Relationship between the type of urinary incontinence and falls among frail elderly women in Japan

The effect of conservative non-pharmacological interventions on the management of urinary incontinence in older adults living with frailty: Systematic review and meta-analysis

BACKGROUND

Urinary incontinence (UI) is highly prevalent among older adults with frailty, impacting function, quality of life and risk of long-term care admission.

OBJECTIVE

To systematically review and synthesise the results of randomised controlled trials (RCTs) investigating the effect of conservative non-pharmacological interventions on the management of UI in older adults aged ≥ 65 years living with frailty.

METHODS

Five databases (Cochrane Library, Medline (EBSCO), CINAHL (EBSCO), Embase (OVID), PsycINFO (EBSCO)) were searched from inception to April 2024 for RCTs that evaluated conservative non-pharmacological interventions for UI in older adults living with frailty. Two independent reviewers screened records, assessed methodological quality using the Cochrane Risk of Bias (RoB 2.0) Tool and Level of Evidence was summarised using GRADE guidelines. A meta-analysis using a random-effects model or narrative synthesis were performed as appropriate.

RESULTS

Twelve RCTs, including 1,580 participants, with medium to high risk of bias were included. Conservative non-pharmacological interventions (categorised as single component or multicomponent interventions) resulted in a non-statistically significant reduction of objective measures of UI (6 RCTs, g = -0.39, p = 0.090; pooled effect size, with CI = -0.39 [-0.832, 0.060], I2 = 85.26%, with very low certainty of evidence). Improvements in functional ability were not found to be statistically significant (5 RCTs, g = 0.20, p = 0.39, pooled effect size, with CI = 0.20 [- 0.251, 0.642], I2 = 85.87%, and very low certainty of evidence). The interventions did not result in adverse events. Studies did not evaluate caregiver quality of life.

CONCLUSIONS

Very low-quality evidence found that conservative non-pharmacological interventions had beneficial but not statistically significant effects on objective UI and functional ability. Due to the high incidence of intervening illnesses and mortality in older adults living with frailty, it is recommended that future studies assess the effect of implementing tailored interventions addressing modifiable risk factors using more appropriate study design and outcome measures.

REGISTRATION

This review was prospectively registered on the International Prospective Register of Systematic Reviews, PROSPERO (CRD42022316287; https://www.crd.york.ac.uk/prospero/).

Lower Urinary Tract Symptoms and Fall Risk: An Important Problem in Older Women with Cognitive Frailty

INTRODUCTION AND HYPOTHESIS

The objective of our study is to investigate the presence of lower urinary tract symptoms (LUTS) and its correlation with the risk of falling in older women with cognitive frailty.

METHODS

The descriptive study was conducted on 102 female older adults, 60 women were classed as cognitively frail and 42 as healthy. Women were classified as having mild cognitive impairment based on the Clinical Dementia Rating Scale and as frail based on the Clinical Frailty Scale. The Bristol Female Lower Urinary Tract Symptoms questionnaire and Timed Up and Go test were applied to determine LUTS and fall risk respectively.

RESULTS

Cognitively frail women scored considerably higher for LUTS including quality of life, filling, incontinence, and voiding, than the healthy group (p < 0.001). Timed Up and Go test seconds were significantly longer in cognitively frail women (p < 0.001).

CONCLUSIONS

These data suggest the notion that cognitive frailty might increase the risk of LUTS and falls. Older women at high fall risk are more likely to have LUTS. Thus, health practitioners must recognize that embarrassment may prevent individuals from seeking urinary care. Even in the absence of patient complaints, older women with cognitive frailty should have a comprehensive fall history and LUTS testing. Implementing LUTS and fall-risk measures may avoid future falls and serious complications such as fractures.

Age-related effects on absolute and relative isokinetic knee extensor strength in community-dwelling older men and women at a French geriatric day hospital

PURPOSE

Isokinetic knee extensor strength is poorly evaluated in geriatric day hospitals (GDHs), despite its potential functional significance compared to grip strength. This study aimed to investigate age-related effects on absolute and relative isokinetic knee extensor peak torque (KEPT) data in community-dwelling older GDH patients.

METHODS

A total of 472 French GDH patients (179 men and 293 women, aged 75-94 years) participated in this study. Absolute and relative KEPT were measured at six distinct angular velocities between 0.52 and 3.14 rad/s. In addition, comfortable gait speed and grip strength were assessed. Participants were stratified by sex and age using 5-year intervals. One-way ANOVAs were used to examine age-related effects on KEPT values. Multiple linear regression models were employed to investigate the associations between gait speed and both mean KEPT values and grip strength, with separate models conducted on absolute and relative values.

RESULTS

The recruited GDH patients presented lower absolute and relative KEPT values in comparison with established reference values for healthy community-dwelling older individuals, with men being consistently stronger than women. Notably, there was a significant decline in both absolute and relative KEPT values beyond the age of 85 for both sexes. Importantly, the multiple linear regression analyses conducted revealed a significant positive relationship between gait speed and mean KEPT values, surpassing the association with grip strength.

CONCLUSIONS

These findings underscore the clinical importance of assessing isokinetic knee extensor strength in community-dwelling older GDH patients, particularly for tailoring personalized physical activity interventions.

The impact of urinary incontinence on falls: A systematic review and meta-analysis

OBJECTIVE

Previous studies on the association between urinary incontinence (UI) and falls have reported conflicting results. We, therefore, aimed to evaluate and clarify this association through a systematic review and meta-analysis of relevant studies.

METHODS

We performed a literature search for relevant studies in databases including PubMed and EMBASE from inception up to December 13, 2020, using several search terms related to UI and falls. Based on the data reported in these studies, we calculated the pooled odds ratios (ORs) for falls and the corresponding 95% confidence intervals (CIs) using the Mantel-Haenszel method.

RESULTS

This meta-analysis included 38 articles and a total of 230,129 participants. UI was significantly associated with falls (OR, 1.62; 95% CI, 1.45-1.83). Subgroup analyses based on the age and sex of the participants revealed a significant association between UI and falls in older (≥65 years) participants (OR, 1.59; 95% CI, 1.31-1.93), and in both men (OR, 1.88; 95% CI, 1.57-2.25) and women (OR, 1.41; 95% CI, 1.29-1.54). Subgroup analysis based on the definition of falls revealed a significant association between UI and falls (≥1 fall event) (OR, 1.61; 95% CI, 1.42-1.82) and recurrent falls (≥2 fall events) (OR, 1.63; 95% CI, 1.49-1.78). According to the UI type, a significant association between UI and falls was observed in patients with urgency UI (OR, 1.76; 95% CI, 1.15-1.70) and those with stress UI (OR, 1.73; 95% CI, 1.39-2.15).

CONCLUSIONS

This meta-analysis, which was based on evidence from a review of the published literature, clearly demonstrated that UI is an important risk factor for falls in both general and older populations.

Kidney function and other factors and their association with falls : The screening for CKD among older people across Europe (SCOPE) study

Background

Reduced kidney function has become a major public health concern, especially among older people, as Chronic Kidney Disease (CKD) is associated with increased risk of end stage renal disease and mortality. Falls are a serious negative health outcome in older persons with one third of people aged 65 years experiencing a fall per year and increasing fall rates with increasing age. The impact of CKD on falls in older community-dwelling persons is not well investigated. Additionally, lower urinary tract symptoms (LUTS) may also increase the risk of falls. Therefore, our aim was to investigate the impact of CKD and LUTS on falls as well as on injurious falls.

Methods

The SCOPE study is an observational, multinational, multicenter, prospective cohort study involving community-dwelling older persons aged 75 years and more recruited from August 2016 to March 2018 in seven European countries. The main outcomes of the present study were any falls and any injurious falls during the 12 months before enrolment. The cross-sectional association of estimated glomerular filtration rate (eGFR) and LUTS with study outcomes was investigated by logistic regression analysis adjusted for baseline characteristics of enrolled subjects.

Results

Our series consisted of 2256 SCOPE participants (median age = 79.5 years, 55.7% female). Of them, 746 participants experienced a fall and 484 reported an injurious fall in the 12 months prior to baseline assessment. CKD was not significantly associated with falls (OR = 0.95, 95%CI = 0.79–1.14 for eGFR< 60; OR = 1.02, 95%CI = 0.81–1.28 for eGFR< 45; OR = 1.08, 95%CI = 0.74–1.57 for eGFR< 30) or injurious falls (OR = 0.91, 95%CI = 0.67–1.24 for eGFR< 60; OR = 0.93, 95%CI = 0.63–1.37 for eGFR< 45; OR = 1.19, 95%CI = 0.62–2.29 for eGFR< 30). LUTS were found significantly associated with both falls (OR = 1.56, 95%CI = 1.29–1.89) and injurious falls (OR = 1.58, 95%CI = 1.14–2.19), and such associations were confirmed in all multivariable models.

Conclusions

Cross-sectional data suggest that CKD may not be associated with history of falls or injurious falls, whereas LUTS is significantly associated with the outcomes.

Trial registration

This study was registered on 25th February 2016 at clinicaltrials.gov (NCT02691546).

Association between cumulative anticholinergic burden and falls and fractures in patients with overactive bladder: US-based retrospective cohort study

OBJECTIVE

To estimate the association between cumulative anticholinergic burden and falls and fractures in patients with overactive bladder (OAB).

DESIGN

A retrospective claims-based study (2007-2015) of patients with OAB; outcomes from a subset were contrasted to a non-OAB comparison.

SETTING

United States, commercially and Medicare-insured population.

PARTICIPANTS

154 432 adults with OAB and 86 966 adults without OAB, mean age of 56 years, and 67.9% women.

MAIN OUTCOME MEASURES

Cumulative anticholinergic burden, a unitless value representing exposure over time, was estimated over the 12 months pre-index ('at baseline') and every 6 months post index. Burden was categorised as no burden (0), low burden (1-89), medium burden (90-499) or high burden (500+). Unadjusted rates of falls or fractures were estimated, and the increased risk associated with anticholinergic burden (measured at the closest 6-month interval prior to a fall or fracture) was assessed using a Cox proportional hazards model and a marginal structural model.

RESULTS

Median (IQR) baseline anticholinergic burden was 30 (0.0-314.0) and higher among older (≥65 years, 183 [3.0-713.0]) versus younger (<65 years, 13 [0.0-200.0]) adults. The unadjusted rate of falls or fractures over the period was 5.0 per 100 patient-years, ranging from 3.1 (95% CI 3.0-3.2) for those with no burden, to 7.4 (95% CI 7.1-7.6) for those with high burden at baseline. The adjusted risk of falls and fractures was greater with higher anticholinergic burden in the previous 6 months, with an HR of 1.2 (95% CI 1.2 to 1.3) for low burden versus no burden, to 1.4 (95% CI 1.3 to 1.4) for high versus no burden. Estimates from marginal structural models adjusting for time-varying covariates were lower but remained significantly higher with a higher anticholinergic burden. Rates of falls and fractures were approximately 40% higher among those with OAB (vs those without).

CONCLUSION

Higher levels of anticholinergic burden are associated with higher rates of falls and fractures, highlighting the importance of considering anticholinergic burden when treating patients with OAB.

[Palliative long-term urinary bladder drainage: the uro-geriatric point of view]

A serious voiding disorder or urinary incontinence represent indications for long-term catheterization of the urinary bladder. Treatment by a transurethral or suprapubic bladder catheter for life-long bladder drainage is accompanied by technical short-term complications and long-term sequelae. The mortality risk associated with inserting a suprapubic catheter is approximately 2% due to an incorrect bladder puncture. Long-term consequences of life-long bladder drainage are hematuria, infection, spasms, stone formation, obstruction, catheter loss, risk of falls and automanipulation especially in cognitively impaired persons. These constitute frequent reasons for emergency treatment or hospitalization. Further problem areas are dependency on caregivers to perform the catheter change and dermal problems in the area of the fistula stoma. To what extent this limits the quality of life of those affected remains unclear up to now. The acute complications and the long-term consequences of life-long bladder drainage make careful decision-making necessary after other therapeutic options have failed, are not appropriate or not desired.

A Systematic Review of Frailty Assessments in Women With Pelvic Floor Disorders: Are We Following the American College of Surgeons National Surgical Quality Improvement Program/American Geriatric Society Guidelines?

INTRODUCTION

Associations between frailty and women with pelvic floor disorders (PFDs) are not well understood. This study seeks to describe studies among women with PFD and the associated frailty assessments as recommended in the American College of Surgeons National Surgical Quality Improvement Program/American Geriatric Society (ACS NSQIP/AGS) guidelines.

METHODS

This systematic review was registered with PROSPERO using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The GRADE (Grading of Recommendations, Assessment, Development and Evaluations) criteria are applied to assess study quality. Data synthesis is descriptive. Outcomes of interest include the ratio of studies adhering to the ACS NSQIP/AGS guidelines and evidence for frailty assessments versus usual care for women with PFDs.

RESULTS

Twenty studies regarding frailty and PFDs were included for systematic review. Studies were categorized as relating to (1) epidemiology, (2) frailty and incontinence, (3) postoperative morbidity, and (4) surgical choice. Most studies (5/20) did not define frailty or failed to follow the ACS NSQIP/AGS guidelines. All studies were of very low to low quality. Collectively, each category generated very low GRADE quality evidence of frailty and the relationship to PFDs.

CONCLUSIONS

Most studies regarding frailty among women with PFDs did not define frailty as recommended in the ACS NSQIP/AGS guidelines. The evidence regarding PFDs and frailty is of very low quality. This is the first systematic review regarding frailty assessments specifically among women with PFDs. Paucity of data regarding frailty in women with PFDs, particularly with regard to surgical choice and surgical counseling, highlights the need for further study in this area.

Urinary Incontinences Are Related with Fall and Fragility Fractures in Elderly Population: Nationwide Cohort Study

Background

This prospective cohort study used nationwide claims data to investigate the incidence of fall and fragility fractures in association with urinary incontinence (UI) in the elderly, and to compare mortality after fragility fractures in elderly patients with or without incontinence.

Methods

A total of 39,854 Korean adults (age, 66-80 years) who participated in health examinations between 2007 and 2012 and were followed up until 2015 were analyzed. Patient and comparison groups were classified according to the presence or absence of UI. The cumulative incidence of osteoporotic fragility fractures and falls in the 2 groups was assessed and compared. Hazard ratios for fragility fractures were calculated for the risk of UI in association with falls using a Cox proportional hazards model.

Results

Of 39,854 elderly participants, 5,703 were classified in the UI group, while 34,151 were placed in the comparison group. Fall rates were significantly higher (20.8%) in the incontinence group than in the comparison group (4.7%) (P<0.001). Women in the incontinence group (13.9%) showed a significantly higher incidence of all types of fragility fractures than those in the comparison group (11.8%) (P=0.005). After adjustment for confounders, UI was not a significant risk factor for fragility fractures in men (P=0.878) or women (P=0.324).

Conclusions

This study demonstrated that elderly women with UI have a significantly higher incidence of osteoporotic fragility fractures. In addition, elderly women are at higher risk for falls.

The Association Between Overactive Bladder and Falls and Fractures: A Systematic Review

INTRODUCTION

Urinary symptoms are associated with an increased risk of falls, but few studies have focused on patients with overactive bladder (OAB). This study aimed to synthesize estimates of the risk of falls and fractures in patients with OAB.

METHODS

Medline, EMBASE, the Cumulative Index to Nursing and Allied Health Literature, and Scopus were systematically searched for observational studies that focused on patients with OAB. When available, data from a non-OAB comparison sample were included. Double independent review and data extraction were performed. Falls and fractures data were summarized by unadjusted and adjusted risks, and percent attributable risk (PAR) of falls and fractures associated with OAB.

RESULTS

Fifteen studies were included in the analyses. The proportion of patients with OAB experiencing at least one fall over a year ranged from 18.9% to 50.0%, and the proportion of patients with OAB experiencing recurrent or serious falls ranged from 10.2% to 56.0%. In studies that included a non-OAB comparison sample, a higher risk of falls was observed in patients with OAB compared to those without. A significantly increased (1.3- to 2.3-fold) adjusted OAB-associated risk of falls was reported, while unadjusted PARs for OAB associated falls ranged from 3.7% to 15.5%. Risk was higher among women and those 65 years of age or older. While analysis of fractures showed elevated point estimates, most studies were underpowered to detect a statistically significant difference between groups.

CONCLUSIONS

Evidence from the published literature clearly demonstrates the importance of OAB and its symptoms as risk factors for falls and fractures.

FUNDING

Astellas.

Fall Risk Factors in Mid-Age Women: The Australian Longitudinal Study on Women's Health

INTRODUCTION

In contrast to older adults, little is known about risk factors for falls in adults aged 50-64 years, despite a high prevalence of falls in this age group. The aim was to identify risk factors for falls in mid-age women and explore how associations change with age.

METHODS

Data were analyzed in 2016 from women aged 50-55 years in 2001 (born 1946-1951) in the Australian Longitudinal Study on Women's Health. The predictor variables were health-related factors (measured 2001, 2004, 2007, 2010) and the outcome was falls in the past 12 months (measured 2004, 2007, 2010, 2013). Prospective associations between predictor variables and falls measured 3 years later were analyzed using logistic regression with complete data for 4,629, 7,096, 5,911, and 5,774 participants.

RESULTS

In surveys, 20.5% (2004), 30.7% (2007), 30.5% (2010), and 26.6% (2013) of women reported a fall in the previous 12 months. In the univariable models, most factors were associated with falls 3 years later. In the multivariable models, higher odds of falling were found for overweight and obese women compared with healthy weight women at all survey intervals (OR range, 1.15-1.43). Impaired vision (OR range, 1.25-1.35) and poor physical functioning (OR range, 1.24-1.66) were associated with falls at three survey intervals. Depression (OR range, 1.31-1.42), leaking urine (OR range, 1.25-1.49), stiff/painful joints (OR range, 1.26-1.62), severe tiredness (OR range, 1.29-1.49), osteoporosis (OR range, 1.25-1.52), and hormone replacement therapy (OR range, 0.69-0.79) were associated with falls at two survey intervals. There was no obvious age-related increase or decrease in the number of statistically significant associations.

CONCLUSIONS

Identified fall risk factors varied over time, highlighting that falling involves a complex interplay of risk factors in mid-age women.

Continence Across Continents To Upend Stigma and Dependency (CACTUS-D): study protocol for a cluster randomized controlled trial

Background

Urinary incontinence occurs in 40 % of women aged 65 years and over; however, only 15 % seek care and many delay healthcare seeking for years. Incontinence is associated with depression, social isolation, reduced quality of life, falls and other comorbidities. It is accompanied by an enormous cost to the individual and society. Despite the substantial implications of urinary incontinence on social, psychological and physical well-being of older women, the impact of continence promotion on urinary symptom improvement and subsequent effects on falls, quality of life, stigma, social participation and the cost of care remains unknown.

Methods

This study is a mixed methods multi-national open-label 2-arm parallel cluster randomized controlled trial aiming to recruit 1000 community-dwelling incontinent women aged 65 years and older across Quebec, Western Canada, France and United Kingdom. Participants will be recruited through community organizations. Data will be collected at 6 time points: baseline and 1 week, 3 months, 6 months, 9 months and 12 months after baseline. One of the primary objectives is to evaluate whether the continence promotion intervention improves incontinence symptoms (measured with the Patient Global Impression of Improvement questionnaire, PGI-I) at 12 months post intervention compared to the control group. Other co-primary outcomes include changes in incontinence-related stigma, fall reduction, and incremental cost-effectiveness ratio and quality-adjusted life years. Data analysis will account for correlation of outcomes (clustering) within community organizations. A qualitative sub-study will explore stigma reduction.

Discussion

Community-based continence promotion programs may be a cost-effective strategy to reduce urinary incontinence, stigma and falls among older women with untreated incontinence, and simultaneously improve quality of life and healthy active life expectancy.

Trial registration

ClinicalTrials.gov: NCT01858493, registered 13 May 2013

Noctural Enuresis as a Risk Factor for Falls in Older Community Dwelling Women with Urinary Incontinence

PURPOSE

We determined the association of urinary symptoms with fall risk and physical limitations in older community dwelling women with urinary incontinence.

MATERIALS AND METHODS

We performed an in-depth assessment of daytime and nighttime urinary symptoms, fall risk, physical function, physical performance tests and mental function in older community dwelling women with urinary incontinence who had not sought care for urinary symptoms. All assessments were performed in participant homes. We used univariable and multivariable linear regression to examine the relationship of urinary symptoms to fall risk, physical function and physical performance.

RESULTS

Of 37 women with a mean ± SD age of 74 ± 8.4 years who had urinary incontinence 48% were at high risk for falls. Nocturnal enuresis was reported by 50% of the women. Increased fall risk was associated with increasing frequency of nocturnal enuresis (p = 0.04), worse lower limb function (p <0.001), worse upper limb function (p <0.0001) and worse performance on a composite physical performance test of strength, gait and balance (p = 0.02). Women with nocturnal enuresis had significantly lower physical performance test scores than women without nocturnal enuresis (median 7, range 0 to 11 vs 9, range 1 to 12, p = 0.04). In a multivariable regression model including age, nocturnal enuresis episodes and physical function only physical function was associated with an increased fall risk (p <0.0001).

CONCLUSIONS

Nocturnal enuresis is common in older community dwelling women with urinary incontinence. It may serve as a marker of fall risk even in women who do not seek care for urinary symptoms. Interventions targeting upper and lower body physical function could potentially decrease the risk of falls in older women with urinary incontinence.

Comorbidities and personal burden of urgency urinary incontinence: a systematic review

AIMS

Studies on the burden and comorbidities associated with urgency urinary incontinence (UUI) are difficult to compare, partly because of the evolution of definitions for lower urinary tract symptoms and the various instruments used to assess health-related quality of life (HRQL). This article summarises published evidence on comorbidities and the personal burden associated specifically with UUI to provide clinicians with a clear perspective on the impact of UUI on patients.

METHODS

A PubMed search was conducted using the terms: (urgency urinary incontinence OR urge incontinence OR mixed incontinence OR overactive bladder) AND (burden OR quality of life OR well-being OR depression OR mental health OR sexual health OR comorbid), with limits for English-language articles published between 1991 and 2011.

RESULTS

Of 1364 identified articles, data from 70 retained articles indicate that UUI is a bothersome condition that has a marked negative impact on HRQL, with the severity of UUI a predictor of HRQL. UUI is significantly associated with falls in elderly individuals, depression, urinary tract infections, increased body mass index, diabetes and deaths. The burden of UUI appears to be greater than that of stress urinary incontinence or overactive bladder symptoms without UUI. UUI adversely impacts physical and mental health, sexual function and work productivity.

CONCLUSIONS

UUI is associated with numerous comorbid conditions and inflicts a substantial personal burden on many aspects of patients' lives. Healthcare providers should discuss UUI with patients and be aware of the impact of UUI and its associated comorbidities on patients' lives.

Lower urinary tract symptoms and falls risk among older women receiving home support: a prospective cohort study

Background

Although lower urinary tract symptoms have been associated with falls, few studies have been undertaken to understand this relationship in vulnerable community dwelling older adults. The purpose of this study was to describe the relationship over time of falls risk and lower urinary tract symptoms among community based older women receiving home support services.

Methods

A prospective cohort study which took place in an urban setting in western Canada. Participants were 100 older women receiving home care or residing in assisted living with home support services and were followed for six months. Demographic characteristics were collected at baseline, with the Timed Up and Go (TUG), International Consultation on Incontinence Questionnaire Female Lower Urinary Tract Symptoms (ICIQ-FLUTS), and self-report of falls collected at baseline, 3 and 6 months. Descriptive statistics were used to summarize demographic data. Differences between the three visits were analyzed using the Friedman test with post hoc analysis and associations between variables by the Spearman Rank-Order Correlation Coefficient.

Results

One hundred women initially enrolled; 88 and 75 remained at three months and six months. Mean age = 84.3 years; 91% reported at least one urinary symptom at baseline and 35% reported falling in the six months prior to enrollment; 15.9% reported falling between the baseline and three months and 14.6% between three and six months. Mean TUG scores at each time point indicated falls risk (27.21, 29.18 and 27.76 seconds). Significant correlations between TUG and ICIQ-FLUTS (r ₌ 0.33, p < .001; r ₌ 0.39, p < .001) as well as TUG and overactive bladder scores (r ₌ 0.25, p = .005; r ₌ 0.28, p < .008) were found at baseline and three months, but not six months.

Conclusions

The association of lower urinary tract symptoms and falls risk in this group of vulnerable community dwelling older women at baseline and three months has potential clinical relevance. Lack of correlation at six months may be due loss of less robust participants, illuminating the difficulty in following frailer groups over time. Further studies are needed to understand the contribution of urinary symptoms to falls risk, and clinicians should incorporate continence assessment within falls risk assessment.

Association between the Geriatric Giants of urinary incontinence and falls in older people using data from the Leicestershire MRC Incontinence Study

OBJECTIVE

To determine whether urinary incontinence per se and different types of urinary incontinence individually are associated with an increased risk of falls in those aged 70 years and over. To investigate whether the presence of urinary symptoms, poor quality of life and physical limitations in this population with urinary incontinence is associated with falls.

DESIGN

Study using data from the cross-sectional postal questionnaire undertaken in the Leicestershire Medical Research Council Incontinence Study.

SETTING

Leicestershire.

PARTICIPANTS

A total of 5,474 people aged 70 years or more living in the community randomly selected from general practitioners' lists.

RESULTS

Urinary incontinence and both urge and stress incontinence were positively related to falls (P < 0.0001, P < 0.001 and P = 0.007, respectively). The larger the volume of urine lost, the greater the risk of falls (P < 0.0001). Falls were associated with the presence of urinary symptoms (P = 0.01 or less), physical limitations (P = 0.001 or less) and having a poorer quality of life (P = 0.004 or less) in respondents with urinary incontinence.

CONCLUSIONS

An association has been shown between falling and urinary leakage including the previously unreported association with stress leakage. Falling and urinary incontinence were found to be associated with physical limitations and had an impact on quality of life.

State of the science: conservative interventions for urinary incontinence in frail community-dwelling older adults

This systematic literature review aimed to identify conservative interventions for reducing urinary incontinence (UI) in non-institutionalized frail older adults. Randomized and quasi-experimental studies published in English reporting outcomes on UI frequency, severity, or quality of life were included and rated for quality. Studies reporting improvements over 50% in UI outcomes were considered clinically significant. Seven studies with 683 participants (75% female) were eligible. Multicomponent behavioral interventions including pelvic floor muscle exercises and bladder training had the strongest evidence for reducing UI. The evidence supporting comprehensive geriatric assessment with multicomponent behavioral interventions, pattern urge response training, and toilet skills was limited. There is insufficient evidence to derive firm conclusions regarding the use of conservative interventions. Clinical trials are needed on a variety of interventions to guide practice on UI prevention and management in frail community-dwelling older adults.

Episodes of falling among elderly people: a systematic review and meta-analysis of social and demographic pre-disposing characteristics

CONTEXT

The multifactorial nature of falls among elderly people is well-known. Identifying the social-demographic characteristics of elderly people who fall would enable us to define the typical profile of the elderly who are at risk of falling.

OBJECTIVE

We aimed to isolate studies in which the social-demographic risk factors for falls among the elderly have been evaluated and to carry out a meta-analysis by combining the results of all of these selected studies.

METHOD

We did a systematic literature review using the key words "accidental fall / numerical data" and "risk factors." Inclusion criteria entailed the selection of articles with the following characteristics: population of subjects aged 60 years or over, falls that took place in everyday life, and social-demographic risk factors for falls.

RESULTS

3,747 indexed articles published between 1981 and 2007 were identified, and 177 studies with available data were included, of which 129 had data on social-demographic risk factors for falls. Difficulties in activities of daily living (ADL) or in instrumental activities of daily living (IADL) double the risk of falling: The OR and 95% Cl were 2.26 (2.09, 2.45) for disturbance ADL and 2.10 (1.68, 2.64) for IADL. The OR and 95% Cl for Caucasians were 1.68 (0.98 - 2.88) and 0.64 (0.51 - 0.80) for Hispanics. In the subgroup of patients older than eighty, being married protected people from falling with an OR and 95% Cl =0.68 (0.53 - 0.87).

CONCLUSION

Defining factors that create a risk of falling and protect elderly people from falls using social-demographic characteristics lets us focus on an "at risk" population for which a specific program could be developed.

Lower urinary tract symptoms, incontinence and falls in elderly people: time for an intervention study

Falls in older people constitute a common health hazard, which has attracted much attention and research. There are many evidence-based interventions, which have been shown to reduce the subsequent risk of falls. There is good evidence for an association between the risk of falling and the presence of urinary incontinence in older people, but incontinence has not been routinely included in interventions targeted to reduce falls. This article reviews the evidence for current falls intervention and the association between falls and urinary incontinence, making the case for an intervention study.

Pharmacological Management of Women with Mixed Urinary Incontinence

Mixed urinary incontinence (MUI) is a symptomatic diagnosis. It is defined by the International Continence Society as the complaint of involuntary leakage associated with urgency and also with exertion, effort, sneezing and coughing. A search of medical databases revealed that only a small number of limited studies that assess the prevalence, epidemiology and treatment of MUI have been conducted. Most studies have looked separately at either stress urinary incontinence or urgency urinary incontinence. Thus, management of MUI involves a combination of treatments for both stress and urgency incontinence, but should concentrate initially on the most bothersome and/or predominant symptom. Initial management includes an accurate history and examination, which is supplemented by a bladder diary and quality-of-life questionnaire. Once a preliminary diagnosis is established, first-line therapy includes patient education and lifestyle interventions, such as weight loss. This is supplemented by pelvic floor muscle training and bladder training, which help with both components of MUI. Oral pharmacotherapy often acts synergistically with the previous treatments; however, only very few randomised, placebo-controlled trials have looked at the effects of pharmacotherapy on MUI. The two main classes of drugs are the antimuscarinics, which are effective in urgency incontinence, and the serotonin-norepinephrine re-uptake inhibitors, which are effective in stress incontinence. Combination of these two drug classes is a feasible option but has not been tested in any trials to date. Should these treatments fail, then patients should be referred for cystometry to confirm the diagnosis. Treatment options available following urodynamics include invasive minor and major surgical procedures, which either treat the stress or urgency component of MUI but not both. Surgical procedures carry the risk of infection, haemorrhage and failure.