Pelvic Floor Disorders in Frail Older Women

The impact of frailty, a state of vulnerability to insult with reduced likelihood of full recovery, on clinical outcomes following medical intervention has been recognized for some years.  Frailty can be described as a phenotypic state, comprising unintentional weight loss, reduced grip strength, slow gait speed, daily exhaustion, and decreased activity¹ or as a result of accumulated deficits, a frailty index expressed as the number of deficits divided by the number of total deficits, producing a fraction.² There are multiple methods of measuring frailty, all of which have been variably validated and many which have been utilized in the surgical environment.^3,4 Clinical impression, rather than formal assessment, misclassifies 50% of women with frailty.⁵

The prevalence of frailty increases in association with age, as does the prevalence of pelvic floor disorders. Estimates of frailty prevalence vary enormously ranging between 4.0-59.1% in community dwelling older adults,⁶ 21 - 47% in hospitalized older adults,⁷ and 50-70% of older residents of nursing homes.^8,9 In a recent prospective observational study from a single secondary referral center for PFD, frailty, assessed using the Groningen Frailty Indicator was present in 54.4% of the 263 women included.¹⁰ Women without frailty are more likely than the frail to proceed to surgical treatment for their pelvic floor dysfunction. Given that the proportion of adults surviving into late life continues to increase, and in the absence of major shifts in the distribution of comorbidity and disability, then we are likely to encounter increasing numbers of frail older adults with pelvic floor disorders.

In the 6th (& 7th) edition of the International Consultation on Incontinence, the dearth of data addressing frail older adults was recognized but the Committee noted that evidence of efficacy in community dwelling older adults may well inform care of those with frailty, considering intended benefits, potential harms, the preferences of the older adult (and their care partner) and the burden of the intended management plan.¹¹

Conservative Therapies

Most data supporting conservative therapies in frail older women come from trials in long term care (nursing homes); these data are limited by the age of the studies. The population of adults in nursing care has become increasingly complex and dependent over the last thirty years, when many of the index trials of prompted voiding, for example, were first reported and may now be less relevant to this increasingly vulnerable population. In the absence of trials in frail older adults, and given the increased propensity for potential harm, no recommendation can be made about any individual lifestyle intervention for treatment of UI. If modifiable lifestyle factors are established as risk factors, these could be targeted for treatment following assessment. Voiding programs can be used for older adults with cognitive and physical impairments who have difficulty learning new behaviors or difficulty actively participating in self-care activities, as well as in frail older adults. The addition of exercise programs to improve gait speed and stamina adds to benefit.¹² Ultrasound assisted prompted voiding programs may be more effective than traditional approaches in nursing care, but at the expense of additional staff burden.¹³ Pelvic floor muscle therapy (PFMT) is beneficial in improving UI in healthy adults and non-frail older adults, and biofeedback-assisted PFMT improved UI in homebound older adults. Older adults with Parkinson’s disease and stroke also benefit, suggesting that the only limitation is the ability to perform contractions and to adhere to the program. Multicomponent interventions appear to hold the greatest potential for benefit in urinary incontinence, those consisting of PFMT combined with lifestyle, mobility and nutritional interventions appear to be effective.^14,15

Data for the use of pharmacotherapy for OAB in frail older adults remains sparse. A systematic review in 2015 concluded that anticholinergics have a small, but significant, effect on urinary leakage in older adults with UUI and that “treatment with drugs for UUI in the frail elderly is not evidence based.”¹⁶ The beta-3 agonists mirabegron and vibegron were not included in this analysis. Although there are data supporting efficacy in community dwelling older adults, there remain none on their use in frail women. There are no data on topical agents for frail older women but given the low likelihood of harms, data on efficacy in ameliorating urinary urgency and vaginal symptoms, there appears to be no reason not to recommend use. For frail older women with prolapse, PFMT and intravaginal pessaries remain viable options for women wishing to avoid, or who are unfit for, surgical intervention.  Data from frail older women are lacking but, those from community dwelling older women suggest that pessaries are a viable treatment option. Particular attention should be paid to long term management plans for care of women living with dementia, where removal of a pessary in the face of severe dementia or retention of the pessary without intervention may potentially be considered when changing or cleaning may cause undue distress.¹⁷

The use of posterior tibial nerve stimulation for OAB has been assessed in nursing home residents. Unfortunately, in a randomized controlled trial, an intervention comprising 30-minute sessions of transcutaneous posterior tibial nerve stimulation or sham stimulation over a 6-week period resulted in no difference in incontinence between the intervention and sham groups.¹⁸ There are no data from community dwelling older adults living with frailty but in a multicenter randomized, sham‐controlled trial in 220 patients with 45% older than 65 years, statistically significantly more people in the treatment group than the sham group experienced either a marked or moderate improvement in their symptoms, (58% vs. 22%, p< 0.001) which was sustained in those available for follow up at three years.^19,20

Surgical Therapies

Here, a frailty assessment has utility in proactive care and discharge planning.  Women with frailty are at greater risk of procedure and non-procedure related complications (mostly cardio-respiratory) and impaired outcomes compared to younger women but are satisfied and experience improved quality of life, given that there is improvement in continence.^21,22,23 Prolapse surgery may be reconstructive or obliterative, depending upon the choice of the woman. Frail women experience increased lengths of hospital stay and 30-day complications compared to non-frail women.²⁴ Colpocleisis is associated with satisfactory results for prolapse.²⁵ A recent study showed that frail older women did not experience greater rates of complications than non-frail women, but complication rates were higher in women undergoing reconstructive surgery.²⁶

In a nursing home resident cohort including both sling and pelvic organ prolapse surgery, residents were propensity matched to community-dwelling older women based on procedure type, age, comorbidity, race, and calendar year. Among this cohort, 34% demonstrated 30-day complications and 1-year mortality was 7%. The relative risk of each outcome was higher among the residents, highlighting that factors other than age and comorbidity (such as frailty and physical and cognitive impairment) may account for these inferior outcomes.²⁷ There are no data on the use of intravesical onabotulinumtoxin A injection for overactive bladder in older women with frailty.

There are yet no data on the utility of rehabilitation prior to surgical intervention to mitigate the impact of frailty in older women with pelvic floor disorders.

In conclusion, data on treatment for pelvic floor disorders in older women with frailty are lacking. Most management must be pragmatically based upon assessment and balance of risks, taking into the account the treatment preferences of the woman and, where relevant, her care partner. Assessment of frailty is useful in care planning but there is no evidence of the utility of pre-operative conditioning in improving outcomes from surgical care. There remains much to learn.

REFERENCES

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