**3. Aging of the urinary tract – Role of the comorbidity and the polypharmacy**

With aging, the lower urinary tract undergoes to a series of morphological and/or functional changes that can lead to a different dynamic behaviour and the possibility of

Frailty is a non-specific state of vulnerability, which reflects multisystem physiological change. These changes do not always means a disease status, so some very elderly, are frail without a specific life threatening illness. Current thinking is that, not only the physical way contributes to this syndrome, because also psychological, cognitive, and social factors take a

Together, these signs and symptoms seem to reflect a reduced functional reserve and consequent decrease in adaptation to different type of stressors, and perhaps even in the absence of extrinsic stressors. The overall consequence is that frail elderly are at higher risk for accelerated physical and cognitive decline, disability and death. All these frailty's characteristics can easily be applied to the definition and characterization of the aging process per se, and there is little consensus in the literature concerning the physiological/biological pathways associated with or determining frailty. It is probably true to say that a consensus view would implicate heightened chronic systemic inflammation as

Many other authors have focused on the popular definition proposed and tested in the Cardiovascular Health Study in the United States and known as the phenotypic definition of frailty. That study defined frailty by the occurrence of at least 3 of the following 5 deficits in an individual: slow walking speed, impaired grip strength, a self-report of declining activity levels, unintended weight loss, or exhaustion. In addition to the phenotypic and other approaches, frailty is considered as a risk state caused by the age-associated accumulation of

The frailty can be considered as a complex phenomenon, with multiple links and interactions between the clinical, functional, mental and social components. In this sense, the use of the Geriatric Comprehensive Assessment (GCA) could be very useful in the detection of the frail condition of an older people. Through assessment of general health (comorbidity), function, cognition, mood and motivation, the special senses, nutrition and medications, this tool facilitates identification of health issues and the appropriate intervention and follow-up for them. As part of a comprehensive management plan, CGA also supports continued independence and improved quality of life for an individual in association with reduced medical costs (Rockwood & Mitnitski, 2011; Rosen & Reuben,

Based on these concepts, a frail elderly would be a very old person (usually more than 80-85 years), with high comorbidity, functional handicaps, cognitive impairment and also limitations in the familiar and social areas. In this group of older persons, it is expected the

In frail elderly, UI constitutes a syndromic model with multiple interacting risk factors, such as age-related physiologic changes, comorbidity, and common pathways between them, in which the accumulated effects of multiple impairments increase vulnerability to situational

**3. Aging of the urinary tract – Role of the comorbidity and the polypharmacy**  With aging, the lower urinary tract undergoes to a series of morphological and/or functional changes that can lead to a different dynamic behaviour and the possibility of

highest known prevalence of UI of any group of age (around 50-70%).

decisive role and need to be taken into account in its definition and treatment.

a major contributor to frailty (Fulop et al, 2011).

deficits (Rockwood & Mitnitski, 2011).

changes (Inouye et al, 2007).

2011).

alterations in urine storage and bladder emptying functions. These functions as well as urinary continence are maintained due to the integrity of the lower urinary tract, the nervous system, the visceral supporting mechanism (pelvic floor) and the urine production mechanism. There must also be adequate perception and interpretation of the urge to pass urine, as well as the physical capacity to go to the toilet and to perform the activity.

The most relevant changes of lower urinary tract with aging are listed in Table 1.


Table 1. Lower urinary tract: main physiological changes with aging

In general, it is accepted that detrusor muscle contractility, bladder capacity and ability to put off micturition decrease in both sexes with aging. In addition, the prevalence of bladder hyperactivity increases. In women the maximum pressure of urethral closure and length of the functional urethra decreases, and post-micturition bladder residual volume increases up to 50-100 ml. Physiologically, elderly people tend to excrete more urine at night, even when there are no exacerbating factors such as heart failure, venous insufficiency, renal disease or prostatism. In men the prostate increases in volume meanwhile hypoestrogenism in women affects both the genital apparatus and urinary tract. Thus, the healthy elderly individual is much more vulnerable to suffering urinary pathological processes such as incontinence, infections, urinary retention and outflow obstruction (Verdejo, 2000).

Geriatric Urinary Incontinence – Special Concerns on the Frail Elderly 117

**MEDICATIONS EFFECTS ON CONTINENCE Diuretics Polyuria, urgency, frequency** 

**Triciclic Antidepressants Sedation, anticholinergic effect** 

**α-adrenergic antagonists Decrease urethral resistance** 

**Selective Serotonin Reuptake** 

**Angiotensin Converting Enzyme inhibitors** 

impaired contractility).

**4.1 Acute or transient incontinence** 

**D Delirium Dementia** 

 **Retention I Infection Inflammation Impaction Stool P Pharmaceutical agents** 

 **Polyuria** 

**R Restricted Mobility** 

(acute or chronic).

**Inhibitor** 

**Hypnotics Sedation, impaired mobility, delirium Antipsychotics Sedation, impaired mobility, parkinsonism, delirium Anticholinergics Delirium, stool impaction, urinary retention** 

**Opioid analgesics Immobility, stool impaction, delirium, urinary retention Cholinesterase inhibitors Increase bladder contractility, urgency** 

**sedation** 

**Cough** 

Table 3. Main drugs that can be associated with UI, with their mechanism of action

**Calcium antagonists Constipation, stool impaction, urinary retention** 

**4. Geriatric urinary incontinence – Main clinical types in the frail population**  There are several types of UI in the frail elderly population, and more frequently than other age groups, it could presents in a mixed form (urge + stress; detrusor hyperactivity with

A practical and useful approach to the frailest incontinent patient is based on its duration

Acute or transient incontinence it refers to cases of short course incontinence (lasting less than four weeks), including those situations in which loss of continence is considered to be functional, without any associated structural disorder. This clinical type of UI is very common in the frail elderly, especially in the more complex elderly and with higher disability. In these cases, the medical history and physical examination will often suggest the cause. The use of mnemonic rules (DRIP or DIAPPERS), has been proposed in order to

memorize the possible causes (Schröder et al, 2009; Griebling, 2009). (Table 4).

Table 4. Transient causes of urinary incontinence, based on mnemonic rules

**Stimulation of cholinergic bladder receptors,** 

**D Delirium/Dementia** 

**A Atrophic vaginitis P Pharmaceutical agents P Psychological causes E Endocrine conditions R Restricted mobility S Stool impaction** 

**I Infection** 

Since the last 10-12 years, the role played by the pelvic floor in micturition dynamics and especially in the maintenance of continence has been increasingly recognised. The age related deterioration in pelvic floor functions has a multifactorial origin (physiological and pathological). With increasing age, a reduction in the muscle fibre/connective tissue ratio has been demonstrated and the connective tissue becomes more elastic with less energy needed to provoke an irreversible lesion. Some of these changes have also been described in multiparous women and in those with pelvic prolapse. As well as oestrogen deficit, other factors contributing to the deterioration of the pelvic floor include mechanical trauma, and neurological denervation. These mechanisms can modify the normal angulation of the posterior wall of the bladder and the proximal urethra, leading to stress incontinence (Verdejo, 2000; Cheng, 2007).

In fact, physiologically, the frail elderly has a high risk to suffer the loss of continence. However, the physiological circumstances of aging, the multiple diseases characteristic of the frail elderly (dementia, motor disorders, cerebrovascular disease, Parkinson's disease, malnutrition), functional deterioration (immobility, dementia) drug treatment (diuretics, psychotropic agents, anticholinergics) (Ruby CM et al, 2010) and even iatrogenic factors (catheterization, physical restriction, adverse reactions) are going to have a significant influence on the function of the lower urinary tract (Verdejo, 2004; DuBeau, 2006).

Nowadays, it is accepted that greater responsibility is given to comorbidity, functional impairment (physical and / or mental) and polypharmacy to justify the prevalence of incontinence in the frailest elderly. Table 2 presents the main medical problems more frequently associated with incontinence in the frail elderly.


Table 2. Main medical and functional conditions associated with UI in the frail elderly.

However, it is very important to highlight that the pharmacologic treatment play a significant etiologic role in the loss of urinary continence, especially in the frail elderly, and it could be related to different mechanisms. Table 3 presents the main drug groups, along with its mechanism of action, most often associated with loss of continence or worsening the symptoms of incontinence.

Since the last 10-12 years, the role played by the pelvic floor in micturition dynamics and especially in the maintenance of continence has been increasingly recognised. The age related deterioration in pelvic floor functions has a multifactorial origin (physiological and pathological). With increasing age, a reduction in the muscle fibre/connective tissue ratio has been demonstrated and the connective tissue becomes more elastic with less energy needed to provoke an irreversible lesion. Some of these changes have also been described in multiparous women and in those with pelvic prolapse. As well as oestrogen deficit, other factors contributing to the deterioration of the pelvic floor include mechanical trauma, and neurological denervation. These mechanisms can modify the normal angulation of the posterior wall of the bladder and the proximal urethra, leading to stress incontinence

In fact, physiologically, the frail elderly has a high risk to suffer the loss of continence. However, the physiological circumstances of aging, the multiple diseases characteristic of the frail elderly (dementia, motor disorders, cerebrovascular disease, Parkinson's disease, malnutrition), functional deterioration (immobility, dementia) drug treatment (diuretics, psychotropic agents, anticholinergics) (Ruby CM et al, 2010) and even iatrogenic factors (catheterization, physical restriction, adverse reactions) are going to have a significant

Nowadays, it is accepted that greater responsibility is given to comorbidity, functional impairment (physical and / or mental) and polypharmacy to justify the prevalence of incontinence in the frailest elderly. Table 2 presents the main medical problems more

influence on the function of the lower urinary tract (Verdejo, 2004; DuBeau, 2006).

**Comorbidity \* Neurological diseases: Stroke; Dementias; Parkinson's disease;** 

Table 2. Main medical and functional conditions associated with UI in the frail elderly.

However, it is very important to highlight that the pharmacologic treatment play a significant etiologic role in the loss of urinary continence, especially in the frail elderly, and it could be related to different mechanisms. Table 3 presents the main drug groups, along with its mechanism of action, most often associated with loss of continence or worsening the

**\* Endocrine diseases: Diabetes Mellitus \* Cardiac diseases: Heart failure** 

**Neoplasms; Lithiasis; Prior Surgery.** 

**- Cognitive impairment; Dementia - Poor mobility; Immobility - Dependence on ADL's**

**spinal cord injury; autonomic and peripheral disautonomies** 

**\* Urological diseases: Benign Prostatic Hyperplasia; Infections;** 

**\* Gynaecological pathologies: pelvic floor damage; prolapses; prior** 

**\* Digestive diseases: chronic constipation; fecal impaction.** 

frequently associated with incontinence in the frail elderly.

**surgery**

**Functional impairment** 

symptoms of incontinence.

(Verdejo, 2000; Cheng, 2007).


Table 3. Main drugs that can be associated with UI, with their mechanism of action
