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Peron EP, McDaniel JS, Van Tassell B, Donohoe KL. An active-learning laboratory on urinary incontinence products for pharmacy students. CURRENTS IN PHARMACY TEACHING & LEARNING 2024; 16:102135. [PMID: 38945106 DOI: 10.1016/j.cptl.2024.102135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 06/05/2024] [Accepted: 06/16/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND AND PURPOSE To describe an active-learning laboratory on urinary incontinence (UI) and its effect on students' confidence and comfort in addressing UI. EDUCATIONAL ACTIVITY AND SETTING Second year pharmacy students (n = 98) participated in an active-learning laboratory focused on UI with four components: catheter lecture and demonstration, UI product overview, hands-on practice with UI absorbent products, and a debrief on the activity focused on difficult conversations. Students completed an optional retrospective pre-post survey at the end of the laboratory including five confidence questions, ranking of activities in the laboratory, and open-ended responses on how to change the activity as well as what was one takeaway from the debrief. Descriptive statistics assessed survey responses. Changes in student confidence were assessed using paired t-tests. Thematic analysis was used for the open-ended debrief question. FINDINGS Of the 101 students who participated in the laboratory, 98 students completed the pre/post-survey (response rate: 97%). Students demonstrated a significant increase in their confidence in all five areas assessed. The hands-on activity with the absorbent products was rated as the most useful activity. The themes from the debrief on difficult conversations included: self-awareness, expanding viewpoints, cultural sensitivity, and professional duty. Student feedback on the UI active-learning laboratory was largely positive, with most students suggesting no changes (n = 75) to the activity. SUMMARY An active-learning laboratory on UI helped improve confidence and was well received by pharmacy students.
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Affiliation(s)
- Emily P Peron
- Virginia Commonwealth University School of Pharmacy, Richmond, VA, United States of America.
| | - Jessica S McDaniel
- Virginia Commonwealth University School of Pharmacy, Richmond, VA, United States of America
| | - Benjamin Van Tassell
- Virginia Commonwealth University School of Pharmacy, Richmond, VA, United States of America.
| | - Krista L Donohoe
- Virginia Commonwealth University School of Pharmacy, Richmond, VA, United States of America.
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Burgio K, Echt K, Markland A, Enemchukwu E, Williams B. A mobile telehealth program for behavioral treatment of urinary incontinence in women Veterans: Qualitative evaluation of MyHealth eBladder. J Women Aging 2024:1-17. [PMID: 39331496 DOI: 10.1080/08952841.2024.2401716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 08/16/2024] [Accepted: 08/30/2024] [Indexed: 09/29/2024]
Abstract
Women Veterans constitute a distinctive cohort whose exposure to military service can contribute to development of bladder conditions, such as urinary incontinence (UI), as they age. Behavioral therapies are recommended as first-line treatment for incontinence, yet many VA Medical Centers do not have staff trained to administer them. The purpose of this research study was to conduct a qualitative program evaluation of MyHealtheBladder, a mobile telehealth version of an evidence-based eight-week behavioral treatment program designed for women Veterans with incontinence. MyHealtheBladder uses mobile telehealth technology to teach pelvic floor muscle exercises, bladder control strategies, fluid management, risk factor reduction, and self-monitoring. Eighteen women Veterans who completed a pilot study of MyHealtheBladder participated in semi-structured telephone interviews exploring their experience with the program. A directed content analysis was conducted of the transcribed interview data. Participants described ease of accessing MyHealtheBladder using smart phones and other mobile devices, emphasizing the flexibility of using the program at home, work, or while traveling. Most participants described program content as understandable, relevant, and easy to follow. They discussed how the program increased knowledge of UI, promoted consistency in practicing behavioral therapy, strengthened pelvic floor muscles, reduced urine leakage, and improved psychosocial wellbeing. Suggestions for improvement included more interaction with staff, more individualized tailoring of content to UI type, incorporating in-person clinic visits, and including supplementary material. Participants uniformly endorsed the program and recommended it for other women Veterans, as well as for those in active duty to prevent or treat UI earlier in the life course.
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Affiliation(s)
- Kathryn Burgio
- Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Birmingham, AL, USA, and Atlanta, GA, USA
- Department of Medicine, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - Katharina Echt
- Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Birmingham, AL, USA, and Atlanta, GA, USA
- Department of Medicine, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
- Department of Medicine, Emory University, Atlanta, GA, USA
| | - Alayne Markland
- Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Birmingham, AL, USA, and Atlanta, GA, USA
- Department of Medicine, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - Ekene Enemchukwu
- Department of Urology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Beverly Williams
- Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Birmingham, AL, USA, and Atlanta, GA, USA
- Department of Medicine, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
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Kido Y, Yoshimura Y, Wakabayashi H, Nagano F, Bise T, Matsumoto A, Shimazu S, Shiraishi A, Yoneda K, Hamada T, Kuzuhara A. Effect of Chair-stand Exercise on Improving Urinary and Defecation Independence in Post-stroke Rehabilitation Patients with Sarcopenia. Prog Rehabil Med 2024; 9:20240029. [PMID: 39280961 PMCID: PMC11393472 DOI: 10.2490/prm.20240029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Accepted: 08/29/2024] [Indexed: 09/18/2024] Open
Abstract
Objectives There is a lack of evidence regarding the association between whole-body exercise and independence in urination and defecation. This study aimed to evaluate the effect of chair-stand exercise on improving urination and defecation independence in post-stroke patients with sarcopenia. Methods A retrospective study was conducted on stroke patients admitted to a community rehabilitation hospital between 2015 and 2021. Patients diagnosed with sarcopenia who required assistance with bladder and bowel management were included. The primary outcomes were the Functional Independence Measure (FIM) scores for urination (FIM-Bladder) and defecation (FIM-Bowel) at discharge. Multiple regression analysis was used to examine the association between chair-stand exercise and the outcomes, adjusting for potential confounders. Results Of 586 patients, 187 patients (mean age 79.3 years, 44.9% male) were included in the urination analysis, and 180 patients (mean age 79.3 years, 44.4% male) were included in the defecation analysis. Multiple regression analysis showed that the number of chair-stand exercises was independently positively associated with FIM-Bladder at discharge (β=0.147, P=0.038) and FIM-Bladder gain (β=0.168, P=0.038). Similarly, the number of chair-stand exercises was independently positively associated with FIM-Bowel at discharge (β=0.149, P=0.049) and FIM-Bowel gain (β=0.166, P=0.049). Conclusions Chair-stand exercise was positively associated with improved urination and defecation independence in post-stroke patients with sarcopenia. Incorporating whole-body exercises, such as chair-stand exercise, in addition to conventional rehabilitation programs may help improve voiding independence, reduce incontinence, and enhance quality of life in these patients.
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Affiliation(s)
- Yoshifumi Kido
- Department of Rehabilitation, Kumamoto Rehabilitation Hospital, Kikuyo, Japan
| | - Yoshihiro Yoshimura
- Center for Sarcopenia and Malnutrition Research, Kumamoto Rehabilitation Hospital, Kikuyo, Japan
| | - Hidetaka Wakabayashi
- Department of Rehabilitation Medicine, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Fumihiko Nagano
- Center for Sarcopenia and Malnutrition Research, Kumamoto Rehabilitation Hospital, Kikuyo, Japan
| | - Takahiro Bise
- Department of Rehabilitation, Kumamoto Rehabilitation Hospital, Kikuyo, Japan
| | - Ayaka Matsumoto
- Department of Pharmacy, Kumamoto Rehabilitation Hospital, Kikuyo, Japan
| | - Sayuri Shimazu
- Center for Sarcopenia and Malnutrition Research, Kumamoto Rehabilitation Hospital, Kikuyo, Japan
| | - Ai Shiraishi
- Department of Dental Office, Kumamoto Rehabilitation Hospital, Kikuyo, Japan
| | - Kouki Yoneda
- Center for Sarcopenia and Malnutrition Research, Kumamoto Rehabilitation Hospital, Kikuyo, Japan
| | - Takenori Hamada
- Department of Rehabilitation, Kumamoto Rehabilitation Hospital, Kikuyo, Japan
| | - Aomi Kuzuhara
- Center for Sarcopenia and Malnutrition Research, Kumamoto Rehabilitation Hospital, Kikuyo, Japan
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High RA, Ford CB, Handa VL, Anger J. Incidence of Dementia Among Medicare Beneficiaries With and Without Urinary Incontinence. UROGYNECOLOGY (PHILADELPHIA, PA.) 2024:02273501-990000000-00263. [PMID: 39227580 DOI: 10.1097/spv.0000000000001552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/05/2024]
Abstract
IMPORTANCE Dementia and urinary incontinence (UI) have been associated in cross-sectional studies. The temporal relationship between these 2 conditions is not well understood. OBJECTIVE The aim of the study was to investigate the risk of incident dementia in female adults with and without UI using the Medicare 5% Limited Data Set. STUDY DESIGN This retrospective cohort study matched females with UI to continent controls by index year, age, and dual Medicare/Medicaid eligibility. A 2-year look back period was used to exclude prevalent dementia and neurologic disorders. The 5-year cumulative incidence of dementia was estimated for women with UI and controls. Cox proportional hazard models assessed the association of variables with dementia, adjusting for age, dual Medicare/Medicaid eligibility, race, and comorbidities. RESULTS A total of 8,651 female beneficiaries with UI (n = 8,651) were more likely than matched controls (n = 8,651) to report White race and several medical comorbidities. The 5-year cumulative incidence of dementia diagnosis was lower in the UI versus controls (8.8% vs 10.6%, P < 0.001). In multivariable analysis with adjustment for covariates, UI diagnosis was associated with a lower hazard of dementia diagnosis (hazard ratio 0.82 [0.74, 0.91], P < 0.001). CONCLUSIONS Among female Medicare beneficiaries without baseline neurologic disorders, having any UI diagnosis was associated with a lower risk of dementia diagnosis. Further studies assessing UI symptoms and dementia diagnosis with rigorous and valid assessment tools are needed to confirm this finding.
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Affiliation(s)
- Rachel A High
- From the Department of Women's Health, University of Texas at Austin Dell Medical School, Austin, TX
| | - Cassie B Ford
- Department of Population Health, Duke University, Durham, NC
| | - Victoria L Handa
- Department of Gynecology & Obstetrics, Johns Hopkins Medical Center, Baltimore, MD
| | - Jennifer Anger
- Department of Urology, University of California San Diego, San Diego, CA
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Manaila AI, Roman NA, Baseanu ICC, Minzatanu D, Tuchel VI, Basalic EB, Miclaus RS. The Efficiency of Rehabilitation Therapy in Patients Diagnosed with Neurogenic Bladder: A Systematic Review. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1152. [PMID: 39064583 PMCID: PMC11278912 DOI: 10.3390/medicina60071152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Revised: 07/10/2024] [Accepted: 07/15/2024] [Indexed: 07/28/2024]
Abstract
Considerable research efforts have been directed towards investigating neurogenic bladder dysfunction over the preceding decade. This condition stands as the most prevalent and incapacitating pelvic floor disorder amidst patients afflicted with specific upper motor neuron syndromes, including multiple sclerosis, stroke, and spinal cord injury. The current study aims to bring up-to-date findings on rehabilitation methods for treating neurogenic bladder. The Web of Science database (MEDLINE, PsychINFO, EMBASE, CENTRAL, ISRCTN, and ICTRP) was screened for randomized controlled studies and clinical studies using combinations of keywords including "neurogenic bladder", "stroke", "multiple sclerosis", and "spinal cord injury". The PEDro scale was used to assess the quality of the articles included in this study. After a thorough examination, eleven articles met the criteria for inclusion in our research. The outcome measures showed a variety of forms of electrostimulation that can be combined with or without PFMT. These interventions significantly enhance health-related quality of life, as evidenced by various assessment methods. The physical approach constitutes an effective therapeutic method that can reduce the severity of urinary incontinence.
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Affiliation(s)
- Adina Ionelia Manaila
- Department of Fundamental, Preventive, and Clinical Disciplines, Faculty of Medicine, Transilvania University of Brasov, 500036 Brasov, Romania
- Neurorehabilitation Department, Clinical Hospital of Psychiatry and Neurology, 500036 Brasov, Romania
| | - Nadinne Alexandra Roman
- Department of Fundamental, Preventive, and Clinical Disciplines, Faculty of Medicine, Transilvania University of Brasov, 500036 Brasov, Romania
- Neurorehabilitation Department, Clinical Hospital of Psychiatry and Neurology, 500036 Brasov, Romania
| | - Ionut Cristian Cozmin Baseanu
- Department of Fundamental, Preventive, and Clinical Disciplines, Faculty of Medicine, Transilvania University of Brasov, 500036 Brasov, Romania
- Neurorehabilitation Department, Clinical Hospital of Psychiatry and Neurology, 500036 Brasov, Romania
| | - Diana Minzatanu
- Department of Fundamental, Preventive, and Clinical Disciplines, Faculty of Medicine, Transilvania University of Brasov, 500036 Brasov, Romania
- Neurorehabilitation Department, Clinical Hospital of Psychiatry and Neurology, 500036 Brasov, Romania
| | - Vlad Ionut Tuchel
- Department of Fundamental, Preventive, and Clinical Disciplines, Faculty of Medicine, Transilvania University of Brasov, 500036 Brasov, Romania
- Neurorehabilitation Department, Clinical Hospital of Psychiatry and Neurology, 500036 Brasov, Romania
| | - Elena Bianca Basalic
- Department of Fundamental, Preventive, and Clinical Disciplines, Faculty of Medicine, Transilvania University of Brasov, 500036 Brasov, Romania
- Neurorehabilitation Department, Clinical Hospital of Psychiatry and Neurology, 500036 Brasov, Romania
| | - Roxana Steliana Miclaus
- Department of Fundamental, Preventive, and Clinical Disciplines, Faculty of Medicine, Transilvania University of Brasov, 500036 Brasov, Romania
- Neurorehabilitation Department, Clinical Hospital of Psychiatry and Neurology, 500036 Brasov, Romania
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Kuchel GA. AGS/NIA Conference Series on delirium, sleep disorders, and urinary incontinence. J Am Geriatr Soc 2024; 72:1620-1622. [PMID: 38433532 PMCID: PMC11090761 DOI: 10.1111/jgs.18806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 01/06/2024] [Indexed: 03/05/2024]
Affiliation(s)
- George A Kuchel
- UConn Center on Aging, UConn Health, Farmington, Connecticut, USA
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7
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Abadir P, Whitson H. Geriatric research through the lens of AGS/NIA U13: Two decades of interdisciplinary dialogues that have propelled the field. J Am Geriatr Soc 2024; 72:1623-1626. [PMID: 38363144 DOI: 10.1111/jgs.18810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/09/2024] [Accepted: 01/14/2024] [Indexed: 02/17/2024]
Affiliation(s)
- Peter Abadir
- Department of Medicine, Division of Geriatrics Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Heather Whitson
- Department of Medicine, Duke University, Durham, North Carolina, USA
- Durham VA GRECC, Durham VA Geriatrics Research, Education, and Clinical Center, Durham, North Carolina, USA
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Morse L, Cooper BA, Ritchie CS, Wong ML, Kober KM, Harris C, Shin J, Oppegaard K, Hammer MJ, Schimmel AC, Paul SM, Conley YP, Levine JD, Miaskowski C. Stability and consistency of symptom clusters in younger versus older patients receiving chemotherapy. BMC Geriatr 2024; 24:164. [PMID: 38365584 PMCID: PMC10870638 DOI: 10.1186/s12877-024-04755-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 01/28/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND By 2035, the number of newly diagnosed cancer cases will double and over 50% will be in older adults. Given this rapidly growing demographic, a need exists to understand how age influences oncology patients' symptom burden. The study purposes were to evaluate for differences in the occurrence, severity, and distress of 38 symptoms in younger (< 60 years) versus older (≥ 60 years) oncology patients undergoing chemotherapy and to evaluate for differences in the stability and consistency of symptom clusters across the two age groups. METHODS A total of 1329 patients were dichotomized into the younger and older groups. Patients completed demographic and clinical questionnaires prior to the initiation of their second or third cycle of chemotherapy. A modified version of Memorial Symptom Assessment Scale was used to evaluate the occurrence, severity, and distress of 38 common symptoms associated with cancer and its treatment. Differences between the two age groups in demographic and clinical characteristics and ratings of occurrence, severity, and distress for the 38 symptoms were evaluated using parametric and nonparametric tests. Exploratory factor analyses were done within each age group to identify symptom clusters using symptom occurrence rates. RESULTS Compared to the younger group (14.8 (± 7.0)), older adults reported a lower mean number of symptoms (12.9 (± 7.2)). Older patients experienced lower occurrence rates for almost 50% of the symptoms. Regarding symptom clusters, an eight-factor solution was selected for both age groups. Across the two age groups, the eight symptom clusters (i.e., physical and cognitive fatigue, respiratory, psychological, hormonal, chemotherapy-related toxicity, weight gain, gastrointestinal, epithelial) were stable. However, symptoms within the physical and cognitive, chemotherapy-related toxicity, and gastrointestinal clusters were not consistent across the age groups. CONCLUSIONS To be able to provide tailored and effective symptom management interventions to older oncology patients, routine assessments of the core symptoms unique to the symptom clusters identified for this group warrants consideration. The underlying mechanism(s) for these inconsistencies in symptom burden is an important focus for future studies.
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Affiliation(s)
- Lisa Morse
- School of Nursing, University of California, San Francisco, CA, USA
| | - Bruce A Cooper
- School of Nursing, University of California, San Francisco, CA, USA
| | - Christine S Ritchie
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital Morgan Institute, Boston, MA, USA
| | - Melisa L Wong
- School of Medicine, University of California, San Francisco, CA, USA
- Division of Research, Kaiser Permanente Medical Group, Oakland, CA, USA
| | - Kord M Kober
- School of Nursing, University of California, San Francisco, CA, USA
| | - Carolyn Harris
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joosun Shin
- Dana Farber Cancer Institute, Boston, MA, USA
| | | | | | | | - Steven M Paul
- School of Nursing, University of California, San Francisco, CA, USA
| | - Yvette P Conley
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jon D Levine
- School of Medicine, University of California, San Francisco, CA, USA
| | - Christine Miaskowski
- School of Nursing, University of California, San Francisco, CA, USA.
- School of Medicine, University of California, San Francisco, CA, USA.
- Department of Physiological Nursing, School of Nursing, University of California, 2 Koret Way- N631Y, 94143-0610, San Francisco, CA, USA.
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9
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Fisher SR, Villasante-Tezanos A, Allen LM, Pappadis MR, Kilic G. Comparative effectiveness of pelvic floor muscle training, mirabegron, and trospium among older women with urgency urinary incontinence and high fall risk: a feasibility randomized clinical study. Pilot Feasibility Stud 2024; 10:1. [PMID: 38178267 PMCID: PMC10765875 DOI: 10.1186/s40814-023-01440-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 12/21/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Untreated, urgency urinary incontinence (UUI) and overactive bladder (OAB) can precipitate a vicious cycle of decreasing physical activity, social isolation, fear of falling, and falls. Structured behavioral interventions and medications are common initial treatment options, but they elicit their effects through very different mechanisms of action that may influence fall-related outcomes differently. This study will determine the feasibility of conducting a comparative effectiveness, three-arm, mixed methods, randomized clinical trial of a behaviorally based pelvic floor muscle training (PFMT) intervention versus two recent drug options in older women with UUI or OAB who are also at increased risk of falling. METHODS Forty-eight women 60 years and older with UUI or OAB who screen positive for increased fall risk will be recruited through the urogynacology and pelvic health clinics of our university health system. Participants will be randomly assigned to one of three 12-week treatment arms: (1) a course of behavioral and pelvic floor muscle training (PFMT) provided by physical therapists; (2) the beta-3 agonist, mirabegron; and (3) the antimuscarinic, trospium chloride. Study feasibility will be established through objective metrics of evaluability, adherence to the interventions, and attrition. We will also assess relevant measures of OAB symptom severity, quality of life, physical activity, incident falls, and concern about falling. DISCUSSION The proposed research seeks to ultimately determine if linkages between reduction in UI symptoms through treatment also reduce the risk of falling in this patient population. TRIAL REGISTRATION NCT05880862. Registered on 30 May 2023.
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Affiliation(s)
- Steve R Fisher
- Department of Physical Therapy, University of Texas Medical Branch at Galveston, Galveston, USA.
| | | | - Lindsay M Allen
- Department of Physical Therapy, University of Texas Medical Branch at Galveston, Galveston, USA
| | - Monique R Pappadis
- Department of Population Health and Health Disparities, University of Texas Medical Branch at Galveston, Galveston, USA
| | - Gokhan Kilic
- Department of Obstetrics and Gynecology, University of Texas Medical Branch at Galveston, Galveston, USA
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10
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Biscola NP, Bartmeyer PM, Christe KL, Colman RJ, Havton LA. Detrusor underactivity is associated with metabolic syndrome in aged primates. Sci Rep 2023; 13:6716. [PMID: 37185781 PMCID: PMC10130177 DOI: 10.1038/s41598-023-33112-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 04/07/2023] [Indexed: 05/17/2023] Open
Abstract
Lower urinary tract (LUT) dysfunction is prevalent in the elderly population, and clinical manifestations include urinary retention, incontinence, and recurrent urinary tract infections. Age-associated LUT dysfunction is responsible for significant morbidity, compromised quality of life, and rising healthcare costs in older adults, but its pathophysiology is not well understood. We aimed to investigate the effects of aging on LUT function by urodynamic studies and metabolic markers in non-human primates. Adult (n = 27) and aged (n = 20) female rhesus macaques were evaluated by urodynamic and metabolic studies. Cystometry showed detrusor underactivity (DU) with increased bladder capacity and compliance in aged subjects. Metabolic syndrome indicators were present in the aged subjects, including increased weight, triglycerides, lactate dehydrogenase (LDH), alanine aminotransferase (ALT), and high sensitivity C-reactive protein (hsCRP), whereas aspartate aminotransferase (AST) was unaffected and the AST/ALT ratio reduced. Principal component analysis and paired correlations showed a strong association between DU and metabolic syndrome markers in aged primates with DU but not in aged primates without DU. The findings were unaffected by prior pregnancies, parity, and menopause. Our findings provide insights into possible mechanisms for age-associated DU and may guide new strategies to prevent and treat LUT dysfunction in older adults.
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Affiliation(s)
- Natalia P Biscola
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Petra M Bartmeyer
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kari L Christe
- California National Primate Research Center, University of California at Davis, Davis, CA, USA
| | - Ricki J Colman
- Wisconsin National Primate Research Center, University of Wisconsin-Madison, Madison, WI, USA
- Department of Cell and Regenerative Biology, University of Wisconsin-Madison, Madison, WI, USA
| | - Leif A Havton
- Departments of Neurology and Neuroscience, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, New York, NY, 10029, USA.
- James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA.
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11
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Kido Y, Yoshimura Y, Wakabayashi H, Nagano F, Matsumoto A, Bise T, Shimazu S, Shiraishi A. Improvement in sarcopenia is positively associated with recovery of independence in urination and defecation in patients undergoing rehabilitation after a stroke. Nutrition 2023; 107:111944. [PMID: 36634435 DOI: 10.1016/j.nut.2022.111944] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 11/13/2022] [Accepted: 12/08/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVES This study aimed to examine the association between improvement in sarcopenia and the recovery of urinary and defecatory independence in patients undergoing convalescent rehabilitation. METHODS A retrospective cohort study was conducted of 849 older inpatients after a stroke. Of these, patients with sarcopenia and dependent voiding movements were targeted. Sarcopenia was assessed according to the Asian Working Group for Sarcopenia 2019, and diagnosed using handgrip strength (HGS) and skeletal muscle-mass index. Outcomes were sphincter control items of the Functional Independence Measure (FIM) at the time of discharge: urinary (FIM-Bladder) and defecation (FIM-Bowel). A score of six or higher was considered independent. A logistic regression analysis was used to determine whether sarcopenia improvement was associated with outcomes. RESULTS Of the patients recruited, 151 were diagnosed with sarcopenia at baseline, of whom patients dependent in urination (109 patients) and defecation (102 patients) were included in the analysis. The multivariate analysis showed that improvement in sarcopenia (odds ratio [OR]: 3.28; 95% confidence interval [CI],1.01-10.70; P = 0.048) and HGS (OR: 6.25; 95% CI, 1.45-26.90; P = 0.014) were independently associated with FIM-Bladder at the time of discharge. Improvement in HGS (OR: 4.33; 95% CI, 0.99-18.90; P = 0.048) was independently associated with FIM-Bowel at the time of discharge CONCLUSIONS: Improvement in sarcopenia and muscle strength during hospitalization may have a positive effect on urinary independence in stroke patients undergoing convalescent rehabilitation, and improvement in muscle strength may have a positive effect on defecation independence. Multidisciplinary sarcopenia treatment should be implemented in addition to conventional rehabilitation for these patients.
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Affiliation(s)
- Yoshifumi Kido
- Center for Sarcopenia and Malnutrition Research, Kumamoto Rehabilitation Hospital, Kumamoto, Japan
| | - Yoshihiro Yoshimura
- Center for Sarcopenia and Malnutrition Research, Kumamoto Rehabilitation Hospital, Kumamoto, Japan.
| | - Hidetaka Wakabayashi
- Department of Rehabilitation Medicine, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Fumihiko Nagano
- Center for Sarcopenia and Malnutrition Research, Kumamoto Rehabilitation Hospital, Kumamoto, Japan
| | - Ayaka Matsumoto
- Center for Sarcopenia and Malnutrition Research, Kumamoto Rehabilitation Hospital, Kumamoto, Japan
| | - Takahiro Bise
- Center for Sarcopenia and Malnutrition Research, Kumamoto Rehabilitation Hospital, Kumamoto, Japan
| | - Sayuri Shimazu
- Center for Sarcopenia and Malnutrition Research, Kumamoto Rehabilitation Hospital, Kumamoto, Japan
| | - Ai Shiraishi
- Center for Sarcopenia and Malnutrition Research, Kumamoto Rehabilitation Hospital, Kumamoto, Japan
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12
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Bauer SR, McCulloch CE, Cawthon PM, Ensrud KE, Suskind AM, Newman JC, Harrison SL, Senders A, Covinsky K, Marshall LM. Longitudinal Associations between Concurrent Changes in Phenotypic Frailty and Lower Urinary Tract Symptoms among Older Men. J Frailty Aging 2023; 12:117-125. [PMID: 36946708 PMCID: PMC10149140 DOI: 10.14283/jfa.2022.33] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Lower urinary tract symptoms (LUTS) are associated with prevalent frailty and functional impairment, but longitudinal associations remain unexplored. OBJECTIVES To assess the association of change in phenotypic frailty with concurrent worsening LUTS severity among older men without clinically significant LUTS at baseline. DESIGN Multicenter, prospective cohort study. SETTING Population-based. PARTICIPANTS Participants included community-dwelling men age ≥65 years at enrollment in the Osteoporotic Fractures in Men study. MEASUREMENTS Data were collected at 4 visits over 7 years. Phenotypic frailty score (range: 0-5) was defined at each visit using adapted Fried criterion and men were categorized at baseline as robust (0), pre-frail (1-2), or frail (3-5). Within-person change in frailty was calculated at each visit as the absolute difference in number of criteria met compared to baseline. LUTS severity was defined using the American Urologic Association Symptom Index (AUASI; range: 0-35) and men with AUASI ≥8 at baseline were excluded. Linear mixed effects models were adjusted for demographics, health-behaviors, and comorbidities to quantify the association between within-person change in frailty and AUASI. RESULTS Among 3235 men included in analysis, 48% were robust, 45% were pre-frail, and 7% were frail. Whereas baseline frailty status was not associated with change in LUTS severity, within-person increases in frailty were associated with greater LUTS severity (quadratic P<0.001). Among robust men at baseline, mean predicted AUASI during follow-up was 4.2 (95% CI 3.9, 4.5) among those meeting 0 frailty criteria, 4.6 (95% CI 4.3, 4.9) among those meeting 1 criterion increasing non-linearly to 11.2 (95% CI 9.8, 12.6) among those meeting 5 criteria. CONCLUSIONS Greater phenotypic frailty was associated with non-linear increases in LUTS severity in older men over time, independent of age and comorbidities. Results suggest LUTS and frailty share an underlying mechanism that is not targeted by existing LUTS interventions.
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Affiliation(s)
- S R Bauer
- Scott R. Bauer, SFVA Medical Center, Division of General Internal Medicine 4150 Clement St., Building 2, Room 135, San Francisco, CA 94121, USA, , Phone: 415-221-4810 x24322, Twitter handle: @ScottBauerMD, Publicly available data: https://mrosonline.ucsf.edu
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Yoshida M, Satake S, Ishida K, Tanaka Y, Ukai M. A non-interventional cross-sectional re-contact study investigating the relationship between overactive bladder and frailty in older adults in Japan. BMC Geriatr 2022; 22:68. [PMID: 35062875 PMCID: PMC8783467 DOI: 10.1186/s12877-022-02756-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 01/05/2022] [Indexed: 11/18/2022] Open
Abstract
Background Increasing age is associated with frailty and a higher prevalence of overactive bladder (OAB). Given the rapidly increasing proportion of older adults in Japan, a better understanding of the relationship between frailty and OAB is needed to inform future healthcare planning. This study assessed the association between frailty and OAB in older adults in Japan and evaluated the impact on their health-related quality of life (HRQoL). Methods This was a cross-sectional re-contact study of respondents who previously completed the National Health and Wellness Survey 2018 in Japan. Participants were aged ≥65 years and Japanese speakers and readers. As part of a customized online survey, participants were screened for frailty using the Kihon Checklist (frail = scores ≥8 points) and OAB using the overactive bladder symptom score (OAB = total score ≥ 3 points and ≥ 2 points on question 3). The primary endpoint was the odds ratio of frailty in older adults with and without OAB assessed using a multivariable logistic regression model. Secondary endpoints were the prevalence rates of OAB and frailty. Exploratory endpoints assessed HRQoL using the Medical Outcomes Study 12-Item Short Form Survey Instrument version 2 (SF-12v2). Results Overall, 2953 participants were included: 150 (5.1%) were frail OAB, 416 (14.1%) non-frail OAB, 287 (9.7%) frail non-OAB, and 2100 (71.1%) non-frail non-OAB. There was a statistically significant correlation between frailty and OAB demonstrated by an adjusted odds ratio (95% CI) of 2.78 (2.18–3.54; p < 0.001). The prevalence (95% CI) of OAB was 34.3% (29.9–38.8) in frail and 16.5% (15.1–18.0) in non-frail older adults; the prevalence of frailty was 26.5% (22.9–30.1) and 12.0% (10.7–13.3) in older adults with and without OAB. HRQoL was assessed in 150 participants per group. The adjusted HRQoL analyses showed significantly lower scores in participants who were frail OAB vs. frail non-OAB for most of the SF-12v2 scores/sub-component scores. Conclusions These data highlight the statistically significant positive correlation between frailty and OAB among older adults in Japan and may provide valuable information on the burden of OAB and frailty on older adults to healthcare professionals when considering future healthcare planning. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-02756-7.
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Abstract
Advanced Parkinson's disease (PD) often brings a set of motor and non-motor features that are particularly challenging to manage. Medication options can be limited by side-effects and quality of life can be severely affected by an accumulating burden of nonmotor symptoms. Here, we reviewed the literature and our clinical experience with the aim of providing a practical approach to the management of advanced PD. We provide guidelines for treatment of physical and neurobehavioral concerns, that occur in advanced PD.
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Tai H, Liu S, Wang H, Tan H. Determinants of Urinary Incontinence and Subtypes Among the Elderly in Nursing Homes. Front Public Health 2021; 9:788642. [PMID: 34938714 PMCID: PMC8685234 DOI: 10.3389/fpubh.2021.788642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 11/15/2021] [Indexed: 11/13/2022] Open
Abstract
Urinary incontinence (UI) is a common problem among older adults. This study investigated the prevalence of UI in nursing home residents aged ≥75 years in China and examined potential risk factors associated with UI and its subtypes. Data were collected during face-to-face interviews using a general questionnaire, the International Consultation Incontinence Questionnaire Short-Form, and the Barthel Index. A total of 551 participants aged ≥75 years residing in Changsha city were enrolled from June to December 2018. The UI prevalence rate among nursing home residents aged ≥75 years was 24.3%. The most frequent subtype was mixed (M) UI (38.1%), followed by urge (U) UI (35.1%), stress (S) UI (11.9%), and other types (14.9%). In terms of severity, 57.5% had moderate UI, while 35.1% had mild and 7.5% had severe UI. Constipation, immobility, wheelchair use, cardiovascular disease (CVD), and pelvic or spinal surgery were significant risk factors for UI. Participants with a history of surgery had higher risks of SUI (odds ratio [OR] = 4.87, 95% confidence interval [CI]: 1.55–15.30) and UUI (OR = 1.97, 95% CI: 1.05–3.71), those who were immobile or used a wheelchair had higher rates of MUI (OR = 11.07, 95% CI: 4.19–29.28; OR = 3.36, 95% CI: 1.16–9.78) and other UI types (OR = 7.89, 95% CI: 1.99–31.30; OR = 14.90, 95% CI: 4.88–45.50), those with CVD had a higher rate of UUI (OR = 2.25, 95% CI: 1.17–4.34), and those with diabetes had a higher risk of UUI (OR = 2.250, 95% CI: 1.14–4.44). Use of oral antithrombotic agents increased UUI risk (OR = 4.98, 95% CI: 2.10–11.85) whereas sedative hypnotic drug use was associated with a higher risk of MUI (OR = 3.62, 95% CI: 1.25–10.45). Each UI subtype has distinct risk factors, and elderly residents of nursing homes with a history of CVD and pelvic or spinal surgery who experience constipation should be closely monitored. Reducing time spent in bed and engaging in active rehabilitation including walking and muscle strengthening may aid in UI prevention and treatment.
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Affiliation(s)
- Hongyan Tai
- Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Shunying Liu
- Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Haiqin Wang
- Geriatric Department, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Hongzhuan Tan
- Xiangya School of Public Health, Central South University, Changsha, China
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16
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Parker-Autry C, Neiberg RH, Leng I, Colombo L, Kuchel GA, Kritchevsky SB. The geriatric incontinence syndrome: Characterizing geriatric incontinence in older women. J Am Geriatr Soc 2021; 69:3225-3231. [PMID: 34519024 DOI: 10.1111/jgs.17374] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 05/24/2021] [Accepted: 05/27/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Among older women, the clinical presentation of urinary incontinence (UI) is heterogeneous; presenting as a pelvic floor condition or geriatric syndrome. We aimed to characterize the geriatric incontinence syndrome (GIS) to establish its foundation in clinical practice. DESIGN Prospective study. SETTING Geriatric Clinical Research Unit. PARTICIPANTS Sixty-one community-dwelling women aged 70 and older with bothersome UI symptoms. MEASUREMENTS UI symptom type and severity were determined by 3-day bladder diary. UI severity was defined; moderate UI defined as <2 UI episodes/day and severe UI defined as ≥2 UI episodes/day. Subjective assessment of physical performance was determined using the Short Physical Performance Battery (SPPB) score. Total SPPB scores >9 define normal physical performance and scores ≤9 defined impaired physical performance. RESULTS The average age was 77.1 ± 5.8 (mean ± SD) years; 69% of women had severe UI and 31% had moderate UI. Demographic characteristics were similar between groups. Daytime voiding frequency was 7.1 ± 2.9 and nocturia was present equally between groups. The majority of women (59%) with severe UI had SPPB ≤9 compared with 26% among women with moderate UI (p = 0.02); featuring significantly slower chair stand scores (2.3 ± 1.4 vs 3.3 ± 0.9, p = 0.007) and gait speed (0.08 ± 0.2 m/s compared with 1.0 ± 0.2 in women with moderate UI). CONCLUSIONS A multifactorial GIS may be present in older women evidenced by the co-existence of severe UI, physical disability, slower chair stand pace, and gait speed. Prospective studies are needed to understand how these clinical features may impact the clinical care of older incontinent women.
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Affiliation(s)
- Candace Parker-Autry
- Department of Urology, Section on Female Pelvic Health, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Rebecca H Neiberg
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Iris Leng
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Lisa Colombo
- Department of Physical Therapy, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - George A Kuchel
- UConn Center on Aging, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Stephen B Kritchevsky
- S.B. Kritchevsky, Sticht Center for Healthy Aging and Alzheimer's Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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17
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Navigating through incontinence: A qualitative systematic review and meta-aggregation of the experiences of family caregivers. Int J Nurs Stud 2021; 123:104062. [PMID: 34461378 DOI: 10.1016/j.ijnurstu.2021.104062] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 06/30/2021] [Accepted: 08/08/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Community dwelling older adults who are care dependent are highly affected by incontinence, resulting in substantial informal caregiver burden. Understanding the experiences of these caregivers is needed to develop supportive programs that reduce caregiver burden and rates of institutionalization for care recipients. OBJECTIVES This systematic review aimed to critically appraise and synthesize the qualitative literature on the perceptions, experiences, and consequences of informal caregivers managing incontinence in community dwelling older adults. DESIGN A qualitative evidence synthesis using meta-aggregation. DATA SOURCES CINAHL, Embase, Ovid Medline, PsycInfo, Scopus, and ProQuest Dissertations and Theses. REVIEW METHODS A comprehensive search was conducted to identify qualitative studies of all designs, published in English from January 1970 to November 2020, reporting on the experiences of unpaid adult family members or friends providing care at home to an adult aged 60 or older with urinary and/or fecal incontinence. Screening, data extraction, and quality appraisal were conducted independently by two reviewers, with disagreements resolved by consensus with all team members. Joanna Briggs Institute (JBI) processes were used to assess study quality, and the dependability and credibility of both study findings and synthesized findings. All articles included met predetermined criteria. RESULTS Database searches yielded 1165 references, of which 117 full-text documents were screened. Seven articles of moderate to high methodological quality met eligibility criteria and were included. Studies occurred in nine countries with 134 participants who were mostly female spouses of the care recipient. From these eligible studies, 49 findings were extracted with 35 equivocal or credible findings eligible for meta-aggregation. Findings were synthesized into the following four categories: 1) emotional responses, 2) physical, financial, and social consequences, 3) family roles and caregiver support, and 4) management and coping strategies. CONCLUSIONS Informal caregivers experience many physical, psychosocial, and financial challenges in caring for an older family member with incontinence. Educational and supportive programs for managing incontinence should be multi-component and tailored to meet the individual needs of informal caregivers. Future research should incorporate strategies to cope with emotional responses and offer practical strategies for managing incontinence. PROSPERO REGISTRATION CRD42017069185.
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Okumatsu K, Osuka Y, Suzuki T, Kim M, Kojima N, Yoshida Y, Hirano H, Kim H. Urinary incontinence onset predictors in community-dwelling older women: A prospective cohort study. Geriatr Gerontol Int 2020; 21:178-184. [PMID: 33350045 DOI: 10.1111/ggi.14108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 10/22/2020] [Accepted: 11/20/2020] [Indexed: 11/26/2022]
Abstract
AIM We aimed to investigate whether physical function was associated with urinary incontinence (UI) onset in community-dwelling older Japanese women. METHODS This was a 4-year prospective cohort study. After excluding participants with UI and missing data in the baseline survey, we included 890 participants in the analyses. Physical function including grip strength, maximal walking speed, knee extension strength, single-leg balance, and timed up and go (TUG) were measured. The primary outcome was the onset of all UI and different types of UI (urge, stress and mixed) based on the questionnaire survey. Binary logistic regression analysis was applied to calculate the adjusted odds ratios and 95% confidence intervals for the association between physical function and the risk of all UI and different types of UI incident. RESULTS Among the 890 participants, 221 (25%) developed UI during the 4-year follow-up. After adjusting for confounders, better knee extension strength, maximal walking speed and TUG were significantly associated with a lower risk of all UI and urge UI onset, and better single-leg balance and TUG were significantly associated with a lower risk of mixed UI onset (P for trend <0.05). No significant association was found between physical function and the risk of stress UI onset. CONCLUSIONS This study confirmed that better lower extremity physical function is associated with lower risk of urge and mixed UI onset, indicating that exercise programs focusing on maintaining and improving lower extremity physical function may be useful for reducing such events among older women. Geriatr Gerontol Int 2021; 21: 178-184.
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Affiliation(s)
- Koki Okumatsu
- Research Team for Promoting Independence and Mental Health, Tokyo Metropolitan Institute of Gerontology, Itabashi-ku, Japan.,Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan
| | - Yosuke Osuka
- Research Team for Promoting Independence and Mental Health, Tokyo Metropolitan Institute of Gerontology, Itabashi-ku, Japan
| | - Takao Suzuki
- Institute of Gerontology, J.F. Oberlin University, Machida-shi, Japan
| | - Miji Kim
- Department of Biomedical Science and Technology, College of Medicine, East-West Medical Research Institute, Kyung Hee University, Seoul, Republic of Korea
| | - Narumi Kojima
- Research Team for Promoting Independence and Mental Health, Tokyo Metropolitan Institute of Gerontology, Itabashi-ku, Japan
| | - Yuko Yoshida
- Research Team for Human Care, Tokyo Metropolitan Institute of Gerontology, Itabashi-ku, Japan
| | - Hirohiko Hirano
- Research Team for Promoting Independence and Mental Health, Tokyo Metropolitan Institute of Gerontology, Itabashi-ku, Japan
| | - Hunkyung Kim
- Research Team for Promoting Independence and Mental Health, Tokyo Metropolitan Institute of Gerontology, Itabashi-ku, Japan
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Birder LA, Wolf-Johnston A, Wein AJ, Cheng F, Grove-Sullivan M, Kanai AJ, Watson AM, Stoltz D, Watkins SC, Robertson AM, Newman D, Dmochowski RR, Jackson EK. Purine nucleoside phosphorylase inhibition ameliorates age-associated lower urinary tract dysfunctions. JCI Insight 2020; 5:140109. [PMID: 32910805 PMCID: PMC7605521 DOI: 10.1172/jci.insight.140109] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 09/04/2020] [Indexed: 12/29/2022] Open
Abstract
In the aging population, lower urinary tract (LUT) dysfunction is common and often leads to storage and voiding difficulties classified into overlapping symptom syndromes. Despite prevalence and consequences of these syndromes, LUT disorders continue to be undertreated simply because there are few therapeutic options. LUT function and structure were assessed in aged (>25 months) male and female Fischer 344 rats randomized to oral treatment with a purine nucleoside phosphorylase (PNPase inhibitor) 8-aminoguanine (8-AG) or vehicle for 6 weeks. The bladders of aged rats exhibited multiple abnormalities: tactile insensitivity, vascular remodeling, reduced collagen-fiber tortuosity, increased bladder stiffness, abnormal smooth muscle morphology, swelling of mitochondria, and increases in urodamaging purine metabolites. Treatment of aged rats with 8-AG restored all evaluated histological, ultrastructural, and physiological abnormalities toward that of a younger state. 8-AG is an effective treatment that ameliorates key age-related structural and physiologic bladder abnormalities. Because PNPase inhibition blocks metabolism of inosine to hypoxanthine and guanosine to guanine, likely uroprotective effects of 8-AG are mediated by increased bladder levels of uroprotective inosine and guanosine and reductions in urodamaging hypoxanthine and xanthine. These findings demonstrate that 8-AG has translational potential for treating age-associated LUT dysfunctions and resultant syndromes in humans.
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Affiliation(s)
- Lori A Birder
- Department of Medicine, Renal-Electrolyte Division, and.,Department of Pharmacology and Chemical Biology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | | | - Alan J Wein
- Division of Urology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Fangzhou Cheng
- Department of Mechanical Engineering and Materials Science, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Mara Grove-Sullivan
- Department of Cell Biology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Anthony J Kanai
- Department of Medicine, Renal-Electrolyte Division, and.,Department of Pharmacology and Chemical Biology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Alan M Watson
- Department of Cell Biology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Donna Stoltz
- Department of Cell Biology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Simon C Watkins
- Department of Cell Biology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Anne M Robertson
- Department of Mechanical Engineering and Materials Science, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Diane Newman
- Division of Urology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Roger R Dmochowski
- Department of Urology, Vanderbilt Medical Center, Nashville, Tennessee, USA
| | - Edwin K Jackson
- Department of Pharmacology and Chemical Biology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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20
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Tarcan T, Selai C, Herve F, Vrijens D, Smith PP, Apostolidis A, Panicker JN, Kirschner-Hermanns R, Arlandis S, Mosiello G, Dmochowski R, Cardozo L, von Gontard A. Should we routinely assess psychological morbidities in idiopathic lower urinary tract dysfunction: ICI-RS 2019? Neurourol Urodyn 2020; 39 Suppl 3:S70-S79. [PMID: 32662559 DOI: 10.1002/nau.24361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 04/02/2020] [Indexed: 12/20/2022]
Abstract
AIMS Psychological morbidities play a major role in idiopathic lower urinary tract dysfunction (iLUTD). The aim of the Think Tank (TT) was to discuss the relevance of psychological morbidities in idiopathic LUTD over the life span, including overactive bladder (OAB) or dysfunctional voiding (DV) and methods of assessment. METHODS The paper is based on a selective review of the literature and in-depth discussions, leading to research recommendations regarding the assessment of psychological morbidities in iLUTD on children and adults held during the TT of the International Consultation on Incontinence Research Society in 2019. RESULTS Psychological comorbidities affect the health behaviors and treatment outcomes in patients with iLUTD. Both clinically relevant comorbid mental disorders, as well as subclinical psychological symptoms have a major impact and negatively influence incontinence treatment. Research is needed to elucidate mechanisms underlying iLUTD and psychological comorbidities. Clinical studies are needed to determine how perception generation and cognition impacts on the relationship of urinary perceptions, symptoms, and objective urodynamic function. Due to high psychological comorbidity rates, screening with validated, generic questionnaires for emotional and behavioral disorders in children with nocturnal enuresis, daytime urinary incontinence, and fecal incontinence is recommended. Brief screening is recommended for all adults with iLUTD, especially with OAB and DV, who are refractory to treatment. CONCLUSIONS Due to the high rate and relevance in clinical practice, screening for psychological comorbidities is recommended for all age groups. The research recommendations of this TT may be followed to improve the assessment of psychological morbidities in iLUTD.
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Affiliation(s)
- Tufan Tarcan
- Department of Urology, Marmara University School of Medicine, Istanbul, Turkey.,Department of Urology, Koç University School of Medicine, Istanbul, Turkey
| | - Caroline Selai
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, UK
| | - François Herve
- Department of Urology, Cliniques Universitaires Saint Luc, Brussels, Belgium
| | - Desiree Vrijens
- Department of Urology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Phillip P Smith
- Department of Surgery, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Apostolos Apostolidis
- 2nd Department of Urology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Jalesh N Panicker
- Department of Uro-Neurology, The National Hospital for Neurology and Neurosurgery and UCL Institute of Neurology, London, UK
| | - Ruth Kirschner-Hermanns
- Department of Urology, Pediatric Urology, and Neurourology, University Hospital of Bonn, Bonn, Germany
| | - Salvador Arlandis
- Department of Urology, La Fe University and Polytechnic Hospital, Valencia University, Spain
| | - Giovanni Mosiello
- Department of Surgery, Neuro-Urology Unit, Bambino Gesu Pediatric Hospital, Rome, Italy
| | - Roger Dmochowski
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Linda Cardozo
- Department of Urogynaecology, King's College Hospital, London, UK
| | - Alexander von Gontard
- Department of Child and Adolescent Psychiatry, Saarland University Hospital, Homburg, Germany
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A Call to Action - Nursing Must Do More to Reduce Lower Urinary Tract Symptoms. Int J Nurs Stud 2020; 107:103577. [PMID: 32339932 DOI: 10.1016/j.ijnurstu.2020.103577] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 03/11/2020] [Accepted: 03/12/2020] [Indexed: 12/26/2022]
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22
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Suzuki M, Okochi J, Iijima K, Murata T, Kume H. Nationwide survey of continence status among older adult residents living in long-term care facilities in Japan: The prevalence and associated risk factors of incontinence and effect of comprehensive care on continence status. Geriatr Gerontol Int 2020; 20:285-290. [PMID: 31991532 DOI: 10.1111/ggi.13872] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 12/22/2019] [Accepted: 01/04/2020] [Indexed: 12/15/2022]
Abstract
AIM This study aimed to identify the prevalence of urinary, fecal and double incontinence among Japanese residents aged ≥65 years living in long-term care facilities. Furthermore, the association between baseline characteristics and changes in toileting activity after a 3-month comprehensive care among older individuals was investigated. METHODS We examined the prevalence of incontinence and its significant predictors. The association between the Functional Independence Measure score at baseline and each type of incontinence (urinary, fecal or double incontinence) was examined using a logistic regression model. Similarly, the association between the Functional Independence Measure score at baseline and improvement in toileting activity after a 3-month comprehensive care was examined. RESULTS In total, 2517 residents (670 men and 1847 women) were recruited. The prevalence rates of urinary, fecal and double incontinence were 66.9%, 42.8% and 41.1%, respectively. In multivariate analysis, the sum of the motor subscales after removing four continence items and the sum of the cognitive subscales of the Functional Independence Measure score at baseline were significantly associated with all types of incontinence. The sum of the motor subscales after removing four continence items of the Functional Independence Measure score was associated with improved toileting activity. CONCLUSIONS This study presented the prevalence of urinary, fecal and double incontinence among residents living in long-term care facilities in Japan. The Functional Independence Measure items at baseline were associated with not only continence status, but also improved toileting activity after 3-month comprehensive care. Geriatr Gerontol Int 2020; 20: 285-290.
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Affiliation(s)
- Motofumi Suzuki
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Urology, Tokyo Teishin Hospital, Tokyo, Japan
| | - Jiro Okochi
- Tatsumanosato Long-Term Care Health Facility, Osaka, Japan
| | - Katsuya Iijima
- Institute of Gerontology, The University of Tokyo, Tokyo, Japan
| | - Taro Murata
- Department of Urology, Tokyo Teishin Hospital, Tokyo, Japan
| | - Haruki Kume
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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23
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Al-Naggar IM, Hardy CC, Taweh OG, Grabauskas T, Mulkey DK, Kuchel GA, Smith PP. HCN as a Mediator of Urinary Homeostasis: Age-Associated Changes in Expression and Function in Adrenergic Detrusor Relaxation. J Gerontol A Biol Sci Med Sci 2019; 74:325-329. [PMID: 30124776 DOI: 10.1093/gerona/gly137] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Indexed: 12/19/2022] Open
Abstract
The Hyperpolarization activated, cyclic nucleotide gated (HCN) channel is a candidate mediator of neuroendocrine influence over detrusor tonus during filling. In other tissues, HCN loss with aging is linked to declines in rhythmicity and function. We hypothesized that HCN has an age-sensitive expression profile and functional role in adrenergic bladder relaxation. HCN was examined in bladders from young (2-6 months) and old (18-24 months) C57BL/6 female mice, using qRT-PCR, RNAScope, and Western blots. Isometric tension studies were conducted using bladder strips from young wild-type (YWT), old wild-type (OWT), and young HCN1 knock-out (YKO) female mice to test the role HCN in effects of β-adrenergic stimulation. Hcn1 is the dominant HCN isoform RNA in the mouse bladder wall, and is diminished with age. Location of Hcn RNA within the mouse bladder wall is isoform-specific, with HCN1 limited to the detrusor layer. Passively-tensioned YWT bladder strips are relaxed by isoproterenol in the presence of HCN function, where OWT strips are relaxed only in the presence of HCN blockade. HCN has an age-specific expression and function in adrenergic detrusor relaxation in mouse bladder strips.
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Affiliation(s)
- Iman M Al-Naggar
- UConn Center on Aging, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Cara C Hardy
- UConn Center on Aging, University of Connecticut School of Medicine, Farmington, Connecticut.,Department of Neuroscience, UConn Health, Farmington, Connecticut
| | - Omar G Taweh
- Department of Physiology and Neurobiology, University of Connecticut, Farmington, Connecticut
| | - Titas Grabauskas
- UConn Center on Aging, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Daniel K Mulkey
- Department of Physiology and Neurobiology, University of Connecticut, Farmington, Connecticut.,University of Connecticut Institute for Brain and Cognitive Science, Storrs, Connecticut
| | - George A Kuchel
- UConn Center on Aging, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Phillip P Smith
- UConn Center on Aging, University of Connecticut School of Medicine, Farmington, Connecticut.,Department of Neuroscience, UConn Health, Farmington, Connecticut.,Department of Physiology and Neurobiology, University of Connecticut, Farmington, Connecticut.,Department of Surgery, UConn School of Medicine, Farmington, Connecticut
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Abstract
Purpose of review In this article, we will review current dilemmas regarding evaluation and management of the geriatric bladder incorporating concepts of normal changes of aging as well as common lower urinary tract dysfunction. Recent findings Increasing age leads to functional changes in essentially all organ systems including the genitourinary system. Understanding the natural changes with age of the bladder as well as the signs and symptoms of pathologic conditions is paramount to diagnosis and treatment of urologic conditions in the geriatric population. Summary There are several conundrums in the diagnosis and evaluation of the geriatric bladder including the ability of the bladder to store, empty, as well as sensitivity disturbances. Diagnostic testing and goals of treatment should be individualized for each patient and personalized to consider patient comorbidities, limitations, and expectations.
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Hardy CC, Keilich SR, Harrison AG, Knight BE, Baker DS, Smith PP. The aging bladder phenotype is not the direct consequence of bladder aging. Neurourol Urodyn 2019; 38:2121-2129. [PMID: 31452236 DOI: 10.1002/nau.24149] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 08/06/2019] [Indexed: 12/15/2022]
Abstract
AIMS The prevalence of urinary dysfunction increases with age, yet therapies are often suboptimal. Incomplete understanding of the linkages between system, organ, and tissue domains across lifespan remains a knowledge gap. If tissue-level changes drive the aging bladder phenotype, parallel changes should be observed across these domains. In contrast, a lack of inter-domain correlation across age groups would support the hypothesis that urinary performance is a measure of the physiologic reserve, dependent on centrally-mediated adaptive mechanisms in the aging system. METHODS Male and female mice across four age groups underwent sequential voiding spot assays, pressure/flow cystometry, bladder strip tension studies, histology, and quantitative PCR analyses. The primary objective of this study was to test the impact of age on the cortical, autonomic, tissue functional and structural, and molecular domains, and identify inter-domain correlations among variables showing significant changes with age within these domains. RESULTS Behavior revealed diminished peripheral voiding and spot size in aged females. Cystometry demonstrated increased postvoid residual and loss of volume sensitivity, but the preservation of voiding contraction power, with almost half of oldest-old mice failing under cystometric stress. Strip studies revealed no significant differences in adrenergic, cholinergic, or EFS sensitivity. Histology showed increased detrusor and lamina propria thickness, without a change in collagen/muscle ratio. Adrb2 gene expression decreased with age. No consistent inter-domain correlations were found across age groups. CONCLUSIONS Our findings are consistent with a model in which centrally-mediated adaptive failures to aging stressors are more influential over the aging bladder phenotype than local tissue changes.
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Affiliation(s)
- Cara C Hardy
- Center on Aging, UConn Health, University of Connecticut SOM, Farmington, Connecticut.,Department of Neuroscience, UConn Health, University of Connecticut SOM, Farmington, Connecticut.,Institute for Brain and Cognitive Sciences, University of Connecticut, Storrs, Connecticut
| | - Spencer R Keilich
- Center on Aging, UConn Health, University of Connecticut SOM, Farmington, Connecticut.,Department of Immunology, UConn Health, University of Connecticut SOM, Farmington, Connecticut
| | - Andrew G Harrison
- Center on Aging, UConn Health, University of Connecticut SOM, Farmington, Connecticut.,Department of Immunology, UConn Health, University of Connecticut SOM, Farmington, Connecticut
| | - Brittany E Knight
- Department of Neuroscience, UConn Health, University of Connecticut SOM, Farmington, Connecticut
| | - Dylan S Baker
- Center on Aging, UConn Health, University of Connecticut SOM, Farmington, Connecticut
| | - Phillip P Smith
- Center on Aging, UConn Health, University of Connecticut SOM, Farmington, Connecticut.,Department of Neuroscience, UConn Health, University of Connecticut SOM, Farmington, Connecticut.,Institute for Brain and Cognitive Sciences, University of Connecticut, Storrs, Connecticut.,Department of Surgery, UConn Health, University of Connecticut SOM, Farmington, Connecticut
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Vaughan CP, Fitzgerald CM, Markland AD. Management of Urinary Incontinence in Older Adults in Rehabilitation Care Settings. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2019. [DOI: 10.1007/s40141-019-00221-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Smith K, Sutherland A, Hyde Z, Crawford R, Dwyer A, Malay R, Skeaf L, Flicker L, Atkinson D, LoGiudice D. Assessment, incidence and factors associated with urinary incontinence in older Aboriginal Australians. Intern Med J 2018; 49:1111-1118. [PMID: 30548387 DOI: 10.1111/imj.14192] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 12/03/2018] [Accepted: 12/06/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Little is known about urinary incontinence in older Aboriginal Australians. AIM To describe urinary incontinence assessment, prevalence, incidence and associated conditions in older Aboriginal Australians. METHODS Wave 1 consisted of 363 Aboriginal participants aged ≥45 years from Western Australia; 289 participants participated in Wave 2, with 184 included at both time points. Urinary incontinence was assessed by self-report, family report and the modified International Consultation on Incontinence Questionnaire (ICIQ). We investigated factors associated with incontinence with binary logistic regression. Sensitivity and specificity analyses of incontinence measures were undertaken using the ICIQ score ≥2 as the reference standard. RESULTS Participant mean age was 61.2 ± 11.2 years. Prevalence of incontinence at Wave 2 (n = 289) using self-report was 24.6%; using ICIQ ≥2 was 22.5%; and family report 14.2%. Incidence after follow-up of 6.7 years was 33 (23.6%), higher than estimates of 5-20% in other populations. Cross-sectional associations with incontinence include female sex (odds ratio (OR) = 6.82; 95% confidence interval (CI) 2.98-15.57), stroke (OR = 3.55; 95% CI 1.43-8.77), head injury (OR = 3.15; 95% CI 1.54-6.45) and depressive symptoms (OR = 1.07; 95% CI 1.01-1.14). Longitudinal associations were age (OR = 1.05; 95% CI 1.01-1.09) and female sex (OR = 2.37; 95% CI 0.99-5.67). Sensitivity (81.5%) and specificity (93.5%) of self-report were high. CONCLUSION The prevalence and incidence of urinary incontinence in Aboriginal Australians is high with risk factors of older age and female sex. The modified ICIQ and self-report appear to be appropriate incontinence screens. Further research to understand causes and treatments within this population is urgently required.
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Affiliation(s)
- Kate Smith
- Western Australian Centre for Health and Ageing, University of Western Australia, Perth, Western Australia, Australia.,Centre for Aboriginal Medical and Dental Health, University of Western Australia, Perth, Western Australia, Australia
| | - Ailsa Sutherland
- Kimberley Aged and Community Services, Broome, Western Australia, Australia
| | - Zoë Hyde
- Western Australian Centre for Health and Ageing, University of Western Australia, Perth, Western Australia, Australia
| | - Ruth Crawford
- Kimberley Aged and Community Services, Broome, Western Australia, Australia
| | - Anna Dwyer
- Western Australian Centre for Health and Ageing, University of Western Australia, Perth, Western Australia, Australia.,Nulungu Research Institute, University of Notre Dame, Broome, Western Australia, Australia
| | - Roslyn Malay
- Western Australian Centre for Health and Ageing, University of Western Australia, Perth, Western Australia, Australia
| | - Linda Skeaf
- Western Australian Centre for Health and Ageing, University of Western Australia, Perth, Western Australia, Australia
| | - Leon Flicker
- Western Australian Centre for Health and Ageing, University of Western Australia, Perth, Western Australia, Australia
| | - David Atkinson
- Rural Clinical School of WA, University of Western Australia, Perth, Western Australia, Australia.,Kimberley Aboriginal Medical Services, Broome, Western Australia, Australia
| | - Dina LoGiudice
- Aged Care, Melbourne Health and The University of Melbourne, Melbourne, Victoria, Australia
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Vespasiani-Gentilucci U, Pedone C, Muley-Vilamu M, Antonelli-Incalzi R. The pharmacological treatment of chronic comorbidities in COPD: mind the gap! Pulm Pharmacol Ther 2018; 51:48-58. [PMID: 29966745 DOI: 10.1016/j.pupt.2018.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 06/27/2018] [Accepted: 06/29/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is commonly associated with other chronic diseases, which poses several diagnostic and therapeutic problems. Indeed, important comorbidities frequently remain unrecognized and, then, untreated, whereas respiratory drugs may have non respiratory side effects, and selected non respiratory drugs may variably affect the respiratory function. OBJECTIVE to describe: how COPD affects the presentation and contributes to the diagnostic challenges of its most common comorbidities; how coexisting COPD impacts the therapeutic approach to selected comorbidities and viceversa. METHODS we distinguish comorbidities of COPD depending upon whether they are complications of COPD or share risk factors, mainly smoke, with it or, finally, aggravate COPD. We describe atypical presentations of and diagnostic clues to comorbidities and suggest screening procedures. Finally, the main therapeutic problems, as resulting from the risk of untoward effects of therapies of COPD and its comorbidity, with special attention to drug-drug interactions and possible overdosages, are described. RESULTS selected complications of COPD, such as osteoporosis, sarcopenia and dysphagia, are rarely recognized and treated, likely due to the poor awareness of them. Important comorbidities, such as coronary artery disease, chronic heart failure, obstructive sleep apnoea syndrome and chronic renal failure, also should be systematically searched for because of their commonly variant presentation. Disease-related symptoms should be distinguished from drug effects or drug-drug interaction effects. CONCLUSIONS a truly comprehensive view of the complex COPD patient, hopefully capitalizing on multidimensional geriatric assessment, is needed to dissect the many components of health status impairment and to provide the optimal care. Selected screening procedures are highly desirable to identify frequently missed comorbidities. Pharmacosurveillance is an essential part of the approach to COPD and its comorbidities.
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Affiliation(s)
| | - Claudio Pedone
- Internal Medicine and Geriatrics Area, University Campus Bio-Medico of Rome, Italy
| | - Moises Muley-Vilamu
- Internal Medicine and Geriatrics Area, University Campus Bio-Medico of Rome, Italy
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What don't we know about bladder control and why does it matter? An AGS-NIA collaborative conference sought answers - and progress. Geriatr Nurs 2018; 39:128-129. [PMID: 29336829 DOI: 10.1016/j.gerinurse.2017.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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