Vitamin D and incident urinary incontinence in older adults.

BACKGROUND/OBJECTIVES: The aim of this study is to determine whether vitamin D status is associated with incident urinary incontinence (UI) among community-dwelling older adults. SUBJECTS/METHODS: The University of Alabama at Birmingham Study of Aging is a prospective cohort study of community-dwelling Medicare enrollees. Standardized assessment of UI was conducted using the validated Incontinence Severity Index. The analysis of 25-hydroxyvitamin D [25(OH)D] levels was performed on stored baseline sera. UI was assessed every 6-12 months for up to 42 months. The analyses included multivariable logistic regression and Cox proportional hazard models. RESULTS: Of 350 participants (175 male, 147 black, mean age 73.6±5.8), 54% (189/350) were vitamin D deficient (25(OH)D <20 ng/ml) and 25% (87/350) were vitamin D insufficient (25(OH)D: 20 ng/ml to <30 ng/ml). Among the 187 subjects with no UI at baseline, 57% (107/187) were vitamin D deficient and 24% (45/187) were vitamin D insufficient. A total of 175 of the 187 subjects had follow-up evaluation for incident UI over 42 months, and incident UI occurred in 37% (65/175). After adjustment, cumulative incident UI at 42 months was associated with baseline vitamin D insufficiency (P=0.03) and demonstrated a trend association with deficiency (P=0.07). There was no association between baseline vitamin D status and the time to incident UI. CONCLUSIONS: These preliminary results support an association between vitamin D and incident UI in community-dwelling older adults. Future studies may target specific at-risk groups, such as men with BPH or women with pelvic floor disorders for evaluation of the impact of vitamin D supplementation on urinary symptoms.

Impact of behaviour and lifestyle on bladder health.

Bladder conditions, including UTI, UI, and bladder cancer, are highly prevalent and affect a wide range of populations. There are a variety of modifiable behavioral and lifestyle factors that influence bladder health. Some factors, such as smoking and obesity, increase the risk or severity of bladder conditions, whereas other factors, such as pelvic floor muscle exercise, are protective. Although clinical practice may be assumed to be the most appropriate ground for education on behavioral and lifestyle factors that influence bladder health, it is also crucial to extend these messages into the general population through public health interventions to reach those who have not yet developed bladder conditions and to maximize the prevention impact of these behaviors. Appropriate changes in these factors have the potential for an enormous impact on bladder health if implemented on a population-based level.

Behavioral therapy to treat urinary incontinence in Parkinson disease.

OBJECTIVE: To assess the feasibility and efficacy of exercise-based behavioral therapy to treat urinary incontinence (UI) in older adults with Parkinson disease (PD). METHODS: Participants with PD ≥50 years with ≥4 UI episodes on a 7-day bladder diary were recruited from movement disorders clinics. In 5 visits over 8 weeks, participants learned pelvic floor muscle exercises using computer-assisted EMG biofeedback, and bladder control strategies including urge suppression. Bladder diaries were used to reinforce techniques and monitor the primary outcome of UI frequency. Secondary outcomes included additional reporting of lower urinary tract symptoms, symptom bother, and quality of life (QOL) using the International Consultation on Incontinence Questionnaire for overactive bladder (ICIQ-OAB). RESULTS: Twenty participants were enrolled (90% male, age 66.5 ± 6.2 [mean ± SD], with PD for 6.9 ± 5.4 years) and 17 completed the study. The median (interquartile range) weekly frequency of baseline UI episodes was 9 (4-11) and following intervention was 1 (0-3), representing an 83.3% reduction (45.5-100.0, p = 0.0001). QOL scores on the ICIQ-OAB improved from 71.1 ± 23.9 to 54.7 ± 15.4 (p = 0.002). CONCLUSIONS: In this uncontrolled pilot study of an exercise-based, biofeedback-assisted behavioral intervention, older participants with PD demonstrated statistically significant and clinically meaningful reductions in frequency of UI and improvement in QOL. Randomized controlled trials to assess behavioral therapies for UI in patients with PD are warranted. CLASSIFICATION OF EVIDENCE: This study provides Class IV evidence that exercise-based, biofeedback-assisted behavioral intervention can reduce UI frequency in patients >50 years old with PD.

The association of nocturia with incident falls in an elderly community-dwelling cohort.

OBJECTIVE: The aim of this study was to examine the association of nocturia with incident falls in a population-based sample of community-dwelling elderly persons. METHODS: The University of Alabama at Birmingham Study of Aging is a prospective cohort study of 1000 community-dwelling older adults in the USA designed to examine factors associated with impaired mobility. Subjects were recruited from a stratified, random sample of Medicare beneficiaries to include equal numbers of black women, black men, white women and white men. Nocturia was assessed at baseline and falls were assessed at baseline and every 6 months for a total of 36 months of follow-up. RESULTS: A total of 692 individuals (mean age 74.5 +/- 6.2, 48% female, 52% black) did not fall in the 12 months prior to baseline. Of these 692, 214 (30.9%) reported falling at least once during the subsequent 3 years. In unadjusted analysis, three or more nightly episodes of nocturia were associated with an incident fall [RR = 1.27, 95% CI (1.01-1.60)]. After multivariable logistic regression, three or more episodes of nocturia were associated with an increased risk of falling [RR = 1.28, (1.02-1.59)]. DISCUSSION: In a racially diverse, community-based sample of older men and women who had not fallen in the previous year, nocturia three or more times a night was associated in multivariable analysis with a 28% increased risk of an incident fall within 3 years. While this study has several advantages over previous reports (longitudinal follow-up, performance-based measures of function, population-based sampling), causality cannot be ascertained. Further research is needed to ascertain the impact of treatments to reduce nocturia as part of a multi-component programme to reduce fall risk.

Practical aspects of lifestyle modifications and behavioural interventions in the treatment of overactive bladder and urgency urinary incontinence.

Behavioural interventions are effective treatments for overactive bladder (OAB) and urgency urinary incontinence (UUI). They are in part aimed at improving symptoms with patient education on healthy bladder habits and lifestyle modifications, including the establishment of normal voiding intervals, elimination of bladder irritants from the diet, management of fluid intake, weight control, management of bowel regularity and smoking cessation. Behavioural interventions also include specific training techniques aimed at re-establishing normal voiding intervals and continence. Training techniques include bladder training, which includes a progressive voiding schedule together with relaxation and distraction for urgency suppression, and multicomponent behavioural training, which, in conjunction with pelvic floor muscle (PFM) exercises, includes PFM contraction to control urgency and increase the interval between voids. Guidelines for the conservative treatment of OAB and UUI have been published by several organisations and the physiological basis and evidence for the effectiveness of behavioural interventions, including lifestyle modifications, in the treatment of OAB and UUI have been described. However, many primary care clinicians may have a limited awareness of the evidence supporting the often straight-forward treatment recommendations and guidance for incorporating behavioural interventions into busy primary care practices, because most of this information has appeared in the specialty literature. The purpose of this review is to provide an overview of behavioural interventions for OAB and UUI that can be incorporated with minimal time and effort into the treatment armamentarium of all clinicians that care for patients with bladder problems. Practical supporting materials that will facilitate the use of these interventions in the clinic are included; these can be used to help patients understand lifestyle choices and voiding behaviours that may improve function in patients experiencing OAB symptoms and/or UUI as well as promote healthy bladder behaviours and perhaps even prevent future bladder problems. Interventions for stress urinary incontinence are beyond the scope of this review.

Psychological improvements associated with behavioral and drug treatment of urge incontinence in older women.

The purpose of this study was to explore changes in psychological distress associated with behavioral treatment and drug treatment for urge incontinence in community-dwelling older women. Participants were 197 ambulatory, nondemented women (aged 55 years or older) with persistent urge urinary incontinence. Participants were patients in a randomized clinical trial comparing biofeedback-assisted behavioral treatment, drug treatment with oxybutynin chloride, and a placebo-control condition. Psychological distress was measured before and after treatment using the Hopkins Symptom Checklist (SCL-90-R). Multivariate and univariate analyses of variance showed that the two treatment groups and the control group had similar significant improvements on the nine subscales and the global severity index. Analysis of individual SCL-90-R subscale scores revealed trends suggesting that behavioral treatment tended to produce the largest improvements. The reductions of distress were not correlated consistently with reduction of incontinence. The results of this study showed that psychological distress was significantly reduced after treatment, regardless of the type of treatment.

Reliability assessment of the bladder diary for urinary incontinence in older women.

BACKGROUND: A reliable method of documenting the frequency of incontinent episodes is essential for assessment of treatment outcome in both clinical practice and research studies. Bladder diaries, completed prospectively by the patient, have been widely used for this purpose. This study investigated the number of consecutive days of bladder diary reports of incontinence frequency necessary to obtain adequate internal consistency (reliability). METHODS: Participants were 214 community-dwelling women, aged 40 to 90 years, with a history of stress, urge, or mixed urinary incontinence, persisting at least 3 months with a frequency of two or more episodes of urine leakage per week. Each participant kept a 14-day bladder diary documenting the time and circumstances of each incontinence episode. RESULTS: The mean age of participants was 63.5 years; 16.9% were African American. Women with predominantly urge incontinence (n = 138) reported a daily frequency of 2.1 incontinent episodes. Although there was a statistically significant difference between Week 1 (2.4 episodes per day) and Week 2 (2.0 episodes per day; p < .0001), five days were necessary to obtain an internal consistency of .90 for Cronbach's alpha. Women with predominantly stress incontinence (n = 76) had no statistical difference between Week 1 and Week 2 in frequency of incontinence, reporting an average 2.2 accidents per week in Week 1 and 2.1 in Week 2. However, 7 days of bladder diary were required before adequate internal consistency was reached. CONCLUSION: Seven consecutive days of bladder diary provides a stable and reliable measurement of the frequency of incontinence episodes in community-dwelling women.

Measurement of postvoid residual urine with portable transabdominal bladder ultrasound scanner and urethral catheterization.

The study was a clinical series of 95 ambulatory women with urinary incontinence. After voiding, each subject was scanned with a BladderScan BVI 2500, then catheterized for postvoid residual (PVR) and then scanned again. The mean PVR obtained by ultrasound was 49 ml, significantly larger than the mean PVR of 32 ml obtained by catheterization. Correlation analysis showed that the difference was not related to age, weight, body mass index, parity, pelvic prolapse or prior incontinence surgery, but was associated with prior hysterectomy and uterine prolapse. Regression analysis revealed that the difference was independently related to prior hysterectomy only. Postcatheterization ultrasound detected a mean of 22 ml, suggesting that the difference between the PVR values may be due to residual urine not removed by catheterization. Finally, ultrasound had a sensitivity of 66.7% and a specificity of 96.5% in detecting PVR > or = 100 ml. Portable ultrasound scanners are quick, easy to use, reasonably sensitive, and very specific for determining elevated PVR.

Combined behavioral and drug therapy for urge incontinence in older women.

OBJECTIVE: The purpose of this study was to examine the effects of combining behavioral treatment and drug treatment for urge incontinence in community-dwelling older women. DESIGN: Modified crossover design (extension of a randomized clinical trial). Eligible subjects were stratified according to type and severity of incontinence and randomized to behavioral treatment, drug treatment, or a control condition (placebo). Subjects not totally continent or not satisfied after 8 weeks of a single treatment were offered the opportunity to cross over into combined therapy. SETTING: A university-based outpatient geriatric medicine clinic. PARTICIPANTS: Subjects in the clinical trial were 197 ambulatory, nondemented, community-dwelling women (age 55 years or older) with persistent urge urinary incontinence. Thirty-five subjects participated in combined treatment. INTERVENTION: One group of subjects received four sessions (over 8 weeks) of biofeedback-assisted behavioral training followed by 8 weeks of behavioral training combined with drug therapy (oxybutynin chloride individually titrated from 2.5 mg to 15 mg daily). The second group received drug therapy first, followed by 8 weeks of drug therapy combined with behavioral training. MEASUREMENTS: Bladder diaries completed by subjects before and after each treatment phase were used to calculate change in the frequency of incontinent episodes. RESULTS: Eight subjects (12.7%) crossed from behavioral treatment alone to combined behavioral and drug therapy. Additional benefit was seen in improvement from a mean 57.5% reduction of incontinence with single therapy to a mean 88.5% reduction of incontinence with combined therapy (P = .034). Twenty-seven subjects (41.5%) crossed from drug therapy alone to combined drug and behavioral treatment. They also showed additional improvement, from a mean 72.7% reduction of incontinence with single therapy to a mean 84.3% reduction of incontinence with combined therapy (P = .001). CONCLUSIONS: This study shows that combining drug and behavioral therapy in a stepped program can produce added benefit for patients with urge incontinence.

Behavioral vs drug treatment for urge urinary incontinence in older women: a randomized controlled trial.

CONTEXT: Urinary incontinence is a common condition caused by many factors with several treatment options. OBJECTIVE: To compare the effectiveness of biofeedback-assisted behavioral treatment with drug treatment and a placebo control condition for the treatment of urge and mixed urinary incontinence in older community-dwelling women. DESIGN: Randomized placebo-controlled trial conducted from 1989 to 1995. SETTING: University-based outpatient geriatric medicine clinic. PATIENTS: A volunteer sample of 197 women aged 55 to 92 years with urge urinary incontinence or mixed incontinence with urge as the predominant pattern. Subjects had to have urodynamic evidence of bladder dysfunction, be ambulatory, and not have dementia. INTERVENTION: Subjects were randomized to 4 sessions (8 weeks) of biofeedback-assisted behavioral treatment, drug treatment (with oxybutynin chloride, possible range of doses, 2.5 mg daily to 5.0 mg 3 times daily), or a placebo control condition. MAIN OUTCOME MEASURES: Reduction in the frequency of incontinent episodes as determined by bladder diaries, and patients' perceptions of improvement and their comfort and satisfaction with treatment. RESULTS: For all 3 treatment groups, reduction of incontinence was most pronounced early in treatment and progressed more gradually thereafter. Behavioral treatment, which yielded a mean 80.7% reduction of incontinence episodes, was significantly more effective than drug treatment (mean 68.5% reduction; P=.04) and both were more effective than the placebo control condition (mean 39.4% reduction; P<.001 and P=.009, respectively). Patient-perceived improvement was greatest for behavioral treatment (74.1% "much better" vs 50.9% and 26.9% for drug treatment and placebo, respectively). Only 14.0% of patients receiving behavioral treatment wanted to change to another treatment vs 75.5% in each of the other groups. CONCLUSION: Behavioral treatment is a safe and effective conservative intervention that should be made more readily available to patients as a first-line treatment for urge and mixed incontinence.

Teaching and maintaining behavior management skills with nursing assistants in a nursing home.

This article describes a nursing staff training program in basic behavior management skills and a formal staff management system to encourage the application of these basic skills on the nursing unit. Behavioral skills training consists of a 5-hour in-service followed by three weeks of on-the-job training to ensure accurate application of behavior management skills. Following training, a staff management system is used to facilitate long-term use of the skills. Components of the staff management system include supervisory monitoring of the nursing assistants (NAs) by licensed practical nurses (LPNs), NA self-monitoring, verbal and written performance feedback, and incentives.

Nutritional status of urban homebound older adults.

The purposes of this study were to assess comprehensively the nutritional status of frail older adults living in an urban area and to identify factors associated with nutritional insufficiency. Subjects were 49 adults aged > or = 65 y followed by the Jefferson County Home Health Department. Twenty-nine percent of the women and 63% of the men had a body mass index (BMI; in kg/m2) < 24. Nineteen percent had serum albumin concentrations < 35 g/L (3.5 g/dL). More than one-half of the subjects reported symptoms of oral health problems. The key dependent variables were serum albumin concentration and BMI. In univariate analyses, a lower BMI correlated with oral symptoms, male sex, increased age, and less education. Lower serum albumin concentrations were associated with advanced age, increased dependence in Activities of Daily Living (ADL), oral symptoms, and presence of a caregiver. A stepwise multiple-regression model for BMI and serum albumin showed that predictors of low BMI were increased age, less education, difficulty in chewing, and absence of dentures. Variables in the model for lower serum albumin concentrations were sex, increased age, increased dependence in ADLs, and wearing of dentures. In a secondary analysis that controlled for age, education level, functional status, and sex, oral symptoms remained associated with lower BMI but not with lower serum albumin concentrations. This study found a high prevalence of undernutrition in urban homebound older adults and suggests that oral health disability may affect nutritional status in this population.

Behavioral interventions for incontinence in ambulatory geriatric patients.

Behavioral intervention is a group of therapies used to modify stress, urge, or mixed urinary incontinence by changing patient bladder habits or by teaching new skills. Three broad categories of behavioral treatment are reviewed: pelvic muscle exercise, biofeedback, and bladder training. The literature concerning each of these methods indicates that the treatments are effective for most community-dwelling older adults. More research is needed to identify the best methods for implementing these treatments, to explore the role of various components of treatment packages, to examine issues of durability, and to improve adherence to behavioral protocols necessary for long-term effectiveness.

Pharmacologic treatment of lower urinary tract dysfunction in geriatric patients.

Medications to treat lower urinary tract dysfunction in older adults are selected to alter specific physiologic parameters. Pharmacotherapy alone results in modest clinical improvement. Because of the high prevalence of adverse drug reactions and polypharmacy in the geriatric population, medication should be used for those conditions that do not respond sufficiently to behavioral therapy. For stress incontinence, medications with alpha-adrenergic agonist properties are the mainstay of pharmacotherapy because they increase outlet resistance. Pharmacotherapy of urinary frequency and urge incontinence aims to decrease detrusor irritability and increase bladder capacity by inhibiting cholinergic stimulation of the bladder. In addition to these medications, in postmenopausal women, estrogen seems to have an additive effect for both urge and stress incontinence. More randomized, placebo-controlled, double-blinded clinical trials are needed that compare various pharmacologic agents and combinations, as well as pharmacotherapy with other forms of treatment for lower urinary tract dysfunction.

Nocturnal enuresis in community-dwelling older adults.

OBJECTIVE: To investigate the prevalence and characteristics of nocturnal enuresis in community-dwelling older adults and to identify potential predisposing variables. DESIGN: Interview survey. SETTING: Five rural counties in northwestern Pennsylvania. PARTICIPANTS: Subjects were 3884 community-dwelling older adults aged 65 to 79 years who volunteered for a health promotion demonstration. MEASUREMENTS: The dependent variable was self-reported accidental loss of urine during sleep. Independent variables included demographic variables, self-reported disease history and symptomatology, and standardized screening instruments for depression (CES-D), dementia (MMSE), and functional status (ADLs). MAIN RESULTS: Prevalence of nocturnal enuresis was 2.1%, and was significantly higher among women (2.9%) compared with men (1.0%; P < .0001). Compared with subjects with daytime incontinence only, those with nocturnal enuresis reported greater severity and impact of incontinence on several parameters. Enuretics were more likely to have received treatment; treatment outcome, however, was significantly less successful. In univariate analyses, enuresis was significantly associated with symptoms of congestive heart failure (CHF), impairment in activities of daily living, depression, and use of sleep medications at least once per week. In stepwise logistic regression modeling, two symptoms of congestive heart failure and regular use of sleep medication entered the model. CONCLUSIONS: Nocturnal enuresis appears to be uncommon among older adults, but it may be associated with poorer therapeutic outcomes compared with the more common forms of daytime incontinence. The findings are consistent with the hypothesis that daytime fluid accumulation followed at night by mobilization of excess fluid is a contributor to enuresis in older adults.

Psychosocial issues in geriatric urology: problems in treatment and treatment seeking.

Psychological and social issues are important in geriatric urology because they affect not only the patient's ability and willingness to seek out therapy, but also their ability to benefit from it. Many older adults with problems of bladder control, such as frequency, urgency, nocturia, and incontinence are deterred from seeking treatment by factors such as social disapproval and belief that bladder symptoms are normal or untreatable. Many older adults who present for treatment experience limitations of mental status or functional ability that merit attention because they can interfere with learning, motivation, and cooperation needed for successful treatment. Strategies are described that help to address these psychosocial issues and needs in older patients.

Urinary incontinence during pregnancy in a racially mixed sample: characteristics and predisposing factors.

The objectives of the study were to assess the prevalence of urinary incontinence symptoms during pregnancy in a racially mixed sample and to identify potential predisposing variables. Five hundred and twenty-three women were interviewed in the hospital on postpartum day 2 or 3 and by telephone at 6-week follow-up. A significantly larger proportion of white women reported accidental loss of urine than did black women (62.6% vs. 46.4%; P < 0.01). A breakdown by type of incontinence indicated that the race effect was largely attributable to the significantly higher prevalence of the symptom of stress incontinence among white women (P < 0.0001). In stepwise logistic regression modeling, previous incontinence, education level, parity and nocturia were selected as the strongest predictors of incontinence in white women. Attendance at childbirth classes was the only predictor of incontinence for black women. The results raise the possibility that higher rates of incontinence among white women might be due to differences in the pelvic floor.

Self-care behaviors of older women with urinary incontinence.

1. Despite the availability of effective treatments for urinary incontinence, many women self-manage incontinence and never have it evaluated or treated. 2. The vast majority of women in this study used one or more self-care behaviors to manage their incontinence; the most frequently used behaviors were locating or staying near bathrooms when out, voiding more frequently, and wearing some type of protective garment. 3. Most women reported that incontinence was not at all or only a little difficult to manage and were satisfied with the self-care behaviors they used to manage this problem despite the fact that most of these behaviors had little or no potential to reduce or eliminate their incontinence.