DADE CE Program 1: Case 1

Program 1: Don't Start: Growing Evidence Against Anticholinergic Drug Use in the Elderly:
Case 1

DJ, an 83-year-old woman suffering from moderate Alzheimer's disease, arrives for an office visit with her primary care provider accompanied by her 85-year-old spouse. Her spouse made the appointment to seek guidance in managing DJ's behavior as her Alzheimer's disease progresses. He is having increasing difficulty managing their life together at home. When interviewing DJ's husband he appears frustrated and perhaps depressed. As he is leaving the exam room he confides that DJ has recently begun to experience incontinence of urine. She seems to urinate without warning and he can't keep up with cleaning her clothes and the house.

Before prescribing an anticholinergic medication for urinary incontinence in this patient, it is important to consider:

Urinary incontinence is common in patients with dementia and has significant consequences for patients and their caregivers. Incontinence can directly contribute to skin irritation and urinary tract infections, and indirectly increase risk of falls. Incontinence may result in early institutionalization.
Reversible causes of incontinence should be ruled out, including medications (e.g. diuretics, cholinesterase inhibitors), infections, atrophic vaginitis, restricted mobility, fecal impaction/constipation or other disease states such as diabetes.
Cognitive deficits can interfere with the ability to recognize the need to go to the toilet and the capability to hold the urine until it is appropriate to go. Finding and recognizing the toilet, as well as disrobing and using the toilet, may also be an issue. Caregivers may best manage functional incontinence through nonpharmacologic approaches, such as timed/prompted voiding, use of absorbent pads, adequate lighting and caregiver education on behavioral interventions.
If a diagnosis of overactive bladder is appropriate, consider prescribing an M3 receptor selective agent such as darifenacin to minimize impact on cognitive function. Continued use of any other medications with anticholinergic effects should be reconsidered as it is well-known that anticholinergic antispasmodic medications may worsen cognitive impairment in dementia patients.

References:

Kay GG, Abou-Donia MB, Messer WS, et al. Antimuscarinic drugs for overactive bladder and their potential effects on cognitive function in older patients. J Am Geriatr Soc 2005;53:2195-2201.

Yap P, Tan D. Urinary incontinence in dementia: A practical approach. Aus Fam Phys 2005;35:237-241.