Medical Therapy in Overactive Bladder of the Elderly

Abstract

The number of patients exhibiting overactive bladder (OAB) symptoms and its associated medical, social, and economic problems will increase with the growing elderly population. The basic therapeutic approach in all elderly people should include the exploration of correctable factors to build a corrective approach for OAB. Lifestyle modifications and behavioral therapies should be attempted initially, but if the patients are persistently bothered by their symptoms with no benefit from initial therapy, pharmacological agents can be added to conservative therapies. Anticholinergics are the most studied and prescribed agents. In the end, treatment of OAB in the elderly requires a careful and holistic evaluation before deciding on the most appropriate management as a number of concomitant factors that can cause OAB symptoms in this age range."urgency, with or without urge incontinence, usually with increased frequency and nocturia." [1]. It is estimated to affect approximately one third of individuals over 65 years old [2,3]. Additionally, current population forecasts estimate a global increase in the proportion of people aged over 65 years, with the greatest rise being in those aged over 80 [4]. It would be reasonable to expect patients exhibiting OAB symptoms, and the subsequent medical, social, and economic burden associated with these patients to increase as well. In a large Japanese study, Homma et al. reported that OAB compromised healthrelated quality of life (QoL) in more than half (53 %) of respondents and affected emotions (42 %), sleep/vitality (37 %), and physical capability (34 %) [5]. The detrimental effects on the individual is closely related to the occurrence of urgency and urge urinary incontinence (UUI), which can make it difficult for them to maintain regular daily activities due to the need to be in close proximity to toilet and the possible embarrassment of urine loss [6••]. More concerning, OAB and especially nocturia has been linked to the rise in the risk of falls, fractures, and even death [3,[7][8][9]. Pathophysiology of Overactive Bladder in the ElderlyNormal bladder function involves a complex coordination of the urinary tract and nervous system. When the bladder fills, it functions as a compliant structure which is capable of relaxation and with pressure that remains lower than the urethral resistance. During normal micturition, a decrease in urethral resistance and tonic contraction of the detrusor smooth muscle occurs. OAB symptoms, on the other hand, are frequently caused by involuntary contraction due to detrusor overactivity (DO), either occurring idiopathically or after neurological insult. A distinction is generally made to distinguish DO from either of these causes, but in the elderly, it is often unclear as it can be a result of normal aging or a prior/ongoing neurological event which is sometimes clinical unapparent. By comparison,

Trends in the use of older overactive bladder agents and uptake of fesoterodine and mirabegron in Canada

“…19 Due to mirabegron's different mechanism of action, it has been shown to lead to fewer side effects in clinical trials that are common among anticholinergics, and which are often a concern when these products are used in an aging population due to their contraindications and adverse effects. 4,12,20 Furthermore, in January 2015 a private co-pay program supported by mirabegron's manufacturer was designed to bridge patients on therapy prior to provincial formulary access in all provinces except British Columbia and Quebec by providing free access to the drug upon its approval by Health Canada. As a result, the faster uptake of mirabegron was likely driven by a combination of its novel mechanism of action, access through the co-pay program and an extensive marketing campaign in North America.…”

“…The choice of the anticholinergic agent generally depends on physician and patient preference, formulary coverage, physician experience, and insurance coverage . Due to mirabegron's different mechanism of action, it has been shown to lead to fewer side effects in clinical trials that are common among anticholinergics, and which are often a concern when these products are used in an aging population due to their contraindications and adverse effects . Furthermore, in January 2015 a private co‐pay program supported by mirabegron's manufacturer was designed to bridge patients on therapy prior to provincial formulary access in all provinces except British Columbia and Quebec by providing free access to the drug upon its approval by Health Canada.…”

“…The prevalence of OAB symptoms is 12.2% in people aged <60 years, increasing to 23.8% in those aged >60 years . Therefore, an increase in the number of people affected by OAB symptoms is expected to rise as the population ages . Effective treatment of severe OAB is a priority for clinicians as it can have considerable negative impact on patient's mental health, sleep quality, work productivity, and overall quality of life…”

“…3 Therefore, an increase in the number of people affected by OAB symptoms is expected to rise as the population ages. 4 Effective treatment of severe OAB is a priority for clinicians as it can have considerable negative impact on patient's mental health, sleep quality, work productivity, and overall quality of life. 1,2,5 Anticholinergic agents are the first line pharmacologic agents for the treatment of OAB, several of which have been approved for use in North America and Europe.…”

“…1,2,5 Anticholinergic agents are the first line pharmacologic agents for the treatment of OAB, several of which have been approved for use in North America and Europe. 4,6,7 Six anticholinergic medications: oxybutynin, flavoxate, tolterodine, darifenacin, solifenacin, and trospium have been available to treat OAB for over three decades, but in recent years two newer agents were approved for use in Canada. The first drug, fesoterodine is a new anticholinergic approved by Health Canada on April 19, 2012.…”