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Dr. Elie Matar: Hello everyone. My name's Dr. Elie Matar. I'm a neurologist and sleep physician based in Sydney. I'm also a clinician scientist studying ways to better understand, diagnose and treat neurodegenerative disorders, with an interest especially in Lewy body dementia, which includes Parkinson's disease with dementia, as well as a condition called dementia with Lewy bodies. Today's topic is the management of bowel and bladder symptoms, which are a very common symptom across Lewy body disorders, but it's also very commonly seen across all dementias and even in older adults without dementia. So, I hope this video can be helpful to people living with dementia and their caregivers, as well as any interested older adults suffering from this condition. So, bowel symptoms are very common in Lewy body dementia, affecting up to 90% of people with this condition and can occur before memory and thinking disturbances become apparent. In fact, it could be one of the earliest signs appearing years or decades before the disease. It can also occur very commonly in people who do not develop dementia so it's not exactly a very specific warning sign. Now, the most common bowel symptom in people with Lewy body dementia is constipation and the symptoms become more severe as the disease progresses and can really affect quality of life. It can worsen other symptoms such as movement symptoms, bladder symptoms, as we'll hear about later, and can even be a reason for hospitalisation. So, prevention is really key but let's start with the basics. What is constipation? Constipation is generally defined as having fewer bowel movements than usual or difficulty passing stools and this may include going less than three times a week. Having stools that are dry, hard or painful to pass or even a feeling that the bowel hasn't emptied completely. Why do people with Lewy body dementia get constipation? There are many reasons for this and there's been a lot of research in this area, especially over the last 10-15 years, and what we've learned is that there are changes in how the brain controls the gut due to the disease itself. And also, the fact that the disease can even affect the nerves in the gut itself. In fact, there are some lines of thought that the disorder might even begin in the gut itself, although there's a lot more research to prove that to be true. Changes in the gut bacteria have also been a very popular reason that have been studied over the last 10-15 years, and there are still a lot of people working on this today. But also, in addition to these disease related factors, there are many other important factors that we see in other older adults who do not have dementia and these include medication related side effects, dehydration, changes in diet and lack of movement. And whilst these can be seen in older adults without dementia, of course these risk factors become more common in those with dementia, as you'll know. So how do we treat constipation? Ultimately, we have to tailor the plan to the individual. At the very foundation, our lifestyle and routine measures. Things like staying well hydrated and increasing fluid intake, as long as that's allowed, in that you don't have any significant heart or kidney conditions that restrict the amount of fluid that you take. Fibre intake is important, and you can get this from natural sources, especially prunes, vegetables, whole grains, and also you can try certain supplements such as psyllium supplements that are easily available over the counter.
Increasing physical activity through gentle walking or movement can also help the bowels move better. And also some behavioural strategies such as having a regular toileting schedule, making sure that you go to the toilet before bed and so forth and, or early in the day and as long as it's a specific time that you try to develop a routine and habit around it. After the routine and lifestyle measures, it's important to review the need for medications that can slow the gut, and this is usually best done with the doctor. So, medications that can slow the gut could include opioid medications, iron supplements, certain antidepressants and certain anticholinergics medications. But again, some of these may be prescribed for a very important reason so do not just stop taking these or reduce them just because you're constipated. Really make sure that you have a chat to the doctor who prescribed them. After you've done the lifestyle and behavioural measures and maybe looked at the medications, then we start to think about medications that can improve bowel motions and what we usually use is a step-wise approach, starting with the gentlest option and adding on, and escalating as we need. Usually, I start with the osmotic laxatives. So, these are laxatives that draw water into the gut to try to loosen the bowel motion and so often those would include medications such as 'Macrogol', which come in sachets that you mix in with water and 'Lactulose', which is a syrup. Then we move on to the stimulant laxatives that directly help the bowel contract, especially if the motility is reduced and these include things like 'Senna' or 'Bisacodyl', which can sometimes be used in combination with some of the osmotic laxatives, or even the laxatives that can have detergent properties, that are not mentioned here. Following on from the stimulant laxatives are the suppositories or enemas, which we usually reserve for severe cases which don't respond and are usually what we use in hospital when patients present, although these can be used as well at home, if required.
And then finally, of course, is manual disimpaction and this is usually reserved again for extreme cases and usually in hospital. Please always use these under doctor guidance because the overuse of some of these medications, especially the stimulants, can lead to unwanted effects. Some of them can cause diarrhoea, and some of them can directly affect the motility of the bowel when used over a long period of time. A question I often get is, "What about pre and probiotics?" Now, probiotics are good bacteria that may help balance the gut and some strains may improve stool frequency and consistency. While prebiotics are the non-digestible fibres that feed the good bacteria and can help by softening the stool, increasing bowel movements, but can in some people, cause bloating or gas. Overall, there is not a lot of evidence for or against their use in Lewy body dementia. It may help some people and should be part of a broader plan with the doctor for addressing constipation and so, therefore, should be considered. They are generally safe, but if they are tried, they should be introduced slowly, so as to not lead to those unwanted side effects and you can of course discontinue these if there is no benefit. So regularly reviewing their benefit is helpful.
So, let's move on to bladder symptoms. Now bladder symptoms are also very, very common in Lewy body dementia and they can appear early in the illness just like constipation, and they can fluctuate and worsen over time. The most common profile of bladder symptoms that we see is an 'overactive' bladder, and that's described by a sudden strong need to urinate which can occur out of the blue, in some cases. This is called 'urinary urgency'. It can also manifest this frequency which is needing to urinate quite often. And nocturia, which is urinating often at night. Why does it happen in Lewy body dementia? Well, just like constipation, it can affect the parts of the brain that control bladder function, as well as affecting the nerves to the bladder itself, leading to an irritated overactive bladder. However, there are other disorders and risk factors that occur in ageing that can also lead to these bladder symptoms. So, the other bladder issues to watch out for would be urgent stress incontinence, where you have leaking urine either before reaching the toilet or during activities such as coughing or standing up. We should always look out for symptoms of obstruction or prostatism which is seen in men, with due to enlarged prostates and that can lead to a feeling of incomplete emptying, hesitancy and voiding more than once soon after finishing. Urinary tract infections can also be very common in adults as we age and these can worsen all the other bladder symptoms I've just talked about, and one particular thing that characterises them is the pain when urinating. Although you do not have to have pain when urinating with a urinary tract infection, but it can be an important clue. And it can, in and of itself, lead to worsened symptoms of dementia across the board and can cause increased confusion and even agitation so we need to watch out for these bladder issues which occur across all dementias and in older adults.
How do we treat overactive bladder? Well first of all, we start with a careful history understanding ‘how severe is this at the moment?’ and that can be done through the use of a bladder diary where you keep track every day of the number of times that someone is going to the bathroom and how much water they pass. As well as sometimes using a bladder scan, where you can see the volume of urine that's left in the bladder after someone has gone to the bathroom. After this, we try to rule out other causes of contributors to overactive bladder, making sure if someone doesn't have a urine infection. So, there's a sudden change in urinary habits, sudden increase in urgency, sudden increase in frequency, sometimes a little bit of pain when passing urine, can really indicate that someone's developed a urine infection. We should also make sure someone doesn't have prostate enlargement, which could be worsening all of these symptoms. And again, reviewing medications that can also worsen the bladder control. Sometimes we need to consider referring to a urologist who specialises in bladder symptoms to perform some particular tests. After this, we then look to treat other specific symptoms if there is nocturia or nocturnal polyuria, which means going to the bathroom, passing a lot of water at night. Maybe things like prompted toileting before bed, reduced caffeine and alcohol intake, especially in the afternoon and in the evening. Reducing the water intake at night, so making sure that you have enough water but having that earlier in the day rather than leaving some drinking to the night. Reviewing the timing of medications especially things like diuretics, which can promote urination, and maybe having them earlier in the day rather than in the evening. And also thinking about ways to make it more safe when someone does need to go to the bathroom so using lighting, commode, having flasks even by the bed or even pads. And, as I mentioned before, constipation can make bladder symptoms worse so if there is constipation, treating that, or preventing that, can also be a way to try to mitigate or reduce the severity of bladder symptoms. Once we've done all that, then we start to think about again medications to specifically treat the overactive bladder so medications for overactive bladder should be used with caution. There are different classes of medication, and they can all have side effects. Some can worsen memory, or blood pressure and it's always important to discuss the risks and benefits with your doctor. Muscle relaxants, so things that loosen and relax in the bladder include 'Mirabegron' or 'Solifenacin', and with, in addition to those, there are other medications in those classes. In addition to tablets, it's also important to keep in mind that sometimes injection of the bladder with 'botulinum toxin', which interferes with a message from the bladder nerves to the bladder muscle, can also be helpful, and doesn't require taking in a tablet that can have side effects everywhere else, but this is a very specialised test. It involves a procedure that is not without its risks and if this is something to be considered, it should be done with a urologist in mind. I would also remember that we have other specialists that specialise in bladder symptoms. So, we have urologists, but also continent nurses which can help provide very practical management strategies and reinforce some of the things that I've been talking about as well as connecting you with certain products that can help make this all safer. And then I've mentioned this briefly, but 'behavioural training' including 'voiding' when prompted, 'timed voiding' and 'habit training' can be helpful in all older adults. So, things like trying to keep the bladder in and trying not to go for certain times and training the bladder. But to be honest, this is quite difficult to implement in people living with dementia and so whilst it's been researched in other situations with older adults, we don't have very strong evidence in people with dementia, but it can be considered. So that's all for this presentation and thank you for listening. I hope you found this helpful.
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