Individualized Care Plan for Urinary Incontinence and Drug Therapy Problems

QUESTION

 

Help me make an individualized, patient-centered, team-based care plan to optimize medication therapy for this patient’s urinary incontinence and other drug therapy problems. Include specific drugs, dosage forms, doses, schedules, and durations of therapy.

CASE STUDY

Chief Complaint

“I can’t seem to control my urine. I feel like I have to urinate all the time. However, when I do go to the bathroom, I pass only a small amount of urine. Sometimes I wet myself. I was started on a medication for my leaking a few weeks ago, but it doesn’t seem to be working. I also can’t seem to remember anything. It is a wonder that I remembered to come to the clinic today. My daughter seems to spend more and more time taking care of me because I am too forgetful.”

HPI

A 65-year-old woman with urinary urgency, frequency, and incontinence presents to the urology clinic for a follow-up visit. She reports soiling her underwear at least two to three times during the day and night and has resorted to wearing panty liners or disposable underwear. Urinary leakage is not worsened by laughing, coughing, sneezing, carrying heavy objects, or walking up and down stairs. She does not report wetting herself without warning. She has been taking oxybutynin extended-release 15 mg PO BID for the past month with no improvement in her voiding symptoms, and she complains of new-onset confusion and difficulty remembering routine tasks.

The patient is accompanied by her daughter, who confirms that the patient’s confusion seems to have started shortly after oxybutynin was started. The patient cannot remember what day it is and can no longer tell time. Also, the patient gets out of bed at night many times to void, and the family is worried that she will fall and hurt herself. The daughter implores the clinician to initiate a more effective treatment for her mother.

PMH

HTN for many years, treated with medications for 10 years

Dyslipidemia for 5 years, controlled with a low-cholesterol diet, weight control, regular exercise, and medication

Postmenopausal; stopped ovulating at age 52

Mild Parkinson disease for the past 5 years treated with amantadine without adverse effects

Has difficulty falling asleep and often has sleepless nights; takes a sedative most nights

No history of spinal or pelvic surgery

FH

Noncontributory

SH

Nonsmoker; social drinker; married, but husband is not involved with her care

Meds

Hydrochlorothiazide 25 mg PO once daily with supper

Irbesartan 300 mg PO daily

Pravastatin 40 mg PO at bedtime

Oxybutynin extended-release 15 mg PO BID

Diphenhydramine 25-50 mg PO at bedtime as needed, usually about five times a week

Amantadine extended-release 274 mg PO once daily at bedtime

All

NKDA

Physical ExaminationGen

WDWN woman

VS

BP 170/94 mm Hg, P 90 bpm, RR 16, T 37°C; Wt 70 kg, Ht 5′2″

Skin

No rashes, wounds, or open sores

HEENT

PERRLA; EOMI; no AV nicking or hemorrhages

Neck/Lymph Nodes

No palpable thyroid masses; no lymphadenopathy

Pulm

Clear to A&P

Breasts

Normal; no lumps

CV

Regular S₁, S₂; (+) S₄; (-) S₃, murmurs, or rubs

Abd

Soft, NTND, (+) bowel sounds

Genit/Rect

Genital examination shows atrophic vaginitis consistent with postmenopausal status. Perineal sensation and anal sphincter tone are normal.

Pelvic examination shows no uterine prolapse and a mild degree of cystocele. Cervix is normal. No pelvic, adnexal, or uterine masses found.

External hemorrhoids; heme (-) stool.

Ext

Normal; equal motor strength in both arms and legs

Neuro

Although alert, the patient is not oriented to correct month, day, or year. CNs II-XII grossly intact; DTRs 3/5 bilaterally; negative Babinski. When asked to recall a series of five objects after 5 minutes, the patient had difficulty and could only recall one object.

Labs

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Na 140 mEq/L	Hgb 12 g/dL
K 4.2 mEq/L	Hct 37%
Cl 105 mEq/L	Plt 400 × 103/mm3
CO2 28 mEq/L	WBC 5.0 × 103/mm3
BUN 17 mg/dL
SCr 1.2 mg/dL
Glu 100 mg/dL

 

UA

No bacteria; no WBC

Other

Using an ultrasonic bladder scan, a residual urine volume was measured after the patient voided. No residual urine was found. The bladder was then filled with 300 mL saline. The patient felt the first desire to void at 100 mL. The catheter was removed. The patient was asked to cough in different positions. No stress urinary incontinence was demonstrated. The patient voided the entire volume of saline that was instilled.

Assessment

Overactive bladder with symptoms of urinary urgency, frequency, and incontinence, which has not responded to oxybutynin extended-release 15 mg PO BID for 1 month. Patient is also having new-onset confusion and forgetfulness, temporally related to starting oxybutynin. The central nervous system adverse effects of oxybutynin are worsened by concomitant use of diphenhydramine, but probably not amantadine. Will evaluate carefully and consider alternative medication options.

ANSWER

Individualized Care Plan for Urinary Incontinence and Drug Therapy Problems

Introduction

This individualized, patient-centered care plan aims to optimize medication therapy for a 65-year-old woman presenting with urinary urgency, frequency, and incontinence. The current treatment with oxybutynin has not been effective and is associated with adverse effects such as confusion and forgetfulness. To address these issues, a comprehensive approach involving both pharmacological and non-pharmacological interventions will be implemented. The plan takes into account the patient’s specific needs, medical history, and concurrent medications.

Pharmacological Intervention

Discontinue Oxybutynin: Due to the adverse effects of confusion and forgetfulness, oxybutynin will be discontinued to avoid further cognitive impairment.

Anticholinergic Alternative: Consider prescribing a different anticholinergic medication that has a lower likelihood of central nervous system side effects, such as trospium chloride or solifenacin. These alternatives may provide similar benefits for overactive bladder symptoms without compromising cognitive function.

Medication Review: Assess the need for diphenhydramine and its potential interactions with the new anticholinergic medication. If possible, reduce or eliminate the use of diphenhydramine to minimize the risk of exacerbating cognitive impairment.

Non-Pharmacological Intervention

Behavioral Strategies: Implement bladder training techniques to improve urinary control and reduce urgency and frequency. This involves scheduled voiding, gradually increasing the time between voids, and practicing pelvic floor exercises.

Fluid Management: Advise the patient to modify her fluid intake by limiting caffeine and alcohol consumption, as they can exacerbate urinary symptoms. Encourage maintaining adequate hydration without excessive fluid intake.

Lifestyle Modifications: Encourage regular physical activity, as exercise can improve bladder control and overall well-being. Provide guidance on maintaining a healthy weight, as obesity can contribute to urinary incontinence.

Community Resources and Referrals

Physical Therapy: Refer the patient to a pelvic floor physical therapist who specializes in treating urinary incontinence. They can provide tailored exercises and techniques to strengthen the pelvic floor muscles and improve bladder control.

Support Groups: Connect the patient and her daughter with local support groups or organizations that focus on managing urinary incontinence. These groups can provide education, emotional support, and resources for coping with the condition.

Conclusion

By implementing an individualized, patient-centered care plan, we aim to optimize medication therapy and address the urinary incontinence and drug therapy problems in this case. The plan involves discontinuing the ineffective medication, considering alternative pharmacological options, and incorporating non-pharmacological interventions. Collaboration with the patient, caregivers, and appropriate healthcare professionals will ensure comprehensive management and improve the patient’s quality of life.