Safe Overactive Bladder Treatments in the Age of Dementia

Addressing a growing problem: dementia and overactive bladder increase with age, and the primary medicines used to treat overactive bladder can cause dementia.

Woman talking about her overactive bladder treatment options

I recently made a presentation in Vail for OB-GYNs and other physicians titled, Overactive Bladder: The More We Learn, The Less We Know. The more we learn part was introducing the results of recent studies on the dementia-causing side effects of medications often used as overactive bladder treatments. The less we know part was that many physicians – and most patients – are not aware of this connection.

Nor are they aware that alternative overactive bladder treatments can be just as effective, even more effective, than the drugs that increase the risk of dementia, which are called anticholinergic medications. And those drugs, such as Vesicare, Ditropan, Toviaz and Enablex, are heavily advertised to consumers (you can usually count on seeing at least one ad during the evening news).

My mission in this blog is to inform you about the problem and to offer alternative treatment options that don’t contribute to dementia.

Overactive bladder (OAB), also called urge incontinence, is a form of urinary incontinence (UI) that involves a sudden and powerful need to urinate. This often results in leaking large amounts of urine before one can reach a bathroom. Frequent urination in the day or night is another sign of OAB, as is urinating during sleep.

  • 13 million Americans are incontinent, and 11 million (84 percent) of those are women.
  • 20-30 percent of women age 40 or older have UI.
  • Only about 18-50 percent of women with UI seek treatment.
  • 50 percent or more of the elderly living at home or in long-term care facilities have UI.
  • UI is the #1 motivating factor for people to put an elderly relative in a nursing home.

Those are eye-opening facts. And there are more effects of UI, such as depression, loss of self-esteem, anxiety, and decrease in excursions, social activity and sexual activity. Then you have the medical issues, from rashes to recurrent urinary tract infections to increased falls, due to hurrying to make it to the bathroom, often at night.

Anticholinergic medications that can help with overactive bladder but cause dementia

That line may sound like making a deal with the devil: You get a decent payoff but end up paying dearly for it in the long run. I agree with that, and so does the American Urogynecologic Society (AUGS).

In their consensus statement on the use of anticholinergic medications for OAB, they state that evidence shows significant associations between these meds and increased risk of cognitive impairment and dementia. AUGS goes on to recommend providers counsel their patients on these risks and to consider other options or the lowest doses possible.

The brand names of anticholinergic medications are Ditropan XL, Detrol LA, Vesicare, Enablex, Toviaz and Sanctura XR. They act by inhibiting one of the body’s cholinergic receptors that is the main trigger for bladder contraction. They are also used as antidepressants and antihistamines – much more often than they are used for OAB, which accounts for only about 10 percent of these drugs’ users.

These anticholinergic medications produce side effects such as dry mouth, dizziness and constipation. Because of those side effects found in anticholinergic medications, most people stop using them, with adherence rates after a year down to 9 percent and less with some of the drugs. And now we know they have another more serious side effect, the possibility of dementia.

This was shown in a study of over 3,000 women published in the Journal of the American Medical Association that concluded: “Higher cumulative anticholinergic use is associated with an increased risk for dementia. Efforts to increase awareness among healthcare professionals and older adults about this potential medication-related risk are important to minimize anticholinergic use over time.”

Other studies investigating the association of cognition loss with anticholinergic medications showed significant effects. Compared with people who did not take anticholinergic medications, people who did use the drugs showed:

  • Reduced brain glucose activity.
  • Evidence of temporal lobe and whole-brain atrophy.
  • An association with progression to mild cognitive impairment and/or Alzheimer’s disease.

And the more anticholinergic medication activity in the drugs a person took, the higher the risk of the above side effects. This new information has changed the way urogynecologists use these drugs for OAB treatment. But since these drugs are used much more as antidepressants and antihistamines, other doctors and patients who use these drugs for those reasons should be aware of these serious side effects of anticholinergic medications.

AUGS and CU Urogynecology suggest several steps for women on anticholinergic medications for OAB. Talk with your doctor about cutting back on dosage for OAB, cutting back on the use of anticholinergic meds taken for other reasons, and going with alternative treatment options.

I recommend other overactive bladder treatment options

We want to move women away from overactive bladder treatments that have dementia and Alzheimer’s disease as side effects. As always at CU Urogynecology, we start with the simplest treatment options before moving to more complex ones. Women and their physicians should consider the following options.

Pelvic floor therapy can have good results on OAB. A recent study of 32 women who undertook 6-9 pelvic floor muscle rehabilitation therapy sessions over 2 weeks (with a follow-up after 6 months) showed:

  • 22.9 percent reduction in the number of urinations in a 24-hour period.
  • 21.3 percent reduction during the day.
  • 34.7 percent reduction at night.
  • Improved quality of life and significant improvements lasting 6 months.

Non-anticholinergic medications are an option. Drugs known as beta-3 agonists, such as mirabegron (Myebritq brand name) can help. Beta-3 agonists are recommended for women at high risk for side effects of anticholinergic medications.

Botox (botulinum toxin) injections can reduce OAB symptoms. It relaxes bladder muscles while increasing the bladder’s storage capacity. Bulking agents are injected into the area around the urethra or into the bladder.

Vaginal estrogen treatment in topical cream, tablet or ring application can reduce urinary frequency and urinary urgency in women with OAB. It should be discussed as an option, though studies on its effectiveness are inconclusive.

A pessary, a small device inserted into the vagina to provide support for the pelvic organs (uterus, bladder and rectum), helps to decrease urine leakage. Often used after pelvic organ prolapse, a pessary can be an option to reduce symptoms of OAB.

Neuromodulatory therapy can be effective as an overactive bladder treatment because it affects the sacral nerve roots that control the muscular impulses of bladder contraction. Percutaneous tibial nerve stimulation (PTNS) is a minimally invasive option appropriate for some individuals and may help prevent a more invasive surgical treatment. Another option is sacral neuromodulation (SNM), including InterStim therapy. This involves surgical implantation of a battery-powered stimulator.

Ways to help yourself out of the OAB predicament

The first way to help yourself is to do Kegel exercises to strengthen your pelvic floor muscles, which can get them in shape to help combat OAB. Several behavior modification options can help. These include some relatively simple steps, such as:

  • Using a bedside commode.
  • Timing your urination.
  • Performing bladder drills to help retrain it.
  • Restricting fluids after 7 p.m.
  • Reducing bladder irritants like caffeine, alcohol and nicotine.

You can make other lifestyle changes in diet to control weight and blood sugar levels, which both can contribute to OAB. A nutritionist can help you get started in that regard. Women on medication for hypertension may also benefit from changing that type of medicine.

We discuss all these options with each of our OAB patients. Together we determine which approach is the best, given her particular condition, her responses to other treatments and her preferences.

With what we now know about the dementia-causing risks of anticholinergic medications, the CU Urogynecology doctors will be very careful in prescribing those as overactive bladder treatments. We encourage OB-GYNs and other physicians to do the same. Women prescribed these medications – for OAB or other conditions – should discuss with their physician the researched links to dementia.