SIR—We read with great interest the recent NICE guidelines on the important problem of urinary incontinence (UI) in women , which has a large impact on frail older people. In general nursing homes UI has been found to have a prevalence 70%, and this rises to 84% of institutionalised demented people [2, 3]. However, despite these data, we feel that this guideline is more aimed towards younger women without significant co-morbidities. The multi-factorial nature (e.g. immobility, polypharmacy and cognitive impairment) of UI in older people coupled with difficulties in assessment of this population group makes this problem harder to evaluate.
The guidance suggests the use of the Abbreviated Mental Test and Mini-Mental State Examination to assess cognitive functions in those over 75 or with reasons to suspect an abnormality. Both of these have been shown to be reasonable screening tests for cognitive impairment, but it should be remembered that they are poor at assessing frontal lobe and non-dominant parietal functions. Impairments here may be particularly important to getting to the toilet, sequencing events and motor control of the bladder (e.g. UI following anterior cerebral artery infarction). Trials that have recruited older patients have tended to exclude those with cognitive impairment [4–6], and evidence for efficacy of interventions among patients with dementia is limited .
The urge subtype of UI has been found to be the most common form in the institutionalised elderly . The guidance recommends bladder retraining as the first-line intervention for this form of incontinence. The occurrence of cognitive problems will clearly make patient cooperation with this difficult and, therefore, potentially ineffective. The second-line strategy of anticholinergic medications may also cause problems. Trials of these drugs often report only dry mouth and blurred vision as significant side effects but they are usually of short duration and lack any formal cognitive follow-up [6, 8]. Anticholinergic medications have been associated with cognitive deterioration and delirium in elderly patients, particularly those with baseline cognitive impairment [9–15]. They may also provoke orthostatic hypotension, thereby increasing the risk of falls. We believe there are subgroups of the elderly in whom these medications should be avoided altogether and those in whom they are commenced should be carefully monitored for the development of cognitive impairment and symptoms of orthostatic hypotension.
Also, the guidance does not cover overflow incontinence, which in the elderly may be due to non-neurological causes such as faecal impaction. Nor does it cover the management of functional incontinence provoked by environmental or mobility issues. Clearly there are limits to the feasible extent of any review, but we feel that this should be reflected in the title of the guidance (and therefore its intended scope)—perhaps a more fitting title would have been ‘Urinary incontinence: the management of urge, stress and mixed types of urinary incontinence in women without significant co-morbidities.’ In summary, the guidance represents an excellent guide to the assessment and management of some forms of UI occurring in some subgroups of women. It does not appear to represent the needs of all women with UI, especially the frail elderly.
We have written formally to NICE, and their response is that they had to keep within very narrow confines for their review and that clinicians should assess the needs each patient prior to commencing any therapy. We believe that to be clinically relevant more attention should have been given to frail older people as they are the largest patient group affected.