Geriatrics - July 2017

Incontinence in ageing individuals 201

n Pelvis examination should look for should be prescribed in elderly TREATMENT APPROACHES
atrophic changes, prolapse and rectal women.3
examination to evaluate the prostate – The underlying causes of
incontinence lead to a gradual
n U rinalysis for: bacteriuria, haematuria, increase in residual urine in the
protein and glucose. bladder, often resulting in recurrent
urinary tract infections. These
Pathology tests should include urea and infections should be treated with
creatinine, blood glucose and urine an antibiotic and the appropriate
cytology. symptomatic medication.
– Medical treatment should be as for
A note of caution – although the assess- benign prostatic hyperplasia.
ment must be comprehensive, it must be n Skin-care regimens to protect skin
as minimally invasive as possible because integrity and prevent skin infections
of embarrassment and apprehension in and urine dermatitis are very
the elderly. So focus on the “must know” important in the elderly.
rather than the “nice to know”.3 n Surgical interventions: If improvement
is insufficient, surgery needs to be
MANAGEMENT OF URINARY considered and can take the form of
INCONTINENCE an anterior vaginal repair or a fixation
of the bladder neck in its normal
In terms of management, and in order to anatomical position behind the pubic
support independent toileting, it is essen- symphysis. Treat as for benign prostatic
tial that the family practitioner hyperplasia when medical options
co-ordinates care by a multi-disciplinary have failed.
team, including an occupational- and a n M anagement of the activities of daily
physiotherapist. The successful manage- living: It is important to mention the
ment of urinary incontinence is based on availability of the following products to
theinformationthatemergedduringtheassess- those elderly patients with a problem:
ment. When considering the manage- – Disposable or re-usable absorbent
ment, the following options need to be undergarments, underpads and
taken into account: bed-pads for heavy leakage
n Behavioural therapy, including – Feminine hygiene products for
urine containment in cases of light
changing the drinking- and bladder- and infrequent urine loss
emptying habits, are important. – Bedside commodes or urinals
n Pelvic floor rehabilitation in the form of
pelvic muscle exercises (Kegel CONCLUSION
exercises) is very useful mainly in stress
incontinence, even in the older There are probably few things as satisfying
individual. as having an elderly patient confirm that
n Pharmacological options are mainly for simple behavioural changes, including
stress and urge incontinence and of time voiding, urge inhibition and pelvic
little use in overflow incontinence. muscle exercises, have resulted in a
Pharmaceutical agents should be tried marked decrease in both incontinence
if behavioural treatment is and nocturia. This is, however, only
unsatisfactory. possible if the family practitioner is aware
– These drugs include anticholinergic of the high prevalence of the problem in
the elderly, and applies a whole-person
agents tolterodine 1 or 2 mg twice approach in the evaluation and manage-
daily or oxybutynin 2,5-5 mg up to ment of the problem.
four times daily. The use of these
drugs may be limited by their side HANDBOOK OF GERIATRIC MEDICINE
effects of dry mouth, constipation
and confusion.
– Systemic or topically oestrogens
reverse the urogenital atrophy and

202 URINARY SYSTEM CONDITIONS

REFERENCES women aged 50 and over. Acta Obstet
1. Lekan-Rutledge D. Urinary Incontinence Gynecol Scand. 2005;84:72.
3. Merkelj I, Quillen JH. Urinary incontinence
strategies for frail elderly women. Urol Nurs. in the elderly. South African Med J.
2014;24(4). 2001;94(10).
2. Oskay UY, Beji NK, Yalcin O. A study on
urological complaints of postmenopausal

HANDBOOK OF GERIATRIC MEDICINE

Cancer screening in the elderly patient – general guidelines 203

Cancer screening in the elderly TREATMENT APPROACHES
patient – general guidelines

Dr D Eedes In the main, we have to extrapolate the
MBChB FFRAD(T) (SA) data for younger patients to guide us.
 Clinical Oncology Advisor, Cape Town Once again, the art of medicine is in
understanding the potential pros and
Patient care administered at the extremes cons of screening, and matching these to
of life, to the young and the old, is charac- the individual patient’s expectations and
terised by unique issues associated with preferences.
paediatrics and geriatric medicine. The
special vulnerabilities of these groups are For the older patient, individualised
accentuated when it comes to cancer screening or surveillance is generally
prevention, screening, early detection and recommended.
treatment. Paediatric oncology is well
structured to deal with the special prob- CANCER SCREENING
lems associated with cancers of childhood. GOALS OF CANCER-SCREENING
While most general oncologists consider
themselves prepared to deal with the older The goal of cancer-screening should be to
cancer patient, the current growth of the identify at an early stage an asympto-
geriatric population has led to the devel- matic patient at risk of developing a
opment of specialised geriatric oncologists cancer or to detect the cancer at a pre-
in some parts of the world. clinical stage where early treatment
would extend the patient’s life by cure as
The issues, complexities and limitations well as improve the quality of that
of cancer screening in the older patient extended life.
are examined in this article.
POTENTIAL PROBLEMS OF ROUTINE
The global elderly population (older CANCER SCREENING
than 60 years) is estimated to grow to The potential problems from routine
more than two billion by 2050. This is an cancer screening include:
age group that in most countries will n Over-diagnosis – the diagnosis of a
constitute a large percentage of the
population.1 In the USA, those older than condition that will never cause a
65 constitute over 60 % of all new cancer patient symptoms or death during his/
cases.2 While most cancer clinical trials her lifetime
limit the upper age range to 65, there are n Misdiagnosis/inaccurate/indeterminate
moves to redress this imbalance. test results – false positive, false
negative or inaccurate test results
CLINICAL TRIALS AND THE ELDERLY n P sychological impact of a diagnosis –
the negative emotional impact of the
Clinical trials very often limit the upper and diagnosis of a potentially life-
lower limits of age and usually exclude threatening disease
patients below 18 and over 65. Accruing n Morbidity of screening tests – the
older patients into clinical trials is difficult in physical and financial burden of
view of comorbidities, socio-economic undergoing a screening test
factors and in some cases, ethical issues. n P roblems of treatment – the side
Even though the elderly constitute an ever- effects of a treatment that may
increasing percentage of the population, negatively affect the patient’s quality
reliable data regarding benefits of cancer of life
therapies are lagging in this group. n P atient preference regarding
Population studies which look at issues screening that is not taken into
such as screening are particularly poor in account.
data for the over-65 age group.3,4

HANDBOOK OF GERIATRIC MEDICINE

204 ONCOLOGY SCREENING AND CARE

RISK VERSUS BENEFIT OF CANCER younger patient, be they physiological, C
SCREENING psychological, social or philosophical. M
The potential damage vs the benefits of While data from younger population Y
screening for a particular cancer should groups may be used to guide clinical CM
be kept in mind and be part of any discus- decision-making, these differences must MY
sion with a patient about options. Shared not be ignored. Addressing the outcomes CY
decision-making where the potential relevant to the patient has become CMY
problems of a screening test are weighed central in guiding cancer-screening. K
up against the benefits is strongly recom-
mended. Discussion around the impact of Geriatric patients often have functional,
a positive test on the patient and around cognitive and nutritional limitations, as
the pros, cons and increased longevity well as poor social support.7,8 This places a
attributable to a potential treatment is greater responsibility on the doctor in
important. terms of informing a patient of the pros
and cons of any screening intervention.
The complexities of patient preparation
for some tests (e.g., colonoscopy) as well There are very few clinical trial data about
as the logistical issues relating to these the benefits vs the problems of screening for
tests should be discussed. The potential cancer in the older population. As people
physical complications of a test should over 65 are a hetergeneous group, cancer-
also be considered, for example, the risks screening in these patients cannot be based
associated with endoscopy or biopsy, on age alone. Studies suggest that patients
taking into account the particular with a life expectancy of less than 10 years
patient’s comorbidities. will probably not derive a benefit from
screening for major cancers like breast-,
CANCER SCREENING prostate- and colorectal cancer. However,
AND THE ELDERLY there is a need for more evidence-based
Cancer is primarily a disease of older adults guidance in this field.
and is the second leading cause of death
in people 65 years or older in the Western The logistics of the preparation required
world. The elderly patient has special char- for certain cancer-screening tests (fasting,
acteristics and needs. His/her variable bowel prep, and so on) or just getting to
levels of fitness, frailty and vulnerability, and from a screening test itself may be
require a measured approach when difficult, exhausting and expensive for an
discussing cancer screening, or indeed, older, frail patient.
the potential treatment for a cancer that
may be detected. More recently, there For many older patients, the realities of
has been a significant expansion of the issues around any treatment for
approaches to treat cancer and, with this, cancer detected on screening cannot be
an increase in toxicities and complications. ignored. Although this may seem obvious,
A considered approach is required when it needs to be remembered that it is point-
embarking on investigations in the asymp- less performing a screening test on a
tomatic elderly patient.5,6 patient who would decline surgical, radia-
tion or chemotherapy treatments if a
The majority of cancer-screening guide- cancer were indeed detected.
lines are from evidence derived at
population level and are thus based on Certain studies in the USA have shown
studies that mainly include younger that patients over 75 and/or with a limited
patients. Individual variations in life expec- life expectancy are undergoing ever-
tancy, comorbid conditions, functional higher rates of cancer-screening that may
status or personal preference are gener- result in harm, including having a negative
ally not addressed in these studies. financial impact.

The older patient often has different FURTHER GUIDANCE
risk-benefit considerations from the
An individualised approach to cancer-
HANDBOOK OF GERIATRIC MEDICINE screening decisions is strongly recom-
mended. This needs to be done firstly to