NICE guidelines on urinary incontinence in women

SIR—We read with great interest the recent NICE guidelines on the important problem of urinary incontinence (UI) in women [1], 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 [3]. The urge subtype of UI has been found to be the most common form in the institutionalised elderly [7]. 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 …