Evaluation and management of urinary incontinence in nursing home residents: unique considerations for an at-risk population

Introduction

Overactive bladder (OAB) and associated urgency urinary incontinence (UUI) are common diagnoses in the general population and more so among nursing home (NH) residents, affecting between 36–77% of individuals (1,2). Many NH residents with OAB/UUI have a variety of medical comorbidities that lead to nuances in their care (2,3). Furthermore, the NH environment itself can impact their care and attitudes towards their symptoms. The medical and social background of these patients can also affect the selected approach to treatment.

Epidemiology and definitions

The NH population, while small, is subject to a disproportionately high negative health burden (4-6). This population has higher medical acuity, more comorbidities, and a higher rate of medical errors compared to the general population (6-10).

A common comorbidity of NH residents is OAB, sometimes with associated UUI ((1,2). While bladder overactivity is a common etiology of UI in the NH population, the etiology of UI is often a combination of UUI, functional incontinence, stress UI (SUI), and overflow incontinence (11-13). As such, many articles reporting on UI in the NH population do not designate a type of UI but refer to undifferentiated UI. Therefore, while this article focuses on OAB/UUI, certain sections will present data on undifferentiated UI. Given the functional limitations of NH residents, functional incontinence will be discussed as well.

The International Continence Society (ICS) defines OAB as “Urinary urgency, usually accompanied by increased daytime frequency and/or nocturia, with UI (OAB-wet) or without (OAB-dry), in the absence of urinary tract infection or other detectable disease” (1,2,14). Functional incontinence refers to non-urologic causes of UI, such as impaired mobility and impaired cognition (15).

The prevalence of OAB/UUI in the general population varies in the literature depending on the definitions used for OAB and the population studied, with as many as 27.2% of men and 43.1% of women experiencing this condition (16-19). The rate of OAB/UUI in the NH population is higher than in the general population. A 2009 systematic review of undifferentiated UI rates in the NH population included 16 studies and found a UI prevalence ranging from 43–77%, with a median of 58% and a 2019 cohort study of 1.2 million NH residents noted that 36% had OAB (1,2).

UI in the NH and special considerations

UI in NH residents is associated with functional decline or frailty, decreased mobility and increased falls, lower cognitive function, and multiple other medical comorbidities. The intersectionality of UI with these medical and social factors in the NH population impacts the clinical approach to managing these individuals.

UI, frailty, functional status, and mobility in NH residents

There is a well-established relationship between UI and frailty, declining functional status, and difficulty completing activities of daily living (ADLs). Frailty is very common in the NH population, with a 2018 systematic review finding approximately 90% of NH residents were frail or pre-frail (20). Frailty itself is an evolving clinical entity that reflects an individual’s increased likelihood of having adverse outcomes compared to another individual of the same age (21). The Report on Incontinence in Frail Elderly Persons of the 6^th International Consultation on Incontinence defines a frail person “as someone aged 65 years or over and with some or all of impaired physical activity, mobility, strength, nutrition, and endurance” (22). Frailty and incontinence have both been identified as “geriatric syndromes”, which are described by Inouye et al. as “multifactorial, and associated with substantial morbidity and poor outcomes” (22,23). There is substantial overlap of these two syndromes, as those with frailty had twice the incidence of UI at 39.1% compared to 19.4% of those without (24). While frailty is not equivalent to disability, multiple studies have demonstrated this relationship between frailty or decreased ability to perform ADLs and lower urinary tract symptoms (25-27).

Difficulty completing ADLs, decreased functional status, and reduced mobility can limit one’s ability to reach a restroom in time and significantly impact continence. In the NH population, reduced functional status and associated measures such as up-and-go testing and chair-sit-and-reach testing are strongly associated with UI and can result in functional incontinence (28,29). Impaired ADL performance was one of three factors found to be 91% predictive of UI in the NH population, along with diminished alertness and fecal impaction (3). Multiple other studies support this relationship (29-32). Decreased mobility, need for a wheelchair, and physical restraints have similarly been associated with UI in the NH population (1,33-35).

UI in the NH resident is closely and consistently related to functional decline and frailty. While otherwise healthy persons can certainly have UI, when placed in a clinical context of overall declining health status, UI can be considered a marker of a patient’s functional status (10).

UI and medical comorbidities in NH residents

The presence of UI in NH residents has been associated with several other medical comorbidities, including hypertension, electrolyte disorders, and fecal impaction (2,3). Again, this needs to be contextualized within the setting of higher levels of frailty as well. That is, not only are NH residents with UI more likely to have several co-existing medical comorbidities, but if they are frail, they are also more likely to have negative outcomes as a result of these conditions.

One of the most cited comorbidities of UI is fecal incontinence (FI) (11,29,31). NH residents with one kind of incontinence are more likely to have dual FI and UI (33,36). Both FI and UI are pelvic floor disorders, and both have been found to be markers of overall physical decline (11).

UI and cognitive decline in NH residents

UI is associated with a decline in cognitive measures in addition to the medical ones noted above (29,30,37). Up to 64% of NH residents have a diagnosis of dementia or have cognitive impairment and the prevalence of UI in NH patients with dementia is as high as 84% (38-42).

Multiple large cohort studies have supported the relationship between cognitive performance and UI. A Swiss cross-sectional study of over 40,000 NH residents by Schumpf et al. found an association between cognitive performance scales and UI (32). A cross-sectional study of 29,000 NH residents also supported the association of decreased cognitive performance with UI, in conjunction with decreased ADL performance and frailty (36). Moreover, UI is more likely to develop in patients with dementia than in those who are cognitively intact, and once a patient with dementia has UI, it is more difficult to treat (43).

Delirium and psychiatric comorbidities

Delirium and the use of certain psychiatric medications both represent reversible causes of UI (44). Delirium frequently coexists with UI and polypharmacy in the elderly (45,46). Psychiatric medications such as antipsychotics, antidepressants, and hypnotics are especially associated with UI in the NH population as are depression, anxiety, and insomnia (29,46,47).

Impact and temporal relationships

OAB/UUI in the general population is associated with a high healthcare burden and a significant economic impact, including decreased productivity (48). In the NH setting, UI increases residents’ yearly NH costs by five to ten thousand dollars (49,50). Broader measures of economic impact have placed the cost of UI in NHs in the order of billions (51,52).

Most studies support that UI predicts negative healthcare outcomes such as NH admission. In a 1997 retrospective study of nearly 6,000 NH residents, Thom et al. found the diagnosis of UI is associated with a 1/3 to 1/2 higher risk of hospitalization or 2 to 3 times higher risk of NH admission (53). Berete et al. performed a longitudinal, survey-based study of nearly 2,000 elderly participants over a longer 5-year timeframe and found several predictors of NH admission, including UI, fall history, depression, dementia, increasing age, lower educational status, living alone, and need for home health care services (54).

Not all data support the association between UI and negative healthcare outcomes. A recent, large retrospective study using data from over 600,000 NH admissions found that UI was protective against hospitalization (55). Other studies from the 2000s found that while treatment of UI can lead to improved functional outcomes, treatment does not appear to decrease the rate of hospitalization (56,57). A prospective cohort study of over 7,000 patients age 70 or greater, by Holroy-Leduc et al. found that while baseline incontinence in elderly patients was an independent predictor for a decline of Instrumental ADLs, it was not an independent predictor for NH admission or for higher rate of all-cause mortality (58).

Other studies have examined medical diagnoses that may predispose UI development and found that UI is more common following a diagnosis of Parkinson’s disease, dementia, stroke, depression, or congestive heart failure (53). A longitudinal study of individuals aged 60 years and older examined the development of both UI and frailty over 5 years. In this study, worsening frailty scores (per the 5-item modified frailty index) were associated with worsening lower urinary tract symptoms (59). Moreover, the longer the length of stay of an NH resident, the more likely they are to have UI (30,31).

Social and institutional considerations for UI in NH residents

UI and NH environment

Aside from a higher burden of medical comorbidities, NH residents with UI differ from elderly patients living independently because the stakeholders in their care differ– institutional, staff, nursing, and family preferences all play a role in these patients’ care (60).

Systemic barriers and factors related to nursing staff can hinder appropriate UI care in NH (57,61-64). A qualitative study of barriers to UI care in NH by Skotnes et al. identified three areas of concern: resident-related physical or cognitive barriers, barriers pertaining to nursing staff, and institutional barriers (61).

Structural barriers, as discussed by Skotnes et al., include a lack of resources, lack of organization, rigid routines, and lack of leadership (61). Other studies echo the lack of institutional support, including inadequate staffing, as a barrier impacting employees’ ability to properly manage UI (62,64). Lack of structural support can also result in low documentation and implementation of incontinence treatment plans, which then interplays with caretaker barriers to UI management (57).

Caretaker-specific barriers include gaps in overall caretaker knowledge or training and variable levels of caretaker expertise regarding incontinence care (65,66). Caretaker attitudes towards UI and even broader considerations, such as caretaker attitudes towards the elderly in general, impact UI care (61,62). For example, NH residents note a lack of open communication regarding UI (67).

Furthermore, staff attitudes and knowledge about incontinence care can impact their care preferences, which do not always align with resident preferences. A survey-based study found that nurses at long-term care facilities preferred timed voiding and behavioral modification at a higher rate than patients or families (68). Importantly, staff attitudes and staff well-being are vital to the therapeutic relationship; Caretaker satisfaction positively correlates to improved resident outcomes (69).

NH residents are not the only ones affected by NH structural deficits—NH employees themselves are subject to the institutional burdens of the NH environment and work under conditions of greater physical and emotional stress than their counterparts in the community (70). Incontinence care is physically and emotionally demanding for both caretakers and NH residents. When combined with structural shortcomings and the complexities of caretaker attitudes, incontinence care can predispose to elder abuse in a NH environment (71,72). In this manner, the NH environment exaggerates the social component of a medical condition.

NH resident and family perspectives on UI

The medical, social, and structural factors that differentiate NH residents from community residents also impact resident perceptions of their symptoms. A 2012 review by Ostaszkiewicz et al. details that NH residents have low expectations of cure or treatment success (71). They also report guilt and shame regarding NH staff providing sanitary care after episodes of incontinence (67,72-75) This can lead patients to attempt to self-treat with fluid restriction and pads rather than seek care (72).

UI also affects the relationships of patients with their family members. It can lead to family conflict about management strategies (Farage 2008), and the presence of UI impacts both family and patient medical decision-making on subjects beyond incontinence care (76,77). UI in the elderly places a large emotional and logistical burden on family caretakers (78).

UI and quality of life (QOL)

OAB/UUI negatively impacts QOL in both the general and NH population (25,31,79). OAB impacts overall health measures, sleep quality, and mental health (18,80-87). UI can also cause psychosocial distress and humiliation in addition to medical sequelae (75,86,87). UI was second only to cognitive and functional decline as a predictor of worsening QOL for institutionalized patients (88). UI was especially associated with worsened QOL in frail NH residents who already suffered from cognitive or functional decline (88). The NH-specific concerns of guilt, shame, and even abuse, while less tangible, must be considered when discussing QOL in NH residents with UI.

Evaluation

The evaluation of NH residents with suspected OAB/UUI is more nuanced than evaluation for the general population. The American Urological Association (AUA)/Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU) Guideline on Diagnosis and Treatment of Non-Neurogenic Overactive Bladder (OAB) in Adults recommends that the minimal assessment necessary for OAB/UUI in the general population is a medical history, physical exam, and urinalysis (89).

The guideline discusses the importance of taking a complete history of urinary symptoms including storage and emptying symptoms and fluid history (89). Comorbid conditions listed in the AUA/SUFU guidelines overlap with associations of UI in the NH population such as neurologic disease and FI. The AUA/SUFU guidelines also include the assessment of concerns that may lead to functional incontinence, such as mobility or cognitive deficits as part of a detailed history (89). Given the high burden of medical comorbidity in the NH population, as discussed above, obtaining a detailed history is of utmost importance in this population. Before treatment of UI symptoms, providers should attempt to identify potentially reversible or remediable factors that may contribute to incontinence (22). The Report on Incontinence in Frail Elderly Persons of the 6^th International Consultation on Incontinence provides a list of comorbidities and medications that affect the lower urinary tract to consider in frail elderly patients (22). Despite these recommendations, the current state of UI assessment in NH is lacking. An interview-based study of over 100 incontinent NH residents across 18 NHs found a majority of incontinent residents have no documentation of relevant medical history that would impact UI (57).

The AUA/SUFU guideline states the degree of bother and comorbid conditions that impact GU symptoms should be assessed as well. As previously discussed, the institutional environment affects residents’ perception of their disease process. While the AUA/SUFU recommends a physical exam as a minimal assessment, this is often not performed for NH patients. UI is under-evaluated in NH patients. Only 15% of patients with UI had a physical exam assessment, and only 2% of women undergo a pelvic exam as part of their evaluation (90).

All women with incontinence should obtain urine testing for infection or hematuria. However, the high prevalence of asymptomatic bacteriuria in the NH population makes the significance of positive dipstick in a resident with long-term UI less clear (91-93). Bladder diaries should be considered in this population, given that they may be less likely to provide reliable micturition information on inquiry (89,94). Further evaluation, such as cystoscopy or imaging, will vary based on the particular clinical situation of each patient (89,94).

Treatment

This review will focus on OAB/UUI treatment in the NH population. Any treatment algorithm for OAB/UUI must be considered within the institutional framework of NH living, in the setting of this patient population’s particular preferences, and in the setting of their comorbidities.

The AUA and the SUFU provide a stepwise algorithm for treating OAB/UUI, starting with conservative management, then medical management, and finally procedural or surgical management (89). This National Institute for Health and Care Excellence (NICE) 2019 guidelines for UUI similarly start with conservative management, as does the American Urogynecologic Society 2021 Clinical Consensus Statement (94,95). Of note, these guidelines are for the general population, not for the NH population.

Nuances as they pertain to the NH population will be highlighted when indicated. The Report on Incontinence in Frail Elderly Persons of the 6^th International Consultation discusses a treatment for UI in elderly frail patients, which is a population that overlaps with the NH population (22). The Report on Incontinence suggests a similar initial algorithm for management of UUI, suggesting lifestyle and behavioral interventions and a trial of medical management (22).

Considerations regarding functional incontinence

Treatment of other etiologies of UI should be considered and treated as clinically indicated. As previously discussed, NH residents may have multiple etiologies for UI, with UUI and functional incontinence being common etiologies (12,13). Decreased mobility, frailty, and impaired cognition can all contribute to functional impairment and, as a consequence, functional incontinence in this population (11). Therefore, when discussing treatment of OAB/UUI in the NH population, care must be taken to consider functional components of incontinence.

Conservative management

Conservative management for OAB/UUI the general population includes lifestyle interventions, including reducing caffeine, modifying fluid intake, and weight loss for those with a body mass index greater than 30 (94). Pads and incontinence undergarments are recommended as a coping strategy, not a treatment (94). Pelvic floor physical therapy and pelvic floor muscle exercises are also recommended as treatment strategies by both the AUA/SUFU and NICE (89,94). Of note, these guidelines are for the general population and do not account for the needs of the NH population.

Functional concerns are of special importance when discussing conservative management of OAB/UUI. Certain types of conservative OAB/UUI management, such as physical therapy and pelvic floor muscle exercises, are impacted by patients’ functional status. Behavioral interventions, such as timed voiding, are also impacted by functional concerns, such as impaired mobility or cognition. As such, the management of OAB/UUI overlaps with functional concerns and with the management of functional incontinence in the NH population. Moreover, behavioral modifications and pelvic floor physical therapy can also serve as treatment for SUI if patients have this form of incontinence as well (96,97).

This section, therefore, discusses treatment modalities for OAB/UUI as they pertain to NH residents, but with consideration towards functional concerns and functional incontinence. Of note, while the strategies discussed overlap with OAB/UUI conservative treatment, the study populations often include patients with undifferentiated UI. The lack of specificity regarding UI type means that care must be taken when drawing conclusions about OAB/UUI treatment. However, the benefit of discussing conservative management in NH populations with undifferentiated UI lies in the fact that these populations more closely reflect the clinical reality of NH care.

Multiple review articles support the benefit of conservative management for UI in the NH population (89,90). A 2023 systematic review of behavioral interventions for UI for female NH residents groups these treatment strategies into the following categories: voiding strategies, increasing physical activity, functional mobility training, pelvic floor muscle training, fluid training, and combinations of these (98). Voiding strategies, fluid training, and pelvic floor muscle training can serve as OAB/UUI treatments or SUI treatment, while mobility training and an increase in physical activity all treat functional aspects of incontinence.

With regard to behavioral changes such as fluid restriction, Shaw and Wagg discuss the potential dangers of this treatment strategy in frail older adults, warning fluid restriction in certain frail patients or patients with cardiac or renal comorbidities may lead to deleterious adverse effects and should be pursued with caution (99).

A 2019 review article on timed voiding found NH UI behavioral programs not only decrease the severity of UI, but also decrease negative medical sequelae and increase NH resident requests for voiding (100). Comprehensive voiding protocols often are resource intensive and require significant caretaker involvement and prompted voiding every 2–2.5 hours (98,101,102). While prompted voiding and behavioral programs often result in improvement in UI, NH residents can expect to have 1 to 2 fewer incontinent episodes per day, but may not achieve continence (100). In fact, full continence may not be achievable for many frail elderly patients with UI (22). Moreover, the AUA/SUFU acknowledge that conservative interventions require active patient participation, which may be limited in certain institutionalized patients (89).

Pelvic floor muscle exercises have been evaluated in elderly and frail patients and have been found to be beneficial for incontinence (103-105). While there is less data on institutionalized patients, available data supports the positive impact of physical exercise programs with or without pelvic floor muscle exercises on incontinence in NH residents (106,107). Of note, a randomized control trial of 256 NH residents found a physical exercise program and incontinence care every two hours led to improved continence outcomes, but would need significant increases in staffing to implement widely (108).

Despite recommendations for using incontinence pads for symptom coping, not treatment, most patients residing at NHs are managed primarily with these products (30). Many NH residents also receive concomitant toilet training and prompted voiding (30). Up to 15% have indwelling catheters, although rates vary depending on the setting (29,109).

The data in these reviews on conservative management have certain limitations: Most data is derived from studies on women, so generalizability to men may be limited. Moreover, while these data study conservative treatment strategies are used for OAB/UUI, the study populations included often had undifferentiated UI or aspects of functional incontinence (89).

UI treatment may have effects reaching beyond the condition itself. Behavioral and exercise-related interventions to treat UI can blunt functional decline and increase patient satisfaction (108). Even small institutional changes, such as utilizing a different type of UI pad, can improve patient satisfaction and comfort (110). In order for these changes to be effective, NH staff need buy-in and implementation at all levels is essential (111).

Given the medical and functional limitations of this population, additional measures may be necessary to maintain dry and intact skin, such as the use of external female catheters or bedside commodes (112,113). Another resource-intensive need of NH residents with UI is skin care. Approximately 6% of NH patients with incontinence will develop skin damage related to their incontinence (114). Holistic treatment of incontinence in the NH population requires the use of barrier creams and wipes to maintain skin integrity (115). Complete incontinence care with conservative measures involves a broader range of treatments and considerations in the frail NH population than in non-frail adults with the same condition.

Structural support is needed not only for incontinence programs, but also for associated skin-breakdown prevention and treatment (111). This is of even greater importance for patients with dual fecal incontinence and UI (11).

While institutional barriers can hinder the implementation of behavioral programs, strategies such as increasing staff education and decreasing staff turnover can help facilitate the adoption of incontinence programs (37,64). Education of NH staff should also be considered as part of conservative management of UI, because nursing education can lead to improved attitudes and increased compliance with treatment algorithms (111,116-118). System-wide collaborative changes that focus on teamwork, such as encouraging team meetings and discouraging a hierarchical approach to resident care, are often necessary to achieve a high implementation rate (64,119). While behavioral modifications for a community-living patient might involve only patient education, the same intervention is more nuanced and can involve a multi-level implementation strategy in this population.

Medical management

Medical management is the second line of therapy according to the AUA/SUFU and NICE guidelines. Historically, the cornerstone of medical management has been oral anticholinergics, but more recently, it has come to include beta-3 agonists. Anticholinergic use has gained attention recently as both the AUA/SUFU and the America Urogynecologic Society (AUGS) recommend using caution when prescribing anticholinergics in the elderly and frail population due to the increased risk of developing cognitive impairment, with AUGS recommending special caution in those aged 70 years or greater (89,95). The Report on Incontinence in Frail Elderly Persons of the 6^th International Consultation includes anticholinergic use in the algorithm for treatment of UI in frail elderly persons, but cautions about potential risks associated this class of medicines (22).

Anticholinergic use among the elderly has a historically high baseline, with nearly 40% of Medicare recipients between 2013 and 2015 with OAB taking anticholinergic medications (120). The NH population has an exceptionally high anticholinergic burden, with nearly 90% of NH residents having some anticholinergic use for any indication (121).

Emerging data have demonstrated an increased risk of dementia in patients receiving anticholinergic therapy, with a 2021 systematic review and meta-analysis noting that anticholinergic use greater than three months increases the risk for dementia by 46% (122). The risk of developing cognitive deficits is associated with the duration of exposure and has now been frequently documented in the elderly (123-129).

Studies of anticholinergics used for OAB treatment are more heterogeneous in terms of associations with cognitive impairment. Multiple short-term studies of anticholinergic medications (days to weeks) for OAB have often found no increased risk of dementia (130-134). In contrast, longer-term studies are more likely to demonstrate sustained cognitive adverse effects (135,136). Two case-control studies found anticholinergic use for greater than three months was associated with up to a 65% increased risk of dementia (122-124). The case-control study by Richardson et al., however, notes that certain OAB antimuscarinics, oxybutynin and tolterodine, are predominantly responsible for a significant amount of the urologic-focused data (123). A 2022 nested case-control study over a 5-year timeframe showed that anticholinergic OAB treatment was associated with a dose-response increase in the risk of developing dementia (135). However, a UK Biobank cohort study of over 500,000 participants found no association of urologic antimuscarinics and dementia, while finding such a relationship for antimuscarinic antidepressants, antiepileptics, and antidiuretics (137). Taken together, this suggests not all antimuscarinic exposure may lead to the same negative cognitive effects, but that there is reason for caution.

While not all anticholinergic exposure is associated with equally deleterious risk, anticholinergic use is now considered by certain authors as a modifiable risk factor of dementia (121,138). Conversely, a prospective non-intervention cohort study of general-population patients taking antimuscarinic medications for any indication indicates discontinuation of anticholinergics may be associated with a reduced risk of cognitive impairment (127). Polypharmacy in tandem with anticholinergics exacerbates these adverse effects (139). Beyond the society guidelines above, reviews regarding OAB medication safety urge practitioners to limit anticholinergic medications in elderly or vulnerable populations. If anticholinergics are prescribed in this population, certain precautions can be taken to decrease cognitive effects. Practitioners should consider medications less likely to cross the blood-brain barrier, such as the quaternary amine trospium (140). Other options include permeability-glycoprotein substrates such as trospium, darifenacin, and fesoterodine which are actively transported from the brain and result in lower central nervous system penetration (141).

Before the recognition that anticholinergics may lead to cognitive impairment, there was a body of literature concerned with the medical undertreatment of NH residents. Multiple retrospective studies of NH residents found that less than 10% of candidates for medical treatment receive it despite its effectiveness for UUI management (30,142). In fact, most studies in the elderly demonstrated the efficacy of OAB medications for this population, though they may be less effective than their younger counterparts or require a higher dose to achieve the same effects (134,143-146).

The low rate of OAB anticholinergic treatment In NH residents is no longer considered problematic, as it is now a protective factor—whether intentionally or not—for the NH population. A 2020 study demonstrated anticholinergic stewardship in NH, with OAB anticholinergics discontinuation in 2/3 of residents, often due to comorbidities or medication burden (147).

As opposed to anticholinergics, beta-3 agonists have a better safety profile and proven efficacy in the elderly population, including in those over 80 years old (148-150). In a double-blind, placebo-controlled study of mirabegron in elderly patients older than 65, the PILLAR patients 65 by Wagg et al. reported that 72% of patients taking mirabegron had a greater than 50% improvement compared to 60% of patients having that improvement on placebo (149). A prospective 12-week study of beta-3 agonists for UUI in 43 patients, including 12 with a Vulnerable Elders Survey (VES-13) score ≥7, over 80 showed improved OAB and UUI, and QOL, with a less than 5% withdrawal rate due to adverse events (148). A 2020 meta-analysis reported anticholinergics and beta-3 agonists are comparable in efficacy with beta-3 agonists while having fewer adverse events (151).

Medical management is appropriate in the NH population, but anticholinergics should be prescribed with caution in elderly or frail patients, which comprise most NH residents. While medical undertreatment with anticholinergics is now in line with current recommendations, the same is not valid for undertreatment with beta-3 agonists. Beta-3 agonists remain a viable medical treatment for OAB in the elderly and frail population given comparable efficacy to antimuscarinics and low rate of adverse events. Relevant patient comorbidities, such as uncontrolled hypertension, must be considered before initiation. Moreover, the financial impact of prescriptions should be considered, given that beta-3 agonists or certain antimuscarinics may be cost-prohibitive for certain patients (152).

Advanced therapies

Patients who do not respond to first-line therapy and are intolerant of or unable to take second-line pharmacotherapy may progress to the third-line treatments, which include chemodenervation of the bladder with onabotulinumtoxin-A (BTX-A), sacral neuromodulation (SNM), and percutaneous tibial nerve stimulation (PTNS) (89).

Third-line therapy may be appropriate in elderly or frail patients due to polypharmacy, medication adverse side-effect profiles, and contraindications to earlier lines of treatments. For similar reasons, third-line therapies in this population have their own set of considerations (153). Zillioux et al. provide an excellent review of third-line treatments for elderly patients, concluding that all three modalities are efficacious in this population and should be considered in appropriate patients (153). Of note, Zilioux et al.’s review is of elderly patients, and while there is overlap of the elderly population with the institutionalized population, one is not necessarily generalizable to the other.

BTX-A is an attractive therapy for the elderly population as it avoids the systemic effects of medical therapy and often avoids a procedure requiring anesthesia. BTX-A injections appear to be effective for treating refractory OAB in the elderly population, but no randomized control studies have studied the effect of BTX-A stratified by age (153-156). Overall, BTX-A may be less effective in the elderly population and associated with a higher risk of acute urinary retention, urinary tract infection, and elevated PVRs (153). A secondary analysis of the Refractory Overactive Bladder: Sacral NEuromodulation versus BoTulinum Toxin Assessment (ROSETTA) trial, which is a randomized control trial comparing BTX-A to SNM, found increasing age was associated with decreasing efficacy of BTX-A (157,158). Of note, there are currently no studies looking at the effects of BTX-A in the institutionalized population.

SNM is the implantation of a neuromodulator into the S3 foramen and is FDA-approved for refractory UUI and OAB. SNM is also FDA-approved for the management of FI, so it may be appropriate for patients with dual incontinence. SNM appears to be safe and to have a high rate of implantation in the elderly population, although some studies report that success may modestly decrease in the very elderly (153,159-164). Similarly, a secondary analysis of the ROSETTA trial found that older patients had poorer responses to SNM compared to their younger counterparts (157). A prospective study of 45 patients found that SNM was equally efficacious for frail and non-frail patients (165). However, no other prospective trials have examined the outcomes of SNM in the frail population. Moreover, in the elderly and frail population, appropriate surgical patient selection must be considered.

PTNS is safe and efficacious in elderly patients but is associated with poor compliance (153). Decreased mobility and difficulty with adhering to the schedule of twelve weekly ambulatory visits followed by maintenance therapy can also limit the practical implementation of PTNS in the NH population (166,167). Of note, a randomized control trial of transcutaneous tibial nerve stimulation (TTNS) versus sham in institutionalized patients found TTNS performed no better than sham (168). However, tibial nerve stimulation may be appropriate for certain elderly patients, given that it does not require surgery and does not carry the risk of UTI or urinary retention.

While there is some data regarding the third-line treatment in OAB in elderly patients, there is limited data regarding third-line therapies in NH residents. In the general population, third-line therapies are more effective for OAB/UUI treatment than medical management (169). Given the structural and epidemiologic differences between NH residents and other populations, the data on elderly persons may not be fully generalizable to NH residents. Moreover, the risks associated with sedation for third-line therapies such as SNM and potentially BTX-A must also be considered in this population, given that anesthetic risk increases in the elderly (170). However, considering available efficacy data and given the lack of systemic effects of advanced therapies compared to second-line medications, third-line therapies warrant consideration in the NH population.

Conclusions

The NH population has both a high rate of OAB/UUI and medical comorbidities, frailty, and diminished functional status. There are many factors specific to the NH environment that influence residents’ and staff’s attitudes toward UI care and ultimately impact the treatment provided for this condition.

Conservative management should be considered the first-line intervention for these patients, but there are clear and practical barriers to its implementation. Second-line medical therapy of beta-3 agonists should be considered in appropriately selected patients; however anticholinergics should be used with caution in frail or elderly individuals. Third-line procedural therapies may suit appropriately selected patients, but data about their outcomes in NH residents specifically is lacking.

NH residents constitute a population with unique needs, and research on the general public may not be generalizable for the institutionalized population. While current studies help to highlight nuances both in the population and their treatment, further study is warranted, especially in the domain of third-line OAB/UUI therapy for the NH population. The many barriers to UI management in the NH population highlight an important avenue for future research to improve the care of this at-risk population.

Acknowledgments

Funding: None.

Footnote

Peer Review File: Available at https://gpm.amegroups.com/article/view/10.21037/gpm-24-5/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gpm.amegroups.com/article/view/10.21037/gpm-24-5/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Offermans MP, Du Moulin MF, Hamers JP, et al. Prevalence of urinary incontinence and associated risk factors in nursing home residents: a systematic review. Neurourol Urodyn 2009;28:288-94. [Crossref] [PubMed]
2. Sura SD, Aparasu RR. PUK19 overactive bladder patients in the nursing homes: resident characteristics and treatment pattern. Value in Health 2019;22:S384. [Crossref]
3. Valk M, Moons KG, Cools HJ, et al. Classifying the probability of urinary incontinence in psychogeriatric nursing home patients. Arch Gerontol Geriatr 2002;34:79-91. [Crossref] [PubMed]
4. Post-acute and Long-term Care Providers and Services Users in the United States [Internet]. Centers for Disease Control and Prevention; 2017 [cited 2023 Dec 11]. Available online: https://www.cdc.gov/nchs/data/series/sr_03/sr03-047.pdf
5. Fact Sheet: Aging in the United Staes [Internet]. Population Reference Bureau; Available online: https://www.prb.org/resources/fact-sheet-aging-in-the-united-states/#:~:text=The%20number%20of%20Americans%20ages,more%20racially%20and%20ethnically%20diverse.
6. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington (DC): National Academies Press (US); 2022 Apr 6.
7. Castle NG, Ferguson JC. What is nursing home quality and how is it measured? Gerontologist 2010;50:426-42. [Crossref] [PubMed]
8. Ng R, Lane N, Tanuseputro P, et al. Increasing Complexity of New Nursing Home Residents in Ontario, Canada: A Serial Cross-Sectional Study. J Am Geriatr Soc 2020;68:1293-300. [Crossref] [PubMed]
9. Griffith MF, Levy CR, Parikh TJ, et al. Nursing Home Residents Face Severe Functional Limitation or Death After Hospitalization for Pneumonia. J Am Med Dir Assoc 2020;21:1879-84. [Crossref] [PubMed]
10. Bartley MM, Quigg SM, Chandra A, et al. Health Outcomes From Assisted Living Facilities: A Cohort Study of a Primary Care Practice. J Am Med Dir Assoc 2018;19:B26. [Crossref] [PubMed]
11. Leung FW, Schnelle JF. Urinary and fecal incontinence in nursing home residents. Gastroenterol Clin North Am 2008;37:697-707. x. [Crossref] [PubMed]
12. Resnick NM, Yalla SV, Laurino E. The pathophysiology of urinary incontinence among institutionalized elderly persons. N Engl J Med 1989;320:1-7. [Crossref] [PubMed]
13. Jerez-Roig J, Santos MM, Souza DL, et al. Prevalence of urinary incontinence and associated factors in nursing home residents. Neurourol Urodyn 2016;35:102-7. [Crossref] [PubMed]
14. ICS Glossary: Lower Urinary Tract Overactive Bladder (OAB) Syndrome [Internet]. International Continence Society; [cited 2023 Dec 11]. Available online: https://www.ics.org/glossary/symptom/lowerurinarytractsymptomluts
15. Alexander L, Shakespeare K, Barradell V, et al. Management of urinary incontinence in frail elderly women. Obstetrics, Gynaecology & Reproductive Medicine 2015;25:75-82. [Crossref]
16. Fenner DE, Trowbridge ER, Patel DA, et al. Establishing the prevalence of incontinence study: racial differences in women’s patterns of urinary incontinence. J Urol 2008;179:1455-60. Correction appears in J Urol. 2008;180:415.
17. Dooley Y, Kenton K, Cao G, et al. Urinary incontinence prevalence: results from the National Health and Nutrition Examination Survey. J Urol 2008;179:656-61. [Crossref] [PubMed]
18. Coyne KS, Sexton CC, Vats V, et al. National community prevalence of overactive bladder in the United States stratified by sex and age. Urology 2011;77:1081-7. [Crossref] [PubMed]
19. Coyne KS, Sexton CC, Bell JA, et al. The prevalence of lower urinary tract symptoms (LUTS) and overactive bladder (OAB) by racial/ethnic group and age: results from OAB-POLL. Neurourol Urodyn 2013;32:230-7. [Crossref] [PubMed]
20. Kojima G. Frailty as a Predictor of Nursing Home Placement Among Community-Dwelling Older Adults: A Systematic Review and Meta-analysis. J Geriatr Phys Ther 2018;41:42-8. [Crossref] [PubMed]
21. Rockwood K, Howlett SE. Fifteen years of progress in understanding frailty and health in aging. BMC Med 2018;16:220. [Crossref] [PubMed]
22. Gibson W, Johnson T, Kirschner-Hermanns R, et al. Incontinence in frail elderly persons: Report of the 6th International Consultation on Incontinence. Neurourol Urodyn 2021;40:38-54. [Crossref] [PubMed]
23. Inouye SK, Studenski S, Tinetti ME, et al. Geriatric syndromes: clinical, research, and policy implications of a core geriatric concept. J Am Geriatr Soc 2007;55:780-91. [Crossref] [PubMed]
24. Veronese N, Soysal P, Stubbs B, et al. Association between urinary incontinence and frailty: a systematic review and meta-analysis. Eur Geriatr Med 2018;9:571-8. [Crossref] [PubMed]
25. Yoshida M, Satake S, Ishida K, et al. A non-interventional cross-sectional re-contact study investigating the relationship between overactive bladder and frailty in older adults in Japan. BMC Geriatr 2022;22:68. [Crossref] [PubMed]
26. Bauer SR, Cawthon PM, Ensrud KE, et al. Lower urinary tract symptoms and incident functional limitations among older community-dwelling men. J Am Geriatr Soc 2022;70:1082-94. [Crossref] [PubMed]
27. Monaghan TF, Wagg AS, Bliwise DL, et al. Association between nocturia and frailty among elderly males in a veterans administration population. Aging Clin Exp Res 2020;32:1993-2000. [Crossref] [PubMed]
28. Chiu AF, Huang MH, Hsu MH, et al. Association of urinary incontinence with impaired functional status among older people living in a long-term care setting. Geriatr Gerontol Int 2015;15:296-301. [Crossref] [PubMed]
29. Farrés-Godayol P, Jerez-Roig J, Minobes-Molina E, et al. Urinary Incontinence and Its Association with Physical and Psycho-Cognitive Factors: A Cross-Sectional Study in Older People Living in Nursing Homes. Int J Environ Res Public Health 2022;19:1500. [Crossref] [PubMed]
30. Jumadilova Z, Zyczynski T, Paul B, et al. Urinary incontinence in the nursing home: resident characteristics and prevalence of drug treatment. Am J Manag Care 2005;11:S112-20. [PubMed]
31. Xu D, Kane RL. Effect of urinary incontinence on older nursing home residents’ self-reported quality of life. J Am Geriatr Soc 2013;61:1473-81. [Crossref] [PubMed]
32. Schumpf LF, Theill N, Scheiner DA, et al. Urinary incontinence and its association with functional physical and cognitive health among female nursing home residents in Switzerland. BMC Geriatr 2017;17:17. [Crossref] [PubMed]
33. Nelson R, Furner S, Jesudason V. Urinary incontinence in Wisconsin skilled nursing facilities: prevalence and associations in common with fecal incontinence. J Aging Health 2001;13:539-47. [Crossref] [PubMed]
34. Jachan DE, Müller-Werdan U, Lahmann NA. Impaired Mobility and Urinary Incontinence in Nursing Home Residents: A Multicenter Study. J Wound Ostomy Continence Nurs 2019;46:524-9. [Crossref] [PubMed]
35. Hakverdioğlu Yönt G, Kisa S, Princeton DM. Physical Restraint Use in Nursing Homes-Regional Variances and Ethical Considerations: A Scoping Review of Empirical Studies. Healthcare (Basel) 2023;11:2204. [Crossref] [PubMed]
36. Chiang L, Ouslander J, Schnelle J, et al. Dually incontinent nursing home residents: clinical characteristics and treatment differences. J Am Geriatr Soc 2000;48:673-6. [Crossref] [PubMed]
37. Kohler M, Schwarz J, Burgstaller M, et al. Incontinence in nursing home residents with dementia: Influence of an educational program and nursing case conferences. Z Gerontol Geriatr 2018;51:48-53. [Crossref] [PubMed]
38. Gaugler JE, Yu F, Davila HW, et al. Alzheimer’s disease and nursing homes. Health Aff (Millwood) 2014;33:650-7. [Crossref] [PubMed]
39. Alzheimer’s Association. 2013 Alzheimer’s disease facts and figures. Alzheimers Dement 2013;9:208-45. [Crossref] [PubMed]
40. Mukamel DB, Saliba D, Ladd H, et al. Dementia Care Is Widespread In US Nursing Homes; Facilities With The Most Dementia Patients May Offer Better Care. Health Aff (Millwood) 2023;42:795-803. [Crossref] [PubMed]
41. Rose AE, Azevedo KJ, Payne CK. Office bladder distention with electromotive drug administration (EMDA) is equivalent to distention under general anesthesia (GA). BMC Urol 2005;5:14. [Crossref] [PubMed]
42. Schüssler S, Dassen T, Lohrmann C. Care dependency and nursing care problems in nursing home residents with and without dementia: a cross-sectional study. Aging Clin Exp Res 2016;28:973-82. [Crossref] [PubMed]
43. Zhao P, Zhang G, Shen Y, et al. Urinary dysfunction in patients with vascular cognitive impairment. Front Aging Neurosci 2022;14:1017449. [Crossref] [PubMed]
44. Wilson JE, Mart MF, Cunningham C, et al. Delirium. Nat Rev Dis Primers 2020;6:90. [Crossref] [PubMed]
45. Hogan DB. Revisiting the O complex: urinary incontinence, delirium and polypharmacy in elderly patients. CMAJ 1997;157:1071-7. [PubMed]
46. Brandeis GH, Baumann MM, Hossain M, et al. The prevalence of potentially remediable urinary incontinence in frail older people: a study using the Minimum Data Set. J Am Geriatr Soc 1997;45:179-84. [Crossref] [PubMed]
47. Chen YM, Hwang SJ, Chen LK, et al. Urinary incontinence among institutionalized oldest old Chinese men in Taiwan. Neurourol Urodyn 2009;28:335-8. [Crossref] [PubMed]
48. Tang DH, Colayco DC, Khalaf KM, et al. Impact of urinary incontinence on healthcare resource utilization, health-related quality of life and productivity in patients with overactive bladder. BJU Int 2014;113:484-91. [Crossref] [PubMed]
49. Shih YC, Hartzema AG, Tolleson-Rinehart S. Labor costs associated with incontinence in long-term care facilities. Urology 2003;62:442-6. [Crossref] [PubMed]
50. Borrie MJ, Davidson HA. Incontinence in institutions: costs and contributing factors. CMAJ 1992;147:322-8. [PubMed]
51. Hu TW. The economic impact of urinary incontinence. Clin Geriatr Med 1986;2:673-87. [PubMed]
52. Irwin DE, Mungapen L, Milsom I, et al. The economic impact of overactive bladder syndrome in six Western countries. BJU Int 2009;103:202-9. [Crossref] [PubMed]
53. Thom DH, Haan MN, Van Den Eeden SK. Medically recognized urinary incontinence and risks of hospitalization, nursing home admission and mortality. Age Ageing 1997;26:367-74. [Crossref] [PubMed]
54. Berete F, Demarest S, Charafeddine R, et al. Predictors of nursing home admission in the older population in Belgium: a longitudinal follow-up of health interview survey participants. BMC Geriatr 2022;22:807. [Crossref] [PubMed]
55. O’Malley AJ, Caudry DJ, Grabowski DC. Predictors of nursing home residents’ time to hospitalization. Health Serv Res 2011;46:82-104. [Crossref] [PubMed]
56. Bates-Jensen BM, Alessi CA, Al-Samarrai NR, et al. The effects of an exercise and incontinence intervention on skin health outcomes in nursing home residents. J Am Geriatr Soc 2003;51:348-55. [Crossref] [PubMed]
57. Schnelle JF, Cadogan MP, Grbic D, et al. A standardized quality assessment system to evaluate incontinence care in the nursing home. J Am Geriatr Soc 2003;51:1754-61. [Crossref] [PubMed]
58. Holroyd-Leduc JM, Mehta KM, Covinsky KE. Urinary incontinence and its association with death, nursing home admission, and functional decline. J Am Geriatr Soc 2004;52:712-8. [Crossref] [PubMed]
59. Ozaki Y, Hatakeyama S, Imai A, et al. Relationship between lower urinary tract symptoms and frailty. Int J Urol 2023;30:606-13. [Crossref] [PubMed]
60. Palmer MH. Urinary incontinence quality improvement in nursing homes: where have we been? Where are we going? Urol Nurs 2008;28:439-44, 453. [PubMed]
61. Skotnes LH, Hellzen O, Kuhry E. Perceptions and barriers that influence the ability to provide appropriate incontinence care in nursing home residents: Statements from nursing staff. Open Journal of Nursing 2013;03:437-44. [Crossref]
62. Tannenbaum C, Labrecque D, Lepage C. Understanding barriers to continence care in institutions. Can J Aging 2005;24:151-9. [Crossref] [PubMed]
63. Liao CH, Kuo HC. Increased risk of large post-void residual urine and decreased long-term success rate after intravesical onabotulinumtoxinA injection for refractory idiopathic detrusor overactivity. J Urol 2013;189:1804-10. [Crossref] [PubMed]
64. Lyons SS. How do people make continence care happen? An analysis of organizational culture in two nursing homes. Gerontologist 2010;50:327-39. [Crossref] [PubMed]
65. Saxer S, de Bie RA, Dassen T, Halfens RJ. Nurses’ knowledge and practice about urinary incontinence in nursing home care. Nurse Educ Today 2008;28:926-34. [Crossref] [PubMed]
66. Christianson TM, Hoot TJ, Todd M. Understanding Nursing Knowledge of Continence Care and Bladder Scanner Use in Long-Term Care: An Evaluation Study. Gerontol Geriatr Med 2021;7:23337214211046090. [Crossref] [PubMed]
67. MacDonald CD, Butler L. Silent no more: elderly women’s stories of living with urinary incontinence in long-term care. J Gerontol Nurs 2007;33:14-20. [Crossref] [PubMed]
68. Johnson TM, Ouslander JG, Uman GC, et al. Urinary incontinence treatment preferences in long-term care. J Am Geriatr Soc 2001;49:710-8. [Crossref] [PubMed]
69. Plaku-Alakbarova B, Punnett L, Gore RJ, et al. Nursing Home Employee and Resident Satisfaction and Resident Care Outcomes. Saf Health Work 2018;9:408-15. [Crossref] [PubMed]
70. Hasson H, Arnetz JE. Nursing staff competence, work strain, stress and satisfaction in elderly care: a comparison of home-based care and nursing homes. J Clin Nurs 2008;17:468-81. [Crossref] [PubMed]
71. Ostaszkiewicz J. A conceptual model of the risk of elder abuse posed by incontinence and care dependence. Int J Older People Nurs 2018;13:e12182. [Crossref] [PubMed]
72. Robinson JP. Managing urinary incontinence in the nursing home: residents’ perspectives. Journal of Advanced Nursing 2000;31:68-77. [Crossref] [PubMed]
73. Birgersson AB, Hammar V, Widerfors G, et al. Elderly women’s feelings about being urinary incontinent, using napkins and being helped by nurses to change napkins. Journal of Clinical Nursing 1993;2:165-71. [Crossref]
74. Ostaszkiewicz J, O’Connell B, Dunning T. Residents’ perspectives on urinary incontinence: a review of literature. Scand J Caring Sci 2012;26:761-72. [Crossref] [PubMed]
75. Hägglund D, Wadensten B. Fear of humiliation inhibits women’s care-seeking behaviour for long-term urinary incontinence. Scand J Caring Sci 2007;21:305-12. [Crossref] [PubMed]
76. Farage MA, Miller KW, Berardesca E, et al. Psychosocial and societal burden of incontinence in the aged population: a review. Arch Gynecol Obstet 2008;277:285-90. [Crossref] [PubMed]
77. Jones CP, Shaw NM, Mena J, et al. The relationship between frailty, incontinence severity, and treatment decisions for men with post-prostatectomy stress urinary incontinence: a mixed methods analysis. Transl Androl Urol 2023;12:840-8. [Crossref] [PubMed]
78. Bektas Akpinar N, Unal N, Akpinar C. Urinary Incontinence in Older Adults: Impact on Caregiver Burden. J Gerontol Nurs 2023;49:39-46. [Crossref] [PubMed]
79. Soysal P, Veronese N, Ippoliti S, et al. The impact of urinary incontinence on multiple health outcomes: an umbrella review of meta-analysis of observational studies. Aging Clin Exp Res 2023;35:479-95. [Crossref] [PubMed]
80. Stewart WF, Van Rooyen JB, Cundiff GW, et al. Prevalence and burden of overactive bladder in the United States. World J Urol 2003;20:327-36. [Crossref] [PubMed]
81. Milsom I, Kaplan SA, Coyne KS, et al. Effect of bothersome overactive bladder symptoms on health-related quality of life, anxiety, depression, and treatment seeking in the United States: results from EpiLUTS. Urology 2012;80:90-6. [Crossref] [PubMed]
82. Sexton CC, Coyne KS, Thompson C, et al. Prevalence and effect on health-related quality of life of overactive bladder in older americans: results from the epidemiology of lower urinary tract symptoms study. J Am Geriatr Soc 2011;59:1465-70. [Crossref] [PubMed]
83. Kinsey D, Pretorius S, Glover L, et al. The psychological impact of overactive bladder: A systematic review. J Health Psychol 2016;21:69-81. [Crossref] [PubMed]
84. Bartoli S, Aguzzi G, Tarricone R. Impact on quality of life of urinary incontinence and overactive bladder: a systematic literature review. Urology 2010;75:491-500. [Crossref] [PubMed]
85. Vrijens D, Drossaerts J, van Koeveringe G, et al. Affective symptoms and the overactive bladder - a systematic review. J Psychosom Res 2015;78:95-108. [Crossref] [PubMed]
86. Gallagher MS. Urogenital distress and the psychosocial impact of urinary incontinence on elderly women. Rehabil Nurs 1998;23:192-7. [Crossref] [PubMed]
87. Hägglund D, Ahlström G. The meaning of women’s experience of living with long‐term urinary incontinence is powerlessness. Journal of Clinical Nursing 2007;16:1946-54. [Crossref] [PubMed]
88. Dubeau CE, Simon SE, Morris JN. The effect of urinary incontinence on quality of life in older nursing home residents. J Am Geriatr Soc 2006;54:1325-33. [Crossref] [PubMed]
89. Lightner DJ. Diagnosis and Treatment of Non-Neurogenic Overactive Bladder (OAB) in Adults: AUA/SUFU Guideline. American Urological Association; 2019.
90. Watson NM, Brink CA, Zimmer JG, et al. Use of the Agency for Health Care Policy and Research Urinary Incontinence Guideline in nursing homes. J Am Geriatr Soc 2003;51:1779-86. [Crossref] [PubMed]
91. Hedin K, Petersson C, Widebäck K, et al. Asymptomatic bacteriuria in a population of elderly in municipal institutional care. Scand J Prim Health Care 2002;20:166-8. [Crossref] [PubMed]
92. Ajayi T, Radhakrishnan R. Urinary tract infection in older adults in long-term care facilities. CMAJ 2016;188:899. [Crossref] [PubMed]
93. Brazier AM, Palmer MH. Collecting clean-catch urine in the nursing home: obtaining the uncontaminated specimen. Geriatr Nurs 1995;16:217-24. [Crossref] [PubMed]
94. NICE Guidance - Urinary incontinence and pelvic organ prolapse in women: management: © NICE (2019) Urinary incontinence and pelvic organ prolapse in women: management. BJU Int 2019;123:777-803. [Crossref] [PubMed]
95. Clinical Consensus Statement: Association of Anticholinergic Medication Use and Cognition in Women With Overactive Bladder. Female Pelvic Med Reconstr Surg 2021;27:69-71. [Crossref] [PubMed]
96. Rovner ES, Wein AJ. Treatment options for stress urinary incontinence. Rev Urol 2004;6:S29-47. [PubMed]
97. Friedman B. Conservative treatment for female stress urinary incontinence: simple, reasonable and safe. Can Urol Assoc J 2012;6:61-3. [Crossref] [PubMed]
98. Allen LM, Nalley C, Devries AR, et al. Efficacy of Behavioral Interventions for Urinary Incontinence Among Women Residing in Nursing Homes: A Systematic Review. J Wound Ostomy Continence Nurs 2023;50:57-65. [Crossref] [PubMed]
99. Shaw C, Wagg A. Overactive Bladder in Frail Older Adults. Drugs Aging 2020;37:559-65. [Crossref] [PubMed]
100. Newman DK. Prompted Voiding for Individuals With Urinary Incontinence. J Gerontol Nurs 2019;45:14-26. [Crossref] [PubMed]
101. Lai CKY, Wan X. Using Prompted Voiding to Manage Urinary Incontinence in Nursing Homes: Can It Be Sustained? J Am Med Dir Assoc 2017;18:509-14. [Crossref] [PubMed]
102. Siswoyo Lestari C. The influences of prompted voiding for urinary incontinence among older people in nursing homes. Int J Uro Nurs 2021;15:27-32. [Crossref]
103. Stenzelius K, Molander U, Odeberg J, et al. The effect of conservative treatment of urinary incontinence among older and frail older people: a systematic review. Age Ageing 2015;44:736-44. [Crossref] [PubMed]
104. Sherburn M, Bird M, Carey M, et al. Incontinence improves in older women after intensive pelvic floor muscle training: an assessor-blinded randomized controlled trial. Neurourol Urodyn 2011;30:317-24. [Crossref] [PubMed]
105. Lee BA, Kim SJ, Choi DK, et al. Effects of Pelvic Floor Muscle Exercise on Urinary Incontinence in Elderly Women With Cognitive Impairment. Int Neurourol J 2017;21:295-301. [Crossref] [PubMed]
106. Vinsnes AG, Helbostad JL, Nyrønning S, et al. Effect of physical training on urinary incontinence: a randomized parallel group trial in nursing homes. Clin Interv Aging 2012;7:45-50. [Crossref] [PubMed]
107. Tak EC, van Hespen A, van Dommelen P, et al. Does improved functional performance help to reduce urinary incontinence in institutionalized older women? A multicenter randomized clinical trial. BMC Geriatr 2012;12:51. [Crossref] [PubMed]
108. Schnelle JF, Kapur K, Alessi C, et al. Does an exercise and incontinence intervention save healthcare costs in a nursing home population? J Am Geriatr Soc 2003;51:161-8. [Crossref] [PubMed]
109. Gammack JK. Use and management of chronic urinary catheters in long-term care: much controversy, little consensus. J Am Med Dir Assoc 2003;4:S52-9. [Crossref] [PubMed]
110. Al-Samarrai NR, Uman GC, Al-Samarrai T, et al. Introducing a new incontinence management system for nursing home residents. J Am Med Dir Assoc 2007;8:253-61. [Crossref] [PubMed]
111. McDaniel C, Ratnani I, Fatima S, Abid MH, Surani S. Urinary Incontinence in Older Adults Takes Collaborative Nursing Efforts to Improve. Cureus 2020;12:e9161. [Crossref] [PubMed]
112. Beeson T, Davis C. Urinary Management With an External Female Collection Device. J Wound Ostomy Continence Nurs 2018;45:187-9. [Crossref] [PubMed]
113. Shah D, Badlani G. Treatment of overactive bladder and incontinence in the elderly. Rev Urol 2002;4:S38-43. [PubMed]
114. Bliss DZ, Mathiason MA, Gurvich O, et al. Incidence and Predictors of Incontinence-Associated Skin Damage in Nursing Home Residents With New-Onset Incontinence. J Wound Ostomy Continence Nurs 2017;44:165-71. [Crossref] [PubMed]
115. Bliss DZ, Gurvich OV, Mathiason MA, et al. Prevention of Incontinence-Associated Skin Damage in Nursing Homes. West J Nurs Res 2017;39:643-59. [Crossref] [PubMed]
116. Collette C, Bravo G. Tu le M. Development of a urinary incontinence educational program using a competency-based approach and case method. J Nurses Staff Dev 2009;25:E5-E10. [Crossref] [PubMed]
117. Trad W, Flowers K, Caldwell J, et al. Nursing assessment and management of incontinence among medical and surgical adult patients in a tertiary hospital: a best practice implementation project. JBI Database System Rev Implement Rep 2019;17:2578-90. [Crossref] [PubMed]
118. Rahman AN, Schnelle JF, Yamashita T, et al. Distance learning: a strategy for improving incontinence care in nursing homes. Gerontologist 2010;50:121-32. [Crossref] [PubMed]
119. Deutschman M. Interventions to nurture excellence in the nursing home culture. J Gerontol Nurs 2001;27:37-43. [Crossref] [PubMed]
120. Kachru N, Holmes HM, Johnson ML, et al. Antimuscarinic use among older adults with dementia and overactive bladder: a Medicare beneficiaries study. Curr Med Res Opin 2021;37:1303-13. [Crossref] [PubMed]
121. Chatterjee S, Gupta D, Caputo TA, et al. Disparities in Gynecological Malignancies. Front Oncol 2016;6:36. [Crossref] [PubMed]
122. Dmochowski RR, Thai S, Iglay K, et al. Increased risk of incident dementia following use of anticholinergic agents: A systematic literature review and meta‐analysis. Neurourology and Urodynamics 2021;40:28-37. [Crossref] [PubMed]
123. Richardson K, Fox C, Maidment I, et al. Anticholinergic drugs and risk of dementia: case-control study. BMJ 2018;361:k1315. [Crossref] [PubMed]
124. Coupland CAC, Hill T, Dening T, et al. Anticholinergic Drug Exposure and the Risk of Dementia: A Nested Case-Control Study. JAMA Intern Med 2019;179:1084-93. [Crossref] [PubMed]
125. Gray SL, Anderson ML, Dublin S, et al. Cumulative use of strong anticholinergics and incident dementia: a prospective cohort study. JAMA Intern Med 2015;175:401-7. [Crossref] [PubMed]
126. Ancelin ML, Artero S, Portet F, et al. Non-degenerative mild cognitive impairment in elderly people and use of anticholinergic drugs: longitudinal cohort study. BMJ 2006;332:455-9. [Crossref] [PubMed]
127. Carrière I, Fourrier-Reglat A, Dartigues JF, et al. Drugs with anticholinergic properties, cognitive decline, and dementia in an elderly general population: the 3-city study. Arch Intern Med 2009;169:1317-24. [Crossref] [PubMed]
128. Jessen F, Kaduszkiewicz H, Daerr M, et al. Anticholinergic drug use and risk for dementia: target for dementia prevention. Eur Arch Psychiatry Clin Neurosci 2010;260:S111-5. [Crossref] [PubMed]
129. Gildengers A, Stoehr GP, Ran X, et al. Anticholinergic Drug Burden and Risk of Incident MCI and Dementia: A Population-based Study. Alzheimer Dis Assoc Disord 2023;37:20-7. [Crossref] [PubMed]
130. Lackner TE, Wyman JF, McCarthy TC, et al. Efficacy of oral extended-release oxybutynin in cognitively impaired older nursing home residents with urge urinary incontinence: a randomized placebo-controlled trial. J Am Med Dir Assoc 2011;12:639-47. [Crossref] [PubMed]
131. Wagg A, Dale M, Tretter R, et al. Randomised, multicentre, placebo-controlled, double-blind crossover study investigating the effect of solifenacin and oxybutynin in elderly people with mild cognitive impairment: the SENIOR study. Eur Urol 2013;64:74-81. [Crossref] [PubMed]
132. Wesnes KA, Edgar C, Tretter RN, et al. Exploratory pilot study assessing the risk of cognitive impairment or sedation in the elderly following single doses of solifenacin 10 mg. Expert Opin Drug Saf 2009;8:615-26. [Crossref] [PubMed]
133. Lipton RB, Kolodner K, Wesnes K. Assessment of cognitive function of the elderly population: effects of darifenacin. J Urol 2005;173:493-8. [Crossref] [PubMed]
134. Staskin DR. Overactive bladder in the elderly: a guide to pharmacological management. Drugs Aging 2005;22:1013-28. [Crossref] [PubMed]
135. Malcher MF, Droupy S, Berr C, et al. Dementia Associated with Anticholinergic Drugs Used for Overactive Bladder: A Nested Case-Control Study Using the French National Medical-Administrative Database. J Urol 2022;208:863-71. [Crossref] [PubMed]
136. Matta R, Gomes T, Juurlink D, et al. Receipt of Overactive Bladder Drugs and Incident Dementia: A Population-based Case-control Study. Eur Urol Focus 2022;8:1433-40. [Crossref] [PubMed]
137. Mur J, Russ TC, Cox SR, et al. Association between anticholinergic burden and dementia in UK Biobank. Alzheimers Dement (N Y) 2022;8:e12290. [Crossref] [PubMed]
138. Duong V, Iwamoto A, Pennycuff J, et al. A systematic review of neurocognitive dysfunction with overactive bladder medications. Int Urogynecol J 2021;32:2693-702. [Crossref] [PubMed]
139. Park HY, Park JW, Song HJ, et al. The Association between Polypharmacy and Dementia: A Nested Case-Control Study Based on a 12-Year Longitudinal Cohort Database in South Korea. PLoS One 2017;12:e0169463. [Crossref] [PubMed]
140. Araklitis G, Robinson D. The cognitive safety of antimuscarinics in the treatment of overactive bladder. Expert Opin Drug Saf 2020;19:1303-13. [Crossref] [PubMed]
141. Chancellor MB, Staskin DR, Kay GG, et al. Blood-brain barrier permeation and efflux exclusion of anticholinergics used in the treatment of overactive bladder. Drugs Aging 2012;29:259-73. [Crossref] [PubMed]
142. Narayanan S, Cerulli A, Kahler KH, et al. Is drug therapy for urinary incontinence used optimally in long-term care facilities? J Am Med Dir Assoc 2007;8:98-104. [Crossref] [PubMed]
143. Wagg A. Treating overactive bladder in the elderly. Can Urol Assoc J 2011;5:S149-51. [Crossref] [PubMed]
144. Wagg A, Wyndaele JJ, Sieber P. Efficacy and tolerability of solifenacin in elderly subjects with overactive bladder syndrome: a pooled analysis. Am J Geriatr Pharmacother 2006;4:14-24. [Crossref] [PubMed]
145. Kraus SR, Ruiz-Cerdá JL, Martire D, et al. Efficacy and tolerability of fesoterodine in older and younger subjects with overactive bladder. Urology 2010;76:1350-7. [Crossref] [PubMed]
146. DuBeau CE, Morrow JD, Kraus SR, et al. Efficacy and tolerability of fesoterodine versus tolterodine in older and younger subjects with overactive bladder: a post hoc, pooled analysis from two placebo-controlled trials. Neurourol Urodyn 2012;31:1258-65. [Crossref] [PubMed]
147. Aparasu RR, Sura S, Earla JR, et al. Antimuscarinic Discontinuation in Patients with Overactive Bladder in Nursing Homes: A Retrospective Study of Medicare Beneficiaries. Adv Ther 2020;37:3584-605. [Crossref] [PubMed]
148. Nakagomi H, Mitsui T, Shimura H, et al. Mirabegron for overactive bladder in frail patients 80 years or over (HOKUTO study). BMC Urol 2022;22:40. [Crossref] [PubMed]
149. Wagg A, Staskin D, Engel E, et al. Efficacy, safety, and tolerability of mirabegron in patients aged ≥65yr with overactive bladder wet: a phase IV, double-blind, randomised, placebo-controlled study (PILLAR). Eur Urol 2020;77:211-20. [Crossref] [PubMed]
150. Welk B, McArthur E. Increased risk of dementia among patients with overactive bladder treated with an anticholinergic medication compared to a beta-3 agonist: a population-based cohort study. BJU Int 2020;126:183-90. [Crossref] [PubMed]
151. Lozano-Ortega G, Walker DR, Johnston K, et al. Comparative Safety and Efficacy of Treatments for Overactive Bladder Among Older Adults: A Network Meta-analysis. Drugs Aging 2020;37:801-16. [Crossref] [PubMed]
152. Chen JV, Gahn JC, Nesheim J, et al. Budget Impact Analysis of Vibegron for the Treatment of Overactive Bladder in the USA. Pharmacoeconomics 2022;40:979-88. [Crossref] [PubMed]
153. Zillioux J, Slopnick EA, Vasavada SP. Third-line therapy for overactive bladder in the elderly: Nuances and considerations. Neurourol Urodyn 2022;41:1967-74. [Crossref] [PubMed]
154. Manns K, Khan A, Carlson KV, et al. The use of onabotulinumtoxinA to treat idiopathic overactive bladder in elderly patients is in need of study. Neurourol Urodyn 2022;41:42-7. [Crossref] [PubMed]
155. White WM, Pickens RB, Doggweiler R, et al. Short-term efficacy of botulinum toxin a for refractory overactive bladder in the elderly population. J Urol 2008;180:2522-6. [Crossref] [PubMed]
156. Ou YC, Kao YL, Ho YH, et al. Intravesical Injection of Botulinum Toxin Type A in Patients with Refractory Overactive Bladder-Results between Young and Elderly Populations, and Factors Associated with Unfavorable Outcomes. Toxins (Basel) 2023;15:95. [Crossref] [PubMed]
157. Komesu YM, Amundsen CL, Richter HE, et al. Refractory urgency urinary incontinence treatment in women: impact of age on outcomes and complications. Am J Obstet Gynecol 2018;218:111.e1-9. [Crossref] [PubMed]
158. Richter HE, Amundsen CL, Erickson SW, et al. Characteristics Associated with Treatment Response and Satisfaction in Women Undergoing OnabotulinumtoxinA and Sacral Neuromodulation for Refractory Urgency Urinary Incontinence. J Urol 2017;198:890-6. [Crossref] [PubMed]
159. Jairam R, Drossaerts J, Marcelissen T, et al. Predictive Factors in Sacral Neuromodulation: A Systematic Review. Urol Int 2022;106:323-43. [Crossref] [PubMed]
160. Anger JT, Cameron AP, Madison R, et al. Predictors of implantable pulse generator placement after sacral neuromodulation: who does better? Neuromodulation 2014;17:381-4; discussion 384. [Crossref] [PubMed]
161. Faris AER, Gill BC, Pizarro-Berdichevsky J, et al. Impact of Age and Comorbidities on Use of Sacral Neuromodulation. J Urol 2017;198:161-6. [Crossref] [PubMed]
162. Greenberg DR, Syan R, Young-Lin N, et al. Outcomes of Sacral Nerve Stimulation for Treatment of Refractory Overactive Bladder Among Octogenarians. Neuromodulation 2019;22:738-44. [Crossref] [PubMed]
163. Lee EW, Lee UJ, Lucioni A, et al. Outcomes of Sacral Neuromodulation for Overactive Bladder in Octogenarian Females. Urol Pract 2015;2:22-5. [Crossref] [PubMed]
164. Schönburg S, Bukethal T, Fornara P. Does age alone negatively predict the outcome of sacral neuromodulation? A single-centre retrospective observational study. BMC Urol 2020;20:55. [Crossref] [PubMed]
165. Suskind AM, Kowalik C, Quanstrom K, et al. The impact of frailty on treatment for overactive bladder in older adults. Neurourol Urodyn 2019;38:1915-23. [Crossref] [PubMed]
166. von der Warth R, Kaiser V, Reese C, et al. Barriers and facilitators for implementation of a complex health services intervention in long-term care homes: a qualitative study using focus groups. BMC Geriatr 2021;21:632. [Crossref] [PubMed]
167. Syed ST, Gerber BS, Sharp LK. Traveling towards disease: transportation barriers to health care access. J Community Health 2013;38:976-93. [Crossref] [PubMed]
168. Booth J, Aucott L, Cotton S, et al. Tibial nerve stimulation compared with sham to reduce incontinence in care home residents: ELECTRIC RCT. Health Technol Assess 2021;25:1-110. [Crossref] [PubMed]
169. Liu DD, Xin J, Liu W, et al. Evaluation of Pelvic Floor Dysfunction by Pelvic Floor Ultrasonography after Total Hysterectomy for Cervical Cancer. Scanning 2022;2022:5914344. [Crossref] [PubMed]
170. Lim BG, Lee IO. Anesthetic management of geriatric patients. Korean J Anesthesiol 2020;73:8-29. [Crossref] [PubMed]