Harninkontinenz bei geriatrischen Patienten: Verhaltensintervention, Toilettentraining und physiotherapeutische Interventionen

Zusammenfassung

Einleitung 1/2019 wurde ein update der seit 2005 in AWMF eingestellten und fortlaufend aktualisierten Leitlinie „Harninkontinenz bei geriatrischen Patienten – Diagnostik und Therapie“ durch die interdisziplinäre Arbeitsgruppe „Harninkontinenz“ der Deutschen Gesellschaft für Geriatrie (DGG) publiziert. Aus dieser Leitlinie, die als offizielle Leitlinie DGG akkreditiert ist, stellt der vorliegende Artikel das Kapitel „Verhaltensintervention, Toilettentraining, physiotherapeutische Maßnahmen“ dar.

Methodik In einem strukturierten Bewertungsprozess identifizierte eine Literaturrecherche zunächst die vorhandene Literatur im Kontext des „geriatrischen Patienten“, wie er als zumeist über 70jährig und multimorbid oder über 80jährig durch die Fachgesellschaften definiert ist. Primäre Berücksichtigung fanden randomisierte, doppelblinde, plazebokontrollierte Studien sowie bereits vorhandene Leitlinien zum Thema. Wo keine solchen Untersuchungen vorlagen oder aus methodischen Gründen prinzipiell nicht durchführbar sind, wurden auch Publikationen anderen Designs (nicht randomisierte Untersuchungen, Fallkontrollstudien) zur Leitlinienerstellung herangezogen. Die daraus resultierenden Leitlinienempfehlungen wurden in einem strukturierten Abstimmungsprozess unterzogen; das Ergebnis ist in Prozent der zustimmenden Gruppenmitgliedern angegeben.

Ergebnisse Vor dem Hintergrund der Polypharmazie mit ihren Medikamenteninteraktionen und der besonderen Vulnerabilität des hochbetagten, geriatrischen Patienten sind nicht nicht-pharmakologische und nicht-operative Interventionen besonders wichtig. Diese bedürfen jedoch ein Mindestmaß an Compliance und Restmobilität. Vor diesem Hintergrund wurden Verhaltensinterventionen wie Gewichtsabnahme, Flüssigkeitsmanagement, Diuretikaeinsatz, Stuhlregulierung und Toilettentraining sowie aktive und passive physiotherapeutische Maßnahmen im Hinblick auf ihre Wirkung und Anwendbarkeit bei geriatrischen Patienten überprüft und bewertet.

Schlussfolgerungen Verhaltensinterventionen, Toilettentraining und physiotherapeutische Maßnahmen sind besonders vor dem Hintergrund der mit spezifischen Risiken behafteten medikamentösen oder operativen Therapiealternativen wertvolle Bausteine der geriatrischen Inkontinenzbehandlung und sollten in angepasster Form flankierend oder alleinig bei der Therapie geriatrischer Patienten Anwendung finden.

Abstract

Introduction 1/2019 we presented an update of the AWMF guideline ‘urinary incontinence in frail elderly – diagnostics and therapy. Since its introduction in 2015 the guideline has been under a continuous revision process by the working group ‘Incontinence’ of the German Society for Geriatrics (DGG). From this guideline which is accredited as an official guideline of the DGG we present here the chapter about ‘behavioral therapy’, ‘toilet training’ and ‘physiotherapy’.

Methods A profound literature search was done in a structured evaluation process in the context of a ‘frail elderly’. Most medical societies define a ‘frail elderly’ as someone older than 70 years and multimorbide or older than 80y. We focused on randomized, double blind, placebo controlled studies as well as already published guidelines in this field. In the case no studies were available or not feasible other publications such as not randomized studies or case reports were taken into consideration for our guideline. Recommendations resulted from a structured voting process and the results are stated as percentage of members who agreed.

Results Considering the vulnerability of frail elderly and the limitations of pharmacological and surgical treatment any conservative treatment modalities get a special meaning. All behavioral treatment approaches, however, are only successful if the patient is to some extent compliant and mobile. Keeping these limitations in mind we looked at effect and feasibility of weight loss, fluid management, use of diuretics, bowel regulation and toilet training as well as active and passive phsiotherapeutical interventions.

Conclusion Behavioral treatment, toilet training, and phsiotherapeutical interventions are indispensable modules in the multifaceted approach to improve continence in frail elderly. Caring for multimorbide frail elderly requires carefully outweighing risks of pharmacological and surgical treatment against benefits of low risk interventions such as conservative therapy. Frail elderly often benefit from conservative treatment alone or in combination with other treatment modalities.

Schlüsselwörter

Flüssigkeitsmanagement - Blasentraining - Blasenentleerung nach Aufforderung - Beckenbodentraining

Keywords

fluid management - prompted voiding, bladder drill - incontinence assessment - urodynamics - ultrasound - cystoscopy

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