Transcription:
Overactive Bladder Medications and Dementia

Melanie: Welcome to Better Edge, a Northwestern Medicine podcast for physicians.

I'm Melanie Cole. And joining me today is Dr. Emi Bretschneider. She's an expert in female pelvic medicine and reconstructive surgery, and an Assistant Professor of Obstetrics and Gynecology at Northwestern Medicine. Dr. Bretschneider is passionate about pelvic health and empowering patients through education. We know that urinary incontinence affects anywhere from 20% to 65% of women, depending on their age, parity and menopausal status. Dr. Bretschneider joins us today to talk about the link between medications for overactive bladder used to treat this condition and dementia.

Dr. Bretschneider, it's such a pleasure to have you with us. And as a woman in this certain age group, where this is starting to be popular among women that I know, tell us a little bit about your program at Northwestern Medicine, the type of patients you see and the prevalence of overactive bladder.

Dr Emi Bretschneider: Thank you so much for having me on the program. And, yes, it's definitely something that impacts a lot of women and a lot of patients that I see. So I'm one of six urogynecologists here at Northwestern. We're part of the integrated public health program. And we primarily see patients with pelvic floor disorders such as prolapse, urinary incontinence and fecal incontinence. And one of the most common conditions we see for patients is overactive bladder or OAB for short. And OAB is an umbrella term for a number of bothersome bladder symptoms, such as urgency, frequency, nocturia, and urgency urinary incontinence. This condition affects nearly 30% of women in the US with approximately one in seven experiencing urgency-related leaking, and it can be a major quality of life issue.

Melanie: Wow. Well, I certainly can attest to that as I know so many people. Now, what can you tell us about the connection between overactive bladder medications and new-onset dementia. We hear a lot about these medications on commercials, in the media. Tell us a little bit about anything you know, about this link.

Dr Emi Bretschneider: So there are a number of different treatment options that we offer our patients ranging from first-line treatments, such as pelvic floor physical therapy and behavior modifications to second-line treatments and that's where oral medications come in. And then we have third-line treatments, which I'll go into in a little bit. But there have been a lot of data that's coming out recently highlighting the association between anticholinergic medications and dementia. And one of the most common medications that we use to treat overactive bladder falls within this anticholinergic category. There are a number of studies published in JAMA Internal Medicine, British Medical Journal and other obstetrics and gynecology journals that have highlighted this association between anticholinergic use and dementia later on in life.

Anticholinergic use has been associated with nearly 65% increased risk of developing dementia with a dose-dependent effect. So while these studies are mainly observational and don't necessarily show a cause and effect relationship between anticholinergics and cognitive changes such as dementia, the amount of data that we have now is piling up and it can't be ignored, especially considering the really significant clinical implications of these findings.

Melanie: So you said you would tell us a little bit about some of the other treatments and you mentioned pelvic floor physical therapy and some treatments after the fact, but are medications maybe not your first-line, but your go-to? Is this the main treatment for urinary incontinence? And are certain populations at a more increased risk for dementia caused by these medications?

Dr Emi Bretschneider: Many patients who report any kind of bladder symptoms are often prescribed of course medication by their primary care physicians or OB-GYNs even before they come in to see us. And I think this is partly because medications are relatively easy interventions and patients report significant bother from these bladder symptoms and are seeking treatments. And even though these medications are relatively easy to prescribe and start, these anticholinergic OAB medications may not be the safest or most effective treatment for a patient.

So there are two types of overactive bladder medications that are available. One is the anticholinergic medication as I mentioned. And another type is the beta-3 agonists. And, while beta-3 agonists are effective, it's often difficult to get patients access to these medications due to barriers set up by insurance companies and costs issues. Beta-3 agonists don't have the same cognitive impacts that the anticholinergic medications do have, so they're better choice for patients that we're concerned about.

That being said, there are a lot of patients who don't really respond to overactive bladder medications or they're patients that we're concerned about starting them on such anticholinergic medications. And for those patients, we really want to start or at least consider offering them Botox or sacral neuromodulation. These are what we call third-line treatment options for overactive bladder. Also, peripheral tibial nerve stimulation falls within this category. And these treatments are great options for people who don't respond to overactive bladder medications or are not great candidates to try those medications given, say, age or other cognitive issues at baseline, or they're taking other anticholinergics already.

So Botox is an office procedure where we inject the bladder muscularis with Botox. The effects of this treatment lasts approximately six months. But what's great about this intervention is that it doesn't have any of the cognitive side effects that anticholinergics have. Sacral neuromodulation is another great option for patients, which completely bypasses any kind of concern for cognitive effects. It's an outpatient procedure that involves implanting a lead via the S3 foramen to stimulate the sacral nerve, to normalize and directly modulating the neural activity of the bladder. So it's a great option.

And lastly, if we have PTNS, as I mentioned before, which is percutaneous electrical stimulation. And this is a technique that essentially stimulates the tibial nerve four to five centimeters above the medial malleolus. And it's a great office procedure for patients who don't want Botox or sacral neuromodulation.

Melanie: Dr. Bretschneider, this is so interesting. And for referring physicians and other providers, can you expand a little on patient selection? Because if they are quick to prescribe these medications, but you mentioned there are a few contraindications, what would you like them to know about specific contraindications to taking these medications? Why it would be so important to refer for another method or another modality? And taking history, what would you like them to know about these and patient selection?

Dr Emi Bretschneider: Well, first patients that are older are more likely to experience significant side effects from anticholinergic medications. That's mainly because our brain architecture changes as we age and that blood-brain barrier permeability changes as well. And it makes us more susceptible to brain-related effects of anticholinergic medication, so older patients.

Any patients that are also on other anticholinergic medications are potentially at increased risk for developing side effects, including cognitive status changes or dementia later on. And anticholinergics, as other physicians are very commonly prescribed for a number of conditions, including asthma, COPD, allergies and whatnot. So, if your patient has a number of co-morbid conditions for which they're taking many medications for already, that's something to be very aware of and consider referring sooner than later. Also, patients that have some cognitive changes at baseline are also at higher risk for having cognitive change issues, cognitive status changes due to anticholinergic medications.

That being said, the beta-3 agonists, which have less impact on cognitive status do have a number of contraindications as well. Beta-3 agonists can interact with a number of commonly used medications, including say like metoprolol for high blood pressure. And so if you're concerned at all about your patient's ability or risk factors to taking such medications, then I recommend referring those patients to urogynecologists such as our group or other specialists who are familiar with offering third-line treatments, such as Botox or sacral neuromodulation

Melanie: And before we wrap up, and since this is something I've done a lot of shows, Dr. Bretschneider, but this is the first one on this link. Can you tell us, because for other providers, this may be really new news to them, what research is being done in this area? Or what do you see happening in the next five years? Do you think these medications will evolve? Do you think it will change? What do you see happening and what research is going on right now?

Dr Emi Bretschneider: So there's a lot of observational research that's being conducted right now. And since it's such a very hot topic, we recognize a lot of patients have overactive bladder. A lot of patients are taking anticholinergics for treatment of a number of different conditions. So really establishing this connection between anticholinergic use and dementia is going to be very important.

That being said, there's a number of studies. There's a study coming out of University of Houston, looking at the impact of anticholinergic medications for patients with overactive bladder and looking at there MRI brain imaging. And it's very cool and I'm looking forward to seeing the results of those studies. In our clinic, we're looking at ways to improve access of these third line treatments and beta-3 agonists for our patients with overactive bladder, because we do recognize that there's a huge hurdle for patients in accessing safe, effective treatments for OAB given the financial barriers and issues with insurance companies. And I think there's a big push, especially in OB-GYN, especially in the field of urogynecology and urology to make these safer, more effective treatments available to patients without these barriers in place. So hopefully, in the next five years, we'll see a lot easier access to these safer treatments for OAB for our patients.

Melanie: Thank you so much. What a fascinating topic we were discussing today, Dr. Bretschneider. Thank you so much for joining us. To refer your patient or for more information, please visit our website at urogynecology.nm.org to get connected with one of our providers.

And that concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. Please also remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts. Until next time, I'm Melanie Cole.