I would like to welcome all of you to our next installment of our virtual web-based lecture series. And this is a series of presentations by experts in our subspecialty from across the country developed according to the ABOG Guide for Learning and exclusively for our FPMRS fellows, although we're also happy to be welcoming other AUG members to the webinar as well. The goals are not only to enhance your understanding of the learning objectives, but also allow you the opportunity to interact with experts in our field in real time. Importantly, this presentation is captured and made available for view at any time on the AUG's website. So for those of you all that have not logged into the website to see the past webinars, I encourage you to do so. They're fabulous. And upon completion of this program, you'll be given the opportunity to provide some feedback, which we value greatly, both in terms of how we present and also the content. So for this evening's presentation, it is my pleasure to introduce one of our excellent clinicians, scholars, and researchers and educators, Dr. Elaine Marklin. She is Associate Professor at the University of Alabama in Birmingham, and she's Associate Director of the Birmingham Atlanta Geriatric Research, Education, and Clinical Center, or GREC. She is going to be talking to us this evening about geriatric considerations for women with urinary incontinence and LUTs. Thank you so much, Leslie, and thank you, Gary. I do want to get started. I feel like we have a lot to cover in this hour, and I want this lecture to be comprehensive, but I have to admit, I am not going to be talking today about surgery considerations for the older woman, and I really feel like that could almost be a lecture in of itself. So a lot of what I'm going to discuss is really focused on these objectives. I'm going to really go through a little bit more of the deeper knowledge of the pathophysiology when it comes to aging and the bladder, and look at why it's so important to address potentially reversible transient causes of incontinence and LUTs, and then really look at what is the evidence on the treatment of incontinence and LUTs in older women. So without that, I can't start any talk without some just basic definitions, and I know this audience is well-versed in this, but I'm just going to put this up there to get us started. I can't start a talk without, and I know we've all probably seen this slide, but the epidemiology of incontinence and overactive bladder, as well as LUTs in women. And I just want to point out that we all know that the age is such a big factor in the prevalence of incontinence, and it's not only the prevalence, but it's also a factor in terms of the severity, and that's what this study shows. It really is, as we go through each age group, the prevalence increases with that bump right around the time of menopause, and yet an increasing prevalence along with each age, age decade. And that goes the same for looking at overactive bladder, and this is the OAB Poll Study published in 2009, and I think it's really interesting, and I know that this audience does not see men, but I left this on here because you can see how common overactive bladder is, not only in women, but also men, and how in both genders it increases with age. And even if you age-standardize it, it is much more common in women, the terminology of overactive bladder. So I just wanted to point that out, and then I'm going to move over, and I know this slide is really busy, but what I think is interesting about this, this is again another large multi-country Internet-based trial looking at symptoms related to bladder in several countries, is that it's not just incontinence that's the most common symptom, and I think this is fascinating when you look at the concept of not only how common or what the prevalence is, but how much women are bothered by the symptom. So in this graph, you can see that terminal dribble is actually one of the highest or most prevalent conditions, but also is not a big factor when it comes to bother levels. But you can see here that urgency and urgency with fear of leaking are some of the most bothersome symptoms. Now that doesn't necessarily mean it happens in older women, but we do have some data to suggest that these same symptoms are just as common or even more common in older women, and that older women may be bothered as well in congruence with the severity of their symptoms. And then this graph really just looks at the intersection, and I'm going to focus more on this, but the intersection of these symptoms, overactive bladder symptoms, and other comorbidities. And in the classic studies, even though this is kind of a composite, but we've all heard of the study that getting up at night to urinate increases your risk of falls and fractures in older women. And that study is cited so often, but I don't want you to forget that the prevalence of bladder symptoms is also associated with urinary tract infections, depression, skin infections, incontinence-associated dermatitis, and then other symptoms related to vulvovaginitis. And then you can't have a talk without really mentioning, and this isn't in all women, this isn't just in older women, the impact of these symptoms. It's just a huge symptom burden in terms of social isolation, emotional impact, finance. In 2006, just the data on the financial impact that women with incontinence spend $900 more per year on supplies, over-the-counter supplies, in comparison to their continent counterparts. So we just can't, and I'm preaching to the choir here that everyone on this call truly knows that the impact of these symptoms is tremendous, and it only increases with age. And I think that the reasons why women and people don't get help, I think it's interesting. We often hear all these cited, but most of these reasons do apply to age. So I just wanted to point out that it's a natural part of growing older. There's these misconceptions among women, oh, I'm too old, why bother? It's just a normal part of having had children, having bare children in life, and that I really think that even though these misconceptions, we're trying to do our best to change them, I still hear and see these almost every time I'm in clinic. It's pretty amazing. And then really, what do older adults want from treatment? And I think this is an interesting slide, and I know it's kind of hard to read, but this is a slide that's taken from a paper that published data from a pharmaceutical-sponsored trial actually using Detrol. And this is just looking at the baseline data of the women in the trial, and what they did is really look at a component value. So it's just putting a value to the associated symptoms, plus or minus the standard deviation, and taking into account bother. So I think it's interesting that if you really think about what our patients want, just because you have increasing frequencies or prevalence of incontinence and nocturia and other symptoms with age, it's really, you've got to take into account how bothered, how much on a patient level does it bother them. So I think that's an important concept, and I'm going to come back to that as we go through these slides. Now, you've probably had the talk about all the epidemiologic risk factors and all the risk factors we know, and I've just picked five of the most common on the slide. And I've highlighted age, because that's really the focus of this talk. And I'm going to spend some time really talking about what does age, why is age a risk factor, what do we know about the aging physiology or pathophysiology that lends itself to bladder problems in older women, and not just from a bladder standpoint, but what other pathophysiology and comorbidity problems can contribute to that. So the rest of the talk, I'm really not going to be talking about pregnancy or parity or obesity. I'm going to really try to hone in on those age important factors. And so I think we've all, we all have seen the slides. We know the aging of the U.S. population. It's called the silver tsunami, the graying of the U.S. population. One of the fastest growing age groups are actually women 80 years and older, and of any age group in our society. So I think it's really important to think about what is healthy aging. And it's important to know that, and I say this all the time with our trainees, our fellows and residents doing a geriatric rotation, that it's not actually pediatrics. There's a lot more homogeneity in the aging process and going through the stages. However, there's a lot of heterogeneity in terms of aging and the effects of aging on our bodies as we go through each decade in life. And so I think it's important to know, and I think I found this slide or this picture on the Internet, and I was a little frustrated because I was like, oh, they list all these things that really do affect women, but where is the bladder in this slide? Where does the bladder fall in terms of not only healthy aging but problems? And even though we see that osteoporosis and osteoarthritis has a high impact on morbidity, I would argue that incontinence should be on this slide as well. And so with that, I'm not going to talk so much about the healthy part, but I am going to talk about that the older woman, and I'm not going to focus on that older woman that's more likely to participate in clinical trials or do very well in surgery or be the model patient. I want us to recognize the ones and know the changes that occur in that older woman that isn't the healthy, active person. We all see these people in clinic, and they are the ones, I think, that are the most at risk for some of the treatments that we deliver, and sometimes they are the most resistant to some of the treatments that we have to offer. So with that, I think it's so important to talk about functional status. So I'm going to define frailty. We're going to talk about cognitive changes. We're going to talk about the impact of comorbidities, including polypharmacy in terms of bladder symptoms, and then just mobility. Functional status in general can mean a lot of things, but to a geriatrician, we seem to focus a lot on mobility as well as disability. All right. So moving forward, I want you to think of the term frailty as a noun and not necessarily frail as an adjective. So frailty is actually considered a multifactorial geriatric syndrome, which encompasses at least three of the factors that I list there. So it's unintentional weight loss, defined as 10 pounds lost in at least a year period, low levels of physical activity, exhaustion, weakness measured actually objectively by strength testing, and then walking speed. And if you look across multiple different epidemiologic studies of older adults, you see the prevalence of this is 7%, and that the incident rate is 7% over a four-year period. And identifying older adults that meet this criteria have very significant impacts on, we know that these frail, and I'm using it as an adjective, but an older adult who meets the frailty criteria, they are at risk for death and nursing home placement, and the risk almost doubles, if not triples, if they have dementia or cognitive impairment. And so in this group, we really don't have a sense of in this very, very debilitated overall high comorbidity burden group, what does work? What doesn't work? What is their symptom burden? Is it all the other diseases that are more prevalent that are causing them more problems in their bladder? Or is that bladder really a big part of it? So I think this is an area of research that's needed. So I'll just go ahead and say that I don't want to spend too much more time on this, but I really think we need to spend a little bit more time in dealing with how do we help our older adults meeting these frailty criteria? And I just listed them there again in a concept diagram that shows the interactions. It's not just any one of these. It's got to be at least three, and how the three of those interact to really decrease the functional status and ability of these older adults. And that takes me into the fact that you couple debility, poor functional status, frailty with cognitive problems. So we all experience cognitive aging. There is loss of memory with age. And what makes it pathologic and what makes it cross into a dementia, I'm going to spend a little time on, because I don't know how much your knowledge of this is, but it does have implications. I won't spend too much time on this, because I do want to finish the talk by really going through some of the treatments. But cognitive aging, we all know that we have atrophy over brain volume per year as we age. We all have slower cognitive performance on standardized testing and memory retrieval. And then recall in the quality of our cognitive performance as well as executive function. An example of executive function is driving, something that takes multiple sensory input to perform an action, are sometimes usually maintained as we age. But it's when they aren't maintained that we tend to have what we call mild cognitive impairment that may increase your risk for dementia. So I'm just putting the definitions there of dementia and differentiating it from mild cognitive impairment. The big difference in these two is that it's not just a memory problem, but it's also a problem with language, dementia is, that interferes with daily functioning and independence. So it's dementia when it interferes with the ability to function independently daily. It's mild cognitive impairment when you have a domain that's impaired, but you really can still function independently. So that's the difference. And I know I'm probably boring you, but I just wanted to say that these rates overall do increase with age. We do believe that mild cognitive impairment may be a precursor, increase your risk of Alzheimer's, dementia, and that really we know that dementia and stroke are also huge factors when it comes to control over the bladder from a higher level. And I think it's interesting, I meant to put the reference on here that actually having incontinence after stroke is a poor marker or is a marker for a poor prognosis. So people who have strokes and have incontinence without awareness are much less likely to do well with inpatient rehab. So I think it's just interesting that intersection between the brain and bladder is real. And I do want to talk a little bit more about that. Again, the patients you're seeing in clinic, we all know that people, we see them, that they often come in with a caregiver and the patient may talk very little and the caregiver does a lot of talking. History can be less reliable. We question adherence to therapy. We maybe should consider doing follow-up sooner rather than later. And sometimes that response to treatment may be difficult to gauge. I always have been taught and I truly believe that a bladder diary can be just as good as a cognitive function test for an older woman. If you can't complete a bladder diary, sometimes that is your sense that they just cannot, it's just there's a cognitive difficulty there that's above and beyond education sometimes. So I want to keep that in mind and not to mention that we often see patients in clinic that have caregivers and that doesn't mean we don't treat them, we just have to get that caregiver involved. So now I'm switching gears. I've gone from frailty to cognition and just knowing that you could almost spend an hour talking about the comorbidities and the impact on lower urinary tract symptoms. But everything I've listed on this slide, basically there's a nice review article by Cara Tannenbaum in 2013 that really goes more in depth about all this. But we know that there's so many comorbidities that if you just look at the epidemiologic literature, urinary incontinence and lower urinary tract symptoms are much more common with people with diabetes, arthritis, neurologic, and that's typically stroke and dementia. I think it's very interesting. There's some really interesting data coming out about a vascular hypothesis when it comes to bladder impairment, how common it is that we see that hypertension alone is a risk factor. We all see the impact of having a urinary tract infection on later potentially causing or contributing to bladder symptoms that never really quite go away, depression and anxiety, the overlays with incontinence, and then asthma. And I would also put on the slide the overlap of constipation. Even though IBS is listed, I think specifically for the older adult, constipation is a huge factor. And then there's some very interesting studies. So I think this is a very interesting and ripe area for more research, the impact of functional status, otherwise called sometimes mobility, the ability to be independent in movement and lower urinary tract symptoms. Liz Erickson did a great study where she did epidemiology. She looked at a large trial, or not trial, but epidemiologic research. And she saw that 60% of the older women, and this was a trial or a cohort of older women, who had daily incontinence actually reported a functional disability. And of those, 24% actually reported difficulty or needing help or dependency in toileting. So this is really a big factor. And then I think it's really interesting. There was another trial actually done in France that they looked at the association with urinary symptoms and gait speed as well as balance. And so they found that compared to continent women, women with urgency had more impairment in their gait speed and balance than women with stress incontinence. So it was just a really interesting trial. And then another group looked at bladder function and gait speed. And they only did this with a small trial, 60 women, with a mean age. So this really isn't, to me, it's not geriatric, but a mean age of 50 years. And they showed that actually at a strong desire to void, women had a slower gait speed versus a post-void gait speed. So none of this really gets at that cause or effect, but I think there's some very interesting associations that need further exploration in this area. And so now I'm going to talk a little bit more about what is different in terms of the aging control of the bladder and where that boils down to both a neurologic, muscular, I'm going to say metabolic, but that could be metabolism of drugs as well as metabolic, such as metabolic syndrome and immunology. I'm not going to talk a lot about the microbiome here, but we know very little. And I think this is another area that's ripe of learning how older women may have changes compared to younger women, and more data is really needed to support that. So with that, I'm going to talk about some of the CNS changes. So I'm going to start from the brain level. And we do know that age in general is associated with the loss of myelin and neurons that leads to the inhibited control of micturition. So there's been some wonderful work done by a group out of Pittsburgh, basically put women, they have a whole protocol to do urodynamics in women who are undergoing functional MRI testing, and they've really showed, and it's very fascinating to me, that you have with bladder filling and these urgency actions that people are feeling under urodynamics, that you have decreased activation sometimes in the bilateral insula and dorsal anterior cingulate cortex, and then in the medial prefrontal cortex, you can have that usually inhibits the pontine micturition center, that you can see some changes in older women compared to younger women in terms of their response to urgency. Another trial done by the same group showed that actually more women with urge incontinence had more white matter hyperintensities. So that may suggest a vascular pathology behind that in the pontine micturition center when they were experiencing urgency. And then another trial done by a group in Massachusetts again showed that white matter hyperintensities in these right anterior frontal regions predicted not only the UI in general, but also severity. And those are the images that I show in the slide of some of the regions involved. So they did some fairly unique studies, and I think it's very interesting. And I think we need to know more about that, because we all realize that there's a lot more to the bladder outside of the pelvic floor, even though the bladder is important and is the main focus of most of our treatments in terms of both nerve, muscle, and even sometimes our pharmacologic treatments. We can't forget that there's a lot more going on on the higher level. And I just wanted to put that into pictures here. A lot of the things I talked about, the pontine micturition center, the periaqueductal grade in the midbrain and the response for the integration, the synergy, and phase switching in terms of knowing urgency, how to control that urgency and sensation, and help decrease the urgency on some level to know when to avoid or be able to control it better. And all of this is very important when talking about it and knowing the changes that do occur with aging. So aging changes at cortical level occur, midbrain level, but also from a peripheral nerve level. So we know that in general we do have reduction in the number of parasympathetic as well as sympathetic nerves with age. And there's some evidence that even innervation of the bladder and urethra do decline. Most of this is done in animal models, but it is fascinating that you would also see some changes when you've done bladder biopsies potentially with the nerve and the neurons in the bladder. And then Kim Kenton and her group have done some great studies looking at perception thresholds and they have found that we know that older women tend to have decreased perception thresholds at the level of the urethra and the bladder in terms of that sensation. So not only centrally, peripherally, we also know from older bladder biopsies that we have detrusor fibrosis. So it's not just the nerves, it's the connective tissue. We have more elastin and the bladder elastin is replaced by collagen. There's also some potential apoptosis in the muscle levels at the level of the urethra and decreased musculature in terms of not only just apoptosis, but actual decreased functional ability. And that there's mixed reports. So you'll see this, that there may be more degradation of the M3 receptors with age, but I think most of that data right now, there's a little bit of mixed data. Is it really just M3 or is it other muscarinic receptors in the bladder? And all of this is important because it does impact on treatment. And then we do see some age-related changes in micturition as well where we see a decreased maximal flow rate with age. We do see decreased bladder contractility with increased detrusor underactivity so that impaired contractility is what you're seeing as it ultimately appears on urodynamic testing. Impaired bladder sensation. I've also already mentioned the impaired urethral sensation. Older women tend to have higher post-void residual volumes. Even though we see that and it's been characterized, it doesn't always mean that it's pathologic. If we do notice an increased post-void residual with age, we do notice that women tend to have lower urethral closure pressures. This is thought to be due to estrogen receptors. And I started this because there's data suggesting that the bladder capacity because of all these reasons is actually reduced. But then there's also some studies that suggest that bladder capacity may be unchanged. So it makes it difficult to answer one of those board-style questions on this, but I do want this group to know that the bladder capacity itself, there's a lot of things that can influence bladder capacity and changes with age. So I want you to really think of it more from a contractility standpoint or a compliance. I think we all pretty much the literature suggests that compliance decreases, but that doesn't always in turn relate to a decreased capacity. All right. Now I have a caveat on this slide. I use this slide really just to, because I like pictures, and I've done too much talking with too many words anyway. But I do want you to realize that the terminology has changed, that we really are using urgency incontinence. And the term overflow is really not used in terms of the current ICS guidelines on terminologies that we tend to use elevated post-void residual volume instead of the term overflow. But these terms, you'll still see them in book chapters. You'll still see them in the literature, so they're still there. But I do want you to know that the age-related changes result in we have that decreased sensation of bladder fullness in older women, where you really have less warning. Women will often tell you, I basically stand up and I have the urge and it's just gone. And that's what I mean when I say postural incontinence. You'll see more nocturnal enuresis in older women, where they didn't have problems controlling their bladder at night. They may have had nocturia, but maybe not have had enuresis. And then the bladder does empty less efficiently, where you have more hesitancy, intermittency, slow flow, and incomplete emptying. That doesn't mean it's related to a high post-void residual or any kind of blockage, such as prolapse. But you do see those symptoms often reported. You do see lower urethral pressures, and that can result in stress incontinence and post-void dribbling. But do realize that the urge, we really think, is more from either a potential oversensitivity versus a neurologic etiology. So it's just important to consider multiple things. So now I'm going to switch gears. I think pathophysiology is important, and the changes with the aging bladder are important. But I really want to focus the next part of the talk on treatments. But you can't talk about treatments without doing an adequate history. And I think it's really important, in terms of doing all those behavioral interventions, to really talk about fluid intake and dietary food intake. Now I left a slide on. This is from another talk, so I have to apologize, on urinary and fecal incontinence. So some of these dietary food intakes may not apply to urinary symptoms, but artificial sweeteners, citrus, there is some data suggesting that that definitely can impact bladder symptoms. Over the counter medications, and just we all know that many of the women, by the time they see us in clinic, have had multiple other treatments. And this is what I mean by reversible causes. I think we all, by the time patients get to the urogynecology clinic, you have hoped that the primary care physician or that referring physician has done a good job already at looking all at these other contributing factors. But sometimes I'm really surprised. By the time I see somebody in clinic, and I do work in a specialty continence clinic that's a shared clinic with urogynecology, that sometimes the number of patients that come in, you still want to address these potentially reversible causes. And you see them so commonly in our older adults, whether it's just a medicine or a change, a medicine that's not even related to bladder treatment, you know, a diuretic, a medicine that was given for another reason, and then you ended up with bladder problems and so anticholinergic medicine was given on top of it. But I really think it's important to have a mnemonic. There's a drip mnemonic. There's a diapers mnemonic. And these can be used for urinary incontinence and or fecal incontinence to really rule out the causes that we need to see and treat appropriately before just focusing in on bladder treatments themselves. So I'm going to talk a little bit more about this and just the importance of looking at all the medication list. I really spend a lot of time on this sometimes because there's so many medicines that can affect bladder and bladder function. And these major classes of medicines that I list here, but really when you talk about specific medications, you'll see these often tested too or some of the ones that are known to contribute to certain symptoms. The calcium channel blockers, they can be very much more likely to cause lower extremity edema so that you have increased rates of nocturia as you sleep and your body vasculature is just trying to get rid of the excess lower extremity edema. All of those calcium channel blockers cause constipation that can also impair the bladder. Narcotics can impair bladder sensitivity as can gabapentin and pregabalin. We know that benzos are also involved, multiple aspects, not only just higher level cortical function, but mentation, but actually mobility. Benzos are a huge factor for falls and if people aren't walking or unable to be mobile, they may be highly affected by their bladder urgency. Often cited are the effect of ACE inhibitors on cough and increasing stress incontinence. I would also argue that it may not be ACE inhibitors as much as it is lung problems and chronic cough in general, but there's just so many drugs out there that the big ones are listed here, but there's a lot more that potentially could contribute. I'm just going to quickly go through this patient case of an older woman. Let's just say she's 84, 85. She comes in, she's had worsening incontinence and it's really important, like I said, to go through these contributing factors. What is her past medical history? What are her medications? You don't see very many 84-year-olds that don't have hypertension, that don't have at least three comorbidities. And I didn't even list osteoarthritis here, but she has diabetes. Recently, she was taken off her oral agents and just treated with diet, hypertension. She's got some dementia, so she does come in with her daughter, but all in all, she's still living and functioning mostly independently, but does live with her daughter and relies on her for some help with medications. Her medications include aspirin, an ACE inhibitor. She recently was started on hydrochlorothiazide because of her hypertension and she was recently started on anticholinesterase inhibitor for her memory. So, those are the new medications. So, again, it's not just what medications they're on, but what's new. Dietary-wise, she drinks four diet caffeinated drinks daily. Like most older women, they're just not water drinkers and she also doesn't really have any other dietary considerations. On further testing, just her glucose, spot glucose is up. Her urinalysis also shows some glucose, post-void residual, and I would argue that this really isn't that high for an 84-year-old woman with 100. And then on exam, she had some mild atrophy, not major, but with otherwise no prolapse or it was unremarkable. And so, what is that initial treatment? So, of course, we're all going to consider trying to reduce her caffeine. I would argue that you might want to discontinue the hydrochlorothiazide unless she was very responsive to it in terms of better blood pressure control, then you might want to work with her in terms of making sure she's compliant or adherent to all her medicines. She might want to consider restarting an oral diabetic medication, which may help lower her glucose, which is contributing to her symptoms of increased frequency and urgency incontinence, and also discontinue her ACE inhibitor because, of course, she not only comes with urgency frequency, she's also got some stress leakage. So, I just want you to think of all those medications and contributing factors. And then that switches us up into treatments. And I'm not going to talk about stimulation. I'm really not going to spend much time on devices or anything or Botox or surgery. So, I'm really going to focus on the main behavioral treatments and medications for this talk. I do want you to know that, and I know this has been mentioned in many of the other talks, there's the SUFU-AUA 2013 Clinical Practice Guidelines. There's some really good information in there, even on the impact of some of these treatments and the data that we know that exists for the older woman or even women who are more vulnerable or frail. So, there's some great data in that. And I do mention it for most of the treatments. And when I talk about behavioral treatments, because of my training, I'm not just talking about pelvic floor muscle exercises. I think anything we do in exercise or changing behavior, and exercise is a good example of trying to change behavior and do it more, is all these things are a part of that, whether it's dietary changes, exercise, control strategies, fluid management, weight loss, all these things are behavioral. And really, it's not just one. And I really think of behavioral as being a multi-component program. It's easy to tell people to do an exercise, but what's hard is to coach them how to change their behavior to do it. So, I don't want to overemphasize that this is where we start, and this is where we start not only because of the guidelines, but this is where we start in terms of recommendations. Now, the caveat is, this is where I start, and most of my older women who may have chronic comorbidities, they may have some mobility problems, but I'm not using these in someone who's got cognitive impairment. Maybe mild cognitive impairment, but not dementia. So, I don't want us to think of being restrictive in our first-line approaches just because someone is older and has chronic comorbidities, but really, it's the people who have more advanced dementia that you would, of course, not use these. And so, I don't want to spend too much time going all over each component of those that there is evidence. And I often hear, well, these don't work in older women. Well, actually, some of the trials were done in older women, albeit they were healthy. They were older women showing that behavioral approaches such as what I've mentioned here were almost as good as medication. And using these behavioral approaches were as good as doing biofeedback. There may be a group of people who do need biofeedback. It doesn't have to be done in everyone. And they have been effective not only for stress, but urge and mixed urinary incontinence. And I just, you know, knowing that it's the whole package, that it's just not the exercise, but all those components really do matter in terms of the effectiveness of behavioral treatments for the management. And so, I also want to mention, as I mentioned already, that comparative effectiveness, so we do know that these pelvic floor muscle training behavioral strategies are effective for reducing not only urgency, frequency, nocturia, and incontinence. They are just as likely to be as effective sometimes as anti-muscarinic drug therapy. They're appropriate for first line. And, you know, the jury is still out on doing biofeedback. It is covered by Medicare, so you can get it, but a lot of insurance does not cover it. Now, you may not be seeing patients in a nursing home setting or patients who kind of live in assisted living setting, but there are often many programs in place. And sometimes a care home will actually advertise that we do prompt avoiding or we have a toileting policy. But I just want you to know that just because someone has cognitive impairment and or functional impairment doesn't mean you can't try a behavioral approach. Prompted voiding has been studied. They've even done studies to suggest that with prompted voiding, if they're not responding in the first three days, it might not be effective. But prompted voiding is a behavioral change. It's not just putting someone on a scheduled toileting program, but prompted voiding is really bringing someone into the bathroom. And just by the act of being there in the bathroom and asking and prompting them to void, that they're more likely to remain continent if you really focus on the act of going into the bathroom and asking about having to void. So it's a lot more than just a scheduled toileting program and forcing them to sit on the toilet. All right. So switching into the drugs. I've listed all the drugs there. Does the drug treatment work in the older woman? And so this is just a hypothetical slide. So let's just pretend that we test OAB drug versus OAB drug A versus B. And we're going to do a study and we're really going to look, does it increase urinary incontinent episodes in older women? And you can see there that it is very effective. One drug is better than the other or pretty similar in those younger than 65. But in those older than 65, we see that the drug looks like drug A may be better. But actually, if you break this down just for, let's just pretend this is a pharmaceutically sponsored trial, but they didn't recruit a whole lot of women over the age of 75. But they did have some that really what we don't know, and this is a big unknown, is that if you really break it down by age group in a lot of the older studies, do you see the same effects? And this slide is just there to suggest that maybe by breaking it down and really doing some of these subgroup analysis that in the older groups, you really don't see the difference. But if you looked at the total mean and you just took the random cutoff of 65, you would see an effect by a decreasing in urinary incontinent episodes. But that doesn't mean it really applies to the oldest old. And so that just reflects on the current challenges in clinical trials, that there really is that heterogeneity of the study population and not old. Every 75-year-old woman is really the same in terms of functional or cognitive status. So really a lack of racial, ethnic, and socioeconomic diversity. As I've said, they usually include very healthy older women. They often exclude comorbidities known to affect micturition incontinence. And they usually are limited to patients with really high daytime frequencies. So I just wanted to put in those plugs that the caveat is when you're talking about drugs and drug treatment for the older women, we really don't know a whole lot. And that we also, it's important to consider that it's really the adverse drug effects may be big in the older women. It's just that the theory that with age and disease, you really have this homeostenosis concept, that your capacity to adjust or affect change really decreases with age. So it's your capacity to have this functional reserve or homeostenosis that really tends to change. And it's influenced by not only pharmacokinetic, but pharmacodynamic factors. And so that's what I'm getting at here, is that even though you may not need a large number needed to treat decreased urge incontinence episodes with a drug, you also really have to be careful about the number needed to harm. Because it doesn't take very many more to actually cause side effects. And with that, I am going to present data from I think one of the best, although pharmaceutical companies sponsored studies of treatment with Fesotaridine in a very older at-risk population. And this is a vulnerable elderly study where they recruited 562, and this is men and women that met criteria according to this vulnerable elder questionnaire that they had to have not only some impairments in functional status, but they also could potentially have a little bit of impairment in cognitive status that you see some decreases regardless. And they actually had pretty safe rates of adverse drug events that at 4 and 12 weeks that you see a decrease in urgency incontinent episodes, urgency episodes, nocturnal urgency, the dry rate was higher, micturitions. And I'm not surprised that the adsorbent product didn't really decrease a whole lot even though it is statistically significant there just because we all see those women that are going to wear their pad just in case. So really, what do we know about cognitive impairment from anti-muscarinics? Are they safe to use? We have one trial suggestion they are. A lot of the case reports showing that it does cause cognitive impairment when we use these drugs in older women who are at risk. But really, we know that oxybutynin is worse than Benadryl. Looking at EEG studies, oxybutynin, and this is IR, not the sustained acting, was worse than Tiltaridine and Trospium. And from epidemiologic studies, we've noticed that the prescription event monitoring, more hallucinations with Tiltaridine versus others was reported. And that anticholinergics were definitely associated with some cognitive battery domains. So with that, we have actually done a trial of oxybutynin. Immediate release did not increase delirium in a nursing home population. So a very frailer group of women probably meeting frailty criteria in the nursing home. And then they also did, Darafinicin was no different than placebo in a crossover trial on a computerized cognitive battery. And most of these are done with healthy older adults, so not impaired older adults. And then oxybutynin versus Darafinicin didn't cause any more impairment and delayed recall than placebo. So there's some evidence out there. And then a recent review says that neither age, frailty, nor dementia should be considered a barrier to pharmacologic management, but consideration should really be given to the total anticholinergic load. And I think that's just so important because it goes back to going through all those other medicines. What is the total anticholinergic burden of all the medications that someone's on? We really need more evidence, and we should adapt guidelines under these circumstances. And then lastly, just that combined behavioral and drug. There really isn't a lot of evidence. There's some smaller trials of short duration showing that combined behavioral and drug may be effective for reducing incontinent episodes, frequency nocturia, and also improving quality of life. There's more data for immediate release than extended release, oxybutynin, as well as salteridine and trospium. So there could be more studies there as well. And again, I'm just putting this on there to show that there actually is some data. And in an older, old population for use of Botox, hopefully there'll be some more data in terms of sacral nerve neuromodulation than the older adult. And we often, in our clinical practice, use PTNS for even some of our refractory cases because the lower likelihood of side effects, the downside is having to come into clinic. And I will just say that mirabagron, I kind of left that off the discussion because I know there's a trial ongoing that's similar to the feathered teratine trial in the vulnerable older adult looking at a lot of important outcomes in terms of cognitive status in older adults with lower urinary tract symptoms, overactive bladder, and incontinence with the use of mirabagron. So with that, I'm just going to put up some conclusion slides, and I'm happy to take any questions. All right. Thank you, Dr. Markland. Just before we start our question and answer portion, I want to remind you how to go about asking a question. The Q&A box is located on the right-hand side of your screen. To submit a question, type your question in the small text box at the bottom. And when you're finished, just click the Send button or push Enter. I'll turn things back over to Leslie at this time to handle the Q&A. All right. So we have a question. Could you comment on nocturia and sleep apnea screening? Absolutely. And I think this, I see it so often that I think it's so important to recognize that sleep apnea is often underrecognized in our populations where we are seeing and getting referrals for women with sleep apnea that have not undergone formal testing. So if nocturia is that primary symptom, I think it is important to consider doing, you know, either, you know, modifying a bladder, not just a bladder dia, but a frequency volume chart to really capture what is the volume of urine produced at night versus during the day because that could be a symptom of sleep apnea. But we also know that older adults tend to have more nocturnal urine output. So I think it's really an important intersection of comorbid disease and bladder symptoms. And I think the trials out there actually show us that nocturia improves with appropriate treatment and adherence to treatments for sleep apnea. So and there's actually been, I've heard a lot of urologists and other specialists really say nocturia is not even a bladder problem. It has so much more to do with fluid than it is itself a bladder problem. So I think it's a great question. So thank you. All right. We have another one. Do you use a frailty index clinically? If so, which one do you prefer and why? You know, I think that's a great question, too. I currently don't use a frailty index because I feel like there are some good ones out there. But I think you've got to do more than just a questionnaire assessment. And I think this is the hard part clinically. I think if we all considered gait speed as another vital sign, I think that would be great. I really wish we could do more of that. We do tend to measure frailty in our geriatric clinics. And we do try to measure longitudinally weight loss and functional status. But I can say honestly in like a continence clinic setting, I'm not always doing the best at screening for it. However, we do screen for it in not the use of a validated measure per se, but just looking at those factors and trying to hone in on them. I do think there's some great frailty measures out there that are in use in terms of epidemiologic research to kind of go around it. But I think we all could do a better job of finding a good, useful, validated index that can be used clinically. And to date, I haven't been able to find it. Okay. That is great. Let's see. We have another one. Have there been any studies that look at not only physical therapy for PFMP, behavioral health effects, but also gait training and reducing barriers to physically getting to the bathroom? Great question. Yeah, that's a great question. And yes, there actually has been some trials looking at, and I think it may have been a secondary outcome, but actually doing gait training in conjunction with pelvic floor muscle training and showing that you had actually, with the combined gait and pelvic floor muscle training, some improvements in urinary symptoms. However, I think most of the studies in this area tend to be smaller. They're not large scale, and it's sometimes hard to draw conclusions. But I think that's a really ripe area that needs more exploration. I can say that in a nursing home setting, so you take very debilitated older adults, that prompt avoiding can be much more effective if you combine it with functional training, so physical therapy on gait and helping them functionally, patients get up and down out of a chair. The combination is much more effective than just prompting alone. So I would tend to believe that if it works in a nursing home population, it potentially could work in a population of older women who really do have some limitations that could really benefit maybe even in home physical therapy or some structured program. And I do believe there's people out there studying it now. So I think there's going to be some really great studies coming out soon. And this is Leslie. I have a question. I know that diabetes is associated with more lower urinary tract symptoms. Is there evidence that treating the diabetes and reducing the glucose urea improves bladder symptoms or lower urinary tract symptoms? Yeah, I think that's a great question because I think we all kind of just assume that that's a checkmark. But honestly, I haven't seen a clinical trial specifically with that as the primary outcome. I think sometimes I've seen it as a secondary outcome that by improving glucose, like a diabetes intervention trial that you secondarily may improve by improving diabetes. You can improve bladder symptoms, but it's not always the primary outcome, which makes it kind of hard sometimes to draw a cause and effect. I mean, there is suggestions for sure that improving glucose improves bladder function frequency and potentially urgency. But again, I think that's an area that needs further exploration too. Great. And one last final question that I think a lot of people struggle with is what do you do about prescribing an anticholinergic medication for a patient that's on other medications like for Alzheimer's or Parkinson's, complex medications? I mean, I usually put a call into the neurologist just to check, but what's your take on that? Yeah, that's a great question. I will say there has been some very small actually randomized controlled trials in Parkinson's disease. So Parkinson's disease, we know that that can affect bladder function and there was a trial with the use of, I think it was solafenicin, but it was either darafenicin or solafenicin. But it definitely, you can give that medicine safely and get relief in Parkinson's patients in a very small clinical randomized trial that was done across multiple centers. So there is some evidence for Parkinson's disease. Now, however, we don't have that same evidence, to my knowledge, in patients who are on anticholinesterase inhibitors. So the whole goal of the anticholinesterase inhibitors for people with Alzheimer's and mixed dementias are to increase acetylcholine in the brain. And so it seems counterintuitive to give an anticholinergic medicine for the bladder at the same time as giving a medication like that for Alzheimer's disease. And so I think we tend to, and I know I've done it, but it's after having a long conversation with a caregiver that we can try this medication and knowing the benefits and risk, it may or may not be helpful, but our whole goal is not to cause harm. So I have tried medication with success and also without success of improving symptoms in people that are on anticholinesterase inhibitors. So I think we don't have a lot of data to guide us on that. But having those conversations on benefit and risk can be done. And again, it just boils down to a close follow-up and knowing that if they're helpful, we just monitor potential adverse events. And if they cause problems, you stop them. Great. I think we are, sorry, I'm just checking the question board, sorry. Good. Well, I think we're at the end of our time and we got all the questions answered. So a big thank you to Dr. Marklin for your fantastic presentation. I think this is a challenging population to deal with and I think we can't just ignore this population or say they're too old or too frail to treat. So I think you gave a lot of evidence that it is safe to treat these folks and good treatment points. So thank you to you for carving time out of your schedule and thank you also to all of our participants for taking the time out of your days to participate in this virtual forum with our speaker and with each other. As I stated before, upon completion of this program, you'll be prompted to provide feedback. So please do share your thoughts and impressions with us. And so we are also looking forward to our next program on Wednesday, April 7th. Again, it's 7 p.m. Eastern. Our speaker will be Dr. Elizabeth Miller talking about the aerodynamic evaluation of lower urinary tract symptoms. So until then, everybody be well and we will see you next month.

virtual web-based lecture series

geriatric considerations

women

urinary incontinence

lower urinary tract symptoms

LUTs

aging

reversible causes

behavioral interventions

medication options