Catherine E. DuBeau

Incontinence in the frail elderly: Report from the 4th international consultation on incontinence†

To summarize current knowledge on the etiology, assessment, and management of urinary incontinence (UI) in frail older persons. “Frail” here indicates a person with a clinical phenotype combining impaired physical activity, mobility, muscle strength, cognition, nutrition, and endurance, associated with being homebound or in care institutions and a high risk of intercurrent disease, disability, and death.

Using Assessing Care of Vulnerable Elders Quality Indicators to Measure Quality of Hospital Care for Vulnerable Elders

OBJECTIVES: To assess the quality of care for hospitalized vulnerable elders using measures based on Assessing Care of Vulnerable Elders (ACOVE) quality indicators (QIs).

The Aging Lower Urinary Tract

PURPOSE Age related changes in continence and the GU system, and how they affect the management of LUT dysfunction are discussed. Guidelines are offered regarding the diagnosis and management of incontinence in the elderly population. MATERIALS AND METHODS Published literature and current treatment practice specific to elderly patients with LUT dysfunction were reviewed. RESULTS LUT symptoms in the elderly population are affected by the high prevalence of comorbidity and polypharmacy. In addition, the GU system undergoes age related changes that increase the risk of LUT dysfunction. CONCLUSIONS Incontinence in older persons is almost always caused by multiple factors, of which not all are directly related to the GU system. Issues such as polypharmacy, comorbidity, and the increased risk of medication side effects must be considered in planning treatment. The primary care physician and urologist or gynecologist should establish a partnership to co-manage the broad spectrum of factors affecting continence in elderly patients.

Localization of Brain White Matter Hyperintensities and Urinary Incontinence in Community-Dwelling Older Adults

BACKGROUND Because white matter hyperintensities (WMHs) on magnetic resonance imaging (MRI) may be linked to geriatric syndromes involving mobility, cognition, and affect, we postulated that involvement of areas critical to bladder control could influence urinary incontinence (UI). METHODS One hundred community-dwelling individuals (75-89 years) were recruited into three groups stratified by age and gender reflecting normal and mildly and moderately impaired mobility. Baseline incontinence status and related symptoms were evaluated in 97 individuals using validated instruments (3IQ, Urinary Incontinence Severity Index, Urogenital Distress Inventory, Incontinence Impact Questionnaire). Regional WMH was measured using an MRI brain imaging segmentation pipeline and WM tract-based parcellation atlas. RESULTS Sixty-two (64%) of the participants were incontinent, mostly with urgency (37; 60%) and moderate-severe symptoms (36; 58%). Incontinent individuals were more likely to be women with worse scores for depression and mobility. WMH located in right inferior frontal regions predicted UI severity, with no significant relationship with incontinence, incontinence type, bother, or functional impact. As regards WM tracts, WMH within regions normally occupied by the anterior corona radiata predicted severity and degree of bother, cingulate gyrus predicted incontinence and severity, whereas cingulate (hippocampal portion) and superior fronto-occipital fasciculus predicted severity. CONCLUSIONS Presence of WMH in right inferior frontal regions and selected WM tracts predicts incontinence, incontinence severity, and degree of bother. Our observations support the findings of recent functional MRI studies indicating a critical role for the cingulum in bladder control, while also suggesting potential involvement of other nearby WM tracts such as anterior corona radiata and superior fronto-occipital fasciculus.

Experience of an incontinence clinic for older women: no apparent age limit for potential physical and psychological benefits.

Urinary incontinence (UI) is a common but undertreated condition in older women. Although a variety of noninvasive interventions is available, older women may be hesitant to seek care for UI because of misconceptions about normal aging and treatment futility. We sought to evaluate the effectiveness of a UI clinic specifically tailored to the needs of older women to promote a sense of empowerment and to enhance satisfaction with treatment and outcome. We describe a case series of 52 women between the ages of 65 and 98 who were evaluated at the Geriatric Incontinence Clinic at the McGill University Health Centre over a 1-year period. A standardized telephone questionnaire was administered by a nurse consultant 6 months after each subjects final visit to assess patient satisfaction and current incontinence status. Forty-five women (86%) were available for telephone follow-up and completed the questionnaire. Mean age was 80 years, with urge incontinence in 45%, mixed incontinence (stress and urge) in 33%, impaired bladder emptying with urge symptoms in 10%, and other diagnoses in 12%. Overall, a mean reduction of 1.4 incontinent episodes per day was reported. At follow-up, 30% of the subjects reported being cured of their incontinence, 30% had improved, 20% were the same, and 20% were worse. Over 85% of all women reported satisfaction with their new incontinence status. Women of all ages, independent of the type of UI, type of treatment, and cognitive status, were able to achieve reductions in incontinence symptoms. All patients who had worsened were noncompliant with treatment recommendations at follow-up. Older women can derive significant benefit from a UI assessment. Neither advanced age nor category of incontinence precludes improvements or enhanced satisfaction with treatment. Efforts to improve targeting and compliance may improve outcomes.

Improving urinary incontinence in nursing home residents: are we FIT to be tied?

Despite guidelines, regulations, and research, the problem of urinary incontinence (UI) in nursing home (NH) residents has seen little improvement. The prevalence of UI in NHs increased from 55% to 65% from 1987 to 1997, especially in men, yet since 1987, only four randomized, controlled trials of drug treatment for UI in NH residents have been published. Therefore, management of UI has remained the Incontinence Resident Assessment Protocol of the Minimum Data Set (MDS), prompted voiding strategies, habit training, and, overwhelmingly, the use of absorbent products. Overall, the effectiveness of behavioral interventions as practiced has been disappointing; a 2003 editorial in these pages gave the quality of UI management in NHs ‘‘a failing grade,’’ and there is no indication that it has improved since. Absorbent products are palliative, and habit retraining is ineffective. Prompted voiding decreases UI rates in clinical trials, but its implementation fades once research assistants leave and regular staff take over. Although efficacy is best in selected residents with moderate UI who respond to a 3-day treatment trial, a survey of 486 residents with UI in 18 NHs found that none had chart documentation of an assessment to determine their response to scheduled toileting. In the same study, MDS documentation of scheduled voiding was not reflected in residents’ reports of more frequent toileting. Obviously, we are in desperate need of new approaches. Two researchers to whom we already are indebted for more than 2 decades of indefatigable work to make headway against the problem of NH UI are Joe Ouslander and Jack Schnelle. In this issue, they, together with colleagues, present further evaluation of the effect of their rehabilitation intervention, Functional Incidental Training (FIT), on physical function and UI in NH residents. FIT combines prompted voiding with low-intensity endurance and strength exercises and is conducted in the course of routine care (albeit by trained research aides). This approach addresses UI directly through toileting and indirectly by improving physical function to make toileting easier. The authors’ previous studies in predominantly female residents of community NHs showed that FIT significantly improved UI, endurance, and strength. In their present study, Ouslander et al. evaluated FIT in a 90% male VA NH population notable for a high prevalence of cognitive impairment, psychiatric comorbidity, and functional dependence. This study also differed in its shorter duration and crossover design, allowing evaluation of the intervention’s endurance. Again, FIT resulted in improved endurance (wheeling/walking total distance; time to move 6 m; transfer time; and sit-to-stand time, number, and maximum number), greater strength (biceps curl and hip flexion), and less UI. Considering the population (median age 78, mean Mini-Mental State Examination score 5 15, only about half ambulatory without human assistance, median Charlson index score 5 4), some of the observed magnitudes of change are considerable: 44% median increase in strength, 36% decrease in time for sit-to-stand, and 39% decrease in percentage of checks wet. Impressively, twothirds of those completing FIT improved in at least one measure in all three domains (endurance, strength, and continence) during the 8-week intervention. Clearly, FIT can improve functional outcomes in a wide range of frail older persons in NHs who have significant impairment and comorbidity. But can FIT be generalized into wide practice in NHs? The authors point out that, indeed, the cost is prohibitive; FITrequires 42 to 63 minutes of aide time, making it at least three times as costly as usual care, and it will not pay for itself in terms of preventing illness. Schnelle and his colleagues already have cogently argued that current NH staff limitations and inaccurate data documentation prevent the translation of FIT into regular NH practice. The suggestion to try FIT anyway, ‘‘targeting . . . incontinent residents and assign one per aide for toileting and FIT,’’ likely will be short-lived in practice as well. Also, the crossover results in the present trial indicate that functional gains deteriorate once the intervention stops. These impediments generalize to all behavioral strategies for UI in NHs. Federal policy is being brought to bear, but its effect is uncertain. UI is identified as a quality indicator in the Centers for Medicare and Medicaid Services (CMS) Nursing Home Quality Initiative (NHQI). Intended for use by policy-makers, industry, and consumers to compare care quality across NHs, the UI indicator is the prevalence of UI in ‘‘‘low-risk’ residents without ‘severe dementia’ (loss of intellect including impaired memory and judgment) or loss of ability to perform all the activities of daily living.’’ The NHQI plan is consonant with the Bush administration’s approach to inadequate NH staffing: to use consumerdriven market forces to ‘‘demand’’ increased staffing, rather than establishing minimum staffing levels that could increase government costs, and to move nursing home residents to community settings with the President’s ‘‘Money Follows the Individual’’ initiative. Although CMS takes credit for a decline in restraints and better reporting of pain since the inception of the program, other temporal factors and regulations may account for these changes, and DOI: 10.1111/j.1532-5415.2005.53366.x

Defining and advancing education and conservative therapies of underactive bladder.

In contrast to other forms of voiding dysfunction, underactive bladder (UAB) has traditionally received little research or educational attention. This is changing as our understanding of the underlying mechanisms of detrusor dysfunction and other forms of underactive bladder improves. In addition, the impact of UAB on patient symptoms, general and health-related quality of life, and caregiver burden are becoming more recognized. However, there remains a paucity of data on the subject, and an extensive need for additional research and education on the topic. This paper explores the current state of knowledge about UAB with an emphasis on education regarding the condition and conservative methods of assessment and treatment. Recommendations for future work in this area are considered.

Nocturia in the Elderly

Nocturia is a part of life for most older persons, especially men, nearly 90% of whom experience at least one episode of nighttime voiding [1]. It is often cited as one of the most bothersome of lower urinary tract symptoms (LUTS) [2, 3]. Unlike the other common LUTS, nocturia can cause significant morbidity and even mortality for elderly persons.

55 – Aging and the Lower Urogenital System

Publisher Summary Lower urinary tract (LUT) function in older persons reflects not only aging per se , but also co-morbid disease and changes in sex hormones. Womens focus on the LUT shifts from reproduction to other functions, especially continence and sexual health, whereas that of men increasingly turns to prostate disease. The prevalence of LUT symptoms, such as nocturia, vaginal dryness, and urinary incontinence, increase with age, yet this association is not absolute. Age brings with it increased inter-individual variability, making chronological age a poor marker for health status: an 80-year-old may be a nursing home resident with end-stage dementia, or a vibrant, sexually active working woman. Clinically, the prevalence of LUT symptoms in older persons may be underestimated because of patient under-reporting due to embarrassment, reticence, or assumption that such symptoms are “normal.” Assessment of symptom severity can be compromised by a persons acceptance of “old age” (e.g., “thats what happened to my mother and grandmother”). The fact that only half of older persons with LUT symptoms report them as impacting daily life may have more to do with circumstances and psychological factors than symptom severity. Furthermore, it is crucial to differentiate age-related changes and age-associated pathophysiology from both symptoms and function. Observed changes may not impair function or cause symptoms, but can predispose to dysfunction especially when an additional “insult” occurs. Older individuals have decreased physiological reserve, a phenomenon called “homeostenosis.” Therefore, even a small additional effect can have a major impact on function.