De oude patiënt: operatie of verband K. Everaert Prof. Neurourologie UZ-Gent H. Cobussen-Boekhorst Nurse Practitioner continentiezorg UMC St Radboud, Nijmegen

Inhoud presentatie Theoretische basis en Aan de hand van casuïstiek bekijken welke mogelijkheden er zijn. Zowel op conservatief als operatief gebied presentatie 18 jan 2007 arts assistenten Urologie

Causes of Transient Incontinence D.I.A.P.P.E.R.S. Delirium Infection Atrophic urethritis Pharmaceuticals Psychological Excessive urine output Restricted mobility Stool impaction Adapted from: Resnick NM. Med Grand Rounds. 1984;3:281-290. presentatie 18 jan 2007 arts assistenten Urologie

Prevalentie OAB bij patiënten ouder dan 65 Data From the National Overactive BLadder Evaluation (NOBLE) Research Program. presentatie 18 jan 2007 arts assistenten Urologie

Polypharmacy Oude patiënten nemen gemiddeld 5 verschillende medicamenten Evaluatie van de patiënt moet rekening houden met concomitante medicatie: Medicatie die symptomen van overactieve blaas mimeert bv, diuretica Medicatie die stressincontinentie mimeert, bv, alfa-blokkers Medicatie met anticholinergische nevenwerkingen bv, antidepressiva, antihistaminica, antipsychotica, codeine, slaappillen The elderly adult takes an average of 5 medications (not including vitamins) One study found that 10 of the top 25 prescribed drugs in the elderly had some anticholinergic properties Possible drug effects to consider are those that may cause symptoms that mimic those of OAB, from medications including diuretics and the antihypertensives. Treatment schedules can be manipulated to minimize possible complications between OAB therapies and these medications that also effect filling and voiding Other considerations include: effects from the acetylcholinesterase inhibitors, that primarily act on M1 receptors within the brain, but their effects on the micturition axis are unknown. anticholinergic adverse effects of medications, eg, the antidepressants, antihistamines, antipsychotics, and over‑the‑counter sleep aids like Tylenol PM® (acetaminophen and diphenhydramine). These effects may be augmented by the addition of an antimuscarinic agent. Thus, regimen’s must be scrutinized for potential interactions. DuBeau CE. Geriatrics. 2002;57:12-17. presentatie 18 jan 2007 arts assistenten Urologie

Comorbiditeit Dementie: belangrijkste reden tot institutionalisering is incontinentie! Maligniteit, obstructie en chirurgie hiervoor, UWI Doorligwonden Fracturen: incontinentie/urgency + gangproblemen of duizeligheid Ziekte van Parkinson (0.3 (55+) tot 4.4 (85+)/1000 p-years in Nederland (de Lau 2004) Diabetes (66000 nieuw gediagnosticeerde DM type-2 patiënten (50+)/jaar in Nederland (Dekker 2003) Thomas et al (Pixel study), Int J Geriatr Psychiatry 2004;19:127-35 presentatie 18 jan 2007 arts assistenten Urologie

Pitfalls in diagnose OAB: Sy. v. Parkinson OAB + rigide, dyssynerge sfincter Klachten lijken sterk op die van iemand met prostaat- lijden maar meer pollakisurie en aandrang Hoe meer blaasresidu hoe meer klachten. Dus als geen blaasklachten, geen onderzoek nodig Oxybutinine en andere anticholinergica geven meer residu Oxybutinine geeft deterioratie van het geheugen en daardoor achteruitgang van de hersenfunctie; ook opletten met meer selectieve medicatie Cave Botox SNS? Araki et al, 2000 Lemack et al, 2000 The elderly adult takes an average of 5 medications (not including vitamins) One study found that 10 of the top 25 prescribed drugs in the elderly had some anticholinergic properties Possible drug effects to consider are those that may cause symptoms that mimic those of OAB, from medications including diuretics and the antihypertensives. Treatment schedules can be manipulated to minimize possible complications between OAB therapies and these medications that also effect filling and voiding Other considerations include: effects from the acetylcholinesterase inhibitors, that primarily act on M1 receptors within the brain, but their effects on the micturition axis are unknown. anticholinergic adverse effects of medications, eg, the antidepressants, antihistamines, antipsychotics, and over‑the‑counter sleep aids like Tylenol PM® (acetaminophen and diphenhydramine). These effects may be augmented by the addition of an antimuscarinic agent. Thus, regimen’s must be scrutinized for potential interactions. presentatie 18 jan 2007 arts assistenten Urologie

Prevalence of Nocturia in a US Community-Based Population Nocturia increases with age, with a third of the population over the age of 75 reporting this symptom, nocturia has been associated with falls and fractures in the older population Age Group (years) Coyne KS, et al. BJU Int. 2003;42:948-54. presentatie 18 jan 2007 arts assistenten Urologie

Nocturia: oorzaak multifactorieel Nocturnal Polyuria OAB Sleep Disorders Nocturia can be caused by a number of conditions including OAB and prostatic disease. Often these conditions overlap resulting in difficulties in diagnosis presentatie 18 jan 2007 arts assistenten Urologie

Diagnose van incontinentie in de geriatrische populatie Klinisch onderzoek Urine onderzoek Urodynamica Mictie-incontinentie-residu lijsten Interne geneeskunde The elderly adult takes an average of 5 medications (not including vitamins) One study found that 10 of the top 25 prescribed drugs in the elderly had some anticholinergic properties Possible drug effects to consider are those that may cause symptoms that mimic those of OAB, from medications including diuretics and the antihypertensives. Treatment schedules can be manipulated to minimize possible complications between OAB therapies and these medications that also effect filling and voiding Other considerations include: effects from the acetylcholinesterase inhibitors, that primarily act on M1 receptors within the brain, but their effects on the micturition axis are unknown. anticholinergic adverse effects of medications, eg, the antidepressants, antihistamines, antipsychotics, and over‑the‑counter sleep aids like Tylenol PM® (acetaminophen and diphenhydramine). These effects may be augmented by the addition of an antimuscarinic agent. Thus, regimen’s must be scrutinized for potential interactions. DuBeau CE. Geriatrics. 2002;57:12-17. presentatie 18 jan 2007 arts assistenten Urologie

Behandeling incontinentie in de geriatrische populatie behandelingsopties: Blaastraining, fysiotherapie Plassen op uur, hulp op toilet MAAR: motivatie, tijdrovend, cognitieve functie Pharmacotherapy, chirurgie Combinatie blaastraining en pharmacotherapie is beter dan enkelvoudige therapie Burgio KL et al. J Am Geriatr Soc. 2000;48:370-374. presentatie 18 jan 2007 arts assistenten Urologie

Pharmacotherapy: bemerkingen Nevenwerking meer frequent, bij lagere dosis, meer uitgesproken en met een grotere impact: Constipatie fecale impactie Wazig zicht Droge mond caries Cognitieve achteruitgang The higher frequency and greater severity of adverse events in this population, even at lower treatment doses, also should carefully be considered when choosing pharmacotherapy The specific considerations that need to be addressed in the elderly are constipation and fecal impaction, particularly in bedridden patients blurred vision, which can lead to falls and other problems social isolation and cognitive impairment, which can lead to acute confusion and could possibly be misdiagnosed as dementia effects on the salivary gland that can cause dry mouth leading to tooth decay Lamy PP. Drugs and Aging. 1991;1:385-404. Mintzer and Burns. J R Soc Med. 2000;93:457-462. presentatie 18 jan 2007 arts assistenten Urologie

Anticholinergica en potentieel cognitieve achteruitgang Acetylcholine speelt belangrijke rol in korte termijn geheugen Andere medicatie kan ook cognitieve achteruitgang veroorzaken (bv, antihistaminica, antispasmodica, en antipsychotica) Verschillende gerandomiseerde gecontroleerde studies toonden impact van oxybutinine op cognitieve functie, veel minder dan bij nieuwere medicatie Pleidooi voor tolterodine, solifenacin, darifenacin Drachman DA, et al. Neurobiol Aging. 1980;1:39-43. Katz IR, et al. J Am Geriatr Soc.1998;46:8-13. presentatie 18 jan 2007 arts assistenten Urologie

vochtbeperking: zinloos (graad 1 level of evidence) NOCTURIE vochtbeperking: zinloos (graad 1 level of evidence) Slaappillen verminderen nachtelijke diurese (graad 2) Furosemide 6u voor slapen (graad 3) Imipramine: therapie voor OAB + vermindering nachtelijke urineproductie (graad 3) positie: elevatie benen om resorptie oedeem voor het slapen te verbeteren (graad 3) The elderly adult takes an average of 5 medications (not including vitamins) One study found that 10 of the top 25 prescribed drugs in the elderly had some anticholinergic properties Possible drug effects to consider are those that may cause symptoms that mimic those of OAB, from medications including diuretics and the antihypertensives. Treatment schedules can be manipulated to minimize possible complications between OAB therapies and these medications that also effect filling and voiding Other considerations include: effects from the acetylcholinesterase inhibitors, that primarily act on M1 receptors within the brain, but their effects on the micturition axis are unknown. anticholinergic adverse effects of medications, eg, the antidepressants, antihistamines, antipsychotics, and over‑the‑counter sleep aids like Tylenol PM® (acetaminophen and diphenhydramine). These effects may be augmented by the addition of an antimuscarinic agent. Thus, regimen’s must be scrutinized for potential interactions. presentatie 18 jan 2007 arts assistenten Urologie

NOCTURIE – desmopressin meta-analyse Bewezen verminderde nocturie, nachtelijke polyurie en verbetering QOL Risico hyponatriëmie: 7.6% (3-20%) - korte studies! - cardiale, renale pathologie exclusie - andere medicatie die hyponatriëmie kan veroorzaken verboden Voorzichtigheid en monitoring belangrijk The elderly adult takes an average of 5 medications (not including vitamins) One study found that 10 of the top 25 prescribed drugs in the elderly had some anticholinergic properties Possible drug effects to consider are those that may cause symptoms that mimic those of OAB, from medications including diuretics and the antihypertensives. Treatment schedules can be manipulated to minimize possible complications between OAB therapies and these medications that also effect filling and voiding Other considerations include: effects from the acetylcholinesterase inhibitors, that primarily act on M1 receptors within the brain, but their effects on the micturition axis are unknown. anticholinergic adverse effects of medications, eg, the antidepressants, antihistamines, antipsychotics, and over‑the‑counter sleep aids like Tylenol PM® (acetaminophen and diphenhydramine). These effects may be augmented by the addition of an antimuscarinic agent. Thus, regimen’s must be scrutinized for potential interactions. Weatherall M. J Neurourol Urodyn 2004;23:302-305. presentatie 18 jan 2007 arts assistenten Urologie