Are we shortchanging frail older people when it comes to the pharmacological treatment of urgency urinary incontinence?

Abstract

Overactive bladder and urgency incontinence are common and distressing conditions in older people, for which the first-line pharmacological treatment is a bladder antimuscarinic agent. Of these, oxybutynin is often recommended in guidelines, but is associated with a higher incidence of adverse drug effects, and in particular has been suggested to have deleterious cognitive effects. Despite this, guidelines often suggest oxybutynin as first-line treatment, and insurance based healthcare systems often require oxybutynin to be used as a first-line therapy and fail before reimbursement for the cost of newer anticholinergics is authorised. We reviewed the literature of bladder antimuscarinics in older adults, using the headings overactive bladder, urinary frequency, urgency, urge, oxybutynin, antimuscarinic, older, older people, and frail. In general, oxybutynin had a similar efficacy to other anticholinergic drugs, but a higher incidence of adverse drug events, in particular significant yet unnoticed cognitive impairment. We conclude that oxybutynin should not be used in frail older people.

Mirabegron, alone and in combination, in the treatment of overactive bladder: real-world evidence and experience

“…It has therefore been suggested that the use of oxybutynin should be avoided in the elderly, and in particular the frail elderly. 43 Anticholinergic side-effects, and in particular dry mouth, are the most commonly cited reasons for discontinuing treatment for OAB with antimuscarinic drugs. 24 Older adults are also more likely to be subjected to polypharmacy, the prescription of five or more medications, 44 which exponentially increases the risk of drug-drug interaction and potential for harm.…”

Are older women more likely to receive surgical treatment for stress urinary incontinence since the introduction of the mid‐urethral sling? An examination of Hospital Episode Statistics data

“…Although older women are also more likely than younger women to have urgency incontinence or mixed incontinence, which may be a factor in the clinical decision‐making when considering a sling, the rates of SUI in older women are high; in one large study, a third of women with leakage over the age of 65 had isolated SUI . Over recent years several drugs have become available for urgency incontinence that may be more effective or better tolerated in older women . It may be that more effective treatment of urgency or the urgency component of mixed incontinence has reduced the need for surgical treatment of SUI.…”

“…4 Over recent years several drugs have become available for urgency incontinence that may be more effective or better tolerated in older women. 46 It may be that more effective treatment of urgency or the urgency component of mixed incontinence has reduced the need for surgical treatment of SUI. However, it may be that older women simply want to avoid surgery, and in a managed and rationed healthcare environment, there exist financial and other factors which may provide implicit and explicit incentives to avoid costly interventions for conditions which are not life-threatening.…”

Practical points in the medical treatment of overactive bladder and nocturia in the elderly

“…Cognitive impairment is a serious concern in antimuscarinic therapy for elderly patients with OAB. Oxybutynin is often recommended in guidelines, but it is associated with a high incidence of cognitive impairment, and is therefore not recommended for use in frail older OAB patients [49]. …”