**8. Diagnostic approach of the urinary incontinence in the frail elderly**

In most frail older patients with incontinence, non-invasive diagnostic evaluation can be successfully done, and it will help to decide the conservative management of the patient. As previous mentioned, on the basis of basic step with its components (medical, pharmaceutical, functional, urinary diary, questionnaire of QOL, and a physical

Geriatric Urinary Incontinence – Special Concerns on the Frail Elderly 125

looking more for quality of life instead of the cure of medical problem. Unfortunately, in some patients with immobility or severe dementia, the only alternative could be the use of

Nowadays, the conservative treatment of UI is considered as the mainstay in its management (grade A of recommendation). There are several effective interventions such as: modification of fluid intake pattern; modification of drug treatments; type of clothes used; palliative aids; environmental manipulations; detection and correction of transient causes (especially delirium in the frailest population); and the use of behavioural procedures

Behavioural techniques have been demonstrated be an effective tool in the management of several types of incontinence in the elderly. The technique used depends on the individual's functional and cognitive state. In general, if the patient doesn't have cognitive impairment, pelvic floor muscle exercises and bladder training can be used successfully. For patients with cognitive impairment, the best alternative is prompted voiding (Level 1 of evidence)

It is very important to highlight that all of these techniques have show to reduce the severity of urgency and stress incontinence (grade A of recommendation) (Burgio, 2009; Price et al, 2010). In cases of institutionalized older patients and cognitively impaired, scheduled and prompted voiding have demonstrated to reduce the number of leakages of urine and the severity of the incontinence. However, these techniques require many caregivers and staff in nursing home, so it is not always possible to use them in the disabled and frailest elderly

Moreover of these general interventions, there are several effective pharmacological agents such as antimuscarinics, serotonin and noradrenaline re-uptake inhibitor (SNRI) e.g.

At the present time, there are several available antimuscarinic drugs with a different profile based on the ability to block the muscarinic receptors. Moreover, we have to choose the antimuscarinic drug based on the safety profile. All the antimuscarinic drugs have been widely tested in randomised controlled trials and demonstrate to produce a positive effect in the treatment of urge and mixed incontinence, with about 50% reduction of leakages compared with placebo (Thirugnanasothy, 2010). According to the results of many trials of the incontinent frail elderly population, the overall efficacies of the different antimuscarinic drugs are similar, and so the initial choice of this agent should be based on its safety profile. If one antimuscarinic agent doesn't provide satisfactory relief of symptoms, an alternative

In some cases, we could decide to use antimuscarinics drugs based only on clinical symptoms (frequency, urgency, and nocturia), and also on the severity of leakages

(Wyman et al, 2009; Imamura et al, 2010; Abrams et al, 2010; DuBeau et al, 2010).

palliative aids and general care.

**9.1 Conservative management** 

(Markland et al, 2011).

patients (Thum & Wagg, 2009).

**9.2.1 Antimuscarinic drugs** 

antimuscarinic should be tried.

**9.2 Pharmacologic management** 

Duloxetine or anti-diuretic homones e.g. Desmopressin.


Table 8. Main criteria to refer a frail elderly for specialty evaluation

examination) we are able to distinguish between an acute cause or a chronic cause of incontinence, to detect the great majority of the transient causes, the main risks factors for incontinence and to recognize the clinical type of UI and its main symptoms. With this information would be possible to decide the plan of treatment and the follow-up of the older patients with incontinence.

If the basic step does not drive the physician to a conclusive diagnosis of UI type, or in cases that conservative management of the frail older patients has failed, more extensive or invasive diagnostic techniques should be planed individually. In some cases, could be necessary to practice several complementary techniques in order to discover the etiologic mechanism of the incontinence and also the status of the upper urinary tract.

The gold standard technique in diagnosis of established incontinence is Urodynamics, allowing demonstrate whether an underlying abnormality of storage or voiding is present. Nowadays, this technique is not appropriate for all older patients, and usually it is reserved for selected patients (Thirugnanasothy, 2010). Probably, the main recommendations for this technique in the frail elderly population, is the demonstration of a significant PVR and before planning a surgical procedure to repair urinary incontinence (Verdejo, 2011).

Based on the results of these techniques, especially on Urodynamics, we can obtain definitive diagnosis of UI type and organize better the complete and multidimensional plan of treatment.
