The prevalence of potentially remediable urinary incontinence in frail older people: a study using the Minimum Data Set.

OBJECTIVES: To use the Minimum Data Set (MDS) to describe the frequency and correlates of potentially treatable causes of urinary incontinence among a representative sample of American nursing home residents. To describe current management practices of urinary incontinence in the same population. DESIGN: Cross-sectional study using the dataset that was part of the Health Care Financing Administration (HCFA) evaluation of the MDS. SETTING: 270 Medicaid-certified nursing homes in 10 states. PARTICIPANTS: A total of 2014 nursing home residents 60 years or older (mean = 84.3 +/- 8.7), 75.5% women, 81.9% white, who lived in a nursing home during the fall of 1990 were randomly selected to sample a fixed number of residents for each facility based on facility size. MEASUREMENTS: Incontinence was defined as the presence of at least two episodes of urinary leakage per week in the previous 2 weeks. Management techniques (toileting, pads/briefs, catheters) were those listed in the MDS. Potentially remediable causes of urinary incontinence available in the MDS were: medications (antipsychotics, antidepressants, and antianxiety/hypnotics); congestive heart failure; diabetes mellitus; pedal edema; delirium; depression; and impairments in activities of daily living (ADLs) (transferring, locomotion, dressing, toileting; bedrails; trunk restraints; and chair restraints). RESULTS: Forty-nine percent of residents were incontinent. Of these, 84.0% were managed by pads/briefs, 38.7% by scheduled toileting, 3.5% by indwelling catheter, and 1.2% by external catheter. Of the potentially reversible causes, bivariate analysis revealed associations (P < .1) with use of antidepressants, antipsychotics, and antianxiety/hypnotics; delirium; bedrails; trunk restraints; chair restraints; and ADL impairment. Dementia was also associated with incontinence (P < .1). Multivariate analysis revealed that urinary incontinence was independently associated with impairment in ADLs (OR = 4.2; CI = 3.2,5.6), dementia (OR = 2.3;CI = 1.8,3.0), restraints-trunk (OR = 1.7; CI = 1.5,2.0), chair (OR = 1.4; CI = 1.2,1.6), bedrails (OR = 1.3; CI = 1.1,1.5), and use of antianxiety/hypnotic medications (OR = .7;CI = .5,1.0) (all P < .04). CONCLUSIONS: Current management practices for urinary incontinence are inconsistent with advocated guidelines. These data also confirm the association between incontinence and several potentially remediable conditions and suggest that, even in the nursing home setting, urinary incontinence may respond to efforts to improve conditions not directly related to bladder function. This study underscores the need to examine the impact on urinary incontinence of strategies to address such conditions.

Evaluating a national assessment strategy for urinary incontinence in nursing home residents: reliability of the minimum data set and validity of the resident assessment protocol.

Evaluation of 1 million incontinent American nursing home residents is hampered by both failure to detect incontinence and logistical barriers to diagnostic testing. The nationally mandated Minimum Data Set (MDS) and Resident Assessment Protocol (RAP) were devised to address these deficiencies. Although both instruments are also used in at least 18 other countries, neither has been evaluated. Our goal was to determine the reliability of the MDS and the accuracy of the RAP in predicting the lower urinary tract cause of incontinence. We determined interrater reliability for the 13 MDS items related to urinary incontinence in 123 randomly selected residents of 13 nursing homes in 5 states; forms were completed blindly by 2 nurses from each facility who were trained for a day. The RAP was assessed in 102 representative institutionalized women by blinded evaluation of its diagnostic accuracy compared with the multichannel videourodynamic criterion standard. For the MDS, interrater reliability for incontinence of all grades was excellent (weighted kappa correlation coefficient = 0.90), although reliability was greater at the extremes of measurement than for incontinence of intermediate severity. With the exception of delirium, correlations for the 11 MDS items related to incontinence were 0.65-0.96; for 6 items, correlations were > or = 0.8. The diagnostic accuracy of the RAP, successfully administered to 80% of women, was 70%. The accuracy of the nearly identical algorithm that formed the basis for the RAP was 84%. Importantly, serious misclassifications were not observed for either the RAP or the algorithm. Although its definitions should be modified slightly, the MDS appears to be feasible and reliable when administered by trained staff. In women, the diagnostic accuracy and safety of the RAP are good-particularly when administered as instructed-but the original, sex-specific algorithm is preferable. Together, the MDS and modified RAP provide a useful, stepwise, and non-urodynamically based strategy to guide evaluation and therapy of incontinence in this setting.

Misdiagnosis of urinary incontinence in nursing home women: prevalence and a proposed solution.

Because of the high prevalence of detrusor hyperactivity with impaired contractility (DHIC) in incontinent institutionalized women, we postulated that: 1) single-channel cystometry, the most commonly used diagnostic test, would be inadequate when used alone but that 2) its accuracy could be greatly enhanced by combining it with a previously-performed stress test. To test the hypothesis, we used blinded comparison of a clinical stress test and single-channel cystometry with multichannel videourodynamic evaluation (criterion standard), a strategy designed a priori. Subjects were 97 incontinent women who were considered representative of incontinent nursing home women nationally. With cystometry alone, 9 of 37 women with DHIC (24%) were misdiagnosed as stress-incontinent vs. 1 of 25 with DH (P = .03). In each case, misdiagnosis was due to failure to recognize low-pressure involuntary bladder contractions. Combining cystometry with the stress test improved diagnostic accuracy markedly. Of the 77% of women in whom the results of both tests were congruent, all were correctly classified. When results of the two tests were discordant, neither was superior. Significantly, no woman with stress incontinence was missed by the two-test strategy, nor was anyone with detrusor hyperactivity misclassified. We conclude that in institutionalized elderly women, DHIC commonly mimics other types of urinary tract dysfunction. Thus, single-channel cystometry alone is an inadequate diagnostic test in this population. However, a strategy that combines cystometry with a clinical stress test can correctly classify the majority of such women and identify those in whom the diagnosis is less secure. Use of this simple strategy would facilitate correct diagnosis and initial treatment of most institutionalized women without referral, and also enrich the referred population with those most likely to benefit. Such an approach could significantly improve the approach to this costly and morbid condition.

[Combined arthrosis manifestation of the radial wrist joint]. / Kombiniert auftretende Arthrosen der radialen Handwurzel.

In the following study, the basal joint of the thumb and its neighboring joints of 100 anatomical specimens were inspected radiologically and macroscopically for arthrotic alterations. The comparison of the radiological and macroscopic findings showed that early arthrotic joint alterations cannot be diagnosed by radiograms. Virtually half of the specimens examined demonstrated arthrotic lesions of the basal joint of the thumb, whereas the trapezio-scaphoidal and trapezoido-scaphoidal joints were only affected in one-third of the specimens. Two-thirds of the cases with manifest arthrosis of the metacarpophalangeal joint of the thumb demonstrated additional arthrotic changes in the joints between the scaphoid, trapezium, and trapezoideum. No macroscopic evidence of arthrotic alterations in the remaining radial carpal bones were observed. The architecture of the capsular and ligamentous apparatus as well as the individual variations in the scaphoid bone have both been discussed as possible causes of these phenomena, as were polyarthrotic or secondary arthrotic processes.

Incontinence in the nursing home patient.

Prevalent, morbid, and costly, urinary incontinence in the nursing home poses a major problem for patient, caregiver, and administrator alike. In this article, the authors review the pathophysiology of incontinence in the frail elderly, and give guidelines for how to diagnose and treat this common condition.