Elder Care Interprofessional Provider Sheets

Nocturia in Older Adults

Jorge Camilo Mora, MD, MPH, Department of Geriatrics, Cleveland Clinic Florida

November 2017

TIPS FOR DEALING WITH NOCTURIA
  • Don't underestimate the importance of nocturia. It can have a major effect on quality of life for patients and their families, and nighttime bathroom use poses a risk of falls.
  • When evaluating a patient with nocturia, ask about medical conditions that might be contributing (Table 2) because treating those conditions may lessen nocturia, as well as asking about personal or family stress resulting from nocturia.
  • For patients with lower urinary tract symptoms attributable to prostate enlargement or other urologic or gynecologic abnormality contributing to nocturia, treat those conditions or refer to specialty care for treatment.

Nocturia, defined as voiding at least twice per night that interrupts sleep, is a common complaint in older adults. The prevalence among those 70 years and older is reported to be 69-93% in men and about 75% in women. Because it is so common, clinicians often dismiss nocturia as a normal consequence of aging and provide limited advice on how to deal with it.

The effects of nocturia on quality of life, however, can be profound. It can affect personal relationships due to lack of sleep and associated fatigue. Nocturia can alter self-age concept ("It makes me feel old"), and can lead to depression. Nocturia can also be dangerous, as falls may occur during nighttime awakenings and result in hip fractures or even death. Nighttime awakenings associated with nocturia can affect the sleep of family members and bed partners. It is not surprising, therefore, that nocturia is cited among the reasons why older adults are admitted to care homes.

Table 1. Some Factors That Contribute to Nocturia in Older Adults
Age-associated changes

 
Decreased ability to postpone urination  
Decreased bladder compliance  
Decreased functional bladder capacity
Decreased maximum urinary flow rate
Detrusor overactivity
Increased post-void residual volume
Increased urine production at night
Increased nocturnal catecholamine levels
Increased nocturnal natriuretic peptide levels
Increased nocturnal sodium excretion
Decreased nocturnal antidiuretic hormone levels

The cause of nocturia in older adults is multi-factorial. Age-related changes in the urinary system along with a variety of hormonal changes (Table 1) contribute to nocturia. In addition, medical conditions and medications can increase urine production or predispose to nighttime awakenings and thus increase the risk of nocturia (Table 2). Psychological conditions (e.g., depression and family stress) may also contribute to nighttime awakenings.

Table 2.  Conditions and Medications Associated with Nocturia
Medical Conditions

Diabetes mellitus      
Heart failure 
Hypertension
Obstructive sleep apnea
Prostate enlargement/Prostate cancer      
Recurrent cystitis
Restless Leg Syndrome
Spinal stenosis
Untreated depression

Medications Antihistamines
Beta blockers
Calcium channel blockers
Cholinesterase inhibitors
Diuretics taken in the evening
Selective serotonin reuptake inhibitors
Statins

Evaluation

History and physical are aimed at identifying medical conditions and medications that predispose to nocturia (Table 2) and which, if treated, may lead to resolution of the problem. Check renal function, urinalysis, serum glucose, and post-void residual urine volume. Ask about patterns of fluid intake and the presence of other urinary complaints. A voiding diary can help characterize typical daily timing and volume of voids, episodes of incontinence, and the frequency and volume of fluid intake. Treatment (Table 3) can then be initiated, and the diary can serve as a baseline.

Non-Pharmacologic Treatment

Avoidance of nighttime fluid intake, including alcohol and caffeine, may have benefit, as may voiding before bed. The use of compression stockings and afternoon leg elevation can decrease fluid retention and result in less nighttime urination. Moderate daytime exercise, reducing non-sleep time spent in bed, and keeping a warm bed to decrease cold-induced diuresis have all been shown to improve sleep quality. These approaches to treatment are rarely effective alone, however, and medications are frequently needed.

Pharmacotherapy

For patients with nocturia related to prostate hyperplasia, alpha blockers and 5-alpha reductase inhibitors may be helpful. Persistent symptoms may warrant urology referral.

For those with nocturia related to overactive bladder (i.e., urgency with a decreased ability to store urine), anti-muscarinic agents such as darifenacin, oxybutynin, tolterodine, trospium, and solifenacin can be effective. Their anticholinergic side effects, however, are often a problem for older adults, and they should be used with caution. Indeed, the Beers criteria state that these drugs should be avoided in older adults whenever possible.

Desmopressin nasal spray (Noctiva) was recently approved by the FDA for treating nocturia in adults who awaken at least 2 times/night to urinate. However, this drug can cause severe hyponatremia, resulting in an FDA Black Box Warning. The 2015 American Geriatric Society's Beers list gives a strong recommendation against prescribing this medication to older adults. It is also contraindicated in patients taking loop diuretics or glucocorticoids, and with glomerular filtration rates <50 ml/min.

Diuretics such as hydrochlorothiaizide can be useful. They are a good choice for patients who have concomitant hypertension. When used to treat nocturia, the diuretic should be taken at least 8 hours before bedtime. It will prevent urine accumulation in the bladder before the early sleeping hours. 

Other approaches to treating overactive bladder include injecting botulinum toxin into the detrusor muscle via cystoscope (successful in selected patients) and posterior tibial nerve stimulation (reduces nocturia episodes by 25%). These interventions may be appropriate for patients who are not responsive to other treatments.

Table 3. Approach to Treatment of Nocturia
General Approach
Non-Pharmacologic
Pharmacologic
  • Address underlying medical problems
  • Check for medications that contribute to nocturia
  • Refer to specialist (urologist for prostate hyperplasia, sleep specialist for obstructive sleep apnea, etc.) as needed
  • Avoid caffeine and alcohol
  • Afternoon leg elevation
  • Avoid nighttime fluid intake
  • Compression stockings
  • Moderate exercise
  • Pelvic floor exercises (Kegel)
  • Posterior tibial nerve stimulation
  • Reduce non-sleep time in bed
  • Warm bed
  • Weight loss
  • Alpha blockers and 5-alpha reductase inhibitors for prostate hyperplasia
  • Anti-muscarinics for overactive bladder
  • Botulinum toxin in selected refractory cases
  • Desmopressin
  • Diuretics
  • Vaginal estrogens

References and Resources

  • Asplund R, et al. Nocturia, depression and antidepressant medication. BJU Int. 2005 Apr;95(6):820-3. 
  • Bosch, JL. Weiss, J. The prevalence and causes of nocturia. J Urol. 2010;184(2):440-6. 
  • FDA.  Summary review of regulatory action (Desmopressin/Noctiva).
  • Fujimoto M, Hosomi K, Takada M. Statin-associated lower urinary tract symptoms: data mining of the public version of the FDA adverse event reporting system, FAERS. Int J Clin Pharmacol Ther. 2014 Apr;52(4):259-66. 
  • Moossdorff-Steinhauser HF, Berghmans B. Effects of percutaneous tibial nerve stimulation on adult patients with overactive bladder syndrome: a systematic review. Neurourol Urodyn. 2013 Mar;32(3):206-14. 
  • Varilla V, et al. Nocturia in the elderly: a wake-up call. Cleve Clin J Med.  2011; 78:757-64.

Acknowledgement: Jerry Ciocon, M.D. was a co-author on a previous edition of Elder Care on nocturia