FINAL EXAM STUDY GUIDE
WEEK 5
Urinary incontinence is a common issue within the older adult community. Urinary incontinence can be
distressing and impact the older adult’s quality of life and socialization. Incontinence also increases the
risk of skin breakdown and falls and is a leading reason for placement in long-term care. Treatment of
urinary incontinence is essential to improve health and quality of life.
Living situation: Community 20% of women have incontinence
Living situation: Long-term care 75% of women have incontinence
Men younger than 85 have a lower incidence of incontinence than women of the same age; incidence
rates are similar, however, for men and women aged 85 and above.
Urinary incontinence: Involuntary urine leakage
Urgency: Sudden need to void
Urgency incontinence: Sudden need to void followed by leakage
Frequency: Frequent urination
Hesitancy: Difficulty in initiating urine stream
Straining: Effort to initiate or maintain urine stream
Dribbling: Leakage of small amounts of urine after voiding
Nocturia: Waking during the night to void
Overactive bladder: Urgency, frequency, and nocturia
Risk factors for urinary incontinence include female gender, weakness/functional impairment, advanced
age, obesity, diabetes, depression, and hysterectomy. Other risk factors for urinary incontinence include
neurologic impairment, including past cerebrovascular accident (CVA), cognitive impairment, and fecal
incontinence.
Assessment for urinary incontinence involves obtaining a detailed history of the onset, duration, and
severity of symptoms, including the presence of nocturia and sleep disruption and the impact on quality
of life. An intake and voiding diary can help to identify patterns of nocturia. Some older adults,
particularly women, may not consider occasional urge or stress incontinence as a health burden. For
others, incontinence is distressing and may prevent them from engaging in social activities.
Stress incontinence presents as leakage with exertion or coughing, sneezing, or laughing.
A pelvic exam, urinalysis, and empty supine stress test are appropriate assessments or diagnostic tests.
A pelvic exam is indicated to rule out masses, a mobile urethra, cystocele, or rectocele as possible
reasons for incontinence. A urinalysis is indicated for all clients who present with new or worsened
incontinence to rule out urinary tract infection or hematuria. An empty supine stress test is indicated
and is performed by asking the client to void, then observing the urethra in lithotomy position while the
client is bearing down. A post-void residual (PVR) may be appropriate for clients who are suspected to
have overflow incontinence; therefore, it is not indicated at this time.
The provider’s first step is to establish goals for treatment with the client. Some clients may be satisfied
with using protective undergarments for occasional incontinence and refuse additional intervention.
Treatment, when indicated, should begin with the least invasive strategy and move stepwise as needed.
,If the physical exam reveals no abnormalities, referral to urology may be unnecessary unless behavior
and medication strategies do not succeed.
Treat Comorbidity
Comorbidities, such as sleep apnea and diabetes, must be managed before implementing other
treatments for urinary incontinence. Current medications should be reviewed to identify those that
might precipitate incontinence.
Lifestyle
Lifestyle interventions include weight loss, reducing consumption of caffeine and alcohol, decreasing
fluid intake before bed, and smoking cessation.
Behavioral Therapies
Behavioral therapies include bladder training and pelvic muscle exercises; both are useful for urgency
and stress incontinence.
Bladder training includes frequent voiding (i.e., every 2 hours) along with visualization and muscle
contractions to help control urgency. As training progresses, the time between voluntary voids is
increased. The training process may take several weeks (Mazur-Bialy et al., 2020).
Pelvic muscle exercises, or Kegels, help to strengthen the pelvic floor. Exercises may be done
throughout the day, with a goal of three sets of 10-12 per day. Exercises may begin to improve
incontinence within a month.
Prompted voiding may decrease incontinence episodes in cognitively impaired clients. The caregiver
should prompt the client to report the need to void throughout the day and assist in toileting every 2-3
hours (Mazur-Bialy et al., 2020).
Medications
Pharmacologic therapy is not approved for stress incontinence but may be prescribed for the
management of urgency incontinence or overactive bladder and includes:
Antimuscarinic medications: oxybutynin (Ditropan), tolterodine (Detrol)
• monitor for anticholinergic adverse effects
• drugs interact with drugs that induce CYP2D6
• the American Geriatrics Society 2019 Beers Criteria recommends avoiding antimuscarinics
in clients with dementia or cognitive impairment
Beta-3 Agonist: mirabegron (Myrbetriq)
• interacts with drugs that induce CYP2D6
• potential adverse effect: increased BP
,Minimally Invasive Procedures
Minimally invasive procedures may be considered for clients who have urgency incontinence that does
not respond to behavioral interventions or medications. Referral to urology is appropriate for clients
seeking minimally invasive procedures or surgery.
Procedures for urgency incontinence include:
• onabotulinumtoxinA bladder injections
• instilled in office via cystoscope
• percutaneous tibial nerve stimulation
• electrical stimulation via acupuncture needle
• weekly appointments for 3
months Procedures for stress incontinence
include:
• urethral bulking
• botulinum toxin injections
Surgery
Surgical interventions for stress incontinence include:
• midurethral mesh sling
Surgical interventions for urgency incontinence include:
• sacral neuromodulation: implanted electrode connected to a stimulator
Urinary Tract Infections (UTIs) in the Older Adult
The diagnosis and treatment of urinary tract infections (UTI) in older adults differ from treatment in
younger individuals. UTI is the most common bacterial infection in those over 65 and the most common
cause of sepsis in older adults. Swift recognition of the difference between asymptomatic bacterial
colonization, which may not require treatment, and symptomatic infection is essential (Langford et al.,
2021). Click each of the sections below to learn more.
UTIs in Community-Dwelling Older Adults
For older adults who reside in the community, symptomatic UTIs are similar in presentation to younger
adults and may include dysuria, frequency, urgency, and hematuria. Postmenopausal women may also
complain of incontinence, nocturia, low back pain, and constipation (North American Menopause
Society, 2020). Older adults may experience changes in cognition, including confusion.
Unlike with younger adults, treatment should not be initiated based solely on symptoms, as common
symptoms may mimic other disease processes. A urine dipstick to evaluate for bacteriuria and pyuria is
required. If nitrites and/or leukocytes are present, using symptomatic treatment until microbiology
results are available to direct targeted antibiotic therapy can help reduce antibiotic resistance
(Langford et al., 2021).
UTIs in Long-Term Care Residents
Residents of long-term care facilities may not present with typical signs of UTIs, and they may be more
likely to have chronic urinary symptoms such as frequency, nocturia, or incontinence. Change in mental
status may be the most common symptom associated with UTI in long-term care (Langford et al., 2021).
, Other symptoms of a suspected UTI in this population include a change in urine character,
fever, declining functional status, and hematuria. Evidence-based consensus criteria should be
used to determine when to initiate treatment.
Examine the image below to learn more about consensus criteria for diagnosing UTIs in long-term care
clients.
McGeer criteria
Three of the following:
• Fever >38 C
• New/increased burning, frequency, urgency
• New flank or suprapubic pain
• Change in character of urine
• New or worsening mental status changes
Loeb criteria
Acute dysuria
OR
Fever >37.9 C plus one of the following
• Urgency
• Frequency
• Suprapubic pain
• Gross hematuria
• Costovertebral angle tenderness
• Urinary incontinence
Slide 1
Dorothy is an 89-year-old resident of a long-term care facility. She has a history of dementia, diabetes,
and two previous UTIs within the past year, treated with trimethoprim/sulfamethoxazole. Her primary
nurse calls to report that Dorothy is having increased agitation and periods of incontinence, which is
new behavior for her. Her urine smells foul, and she has a temperature of 38 C with chills.
Slide 2
Which of the following risk factors for UTI are relevant to Dorothy? Select all that apply.
• previous UTI (Correct answer)
• resident of long-term care (Correct answer)
• diabetes (Correct answer)
• dementia (Correct answer)
Rationale: Dorothy’s risk factors for UTI include previous UTI, resident of long-term care facility, and a
history of diabetes and dementia. The number one risk factor in older adults for UTI is a history of
previous UTIs. Other risk factors include:
• increased exposure to organisms (long term care or hospitalizations)
• genitourinary structural/functional abnormalities
• changes in vaginal flora
• diabetes
• Alzheimer’s disease
• Parkinson’s disease
Slide 3
WEEK 5
Urinary incontinence is a common issue within the older adult community. Urinary incontinence can be
distressing and impact the older adult’s quality of life and socialization. Incontinence also increases the
risk of skin breakdown and falls and is a leading reason for placement in long-term care. Treatment of
urinary incontinence is essential to improve health and quality of life.
Living situation: Community 20% of women have incontinence
Living situation: Long-term care 75% of women have incontinence
Men younger than 85 have a lower incidence of incontinence than women of the same age; incidence
rates are similar, however, for men and women aged 85 and above.
Urinary incontinence: Involuntary urine leakage
Urgency: Sudden need to void
Urgency incontinence: Sudden need to void followed by leakage
Frequency: Frequent urination
Hesitancy: Difficulty in initiating urine stream
Straining: Effort to initiate or maintain urine stream
Dribbling: Leakage of small amounts of urine after voiding
Nocturia: Waking during the night to void
Overactive bladder: Urgency, frequency, and nocturia
Risk factors for urinary incontinence include female gender, weakness/functional impairment, advanced
age, obesity, diabetes, depression, and hysterectomy. Other risk factors for urinary incontinence include
neurologic impairment, including past cerebrovascular accident (CVA), cognitive impairment, and fecal
incontinence.
Assessment for urinary incontinence involves obtaining a detailed history of the onset, duration, and
severity of symptoms, including the presence of nocturia and sleep disruption and the impact on quality
of life. An intake and voiding diary can help to identify patterns of nocturia. Some older adults,
particularly women, may not consider occasional urge or stress incontinence as a health burden. For
others, incontinence is distressing and may prevent them from engaging in social activities.
Stress incontinence presents as leakage with exertion or coughing, sneezing, or laughing.
A pelvic exam, urinalysis, and empty supine stress test are appropriate assessments or diagnostic tests.
A pelvic exam is indicated to rule out masses, a mobile urethra, cystocele, or rectocele as possible
reasons for incontinence. A urinalysis is indicated for all clients who present with new or worsened
incontinence to rule out urinary tract infection or hematuria. An empty supine stress test is indicated
and is performed by asking the client to void, then observing the urethra in lithotomy position while the
client is bearing down. A post-void residual (PVR) may be appropriate for clients who are suspected to
have overflow incontinence; therefore, it is not indicated at this time.
The provider’s first step is to establish goals for treatment with the client. Some clients may be satisfied
with using protective undergarments for occasional incontinence and refuse additional intervention.
Treatment, when indicated, should begin with the least invasive strategy and move stepwise as needed.
,If the physical exam reveals no abnormalities, referral to urology may be unnecessary unless behavior
and medication strategies do not succeed.
Treat Comorbidity
Comorbidities, such as sleep apnea and diabetes, must be managed before implementing other
treatments for urinary incontinence. Current medications should be reviewed to identify those that
might precipitate incontinence.
Lifestyle
Lifestyle interventions include weight loss, reducing consumption of caffeine and alcohol, decreasing
fluid intake before bed, and smoking cessation.
Behavioral Therapies
Behavioral therapies include bladder training and pelvic muscle exercises; both are useful for urgency
and stress incontinence.
Bladder training includes frequent voiding (i.e., every 2 hours) along with visualization and muscle
contractions to help control urgency. As training progresses, the time between voluntary voids is
increased. The training process may take several weeks (Mazur-Bialy et al., 2020).
Pelvic muscle exercises, or Kegels, help to strengthen the pelvic floor. Exercises may be done
throughout the day, with a goal of three sets of 10-12 per day. Exercises may begin to improve
incontinence within a month.
Prompted voiding may decrease incontinence episodes in cognitively impaired clients. The caregiver
should prompt the client to report the need to void throughout the day and assist in toileting every 2-3
hours (Mazur-Bialy et al., 2020).
Medications
Pharmacologic therapy is not approved for stress incontinence but may be prescribed for the
management of urgency incontinence or overactive bladder and includes:
Antimuscarinic medications: oxybutynin (Ditropan), tolterodine (Detrol)
• monitor for anticholinergic adverse effects
• drugs interact with drugs that induce CYP2D6
• the American Geriatrics Society 2019 Beers Criteria recommends avoiding antimuscarinics
in clients with dementia or cognitive impairment
Beta-3 Agonist: mirabegron (Myrbetriq)
• interacts with drugs that induce CYP2D6
• potential adverse effect: increased BP
,Minimally Invasive Procedures
Minimally invasive procedures may be considered for clients who have urgency incontinence that does
not respond to behavioral interventions or medications. Referral to urology is appropriate for clients
seeking minimally invasive procedures or surgery.
Procedures for urgency incontinence include:
• onabotulinumtoxinA bladder injections
• instilled in office via cystoscope
• percutaneous tibial nerve stimulation
• electrical stimulation via acupuncture needle
• weekly appointments for 3
months Procedures for stress incontinence
include:
• urethral bulking
• botulinum toxin injections
Surgery
Surgical interventions for stress incontinence include:
• midurethral mesh sling
Surgical interventions for urgency incontinence include:
• sacral neuromodulation: implanted electrode connected to a stimulator
Urinary Tract Infections (UTIs) in the Older Adult
The diagnosis and treatment of urinary tract infections (UTI) in older adults differ from treatment in
younger individuals. UTI is the most common bacterial infection in those over 65 and the most common
cause of sepsis in older adults. Swift recognition of the difference between asymptomatic bacterial
colonization, which may not require treatment, and symptomatic infection is essential (Langford et al.,
2021). Click each of the sections below to learn more.
UTIs in Community-Dwelling Older Adults
For older adults who reside in the community, symptomatic UTIs are similar in presentation to younger
adults and may include dysuria, frequency, urgency, and hematuria. Postmenopausal women may also
complain of incontinence, nocturia, low back pain, and constipation (North American Menopause
Society, 2020). Older adults may experience changes in cognition, including confusion.
Unlike with younger adults, treatment should not be initiated based solely on symptoms, as common
symptoms may mimic other disease processes. A urine dipstick to evaluate for bacteriuria and pyuria is
required. If nitrites and/or leukocytes are present, using symptomatic treatment until microbiology
results are available to direct targeted antibiotic therapy can help reduce antibiotic resistance
(Langford et al., 2021).
UTIs in Long-Term Care Residents
Residents of long-term care facilities may not present with typical signs of UTIs, and they may be more
likely to have chronic urinary symptoms such as frequency, nocturia, or incontinence. Change in mental
status may be the most common symptom associated with UTI in long-term care (Langford et al., 2021).
, Other symptoms of a suspected UTI in this population include a change in urine character,
fever, declining functional status, and hematuria. Evidence-based consensus criteria should be
used to determine when to initiate treatment.
Examine the image below to learn more about consensus criteria for diagnosing UTIs in long-term care
clients.
McGeer criteria
Three of the following:
• Fever >38 C
• New/increased burning, frequency, urgency
• New flank or suprapubic pain
• Change in character of urine
• New or worsening mental status changes
Loeb criteria
Acute dysuria
OR
Fever >37.9 C plus one of the following
• Urgency
• Frequency
• Suprapubic pain
• Gross hematuria
• Costovertebral angle tenderness
• Urinary incontinence
Slide 1
Dorothy is an 89-year-old resident of a long-term care facility. She has a history of dementia, diabetes,
and two previous UTIs within the past year, treated with trimethoprim/sulfamethoxazole. Her primary
nurse calls to report that Dorothy is having increased agitation and periods of incontinence, which is
new behavior for her. Her urine smells foul, and she has a temperature of 38 C with chills.
Slide 2
Which of the following risk factors for UTI are relevant to Dorothy? Select all that apply.
• previous UTI (Correct answer)
• resident of long-term care (Correct answer)
• diabetes (Correct answer)
• dementia (Correct answer)
Rationale: Dorothy’s risk factors for UTI include previous UTI, resident of long-term care facility, and a
history of diabetes and dementia. The number one risk factor in older adults for UTI is a history of
previous UTIs. Other risk factors include:
• increased exposure to organisms (long term care or hospitalizations)
• genitourinary structural/functional abnormalities
• changes in vaginal flora
• diabetes
• Alzheimer’s disease
• Parkinson’s disease
Slide 3
