Challenges in the Management of Nursing Home Residents with Overactive Bladder and/or Urinary Incontinence

1. Challenges in the Pharmacologic Management of Nursing Home Residents (NHR)
With Overactive Bladder (OAB) and/or Urinary Incontinence (UI)
Barbara J. Zarowitz1
, Terrence O’Shea1
, Carrie Allen1
, Eric G. Tangalos2
, Todd Berner3
, Joseph G. Ouslander4
1
Omnicare, Inc.; 2
Mayo Clinic, Rochester, MN; 3
Formerly of Medical Affairs, Americas, Astellas Pharmaceutical Global Development, Northbrook, IL, USA; 4
Florida Atlantic Univ.
The research reported on this poster was supported by Astellas. The investigators retained full independence in the conduct of this research
OBJECTIVESOBJECTIVES
METHODSMETHODS
DISCUSSIONDISCUSSION
The purpose of this descriptive, retrospective study was to determine the
clinical profile and treatment patterns of NHR with OAB and/or UI through
analysis of Minimum Data Set (MDS) [version 3.0] and prescription
claims records. Specific aims included identification of NHR who had
potential:
 relative pharmacologic contraindications to antimuscarinic treatment due
to concomitant anticholinergic medications and/or acetylcholinesterase
inhibitors (AChEIs); and
 non-pharmacologic limitations to treatment with antimuscarinics [i.e.,
severe mobility impairment (SMI) and/or moderate-to-severe cognitive
impairment (MSCI)].
LIMITATIONSLIMITATIONS
CONCLUSIONSCONCLUSIONS
• After receiving IRB approval, a data extract was obtained from the
Omnicare Senior Health Outcomes data repository of linked and de-
identified MDS and prescription claims records from 9/2010
to10/2012
• UI identified by ICD-9 codes or MDS documentation; OAB by ICD-9
codes only
• Cognition assessed by MDS Brief Interview for Mental Status (BIMS)
Summary Scores, calculated Cognitive Performance Scale (CPS)
scores, or Cognitive Skills for Daily Decision Making; Severe Mobility
Impairment identified in MDS Section G (Functional Status)
• A subset of these NHR with prescription claims data was identified
and analyzed for medication utilization. Anticholinergic medications
were identified from an accepted list published in Omnicare’s
Geriatric Pharmaceutical Care Guidelines®
• For the purposes of defining potential antimuscarinic treatment
candidates, we applied two definitions. To define those who would
most likely benefit from treatment (Definition 1), we excluded NHR
with MSCI, severe mobility impairment, and those receiving
anticholinergic, AChEI and antimuscarinic medications at the time of
evaluation. A less restrictive candidate antimuscarinic treatment
population (Definition 2) was defined by excluding only NHR with
MSCI and SMI, and those receiving antimuscarinic therapy, without
concomitant interfering medications, at the time of evaluation.
• The derivation of the study sample is depicted in Figure 1.
• Identifying and excluding NHR with characteristics that precluded
treatment with an antimuscarinic, or potentially contributed to drug-
drug and/or drug-disease interactions that may worsen their
underlying conditions, allowed us to characterize a small cohort
who may benefit from treatment, and in whom no obvious
contraindications to treatment existed.
• Among NHR not currently treated with an antimuscarinic, few met
eligibility criteria for treatment established a priori, (i.e., absence of
MSCI, severe mobility impairment, anticholinergic, antimuscarinic
and AChEI therapy).
• Using the more rigorous definition of eligibility for treatment, as few
as 6.6% of NHR with OAB and/or UI were considered treatment
candidates. Even when only NHR with MSCI and severe mobility
impairment were excluded (Definition 2), just 20.4% were
considered treatment candidates for antimuscarinic therapy;
• When we explored antimuscarinic treatment of residents with OAB
and/or UI and UI alone, we found that 77% of those treated with
antimuscarinics had medications with anticholinergic properties
prescribed concurrently.
• Prescription of anticholinergic drugs in older persons has been
shown to reduce performance in tasks that assessed verbal
memory, higher rates of global cognitive dysfunction, delirium, falls,
poor physical performance and loss of independence;
• Despite a well-documented pharmacodynamic interaction between
antimuscarinic agents and AChEI, we found 24% of NHR with OAB
and/or UI received these concurrently.
• A 50% faster rate of functional decline has been documented for
NHR with higher levels of functioning when antimuscarinics and
AChEIs are administered concomitantly.2
•
*
BACKGROUNDBACKGROUND
There is a paucity of recent data regarding the identification, clinical
profile, and treatment patterns of NHR with OAB and/or UI. As many as
36.7% of short-stay, and 70.3% of long-stay NHR are not in complete
control of their bladder function1. Non-pharmacologic approaches such as
pelvic floor exercises, prompted voiding, and other assistive toileting
programs can be effective for a substantial proportion of NHR with UI.
However, the success of such interventions may be diminished by the
cognitive and/or functional impairments commonly seen in NHR. Studies
have suggested that a subgroup of NHR who do not respond to prompted
voiding alone do improve with antimuscarinic treatment , however,
relatively few NHR may be candidates for such pharmacologic therapy.
I
RESULTS
• The study may have been subject to under-identification of NHR
with OAB given that there is not an MDS- specific item dedicated to
the diagnosis for OAB.
• There are potential inaccuracies in coding of MDS data due to poor
medical historical data and inter-rater variability.
• Our design was not longitudinal and did not evaluate changes in
cognitive or functional status over time. Therefore, we were unable
to draw any conclusions about the contribution of drug-drug and
drug-disease interactions to the status of the NHR.
• This study advances our understanding of the challenges in
prescribing treatment safely and appropriately in elderly NHR with a
high prevalence of underlying cognitive and functional impairment.
• Many NHR are poor candidates to proven non-pharmacological
interventions to address UI.
• Relatively few NHR are candidates for antimuscarinic therapy.
• Alternate drug classes for treatment of comorbid conditions in older
persons with OAB and/or UI should be considered.
REFERENCESREFERENCES
1. Landefeld CS et al. NIH state-of-the-science conference statement: prevention of
fecal and urinary incontinence in adults. Ann Intern Med 2008;148:449-58.
2. Sink KM, Thomas J, Xu H et al. Dual use of bladder anticholinergics and
cholinesterase inhibitors: long-term functional and cognitive outcomes. J Am
Geriatr Soc 2008; 56:847-53.