THE NOCTURIA (OR NYCTURIA) IN ELDERLY
PERSONS WITHOUT PERIPHERAL URINARY PROBLEMS CAN BE REDUCED OR ABOLISHED WITH AN
ANTISTRESS DRUG THERAPY? PRELIMINARY REPORT ON 7 CASES TREATED WITH
ANTIDEPRESSANT-ANTISTRESS DRUGS.
Renato COCCHI, a neurologist and a medical
psychologist.
(Other cases of nocturia treated by antistress drugs)
Summary.
In seven patients (5 F and 2 M; average
age 68 years at first consultation, with 57-79 years range) all suffering from
nocturia, it resulted that the nocturia messed by modulating the stress
reactions by drugs, when considering as normal null or one awakening every
night. In four cases out of seven the sleep had no more breakdowns. The
nocturia is a trouble of the elderly, from nighttime parasympathetic
overstimulation of brain origin, probably linked to the stress of aging. In its
turn it gets out to an increase of the same stress condition, just by altering
the sleeping-waking rhythm. By this away it increases the fall frequency,
sometimes with traumas, and it induces reduced vitality during the day.
Key words: Elderly, nocturia, stress,
nighttime awakening, fall, trauma, vitality, drug therapy.
Drug modulation of stress reactions
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Recently, following an observation of a physician
colleague, my attention kept at a curious fact. His elderly wife with
depression and tinnitus, during the antidepressant-antistress therapy I
prescribed, missed the need to get up often every night, to go to the bathroom
to urinate (See the case no. 5).
A specific question to other elderly persons
who recently came to checkups between November and December 2004, led to track
down other six similar cases
Introduction.
The nocturia (or, the nycturia) is the excessive
need to urinate during the night (at least two waking up again for this
purpose), in particular in elderly people, but it does not occur in same age
persons (Weiss and Blaivas, 2000).
In 2004 this symptom had a particular
investigation in off family situations, rest houses or hospitals, mainly in
relationship to falls and to possible following traumas.
In rest houses for elderly, the residents
have a meaningful risk to fall even linked to the nocturia (Hui-Chi, 2004).
Following a hospital investigation
lasting 13 weeks, it appeared that the half the falls went with evacuation
needs, and they were more common in patient with over 65 years. The falls from
voiding needs have a greater risk to set up subsequent lesions (Hitcho and
coll., 2004).
In an investigation lasted three years, the
most falls in hospital (73.5%) occurred in hospitalization rooms; Other 20% to
the floor between the room and the bath, or in the bath (Von Renteln-Kruse and
Krause, 2004).
It follows on that from the 20% to the 50% of
the falls in the hospital or in rest houses are due to evacuation needs, mainly
to urinate during the night, with risks of even burden traumas.
Various conditions favour these accidents.
The need to urinate more of eight times daily and to go quickly to the bathroom
for urgency to urinate, during the night, are among first ones. The nocturia
has to be added to them, as an awakening for the need to empty the bladder two
or more times every night.
Mainly in its nighttime occurrence, this is
a problem that we tried to resolve. So, by drugs acting on the bladder detrusor
(low dosing tricyclic antidepressants, or oxybutyrine hydrochloride, or
tolterodine tratrate or with desmopressin acetate, a synthetic analogous of the
natural antidiuretic hormone).
In the case histories here presented, all
the patients were still living in their families.
Case histories.
1. F, 77 years old at the first examination,
suffering from not familiar maniac-depressive disorder, since about 45 years,
with onset after delivery. April 2004: I saw her fort the firts time, being in
a depressive phase, in treatment with lithium carbonate, fluoxetin and
triazolam.
She is waking up 2-3 times every night to go
to the bath room to urinate.
She had her last checkup on December 2004:
Since eight days she turned back in the maniacal phase.
At the moment she reverted to the euphoria,
she was taking a regimen with lithium carbonate 300mg, carbamazepine 200mg,
clomipramine 25mg, oxazepam 15 mg, clothiapine 10mg, clonidine 0.075mg,
amantadine 50mg.
Since many months she had 0-1 nocturia
episodes every night.
2. M, 57 years at the first consultation, he
shows results of an ischemic attack in the right half-brain, with paralysis to
the left superior limb and paresis of the left inferior limb.
I visited him on July 2003 for continuous
pain of the left shoulder, only reducible with analgesic drugs, but not with
acupuncture. I hypothesized a thalamic pain. He needs to get up 2-3 times every
night to urinate. I prescribed this drug therapy (daily doses, by the oral
via): Glutamine 125mg; A-adenosil-l-methionine (SAMe) 100mg; pyridoxine 150mg;
carbamazepine 200mg; creatine 2000mg; chlomipramine 20mg; bromazepam 1mg.
The third decade of November 2004: The last
checkup. He is taking drug therapy with Amitriptyline + perphenazine 25mg +
2mg; Glutamine 62.5mg; SAMe 100mg; Creatine 2000mg; Carbamazepine 300mg;
bromazepam 1mg. At night he sleeps at least six hours and half continuous
sleeping. He does not more need to get up to urinate.
3. F, 63 years old at the first
consultation, with problems of the eyes, atypical anxious depression. In the
first decade of September 2004, she had the first visit when she was taking 2mg
lorazepam daily. She was falling asleep late and woke up early, about five in
the morning. Every night she woke twice to go in the bathroom. Her initial
therapy had glutamine 125mg; pyridoxine 75mg; carbamazepine 100mg;
amitriptyline 6mg; lorazepam 0.5mg.
In the first decade of December, she did a
checkup after three months of drug therapy, which varied by increasing
amitriptyline to 10mg daily. She did not need to get up to urinate during all
night.
4. F, 76 years old at the consultation on
January 1996, a widow and the mother of the present author, lived alone since
12 years, she met weekly her son and her daughter. She was suffering from of
senile depression with relapses 2-3 times every year, because she stopped the
drugs when well off. Currently she has gone to live with the daughter, who will
take care of the regular taking of the drugs. Her regimen is now amitriptyline
16.50mg + chlordiazepoxide 8.5mg. When she stopped the therapy, she had to get
up 4-5 times every night to urinate. In therapy she woke up 1-2 times every
night.
The final checkup, on November 2004, did not
show any dementia signs. After eight years of drug therapy, currently with
glutamine 125mg, amitriptyline 5mg + chlordiazepoxide 5mg, lorazepam 1.25mg, a
polyvitaminic compound with mineral salts once for week, she did not have
anymore depressive relapses. Since at least 6-7 years she not has any need to
get up at night to urinate.
5. F, 66 years old, a wife of a general
medicine physician, she at the first consultation in the third decade of
September 2004. She is suffering from an intermittent tinnitus, which started
five months before. Now she is depressed and anxious, besides poorly convinced
in favour of the psychodrugs use. She is taking 0.167mg delorazepam and 150mg
pyridoxine, with null results. She has a bad sleep even because she is lifting
every half an hour to urinate. The husband, as a physician, checked the amount
of the nighttime urine, which came even to 2800ml in total.
I prescribed therapy of glutamine 125mg;
pyridoxine 75mg; carbamazepine 100mg; amitriptyline 10mg; delorazepam 0.334mg.
The last checkup occurred in the third
decade of December 2004, after 98 days of drug therapy. She much improved the
anxiety and the depression, unchanged or slightly diminished the tinnitus.
During the preceding checkup, the carbamazepine increased to 200mg. She is
sleeping well and does not need to get up at night to urinate.
6. M, 57 years at the first
examination he acted in the second decade of September 2004 for subjective
vertigoes, irritability and memory deficits. He has to wake at least three
times every night to urinate. Already in therapy with fluoxetin and triazolam
and levopropionilcarnitine. I prescribed: Glutamine 125mg; 5-hydroxitriptophano
50mg; pyridoxine 75mg; amitriptyline 6mg; oxazepam 7.5mg.
The second checkup in the second decade of December
2004, with unchanged therapy showed that the nocturia was then 0-1 episode
every night.
7. F, of 79 years at the first consultation,
asked for senile anxious and reactive depression, with asthenia. She is waking
3-4 times every night to go in bathrom to urinate.
Initial therapy: Glycine 150 [mg] (in
Biotassina TM), Vit B1-B6-B12 125mg + 125mg + 0.5mg, amitriptyline +
perphenazine 10mg + 2mg, delorazepam 0.5mg.
The second decade of December 2004, the
second checkup, after having previously substituted the glycine with the
glutamine 250mg, during the first checkup. Now, the nocturia episodes sum 0-1
every night.
Tab. 1: Summary of the drugs (daily doses,
by the oral via) and results.
|
Drug |
Dosing (mg) |
No. of patients |
||
|
Glutamine |
62.75-250 |
6 |
||
|
Pyridoxine |
75-150 |
4 |
||
|
Carbamazepine |
100-300 |
4 |
||
|
Amitriptyline |
6-25 |
5 |
||
|
Chlomipramine |
10-25 |
2 |
||
|
Perphenazine |
2 |
2 |
||
|
Oxazepam |
7.5-15 |
2 |
||
|
Lorazepam |
0.5-1.25 |
2 |
||
|
Delorazepam |
0.334 |
2 |
||
|
Bromazepam |
1 mg |
1 |
||
|
Chlordiazepoxide |
5 |
1 |
||
|
Lithium carbonate |
300 |
1 |
||
|
Amantadine |
50 |
1 |
||
|
Clothiapine |
10 |
1 |
||
|
Clonidine |
0.075 |
1 |
||
|
S-adenosil-l-methionine |
100 |
1 |
||
|
Creatine |
2000 |
1 |
||
|
5-hydroxi-triptophan |
50 |
1 |
||
|
Glycine (in Biotassina (R) |
150 |
1 |
||
|
Vit. B1+B6+B12 |
125+125+0.5 |
1 |
||
|
|
||||
|
Total of drugs |
20 // Average per patient: 5.7 |
|||
|
|
||||
|
Results on the nocturia |
Disappearance |
7 out of 7 = 100% |
||
|
Nightime awakenings |
Disappearance |
4 out of 7 = 57.14 % |
||
Nocturia is not more present in seven cases
out seven and in four cases out of seven there is not anymore need to get up to
urinate. The drug therapy was individually tailored.
Discussion.
Already from the title it would seem to
exclude the so-called "overactive bladder" as a peripheral urinary
problem, not because there is not an overactive bladder, but because, as for
me, it is not a primary problem. Even it would be the result of a fluctuating
parasympathetic outflow coming from the brain, as stress reaction. For the
nighttime bedwetting the brain implication is not a new datum (Von Gontard and
coll., 2001), but nighttime bedwetting and nocturia are not the same urinary
trouble.
No patient, of the rest, did mention a
similar diagnosis during the first consultation.
In the second place, this result had not
looked for, but it was incidentally reported for first time by a physician
colleague, as particularly sensitized to his wife trouble. Then it had
systematic investigation in patients who came to the checkup between November
and December 2004. This is the reason of the anecdotal report on these first
seven cases.
The datum, which five cases out of seven are
women, by now it doesn't want to say anything. It doesn't allow to affirm that
it means a specific prevalence of this symptom in the female gender. It could
be simply creditable to the greater easiness of the women, even elderly ones,
to have depressive pathology. Otherwise, it could even be truly casual.
In all these seven patients I prescribed at
least a tricyclic antidepressant, sometimes by replacing the antidepressant
previously taken. The peripheral anticholinergic (antispasmodic) action of the
tricyclic antidepressant may have contributed to the improved control on the
voiding of the bladder, by an action on the detrusor muscle. Personally, for
these cases, I am not sure of the efficacy of such an action, as it is also
known from the literature on this matter (Pontari, 1997).
Other used antispasmodics include the
oxibutynine as an inhibitor of the acetylcholine and the tolterodine tartrate,
as an antagonist of the acetylcholinergic muscarinic receptor (Anderson, 2002).
Any of them have been taken by these patients.
Different the action elicited by the
desmopressin acetate, a synthetic analogue of the natural antidiuretic hormone,
on the nocturia. By reducing the urinary outflow, it reduces the bladder
filling and the emptying stimulus (Asplund and coll., 1999; Mattiasson and
coll., 2002; Lose et al., 2003, Rembratt, Andersson and Norgaard, 2003). In
this way it allows longer sleeping times and it reduces the stress from the
broken sleep, which strikes again on the life and on the daily activity
(Kobelt, Borgstrom, and Mattiasson, 2003). None of these patients had used the
desmopressin acetate.
Since I acted on the depression, with the
tricyclics, the 5-hydroxitriptophan and the SAMe, and on the stress reactions
with the benzodiazepines, the glutamine, the pyridoxine and the carbamazepine,
the result on the stress was surely wider. Moreover, it found, as an effect not
looked for, the reduction within the limits of the normalcy, or the
disappearance of the awakenings for the nocturia.
Conclusions.
The nocturia, as awakening out by the need
to urinate, is a trouble of the elderly, probably linked to stress from aging.
In its turn, it drives to an increase of the stress condition, by making worse
the sleeping-waking rhythm. By this way it increases the falling frequency,
even with damage, and less vitality during the day.
In the seven cases here reported we saw that
by modulating with drugs the stress reactions, the nocturia is missing,
considering as normal a nighttime awakening. In four cases out seven no
nighttime awakenings persisted.
(Other cases of nocturia treated by antistress drugs)
References.
Andersson, K.E. The pharmacological treatment
of nocturia. BJU Int., 2002, 90 Suppl 3: 25-27.
Asplund R, , Sundberg B, Bengtsson P. Oral
desmopressin for nocturnal polyuria in elderly subjects: a double-blind,
placebo-controlled randomized exploratory study. BJU Int 1999, 83: 591-595.
Hitcho EB, Krauss MJ, Birge S, Claiborne
Dunagan W, Fischer I, Johnson S, Nast PA, Costantinou E, Fraser VJ.
Characteristics and circumstances of falls in a hospital setting: a prospective
study. Journal of General Internal Medicine, 2004, 19::732-739.
Hui-Chi H. A checklist for assessing the
risk of falls among the elderly. Journal of Nursing Research; 2004,12:131-142.
Kobelt G, Borgstrom F, Mattiasson A.
Productivity, vitality and utility in a group of healthy professionally active
individuals with nocturia. BJU Int., 2003 91: 190-195.
Lose G, Lalos O, Freeman RM, van Kerrebroeck
P and The Nocturia Study Group. Efficacy of desmopressin (Minirino(r)) in the
treatment of nocturia. A double-blind placebo-controlled study in women. Am J
Obstet Gynecol., 2003, 189: 1106-1113.
Mattiasson A, Abrams P, Van Kerrebroeck P,
Walter S, Weiss J. Efficacy of desmopressin in the treatment of nocturia: a
double-blind placebo-controlled study in men. BJU Int. 2002, 89: 855-862.
Pontari, M. Interstitial Cystitis Update.
Infect Urol 1997,10:75-79.
Rembratt A, Andersson K-E, Norgaard JP.
Desmopressin in elderly patients with nocturia: short-term safety and effects
on urine output, sleep and voiding Patterns. BJU Int., 2003, 91: 642-646.
Von Gontard A, Schmelzer D, Seifen S, Pukrop
R. Central nervous system involvement in nocturnal enuresis: evidence of
general neuromotor delay and specific brainstem dysfunction. J Urol., 2001,
166: 2448-2451.
Von Renteln-Kruse W, Krause T. .Fall events
in geriatric hospital in-patients. Results of prospective recording over a 3
year period. Gerontology and Geriatrics. 2004, 3: :9-14.
Weiss JP, Blaivas JG. Nocturia. J Urol.,
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Posted on Internet on 24 December 2004. Copyright by Renato Cocchi, 2004.
Author's address: Dr Renato COCCHI, via Rabbeno,3
42100 Reggio Emilia
renatococchi@libero.it
Drug modulation of stress reactions
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