Lower urinary tract symptoms (LUTS) are an important cause of morbidity and mortality. Overactive bladder (OAB) is the commonest cause of LUTS and urinary incontinence (UI). Although its prevalence increases with age, it is a myth that it is a normal part of ageing.
There is no “one size fits all” in LUTS and it involves multiple organ pathology usually in frail older people. We must also remember that bladder dysfunction is just one part of a larger whole person.
There is significant health burden on the individual and carer as well as a financial burden to the state with both direct and indirect costs. Containment of LUTS is expensive and there are also institutional and carer costs as well as costs attributed to the increased risk of falls in UI patients.
In addition, there are personal costs to consider. Patients might not go out so their social interactions lessen. This can lead to a loss of independence and depression can result. This can lead to reduced quality of life. If the patient is a care home resident they might worry about impact of UI on their carers.
Yet UI is a treatable condition. If the same indifference was shown towards serum cholesterol levels, there would be a national outcry. UI treatment needs, therefore, to be back in the Comprehensive Geriatric Assessment (CGA).
If you reduce panic, then you can reduce the urgency associated with UI. Panic sets in when you have difficulty toileting physically and toilets are inaccessible, there is confusing signage, or perhaps a long toilet queue. Even a strange environment or fear of falling can have an impact,
This strange environment factor also applies to hospitals where patients might think they are “being a bother” or there is reduced carer availability. Routine catheterisation is not the answer and can be expensive. Uncomplicated catheter-associated urinary tract infection (CAUTI) can cost £600 per patient and complicated CAUTI is approximately £3000 upwards.
Nocturia is also an issue in the older population. It is one of the most bothersome symptoms as it leads to disturbed sleep that equals reduced daytime functioning
and impaired cognition. It increases the falls risk of both the patient and the carer. It can also increase carer negativity and burden. In addition, we know that treating nocturnal symptoms improves patient reported outcome measures.
So how can we manage this? There is reduced renal concentrating ability and antidiuretic hormone production with age. This leads to reversed diurnal urine volume and low urine sodium resulting in less daytime frequency and large volume void by night. Treatment involves a daytime diuretic.
With OAB, there is urgency at small volumes during the day and night time. Management includes reduced caffeine intake, bladder drill and/or an antimuscarinic.
The incidence of UI increases with age for both sexes and a move from the home to hospital can cause OAB and UI. Medication does work with no added risk of falls and NICE backs this up. Treatment of the frail elderly needs to be interpreted, however, in context of cognition, physical frailty and environment.
To conclude, effective management really does make a difference to patients so please treat their nocturia/OAB/incontinence. The young old are the same as the young. Geriatricians should not find this difficult even if standard assessments may need adaptations to the individual. One man’s dignity is another man’s solution.