FFS!

Before you panic and think I’ve lost the plot and started swearing in my blog – FFS doesn’t stand for anything bad. (Even though with our politicians behaving badly you may well have been throwing the odd one of these around- Really? You’re shutting down parliament for a week?? Is that even allowed?)

No FFS stands for Falls & Frailty Suck. And they truly do. The last thing you want as you enter the age groups where they start classifying you as elderly, is to be also told you are frail. Because with frailty, comes other risk factors such as increased risk of falls and increased risk of urinary incontinence.

At our recent CFA conference in Sydney- I became aware that the word frailty kept cropping up. It was in quite a few lectures and I have to say I haven’t really been so aware of its use before.

Frailty is defined as the condition of being weak and delicate –‘the increasing frailty of old age’– if you look for synonyms- infirmity, weakness, weakliness (who knew that was a word?) feebleness, debility, enfeeblement, incapacity, impairment, indisposition. 

Now they are all yukky words and ones I do not want to be remembered for as I age. ‘Oh you remember Sue Croft? She was that pelvic floor physio who demonstrated weakliness and enfeeblement in her 90’s’. Whilst I may have spent most of my life dreaming of being a size 8, like a model on a catwalk, but in fact struggled with weight issues constantly – what I know is, being underweight when you are in the elderly category is not good. If you have a fall, you are more likely to break something if you don’t have much fat covering things. And we do store some oestrogen in our fat which helps with our bone density.

No I want to be strong, robust, powerful, healthy with synonyms being vigorous, sturdy, tough, powerfully built, solidly built, as strong as a horse/ox, muscular, sinewy, rugged, hardy, strapping, brawny, burly, husky. 

‘You remember Sue – she was that strapping, rugged, sinewy retired (it must happen one day) pelvic floor physio’. 

Sadly frailty happens – especially if as you get older you are afflicted with ailments of back/hip/knee pain which then affects your mobility and this causes you to respond by sitting more and more and ultimately stopping exercising altogether. And as I mentioned earlier, frailty sadly also contributes to your risk of falls and many other conditions including osteoporosis.

We had a great lecture at the 26th CFA Conference in Sydney from Dr Adrian Wagg (Capital Health Endowed Professor of Healthy Ageing and Division Directore for Geriatric Medicine at the University of Alberta in Edmonton, Canada) on Incontinence in the frail elderly: report from the 6th International Consultation on Incontinence.

He defined frailty from the medical perspective.

Phenotypic model

• Involuntary weight loss (>10%)
• Weakness (grip strength <20th centile)
• Slowness (<1.0 m/s)
• exhaustion
• Decreased physical activity

Accumulated deficits model

The more things wrong with you, the worse you do….it’s called the Frailty Index. It’s independent of the exact number or nature of deficits. It’s a continuous measure derived from a Comprehensive Geriatric Assessment.

Urinary incontinence when affecting the elderly has multiple risk factors across multiple organ systems and domains.

• Co-morbidities (other disease processes going on)
• Medications (multi-pharmacology)
• Physical function impairment
• Cognitive function impairment

There are many changes that occur with the Lower Urinary Tract (LUT) physiology with age:

Decreasing: Bladder capacity, sensation of filling, speed of contraction of the detrusor, contractile function, pelvic floor muscle bulk and tone, sphincteric resistance, urinary flow rate.

Increasing: Urinary frequency, prevalence of post-void residual volumes, outflow obstruction.

Adrian spoke about the link between periventricular white matter hyperintensities (in the brain).Studies in community-dwelling elderly link these structural white matter changes with: Mobility impairment, cognitive impairment, urinary urgency, urinary incontinence and increased prevalence of detrusor overactivity on urodynamic studies.

As you age there is a dramatic increase in multi-morbidity (defined as greater than 2 diseases) but elderly OAB (overactive bladder) patients have more co-morbidities than those without OAB.

Some examples of associated conditions and urinary incontinence:

Peripheral vascular disease, diabetes mellitus, congestive heart failure, venous insufficiency, chronic lung disease, falls and contractures, sleep disordered breathing, stroke, dementia, diffuse Lewy Body disease, Parkinson’s disease, normal pressure hydrocephalus, recurrent infection, constipation, obesity.

So what are the strategies to manage this?

Recognise the conditions which might be impairing ability to toilet successfully and think wider than simply LUTS and toileting. But there is no reason why the normal strategies that we would employ for a younger cohort cannot be employed to treat the frail elderly.

Individualised and influenced by: Goals of care, treatment preferences, estimated remaining life expectancy. Sometimes the only possible outcome may be containment (especially with decreased mobility and dementia).

Recommendations for practice:Active screening for incontinence in all older frail persons as they don’t spontaneously report their symptoms; clinicians need to assess and manage co-existing co-morbidities (which may impact on continence status or the ability to toilet); environmental cues such as toilet visibility, signage, colour differentiation in frail older patients with cognitive impairment.

He talked about the 4 M’s

Mentation, mobility, motivation and manual dexterity.

There should be a comprehensive continence assessment before any recommendation for containment pads; interventions for incontinence should be multi-component, interdisciplinary and person centred; support for caregivers.

Treatment: 

Fluid management; caffeine restriction; alcohol restriction. Dehydration may actually increase the risk of UI in frail elders because of its significant association with constipation and delirium.

Prompted voiding except when people need the assistance of more than one person to transfer- these elders should be managed with ‘check and change‘ (of pads). Functional training in combination with PFMT (pelvic floor muscle training) reduces urinary incontinence and improves walking time in frail older women (Level 2 evidence) (Wagg A Incontinence in frail older persons” ICI 2017)

Impaired mobility:

Many studies have shown an association between stress and urge incontinence and a reduced level of physical activity or physical impairment: Poor mobility 4.7 times the risk of UI; difficulty walking increased the odds of UI by 23-81%; physical impairment measured by SF-36 associated with any and severe UI; ADL disability increased risk of UI by 175%,; increased prevalence of UI associated with physical impairment.

Pharmacological interventions:

• Short term treatment with oxybutynin-IR has small to moderate efficacy in reducing urinary frequency and urgency UI when added to behavioural therapy in long term care residents. (level 2 evidence)
• Low dose oxybutynin ER does not cause delirium in cognitively impaired nursing home residents. (Level 1)
• Oxybutynin IR has been associated with cognitive adverse effects in persons with dementia and or Parkinsons disease (Level3).
• Fesoterodine is effective in ameliorating the symptoms of OAB in robust community dwelling and medically complex older people (Level 1) – this drug is not currently available in Australia.
• There is insufficient to determine the efficacy, tolerability and safety of the following agents in the elderly (Level 4): intravesical Oxybutynin, transdermal Oxybutynin, Tropsium, Tolerodine, Darifenacin, Solifenacin, Mirabegron, Duloxetine, oral and topical oestrogen.
• Excessive anticholinergic load is associated with cognitive impairment in frail older adults (Level 3)
• Anticholinergic agents should be prescribed with due regard to underlying anticholiergic load in older persons. (level 3)
• The effect of cholinergic load on persons with mild demetia is uncertain (Level3).

(Wagg A Incontinence in frail older persons” ICI 2017)

An algorithm from the 2017 ICI Report on Incontinence in the frail elderly

The most important messages I would like you to take from this:

• Start moving, keep moving, stay moving.
• Work on having a healthy bladder and bowel in your earlier years and throughout your life, so your later years are less bothersome
• If you are a patient reading this – take care when putting any medication in your mouth
• If you are a health care professional – then treat your elderly patients as you would your younger patients- they are never to old to be properly assessed and given an evidence-based treatment plan
• Keep your bones as strong as you can – healthy diet, lots of exercise, good variety of exercise, lots of extension exercises, Vitamin D levels adequate.

And below is a little bit of light-hearted fun from my Mum’s mate, Peg. (They are both around 92 with marvelous intact brains.)

Nine Important Facts to Remember as We Grow Older

#9 Death is the number 1 killer in the world.

#8 Life is sexually transmitted.

#7 Good health is merely the slowest possible rate at which one can die

#6 Men have 2 motivations: hunger and hanky panky, and they can’t tell them apart. If you see a gleam in his eyes, make him a sandwich.

#5 Give a person a fish and you feed them for a day. Teach a person to use the Internet and they won’t bother you for weeks, months, maybe years.

#4 Health nuts are going to feel stupid someday, lying in the hospital, dying of nothing.

#3 All of us could take a lesson from the weather. It pays no attention to criticism.

#2 In the 60’s, people took LSD to make the world weird. Now the world is weird, and people take Prozac to make it normal.

#1 Life is like a jar of jalapeno peppers. What you do today may be a burning issue tomorrow.

Thanks to Dr Adrian Wagg for many wonderful lectures at the conference.