Prevalence and burden of overactive bladder in the United States

CONTEXT

the National Overactive BLadder Evaluation (NOBLE) Program was initiated to better understand the prevalence and burden of overactive bladder in a broad spectrum of the United States population.

OBJECTIVE

to estimate the prevalence of overactive bladder with and without urge incontinence in the US, assess variation in prevalence by sex and other factors, and measure individual burden.

DESIGN

US national telephone survey using a clinically validated interview and a follow-up nested study comparing overactive bladder cases to sex- and age-matched controls.

SETTING

noninstitutionalized US adult population.

PARTICIPANTS

a sample of 5,204 adults >/=18 years of age and representative of the US population by sex, age, and geographical region.

MAIN OUTCOME MEASURES

prevalence of overactive bladder with and without urge incontinence and risk factors for overactive bladder in the US. In the nested case-control study, SF-36, CES-D, and MOS sleep scores were used to assess impact.

RESULTS

the overall prevalence of overactive bladder was similar between men (16.0%) and women (16.9%), but sex-specific prevalence differed substantially by severity of symptoms. In women, prevalence of urge incontinence increased with age from 2.0% to 19% with a marked increase after 44 years of age, and in men, increased with age from 0.3% to 8.9% with a marked increase after 64 years of age. Across all age groups, overactive bladder without urge incontinence was more common in men than in women. Overactive bladder with and without urge incontinence was associated with clinically and significantly lower SF-36 quality-of-life scores, higher CES-D depression scores, and poorer quality of sleep than matched controls.

CONCLUSIONS

the NOBLE studies do not support the commonly held notion that women are considerably more likely than men to have urgency-related bladder control problems. The overall prevalence of overactive bladder does not differ by sex; however, the severity and nature of symptom expression does differ. Sex-specific anatomic differences may increase the probability that overactive bladder is expressed as urge incontinence among women compared with men. Nonetheless, overactive bladder, with and without incontinence, has a clinically significant impact on quality-of-life, quality-of-sleep, and mental health, in both men and women.

Changes in driving patterns and worsening depressive symptoms among older adults

OBJECTIVES

This study examined whether changes in driving patterns-driving cessation and reduction-have negative consequences for the depressive symptoms of older Americans and whether these consequences are mitigated for people with a spouse who drives.

METHODS

The project used data from 3 waves of the Asset and Health Dynamics Among the Oldest Old (AHEAD) study. Depressive symptoms were assessed with an abbreviated Center for Epidemiologic Studies-Depression scale. Using 2 models, the project examined how driving cessation and reduction that occurred between Waves 1 and 2 contributed to increases in depressive symptoms between Waves 2 and 3. The first model included the entire sample (N = 5,239), and the second model focused on drivers only (n = 3,543). A third model added interaction terms to the analysis to consider whether respondents who stopped driving but had a spouse who drove were less at risk of worsening depressive symptoms.

RESULTS

Respondents who stopped driving had greater risk of worsening depressive symptoms. Drivers who restricted their driving distances before the study began also had greater risk of worsening depressive symptoms, but seemingly less so than the respondents who stopped driving altogether. For respondents who stopped driving, having a spouse available to drive them did not mitigate the risk of worsening symptoms.

DISCUSSION

Changes in driving patterns can be deleterious for older people's depressive symptoms. Initiatives for assisting older people should focus on strategies that help them retain driving skills, that prepare them for the possible transition from driver to ex-driver, and that ensure that they have access to mental health therapies if driving changes are imminent.

National estimates of the quantity and cost of informal caregiving for the elderly with dementia

OBJECTIVE

Caring for the elderly with dementia imposes a substantial burden on family members and likely accounts for more than half of the total cost of dementia for those living in the community. However, most past estimates of this cost were derived from small, nonrepresentative samples. We sought to obtain nationally representative estimates of the time and associated cost of informal caregiving for the elderly with mild, moderate, and severe dementia.

DESIGN

Multivariable regression models using data from the 1993 Asset and Health Dynamics Study, a nationally representative survey of people age 70 years or older (N = 7,443).

SETTING

National population-based sample of the community-dwelling elderly.

MAIN OUTCOME MEASURES

Incremental weekly hours of informal caregiving and incremental cost of caregiver time for those with mild dementia, moderate dementia, and severe dementia, as compared to elderly individuals with normal cognition. Dementia severity was defined using the Telephone Interview for Cognitive Status.

RESULTS

After adjusting for sociodemographics, comorbidities, and potential caregiving network, those with normal cognition received an average of 4.6 hours per week of informal care. Those with mild dementia received an additional 8.5 hours per week of informal care compared to those with normal cognition (P < .001), while those with moderate and severe dementia received an additional 17.4 and 41.5 hours (P < .001), respectively. The associated additional yearly cost of informal care per case was 3,630 dollars for mild dementia, 7,420 dollars for moderate dementia, and 17,700 dollars for severe dementia. This represents a national annual cost of more than 18 billion dollars.

CONCLUSION

The quantity and associated economic cost of informal caregiving for the elderly with dementia are substantial and increase sharply as cognitive impairment worsens. Physicians caring for elderly individuals with dementia should be mindful of the importance of informal care for the well-being of their patients, as well as the potential for significant burden on those (often elderly) individuals providing the care.

Patterns and risk factors of change in somatic and mood symptoms among older adults

PURPOSE

This paper was concerned with patterns of individual-level, longitudinal change in depressive symptoms and factors related to those patterns among Americans 70+ years of age. Two types of depressive symptoms were considered, somatic and mood symptoms. The paper focused on whether the patterns of change and the risk factors for these two types of symptoms differed, as we might expect among old and oldest-old adults.

METHODS

The analytic sample included self-respondents of the 1993--1995 Asset and Health Dynamics among the Oldest Old (AHEAD) study who were born in 1923 or earlier. Depressive symptoms were assessed using an abbreviated Center for Epidemiologic Studies-Depression (CES-D) Scale. The analyses involved examination of respondents' change scores in depressive symptoms and multivariate models using ordinary least squares (OLS) and seemingly unrelated regressions (SUR).

RESULTS

In aggregate, somatic symptoms were more common than mood symptoms initially and over time. Despite differences in aggregate rates, AHEAD respondents' individual-level patterns of change for the two types of symptoms were similar; i.e., stability was the principal trend (53--60%), followed by improvement (21--26%). A number of factors related to change in one aspect of depressive symptoms and not the other, or had greater effects on one aspect of depressive symptoms than the other; e.g., physical health had greater effects on somatic than mood symptoms.

CONCLUSIONS

This study suggests that, in investigations of the course and risk factors for depressive symptoms among people 70+ years of age, it is important to separate somatic symptoms from mood symptoms; their etiology may differ. In general, factors reflecting respondents' social milieu (e.g., bereavement, residential relocation) may have greater effects on mood than somatic symptoms, whereas certain factors representing physical health may have greater effects on somatic symptoms.

Coping strategies and health care-seeking behavior in a US national sample of adults with symptoms suggestive of overactive bladder

BACKGROUND

Although millions of individuals have symptoms suggestive of overactive bladder (OAB), few ever seek or receive medical treatment for their condition.

OBJECTIVE

The purpose of this study was to describe coping strategies and health care-seeking behavior in a community-based sample of adults with symptoms suggestive of OAB.

METHODS

A cross-sectional household telephone survey of an age- and sex-stratified sample of adults was conducted. The survey consisted of general health-related questions as well as questions related to OAB symptoms. A total of 4896 adults completed the interview Respondents were considered to have OAB if they reported > or = 1 symptom of urinary urgency, frequency, or urge incontinence. A follow-up questionnaire was then mailed to a subsample of the telephone interview respondents. The mailed questionnaire contained questions related to type and severity of OAB symptoms, coping strategies, medical care/treatment, feelings/beliefs about OAB, and quality of life. Half of the phone respondents with urinary incontinence (n = 638) and a random sample of all other phone respondents received the mailed questionnaire (n = 873); 1,034 questionnaires were returned.

RESULTS

Of the respondents with OAB, 69.6% tried > or = 1 nonmedical coping strategy. Respondents with incontinent OAB were significantly more likely than those with continent OAB or those with no OAB (controls) to use nonmedical coping strategies (incontinent OAB, 76.1%; continent OAB, 59.0%; controls, 31.9%; P < 0.001). Fewer than half of the respondents with OAB (43.5%) had spoken with a provider about OAB in the previous 12 months. Medical consultation was associated with sex, type and severity of OAB, number of nonmedical coping strategies tried, number of OAB information sources consulted, inclination to try new OAB medications, and feelings/beliefs about OAB. In 90% of patient-provider discussions about OAB, the patient initiated the topic.

CONCLUSIONS

Individuals manage symptoms suggestive of OAB primarily by using nonmedical coping strategies rather than consulting health care providers. Results of this study support the need for improved clinical recognition of OAB and increased patient-provider communication about this condition.

Self-reported social and emotional impact of urinary incontinence

OBJECTIVE

Incontinence-specific and generic measures of well-being were regressed on potential predictors to identify incontinent respondents at risk for psychosocial distress and to understand the relationship between urinary incontinence (UI) and other determinants of social and emotional status.

DESIGN

Survey data were collected May 1994 through April 1996.

SETTING

Telephone interviews as a supplement to a nationally representative monthly consumer survey.

PARTICIPANTS

Analyses were based on 1,116 continent and 206 incontinent respondents age 40 and older.

MEASUREMENTS

Incontinent respondents self-reported the extent to which urine loss restricted social activities or affected their feelings about themselves. All respondents were asked whether they felt depressed, lonely, or sad. Covariates included sex, age, race, education, social desirability, health status, frequency of urine loss, quantity of loss, and urgency.

RESULTS

The majority of incontinent respondents reported that urine loss did not restrict activities or diminish self-esteem. Incontinent respondents who were younger, male, less educated, lower in social desirability, in poorer health, or losing greater quantities of urine were more likely to report psychosocial distress, although these correlates were not consistently significant. Compared with continent respondents, significantly higher percentages of incontinent respondents reported feeling depressed, lonely, or sad. In the multivariate models, incontinence retained an independent association with loneliness, but not with sadness or depression.

CONCLUSION

Even though the direct psychosocial impact of urine loss may be minor in many cases, UI is associated with a constellation of physical and behavioral factors that can impose a social and emotional burden. This suggests that UI cannot be adequately evaluated or treated without consideration of the patient's overall quality of life.

Health-related quality of life among adults with symptoms of overactive bladder: results from a U.S. community-based survey

OBJECTIVES

To assess, by means of a survey, the impact of the symptoms of overactive bladder (urinary frequency, urgency, and urge incontinence) on the quality of life in a community-based sample of the U.S. population.

METHODS

A telephone survey was conducted in the United States among an age and sex-stratified sample of 4896 noninstitutionalized adults 18 years of age and older. From the responses to the telephone survey, a total of 483 individuals with symptoms of overactive bladder and 191 controls completed a mailed follow-up questionnaire to assess their quality of life using the Medical Outcomes Study Short-Form 20.

RESULTS

After adjustment for age, sex, and the use of medical care, the greatest differences in the quality-of-life scores between the patients with incontinent overactive bladders and the controls were in the health perception (17.6 points; P <0.001) and role functioning (13.0 points; P <0.001) scales. Those with an overactive bladder with the symptoms of frequency or urgency, or both, but without incontinence, also had significantly lower scores than did the controls in mental health (P = 0.026), health perception (P = 0.01), and bodily pain (P = 0.016).

CONCLUSIONS

These data indicate that individuals with an overactive bladder experience decrements in their quality of life relative to community controls. An important new finding from this study is that individuals with an overactive bladder, even without demonstrable urine loss, also have a poorer quality of life than that of controls.

Epidemiology and natural history of urinary incontinence

This paper examines or current state of knowledge of the epidemiology of urinary incontinence. The population studied was community-dwelling non-institutionalized persons. The review includes discussion of the prevalence, incidence, natural history and presence of racial and ethnic differences in the epidemiology of urinary incontinence. We also review correlates and potential risk factors that have been revealed in epidemiological studies. Differences between epidemiological and clinical approaches to a health problem, help-seeking behavior and methodological issues for research are also discussed. We have reviewed a large number of completed studies in the field of urinary incontinence, and have emphasized high-quality and population-based studies. We also wished to present studies from a variety of countries. Because of the abundance of studies, only a small fraction can be presented here. Other studies may have equal standards and useful information, but lack of space precludes their inclusion.

Prevalence of urinary incontinence in middle-aged and older women: a survey-based methodological experiment

OBJECTIVE

To determine whether self-reports of urinary incontinence are influenced by the context in which survey questions are presented. Variation in the extent to which surveys promote complete and accurate reporting may help explain the wide range of published prevalence estimates.

METHODS

Respondents to a nationally representative telephone survey were randomly assigned one of two questionnaire forms. Both forms contained the same incontinence question. One form included an introduction and follow-up probe, which acknowledged the embarrassment of discussing incontinence and stressed the importance of thorough reporting.

RESULTS

Use of the introduction and probe produced a significantly higher prevalence rate, with the effect varying by respondent's age.

DISCUSSION

The prevalence of incontinence is likely to be underestimated unless studies attend to the possibility of biased reporting. The finding of a form by age interaction suggests the importance of survey context in studies of risk factors, as well as in prevalence studies.

Prevalence of urinary incontinence and associated risk factors in postmenopausal women. Heart & Estrogen/Progestin Replacement Study (HERS) Research Group

OBJECTIVE

To determine the prevalence of stress, urge, and mixed urinary incontinence and associated risk factors in postmenopausal women.

METHODS

Before enrollment in a 4-year, randomized trial of combination hormone therapy to prevent coronary heart disease, 2763 participants completed questionnaires on prevalence and type of incontinence. We measured factors potentially associated with incontinence including demographics, reproductive and medical histories, height, weight, and waist-to-hip circumference ratio. We used multivariate logistic models to determine independent associations between those factors and weekly incontinence by type.

RESULTS

The mean (+/- standard deviation [SD]) age of the participants was 67+/-7 years; 89% were white and 8% were black. Fifty-six percent reported weekly incontinence. In multivariate analyses, the prevalence of weekly stress incontinence was higher in white than black women (odds ratio [OR] 2.8, 95% confidence interval [CI] 1.6, 5.1), in women with higher body-mass index (BMI) (OR 1.1 per 5 units, 95% CI 1.0, 1.3), and higher waist-to-hip ratio (OR 1.2 per 0.1 unit, 95% CI 1.0, 1.4). The prevalence of weekly urge incontinence was higher in older women (OR 1.2 per 5 years, 95% CI 1.1, 1.3), diabetic women (OR 1.5, 95% CI 1.1, 2.0) and women who had reported two or more urinary tract infections in the prior year (OR 2.0, 95% CI 1.1, 3.6).

CONCLUSION

Stress and urge incontinence are common in postmenopausal women and have different risk factors, suggesting that approaches to risk-factor modification and prevention also might differ and should be specific to types of incontinence.

Prevalence and severity of urinary incontinence in older African American and Caucasian women

BACKGROUND

Few studies have investigated the prevalence and severity of urinary incontinence in older African American women. Comparisons of findings with those for older Caucasian women could provide important clues to the etiology of urinary incontinence and be used in planning screening programs and treatment services.

METHODS

Data are from the first wave of the Asset and Health Dynamics Among the Oldest Old (AHEAD) study. A nationally representative sample of noninstitutionalized adults 70 years of age and older was interviewed. African Americans were oversampled to ensure that there would be enough minority respondents to compare findings across racial groups.

RESULTS

A statistically significant relationship was found between race and urinary incontinence in the previous year: 23.02% of the Caucasian women reported incontinence, compared with 16.17% of the African American women. Other factors that appear to increase the likelihood of incontinence include education, age, functional impairment, sensory impairment, stroke, body mass, and reporting by a proxy. Race was not related to the severity (as measured by frequency) of urine loss among incontinent older women.

CONCLUSION

This study identifies or confirms important risk factors for self-reported urinary incontinence in a national context, and suggests factors leading to protection from incontinence. Race is found to relate to incontinence, with older African American women reporting a lower prevalence.

Volunteering and mortality among older adults: findings from a national sample

OBJECTIVES

Although a number of authors have proposed that older volunteers should benefit in terms of better health and well-being, few researchers have examined the issue empirically to see whether this is true. The purpose of this article is to build on this literature by empirically examining the association between volunteering and mortality among older adults.

METHODS

Using data from a nationally representative sample, we use Cox proportional hazards regression to estimate the effects of volunteering on the rate of mortality among persons aged 65 and older.

RESULTS

We find that volunteering has a protective effect on mortality among those who volunteered for one organization or for forty hours or less over the past year. We further find that the protective effects of volunteering are strongest for respondents who report low levels of informal social interaction and who do not live alone.

DISCUSSION

We discuss the possibility that the curvilinear relationship we observe between volunteering and mortality is due to a combination of factors, including self-identity, role strain, and meaningfulness. Other research using more precise data is needed to determine whether these ideas are supportable.

The impact of education and heart attack on smoking cessation among middle-aged adults

Considerable evidence supports the premise that higher levels of education lead to enhanced health, including protective health behaviors. This paper focuses on how education affects one health behavior known to lead to enhanced health: the cessation of smoking. In particular, the authors examine the extent to which education influences the decision by middle-aged adults to quit smoking following a heart attack, a potentially life-threatening health event. We first hypothesize that middle-aged adults with more formal education will stop smoking more readily than people with less formal education following the experience of a heart attack. Second, we ask what other factors might underlie and explain that hypothesized effect. Using longitudinal data, the authors track changes in individual smoking behaviors after a heart attack among preretirement-age Americans. We control for documented correlates of smoking and heart attack plus other factors associated with education, heart attack, and smoking that may also influence whether a person quits smoking. In addition to confirming evidence on the education-health association as well as the documented connection between heart attack and smoking cessation, this study provides a surprising twist on those links: Our results show that the move to quit smoking following the experience of a heart attack among middle-aged adults is significantly and dramatically moderated by their level of educational attainment.

Activities and well-being in older age: effects of self-concept and educational attainment

The positive effect of activities on well-being is proposed to be mediated by self-conceptualizations and facilitated by socioeconomic status. The hypothesized processes were estimated with LISREL VIII using data from a large cross-sectional survey with a sample of 679 adults aged 65 and older who were representative of older adults living in the Detroit area. Findings indicate that the frequency of performing both leisure and productive activities yields an effect on physical health and depression and that these effects are mediated in part by a sense of self as agentic, but less clearly by a sense of self as social. Furthermore, socioeconomic status, operationalized as formal educational attainment, facilitates the effect of leisure to a greater extent than that of productive activities.

Measures of cognitive functioning in the AHEAD Study

Decline in cognitive functioning and onset of cognitive impairment are potentially important predictors of elderly persons needing informal assistance and formal health care. This article describes the measures of cognitive functioning that were developed for the Asset and Health Dynamics Among the Oldest Old (AHEAD) study of some 6,500 Americans aged 70 years and older. The study was designed to investigate the impact of health on disbursement of family and economic resources. Evaluation of the cognitive measures in terms of psychometric properties and missing data, telephone administration, and formation of an aggregate index is encouraging. Their construct validity is evidenced by their correlations with sociodemographic characteristics and health indicators that replicate existing findings as well as by their prediction of IADL and ADL functioning that are consistent with theory.

Epidemiology of urinary symptoms in the geriatric population

As the US population ages, there is a growing need for information about the urologic health problems facing older adults. In conjunction with findings from clinical studies and basic research on biological mechanisms, the epidemiologic approach offers insights on the prevalence, etiology, and impact of these geriatric conditions. This information can provide the basis for planning health care services and intervention programs. The authors discuss trends associated with population aging and the challenges posed by the epidemiologic study of older adults. Also reviewed are current findings on the prevalence, incidence, and correlates of urinary incontinence and other common urologic symptoms.

Quality of survey informants' reports about death: verification of dates through a record check

To determine whether relatives and others can provide valid information about the dates of survey respondents' deaths, informants' reports were compared with death certificates for 328 deceased respondents from the MESA study of older adults. About two-thirds (64.6%) of the informants accurately reported the complete date of death. A somewhat larger percentage (70.4%) correctly reported the day of death, whereas 86.9% and 89.6% remembered the year and month, respectively. The percentage of correct reports varies by the relationship between informant and respondent. Also, the findings suggest that women are more accurate reporters than are men, and that the percentage of accurate reports is greater for longer-term relationships.

Robust aging among the young-old, old-old, and oldest-old

This study defined and examined the interrelationships among four multicategory definitions of robust aging: productive involvement, affective status, functional status, and cognitive status. Data are from a sample of 1,644 adults aged 60 and older who participated in a nationwide household survey in 1986. The four robust aging indicators were minimally correlated, suggesting that they tap a multidimensional phenomenon. Several personal characteristics were found to distinguish robustly aging individuals from their less-well-functioning counterparts for at least one robust aging criterion. The most robustly aging individuals reported greater social contact, better health and vision, and fewer significant life events in the past three years than their less robustly aging counterparts. The data also indicated a linear age-related decrease in the proportion of respondents found in the most robust aging categories, but membership in the oldest-old cohort did not preclude one from being identified as aging robustly.

Change in productive activity in late adulthood: MacArthur studies of successful aging

Both cross-sectional comparisons and patterns of change in productive activities among members of the MacArthur Successful Aging cohort were examined. The data came from a three-site longitudinal study of community-dwelling adults aged 70-79. The highest functioning cohort (n = 1,192) was found to be significantly more productive than a comparison group of medium- and low-functioning respondents at baseline in four of five domains examined. In longitudinal models, we tested several hypotheses regarding the determinants of change in levels of productive activity over a three-year period. Overall, 15.1 percent (n = 162) of the cohort became less productive, while another 12.7 percent (n = 136) became more productive. Risk factors for decline in productivity included hospital admission and stroke. Age, functional disability, marriage, and increased mastery were protective against declines. Conversely, Blacks, those who were more satisfied with life at baseline, and those reporting increased mastery were more likely to increase their productivity.

Effects of parental divorce and memories of family problems on relationships between adult children and their parents

We examined adult child-parent relations by childhood family structure and memories of family problems. Relative to those who grew up in two-parent families, adult children of divorce perceive both relationships with mothers and fathers to be of lower quality, although the magnitude of effects is generally two or three times greater for fathers. We find these effects to be significant for positive features of father-child relations, whereby adult children of divorce report feeling significantly less loved and less listened to by their fathers. While in most cases part of the effect of parental divorce on relationship quality can be explained by memories of parental marital conflict or other family problems, there is one exception. Even controlling for memories of family problems, we find adult children of divorce have significantly less contact with their parents than adults from two-parent families. We also examine data about parental surrogates.

The social stratification of aging and health

The way health varies with age is importantly stratified by socioeconomic status (SES)--specifically, education and income. Prior theory and cross-sectional data suggest that among higher SES persons the onset of health problems is usually postponed until rather late in life, while health declines are prevalent in lower SES groups by middle age. Thus, SES differences in health are small in early adulthood, but increase with age until relatively late in life, when they diminish due to selection or greater equalization of health risks and protections. The present paper strengthens our causal and interpretive understanding of these phenomena by showing: (1) that results previously reported for indices of SES hold separately for education and income; (2) that the interaction between age and SES (i.e., education or income) in predicting health can be substantially explained by the greater exposure of lower SES persons to a wide range of psychosocial risk factors to health, especially in middle and early old age, and, to a lesser degree, the greater impact of these risk factors on health with age; and (3) that results (1) and (2) generally hold in short-term longitudinal as well as in cross-sectional data. Implications for science and policy in the areas of aging, health, and social stratification are discussed.

Urinary flow rates and voiding pressures in elderly men living in a community

We reported that difficult bladder emptying symptoms are prevalent in elderly men. Urodynamic tests were conducted among 94 volunteer male respondents identified from our Medical Epidemiologic and Social Aspects of Aging Study in Washtenaw County, Michigan. Urine flow rates were significantly slower among men with symptoms compared to those without symptoms; however, significant overlap exists. Voiding pressures were not significantly different between respondents with and without difficult bladder emptying symptoms. The results of voiding pressure flow studies on all respondents regardless of whether they have symptoms revealed 41% with an obstructive pattern (high pressure and poor flow), 28.2% with an underactive pattern (low pressure and low flow), 20.5% with a mixed pattern (high pressure and normal flow) and 10.3% with a normal pattern. Symptoms hesitancy was more reflective of weaker detrusor pressure and straining pattern. From these results we conclude that symptoms and flow rates should not be used as the sole criterion to diagnose obstruction but, rather, they should be included in the entire spectrum of clinical information needed to arrive at a clinical diagnosis.

Urinary incontinence as a risk factor for mortality

OBJECTIVE

To determine whether mortality is independently associated with urinary incontinence.

DESIGN

6-year prospective study that started in 1983/84.

SETTING

A Midwestern County.

PARTICIPANTS

Probability sample of 1956 community-residing persons 60 years of age and older in 1983/84.

MEASUREMENTS

The independent variables of urinary incontinence, its types and severity, were measured by survey self-report, which was validated with clinical exams. The control variables of age, education, and health status were also self-reported. The dependent variable of death was established during follow-up interviews from reports of previously designated contact persons.

RESULTS

Neither incontinence status nor its severity level or types were found to be positively associated with 6-year mortality in logistic regression analyses that adjusted for age, education, and health status.

CONCLUSION

Whereas urinary incontinence can be an embarrassing and socially debilitating condition, it does not itself predict or contribute to mortality.

Measuring urinary incontinence in surveys

This article discusses aspects of urinary incontinence that require special attention for valid survey measurement. Comments from incontinent older adults illustrate the difficulty of identifying, remembering, and reporting the condition given its gradual onset, episodic course, and embarrassing nature. Ideas for further research and some suggestions for improving the survey measurement of urinary incontinence are offered. Among these are that it be adequately introduced within survey interviews, and that survey questions reflect respondents' experiential knowledge of the condition.

Epidemiology of bladder emptying symptoms in elderly men

We provide estimates of the prevalence, incidence and remission of difficult bladder emptying symptoms (prostatism) among noninstitutionalized men 60 years old and older living in a community in the United States. The prevalence of 1 or more symptoms of prostatism (hesitancy, straining, weak stream, intermittency or use of a catheter) among men who never had prostatic surgery is 35%. The annual incidence rates during years 1 and 2 of followup were 16.4% and 16.1%, respectively. Remission of symptoms of prostatism also was observed. Of the respondents with severe symptoms at baseline 22.9% were asymptomatic 1 year later. The prevalence of prostatic surgery in this population was 20%. The annual incidence rates during years 1 and 2 of followup were 2.6% and 3.3%, respectively. Urological and nonurological correlates of prostatism are identified. The irritative bladder symptoms are all significantly associated with moderate to severe bladder emptying symptoms (p < 0.0005). Nonurological conditions that also are associated with moderate to severe symptoms of prostatism include use of sedatives or tranquilizers, arthritis, poor health status and transient ischemic attacks. These observations are the initial step in documenting and understanding the various symptoms of prostatism, and its application in clinical practice.

Providing support to others and well-being in later life

Although there is now a voluminous literature on supportive social relations in later life, most of this research has been concerned with assessing the beneficial effects of receiving support from others. The purpose of this study is to assess whether giving support to others within informal as well as formal settings might also benefit older help-providers. Findings from a recent nationwide survey of the elderly suggest that giving informal assistance to others (but not formal assistance) appears to bolster feelings of personal control in later life. The data further reveal that greater feelings of personal control are in turn related to lower levels of depressive symptomatology.

Gender differences in affiliation and instrumentality across adulthood

This secondary data analysis tests the hypothesis that gender differences decline across adulthood. Six measures tapping 3 dimensions of affiliation and instrumentality were selected from the cross-sectional sample surveys of The Quality of American Life (1971) and Americans View Their Mental Health (1976). In both studies, approximately 2,200 adults who had been selected from probability samples of households in the continental United States were interviewed. For each measure, the variance explained by age, sex, and Age x Sex interaction terms was compared with the variance explained by age and sex alone. The addition of the interaction terms does not significantly increase the R2 for any of the measures, arguing against a late-life convergence of men's and women's orientations. Although the release from active parenting has been proposed as a basis for declining gender differentiation, limiting the analyses to respondents with children does not change this conclusion.

Relationship between use of diuretics and continence status in the elderly

Although diuretics have been implicated as a cause of urinary incontinence, no evidence has been presented prior to this report to confirm such a relationship. Our epidemiologic survey of 1,956 respondents sixty years of age and older in Washtenaw County, Michigan, revealed 24.6 percent of men and 36.9 percent of women were current users of a diuretic medication. Comparisons between users and non-users of diuretics and continence and incontinence status revealed no significant difference in the prevalence of incontinence in either gender. However, when male respondents who had cystometric examinations were analyzed, it was found that diuretic users who have uninhibited detrusor contractions (UDC) had a significantly higher prevalence of urinary incontinence (85.7%) when compared with non-users with UDC (25%) (p = 0.009). Among men who did not have UDC, use or non-use of diuretics showed a similar relationship but did not reach statistical significance (p = 0.085). There were too few female respondents with UDC to make meaningful analysis in this group.

Relation of work and retirement to health and well-being in older age

Patterns of labor-force participation were studied with a broad array of indicators of physical and psychological well-being. The sheer amount of work--whether people work and, if so, how many hours they work--shows little relationship to health and well-being. Drawing on scattered existing research and theory, it is hypothesized and found that persons whose patterns of labor-force participation (or nonparticipation) reflect their personal preference report higher levels of physical and psychological well-being than do those whose level of labor-force involvement is constrained by other factors. The results do not differ by gender, age (65 years and older vs. 55-64 years), or occupation (professional vs. clerical or sales vs. blue-collar workers). Data are from 1,339 respondents 55 years of age or older in the Americans' Changing Lives Survey, a large national, cross-sectional survey of Americans 25 years of age and older with an oversample of those 60 years of age and older, and are analyzed by ordinary least squares multiple regression.

Gender differences in affiliation and instrumentality across adulthood

This secondary data analysis tests the hypothesis that gender differences decline across adulthood. Six measures tapping 3 dimensions of affiliation and instrumentality were selected from the cross-sectional sample surveys of The Quality of American Life (1971) and Americans View Their Mental Health (1976). In both studies, approximately 2,200 adults who had been selected from probability samples of households in the continental United States were interviewed. For each measure, the variance explained by age, sex, and Age x Sex interaction terms was compared with the variance explained by age and sex alone. The addition of the interaction terms does not significantly increase the R2 for any of the measures, arguing against a late-life convergence of men's and women's orientations. Although the release from active parenting has been proposed as a basis for declining gender differentiation, limiting the analyses to respondents with children does not change this conclusion.

Relation of work and retirement to health and well-being in older age

Patterns of labor-force participation were studied with a broad array of indicators of physical and psychological well-being. The sheer amount of work--whether people work and, if so, how many hours they work--shows little relationship to health and well-being. Drawing on scattered existing research and theory, it is hypothesized and found that persons whose patterns of labor-force participation (or nonparticipation) reflect their personal preference report higher levels of physical and psychological well-being than do those whose level of labor-force involvement is constrained by other factors. The results do not differ by gender, age (65 years and older vs. 55-64 years), or occupation (professional vs. clerical or sales vs. blue-collar workers). Data are from 1,339 respondents 55 years of age or older in the Americans' Changing Lives Survey, a large national, cross-sectional survey of Americans 25 years of age and older with an oversample of those 60 years of age and older, and are analyzed by ordinary least squares multiple regression.

Urodynamic tests for female geriatric urinary incontinence

Most urodynamic tests currently in use in the evaluation of female urinary incontinence have not been applied to a community-based sample to determine their specificity. In this study of a random sample of noninstitutionalized elderly, 258 self-reported continent and 198 self-reported incontinent women sixty years and older, who participated in a household survey, underwent a clinic evaluation (history, physical examination, and urinalysis); of these 67 continent and 100 incontinent female respondents underwent urodynamic testing. The uroflowmetry, cystometry, and supine static urethral pressure profilometry (UPP) findings did not differ significantly between continent and incontinent subjects (whether based on a self-report or a clinician's diagnosis of urinary continence status). Standing static and dynamic UPP and lateral cystography showed significant differences between self-reported continent and incontinent respondents. The provocative stress test significantly distinguishes continence from incontinence, and stress incontinence from other types. The sensitivity of the provocative stress test was 39.5 percent, whereas its specificity is 98.5 percent. Urodynamic testing including uroflow study, static UPP, and lateral cystography should not be used as a screening test but rather selectively as a confirmatory test, and to determine the therapeutic approach, and to assess the outcome of therapy.

Medical correlates of urinary incontinence in the elderly

A probability sample of noninstitutionalized elderly people in Washtenaw County, Michigan, was interviewed to determine the relationship between urinary incontinence and various health conditions. The results show that between both male and female respondents physical mobility problems, specific neurologic symptoms, lower urinary tract problems, bowel problems, respiratory problems, and history of genital surgery are more prevalent among those who are incontinent than among those who are continent. Additional factors associated with incontinence in females are: history of parent and sibling incontinence, incontinence either during pregnancy or postpartum, hearing problems, use of female hormones, and vaginal infections. Incontinence among males is associated with vision problems and a history of and symptoms of cardiovascular disease. These findings suggest urinary incontinence is part of a complex and multifactorial problem. Further studies are needed to confirm and explain these findings.

Two-year incidence, remission, and change patterns of urinary incontinence in noninstitutionalized older adults

In this study, patterns of urinary incontinence, its severity and types were studied by three sequential data collections at annual intervals. The data are from a panel survey of a probability sample of 1,956 noninstitutionalized persons aged 60 and over residing in Washtenaw County, Michigan, who were interviewed in their homes about urine loss. Based on these self-reports, the prevalence of urinary incontinence was 18.9% in men and 37.7% in women. One-year incidence rates of about 20% among women and about 10% among men were found. One-year remission rates were about 12% for women and about 30% for men. When becoming incontinent, respondents were most likely to develop mild incontinence. Those who changed their severity level were most likely to progress from mild to moderate.

Urinary incontinence: medical and psychosocial aspects

Recognition has been growing over the past two decades that urinary incontinence is a rather widespread condition among older adults. Prevalence rates of about 30% for any incontinence and about 5% for severe incontinence among older adults were suggested by several European studies and have recently been confirmed by American studies. The rates are typically higher among women than men. Despite these findings, much about the true distribution of urinary incontinence remains to be firmly established. The proportion of different types and the differences between sexes, ages, and races need to be confirmed using representative population samples and valid measures of incontinence. These distributions cannot be accurately described using clinical populations. Perhaps because urinary incontinence is viewed as highly embarrassing, it has not been a focus of media coverage or public discussion. More attention by the media and by health-care professionals would build public awareness of the condition. Older adults and their caregivers need to know that urinary incontinence is common and treatable, so that they will identify it promptly and bring it to their physicians' attention. Health-care providers and social workers must also be alert to the possibility of incontinence among their clients. They should be prepared to ask older patients directly, because many patients may disregard urine loss or be too embarrassed to mention it. Currently, much of the management of urinary incontinence appears to be self-devised. Many incontinent persons have not talked to a physician about their problem. The largest proportion of those who attempt to control their urine loss use absorbent products or try to avoid loss by awareness of toilet locations and frequent toileting. Reliance on these methods is unfortunate because much progress has been made in developing diagnostic and treatment procedures for urinary incontinence. For example, surgical procedures to rectify an incompetent sphincter have been shown to be effective and are generally accepted. There are a number of medications effective for controlling detrusor instability. Further, various behavioral techniques appear to be promising as noninvasive initial interventions for many patients. We are on weaker ground regarding the prevention of and early intervention in urinary incontinence. The existing epidemiological data on the development of incontinence are poor. We do not know the proportion of urinary incontinence that is transient and the proportion that is chronic or established. Nor do we know the risk factors for onset and progression of the condition.(ABSTRACT TRUNCATED AT 400 WORDS)

Sexual function in the elderly

Little is known about sexual behavior among the elderly living in the community. Questions about sexual activity and its correlates were included in a clinic examination whose participants were identified by a household survey of a probability of Washtenaw County, Michigan, elderly, aged 60 years and over, on the medical, epidemiological, and social aspects of aging. Estimates of proportions based on responses at the clinic examination were also projected to the demographics of the household survey. The estimated proportions of individuals who are sexually active are 73.8% for married men and 55.8% for married women; among unmarried men and women the proportions are 31.1% and 5.3%, respectively. The levels decrease significantly with age in both genders. The estimated proportion of married men with erectile impotence is 35.3%. Significant associations were observed between having problems with mobility and the lack of sexual activity in both genders. The prevalence of impotency was significantly associated with a history of heart attack, urinary incontinence, and the use of sedatives. The consumption of at least one cup of coffee per day was significantly associated with a higher prevalence of sexual activity in women and with a higher potency rate in men.

Age differences in productive activities

Age differences in productive contributions through both paid and unpaid work are examined in commensurate terms. Data are from a nationwide household survey of 3,617 adults age 25 and older conducted in 1986. Older Americans participate in many unpaid productive activities at levels that are comparable to those reached by middle-aged and younger Americans; these activities include volunteer work in organizations, informal help to others, maintenance and repair of their home and possessions, and housework. Relatively few older Americans spend any time participating in paid work and unpaid rearing of children. Largely because of the cessation of paid work and child care, older Americans spend less time overall in productive activities. Women and men spend about equal time in productive activities, but women spend more of it in unpaid work and less of it in paid work. The difficulties with using paid work as the major indicator for describing productivity across the life span are discussed.

Prevalence and outcome of surgery for female incontinence

A 4.7 percent surgery rate to correct urine loss conditions was found by a large scale survey of sixty-year and older non-institutionalized women in a Michigan county. The initial postoperative results reported by the respondents were 74 percent complete continence and 23 percent partial relief. The long-term self-reported outcomes (two years or more post-surgery) were an absolute continence rate of 39 percent and 17 percent with mild incontinence (the median time since surgery was 12 years), whereas the short term (4-23 months, mean 7.1 months) absolute continence rate was 71 percent. The characteristics of the incontinence respondent who had previous surgery showed 70 percent having mixed stress-urge type of incontinence and 66 percent losing urine almost weekly or daily. Bladder emptying symptoms were reported by 30.4 percent of the continent previously-operated respondents compared with 13.0 percent of the incontinent previously-operated respondents. All continent respondents and 84 percent of the incontinent respondents believed that physicians can help people with a urine loss condition.

Methods used to manage urinary incontinence by older adults in the community

This paper addresses the ways that noninstitutionalized older adults deal with involuntary urine loss. The data come from a 1983-1984 sample survey of Washtenaw County, Michigan residents aged 60 and over. Five hundred twelve self-reported incontinent respondents are included in the analyses. About a quarter of the incontinent respondents had discussed their condition with a doctor in the previous year, while 66% used one or more methods to control urine loss. Respondents preferred using absorbent products (47% of those who used some method) and locating a toilet upon reaching a destination (42%). Fewer respondents manipulated their voiding patterns (29%) or diet and fluid intake (17%), or did pelvic muscle exercises (10%). Only 7% were taking medication for their incontinence. Logistic regression analyses were performed to identify factors associated with the choice of actions. Predictors were taken from theoretical models of health service utilization and health behavior, and included predisposing characteristics, health beliefs, enabling factors, and illness variables. Illness variables, particularly severity and type of incontinence, were the best predictors of consultation with a doctor and use of any urine control method. The predictors were less useful for understanding the choice of a specific method.

Age differences in memory performance and memory ratings as measured in a sample survey

Age differences in memory performance were studied in a probability sample of a cross-section of 1,491 adults living in the Detroit metropolitan area, with an oversample of those age 60 and older. Both a recall and a recognition measure were adapted to the survey context by querying respondents about the nature of the questions asked in an immediately preceding interview. Subjective memory assessment was also measured, using global memory ratings performed by the respondent, his or her spouse, and the interviewer. A clear, age-related decline in memory performance was found in this population sample. Subjective memory assessment also declined across age groups, but the relation was weaker. On the basis of multiple regression analyses of the recognition measure and the respondent's self-rated memory, which were judged to have the best measurement qualities, a substantial part of these age differences can be accounted for by differences in sociodemographic composition between age groups, by cognitive functioning and physical health.

Age and response rates to interview sample surveys

The relationship between response rate--a basic indicator of the quality of survey data--and age is investigated. Standard definitions of general and age-specific response rates are presented first. In a systematic assessment of response rates by age, data from several large interview sample surveys and panel resurveys are then examined. Response rates are found to decline linearly with increasing age in both types of surveys, although the decline is not always statistically significant. Potential causes and consequences of low response rates among elderly persons are discussed.

Clinical and cystometric characteristics of continent and incontinent noninstitutionalized elderly

A survey of the clinical and cystometric characteristics of continent and incontinent elderly subjects living in a community has not been reported previously. Household respondents identified initially from a random probability sample were invited to undergo a free clinic evaluation followed by an invitation to free urodynamic testing. Of the 1,955 household respondents 456 women and 298 men attended the clinic. From this group 169 women and 94 men accepted the urodynamic invitation. Cystometric studies reveal a significant difference between the over-all prevalence of uninhibited detrusor contraction between genders, 7.9 per cent for women and 35 per cent for men. The occurrence of uninhibited detrusor contractions is more prevalent among incontinent than continent subjects and this difference is marginally significant. There is no significant association between uninhibited detrusor contractions and symptoms of difficult bladder emptying, irritative symptoms, voiding frequency, nocturia and urodynamic diagnosis of outlet obstruction (normal or high pressure and poor flow) but there were significant associations with responses to questions about the delay in getting to a toilet. The mean bladder capacities of men and women do not differ significantly between the different age groups but the capacity is significantly smaller for those with uninhibited detrusor contractions. The post-void residual urine volume shows no association with the continence status. These findings raise questions regarding our conventional thinking as to the etiology of uninhibited detrusor contractions, especially in men, and of urinary incontinence in general.

Urinary incontinence and psychological distress among older adults

We examined the relationship between urinary incontinence and psychological distress in a sample of community-dwelling older adults. The data are from a probability sample of Washtenaw County, Michigan residents ages 60 years and older, who were interviewed in 1983 and 1984. A total of 747 women and 541 men were included in the analyses. Experiencing urinary incontinence, particularly in a severe form, was weakly related to depression, negative affect, and low life satisfaction. These relationships are partly explained by the fact that incontinent respondents are less healthy than are continent respondents.

Urinary incontinence and psychological distress among older adults

We examined the relationship between urinary incontinence and psychological distress in a sample of community-dwelling older adults. The data are from a probability sample of Washtenaw County, Michigan residents ages 60 years and older, who were interviewed in 1983 and 1984. A total of 747 women and 541 men were included in the analyses. Experiencing urinary incontinence, particularly in a severe form, was weakly related to depression, negative affect, and low life satisfaction. These relationships are partly explained by the fact that incontinent respondents are less healthy than are continent respondents.

Interviewing older adults: the accuracy of factual information

Using data from a probability sample of adults in a metropolitan area, the accuracy of survey measures was assessed by comparisons to administrative records, census counts, and maps. Some types of information, including birth date and make and year of car, were reported accurately by most respondents, whereas frequent errors were detected for other types of information, including voting behavior, house value, and characteristics of neighbors. Comparisons were made with respect to the relative accuracy of the reports of respondents in three age groups: younger than 60, 60 through 69, and 70 or older. For many measures, no age differences were detected, and for those where age differences were observed, the older respondents were sometimes more accurate than the younger respondents. The potential consequences of measurement error are serious. Evidence to date, however, does not indicate consistently that these problems are any more serious for older respondents than for any other age group.

Prevalence of urinary incontinence and other urological symptoms in the noninstitutionalized elderly

The prevalences of urinary incontinence, difficulty in bladder emptying and irritative bladder symptoms are not known in the noninstitutionalized elderly in this country. A survey, consisting of a multi-stage probability sample of 13,912 households, was done in Washtenaw County, Michigan to estimate these prevalences. A total of 1,955 senior citizens 60 or more years old was interviewed. The prevalences of urinary incontinence, difficult bladder emptying and irritative bladder symptoms were 18.9, 22.1 and 11.8 per cent, respectively, in men, and 37.7, 10.8 and 17.4 per cent, respectively, in women. Urinary incontinence was significantly more prevalent among all respondents with bladder emptying and irritative symptoms than those without such symptoms (p less than 0.001). The frequency of voiding was significantly increased among respondents with incontinence, or emptying or irritative symptoms compared to asymptomatic respondents (p less than 0.001). These survey data are of importance to senior citizens, care providers and governmental agencies.