Behavioral therapy utilizing prompted voiding is the most appropriate management of this patient. This patient's incontinence may be due to multiple factors, including structural and functional causes complicated by her cognitive impairment and decreased mobility. Prompted voiding involves regularly asking the patient to report on incontinence, asking the patient if he or she needs to void, providing assistance with access to the bathroom, and praising the patient for continence. This technique has been shown to reduce urinary incontinence in older patients who have caregivers capable of working with them, such as this one, as well as those residing in assisted-care facilities. This intervention is also usually timed so that prompted voiding occurs before accumulation of a large volume of urine in the bladder, reducing the likelihood that incontinence will occur. With active and consistent caregiver involvement, timed and prompted voiding can help achieve improved bladder control.

Antimuscarinic agents are used to decrease urgency, frequency, or incontinence in overactive bladder with urge incontinence. Adverse effects are common, however, including constipation, dry mouth, dizziness, and confusion, and older patients are at greatest risk for adverse consequences. Therefore, an antimuscarinic agent would not be an appropriate therapeutic choice in this older patient with cognitive impairment.

Pelvic floor muscle training is effective in reducing incontinence but requires active participation by the patient. Although training is implemented by physical therapists or advanced practice nurses, both pelvic floor muscle and bladder training require intact cognition and the ability to self-manage and self-sustain a training regimen and are therefore unlikely to be effective in this patient with dementia.

Systemic estrogen therapy has not been shown to alleviate urinary incontinence and may worsen symptoms. It is also associated with increased cardiovascular risks when initiated in women more than 10 years post-menopause.

Attention to skin care and use of absorptive products with frequent changes are extremely important in preventing skin breakdown in older patients with incontinence. A review of modifiable factors is also helpful, including medication use, mobility issues, weight reduction, and caffeine reduction.