Overactive Bladder and Cognitive Impairment: The American Urogynecologic Society and Pelvic Floor Disorders Research Foundation State-of-the-Science Conference Summary Report.

IMPORTANCE: Overactive bladder (OAB) is prevalent in older adults in whom management is complicated by comorbidities and greater vulnerability to the cognitive effects of antimuscarinic medications. OBJECTIVES: The aim of this study is to provide a comprehensive evidence-based summary of the 2021 State-of-the-Science (SOS) conference and a multidisciplinary expert literature review on OAB and cognitive impairment. STUDY DESIGN: The American Urogynecologic Society and the Pelvic Floor Disorders Research Foundation convened a 3-day collaborative conference. Experts from multidisciplinary fields examined cognitive function, higher neural control of the OAB patient, risk factors for cognitive impairment in older patients, cognitive effects of antimuscarinic medications for OAB treatment, OAB phenotyping, conservative and advanced OAB therapies, and the need for a multidisciplinary approach to person-centered treatment. Translational topics included the blood-brain barrier, purine metabolome, mechanotransduction, and gene therapy for OAB targets. RESULTS: Research surrounding OAB treatment efficacy in cognitively impaired individuals is limited. Short- and long-term outcomes regarding antimuscarinic effects on cognition are mixed; however, greater anticholinergic burden and duration of use influence risk. Oxybutynin is most consistently associated with negative cognitive effects in short-term, prospective studies. Although data are limited, beta-adrenergic agonists do not appear to confer the same cognitive risk. CONCLUSIONS: The 2021 SOS summary report provides a comprehensive review of the fundamental, translational, and clinical research on OAB with emphasis on cognitive impairment risks to antimuscarinic medications. Duration of use and antimuscarinic type, specifically oxybutynin when examining OAB treatments, appears to have the most cognitive impact; however, conclusions are limited by the primarily cognitively intact population studied. Given current evidence, it appears prudent to minimize anticholinergic burden by emphasizing nonantimuscarinic therapeutic regimens in the older population and/or those with cognitive impairment.

Evidence-Informed, Interdisciplinary, Multidimensional Action Plan to Advance Overactive Bladder Research and Treatment Initiatives: Directives From State-of-the-Science Conference on Overactive Bladder and Cognitive Impairment.

ABSTRACT: This article outlines an evidence-informed, interdisciplinary, multidimensional, comprehensive action plan for the American Urogynecologic Society to improve care of women with overactive bladder (OAB) while minimizing treatment-related adverse events, including cognitive impairment. It is a "call to action" to advance basic, translational, and clinical research and summarizes initiatives developed at the State-of-the-Science Conference on OAB and Cognitive Impairment to (1) develop framework for a new OAB treatment approach in women, (2) define research gaps and future research priorities, (3) champion health equity and diversity considerations in OAB treatment, (4) foster community and promote education to remove stigma surrounding OAB and urinary incontinence, and (5) elevate visibility and impact of OAB, by creating partnerships through education and engagement with health care professionals, industry, private and public payers, funding agencies, and policymakers.

AUA White Paper on the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.

INTRODUCTION: Medication related problems are common but may be preventable outcomes of prescribing choices. Risks associated with medications in the older adult population are greater due to changes in physiological function with age or disease. Older adults and those with significant comorbidities are often excluded from the clinical trials used to develop medications. In 2012 the American Geriatrics Society published the most recent update of the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Several medications included in sections of the Beers Criteria are frequently used in clinical urology, including nitrofurantoin, alpha-1 blocker medications, and antimuscarinic anticholinergic medications for the treatment of urge incontinence and overactive bladder. We describe the challenges and considerations that are useful in prescribing medications for geriatric patients. METHODS: A literature review was performed targeting publications from 2003 to 2013 on the topics of the Beers Criteria, potentially inappropriate medications and specific urological medications included in the current version of the Beers Criteria. An expert panel was convened to evaluate this information and create this white paper with the purpose of educating the urological community on these issues. RESULTS: The rationale for the creation and implementation of the Beers Criteria and its implications for urological practice are reviewed. Careful examination of the Beers Criteria can help clinicians avoid potentially inappropriate prescribing choices for their geriatric patients. We also identified that the HEDIS® high risk medications list of potentially inappropriate medications has been implemented as a negative quality indicator, even though this was not an original purpose of the Beers Criteria. In other words, decisions of denial of coverage and/or requirements for preauthorization are being made using the Beers Criteria as justification by third party payers and other entities. CONCLUSIONS: The Beers Criteria were developed to improve prescribing practices for older adult patients to reduce or avoid potential risks and complications. We encourage clinicians to educate themselves about the Beers Criteria recommendations and associated initiatives that are aimed at improving the care of older adult patients. Urologists should have a key role in the development, evaluation, implementation and analysis of practice measures and the resulting policies.

How to Use the American Geriatrics Society 2015 Beers Criteria-A Guide for Patients, Clinicians, Health Systems, and Payors.

The Beers Criteria are a valuable tool for clinical care and quality improvement but may be misinterpreted and implemented in ways that cause unintended harms. This article describes the intended role of the 2015 American Geriatrics Society (AGS) Beers Criteria and provides guidance on how patients, clinicians, health systems, and payors should use them. A key theme underlying these recommendations is to use common sense and clinical judgment in applying the 2015 AGS Beers Criteria and to remain mindful of nuances in the criteria. The criteria serve as a "warning light" to identify medications that have an unfavorable balance of benefits and harms in many older adults, particularly when compared with pharmacological and nonpharmacological alternatives. However, there are situations in which use of medications included in the criteria can be appropriate. As such, the 2015 AGS Beers Criteria work best not only when they identify potentially inappropriate medications, but also when they educate clinicians and patients about the reasons those medications are included and the situations in which their use may be more or less problematic. The criteria are designed to support, rather than supplant, good clinical judgment.

Defining and advancing education and conservative therapies of underactive bladder.

In contrast to other forms of voiding dysfunction, underactive bladder (UAB) has traditionally received little research or educational attention. This is changing as our understanding of the underlying mechanisms of detrusor dysfunction and other forms of underactive bladder improves. In addition, the impact of UAB on patient symptoms, general and health-related quality of life, and caregiver burden are becoming more recognized. However, there remains a paucity of data on the subject, and an extensive need for additional research and education on the topic. This paper explores the current state of knowledge about UAB with an emphasis on education regarding the condition and conservative methods of assessment and treatment. Recommendations for future work in this area are considered.

Effect of fesoterodine in vulnerable elderly subjects with urgency incontinence: a double-blind, placebo controlled trial.

PURPOSE: We evaluated the efficacy and safety of flexible dose fesoterodine in medically complex vulnerable elderly subjects with urgency urinary incontinence. MATERIALS AND METHODS: In this 12-week, randomized, double-blind, flexible dose, placebo controlled trial, subjects were community dwelling men and women 65 years old or older. Subjects had scores of 3 or more on the VES-13 (Vulnerable Elders Survey) and 20 or more on the MMSE (Mini-Mental State Examination), and 2 to 15 urgency urinary incontinence episodes and 8 or more micturitions per 24 hours on 3-day baseline diaries. Subjects randomized to fesoterodine received 4 mg once daily for 4 weeks and could then increase to 8 mg based on discussion with the investigator. Subjects receiving 8 mg could decrease the dose to 4 mg at any time (sham escalation and de-escalation for placebo). The primary outcome measure was change in daily urgency urinary incontinence episodes. Secondary outcomes included changes in other diary variables and patient reported quality of life measures. Safety evaluations included self-reported symptoms and post-void residual volume. RESULTS: A total of 562 patients were randomized (mean age 75 years, 50.4% age 75 years or greater). Subjects had high rates of comorbidities, polypharmacy and functional impairment. At week 12 the fesoterodine group had significantly greater improvements in urgency urinary incontinence episodes per 24 hours (-2.84 vs -2.20, p = 0.002) and most other diary variables and quality of life, as well as a higher diary dry rate (50.8% vs 36.0%, p = 0.002). Adverse effects were generally similar to those of younger populations including risk of urinary retention. CONCLUSIONS: To our knowledge this is the first antimuscarinic study in a community based, significantly older, medically complex elderly population with urgency urinary incontinence. Flexible dose fesoterodine significantly improved urgency urinary incontinence episodes and other outcomes vs placebo, and was generally well tolerated.

The New England Research Institutes, Inc. (NERI) Nocturia Advisory Conference 2012: focus on outcomes of therapy.

A consensus statement published in 2011 summarised current research, clinical approaches, and treatment options for nocturia. Since that time, new research has refined our understanding of nocturia in clinically important ways and new evidence has been presented on the efficacy and outcomes of several treatment methods for this underreported, infrequently recognised, and undertreated problem in adults. This paper provides updated guidance to clinicians in light of recent advances in the field.

Efficacy and tolerability of fesoterodine versus tolterodine in older and younger subjects with overactive bladder: a post hoc, pooled analysis from two placebo-controlled trials.

AIMS: To assess the efficacy and tolerability of fesoterodine 8 mg versus tolterodine extended release (ER) 4 mg in subjects with overactive bladder (OAB) stratified by age (<65, 65-74, and ≥75 years). METHODS: This was a post hoc analysis of data from two double-blind trials. Subjects reporting ≥1 urgency urinary incontinence (UUI) episode and ≥8 micturitions/24 hr at baseline were randomized to fesoterodine (4 mg for 1 week, 8 mg for 11 weeks), tolterodine ER 4 mg, or placebo. Subjects completed 3-day bladder diaries, Urgency Perception Scale (UPS), Patient Perception of Bladder Condition (PPBC), and OAB questionnaire (OAB-q) at baseline and week 12. The primary endpoint in both studies was change from baseline to week 12 in UUI episodes. RESULTS: Among subjects <65 years (n = 2,670), improvements in UUI episodes, micturitions, urgency episodes, severe urgency episodes, frequency-urgency sum, UPS, PPBC, and all OAB-q scales and domains were significantly greater with fesoterodine versus tolterodine ER, and diary-dry rates were significantly higher. Among subjects 65-74 years (n = 990), improvements in mean voided volume per void, PPBC, and OAB-q Symptom Bother and Coping were significantly greater with fesoterodine versus tolterodine ER. Among subjects aged ≥75 years (n = 448), improvements in urgency episodes, severe urgency episodes, frequency-urgency sum, UPS, and OAB-q Symptom Bother were significantly greater with fesoterodine versus tolterodine ER. Both active treatments produced significant improvements in most outcomes versus placebo across age groups. Adverse event rates were similar among age groups. CONCLUSIONS: Fesoterodine 8 mg consistently improved several OAB-related variables versus tolterodine ER 4 mg in subjects aged <65, 65-74, and ≥75 years, with some differences reaching statistical significance, and was generally well tolerated.

The evaluation and treatment of nocturia: a consensus statement.

What's known on the subject? and What does the study add? Nocturia is currently defined by the International Continence Society (ICS) as the complaint that an individual has to wake at night one or more times to void. It is, however, an underreported, understudied, and infrequently recognized problem in adults. Many factors may contribute to nocturia which are treatable, yet patients do not seek care or the condition may not be identified by providers. This paper aims to help healthcare providers better serve patients who are experiencing nocturia by summarizing current research, clinical approaches, and treatment options. The results of the conference provide a balanced evaluation of the full treatment armamentarium capable of meeting the needs of patients with the manifold causes of nocturia such as nocturnal polyuria, overactive bladder, or benign prostatic hyperplasia.

Patient expectations did not predict outcome of drug and behavioral treatment of urgency urinary incontinence.

OBJECTIVES: : This study aimed to determine whether expectations of treatment outcomes in women participating in a drug and behavioral treatment trial for urge urinary incontinence are related to patient factors, demographics, health-related locus of control, and treatment outcomes. METHODS: : Baseline assessments included expectations (improvement in bladder condition, time to improvement in bladder condition, and duration of improvement) and the Medical Health Locus of Control (MHLC) scale. Outcomes were measured by the Patient Global Impression of Improvement scale (PGI-I) at the end of active treatment (10 weeks) and 8 months after trial start. RESULTS: : At baseline among 173 subjects, 114 (66%) believed their incontinence would get "very much better," 94 (55%) expected improvement by 1 month, and 111 (66%) expected improvement would last for the rest of their lives. There were no significant associations between baseline expectations or MHLC with the Patient Global Impression of Improvement scale at 10 weeks or 8 months. CONCLUSIONS: : Expectations of treatment outcome and MHLC did not predict eventual patient-reported treatment outcome in this sample of women with urge-predominant urinary incontinence participating in a trial of drug and behavioral therapy.

Incontinence in the frail elderly: report from the 4th International Consultation on Incontinence.

AIMS: To summarize current knowledge on the etiology, assessment, and management of urinary incontinence (UI) in frail older persons. "Frail" here indicates a person with a clinical phenotype combining impaired physical activity, mobility, muscle strength, cognition, nutrition, and endurance, associated with being homebound or in care institutions and a high risk of intercurrent disease, disability, and death. METHODS: Revision of 3rd ICI report using systematic review covering years 2004-2008. RESULTS: We focus on the etiologic, management, and treatment implications of the key concept that UI in frail persons constitutes a syndromic model with multiple interacting risk factors, including age-related physiologic changes, comorbidity, and the common pathways between them. We present new findings with evidence summaries based on all previous data, and an evidence-based algorithm for evaluation and management of UI in frail elderly. We also present new evidence and summarize the data on etiology and management of nocturia and urinary retention in frail elderly. CONCLUSIONS: Despite the overwhelming burden of UI among this population, there remains a continuing paucity of new clinical trials in frail elderly, limiting evidence for the effectiveness of the full range of UI therapy. Future research is needed on current UI treatments (especially models of care delivery, and pharmacologic and surgical therapies), novel management approaches, and the etiologic mechanisms and pathways of the syndromic model.

Localization of brain white matter hyperintensities and urinary incontinence in community-dwelling older adults.

BACKGROUND: Because white matter hyperintensities (WMHs) on magnetic resonance imaging (MRI) may be linked to geriatric syndromes involving mobility, cognition, and affect, we postulated that involvement of areas critical to bladder control could influence urinary incontinence (UI). METHODS: One hundred community-dwelling individuals (75-89 years) were recruited into three groups stratified by age and gender reflecting normal and mildly and moderately impaired mobility. Baseline incontinence status and related symptoms were evaluated in 97 individuals using validated instruments (3IQ, Urinary Incontinence Severity Index, Urogenital Distress Inventory, Incontinence Impact Questionnaire). Regional WMH was measured using an MRI brain imaging segmentation pipeline and WM tract-based parcellation atlas. RESULTS: Sixty-two (64%) of the participants were incontinent, mostly with urgency (37; 60%) and moderate-severe symptoms (36; 58%). Incontinent individuals were more likely to be women with worse scores for depression and mobility. WMH located in right inferior frontal regions predicted UI severity, with no significant relationship with incontinence, incontinence type, bother, or functional impact. As regards WM tracts, WMH within regions normally occupied by the anterior corona radiata predicted severity and degree of bother, cingulate gyrus predicted incontinence and severity, whereas cingulate (hippocampal portion) and superior fronto-occipital fasciculus predicted severity. CONCLUSIONS: Presence of WMH in right inferior frontal regions and selected WM tracts predicts incontinence, incontinence severity, and degree of bother. Our observations support the findings of recent functional MRI studies indicating a critical role for the cingulum in bladder control, while also suggesting potential involvement of other nearby WM tracts such as anterior corona radiata and superior fronto-occipital fasciculus.

The Curriculum for the Hospitalized Aging Medical Patient program: a collaborative faculty development program for hospitalists, general internists, and geriatricians.

BACKGROUND: The University of Chicago Curriculum for the Hospitalized Aging Medical Patient (CHAMP) faculty development program (FDP) is targeted at hospitalists and other internists who teach residents and students in the hospital setting. The aim of CHAMP is to increase the quantity and quality of teaching of geriatric medicine pertinent to the inpatient setting. METHODS: Hospitalist and general internist faculty members who attend on the University of Chicago Medicine teaching service were invited to participate. The CHAMP FDP consisted of twelve 4-hour sessions. Two hours of each session covered inpatient geriatrics content, and 2 hours addressed improving clinical teaching (both general teaching skills and challenges specific to the inpatient wards) and teaching the Accreditation Council for Graduate Medical Education core competencies with geriatrics content. The evaluation included a self-report survey of the impact on the graduates' teaching and clinical practice. RESULTS: The FDP was piloted in early 2004 with a core group of geriatrics and hospitalist faculty. Three subsequent cohorts totaling 29 hospitalist and general internal medicine faculty members completed the FDP by the fall of 2006. Faculty participants evaluated the program positively, and significant improvements in knowledge, attitudes to geriatrics, and perceived behavior in teaching and practicing geriatrics skills were found. CONCLUSIONS: The integration of teaching techniques and geriatrics content was enthusiastically accepted by University of Chicago hospitalists and general internists who teach residents and medical students in the inpatient setting. The program has potential for widespread suitability to all teaching faculty who care for the older hospitalized patient.

Using assessing care of vulnerable elders quality indicators to measure quality of hospital care for vulnerable elders.

OBJECTIVES: To assess the quality of care for hospitalized vulnerable elders using measures based on Assessing Care of Vulnerable Elders (ACOVE) quality indicators (QIs). DESIGN: Prospective cohort study. SETTING: Single academic medical center. PARTICIPANTS: Subjects aged 65 and older hospitalized on the University of Chicago general medicine inpatient service who were defined as vulnerable using the Vulnerable Elder Survey-13 (VES-13), a validated tool based on age, self-reported health, and functional status. MEASUREMENTS: Inpatient interview and chart review using ACOVE-based process-of-care measures referring to 16 QIs in general hospital care and geriatric-prevalent conditions (e.g., pressure ulcers, dementia, and delirium); adherence rates calculated for type of care process (screening, diagnosis, and treatment) and type of provider (doctor, nurse). RESULTS: Six hundred of 845 (71%) older patients participated. Of these, 349 (58%) were deemed vulnerable based on VES-13 score. Three hundred twenty-eight (94%) charts were available for review. QIs for general medical care were met at a significantly higher rate than for pressure ulcer care (81.5%, 95% confidence interval (CI)=79.3-83.7% vs 75.8%, 95% CI=70.5-81.1%, P=.04) and for delirium and dementia care (81.5%, 95% CI=79.3-83.7 vs 31.4% 95% CI=27.5-35.2%, P<.01). According to standard nursing assessment forms, nurses were responsible for high rates of adherence to certain screening indicators (pain, nutrition, functional status, pressure ulcer risk; P<.001 when compared with physicians), although in patients with functional limitations, nurse admission assessments of functional limitations often did not agree with reports of limitations by patients on admission. CONCLUSION: Adherence to geriatric-specific QIs is lower than adherence to general hospital care QIs. Hospital care QIs that focus on screening may overestimate performance by detecting standard nursing or protocol-driven care.

Knowledge and attitudes of nursing home staff and surveyors about the revised federal guidance for incontinence care.

PURPOSE: We assessed nursing home staff and state nursing home surveyors regarding their knowledge and attitudes about urinary incontinence, its management, and the revised federal Tag F315 guidance for urinary incontinence. DESIGN AND METHODS: We conducted a questionnaire survey of a convenience sample of nursing home staff and state nursing home surveyors from a midwestern state attending two statewide workshops on the revised guidance. RESULTS: Of 558 attendees, 500 (85%) responded, including 39% of the state's directors of nursing and 57% of state nursing home surveyors. There were striking deficiencies in knowledge regarding urinary incontinence and catheter care, with significant discrepancies by type of respondent, particularly between state surveyors and nursing home staff. Staff cited documentation and staffing levels as the most frequent concerns about implementation. Open-ended responses reflected the divergence of concerns and antagonism among the stakeholders, and staff nurses' feeling that F315 violated residents' rights. IMPLICATIONS: The revised Tag F315 guidance will be unlikely to improve the quality of urinary incontinence care in nursing homes because of significant knowledge and attitudinal discrepancies between nursing home staff and state surveyors, facility staff's focus on documentation and staffing, and reliance on implementation strategies known to be ineffective. Federal, state, and other urinary incontinence guideline efforts should focus on managerial structures and methods to improve quality nursing home care. Research is needed to address how nursing home residents and families define and value "quality" urinary incontinence management and to incorporate these in quality-improvement strategies and measures.

Beyond the bladder: management of urinary incontinence in older women.

Unlike urinary incontinence (UI) in younger women, UI in older women is usually multifactoral in etiology and involves factors beyond the more common types of lower urinary tract (LUT) pathophysiology associated with UI in younger women. The evaluation and management of UI in older women, therefore, must itself be multifactoral and sometimes multidisciplinary, and encompass an understanding of age-related LUT changes, age-specific LUT pathophysiology, and a broadened, multidimensional concept of continence.

The effect of urinary incontinence on quality of life in older nursing home residents.

OBJECTIVES: To determine whether nursing home residents with urinary incontinence (UI) have worse quality of life (QoL) than continent residents, whether the relationship between UI and QoL differs across strata of cognitive and functional impairment, and whether change in continence status is associated with change in QoL. DESIGN: Retrospective cohort study using a Minimum Data Set (MDS) database to determine cross-sectional and longitudinal (6 month) associations between UI and QoL. SETTING: All Medicare- or Medicaid-licensed nursing homes in Kansas, Maine, Mississippi, New York, and South Dakota during 1994 to 1996. PARTICIPANTS: All residents aged 65 and older, excluding persons unable to void or with potentially unstable continence or QoL status (recent nursing home admission, coexistent delirium, large change in functional status, comatose, near death). MEASUREMENTS: UI was defined as consistent leakage at least twice weekly over 3 months and continence as consistent dryness over 3 months. QoL was measured using the validated MDS-derived Social Engagement Scale. RESULTS: Of 133,111 eligible residents, 90,538 had consistent continence status, 58,850 (65%) of whom were incontinent. UI was significantly associated with worse QoL in residents with moderate cognitive and functional impairment. New or worsening UI over 6 months was associated with worse QoL (odds ratio = 1.46, 95% confidence interval = 1.36-1.57) and was second only to cognitive decline and functional decline in predicting worse QoL. CONCLUSION: This is the first study to quantitatively demonstrate that prevalent and new or worsening UI decreases QoL even in frail, functionally and cognitively impaired nursing home residents. These results provide a crucial incentive to improve continence care and quality in nursing homes and a rationale for targeting interventions to those residents most likely to benefit.

The aging lower urinary tract.

PURPOSE: Age related changes in continence and the GU system, and how they affect the management of LUT dysfunction are discussed. Guidelines are offered regarding the diagnosis and management of incontinence in the elderly population. MATERIALS AND METHODS: Published literature and current treatment practice specific to elderly patients with LUT dysfunction were reviewed. RESULTS: LUT symptoms in the elderly population are affected by the high prevalence of comorbidity and polypharmacy. In addition, the GU system undergoes age related changes that increase the risk of LUT dysfunction. CONCLUSIONS: Incontinence in older persons is almost always caused by multiple factors, of which not all are directly related to the GU system. Issues such as polypharmacy, comorbidity, and the increased risk of medication side effects must be considered in planning treatment. The primary care physician and urologist or gynecologist should establish a partnership to co-manage the broad spectrum of factors affecting continence in elderly patients.