Modifiable factors for urinary incontinence - type cause and effect poster
1
Urinary incontinence type, cause and effect: result of a pilot study Michelle Lai 1 , Chok Lui 2 , Charles Inderjeeth 2 , Jan Little 1 , Mary King 3 1 Dept of Community and Geriatric Medicine, Fremantle Hospital, Fremantle, Western Australia. 2 Dept of Rehabilitation and Aged Care, Sir Charles Gairdner Hospital, Perth, Western Australia. 3 Corporate nursing, Sir Charles Gairdner Hospital, Perth, Western Australia. Background: • Key management in urinary incontinence (UI) in older patients is to identify potentially reversible causes, so appropriate steps can be instituted to reduce their impact. • Little data exist pertaining to modifiable causes of UI among older ambulatory patients. Most studies examining risk factors were conducted in middle aged (1) (2) , homebound, frail (3)(4) or institutionalised older patients (5) . Known risk factors in older community dwelling individuals were ill-defined. These include co- morbidities such as stroke, diabetes, arthritis, obesity, depression, mobility and functional impairment (6)(7) . Aim: • To describe the correlates of modifiable causes of UI in this population. Method: • In this cross-sectional study, 91 patients were recruited from a general geriatric and 2 continence clinics, including 27 patients without incontinence as control. Continence advisors or clinicians completed questionnaires after initial assessment with history, clinical examination, bladder chart and bladder scan. Univariate and multivariate analysis were performed. Table 1 Demographic characteristics of patients with all cause incontinence Characteristics Patients with (n=64) Male (n=15) Female (n= 49) all cause incontinence Age 79.56± 8.53 74.40 ±6.22 81.14 ±8.57 a Residence (n,%) Community 63 (98.4) 15 (100) 48 (98.0) Hostel 1 (1.6) 0 (0) 1 (2.0) Ethnicity White 59 (92.2) 13 (86.7) 46 (93.9) Asian 2 (3.1) 1 (6.7) 1 (2.0) Others 3 (1.7) 1 (6.7) 2 (4.1) Cognition Normal 50 (78.1) 12 (80.0) 38 (77.6) MCI 1 (1.6) 1 (6.7) 1 (2.0) Dementia 8 (12.5) 1 (6.7) 7 (14.3) Not documented 5 (7.8) 1 (6.7) 3 (6.1) MMSE 25.70±4.21 28.00±2.35 24.93±4.46 ADL High functioning 20 (31.2) 1 (6.7) 19 (38.8) Moderately impaired 34 (53.1) 13 (86.7) 21 (42.9) Severely impaired 5 (7.8) 1 (6.7) 4 (8.2) Not documented 5 (7.8) 0 5 (10.1) a P =0.05, compared with male group Table 3. Multivariate analysis of reversible risk factors for urge and mixed (urge and stress) incontinence Attributes Unadjusted Age-adjusted OR (95% CI) p-value OR (95% CI) p-value For urge incontinence (n=40/91): Tea/coffee consumption 5.48(1.70-17.70) <0.01 5.62(1.73-18.32) <0.01 Poor ADL 3.52(1.18-10.51) 0.02 3.55(1.18-10.66) 0.02 Constant -1.27 0.59 For mixed incontinence (n=15/91): Depression 4.32(1.05-17.72) 0.04 4.33(1.03-18.13) 0.05 Diuretics 3.76(1.02-13.85) 0.05 3.75(0.96-14.60) 0.06 Hypnotics 8.12(1.54 -42.77) 0.01 8.12(1.54-42.77) 0.01 Constant -2.61 -2.63 where OR=odds ratio Result: • Patients were predominantly Caucasian (92.2%) and female (76.6%) [mean age=79.24, SD=8.47] . • Logistic regression analysis (table 3) revealed that patients presented with urge incontinence were more likely to consume regular tea/coffee (adjusted OR 5.62, 95% CI 1.73-18.32) and have functional disability (adjusted OR 3.55, 95% CI 1.18-10.66). • Patients with mixed (urge and stress) incontinence were more likely to have depression(adjustedOR4.33,95%CI1.03-18.13),usediuretics(adjustedOR3.75, 95% CI 0.96-14.60) and hypnotics (adjusted OR 8.12, 95% CI 1.54-42.77). • For both types of incontinence, only patients with diuretics reported worse perceived bladder symptoms (OR 5.18, 95% CI 1.03-26.13 respectively) compared to those without these 2 features. However, there was no difference in bladder charts between the 2 groups. • The number of patients with stress incontinence was too small to perform risk factor analysis. Table 2. Univariate analysis of reversible factors and age with urinary urge and mixed (urge and stress) incontinence Attributes Case (N) Urge incontinence (n=40) Mixed incontinence (n=15) OR (95% CI) p-value OR (95% CI) p-value Age, years 55-75 26 1.0 (referent) 1.0 (referent) >75 65 0.46 (0.18-1.16) 0.11 3.00 (0.65-14.35) 0.22 Lifestyle factors Tea/coffee consumption 18 4.43 (1.42-13.79) <0.01* 1.02 (0.25-4.06) 0.98 Medications Diuretics 21 0.73 (0.27-1.98) 0.54 2.71 (0.84-8.80) 0.11 NSAID 9 1.68 (0.42-6.71) 0.46 0.61 (0.70-5.25) 0.63 Anti-psychotics 3 0.63 (0.06-7.19) 0.70 NA a 0.29 Anti-depressants 18 0.63 (0.27-2.21) 0.63 1.61 (0.45-5.81) 0.49 Hypnotics 8 0.40 (0.08-2.07) 0.25 6.55 (1.43-30.05) 0.02* Medical conditions Congestive cardiac failure 10 2.07 (0.54-7.92) 0.28 0.53 (0.06-4.54) 0.57 Diabetes Mellitus 20 2.30 (0.84-6.35) 0.10^ 0.87 (0.22-3.43) 0.84 Depression 13 0.52 (0.15-1.83) 0.29 4.25(1.16-15.59) 0.04# Urinary tract infection 9 1.68 (0.42-6.71) 0.46 0.61 (0.07-5.25) 0.54 Constipation 13 0.79 (0.24-2.64) 0.70 0.90 (0.18-4.53) 0.89 Poor ADL 19 2.69 (0.95-7.67) 0.06^ 0.94 (0.24-3.73) 0.93 Likelihood ratio chi-square test was performed. Level of significance at *p<0.01, #p<0.05 and ^p≤0.10 OR = odds ratio NA a not applicable - no case in one cell Power analysis: • We have 80% power to detect an odds ratio of 2.6, based on the assumption that 10% of patients having the attribute. Sample size consideration: • We intend to recruit 283 patients to have 80% power to detect an odds ratio of 2 with significance level of _=0.05. Graph1. Sample size analysis against power from the pilot study Discussion: • Some predictors of UI proven in nursing home setting are not applicable to community patients such as delirium and different levels of restraint. A separate model of risk factors is warranted. • UI was not shown to increase with age in our study. It may be explained by healthy survival bias with the cross-sectional design. Those older than 75 who survived may be healthier and more likely to be continent. The association of UI with hypnotics deserves further investigation. Conclusion: • The modifiable independent risk factors of UI with urgency symptoms in older patients were excessive tea/coffee, diuretic, hypnotic use, depression and functional disability. • Poorer perceived symptoms were reported with diuretic use. • Established UI in the elderly is often multifactorial. Identifying important factors will alert healthcare workers in identifying patients at risk of developing the condition and implementing early preventive measures. • Our results support an extended study to provide evidence to our practice and to explore the effect size of these risk factors. Reference: 1. Coyne KS, Sexton CC, Irwin DE, Kopp ZS, Kelleher CJ, Milsom I. The impact of overactive bladder, incontinence and other lower urinary tract symptoms on quality of life, work productivity, sexuality and emotional well-being in men and women: results from the EPIC study. BJU Int. 2008 Jun;101(11):1388-95. 2. Brown JS, Seeley DG, Fong J, Black DM, Ensrud KE, Grady D. Urinary incontinence in older women: who is at risk? Study of Osteoporotic Fractures Research Group. Obstet Gynecol. 1996 May;87(5 Pt 1):715-21. 3. McDowell JB, Engberg SJ, Rodriguez E, Engberg R, Sereika S. Characteristics of urinary incontinence in homebound older adults. J Am Geriatr Soc 1996;44:963-8. 4. Landi F, Cesari M, RussoA, Onder G, Lttanzio F, Bernaei R. Potentially reversible risk factors and urinary incontinence in frail older people living in community. Age and Aging 2003;32:194-9. 5. Palmer MH, German PS, Ouslander JG. Risk factors for urinary incontinence one year after nursing home admission. Res Nurs Health 1991;14:405-12. 6. Goode PS, Burgio KL, Redden DT, MarklandA, Richter HE, Sawyer P,Allman RM. Population based study of incidence and predictors of urinary incontinence in black and white older adults. J Urol. 2008 Apr;179(4):1449-53. 7. Jackson R, Vittinghoff E, Kanaya A et al. Urinary incontinence in elderly women: findings from the Health, Aging, and Body Composition Study. Obstet Gynecol. 2004 Aug;104(2):301-7. AVPU REF NO: 2317-08
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Transcript of Modifiable factors for urinary incontinence - type cause and effect poster
Urinary incontinence type, cause and effect: result of a pilot study
Michelle Lai1, Chok Lui2, Charles Inderjeeth2, Jan Little1, Mary King3
1 Dept of Community and Geriatric Medicine, Fremantle Hospital, Fremantle, Western Australia. 2 Dept of Rehabilitation and Aged Care, Sir Charles Gairdner Hospital, Perth, Western Australia.
3 Corporate nursing, Sir Charles Gairdner Hospital, Perth, Western Australia.
Background:• Keymanagementinurinaryincontinence(UI)inolderpatientsistoidentify
potentiallyreversiblecauses,soappropriatestepscanbeinstitutedtoreducetheirimpact.
• LittledataexistpertainingtomodifiablecausesofUIamongolderambulatorypatients.Moststudiesexaminingriskfactorswereconductedinmiddleaged(1)
(2),homebound,frail(3)(4)orinstitutionalisedolderpatients(5).Knownriskfactorsinoldercommunitydwellingindividualswereill-defined.Theseincludeco-morbiditiessuchasstroke,diabetes,arthritis,obesity,depression,mobilityandfunctionalimpairment(6)(7).
Aim: • TodescribethecorrelatesofmodifiablecausesofUIinthispopulation.
Method: • In this cross-sectional study, 91 patients were recruited from a general
geriatricand2continenceclinics,including27patientswithoutincontinenceascontrol.Continenceadvisorsorclinicianscompletedquestionnairesafterinitialassessmentwithhistory,clinicalexamination,bladderchartandbladderscan.Univariateandmultivariateanalysiswereperformed.
Table 1 Demographic characteristics of patients with all cause incontinence
Characteristics Patients with (n=64) Male (n=15) Female (n= 49) all cause incontinence Age 79.56±8.53 74.40±6.22 81.14±8.57a
Residence (n,%) Community 63(98.4) 15(100) 48(98.0) Hostel 1(1.6) 0(0) 1(2.0)Ethnicity White 59(92.2) 13(86.7) 46(93.9) Asian 2(3.1) 1(6.7) 1(2.0) Others 3(1.7) 1(6.7) 2(4.1)Cognition Normal 50(78.1) 12(80.0) 38(77.6) MCI 1(1.6) 1(6.7) 1(2.0) Dementia 8(12.5) 1(6.7) 7(14.3) Notdocumented 5(7.8) 1(6.7) 3(6.1)MMSE 25.70±4.21 28.00±2.35 24.93±4.46ADL Highfunctioning 20(31.2) 1(6.7) 19(38.8) Moderatelyimpaired 34(53.1) 13(86.7) 21(42.9) Severelyimpaired 5(7.8) 1(6.7) 4(8.2)
Notdocumented 5(7.8) 0 5(10.1)aP=0.05,comparedwithmalegroup
Table 3. Multivariate analysis of reversible risk factors for urge and mixed
(urge and stress) incontinence
Attributes Unadjusted Age-adjusted OR(95%CI) p-value OR(95%CI) p-value
Forurgeincontinence(n=40/91): Tea/coffeeconsumption 5.48(1.70-17.70) <0.01 5.62(1.73-18.32) <0.01PoorADL 3.52(1.18-10.51) 0.02 3.55(1.18-10.66) 0.02Constant -1.27 0.59Formixedincontinence(n=15/91):Depression 4.32(1.05-17.72) 0.04 4.33(1.03-18.13) 0.05Diuretics 3.76(1.02-13.85) 0.05 3.75(0.96-14.60) 0.06Hypnotics 8.12(1.54-42.77) 0.01 8.12(1.54-42.77) 0.01Constant -2.61 -2.63whereOR=oddsratio
Result: • Patients were predominantly Caucasian (92.2%) and female (76.6%) [mean
age=79.24,SD=8.47].
• Logistic regressionanalysis (table3) revealed thatpatientspresentedwithurgeincontinenceweremorelikelytoconsumeregulartea/coffee(adjustedOR5.62,95%CI1.73-18.32)andhavefunctionaldisability(adjustedOR3.55,95%CI1.18-10.66).
• Patientswithmixed(urgeandstress)incontinenceweremorelikelytohavedepression(adjustedOR4.33,95%CI1.03-18.13),usediuretics(adjustedOR3.75,95%CI0.96-14.60)andhypnotics(adjustedOR8.12,95%CI1.54-42.77).
• Forbothtypesofincontinence,onlypatientswithdiureticsreportedworseperceived bladder symptoms (OR 5.18, 95% CI 1.03-26.13 respectively)comparedtothosewithoutthese2features.However,therewasnodifferenceinbladderchartsbetweenthe2groups.
• Thenumberofpatientswithstressincontinencewastoosmalltoperformriskfactoranalysis.
Table 2. Univariate analysis of reversible factors and age with urinary urge and
mixed (urge and stress) incontinence
Attributes Case (N) Urge incontinence (n=40) Mixed incontinence (n=15) OR (95% CI) p-value OR (95% CI) p-valueAge, years 55-75 26 1.0(referent) 1.0(referent)>75 65 0.46(0.18-1.16) 0.11 3.00(0.65-14.35) 0.22Lifestyle factors Tea/coffeeconsumption 18 4.43(1.42-13.79) <0.01* 1.02(0.25-4.06) 0.98MedicationsDiuretics 21 0.73(0.27-1.98) 0.54 2.71(0.84-8.80) 0.11NSAID 9 1.68(0.42-6.71) 0.46 0.61(0.70-5.25) 0.63Anti-psychotics 3 0.63(0.06-7.19) 0.70 NAa 0.29Anti-depressants 18 0.63(0.27-2.21) 0.63 1.61(0.45-5.81) 0.49Hypnotics 8 0.40(0.08-2.07) 0.25 6.55(1.43-30.05) 0.02*Medical conditionsCongestivecardiacfailure 10 2.07(0.54-7.92) 0.28 0.53(0.06-4.54) 0.57DiabetesMellitus 20 2.30(0.84-6.35) 0.10^ 0.87(0.22-3.43) 0.84Depression 13 0.52(0.15-1.83) 0.29 4.25(1.16-15.59) 0.04#Urinarytractinfection 9 1.68(0.42-6.71) 0.46 0.61(0.07-5.25) 0.54Constipation 13 0.79(0.24-2.64) 0.70 0.90(0.18-4.53) 0.89PoorADL 19 2.69(0.95-7.67) 0.06^ 0.94(0.24-3.73) 0.93Likelihoodratiochi-squaretestwasperformed.Levelofsignificanceat*p<0.01,#p<0.05and^p≤0.10OR=oddsratioNAanotapplicable-nocaseinonecell
Power analysis:• Wehave80%powertodetectanoddsratioof2.6,basedontheassumption
that10%ofpatientshavingtheattribute.
Sample size consideration:• Weintendtorecruit283patientstohave80%powertodetectanoddsratio
of2withsignificancelevelof_=0.05.
Graph1. Sample size analysis against power from the pilot study
Discussion:• SomepredictorsofUIproveninnursinghomesettingarenotapplicableto
communitypatientssuchasdeliriumanddifferentlevelsofrestraint.Aseparatemodelofriskfactorsiswarranted.
• UIwasnotshowntoincreasewithageinourstudy.Itmaybeexplainedbyhealthysurvivalbiaswiththecross-sectionaldesign.Thoseolderthan75whosurvivedmaybehealthierandmorelikelytobecontinent.TheassociationofUIwithhypnoticsdeservesfurtherinvestigation.
Conclusion:• ThemodifiableindependentriskfactorsofUIwithurgencysymptomsinolder
patientswereexcessive tea/coffee,diuretic,hypnoticuse,depressionandfunctionaldisability.
• Poorerperceivedsymptomswerereportedwithdiureticuse.
• EstablishedUIintheelderlyisoftenmultifactorial.Identifyingimportantfactorswillalerthealthcareworkersinidentifyingpatientsatriskofdevelopingtheconditionandimplementingearlypreventivemeasures.
• Ourresultssupportanextendedstudytoprovideevidencetoourpracticeandtoexploretheeffectsizeoftheseriskfactors.
Reference:1. CoyneKS,SextonCC,IrwinDE,KoppZS,KelleherCJ,MilsomI.Theimpactofoveractivebladder,incontinenceand
otherlowerurinarytractsymptomsonqualityoflife,workproductivity,sexualityandemotionalwell-beinginmenandwomen:resultsfromtheEPICstudy.BJUInt.2008Jun;101(11):1388-95.
2. BrownJS,SeeleyDG,FongJ,BlackDM,EnsrudKE,GradyD.Urinaryincontinenceinolderwomen:whoisatrisk?StudyofOsteoporoticFracturesResearchGroup.ObstetGynecol.1996May;87(5Pt1):715-21.
3. McDowellJB,EngbergSJ,RodriguezE,EngbergR,SereikaS.Characteristicsofurinaryincontinenceinhomeboundolderadults.JAmGeriatrSoc1996;44:963-8.
4. LandiF,CesariM,RussoA,OnderG,LttanzioF,BernaeiR.Potentiallyreversibleriskfactorsandurinaryincontinenceinfrailolderpeoplelivingincommunity.AgeandAging2003;32:194-9.
5. PalmerMH,GermanPS,OuslanderJG.Riskfactorsforurinaryincontinenceoneyearafternursinghomeadmission.ResNursHealth1991;14:405-12.
6. GoodePS,BurgioKL,ReddenDT,MarklandA,RichterHE,SawyerP,AllmanRM.Populationbasedstudyofincidenceandpredictorsofurinaryincontinenceinblackandwhiteolderadults.JUrol.2008Apr;179(4):1449-53.
7.JacksonR,VittinghoffE,KanayaAetal.Urinaryincontinenceinelderlywomen:findingsfromtheHealth,Aging,andBodyCompositionStudy.ObstetGynecol.2004Aug;104(2):301-7.
AVPUREFNO:2317-08
