Incontinence: nature’s call to arms

William Gibson is a Clinical Research Fellow at the University of Alberta. His clinical review New Horizons in Urinary Incontinence in Older People was recently published in Age and Ageing journal. He tweets at @drbillgibson 

Urinary incontinence, the condition in which people wet themselves by accident, is a common problem for older people. Around half of older people have “bladder trouble” such as needing to rush or get up lots of times overnight to pee, and up to one in six  will have accidents.

Despite this, many people view these bladder problems as a normal part of ageing (they aren’t), or as something that can’t be treated (they can). Our article reviews some of the recent advances in the understanding of the causes and treatment of bladder problems in older people. A significant cause of bladder problems  is something doctors call over-active bladder, a condition that leads to urgency – the overwhelming, panic-inducing need to pee which is difficult to ignore. Although there are several medication options to treat OAB, they are associated with side effects which limit people’s ability to take them. Newer treatments are becoming available, and it is hoped that these will be better tolerated.

Stress incontinence is the complaint of leaking urine at times such as laughing or coughing. Although it can be treated with exercises or physiotherapy, it can require an operation to fix. Previously, this has meant a major operation. However, since the mid-1990s a much less invasive procedure, a tension-free tape, has been used. Although this is safe and effective in older women, there hasn’t been as much of an uptake as may have been expected.

It is becoming increasingly apparent that incontinence in older people is caused by a problem in the brain as well as the bladder. Brain imaging studies have shown that changes within the brain are closely associated with urinary symptoms. We don’t yet know whether trying to prevent changes occurring over time, for example, by treating blood pressure or cholesterol can also improve bladder function in later life. In addition to changes in the brain, people who are physically frail may also struggle to remain dry, for reasons as simple as not being able to find and get to a toilet. People who live in nursing homes have specific needs relating to continence, and the current best practice for those with a dementia diagnosis is “prompted voiding”, where staff ask on a regular basis if they need to go to the toilet, and assist them if needed. However, it is difficult to maintain these treatments given the time pressures on staff  in care homes.

The main problem with incontinence in older people is a lack of awareness that bladder problems are not a normal part of getting older, that there are treatments available, and that it is realistic to expect a dry old age.

The full paper can be read on the Age and Ageing website here.