How should I approach the management of urinary incontinence in elderly patients with multiple comorbidities?

Approach to managing urinary incontinence in elderly patients with multiple comorbidities:

• Initial assessment: Conduct a thorough clinical assessment to categorise the type of urinary incontinence (stress, urgency, or mixed) and identify predisposing factors, comorbidities, and other diagnoses that may influence management. Use bladder diaries for at least 3 days to document symptoms and severity, which helps tailor treatment ⁴,¹.
• Lifestyle modifications: Recommend lifestyle changes such as reducing caffeine intake, adjusting fluid intake if excessive or inadequate, and encouraging weight loss if BMI is over 30 kg/m2, as these can improve symptoms without pharmacological risks ¹,².
• Non-pharmacological treatments: Consider supervised pelvic floor muscle training after confirming pelvic floor muscle contraction ability, as this is effective and low risk ⁴.
• Medication considerations: Use caution with anticholinergic medicines for overactive bladder in elderly patients, especially those with cognitive impairment or dementia, due to risks of adverse effects including cognitive decline. Avoid oxybutynin immediate release and other anticholinergics with high anticholinergic load. Discuss potential benefits and side effects clearly with the patient ⁴.
• Catheterisation: Consider intermittent catheterisation for urinary retention if the patient or carer can manage it. Indwelling catheters should be a last resort due to risks and should be discussed carefully regarding benefits and harms ⁴.
• Absorbent products and aids: Use absorbent containment products only as a coping strategy pending definitive treatment or as adjuncts, not as primary treatment. Regular review (at least annually) is essential to assess ongoing suitability ⁴.
• Multidisciplinary and specialist referral: Refer to specialist continence services if initial management is insufficient, especially in complex cases with multiple comorbidities, to consider advanced therapies or further assessment ⁴,³.
• Address complications: Monitor and manage complications such as increased fall risk, anxiety, depression, and sleep disturbance, which are common in elderly patients with urinary incontinence ².