Treatment of Overactive Bladder in Elderly Patients

First-Line Non-Pharmacological Approaches

The American College of Physicians recommends bladder training as a first-line treatment for urgency urinary incontinence, which should be implemented in conjunction with pelvic floor muscle training for mixed urinary incontinence, and weight loss and exercise if the patient is overweight or obese, with the goal of reducing symptoms of overactive bladder in a 75-year-old female patient 1, 2
Fluid management and caffeine reduction are also recommended as first-line non-pharmacological approaches for managing overactive bladder symptoms in this patient population 2

The American Urological Association recommends mirabegron as the first-choice alternative treatment for overactive bladder due to its efficacy comparable to antimuscarinics, significantly lower incidence of anticholinergic side effects, and lower risk of cognitive effects, which is particularly important in elderly patients 2, 1
Mirabegron has fewer drug interactions with doxepin compared to alternative antimuscarinics, making it a preferred option for patients taking multiple medications 3
Solifenacin has the lowest risk for discontinuation due to adverse effects among antimuscarinics, and may be considered as an alternative option if beta-3 agonists are contraindicated or unavailable 1

The patient's age and concurrent use of doxepin increase the risk of cognitive impairment with antimuscarinic medications, highlighting the importance of selecting medications with lower anticholinergic burden, such as beta-3 agonists like mirabegron 2, 3
Evidence suggests an association between antimuscarinic medications and the development of incident dementia, which may be cumulative and dose-dependent, emphasizing the need for careful medication selection and monitoring in elderly patients 2

The treatment algorithm recommends mirabegron as the first choice, followed by solifenacin or tolterodine if mirabegron is ineffective or contraindicated, and consideration of adding vaginal estrogen for concurrent hot flashes and urogenital symptoms 2, 1, 4

Monitoring for urinary retention, particularly if using antimuscarinics, and assessing treatment efficacy after 4-8 weeks are crucial components of managing overactive bladder in elderly patients 2
Evaluating for side effects, particularly if using antimuscarinics, such as constipation, dry mouth, and cognitive changes, is essential for optimizing treatment outcomes 1, 2

The American College of Physicians recommends solifenacin as a second-choice alternative due to its low risk for discontinuation due to adverse effects among antimuscarinics 5
Darifenacin has risks for discontinuation due to adverse effects similar to placebo, according to the American College of Physicians 5

Fesoterodine achieves continence more effectively than tolterodine, with a number needed to benefit (NNTB) of 18, as reported by the American College of Physicians 6
Solifenacin achieves continence more effectively than placebo, with a NNTB of 9, according to the American College of Physicians 6

Common antimuscarinic side effects include dry mouth, constipation, and blurred vision, as noted by the American College of Physicians 7

Moderate-quality evidence shows that age does not modify clinical outcomes associated with pharmacologic treatment for urinary incontinence, according to the American College of Physicians 7
High-quality evidence demonstrates that trospium, oxybutynin, and darifenacin effectively improve urinary incontinence and quality of life in older women, as reported by the American College of Physicians 7
Patients receiving multiple medications (7 or more) have increased risk of adverse effects with antimuscarinic agents, as noted by the American College of Physicians 8