What can we do about

comorbidities?

Adrian Wagg Capital Health Professor of Healthy

Ageing

What characterizes older persons? • Well…they’re older than you – regardless of your

age • Positive illusion • Youthful identity

• View of life stages occurring later when one is in middle age and later life

• “age denial” • Middle aged and older adults maintain age

identities 20% more youthful than their actual age

Gana K et al. Aging & Mental Health 2004;8:58-64 Taylor SE. Psychological Bulletin 1988;103:193-210 Rubin DC. Psychological Bulletin and review 2006;13:776-780.

What’s a medically complex older patient?

• Multimorbidity (Co-existence of 2 or more chronic medical conditions) • Between 1985 – 2005, prevalence of

• 3 or more conditions increased by 60% • 4 or more conditions increased by 300%

• Associated with

• increased healthcare utilisation • lower health related quality of life • increased disability, morbidity and mortality

Multimorbidity

BMC Public Health (2015) 15:415

http://www.audit-commission.gov.uk/reports/accessible.asp?ProdID=78C11913-8606-47F2-93F6-EA7345934825

The rise of multimorbidity

ANNALS OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG ✦ VOL. 10, NO. 2 ✦ MARCH/APRIL 2012

Prevalence of multimorbidity (defined as ≥2 diseases) reported in primary care settings

Multi-morbidity’s profile

Lancet 2007; 370: 797-799

UI as a Geriatric Syndrome Multiple risk factors, across multiple organ systems and

domains

UI

Modulating factor

UI

RF 1

RF 2

Tinetti et al11995; Inouye et al, 2007

Young Elderly

Co-morbid conditions 65+ yrs in primary care

0

20

40

60

80

100

n=2612, men=826 women=1786

*Others(Primary Care) –Alcohol related disease 2, Other renal impairment or disease 92, Other gynaecological disease or disorder 24, Other gastroenterological disease or disorder 108, Non-specific and other malignancies 37, Other problems related to childbirth 1 , Delirium 9, Haematological disorders 21, Retention of urine 5, Mental health diagnoses 32, Other urological surgery or disease 39, Learning disability 8, Other endocrine disease or disorder 41, Other respiratory disease or disorder 100, Other cardiac disease or disorder 90, Other vascular (non-cardiac) disease or disorder 22, Other musculoskeletal disease including fracture & Osteoporosis 198, Others 74

*Others(Primary Care) –Alcohol related disease 2, Other renal impairment or disease 92, Other gynaecological disease or disorder 24, Other gastroenterological disease or disorder 108, Non-specific and other malignancies 37, Other problems related to childbirth 1 , Delirium 9, Haematological disorders 21, Retention of urine 5, Mental health diagnoses 32, Other urological surgery or disease 39, Learning disability 8, Other endocrine disease or disorder 41, Other respiratory disease or disorder 100, Other cardiac disease or disorder 90, Other vascular (non-cardiac) disease or disorder 22, Other musculoskeletal disease including fracture & Osteoporosis 198, Others 74

Distribution of co-morbid conditions

0

5

10

15

20

25

30

35

40

Hospitals (n=2011)

primary care (n=1786)

Wagg, A et al 2011 RCP NACC

Prevalent disease in residents with UI/ OAB compared with a matched cohort without UI/OAB

Consultant pharmacist 2015;30: 533-542

Medically complex patients in trials

Distribution of co-existing conditions in patients >65y participating in all trials of fesoterodine

Wagg et al 2016, in press

%

Associated conditions and UI

Dementia Diffuse Lewy body disease Parkinson’s disease Normal Pressure Hydrocephalus recurrent infection Constipation Obesity

Ouslander, J.G. and J.F. Schnelle, Incontinence in the nursing home. Ann Intern Med, 1995. 122(6): p. 438-49. McGrother C, Donaldson M. Continence in Health Care Needs Assessment http://www.hcna.bham.ac.uk/documents/02_HCNA3_D3.pdf

• peripheral vascular disease • diabetes mellitus • congestive heart failure • venous insufficiency • chronic lung disease • falls and contractures • Sleep disordered breathing • stroke

Associated conditions and UI

Dementia Diffuse Lewy body disease Parkinson’s disease Normal Pressure Hydrocephalus recurrent infection Constipation Obesity

Ouslander, J.G. and J.F. Schnelle, Incontinence in the nursing home. Ann Intern Med, 1995. 122(6): p. 438-49. McGrother C, Donaldson M. Continence in Health Care Needs Assessment http://www.hcna.bham.ac.uk/documents/02_HCNA3_D3.pdf

• peripheral vascular disease • diabetes mellitus • congestive heart failure • venous insufficiency • chronic lung disease • falls and contractures • Sleep disordered breathing • stroke

The bladder in PD

• In PD patients diagnosed according to modern criteria, the prevalence of urinary symptoms 27% to 39% using validated questionnaires

• PD patients report significantly more symptoms than healthy controls.

The bladder in PD • Correlation with neurological disability, and to stage of

disease • J Neurol Neurosurg Psychiatry 2000;68:429–433. • Auton Neurosci 2001;92:76–85.

• bladder symptoms only correlate with age. • Arq Neuropsiquiatr 2003;61:359–363. • Age Ageing 1995;24:499 –504.

The bladder in PD • Increased rate of voiding dysfunction, measured by IPSS,

related to severity of disease and age rather than duration

PD medication and the bladder

• detrusor overactivity improved after administration of apomorphine and levodopa

Neurourol Urodyn 1993;12:203–209. • in subjects with on–off phenomena, detrusor overactivity

lessened with levodopa in some and worsened in others. Br J Urol 1985;57:652– 656

• in advanced PD, levodopa exacerbated detrusor overactivity in the filling phase, but also improved bladder emptying

Mov Disord 2003;18:573–578. • The unpredictable effect of medication is not related to

• stage of disease • age • presence or absence of symptoms

Mov Disord 2002;17(Suppl. 5):S218.

Stroke and bladder control

• Incontinence associated with any lesion except for occipital lobe

• anteromedial region, frontal lobe primarily identified Sakakibara R et al J neurol Sci 1996;137: 47-56.

• cortical+subcortical strokes 5.3 times more likely to be associated with incontinence

Gelber DA. et al. Stroke 1993;24:378-382

• Size of stroke more important than location?

Factors leading to incontinence

• Site of cerebral lesion • Motor impairment • Reduction in conscious level • Cognitive impairment • Speech impairment • Female sex

Gelber DA. et al. Stroke 1993;24:378-382 Borrie MJ et al. Age Ageing 1986;15:177-81

Effect on outcome

• 52% dead at 6/12 compared with 7% continent stroke survivors

Nakayama H et al Stroke 1997;28: 58-62

• Incontinent 30 day post stroke survivors 3.9 times more likely to die within 1 year and 2 times within 5 years

Hankey G et al. Stroke 2000;31:2080-86

Anderson C et al Stroke 1994;25:1935-44

Effect on outcome II • Increased disability

• best predictor of severe / moderate disability @ 3/12. OR: 5.4(95%CI: 3.3-9.0)

Taub NA et al. Stroke 1994;25:352-7

• Poor outcome in terms of function • mobility • discharge destination

Brittain KR et al Stroke 1998;29:524-8

Kalra L et al. Postgrad Med J 1993;69:33-36.

Effect on outcome III

• Predicts recovery of limb strength and ADL Barer DH. Age Ageing 1989;18:183-91

• Presence of incontinence better predictor of recovery at four weeks than predictive scoring

Prescott R et al. Stroke 1982;13:641-647.

• Residents of institutional care with incontinence more likely to be stroke sufferers

Chiang L. et al. J Amer Geriatr Soc 2000;48:673-676

Associated morbidity

• Conflicting data on increase in associated depression.

• In the elderly, and in women,positive association. Robinson G et al. Br J Psychiatr 1984;144:256-62

Vetter NJ et al Lancet 1981;2:1275-7.

Underlying diagnosis • Few studies have performed urodynamic studies in

stroke patients • No specific type of incontinence associated with

stroke • Detrusor hyperreflexia commonest lesion, 50-82%

Feder M et al. Euro Neurol 1987;27: 101-105

• Acontractile bladder in 17-25% Linsenmeyer TA. et al. Neurol Rehabil 1992;2:23-6.

• Outflow tract obstruction common Tsuchida S et al. Urology 1983;21:315-319.

Management Strategies

• Few studies have reported on treatment • scheduled voiding programmes appear effective • medication for urge incontinence less so

Gelber DA. Et al. Stroke 1993;24:378-382

• A four month programme of PFMT appeared effective at six

months FU in women with UI Tibaek S, Gard G, Jensen R Int Urogynecol J Pelvic Floor Dysfunct. 2007

Mar;18(3):281-7.

• No systematic attempt to assess treatment efficacy in this

group.

Does exercise help?

• 3/12, twice weekly exercise to increase the muscle strength, walking ability, and pelvic floor muscle. UI affected 66.7% at baseline to 23.3% after intervention

• risk of at least monthly urinary incontinence decreased with increasing quintiles of moderate physical activity

• Increasing levels of total physical activity were significantly associated with a reduced risk of UI (top versus bottom quintile ) OR 0.81, 95% confidence interval [CI] 0.71-0.93;

• Walking, was related to 26% lower risk of developing UI (top versus bottom quintile, OR 0.74, 95% CI 0.63-0.88

Arch Gerontol Geriatr. 2010 Mar 6. J Urol. 2008;179:1012-6 Obstet Gynecol. 2007 Mar;109(3):721-7

Exercise and combined interventions • Older Japanese women • one hourly, twice weekly intervention over three

months • muscle strength, stability and walking and pelvic

floor muscle strength • statistically significant decrease in incontinence

and an increase in maximum walking speed. • The same group, examining the use of a similar

intervention for its effect on stress urinary incontinence found a significant reduction in BMI in the intervention group, probably adding to its benefit

Kim, H., et al., EffectiveneJ Am Geriatr Soc, 2007. 55(12): p. 1932-9. Kim, H.,Yoshida, H, Suzuki,T. syndrome: Arch Gerontol Geriatr. 2010 Mar 6

Nursing home residents

• prompted voiding and individualized, functionally oriented endurance and strength-training exercises

• four times per day, 5 days per week, 8 weeks

• Significant reduction in UI episodes

Ouslander, J.G., et al., J Am Geriatr Soc, 2005. 53(7): p. 1091-100. Bates-Jensen, B.M., et al., J Am Geriatr Soc, 2003. 51(3): p. 348-55

• exercise and incontinence care to improve skin health

• every 2 hours from 8:00 a.m. to 4:30 p.m. (total of four daily care episodes) 5 days a week for 32 weeks

• effective in reducing incontinence

• No effect on skin health

Nursing homes • cognitively impaired

residents • walking exercise for thirty

minutes per day • four weeks • significant reduction in

daytime incontinence episodes

• increase in gait speed and stamina

• NH residents • thrice weekly, 30 minute

intervention • 8 weeks • Increase in the number of

subjects who achieved independent toileting

• a non-significant reduction in daily urine loss

Jirovec, M.M.Int J Nurs Stud, 1991. 28(2): p. 145-51. van Houten, P., W. Achterberg, and M. Ribbe, Gerontology, 2007. 53(4): p. 205-10.

Nocturia

• 30 minute evening walk • effective in reducing nocturia, • improved daytime urinary

frequency • Reduced blood pressure, body

weight, body fat ratio, triglycerides, total cholesterol

• Increased sleep quality

Sugaya, K., et al. Biomed Res, 2007. 28(2): p. 101-5.

So, what to do? • Recognise the conditions which might be impairing the woman’s

ability to toilet successfully • Think wider than simply LUTS and incontinence

• Mobility • Dexterity • Cognition • Sight • Environment

So, what to do? • OT referral? • Easy to read signs • Contrasting colours for

toilet seat and toilet • Don’t leave white

porcelain objects around the house!

Products: http://www.continenceproductadvisor.org/

What matters to older patients? Having an assessment in a private room (91%) Having good channels of communication between all professionals who deal with my bladder/bowel condition (87%) Being assessed by someone who is friendly, understanding and reassuring (87%). Being able to have a full assessment of my problem if I mention it (85%) Having a service that can easily link me to specialists or other services (83%) Having equipment such as pads delivered on time to where I live (83%) Being able to choose from a full range of good quality, reliable, and properly fitting pads, knickers and other products irrespective of cost (83%)

Patient. 2010 Mar 1;3(1):11-23

• Getting regular updates about bladder and bowel conditions, services and equipment free of charge in a form I can understand (76%)

• • Being able to fully understand my condition and what the future holds for me

(74%) • • Whenever possible, being given a choice of treatments by continence

specialists (74%) • • Getting hold of a local expert for advice and or treatment when I need it (67%) • • Being involved in a full discussion about care and treatment face-to-face (67%) •

Patient. 2010 Mar 1;3(1):11-23

Multi-disciplinary care for older people

What multi-professional care does your service offer?

• Patient assessment and continence promotion regardless of age, rather than pad provision

• Improving attitudes towards continence and older people • rapid and appropriate patient referral pathways • strengthened inter-service collaborations • investment in service capacity • higher profile of UI within medical and nurse training

Barriers to better care

Orrell A BMJ Open 2013;3:e002926. doi:10.1136/bmjopen-2013- 002926

Service delivery model

PLoS One. 2014 Aug 14;9(8):e104129. doi: 10.1371/journal.pone.0104129.

• Evidence suggests that this part of the service model is crucial

• poorly done, both in primary and secondary care

• where done well, is largely because of local champions

Service delivery model

PLoS One. 2014 Aug 14;9(8):e104129. doi: 10.1371/journal.pone.0104129.

1.Develop robust referral pathways • to ensure patients receive timely, equitable and effective

care

2. Use continence nurse specialists for initial assessment and treatment, where available

• Can manage and treat incontinence more effectively than primary care physicians

• Where not possible, focus on training existing healthcare professionals

Recommendations

3.Use a case co-ordinator to ensure a “patient-centred” approach

• Accompanies service user along care pathway • Single point of contact to ensure smooth delivery of care

4. Promote use of self-management tools or

techniques • Patients & caregivers may prefer active role in treatment

decision-making • Providing information on managing incontinence can

lessen demand

Recommendations

5. Specialists should play a key role in quality governance, training and dissemination of best practice

• Should have well-defined roles separate to those providing initial assessment and treatment...

• HOWEVER, hold key insights and knowledge in the areas of quality governance, training and dissemination of best practice

6. Use a comprehensive standardised assessment of user, product, and usage-related factors to assess needs with regards to containment products

• Use standardised assessment of following factors as per international standard (ISO 15621: 2011):User –related factors; Product-related factors; Usage-related factors

• Needs of each patient must be reassesed periodically

Recommendations

7. Technology should enable self-care, connect patients and caregivers, and enable providers to monitor progress and troubleshoot problems

• Technology can: • Fill gaps where resources and manpower are lacking • Connect patients, caregivers and health care professionals • Overcome embarrassment and stigma for patients visiting their doctor

8. For payers: in order to provide the highest quality continence care, ensure care standards are incentivised

• Transparency on outcome indicators can motivate improved performance • Financial incentives linked to outcomes can also motivate powerfully • Operational performance measures can indicate level of efficiency

Recommendations

46

9. Establish accredited programmes of training • Recommend establishment of certificate in continence care

nursing • Where there is a shortage of nurses, set up accredited

training programmes for other health and social care professionals

Recommendations

• recognising the additional factors which predispose older people to toileting unsuccessfully

• The “integrated” continence service is still a desirable concept • Treating comorbidities • Medication review • Pragmatic treatments • Appropriate use of therapies

But team approach needed:

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/198033/National_Service_Framework_for_Older_People.pdf