May/June 2023

Urinary Health: Overactive Bladder Care to Address All Aspects of the Quadruple Aim
By Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD
Today’s Geriatric Medicine
Vol. 16 No. 3 P. 6

The Challenge of Anticholinergic Deprescribing in Older Adults

To improve the health care system in the United States, the Triple Aim was put forth by the Institute for Healthcare Improvement, comprising the following goals: improving population health, improving the experience of patients receiving care, and reducing health care costs.1 An effective health care system cannot be achieved without effective care professionals. Thus, a fourth aim was added to address the need for the wellbeing of care professionals, transforming the Triple Aim into the Quadruple Aim.2,3 Management of overactive bladder (OAB) is important for all four aspects of the Quadruple Aim. OAB and urinary incontinence (UI), a common symptom of OAB, can greatly decrease quality of life.4 OAB affects approximately 30 million adults ≥40 years of age in the United States, and prevalence increases with age.5 OAB is associated with a high economic burden, including high medical costs, lost productivity, and high health care resource utilization.6,7 A recent publication of the results of a survey sent to directors of nursing (DONs) reported on the impact of UI on residents and staff of long term care facilities.8 According to responding DONs, most (62%) of their residents had UI. However, only a small percentage of residents with UI (15%) were being treated with medications for OAB. Residents with UI were instead being cared for with continence care products (pads/diapers) and toileting programs, but only 21% of patients were reported to show improvement from the toileting program. DONs reported an average of 14 falls per month per facility and falls commonly occurred while residents were trying to get to the bathroom.8 The staff burden and costs of falls in nursing homes are considerable. Falls account for 6% and 8% of the overall (not limited to the long term care setting) annual Medicare and Medicaid expenditures, respectively.9 The findings from the DON survey suggest that there are missed opportunities in managing OAB in older adults. Long term care is not limited to skilled nursing facilities; these services are increasingly being provided in the community. Thus, learnings from the DON survey should also be applied more widely to community-based OAB management.

Getting the Right Treatment
Guidelines set forth by the American Urological Association/Society of Urodynamics, Female Pelvic Medicine, and Urogenital Reconstruction for the treatment of OAB, including OAB with UI, recommend behavioral therapy with or without pharmacotherapy as first-line treatment; oral anticholinergics and beta-3 adrenergic agonists are recommended as second-line treatment.10 Because OAB is a chronic condition, the treatment of OAB should be long term. Although anticholinergics are efficacious in treating the symptoms associated with UI, long-term use of anticholinergic medications is associated with side effects, including dry mouth, constipation, and blurred vision that may limit their use.10-12 The potential for cognitive side effects has also been linked to long-term anticholinergic use.13-16 A meta-analysis of six studies that evaluated the impact of ≥three months of anticholinergic medication use compared with nonuse in incident dementia, Alzheimer’s disease, and cognitive impairment has estimated a 46% increase in the risk of developing dementia associated with anticholinergics.17 Although exposure definitions and the outcomes measured limited the number of studies that were included in the meta-analysis, the results of the sensitivity analysis were strong and support the findings of the previous studies.17 Some common anticholinergic drugs for treating OAB (darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, and trospium) have the highest score on the Anticholinergic Cognitive Burden Scale.18 The burden of anticholinergics is cumulative, meaning both length of time on treatment and number of anticholinergic treatments contribute to burden. As anticholinergic burden increases, so does the risk of falls (with or without fractures), all-cause mortality, adverse events (especially cardiovascular related), and cognitive effects.10,15 Older adults in long term care likely have comorbid conditions for which they may also receive an anticholinergic medication and thus may have a higher anticholinergic burden.19

With the growing evidence highlighting potential safety risks, so grows the list of organizations putting forth statements and recommendations regarding the reduction and/or deprescribing of anticholinergic medications, especially for older adults. The American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults provides guidance for medication selection.20 Specifically, the avoidance of anticholinergics is recommended because of the risk of confusion, dry mouth, constipation, and other anticholinergic effects. Because anticholinergic burden increases with collective dose and duration of use of all medications with anticholinergic properties, the Beers Criteria further recommends minimizing the number of anticholinergics owing to increased risk of cognitive decline. The American Urogynecologic Society has issued a consensus statement for patients with OAB for whom behavioral therapies have failed. For these patients, health care professionals should provide counseling on the associated risk of cognitive impairment, dementia, and Alzheimer’s disease associated with anticholinergic medications and weigh these risks against the potential benefits. Similar to the American Geriatrics Society Beers Criteria, the American Urogynecologic Society recommends that overall anticholinergic burden should be lowered by prescribing the lowest effective dose and/or lowering doses of already prescribed treatments; alternative medications that do not add to the cumulative anticholinergic burden should be considered, especially with patients with high risk.21 Recently, a SUFU committee convened to release statements regarding the current understanding of the cognitive risks related to OAB medications. The committee concluded that use of anticholinergic OAB medications for ≥three months was likely associated with an increased risk of new-onset dementia, and cognitive risks should be considered in all patient populations.22 The committee went on to recommend that beta-3 adrenergic receptor agonists should be trialed before turning to anticholinergics and to proceed to an anticholinergic only if necessary. Lastly, the committee stated oxybutynin, in particular, should be avoided.

Results from the DON survey indicated that there may be a need for improved education and training on the appropriate ways to treat the symptoms of OAB. DON survey respondents noted that residents receiving OAB pharmacotherapy were most commonly prescribed oxybutynin or another anticholinergic medication. This high rate of prescriptions for oxybutynin may be due in part to its low cost compared with other medications. However, 75% of DONs surveyed were unaware of the potential link between anticholinergic medication use and risk of cognitive side effects. Thus, there are opportunities to ensure residents receive treatments that align with current recommendations. To better recognize patients in need of improved care, EHR data can be used by health care providers to identify patients with OAB not receiving pharmacotherapy, as well as patients receiving OAB anticholinergic medications who may benefit from a medication change. The latter group of residents in long term care may be particularly helped by consultant pharmacists who, during drug regimen reviews, can assess current treatment plans and analyze where a change may be warranted. For community-dwelling patients, pharmacist-led medication therapy management has an important role in ensuring appropriate treatment plans. A systematic review of interventions to reduce anticholinergic burden in older adults reported findings from eight studies; in six of the included studies, pharmacists initiated the treatment intervention for patients in a variety of settings, including hospital, community, and long term care facilities.23 Indeed, a recent study of a pharmacist-led program for deprescribing anticholinergic medications specifically for OAB in older adults was shown to be successful in decreasing anticholinergic burden in these patients.24 In this observational study, pharmacists used clinical decision support software to identify older, community-dwelling patients with OAB who may be taking inappropriate medications. Recommendations were made by the pharmacists to the appropriate prescriber, who then chose whether to implement any changes to treatment. Most of the recommendations were followed by the physician and, in turn, the patients.

Improve Experience of OAB to Improve Population Health
Once residents of long term care facilities and community-dwelling patients with OAB are better managed with pharmacotherapy, improvements in the various aspects of the Quadruple Aim could be realized. Pharmacotherapy for the treatment of UI related to OAB could decrease costs associated with OAB care in long term care facilities by decreasing the frequency of falls, use of incontinence pads, and linen changes. Most DONs (54%) considered cost of UI products to be higher compared with other supplies bought by facilities for the care of residents. DON survey respondents indicated that staff members spent more than 50% of their time on UI needs, and 59% of DONs reported that UI management contributes to turnover of nursing staff. When OAB with UI is better managed under pharmacotherapy, caregivers and staff may be able to spend less time changing pads and linens, which could aid in decreasing caregiver burnout and staff turnover. This is important as “caregiver” does not simply refer to nursing staff working in facilities but also to family members managing OAB/UI at home. As a result, the learnings from this survey on better management of OAB/UI have applications beyond nursing homes to patients being cared for at home as well.

How the Areas of the Quadruple Aim May Be Improved When OAB/UI Is Better Managed
Aim: Outcome/Potential Improvement
Patient Experience: Improved quality of life, fewer UI episodes
Patient Outcomes: Fewer symptoms, improved patient satisfaction
Cost of Care: Decreased medical costs and healthcare resource utilization (fewer continence care products [pads/diapers]); reduced staff turnover; reduced burden on family and community-based caregivers
Clinician Experience: Reduced staff burden and/or burnout due in part to less time spent on toileting programs, laundering, and other OAB- and UI-related issues

All aspects of the Quadruple Aim (patient experience, patient outcomes, clinician experience, cost of care) are negatively impacted by UI related to OAB. The patient experience is affected by factors such as falls (the risk of which are related to both OAB and anticholinergic use) and anticholinergic adverse events. The burden of caring for UI can cause burnout of caregivers in the care facility and those in the community as well. Management of UI is, therefore, an important aspect of improving population health.

— Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD, is an adjunct assistant professor in the Jefferson College of Population Health at Thomas Jefferson University in Philadelphia.

Acknowledgments: Medical writing support was provided by Tania R Iqbal, PhD, CMPP, of The Curry Rockefeller Group, LLC (Tarrytown, New York), and was funded by Urovant Sciences (Irvine, California).

Disclosures: Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD, is an advisor to Urovant Sciences.

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