Clinical Practice Guidelines for Adults:

Introduction
Recommended Steps in Assesment and Management
Guidelines
References
Appendix

1. Physiological Changes Associated With Aging That May Influence Continence

Lower Urinary Tract:

Although the precise impact of normal aging on bladder function remains to be defined, a number of physiologic changes have been described. Bladder capacity, urethral compliance, maximal urethral closing pressure and flow rates, all appear to decline in healthy continent women (Resnick, 1995, 1996). Post-void residuals and involuntary detrusor contractions increase in both genders, while urethral resistance increases in older men (Resnick, 1996).

None of these factors alone or even in combination result in incontinence. Nevertheless, any of these may contribute towards the loss of continence in an otherwise vulnerable individual.

Other Systems:

The vast majority of older individuals remain fully mobile even at an advanced age. Nevertheless, speed, range and functional flexibility of locomotion are all reduced even in ostensibly healthy older individuals. Such changes may, for example, impact upon the individual's ability to reach the bathroom following onset of urgency. Moreover, even relatively minor changes in visual perception and fine motor coordination may influence the removal of clothes and positioning in the bathroom.

Diurnal pattern of fluid excretion also changes, with older individuals excreting a much larger proportion of their ingested fluid at night (Kirkland et al, 1983). Sleep patterns are altered in aging, with increased episodes of nocturnal awakening (Martin et al, 1999). Together these changes result in increased nocturia. The risk of incontinence and falls at night is particularly great due to changes in lighting. As well, neuropsychologic and perceptual changes associated with transition from sleep to an awake state may also be problematic.

Finally, response to medication changes in old age. This also occurs in healthy older individuals showing altered responsiveness to some medications and a greater risk of adverse reactions (Tumer et al, 1992). Anticholinergic medications represent a particular risk with a much greater risk of xerostomia, constipation, urinary retention and impaired cognition. The percentage of body composition which is fat tends to increase, while lean body mass decreases. Thus, the volume of distribution of lipid soluble drugs tends to increase, while that of water soluble compounds tends to decrease. Decreased renal clearance of the latter category medications requires dose adjustments in many, if not all, older individuals.

For all these reasons, the initial dose of any medication prescribed for an older individual requires careful consideration and should nearly always be lower than that used in younger adults.

References

• Resnick NM. Urinary incontinence. Lancet 1995; 346: 94-9.
• Resnick NM. Geriatric incontinence. Urol Clin North Am 1996; 23: 55-74.
• Kirkland JL, Lye M, Levy DW, Banerjee AK Patterns of urine flow and electrolyte excretion in healthy elderly people. Br Med J (Clin Res Ed) 1983; 287: 1665-7. Martin J, Shochat T, Gehrman PR, Ancoli-Israel S. Sleep in the elderly. Respir Care Clin N Am. 1999; 5: 461-72.
• Tumer N, Scarpace PJ, Lowenthal DT. Geriatric pharmacology: basic and clinical considerations. Ann Rev Pharmacol Toxicol. 1992; 32: 271-302.

2. Incomplete Bladder Emptying/Urinary Retention

Urinary retention (UR) in the elderly has been associated with poor outcomes including urinary tract infections, bladder overdistension, and higher hospital fatalities (Simforoosh et al, 1997; Smith and Albazzaz, 1996). Overdistension following surgery under general anesthesia is probably the most common cause of acute urinary retention (Jacobsen et al, 1997; Waterhouse et al, 1987). UR can be silent and lower abdominal symptoms of acute UR may be masked in the elderly by analgesics or may not be perceived due to cognitive impairment. Clinical examination of the abdomen is a notoriously unreliable method of detecting UR. The definition of UR based on the volume of a post void residual urine (PVR) is somewhat arbitrary. It depends on the population being studied or the clinically relevant condition. Smith and Albazzaz (1996) defined PVR greater than 300 ml in a study of outcomes in elderly women undergoing surgery for proximal hip fracture. Mainprize and Drutz (1989) in studying women with chronic persistent urinary tract symptoms used >30 ml as being abnormal in this population. Grosshans et al (1993) used 50 ml PVR to report a prevalence of 34% UR in elderly patients on an acute care ward. A literature review revealed 16 papers with a range of "normal" post void residual urine from 0 to less than 250 ml. Diokno (1990) maintains one cannot establish a "normal" or "pathologic" value, while most authors accept a figure of between 100-150 ml as being within the normal range. Clinically significant volumes may vary between a lower limit of 50 ml and an upper limit of 300 ml (Grosshans et al 1993; Marks et al, 1997; Smith and Albazzaz 1996). The post void residual urine may vary in the elderly and may reflect lower urinary tract obstruction, poor contractility or detrusor hyperactivity with impaired contractility (DHIC) (Resnick et al, 1987, 1989) or a combination of these entities.

In the elderly, as part of investigation of incontinence, Ouslander has listed criteria for referral of elderly incontinent patients for urologic/gynecological urodynamic evaluation. A post?void residual urine of greater than 100 ml is one suggested indication for referral (Ouslander et al. 1989).

Before the ready availability of the portable bladder ultrasound, the AHCPR Practice Guidelines for Urinary Incontinence suggested in/out catheterization to rule out urinary retention in any person with urinary incontinence (AHCPR, 1992).

In/out catheterization remains the gold standard for precise measurement of PVR volumes. Catheterization, especially after hip fracture, post stroke, or in the presence of cognitive impairment, can be very challenging for nursing staff and uncomfortable for elderly people with these conditions. Portable bladder ultrasound offers a non invasive painless method of estimating the post void residual urine and eliminates the risk of introducing urinary infection or causing urethral trauma by catheterization. Previous research, in various settings, has supported portable hand?held ultrasound scanners as non?invasive, cost effective, reliable and accurate tools for measuring PVR urine (Chan, 1993; Grosshans et al, 1993; Lewis, 1995; Mainprize and Drutz, 1989; Marks et al, 1997; Ouslander et al, 1994; Resnick 1995, Revord et al, 1993; Simforoosh et al, 1997; Smith and Albazzaz, 1996; Wagner and Schmid, 1997).

Portable ultrasound has been evaluated in a nursing home population (Ouslander et al, 1994) and in a younger population (mean age 58) undergoing urodynamics (Coombes and Millard, 1994). It has been found to have an acceptable level of accuracy. Portable ultrasound is an acceptable alternative to in/out catheterization.

References

• Chan H. Noninvasive bladder volume measurement. J Neuroscience Nursing 1993; 25: 309-312.
• Coombes GM, Millard RJ. The accuracy of portable ultrasound scanning in the measurement of residual urine volume. J Urol 1994; 152: 2083-2085.
• Diokno AC. Diagnostic categories of incontinence and the role of urodynamic testing. Journal of the American Geriatrics Society 1990; 38: 300-305.
• Grosshans CI, Passadori Y, Peter B. Urinary retention in the elderly: A study of 100 hospitalized patients. J Amer Geriatr Soc 1993; 41: 633-638.
• Jacobsen SJ, Jacobson DJ, Girman CJ, Roberts RO, Rhodes T, Guess HA, Lieber
• MM. Natural history of prostatism: Risk factors for acute urinary retention. J Urol 1997; 158: 481-487.
• Lewis NA. Implementing a bladder ultrasound program. Rehab Nursing 1995; 20: 215-217.
• Mainprize TC, Drutz HP. Accuracy of total bladder volume and residual urine measurements: Comparison between real-time ultrasonography and catheterization. Amer J Obstetr Gynecol 1989; 160: 1013-1016.
• Marks LS, Dorey FJ, Macairan ML, Park C, DeKernion JB. Three-dimensional ultrasound device for rapid determination of bladder volume. Urology 1997; 50: 341-348.
• Ouslander JG, Simmons S, Tuico E, Nigam JG, Fingold S, Bates-Jensen B, Schnelle JF. (1994). Use of a portable ultrasound device to measure post-void residual volume among incontinent nursing home residents. J Amer Geriatr Soc 1994; 42: 1189-1192.
• Resnick B. A bladder scan trial in geriatric rehabilitation. Rehab Nursing 1995; 20: 194-196.
• Resnick NM, Yalla SV: Detrusor hyperactivity with impaired contractile function. An unrecognized but common cause of incontinence in elderly patients. JAMA 1987; 257: 3076-3081.
• Resnick NM, Yalla SV, Laurino E: The pathophysiology and clinical correlates of established urinary incontinence in frail elderly. N Engl J Med 1989; 320: 1-7.
  Revord JP, Opitz JL, Murtagh P, Harrison J. Determining residual urine volumes using a portable ultrasonographic device. Arch Phys Med Rehab 1993; 74: 457.
• Simforoosh N, Dadkhah F, Hosseini SY, Asgari MA, Nasseri A, Safarinejad MR. Accuracy of residual urine measurement in men: Comparison between real-time ultrasonography and catheterization. J Urol 1997; 158: 59-61.
• Smith NKG, Albazzaz MK. A prospective study of urinary retention and risk of death after proximal femoral fracture. Age Ageing 1996; 25: 150-154.
  U.S. Department of Health and Human Service. Urinary incontinence in adults: Clinical practice guideline. AHCPR Publication No. 92-0038. Rockville, MD: Agency for Health Care Policy and Research (AHCPR), Public Health Service. 1992.
• Wagner ML, Schmid MM. Exploring the research base and outcome measures for portable bladder ultrasound technology. Med Surg Nursing J Adult Health, 1997; 6: 304-313.
• Waterhouse N, Beaumont AR, Murray K, Staniforth P, Stone MH. Urinary retention after total hip replacement. J Bone Joint Surg 1987: 69-B: 64-66.