REVIEW ARTICLE Are we shortchanging frail older people when it comes to the pharmacological treatment of urgency urinary incontinence? W. Gibson, 1 A. Athanasopoulos, 2 H. Goldman, 3 H. Madersbacher, 4 D. Newman, 5 J. Spinks, 6 J. J. Wyndaele, 7 A. Wagg 8 SUMMARY Overactive bladder and urgency incontinence are common and distressing condi- tions in older people, for which the first-line pharmacological treatment is a blad- der antimuscarinic agent. Of these, oxybutynin is often recommended in guidelines, but is associated with a higher incidence of adverse drug effects, and in particular has been suggested to have deleterious cognitive effects. Despite this, guidelines often suggest oxybutynin as first-line treatment, and insurance based healthcare systems often require oxybutynin to be used as a first-line therapy and fail before reimbursement for the cost of newer anticholinergics is authorised. We reviewed the literature of bladder antimuscarinics in older adults, using the head- ings overactive bladder, urinary frequency, urgency, urge, oxybutynin, antimuscari- nic, older, older people, and frail. In general, oxybutynin had a similar efficacy to other anticholinergic drugs, but a higher incidence of adverse drug events, in parti- cular significant yet unnoticed cognitive impairment. We conclude that oxybutynin should not be used in frail older people. Review criteria The information considered in the review was gathered with a literature search using the headings overactive bladder, urinary frequency, urgency, urge, oxybutynin, antimuscarinic, older, older people and frail. These were manually reviewed for relevant articles, specifically those relating to overactive bladder and its treatment in older people, and to the pharmacology, efficacy and adverse effect profile of oxybutynin. Message for the clinic Although commonly prescribed and recommended in guidelines, oxybutynin is associated with significantly worse adverse effects than other, more specific antimuscarinics, and its use in the frail elderly should be avoided. Introduction Urgency urinary incontinence (UUI) is common and distressing condition, and is highly prevalent in frail, older people. Many national guidelines suggest immediate-release oxybutynin as first-line pharmaco- therapy. However, this choice of drug may be associ- ated with unacceptable and hidden adverse effects. This review examines the evidence for oxybutynin in frail older people and discusses why this particular drug may not be the best choice for older patients. The overactive bladder Overactive bladder (OAB) is a chronic clinical symp- tom complex, characterised by urgency, the com- plaint of a sudden, compelling desire to pass urine, which is difficult to defer, in the absence of urinary tract infection or other obvious pathology (1,2). It is often accompanied by frequency of daytime micturi- tion, as well as nocturia, and may be associated with urinary incontinence (UI). The symptoms of OAB are not synonymous with a diagnosis of detrusor overactivity (DO). Based upon the observation of spontaneous detrusor contractions during the storage phase of micturition during uro- dynamic studies (1); only around half of patients with DO have symptoms of OAB (3) and vice versa (4). Pharmacologically, OAB symptoms can be relieved by anticholinergic agents, which are thought to act by inhibiting the M 2 and M 3 subtype of muscarinic receptors in the urinary bladder, perhaps leading to a decrease in detrusor contractions, and an alteration of sensory function during the storage phase (5). The prevalence of OAB increases with age. OAB symptoms affect approximately 20% of men and women aged ≥ 60 years (6). UI is relatively uncom- mon in those ≤ 39 years of age (women, 0.4%; men, 1.0%) but has a significantly greater prevalence in those ≥ 60 years of age (10.4% for men and 19.3% for women) and a survey in Norway showed a four- fold greater prevalence of UI in the over 90s than the under 30s (7). Urgency incontinence is the common- est cause of UI in older people. Use of oxybutynin to treat OAB Oxybutynin (4-diethylaminobut-2-ynyl-2-cyclohexyl- 2-hydroxy-2-phenylethanoate) has been used for the treatment of OAB since its introduction in the 1970s ª 2014 John Wiley & Sons Ltd Int J Clin Pract, September 2014, 68, 9, 1165–1173. doi: 10.1111/ijcp.12447 1165 1 Division of Geriatric Medicine, University of Alberta, Edmonton, AB, Canada 2 Department of Urology, Univesity of Patras, Patra, Greece 3 Cleveland Clinic, Glickman Urologic and Kidney Institute, Cleveland, OH, USA 4 Department of Neurology, Innsbruck Medical University, Innsbruck, Austria 5 Division of Urology, Penn Center for Continence and Pelvic Health, University of Pennsylvania Medical Center, Philadelphia, PA, USA 6 Court View Surgery, Rochester, UK 7 Urology and Urological Rehabilitation, University Hospital Antwerp, Antwerp, Belgium 8 Department of Medicine, University of Alberta, Edmonton, AB, Canada Correspondence to: William Gibson, Division of Geriatric Medicine, University of Alberta, Edmonton, AB, Canada Tel.: +1 780 492 0133 Fax: +1 780 492 2874 Email: wgibson@ualberta.ca Disclosure WG has received speaker fees from Astellas and Pfizer. AA is or has been an investigator, lecturer, and consultant for pharmaceutical companies producing or developing drugs for lower urinary tract symptoms, including Pfizer, Astellas, UCB, Lilly, Allergan and Ranbaxy. JS has received payments for speaking on behalf of or advising Pfizer, Astellas and AMco. AW has received financial support from Atellas, Pfizer, SCA and Watson Pharma for consulting,