evaluate whether other BAMs (i.e., those with bladder receptor selectivity, low central nervous system penetration and/or extended-release formulation) are safer for these patients. Similar studies following the experience of patients treated with these potentially safer drugs in regular care settings are needed to provide the evidence for answering this important clinical question: “how can we do more good than harm in treating frail elderly patients with urge or mixed urinary incontinence?”
References:
- Drutz HP, Appell RA, Gleason D, et al. Clinical efficacy and safety of tolterodine compared to oxybutynin and placebo in patients with overactive bladder. International Urogynecology Journal and Pelvic Floor Dysfunction 10:283-289, 1999
- Ouslander JG, Maloney C, Grasela TH, et al. Implementation of a nursing home urinary incontinence management program with and without tolterodine. Journal of the American Medical Directors Association 2:207-14, 2001
- Zinner N, Mattiasson A, Stanton S. Efficacy, safety, and tolerability of extended-release once-daily tolterodine treatment for overactive bladder in older versus younger patients. Journal of the American Geriatrics Society 50:799-807, 2002
- Johnson TM, Ouslander JG, Uman GC, et al. Urinary incontinence treatment preferences in long-term care. Journal of the American Geriatrics Society 49:710, 2001
- Dubeau C: Improving urinary incontinence in nursing home residents: are we FIT to be tied? Journal of the American Geriatrics Society 53:1254-1256, 2005
- Moga DC, Carnahan RM, Lund BC, et al. Risks and benefits of bladder antimuscarinics among elderly residents of Veterans Affairs Community Living Centers. J Am Med Dir Assoc 14:749-60, 2013
- Braithwaite RS, Col N, Wong J. Estimating hip fracture morbidity, mortality and costs. Journal of the American Geriatrics Society 51:364-370, 2003
Written by:
Daniela C. Moga, MD, PhDa, b, c and Ryan M. Carnahan, PharmD, MS, BCPPc as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
aUniversity of Kentucky, Department of Pharmacy Practice and Science, Institute for Pharmaceutical Outcomes and Policy
bUniversity of Kentucky, Department of Epidemiology
cUniversity of Iowa, Department of Epidemiology
