Consensus document on the detection and diagnosis of urinary incontinence in older people

Associated factors of stress, urgency, and mixed urinary incontinence in a geriatric outpatient assessment of older women with hip fracture

PURPOSE

Urinary incontinence (UI) is known to be common among older female hip fracture patients. Little is known about different subtypes of UI among these patients. Our aim was to identify factors associated with subtypes of UI in a cross-sectional design.

METHODS

1,675 female patients aged ≥ 65 and treated for their first hip fracture in Seinäjoki Central Hospital, Finland, during 2007-2019, were included in a prospective cohort study. Of these, 1,106 underwent comprehensive geriatric assessment (CGA), including questions on continence, at our geriatric outpatient clinic 6 month post-fracture. A multivariable-adjusted multinomial logistic regression model was used to examine factors associated with UI subtypes.

RESULTS

Of the 779 patients included, 360 (46%) were continent and 419 (54%) had UI 6-month post-fracture. Of the women with UI, 117 (28%) had stress UI, 183 (44%) had urgency UI and 119 (28%) had mixed UI, respectively. Mean age of the patients was 82 ± 6,91. In multivariable analysis, depressive mood and poor mobility and functional ability were independently associated with stress UI. Fecal incontinence (FI) and Body Mass Index (BMI) over 28 were independently associated with urgency UI. Mixed UI shared the aforementioned factors with stress and urgency UI and was independently associated with constipation.

CONCLUSIONS

Mixed UI was associated with most factors, of which depressive mood and impaired mobility and poor functional ability were shared with stress UI, and FI and higher BMI with urgency UI. CGA is key in assessing UI in older hip fracture patients, regardless of subtype.

Perceptions of primary health care nurses and general practitioners in the care of older people with urinary incontinence

AIMS

To identify the challenges and opportunities among primary health care nurses and general practitioners (GPs) in the care of older people with urinary incontinence (UI) and other chronic conditions in China.

BACKGROUND

UI is highly prevalent among community-dwelling older people with chronic conditions but is underreported and poorly managed. Understanding the factors that affect primary health care professionals' practices in their care for this population is imperative to foster nurse-led UI care services.

DESIGN

A qualitative descriptive study.

METHODS

Four focus groups were held with 24 primary health care nurses and GPs in Changsha, Hunan Province, China, between July and September 2021. A reflective thematic analysis was used to identify themes.

RESULTS

This study revealed misconceptions regarding older people living with UI and other chronic conditions in primary care health professional participants. Moreover, primary health care nurses had very limited autonomy in UI diagnosis and initiating care interventions for this patient population. By reflecting on practices, participants recognized various practical solutions to improve the detection and management of UI. Participants also identified barriers to accessing care services in older people with UI. They suggested changes in the health care system to achieve universal access to UI care services for older people.

CONCLUSION

Nurse-led UI care services in primary health care for community-dwelling older people with chronic conditions are in high demand but are underdeveloped due to professional and health care system factors.

IMPACT

Findings from this study provide new insights into challenges faced by primary health care professionals and illuminate practical solutions to address these challenges.

REPORTING METHODS

Adherence to COREQ guidelines was maintained.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Exploring support, experiences and needs of older women and health professionals to inform a self-management package for urinary incontinence: a qualitative study

OBJECTIVES

Many women attempt to manage urinary incontinence (UI) independently with variable success while health professionals may be unaware of their needs. This study aimed to (1) understand older women's experiences of UI, their self-management strategies and support needs; (2) explore health professionals' experiences of supporting women and providing relevant services and (3) combine their experiences contribute to development of a theory-based and evidence-based self-management package for UI.

DESIGN

Qualitative semi-structured interviews were conducted with 11 older women with UI and 11 specialist health professionals. Data were analysed independently using the framework approach, then synthesised in a triangulation matrix to identify implications for content and delivery of the self-management package.

SETTING

Community centres, community continence clinic and urogynaecology centre of a local teaching hospital in northern England.

PARTICIPANTS

Women aged 55 years and over who self-reported symptoms of UI and health professionals delivering UI services.

RESULTS

Three overarching themes emerged. Older women see UI as a 'fact of life' but many struggle with it: women typically considered UI as part of ageing yet expressed annoyance, distress, embarrassment and had made significant lifestyle changes. Access to information and limited high-quality professional support: health professionals provided specialist UI care and information. Yet less than half of women accessed specialist services, those who had, highly valued these services. 'Trial and error' with different self-management strategies: women had tried or were using different strategies (continence pads, pelvic floor exercises, bladder management and training, fluid management and medication), with mixed success. Health professionals provided evidence-based, personalised support and motivation.

CONCLUSIONS

Findings informed the content of the self-management package that focused on providing facts, acknowledging challenges of living with/self-managing UI, sharing others' experiences, using motivational strategies and self-management tools. Delivery preferences were independent use by women or working through the package with a health professional.

Impact of Urinary Incontinence Related to Overactive Bladder on Long-Term Care Residents and Facilities: A Perspective From Directors of Nursing

The current study assessed the impact of urinary incontinence (UI) on residents, staff, care processes, and quality measures in long-term care (LTC) settings. A 70-question quantitative online survey was sent to directors of nursing (DONs) who had worked for ≥1 year in a ≥100-bed facility (≥80% LTC beds). Of the 62% of residents with UI, 40% were always incontinent, and 81% used incontinence products for UI. Overall, 59% of DONs reported that UI management contributes to certified nursing assistant turnover. Approximately 36% of resident falls occurred while trying to get to the bathroom. LTC quality measures reported as significantly impacted by UI included urinary tract infection and falls with major injury. Only 14% of residents with UI were treated with medication. Most (75%) DONs were unaware of any link between anticholinergic medications and risk of cognitive side effects. These results highlight the need for improved UI treatment, awareness, and management in this population. [Journal of Gerontological Nursing, 48(7), 38-46.].

Tolerability of duloxetine in elderly and in non-elderly adults: a protocol of a systematic review and individual participant data meta-analysis of randomized placebo-controlled trials

BACKGROUND

Duloxetine is an antidepressant that benefits from a wide range of approval in the elderly population, while its safety for use compared to non-elderly is not clearly assessed. This protocol outlines a systematic review and individual participant data meta-analysis comparing the tolerability of duloxetine between elderly and non-elderly.

METHODS

Searches will be conducted in PubMed, ClinicalTrials.gov , Clinicaltrialsregister.eu, data sharing platforms, FDA drug approval packages, European public assessment reports and withdrawn applications from the EMA website. The review will be performed on studies available in electronic databases from their date of inception to the 31 March 2022. Only randomized controlled clinical trials, comparing duloxetine to placebo, will be included in this meta-analysis. The studies will be selected if they comprise both elderly and non-elderly adults, in conditions of use of duloxetine approved by the European Medical Agency (EMA) and the Food and Drug Administration (FDA). The primary outcome will be the rate ratio of serious adverse events under duloxetine compared to placebo, between participants at least 65 years old and non-elderly. Second, the number of any adverse events, clinical efficacy and quality of life will be compared between elderly and non-elderly under both interventions. The quality of evidence in the tolerability of duloxetine will be assessed using the GRADE system. A one or two-stage individual participant data random effect meta-analysis will be conducted depending on the availability of the data.

DISCUSSION

This meta-analysis will investigate the tolerability safety of duloxetine in the elderly population across all conditions approved by European and American regulatory authorities. The results from this meta-analysis are intended to help prescribers to provide better care for the elderly population.

SYSTEMATIC REVIEW REGISTRATION

The protocol has been registered at the International Prospective Register of Systematic Reviews (PROSPERO; registration number: CRD42019130488 ).

Pilot of Patient Engagement in Continence Care on Geriatric Rehabilitation Units

PURPOSE

The aim of this study was to pilot a process of engaging geriatric rehabilitation patients in the assessment and management of their continence concerns.

DESIGN

A descriptive study was conducted.

METHODS

The study has four phases: (1) staff education on continence with a pre-post knowledge quiz, (2) design of patient engagement process by a working group, (3) a 6-week pilot of a patient symptom questionnaire and process of engaging patients with audits of disciplinary admission histories and documentation, and (4) patient and staff feedback surveys.

RESULTS

Patients in geriatric rehabilitation identify a range of bladder and bowel symptoms. However, there was little documented evidence from the interprofessional team that corresponded to patients' reported symptoms.

CONCLUSION

Further research into symptoms bothersome to patients and engagement of both patients and the interprofessional team in addressing these in the rehabilitation setting is needed.

CLINICAL RELEVANCE TO REHABILITATION NURSING

Patients admitted to geriatric rehabilitation have a range of bladder and bowel symptoms, which need to be addressed.

Care dependency and management of urinary incontinence in nursing homes: A descriptive study

AIM

To explore the differences in managing urinary incontinence in residents in nursing homes aged 65 years or older in relation to their care dependency.

DESIGN

The 2015 data of the Dutch annual independent (Inter)national Prevalence Measurement of Quality of Care of Maastricht University were used. The design involved a cross-sectional, multi-centre point prevalence measurement in hospitals, care homes, and home care.

METHODS

Secondary data analysis on the data provided by care home organizations.

RESULTS

In the care independent group, the solely use of absorbing material was the mostly applied intervention. In the group of care dependent persons, the combination of absorbing material with toilet on set times and on individual basis was the most common approach.

CONCLUSION

The outcome of this study indicated that the management of urinary incontinence in residents in nursing homes differs depending on their care dependency.

IMPACT

Caregivers in nursing homes should be aware of preferences of residents regarding the management of their urinary incontinence. Researchers should investigate criteria used by caregivers and care receivers into the decision of the application of interventions for urinary incontinence.

Non-pharmacological, non-surgical interventions for urinary incontinence in older persons: A systematic review of systematic reviews. The SENATOR project ONTOP series

BACKGROUND

Urinary incontinence is especially common in older age. Non-pharmacological therapies are particularly desirable in this group.

OBJECTIVE

To define optimal evidence-based non-pharmacological, non-surgical therapies for urinary incontinence in older persons.

METHODS

A Delphi process determined critical outcome measures of interest. Studies of any non-pharmacological intervention reporting critical outcomes were identified through database searches for relevant systematic reviews in Medline, Embase, CINAHL, PsycInfo and Cochrane up to June 2018. Primary trials with a population mean age ≥65years were identified, from which data were extracted and risk of bias was assessed. Qualitative analysis and meta-analysis, when possible, were undertaken, followed by grading of the evidence using GradePro software. Finally, bullet-point recommendations were formulated for the indications and contraindications for non-pharmacological interventions for urinary incontinence in older persons.

RESULTS

Frequency of incontinence was identified as a critically important outcome. In total, 33 systematic reviews were identified with 27 primary trials meeting inclusion criteria. Evaluated therapies included exercise therapy, habit retraining, behavioural therapy, electrical stimulation, transcutaneous tibial nerve stimulation, magnetic stimulation, caffeine reduction and acupuncture. From meta-analysis, group exercise therapy and behavioural therapy in women were beneficial in reducing episodes of incontinence (mean reduction of 1.07 (95 %CI 0.69-1.45) and 0.74 (95 %CI 0.42-1.06) episodes per day respectively, evidence grade 'moderate'). Evidence for other interventions was limited and of insufficient quality.

CONCLUSIONS

There is sufficient evidence to warrant recommendation of group exercise therapy for stress incontinence and behavioural therapy for urgency, stress or mixed urinary incontinence in older women. Evidence was insufficient to recommend any other non-drug therapy.

Antimuscarinic drug therapy for overactive bladder syndrome in the elderly - are the concerns justified?

INTRODUCTION

The use of antimuscarinic drugs is common in the management of the overactive bladder (OAB). Concerns have been raised over their use in the elderly population in whom the use of these drugs is highly prevalent, consequent to the reported link between these drugs and cognitive impairment and dementia. Areas covered: Recent publications have heightened concerns regarding antimuscarinic drug use in the elderly. In this review, the author discusses the available evidence upon which conclusions have been based and has presented the need for cortical review and need for caution in interpreting the data. The available evidence is inconsistent, differences in pharmacokinetics have not been widely recognized in clinical trials, clinical estimation of antimuscarinic activity has not been standardized, and serum antimuscarinic activity has not been found to correlate with cognitive impairment. Furthermore, the significant heterogeneity within cognitive aging processes raises questions regarding the extent to which various factors, including medication, influences this process. Expert opinion: Whilst caution should indeed be exercised in the use of antimuscarinic medication in the elderly, advocacy of discontinuation of their use may deprive patients of the benefits of improved quality of life from treatment where currently alternative management remain limited or invasive.

Screening for urinary incontinence in acute care for elders unit: comparative performance analysis of Katz's ADL and ICIQ-UI-SF

BACKGROUND

Urinary incontinence (UI) is a frequent, but neglected geriatric syndrome, particularly in vulnerable older patients. Optimizing screening procedures is necessary.

OBJECTIVE

To compare the clinometric performances of the "continence" item of the Katz's ADL scale and the ICIQ-UI-sf for the screening of UI in vulnerable aged patients.

METHODS

A prospective study was conducted in the acute care for elders (ACE) unit of an academic centre. Two independent nurses screened all patients with spontaneous urination for UI with Katz's ADL item and ICIQ-UI-sf upon the hospital admission. The diagnosis of UI resulted from an interdisciplinary conciliating meeting for urinary functional disorders (TOFU), gathering geriatricians and neuro-urologists and was considered as reference.

RESULTS

294 consecutive patients (mean age 86.2 ± 6.5 years; 76.5% female) admitted to the ACE unit were screened; 169 were incontinent (57.5%) according to TOFU. The Katz's ADL item identified 106 incontinent patients with 20 false positives; 83 incontinent patients were not identified. If the sensitivity and specificity of the ICIQ-UI-sf were 100.0%, they were, respectively, 50.9 and 84.0% for the Katz's ADL item. Positive and negative predictive values were 100.0% for ICIQ-UI-sf; 81.1 and 55.9% for ADL, respectively.

CONCLUSION

This study validates the ICIQ-UI-sf as a simple and effective screening tool for UI in vulnerable and complex hospitalized aged patients. It also demonstrates that the "continence" item of the Katz's ADL scale is not sensitive enough for UI screening in this population.

Association between urinary incontinence and frailty: a systematic review and meta-analysis

PURPOSE

Urinary incontinence (UI) and frailty are common geriatric syndromes. Although literature increasingly supports a relationship between these two conditions, no systematic review and meta-analysis has been performed on this topic. Therefore, we aimed to investigate the potential association between UI and frailty, through a meta-analytic approach.

METHODS

A systematic search in major databases was undertaken until 15th March 2018 for studies reporting the association between UI and frailty. The prevalence of UI in people with frailty (vs. those without) was pooled through an odds ratio (OR) and 95% confidence intervals (CIs), with a random-effects model. The other outcomes were summarized descriptively.

RESULTS

Among 828 papers, 11 articles were eligible, including 3784 participants (mean age 78.2 years; 55.1% women). The prevalence of UI was 39.1% in people with frailty and 19.4% in those without. A meta-analysis with five studies (1540 participants) demonstrated that UI was over twice as likely in frail people versus those without (OR 2.28; 95% CI 1.35-3.86; I² = 61%). One cross-sectional study, adjusting for potential confounders and one longitudinal study confirmed that UI is significantly associated with frailty. In two cross-sectional studies, using adjusted analyses, frailty was more common in people with UI.

CONCLUSION

Urinary incontinence is twice as common in older people with frailty compared to older people without frailty. Screening and the development of interventions for UI and frailty could prove useful for this common comorbidity.