Urinary incontinence and poor functional status in fragility fracture patients: an underrecognized and underappreciated association

Factors associated with health-seeking for urinary incontinence in Hong Kong Chinese women: a cross-sectional study

INTRODUCTION AND HYPOTHESIS

To explore levels of urinary incontinence (UI) knowledge among Hong Kong Chinese women and the factors affecting patients' help-seeking behavior.

METHODS

Chinese women with age ≥ 40 years who attended General Out-patient Clinics between May 1 and June 30, 2022, were invited to complete the questionnaire. The questionnaire consisted of four sections: (1) demographic data, (2) knowledge of UI (UI quiz), (3) severity of UI (UDI-6) and impairment of quality of life (QOL) (IIQ-7), and (4) barriers to seeking medical help. Severity of UI, impairment of QOL, knowledge of UI, and sociodemographic characteristics were analyzed regarding their relationship with help-seeking behavior.

RESULTS

Of 351 women, 53.2% had symptoms of UI but only 25.0% symptomatic patients had consulted a doctor. The UI quiz score was 6.82 ± 2.76 (total 14) and the highest incorrect item was "Urinary incontinence is the normal aging" (incorrect rate 86.3%). The most frequent barrier for help-seeking was "The symptoms are not severe and do not affect me." Logistic regression analysis showed that UDI-6 score (adjusted OR = 1.06, P < 0.0001) and UI quiz score (adjusted OR = 1.30, P = 0.001) were the independent impact factors of patient's help-seeking behavior.

CONCLUSIONS

Hong Kong Chinese women's knowledge toward UI is not sufficient, and the consultation rate is low. Besides symptom severity, the knowledge level of UI is the other independent factor affecting patients' help-seeking behavior. Community education on UI may encourage women to seek early help.

Factors associated with urinary and double incontinence in a geriatric post-hip fracture assessment in older women

BACKGROUND

Incontinence and hip fractures are common in older people, especially women, and associated with multiple adverse effects. Incontinence is a risk factor for falls.

AIMS

We aimed to investigate the prevalence of urinary (UI) and double incontinence (DI, concurrent UI and faecal incontinence), and to identify factors associated with UI and DI 6 months post-fracture.

METHODS

A prospective real-life cohort study was conducted consisting of 910 women aged ≥ 65 who were treated for their first hip fracture in Seinäjoki Central Hospital, Finland, between May 2008 and April 2018. Continence status was elicited at baseline and 6 months postoperatively at our geriatric outpatient clinic where all participants underwent a multidisciplinary comprehensive geriatric assessment (CGA) consisting of an evaluation of cognition, nutrition, mood, mobility, and functional ability.

RESULTS

At baseline, 47% of the patients were continent, 45% had UI and 8% had DI, and at follow up, 38%, 52%, and 11%, respectively. The mean age of the patients was 82.7 ± 6.8. Both UI and DI were associated with functional disability and other factors related to frailty. The associations were particularly prominent for patients with DI who also had the worst performance in the domains of CGA. We identified several modifiable risk factors: depressive mood (odds ratio [OR] 1.81; 95% confidence interval [CI] 1.16-2.84) and constipation (OR 1.48, 95% CI 1.02-2.13) associated with UI and, late removal of urinary catheter (OR 2.33, 95% CI 1.31-4.14), impaired mobility (OR 2.08, 95% CI 1.05-4.15), and poor nutrition (OR 2.31, 95% CI 1.11-4.79) associated with DI.

CONCLUSIONS

This study demonstrates a high prevalence of UI and DI in older women with hip fracture and modifiable risk factors, which should be targeted in orthogeriatric management and secondary falls prevention. Patients with DI were found to be an especially vulnerable group.

Multimorbidity Patterns and the Disablement Process among Public Long-Term Care Insurance Claimants in the City of Yiwu (Zhejiang Province, China)

This study aimed to identify multimorbidity patterns and explore the disablement process by utilizing the model raised by Verbrugge and Jette as a theoretical framework. This cross-sectional study used public Long-term Care Insurance (LTCI) claimants’ assessment data of Yiwu city in Zhejiang Province, China, for 2604 individuals aged 60 years and older, from September through December 2018. Latent Class Analysis (LCA) was conducted using 10 common chronic conditions. Structural Equation Modeling was used to examine the disablement process. The latent classes of multimorbidity patterns were the “coronary atherosclerotic heart disease” class (19.0%), the “lower limb fractures” class (26.4%), and the “other diseases” class (54.6%). The structural model results show that coronary atherosclerotic heart disease had a significant influence on incontinence, but it was not statistically significant in predicting vision impairment and mobility impairment. Lower limb fractures had significant effects on vision impairment, incontinence, and mobility impairment. Vision impairment, incontinence, and mobility impairment had significant effects on physical activities of daily living (ADLs). Our findings suggest that different impairments exist from specific patterns of multimorbidity to physical ADL disability, which may provide insights for researchers and policy makers to develop tailored care and provide support for physically disabled older people.

Are Anticholinergic Medications Associated With Increased Risk of Dementia and Behavioral and Psychological Symptoms of Dementia? A Nationwide 15-Year Follow-Up Cohort Study in Taiwan

BACKGROUND/OBJECTIVE

In previous reports, the usage of anticholinergic medications has been associated with an increased risk of dementia with prolonged usage or with a high Anticholinergic Cognitive Burden (ACB). This study aimed to investigate the association between anticholinergic medications and the risk of dementia using data from Taiwan's National Health Research Database (NHIRD).

METHODS

A total of 790,240 patients, with 197,560 patients receiving anticholinergic medications and 592,680 control patients (1:3) matched for sex, age, and index-year, were enrolled from the two million Longitudinal Health Insurance Dataset, a subdataset of the NHIRD, between 2000 and 2015. The time-dependent Cox regression analysis was used to explore the hazard ratio (HR) with a 95% confidence interval for the association between anticholinergics and the risk of dementia during the 15-year follow-up. The behavioral and psychological symptoms of dementia (BPSD) were recognized by the usage of psychotropics. The ACB ranged from zero to three, divided as score <1, 1-1.9, 2-2.9, 3-4.9,and ≧5. The sensitivity analysis was done by excluding the diagnoses of dementia in the first 2 or 4 years after anticholinergic usage.

RESULTS

In the anticholinergic usage cohort, the HR was 1.043 (95% CI = 0.958-1.212, p = 0.139) without a significant difference. The sensitivity analysis revealed no association between the usage of anticholinergics and the risk of dementia. Anticholinergic usage was not associated with BPSD. Male sex, patients of ages of 60-64 and ≧80, usage of antiparkinsonian medications, a history of Parkinson's disease, epilepsy, urinary incontinence, depression, bipolar disorder, and psychotic disorder were independent risk factors of dementia. Increased HRs for dementia were associated with an ACB ≥ 5 and an anticholinergic usage period ≥ 1,460 days.

CONCLUSION

In this study, the usage of anticholinergics was not associated with the risk of dementia or BPSD in a 15-year follow-up study. However, patients with the male sex, patients with ages of 65-79 and ≧80, patients with some comorbidities, high ACB scores, and long anticholinergic treatment duration were associated with the risk of dementia.

Impact of Coexisting Overactive Bladder in Medicare Patients With Dementia on Clinical and Economic Outcomes

BACKGROUND

Patients with dementia commonly suffer from symptoms of overactive bladder (OAB); however, limited research exists on the clinical impact of coexisting OAB among patients with dementia. As such, the objective of this study was to examine the impact of OAB on clinical outcomes, health-care resource use, and associated costs among patients with dementia.

METHODS

We conducted a retrospective cohort analysis of patients with dementia using 3861 matched pairs of patients with and without OAB. Analyses were based on administrative claims data from January 1, 2007, to September 30, 2015, and compared clinical outcomes, health services use, and associated costs.

RESULTS

Patients with dementia and OAB were more likely than those without OAB to have least one fall (incidence rate ratio [IRR]: 1.43, 95% confidence interval [CI], 1.22-1.68, P < .001), fracture (IRR: 1.23, 95% CI, 1.05-1.44, P = .008), combined fall/fracture (IRR: 1.25, 95% CI, 1.11-1.42, P < .001), or urinary tract infection (IRR: 2.75, 95% CI, 2.55-2.96, P < .001). Patients with dementia and OAB demonstrated greater utilization of all-cause encounter types compared to similar patients without coexisting OAB (P < .01). All-cause and dementia-related total health-care costs were approximately 23% (95% CI, 0.19-0.28, P < .001) and 13% (95% CI, 0.05-0.20, P = .001), respectively, greater than similar patients without coexisting OAB.

CONCLUSION

Coexisting OAB was associated with impacts on clinical outcomes, health-care resource utilization, and costs in patients with dementia.

Characteristics of Lower Limb Muscle Strength, Balance, Mobility, and Function in Older Women with Urge and Mixed Urinary Incontinence: An Observational Pilot Study

Purpose: After the age of 65, urinary incontinence (UI) occurs in one of every two women. A positive correlation between falls and urgency UI (UUI) or mixed UI (MUI) has also been identified. However, lower extremity impairments in older women with UUI or MUI have not been thoroughly investigated. The primary goal of this study was to compare lower limb strength, balance, mobility, and function in older women with and without UUI or MUI. The secondary goal was to evaluate the association between these measurements and UI severity. Method: A total of 40 older women with and without UUI or MUI completed standardized tests for lower limb strength (knee flexor or extensor dynamometry, 30-second sit-to-stand test), balance (single-leg stance test, Four Square Step Test, Activities-specific Balance Confidence questionnaire), mobility (10-metre walk test, 6-minute walk test), and function (Human Activity Profile questionnaire, 12-Item Short Form Health Survey). Results: Significant differences in balance and mobility were observed between the two groups. Women with UI had shorter single-leg stance times, lower balance confidence scores, and slower gait speeds. Conclusions: The results from this pilot study suggest that high-functioning older women with UUI or MUI have balance and mobility impairments. More studies are needed to confirm these results. By reporting power calculations for sample size, this pilot study provides a useful basis on which to design and conduct larger studies.

Identifying the most reliable and valid bladder health screening tool: a systematic review

Purpose: Lower urinary tract symptoms are common in advancing age and a major cause of disability through avoidance of activity and social engagement. This systematic review aimed to identify the most valid and reliable brief screening tool for these symptoms or bladder problems, to incorporate into a health promotion programme for older adults to facilitate discussion about self-management.Method: Review eligibility criteria included studies published between 1990 and November 2018, reporting the validity, reliability and/or acceptability of bladder health screening tools. Six electronic databases were searched.Results: Twenty-two studies were included. Three screening tools met the criteria: International Prostate Symptom Score (IPSS); International Consultation on Incontinence Questionnaire Urinary Incontinence Short-Form; Bladder Control Self-Assessment Questionnaire (B-SAQ). Test-retest reliability for total scores of the IPSS and International Consultation on Incontinence Questionnaire Urinary Incontinence Short-Form was acceptable. All three questionnaires showed evidence of acceptable levels of internal consistency and of convergent validity.Conclusion: Having favourable psychometric scores compared to the B-SAQ and for ease of use and trustworthiness of a simple questionnaire, the IPSS and International Consultation on Incontinence Questionnaire Urinary Incontinence Short-Form met the criteria for recommendation for raising awareness and bladder health promoting interventions to reduce associated disability.Implications for RehabilitationLower urinary tract symptoms are common in advancing age and a major cause of disability through avoidance of activity and social engagement.Lower urinary tract symptoms can be prevented or improved through self-management strategies.Help-seeking levels for lower urinary tract symptoms is low but could be improved through continence promotion interventions.The International Prostate Symptom Score and the International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form are bladder health screening questionnaires which would be appropriate to use as part of a continence promotion intervention to help prompt discussions and raise awareness and subsequently improve symptoms and associated disability.

Urinary Incontinences Are Related with Fall and Fragility Fractures in Elderly Population: Nationwide Cohort Study

Background

This prospective cohort study used nationwide claims data to investigate the incidence of fall and fragility fractures in association with urinary incontinence (UI) in the elderly, and to compare mortality after fragility fractures in elderly patients with or without incontinence.

Methods

A total of 39,854 Korean adults (age, 66-80 years) who participated in health examinations between 2007 and 2012 and were followed up until 2015 were analyzed. Patient and comparison groups were classified according to the presence or absence of UI. The cumulative incidence of osteoporotic fragility fractures and falls in the 2 groups was assessed and compared. Hazard ratios for fragility fractures were calculated for the risk of UI in association with falls using a Cox proportional hazards model.

Results

Of 39,854 elderly participants, 5,703 were classified in the UI group, while 34,151 were placed in the comparison group. Fall rates were significantly higher (20.8%) in the incontinence group than in the comparison group (4.7%) (P<0.001). Women in the incontinence group (13.9%) showed a significantly higher incidence of all types of fragility fractures than those in the comparison group (11.8%) (P=0.005). After adjustment for confounders, UI was not a significant risk factor for fragility fractures in men (P=0.878) or women (P=0.324).

Conclusions

This study demonstrated that elderly women with UI have a significantly higher incidence of osteoporotic fragility fractures. In addition, elderly women are at higher risk for falls.

Urinary incontinence in home care: a representative multicenter study on prevalence, severity, impact on quality of life, and risk factors

OBJECTIVES

The objective of the study was to determine the prevalence and severity of urinary incontinence and associated factors in patients receiving home care nursing service.

METHODS

From June to September 2015, a multicenter cross-sectional study was conducted in 923 patients from 102 home care services throughout Germany. The ICIQ-SF was used to determine the characteristics of UI and its impact on QoL. To determine the risks for UI, demographic and social risks, the Barthel Index and medical diagnoses were determined in descriptive and logistic regression analysis.

RESULTS

The prevalence of UI was 62.5% (95% CI 59.3-65.6). The most common reasons for UI were before getting to the toilet 27.6% and when coughing or sneezing 27.3%. If the amount of leakage was medium (high), the mean of the impact on QoL was 4.9, SD 2.7 (5.0, SD 3.6). If the frequency of UI was higher than once a day (permanent), the mean of the impact on QoL was 4.2, SD 2.7 (4.8, SD 3.2). The results of the logistic regression analysis show the highest odds ratios for mobility-inability to walk (4.49), presence of dementia (2.59), and female sex (1.81). The metric variables age (1.02), Barthel Index (0.93), and BMI (1.05) were also statistically significant.

CONCLUSIONS

The prevalence of UI in home care in Germany is high. Since UI is strongest associated with (im-) mobility, preserving or regaining patients' mobility should play a central role in providing care to avoid/minimize UI.

The association between lower urinary tract symptoms and falls: Forming a theoretical model for a research agenda

BACKGROUND

There is a well-recognised association between falls and lower urinary tract symptoms (LUTS) in older adults, with estimates of odd ratios for falls in the presence of LUTS ranging between 1.5 and 2.3. Falls and LUTS are both highly prevalent among older people and both are markers of frailty, with significant associated morbidity, mortality, and healthcare resource cost. This association is not well examined or explained in the literature.

AIMS

We aimed to outline current knowledge of the association between falls and lower urinary tract symptoms and suggest a research program to further investigate this.

MATERIALS AND METHODS

A consensus conference of experts in the field was convened to review the current literature and brainstorm potential future investigative avenues.

RESULTS AND DISCUSSION

Despite the recognition of this association, there has been little research to examine its potential causes, and no intervention trial has established if reducing LUTS or urinary incontinence can reduce the risk of falls. The commonly held assumption that urgency causes falls through rushing to the toilet is likely incorrect. Falls and LUTS are both symptoms of frailty and have many common causes. Gait, balance, and continence are all processes requiring cognitive input, and the concept of dual tasking may be a further link.

CONCLUSION

The significant association between lower urinary tract symptoms and falls is currently unexplained, and further research into the potential causes of this association is needed.

Noctural Enuresis as a Risk Factor for Falls in Older Community Dwelling Women with Urinary Incontinence

PURPOSE

We determined the association of urinary symptoms with fall risk and physical limitations in older community dwelling women with urinary incontinence.

MATERIALS AND METHODS

We performed an in-depth assessment of daytime and nighttime urinary symptoms, fall risk, physical function, physical performance tests and mental function in older community dwelling women with urinary incontinence who had not sought care for urinary symptoms. All assessments were performed in participant homes. We used univariable and multivariable linear regression to examine the relationship of urinary symptoms to fall risk, physical function and physical performance.

RESULTS

Of 37 women with a mean ± SD age of 74 ± 8.4 years who had urinary incontinence 48% were at high risk for falls. Nocturnal enuresis was reported by 50% of the women. Increased fall risk was associated with increasing frequency of nocturnal enuresis (p = 0.04), worse lower limb function (p <0.001), worse upper limb function (p <0.0001) and worse performance on a composite physical performance test of strength, gait and balance (p = 0.02). Women with nocturnal enuresis had significantly lower physical performance test scores than women without nocturnal enuresis (median 7, range 0 to 11 vs 9, range 1 to 12, p = 0.04). In a multivariable regression model including age, nocturnal enuresis episodes and physical function only physical function was associated with an increased fall risk (p <0.0001).

CONCLUSIONS

Nocturnal enuresis is common in older community dwelling women with urinary incontinence. It may serve as a marker of fall risk even in women who do not seek care for urinary symptoms. Interventions targeting upper and lower body physical function could potentially decrease the risk of falls in older women with urinary incontinence.

Impact of Parkinson's disease on the acute care treatment and medium-term functional outcome in geriatric hip fracture patients

INTRODUCTION

Patients with Parkinson's disease (PD) have a heightened risk of sustaining hip fractures due to disturbed balance and gait insecurity. This study aims to determine the impact of PD on the perioperative course and medium-term functional outcome of patients with hip fractures.

MATERIALS AND METHODS

A total of 402 hip fracture patients, aged ≥60 years, were prospectively enrolled. On admission, the American Society of Anesthesiologists score, Mini-Mental Status Examination, and Barthel Index (BI), among other scales, were documented. The Hoehn and Yahr scale was used to assess the severity of PD. The functional outcome was assessed by performance on the BI, Tinetti test (TT), and Timed Up and Go test (TUG) at discharge and at the 6-month follow-up. Additionally, the length of hospitalization, perioperative complications, and discharge management were documented. A multivariate regression analysis was performed to control for influencing factors.

RESULTS

A total of 19 patients (4.7%) had a concomitant diagnosis of PD. The functional outcome (BI, TT, and TUG) was comparable between groups (all p > 0.05). Grade II (52.6 vs. 26.1%; OR = 4.304, p = 0.008) and IV complications (15.8 vs. 4.4%; OR = 7.785, p = 0.012) occurred significantly more often among PD patients. While the diagnosis of PD was associated with a significantly longer mean length of hospital stay (β = 0.119, p = 0.024), the transfer from acute hospital care showed no significant difference (p = 0.246). Patients with an additional diagnosis of PD had inferior results in BI at the 6-month follow-up (p = 0.038).

CONCLUSION

PD on hospital admission is not an independent risk factor for in-hospital mortality or an inferior functional outcome at hospital discharge. However, patients with PD are at risk for specific complications and longer hospitalization at the time of transfer from acute care so as for reduced abilities in activities of daily living in the medium term.

Impact of urinary incontinence on medical rehabilitation inpatients

AIMS

To determine the prevalence of urinary incontinence (UI) and its association with rehabilitation outcomes in patients receiving inpatient medical rehabilitation in the United States.

METHODS

A retrospective, cohort study of 425,547 Medicare patients discharged from inpatient rehabilitation facilities (IRFs) in 2005. We examined prevalence of UI at admission and discharge for 5 impairment groups. We examined the impact of demographics, health, and functional status on the primary outcome, change in continence status, and secondary outcomes of discharge location and 6-month mortality.

RESULTS

Approximately one-quarter (26.6%) of men were incontinent at admission compared to 22.2% of women. In all diagnostic groups, continence status remains largely unchanged from admission to discharge. Patients who are older, have cognitive difficulties, less functional improvement, and longer lengths of stay (LOS), are more likely to remain incontinent, compared to those who improved, after controlling for patient factors and clinical variables. UI was significantly associated with discharge to another post-acute setting (PAC). For orthopedic patients, UI was associated with a 71% increase in the likelihood of discharge to an institutional setting after controlling for patient factors and clinical variables. UI was not associated with death at 6 months post-discharge.

CONCLUSIONS

UI is highly prevalent in IRF patients and is associated with increased likelihood of discharge to institutional care, particularly for orthopedic patients. Greater attention to identifying and treating UI in IRF patients may reduce medical expenditures and improve other outcomes. Neurourol. Urodynam. 36:176-183, 2017. © 2015 Wiley Periodicals, Inc.