Urinary incontinence and the community-dwelling elder: a practical approach to diagnosis and management for the primary care geriatrician

FRAIL-NH Predicts Outcomes in Long Term Care

BACKGROUND/OBJECTIVES

To investigate the predictive validity of the short, simple FRAIL-NH frailty screening tool in the long term care population and to then compare the predictive validity with the frailty index (FI) for 6-month adverse health outcomes.

DESIGN

Retrospective study using the Minimum Data Set (MDS) 3.0 and chart review from June-December 2014.

SETTING

Two Long Term Care Facilities in Saint Louis, MO.

PARTICIPANTS

270 patients ages ≥ 65 years old residing in long term care.

MEASUREMENTS

Frailty was measured using the FRAIL-NH and Frailty Index (FI) criteria. Adverse outcomes measured at 6-month follow-up included falls, hospitalizations, and hospice enrollment/mortality.

RESULTS

Based on screening tool used frailty prevalence was 48.7% for FRAIL-NH and 30.3% for FI. The FRAIL-NH pre-frail (Adjusted Odds Ratio [AOR]=2.62; 95% Confidence Interval [CI]=1.25-5.54; p=0.11) classification was associated with 6 month risk of falling and mortality/hospice enrollment was associated with the frail classification, AOR=3.96 (1.44-10.87, p=0.007). Combining the pre-frail and frail categories both measures predicted 6 month mortality with the FRAIL-NH being the strongest predictor (AOR=3.36; 95%CI=1.26-8.98; p=0.016) and the FI was a more modest predictor with an AOR of 2.28; 95%CI=1.01-5.15; p=0.047. When directly comparing the FRAIL-NH to the FI, the FRAIL-NH pre-frail were at increased risk of falling, AOR=2.42 (1.11-5.92, p=0.027) and the FRAIL-NH frail were at increased risk of hospice enrollment/death, OR=3.25 (1.04- 10.86) p=0.044.

CONCLUSION

In comparison to the FI, the FRAIL-NH preformed just as well at screening for frailty and was a slightly better predictor of adverse outcomes. The FRAIL-NH is a brief, easy-to-administer frailty screening tool appropriate for long term care patients and predicts increased risk of falls in the pre-frail and mortality/hospice enrollment in the frail.

Urinary Incontinence Evaluation and the Utility of Pessaries in Older Women

Urinary incontinence and pelvic organ prolapse are common conditions affecting the elderly. A careful evaluation of urinary incontinence, including history and physical examination, will often determine the etiology of this condition. Vaginal pessaries are a safe and effective treatment for both urinary incontinence and pelvic organ prolapse. They should be considered a viable alternative to surgery especially in the elderly with complicated medical histories. This article reviews the etiology of urinary incontinence, offers a guide in the evaluation of the incontinent woman, and reviews the use of pessaries for the treatment of incontinence and pelvic organ prolapse.

Urinary incontinence: basic evaluation and management in the primary care office

With the increasing number of older adults in the population, the office-based clinician can expect to see more people with UI. Continued UI research is warranted, especially research that includes older adults who reside in the community and frail elderly women who are still living in the community. Better outcome measures should be developed to assess the effectiveness of interventions for UI. Reliance on information obtained from voiding diaries is used extensively, yet the reliability and validity for any specific instrument have not been tested with older adults. Hopelessness and spiritual distress, as precursors to health decline and how they impact on quality of life, should be studied in older adults with UI. Given the prevalence of UI, should it be considered a public health problem for which population-based interventions are used? What is known is that older adults demonstrate significant improvement in symptoms of UI when education, counseling, support, and encouragement in behavior management and lifestyle interventions are provided. When motivated and positive, even frail older adults experience improvement in the severity of urine leakage. Perhaps the single most important action that the office-based clinician can take is to start asking every older adult about UI and to follow with the basic approaches to evaluation and management described in this article.