Aannals of Long-Term Care: Clinical Care and Aging. 2012;20(10):13-14.
May 19-23, 2012; Atlanta, GA
OnabotulinumtoxinA Injections for Treatment of Overactive Bladder Not as Successful in Frail Elders
The success rate of onabotulinumtoxinA injection for the treatment of refractory overactive bladder (OAB) is lower over the long-term for frail elders compared with older patients without impaired activities of daily living (ADLs). In addition, frail elders have a greater risk of urinary retention than those who are not frail.
The finding was presented by Hann-Chorng Kuo, MD, professor and chief, Department of Urology, Buddhist Tzu Chi General Hospital, Hualien, Taiwan, and colleagues during a poster session at the AUA meeting. Kuo and colleagues investigated the safety and efficacy of intravescial onabotulinumtoxinA 100 U in 157 patients with refractory OAB: 52 who were considered frail, defined as age >70 years with impaired ADLs; 47 who were aged >70 years but with no impaired ADLs; and 58 who were aged <70 years. To be eligible for the study, OAB had to be refractory to previous antimuscarinic therapy for more than 3 months.
Based on changes in maximal urinary flow rate, bladder volume, postvoid residual volume, detrusor pressure, and bladder capacity from baseline to 3 months after injection, the cumulative success rate of onabotulinumtoxinA was significantly lower in the frail elders compared with the other two groups, both separately (P=.0049) or combined (P=.0027).
Approximately 59.6% of the frail elders had a postvoid residual volume >150 mL, compared with 42.6% of older patients without impaired ADLs and only 34.5% of patients aged <70 years. Urinary retention was also more common in the frail elders (11.5%) than in the non-frail elders (6.4%) and in those <70 years (3.4%), although these differences failed to achieve statistical significance.
Approximately 7.7% of the frail elders reported general weakness, compared with 0% in the other two groups. Urinary tract infections occurred most often in the patients aged <70 years (27.6%), compared with the frail elders (15.4%) and the non-frail elders (4.3%).—Wayne Kuznar
Fesoterodine is Safe and Well Tolerated in Older Patients With Urinary Incontinence
In medically complex, vulnerable older patients, flexible-dose fesoterodine relieves the symptoms of urgency urinary incontinence (UUI), according to research presented during an AUA poster session. The study is the first of its kind to use an antimuscarinic agent in a medically complex, vulnerable older population with UUI, the authors noted.
In the clinical trial, 562 older patients with UUI were randomized to flexible-dose fesoterodine or placebo. Enrolled in the study were patients aged ≥65 years
who could toilet independently and self-reported a mean of ≥2 but ≤15 UUI episodes and ≥8 micturitions per 24 hours on 3-day bladder diaries completed at baseline.
All were vulnerable to deteriorating health as determined by a score of ≥3 on the Vulnerable Elders Survey (VES-13) and a score of ≥20 on the Mini-Mental State Examination. A score >3 on the VES-13, based on age, health status, and functional ability, portends a 4-fold greater risk of
functional decline or death over the following 2 years.
Patients randomized to flexible-dose fesoterodine started with 4 mg per day for 4 weeks. After 4 weeks on either fesoterodine or placebo, patients could escalate to 8 mg of fesoterodine or placebo, based on discussion with the study investigator on the efficacy, tolerability, and postvoid residual volume. Patients escalating to the 8-mg dose could return to 4 mg at any time during the remaining 8 weeks.
The primary end point was change from baseline to week 12 in UUI episodes per 24 hours. Change from baseline to week 12 in number of micturitions in 24 hours was also evaluated. Adverse events were self-reported and monitored.
Patients randomized to fesoterodine had a significantly larger mean reduction rate in UUI episodes per 24 hours at week 12 (–2.84 vs –2.20; P=.0018) and a significantly larger mean reduction in micturitions in 24 hours at week 12 (–2.34 vs –1.50; P=.0003) than did the placebo group, reported Catherine DuBeau, MD, lead investigator, and clinical chief of geriatric medicine, University of Massachusetts Memorial Medical Center and University of Massachusetts Medical School.
Fesoterodine was well tolerated. Dry mouth (23.5%) and constipation (11.1%) were the most common adverse events in patients receiving fesoterodine, occuring more often in this group than in placebo-treated patients. Serious adverse events were observed in six (2.1%) placebo-treated patients and in eight (2.8%) fesoterodine-treated patients, but none of the events was considered treatment-related. Urinary retention occurred in nine patients (3.2%) who received fesoterodine, three of who required catheterization. Rates of discontinuation because of adverse events were 5.0% and 9.3% for placebo and fesoterodine, respectively. Other adverse events that were more common in the fesoterodine group were diarrhea, fatigue, dyspepsia, headache, and cough.—Wayne Kuznar
Overactive Bladder May Stymie Attempts at Physical Activity
Physical activity levels are lower in people with overactive bladder (OAB) than they are in people with no urinary symptoms, reported Karin S. Coyne, PhD, MPH, and colleagues during a poster session at the AUA meeting.
Previous research from her group at United BioSource Corporation’s Center for Health Outcomes Research, located in Chevy Chase, MD, found that OAB is associated with worse health-related quality of life and higher rates of depression.
The authors conducted an online cross-sectional survey of American adults aged 18 to 70 years. The survey asked participants to complete the Lower Urinary Tract Symptoms (LUTS) tool, a patient-reported outcomes tool, and to answer questions from the 2007-2008 National Health and Nutrition Examination Survey. A total of 818 men and 1505 women with OAB and 1857 men and 1615 women with no or minimal symptoms of OAB responded. Respondents with LUTS other than OAB were excluded.
Achievement of the federally-sponsored Healthy People 2008 and 2010 Physical Activity Guidelines for Americans was compared between respondents with OAB and those with no or minimal OAB symptoms.
Those with OAB were significantly less likely to report moderate and vigorous physical activities in their leisure time. Less than one-third (30.6%) of men with OAB and only about one in five (21.6%) women with OAB reported engaging in vigorous physical activity, compared with 43.9% of men and 33.5% of women with no or minimal symptoms. Moderate leisure activities were reported by 42.5% of the men with OAB compared with 52.5% of men with no or minimal symptoms, and by 41.2% of women with OAB vs 52.2% of women with no or minimal symptoms.
More than one-fourth (27.4%) of men with OAB and nearly one-third of women (32.1%) with OAB indicated that they had limited their activity due to their urinary symptoms compared with about 3% of men and women reporting no or minimal urinary symptoms.
Respondents with OAB were also significantly less likely to meet recommended physical activity levels. Some 60.9% of the men with OAB and 50.1% of the women with OAB met the 2008 Healthy People guidelines for physical activity, compared with 67.5% of men and 58.1% of women with no or minimal symptoms. Similarly, a smaller percentage of men and women with OAB satisfied the 2010 Healthy People guidelines than their counterparts without OAB.
“More research is needed to further evaluate how OAB affects physical activity and health status and to determine causal relationships,” the authors concluded.—Wayne Kuznar
Octogenarians With Prostate Cancer Receive Less Palliative Care for Urinary Symptoms
Palliative care for symptoms associated with ureteral obstruction is used less frequently in octogenarians with advanced prostate cancer than in their younger counterparts, according to an examination of a Medicare database. These are the findings from an examination of the Surveillance, Epidemiology and End Results (SEER)-Medicare linked database of patients with prostate cancer, outlined during an AUA poster session.
Placement of a retrograde ureteral stent or percutaneous nephrostomy are palliative options for relief of obstructive uropathy as a complication of advanced prostate cancer. Benjamin Spencer, MD, MPH, urologic oncologist at New York-Presbyterian Hospital/Columbia University Medical Center, and colleagues investigated the patterns of utilization of palliative therapy for Medicare patients with advanced prostate cancer, who were identified from the SEER-linked database. This yielded 10,848 patients with stage IV prostate cancer and 7872 patients with recurrent prostate cancer. Ureteral obstruction developed in 16% of these patients.
Octogenarians were significantly less likely to undergo retrograde ureteral stent placement than patients aged 65 to 69 years: the adjusted odds ratio (OR) for those aged 80 to 84 years, compared with those aged 65 to 69 years, was 0.41, and the adjusted OR for those aged ≥85 years was 0.30. Other trends were also noted: African-Americans were 48% more likely than whites to undergo percutaneous nephrostomy compared with no treatment; those who received percutaneous nephrostomy were 55% more likely to die than those untreated; survival was not significantly different between those receiving a ureteral stent compared with no treatment; and 9% received their first ureteral stent or percutaneous nephrostomy within 30 days of dying.—Wayne Kuznar