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Monday 19 June 2006

AUA 2006 - Geriatric Urological Society Meeting.

By: George W. Drach, MD

Three speakers led off the Scientific Portion of the meeting. First, Dr. Joe Ouslander discussed Overactive Bladder (OAB): Considerations in the Geriatric Patient. He noted that this problem is found in about 35% of women and 42% of men over age 75. He emphasized that falls risk increases significantly in these patients with urge incontinence.

Patients with OAB often have other problems: neurologic, cardiovascular, musculo-skeletal, diabetes, sleep disorders, psychological (especially depression). Of these, those affecting mobility and cognition contribute to OAB. Another factor is polypharmacy (inappropriate drugs or drug side effects). Patients on diuretics, narcotics, and anti-cholinergics or cholinesterase inhibitors have increasing problems if they already have OAB. To add to these tendencies, other problems such as estrogen deficiency, sphincter weakness, prostatic enlargement/obstruction and incomplete bladder emptying complicate OAB. He believes that most elderly OAB can be diagnosed by a basic evaluation following a history of urinary tract infection, recent surgery, prolapse, sterile hematuria or urinary retention. Complicated urodynamic studies are not needed unless there is difficulty in diagnosis or failure of the first approach at treatment. Treatment is mult-factorial and aimed at the problem causing OAB, along with relief of contributing factors. Recruiting the family or other caregivers is important. He stresses bladder training approaches such as prompted voiding and pelvic floor exercises. He avoids anti-cholinergics unless absolutely necessary. One reason is the demonstrated worsening of mental function with some of these drugs. As an example, comparison of darifenicin and oxybutinin reveal that the first had not more effect on mental function than placebo, but the latter caused significant decrease in mental function. For this reason, he stated: “Use drugs carefully and only in selected patients.”

The goals of treatment need to be realistic and communicated to the patient and caregiver. Try to avoid further frustration, as this leads to cessation of treatment by the patient. This program is primarily for home therapy. Institutionalized patients are treated somewhat differently. He always begins there with a toileting program (timed voiding) and if possible pelvic floor training. If unsuccessful, he then begins a trial of medication, often darifenicin, but “I am very selective about using drug treatment in the frail elderly.”

He was followed by Mary H. Palmer PhD, who spoke on Clinical Research related to Health Policy and Clinical Issues. Her coverage of demographics stressed that there are 140 women for each 100 men over age 65, but we must remember that a 65 year old person still has 18.1 years of life expectancy. 51% of all elderly live in 9 states: CA, FL, NY, TX, PA, OH, IL, MI and NJ. She then spent considerable time discussing issues prevalent in nursing homes (NH). CMS estimates that 50% of NH patients are incontinent. Care of these patients is costly (increased need for trained personnel), morbid (increased falls) and affects QOL. For these reasons, the nursing assistant (NA) is important and is one of top growth levels in jobs, but the career path is poor and has turnover of greater than 100% per year. But some states are responding: NC has developed an NA training program and career ladder. MOST IMPORTANTLY, these concerns about incontinence have led CMS to emphasize “Tag F315”, a citation following NH inspection given for inadequate care/attention to incontinence, catheters and/or urinary tract infections. Hence, “We need to do more continence promotion and disease prevention… (that is) population based versus individual focused attention… (that addresses) modifiable versus immutable risk factors.”

Lastly, Ted Johnson MD presented his talk: Treating Nocturia: a 2006 Update with a Focus on the Older Patient. Definition of nocturia: waking from sleep at night to void, usually 2 or more times per night. Its prevalence: all adults = 37% for men, 43% for women all ages, but for those aged 70 - 79 yrs. 44% men 35% women. Hence a strong link with aging. There are multiple causes: reduced bladder capacity, nocturnal polyuria, sleep disruption, decreased bladder function, BPH, and OAB. Are we treating nocturia or bother? He shows a table that reviews 1228 patients. Some have large bother scores for nocturia > 2, and especially over 3, but several with nocturia x5 have minimal bother.

So he questions why there are those with little nocturia and little bother, vs. those with low nocturia and high bother. He described a study of low bother and high bother patients with 2-3 episodes of nocturia/night. There were 2 significant points that determined the bother score: difficulty in returning to sleep and morning fatigue. He describes an interesting aspect to the Shackleton Antarctic voyage and nocturia: going outside at night to void was the most disagreeable aspect of the trip for many men. They developed an old gas can into a urinal. If the urine level reached within 2” of top, that person had to go outside and dump the urinal, but at least many men did not have to go outside. So he suggests using bedside urinal for many patients. What is the effect size of usual nocturia treatments? He mentions ddAVP, alpha blockers, bladder relaxants and behavioral therapy. First he looked at nocturia in the terazosin and finasteride study. Terazosin decreased nocturia by mean 0.7 times, but placebo did so by 0.3, so net effect was 0.4 - not too great. He then reviewed Tolterodine LA® and nocturia. The mean reduction in nocturia for all equaled no difference. For those with severe OAB there was slight significant decrease only. As for non-drug therapy: he described a trial of behavioral treatment versus oxybutinin. Behavioral therapy alone reduced nocturia by 0.5 times/night; oxybutinin by 0.25 and placebo by -0.5. So it appeared that behavioral was best. Then they looked at multi-component interventions with alpha blockers and prostate shrinkers. He re-evaluated the MTOPS study and showed that only doxazosin really decreased episodes of nocturia, finasteride did not.

What medical co-factors contribute most to nocturia? It is found in over 80% of those with AUA score >8 or hypertension, 70% with diurnal polyuria, 45% with pitting edema or sleep latency, 35% with diabetes or diuretics, 25% with nocturnal polyuria and in 18% with congestive heart failure. He spent a bit of time reviewing use of ddAVP for nocturia. In some studies, nocturia decreased significantly, and bother decreased significantly also. But “ddAVP scares me a bit”. He reviewed the trials, and had several criticisms. For example, in the “Rembratt study”, of many older patients, 75% had low serum sodium at baseline. Hence in using ddAVP you must have baseline sodium and continue to check as you treat the patient. You should select this therapy only for the patient without congestive heart failure, with no diuretic usage, and who is compliant with instructions. Start at 0.1 mg and titrate upward. Overall, nocturia is a multi-factorial problem that requires full evaluation and correction of multiple contributing factors. But perhaps the goal is to minimize the bother score rather than the absolute number of voids/night.

The scientific portion of the meeting concluded with 5 brief papers of work in progress given by urologists involved in the AGS Jahnigen Scholars program.

Lowenstein et al discussed the “Prevalence and Impact of Nocturia”. Nocturia is one of the most bothersome of urology complaints. It is associated with a general deterioration of health. It occurs in 51% of all women over 80. A new definition has arisen: urination at night associated with interruption of sleep. So they asked two basic questions: How many times do you get up to urinate per night on average? And How much of a problem was this? They used a rating scale of 0-10 for each. In their population, 87% reported nocturia once or more and 60% 2 times or more. Of these, 41% had a bother score of 5 or more. There was a definite increase of bother with increased nocturia. Increased bother was more likely with increased frequency and mixed type incontinence and with nocturia in women presenting for pelvic floor care.

John Taylor reviewed macrophage Migration Inhibitory Factor (MIF) and the Aging Bladder. He explained how MIF is involved in pro-inflammatory cytokine function, is expressed in bladder, promotes macrophage and fibroblast survival, and in some data is implicated in pathogenesis of cancer. He notes that there is commonly impaired bladder emptying in the geriatric population, and also detrusor contractility is sometimes decreased. Detrusor Underactivity (DU) is noted. He hypothesizes that MIF contributes to DU and describes work underway to study this problem. One possible mechanism is that MIF seems to increase neovasculature of animal bladder cancer, and MIF knockout mice show decreased response.

Fadi N. Joudi, working with B. Konety, described studies on influence of age on response to intravesical immunotherapy. Illustrating this with Kaplan Meier Curves, he noted that ages 61-70 had best response, but BCG response was worst in those under 50 yrs and over 80 years. So age was an independent risk factor for response. In patients over 80 yrs they found a 74% less likely response to immunotherapy.

Edward Uchio MD presented his studies on Aging Effects on the VHL Tumor Suppressor Pathway in the development of Renal Carcinoma.

He first explained the VHL process. These patients form clear cell renal cancer, also cancers in adrenal, pancreas, brain, spine, eyes and inner ears. The VHL gene produces VHL protein and a related chain of reactions that lead to cancers. The majority of elders who have renal cancer have clear cell renal cancer and also show defects in VHF protein production or function. So he hypothesizes that changes in VHL contribute to formation of renal cell cancer. He then described his complex evaluation process.

B. Konety et al reviewed their study of Profiling Post-operative Risk in Elderly Patients Undergoing Urologic Cancer Surgery. He listed the standard risk assessment tools that are already published. But none are specific for urology. Their hypothesis: it is possible to risk stratify elderly undergoing major urologic cancer surgery. Patients for radical cystectomy or radical nephrectomy were considered. He listed the parameters that they chose and stated that they collaborated with a European group doing a similar study. So far, they have studied a total of 65 patients, 34 cystectomy and 31 nephrectomy. In these they noted a mortality of 11%, and morbidity of 57%. Median LOS was 8 days. ASA and POSSUM scores correlated well with morbidity. But their most important element was ADL that really predicted those who would have postoperative complications. They are still evaluating data and trying to put it into some type of nomogram format.

In a second report, B. Konety reviewed their Consensus on Prostate Cancer Screening in Iowa. This began because they were really concerned about propriety and effects of screening of patients over age 75, because they still have life expectancy of 10.3 years. Iowa has large proportions of elderly. In reviewing 86,600 men over age 75 they found that 63% of those surveyed had performed prostate cancer screening. Most physicians stopped screening after age 80. The Consensus group generated some recommendations: physicians and patients should reassess benefits of screening after age 75. The consensus group suggests stopping or not initiating screening if the patient is not a candidate for treatment. In addition, physicians should use age referenced PSA screening values. They should resume PSA for symptoms consistent with possible development of prostate cancer. If this is done, get 2 tests 1 month apart and base further work-up on these 2 values. If cancer discovered, then use a risk stratified approach to determine the need for therapy.

This wonderful session on the elderly urologic patient revealed the importance of considering the unique qualities of our aging patient population.

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