…faithful to their system, (they) remained in wise and masterly inactivity.
—Sir James Mackintosh (1765–1832), Vindiciae Gallicae
Incontinence is the looming iceberg that threatens to sink the geriatric health care “Titanic” as it sails through the twenty-first century. At least one in three community-dwelling elders has experienced urinary incontinence, often with distressing consequences such as social isolation, depression, institutionalization, excess comorbidity, and increased mortality.
Although there is a relative paucity of data, fecal incontinence may affect as many as one in five community-dwelling older adults. Within the long-term care population, the frequency of either form of incontinence (urinary or fecal) exceeds 50%. In the light of these dire figures, alarmists and cynics may be readily forgiven for labeling incontinence a ubiquitous and deadly geriatric disease.
Economic considerations are just as grim. The total lifetime medical cost of treating a woman with urinary incontinence almost doubles that of a similar woman without incontinence. In the United States, direct health care costs for urinary incontinence exceeds $16 billion per year. Incorporation of indirect health care costs elevates this annual estimate to approximately $26 billion. Undoubtedly, the overall cost of incontinence is much higher, because accurate cost estimates for fecal incontinence are scanty. Indeed, projections for medical expenditures related to geriatric incontinence indicate a substantial increase in the coming decades.
It is concerning that even in the face of such disquieting data, geriatric incontinence continues to battle for legitimacy and recognition among health care professionals. Many primary care providers still fail to diagnose or treat this devastating syndrome in their older patients. Similarly, caregivers and patients alike often fail to present incontinence as a health concern for reasons such as shame, embarrassment, decreased awareness, or ignorance of available treatment options.
Commendably, dedicated geriatric researchers and clinicians continue to develop new technologic and intervention strategies in the areas of urinary and fecal incontinence. However, failure to transmit this information to “frontline” providers, as practical and clinically applicable strategies, will result in the indictment of the geriatric community for unwise “masterly inactivity” as a deadly and preventable disease runs rampant. To this end, I am extremely indebted to all the authors who have made contributions to this issue of the Clinics in Geriatric Medicine. They represent an active and distinguished cohort of skilled clinicians and researchers who continue to aggressively pursue effective prevention and intervention strategies directed toward the syndromes of incontinence in the older adult.
The primary goal of this issue is to distill the massive body of available clinical and research data into concise, evidence-based, relevant synopses directed toward the primary geriatric care provider. To this end, the emphasis in the overall schema of the issue is less didactic and more practical. Clinical approaches to urinary incontinence are addressed in relation to specific populations, namely community-dwelling elders, long-term care residents, and frail and terminally ill elders. One article is dedicated to urodynamic evaluation of continence, as the clinical value of this resource remains an issue of lively controversy among geriatricians and urologists. Providers skilled in the area of incontinence readily acknowledge that nursing management is critical to the success of any intervention strategy. Advanced nursing concepts are presented in a succinct and concise fashion that should prove very helpful to nurses and other health care professionals. Although management is dealt with in several articles, a specific article is devoted to the pharmacologic management of urinary incontinence. This article serves as a highly informative and evidence-based resource for the geriatrician battling with the decision to institute drug therapy in the incontinent older patient. In addition, this issue contains an excellent contribution discussing the surgical management of urinary incontinence from a geriatric perspective. Due to the relative paucity of research and literature in these areas, cross-cultural and psychosocial ramifications of urinary and fecal incontinence, are addressed as separate domains.
Geriatric fecal incontinence is presented in a separate article that provides an excellent overview of the topic and will certainly serve as a valuable reference source for readers. Overall, the contributing authors have succeeded in adding to the available literature an impressive academic resource that functionally transmits evidence-based scientific information and also creates a strong impetus for continued research in this area.
Finally, I would like to thank Dr. Joseph G. Ouslander, a widely acclaimed international expert in the field of geriatric incontinence, for his assistance in identifying several authors who made invaluable contributions to this issue.
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