**9.2 Pharmacologic management**

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

#### **9.2.1 Antimuscarinic drugs**

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 antimuscarinic should be tried.

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

Geriatric Urinary Incontinence – Special Concerns on the Frail Elderly 127

Unfortunately, in the cases of chronic urinary retention or bladder impaired contractility in which the patient keeps a high PVR, should be considered the insertion of an urethral catheter. Intermittent catheterisation is usually safer and effective but obviously requires the patient or the carers to be able to learn and practice this technique. When intermittent catheterisation can not be possible, urethral catheter should be considered, with the secondary risks of this technique (infection, hematuria, urethral trauma, accidental

The main indications for long term indwelling catheterisation are exposed in the table 10.

In the last years the development of surgical procedures has been very important, especially for repairing stress incontinence. Nowadays, we can obtain good results with several







the frail and disabled elderly, and it is associated with a lot of problems.

(it can be performed via a fine needle inserted percutaneously near the ankle).

**Chronic bladder outlet obstruction and surgery is not appropriate Patients or carers are unable to manage intermittent catheterisation** 

**Patients with pressure sores (transient indication)** 

Table 10. Main recommendations for using a long term indwelling catheter:

incontinence who have high comorbidity and high surgical risk.

an average patient satisfaction about 50% at 12 months

response (Duthie et al, 2007; Verdejo, 2011).

**10. Key points in the care of the incontinent frail elderly** 

**Patients severely affected by the leakages Managing incontinence in end of life situations** 

**9.2.5 Catheterisation** 

removal) (Thirugnanasothy, 2010).

**9.3 Surgical procedures** 

techniques (Way, 2009):

bladder damage).

(moderate or severe), but with several requisites: the physical examination and the lab tests have to be normal. In this sense, the theoretical side effects on cognitive function must not limit its use in the elderly (Wagg et al, 2010). Furthermore, in all the cases, we must analyze the individual risks of this treatment with a close follow-up of the frailest older

Table 9 shows a list of drugs with antimuscarinic action most commonly used in the treatment of incontinent frail older patients, with their level of evidence and grade of recommendation (Schröder et al, 2009; DuBeau et al, 2010).


Table 9. Antimuscarinics most commonly used in the incontinent frail elderly

#### **9.2.2 Desmopresin**

Desmopresin is a synthetic vasopressin analogue, with strong anti-diuretic effects. It could be very useful in the treatment of nocturia, but with risk of hyponatremia (between 7.6 to 10%), especially in the frail elderly patients. In addition, desmopresin should not be used in frail elderly due to the high risk of hyponatremia (level 1 of evidence) (DuBeau et al, 2010; Abrams et al; 2010).
