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Optimizing Management of an Overactive Bladder in Long Term Care.

Urinary incontinence (UI) is any involuntary leakage of urine.   It can cause embarrassment, social isolation and transition from community living to long term care.  Overactive bladder (OAB) syndrome is a bladder condition that may cause urinary incontinence (wet OAB) and it is the most common bladder abnormality in residential care.  Symptoms of OAB include:

  • Urgency: a compelling desire to urinate that is difficult to defer, with or without urge incontinence
  • Increased frequency of urination (more than 8 times a day)
  • Nighttime urination (waking up 2 or more times per night to urinate)

The exact cause of OAB is not entirely understood, but we do know that passing urine requires a complex and coordinated message from the bladder to the brain.  Nerve pathways orchestrate these messages and OAB can occur when nerve signals tell the bladder to empty (contract) before it is full. A urinary tract infection, illness, nerve damage or a medication side effect can all also cause symptoms of OAB.

Proper treatment of OAB for the long term care resident requires a diagnosis, review of medications and may involve use of behavioural therapies along with appropriate medications:

Proper Diagnosis

  • Because patients are often embarrassed by incontinence and reluctant to discuss symptoms with their doctor, OAB can often go undiagnosed and therefore untreated.  In nursing homes, diagnosis is necessary for treatment.  Not only are many patients in long term care not diagnosed, but many who have symptoms are not treated, even when they are good candidates for therapy.

Bladder Re-training

  • This is one type of behavioral therapy for OAB.  Others include pelvic floor muscle training, bladder control strategies and fluid management
  • In bladder re-training, the bladder is emptied at specified times so that the resident can resist the urge to urinate at unspecified times.  The use of a record or “bladder diary” can help guide how bladder training can best help re-train bathroom independence.  Not only can this improve bladder function, but it can also help prevent falls from rushing to make it to the bathroom on time.

Medication Review

  • Residents in long term care are often on many medications for multiple chronic medical conditions.  A careful review of the medication profile may reveal certain drugs that can worsen bladder function.  It is important to have the doctor or pharmacist check on this.   

Drug Therapy

  • There are two main classes of medications used to treat OAB and they work in different ways to help relax the bladder muscle during the urine storage phase:
    • Antimuscarinics, which have been used for many years
    • beta-3 adrenergic agonists, which are a newer class of medication  
  • Medications that are used to treat OAB may cause a number of side effects including dry mouth, constipation, hypertension and headache.  Importantly, antimuscarinic medications are also anticholinergic and their use is to be avoided, where possible, in patients with cognitive impairment. The newer OAB medications (beta-3-adrenergic agonists) are selective to the urinary tract and may offer a good treatment option with lower incidence of dry mouth.

The Problem with Paper (absorbent pads):

  • There are times when the use of paper products for UI is necessary and appropriate.  Sometimes during hospitalizations or short term illnesses, perhaps associated with limited mobility or cognition, the elderly may be introduced to the use of absorbent pads to “manage” voiding.  Wherever possible, prompt effort should be undertaken to re-train for maximum independent bladder function.

The Value of Bladder Independence:

Bladder function is important to healthy aging.  If OAB causes incontinence, there is increased risk of:

  • Skin infections
  • urinary tract infection(s)
  • falls
  • hospitalization
  • depression

OAB may lead to social withdrawal and loneliness.

Incontinence caused by OAB is also expensive.  In long term care, additional costs are incurred from use of absorbent paper, linen cleaning and staff time for resident care.  Estimates put this cost at approximately $10,000 per year per long term care resident.

What you can do:

Learn about UI, OAB and the ways that bladder independence can impact daily living, happiness and human dignity.  Pursue the best possible care from medical professionals including physicians, nurses and pharmacists to ensure proper diagnosis and best medication therapy options to both avoid any worsening of UI and ensure optimal treatment of OAB with minimum side effects.  A bladder re-training program, particularly in combination with the right medication, can reduce the need for use of costly absorbent pads and the loss of dignity.

What to expect with effective drug therapy for OAB:

You can tell if a medication given for OAB is working if you have a good knowledge of OAB symptoms before treatment is started.  Nursing homes track information on voiding so you can see if there are fewer episodes of urgency, getting up at night to go and frequency during the day once the medication is started.  While you may not see complete continence, even an improvement can be very meaningful- perhaps facilitating better sleep at night, days spent without wearing absorbent pads or delaying the need for admission to a nursing home. 

Be informed, ask questions, get the right diagnosis and work with health care providers to achieve maximum independent continence.  It’s worth it.

Prepared on behalf of Astellas Pharma

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