The Aging Bladder
It should never be assumed that incontinence is inevitable consequence of aging. However,
certain age changes do occur in the nervous system, kidneys, bladder and urethra which
make the elderly more vulnerable to developing incontinence.
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Changes can occur in the cortical micturition centre of the brain, leading to increase
frequency of micturition, especially at night. Thus the effective bladder capacity may
become reduced. Bladder sensation often changes so that the first desire to void
occurs only just before the urgent desire to void, so the older person is not aware
that there bladder is near full until the bladder sensations react at approximately
90% full giving them little time to reach the toilet. Cortical inhibition of the
micturition reflex may also be reduced, so that unstable bladder contractions occur.
Neurological changes in the brain stem may result in poor co-ordination of detrusor
contraction and sphincter opening (dyssynergic detrusor/sphincter activity). The
failure of the urethral sphincters to relax completely during micturition is often
termed functional obstruction. If this is severe, overflow incontinence may result.
The rhythm of urine production by the kidney changes. Unlike younger people, who
produce most of the urine during the day and less at night, elderly people may
produce the same amount of urine day and night, because their heart and kidneys
work less efficiently and production of anti-diurectic hormone is reduced. In
patients with heart failure, diuresis (urine production) occurs mainly at rest, usually
at night. These factors can lead to incontinence if the person is unable to get up or
get to the toilet during the night.
The closure pressure of the urethra is reduced in ageing women, due to the changes
in the epithelial tissue occurring as the oestrogen level falls after the menopause.
Muscle tone in the pelvic floor can also be reduced in elderly women, partly due to
lack of oestrogen. Weakness of the muscles of the pelvic floor and urethra can lead
to stress incontinence.
Bladder capacity and urine flow rate reduce with age in women. The bladder
capacity may be reduced to half that of a young adult (600mls down to 250mls)
Marieb 1992.
Enlarge prostates (which grows with age) can cause bladder overactivity, as it pushes
up into the bladder it can trigger bladder sensations. The enlarged prostate can also
cause obstructive bladder outflow problems preventing the bladder from emptying
effectively causing retention. If the bladder has to squeeze excessively to empty,
over time the bladder wall becomes overstretched and ineffective resulting in
hypotonic or atonic bladder failure.
Fibrosis is more common, and may result in bladder neck narrowing and voiding
difficulties.
It is common for elderly people to have more than one bladder abnormality, such as an
unstable bladder and stress incontinence, or a voiding problem with unstable contractions.
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Underreporting of incontinence is a problem in all ages (DOH 2000) but Branch et al found
70% of older people did not seek help with their incontinence. The reasons for
underreporting were identified as:
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Embarrassment
Being unaware help was available
Hoping problem would improve
Believed it was part of growing old
Believed nothing could be done
Fear of surgery
Belief too old for treatment
Feel problem is not serious enough
Low expectation of the benefits of treatment
It is also common that elderly patients deny or under report the severity of the problem
because it is a taboo subject and you just don’t talk about it. When the subject is
approached with elderly patients suffering with incontinence they often feel a sense of
relief that they can talk about it and they are not alone.
Elderly people are more susceptible to illness and often are slower in recovery which may
alter their continence. Frailer older patients who are dependant on a carer are more at risk
of developing incontinence. It is a mistake to think that nothing can be done to manage
their incontinence, yes certain management strategies may not be offered because of their
frailty but if a basic continence assessment it made a good management of continence can
be offered with support. Fonda et al (1999) stipulates every person respective of their
frailty or disability should be given the opportunity to achieve continence, this can be
through;
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Independent continence
Dependant continence – dry with assistance from a carer
Social continence – dry with the use of continence aids or appliances
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Transient Incontinence
Transient incontinence is a sudden onset of incontinence. It is temporary or reversible and
is usually related to a specific event, illness or incident. Fonda et al (1999) found transient
causes accounted for a third of cases in the older person living in the community, up to half
of those with incontinence in the hospital setting and a significant proportion of those with
incontinence in a residential care setting. Causes can be related to confusion/Delirium,
infection (UTI) inflammation (vaginitis/urethritis) psychological disorders (depression),
pharmacological factors (sedatives, hypnotics, antimuscarinic) stool impaction polyuria and
reduced mobility.
Transient incontinence may persist if left untreated so assessment is vital to seek cause of
incontinence and treat/improve the individual’s overall bladder function.
Skin problems
Skin in the elderly person becomes less elastic, as well as, thinner due to the reduction of
epidermis and drier cause from sweat glands reducing in size. These factors significantly
cause a reduction in the skins ability to protect it’s self from out side factor of friction and
incontinence.
Caution should be uses in:
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Excessive use of soap as it stripes away the skins natural oils
Talcum powder as it can build up encrustations in the crevices of the skin and groin
which when mixed with sweat and urine can cause friction breaking down the skin
Barrier creams as they can significantly reduce the absorption of incontinence
products (pads) if used they should be used sparingly.
Risk of falling
Frequency, urgency, urge incontinence and nocturia can all be associated with the risk of
falling in the elderly person. In fact the risk of falling increases with urge incontinence by
26% and the risk of fractures by 34%. Brown et al (2000).
Environmental factors such as slippery floors, poor lighting and clutter contribute are a
consequence of falls with many falls occurring in the bathroom. Rubenstein and Josephson
(1993).
The incidents of an elderly person being transferred into a nursing home because of
incontinence and following a fall is increased Thorn et al (1997). But practical solutions such
a commode and strength and balance training can reduce the need to go into care. Brown
et al (2000).
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Urine infection in the Elderly population
UTI’s in the elderly is common, old age is associated with lower immunity and the cases of
asymptomatic bacteruria are known to be higher in this age group.
Causes of UTI’s can be a result of:
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Residual urine
Oestrogen reduction in post menopausal women
Changes in normal flora of the urethra
Poor functional status
Poor hygiene particular E Coli being responsible for 80% due to normal bowel flora
possible cause wiping back to front.
In nursing homes older people are 50% likely to develop a UTI but asymptomatic bacteriuria
should not be treated with antibiotic’s as this can cause resistance organisms McCue (2000).
Helping the elderly patient with cognitive behaviour problems.
It is a mistake to assume that nothing can be done for the incontinent demented patient.
Even patients who are severely mentally impaired can respond to measures directed at:
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Anticipating the times at which micturition is likely
Identifying any behaviour which precedes to micturition
Helping the incontinent person to identify the need to micturate
Helping him/her to recognise the toilet as the appropriate place for micturition
Helping him/her to remember where the toilet is and how to get there
Increasing his/her motivation to be continent
It is important to remember that mental impairment may not be the only problem –
incontinence may be related to other factors, such as constipation, urinary tract infection,
impaired mobility, poor environment etc., which should be treated wherever possible.
Management of the elderly dementia patient suffering with incontinence should be based
on a careful assessment of the individual, with particular attention to his/her normal pattern
of micturition. Staff practices which may predispose to incontinence should be examined.
Management can be tailored to suit the individual. For the very severely impaired,
management may consist of ‘catching’ incontinence before it occurs by toileting at
appropriate times, or of watching the individual for typical pre-micturition behaviour, such
as getting up and wandering, or pulling clothing. For many patients, however, some degree
of independent continence can be achieved by specific techniques of behaviour therapy, as
described below.
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Reality Orientation
Reality orientation is a technique which can be practised by relatives or carers. It aims to
constantly remind the patient who he/she is, where he/she is and when it is. If every one
who cares for the patient follows these guidelines, it is possible to maximise the level of
functioning of the confused elderly person. General morale and motivation are improved,
and there is often a concomitant improvement in continence.
Behaviour modification
In this context, behaviour modification involves rewarding the person who is continent or
who passes urine in the correct place, and ignoring incontinence. This is the reverse of what
often happens in institutions, when the incontinence receive attention and the continent is
ignored. Thus, staff should be generous with attention, praise and physical contact when
the person is dry or uses the toilet correctly. If incontinence occurs, the urine should be
cleared up with the minimum of fuss and physical contact – no smiles or conversation.
Punishment however is never used.
References
Branch L G, Walker L A, Wetle T T, DuBeau C E, Resnick N M 1994 Urinary incontinence
knowledge among community-dwelling people 65 years of age and older. Journal of the
American Geriatrics Society 42(12):1257-1262
Brown J S, Vittinghoff E, Wyman J F et al 2000 Urinary incontinence: does it increase risk
falls and fractures? Journal of the American Geriatrics Society 48:721-725
Department of Health 2000 Good practice in continence services. DoH, London
Fonda D, Benvenuti F, Castleden M et al 1999 Management of incontinence in older people.
In: Abrams P, Khonry S, Wein A (eds) Incontinence: 1st international consultation on
incontinence. Health Publication Ltd Plymouth pp731-773
Marieb E N 1992 Human anathomy and physiology. Benjamin/Cummings, Menlo Park,
California
McCue J D 2000 complicated UTI: effective treatment in the long-term care setting
Geriatrics 55(9): 48-61
Rubenstein L Z, Josephson K R 1993 Clinical research on falls in nursing home. In:
Rubenstein L Z, Wieland D (eds) Improving care in the nursing home: comprehensive
reviews of clinical research. Sage, Newbury Park, pp216-240
Thorn D H, Haan M N, Van den Eeden S K 1997 medically recognised urinary incontinence
and risks of hospitalisation, nursing home admission and mortality. Age and Ageing 26(5):
367-374
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Biography
Getliffe, K & Dolman, M. (2003) Promoting Continence: A clinical Research resource. 2nd
edition. Bailliere Tindall.
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