Lower urinary tract symptoms and urinary incontinence in a geriatric cohort – a population-based analysis

Authors


Stephan Madersbacher, Department of Urology and Andrology, Donauspital, Langobardenstrasse 122, A-1220 Vienna, Austria. e-mail: stephan.madersbacher@wienkav.at

Abstract

Study Type – Symptom prevalence (prospective cohort)

Level of Evidence 1b

What's known on the subject? and What does the study add?

Prevalence and severity of urinary incontinence and lower urinary tract symptoms increase with age and have a considerable negative influence on quality of life.

As a result of demographic changes the proportion of octogenarians will increase in the next decades substantially, yet the literature on urinary incontinence and lower urinary tract symptoms of the oldest old is scant. This population-based study of 85-year-old subjects sheds new light on this topic.

OBJECTIVES

  • • To assess prevalence and severity of lower urinary tract function in 85-year-old men and women.
  • • Little is known on the prevalence of lower urinary tract dysfunction in this geriatric age group, which is now the fastest growing sector of the population worldwide.

PATIENTS AND METHODS

  • • The Vienna Trans-Danube Aging study (VITA) is a longitudinal, population-based study initiated in 2000 that included men/women aged 75 years living in a well-defined area in Vienna.
  • • The main purpose of the VITA study was to identify risk factors for incident Alzheimer's disease.
  • • All study participants alive in 2010 were contacted by mail to complete a detailed questionnaire on various aspects of lower urinary tract symptoms (LUTS) and urinary incontinence (UI).

RESULTS

  • • The response rate was 68%, resulting in a total of 262 questionnaires available for analysis (men n= 96; women n= 166). All study participants were 85 years of age.
  • • Urinary incontinence defined as any involuntary loss during the past 4 weeks was reported by 24% of men and 35% of women (P= 0.04). Stress UI was more frequent in women (39%) than in men (14%, P < 0.01), the difference for urge UI (women 35%, men 25%) was on the border of statistical significance (P= 0.05). Only four individuals (1.5%) needed permanent catheterization.
  • • Urgency (women 56%, men 54%) and daytime frequency (women 70%, men 74%) were equally distributed (P > 0.05). Nocturia more often than twice was more prevalent in men (69%) than in women (49%) (P= 0.02). Overactive bladder, according to International Continence Society criteria, was present in 55% of women and 50% of men.
  • • No difference regarding quality of life impairment as the result of LUTS and UI was noticed between sexes. A few co-morbidities were identified to correlate with UI and storage symptoms.

CONCLUSIONS

  • • These data provide insights into the prevalence and severity of LUTS and UI in individuals in their eighties, to our knowledge the largest population-based study in this age group.
  • • Demographic changes in upcoming decades underline the importance of a thorough understanding of lower urinary tract dysfunction in a geriatric population.
Abbreviations
UI

urinary incontinence

OAB

overactive bladder syndrome

VITA

Vienna Trans-Danube Aging study

INTRODUCTION

Lower urinary tract symptoms (LUTS), urinary incontinence (UI) and overactive bladder syndrome (OAB) belong to the most frequent urological disorders and they all increase with age [1].

As a result of demographic changes, the proportion of individuals aged 80 years or more will rise substantially within the next decades, particularly in industrialized societies [2]. The oldest old, defined variously as those aged 80 or 85 years or older, are now the fastest growing sector of the population worldwide [2]. Many of the oldest old experience disease, disability and dependency with high costs for health and social care [3]. In Austria (population census 2010: 8.3 million) individuals older than 80 years currently comprise 402 000 inhabitants (127 000 men and 275 000 women) and this number is projected to rise to 1.1 million (+173%; by the year 2050 [4]. In 2050, 11% of the total Austrian population will be older than 80 years [4].

Relatively little is known of the prevalence of LUTS in this high age group, particularly in a population-based cohort. Given the profound effect of age on lower urinary tract function, a study population with a narrow age range avoids the inherent age bias. The Vienna Trans-Danube Aging study (VITA) study is a prospective, longitudinal, population-based, cohort study of 75-year-old inhabitants of the two districts of Vienna located on the east side of the river Danube [5]. The VITA study was initiated in 2000, in 2010 all participants still alive were contacted to complete a questionnaire on various aspects of LUTS [5]. These data are presented herein.

METHODS

The VITA study involves all 75-year-old inhabitants of the two districts of Vienna located on the east side of the river Danube [5]. This geographical area represents a working class area with 245 000 inhabitants. Of those, all men and women who were 75 years of age at the beginning of the study were invited to participate (n= 2000). Of these, 606 (247 men) agreed to participate and underwent the baseline investigation. The VITA study was initiated in 2000 with the main scientific aim to identify predictors for dementia in the elderly [5]. The study was initiated and is conducted by the Ludwig Boltzmann-Institute of Aging Research in close co-operation with the Danube Hospital, a large community hospital in this area [5].

The study was approved by the Viennese medical ethics committee and written informed consent was obtained from all participants. Study design, recruitment and clinical investigations were published in detail in 2002 [5]. Final participation rate was 30.2%. For the following analysis we have used data generated during the baseline investigation in men.

Austria has a public, equal-access health-care system with compulsory insurance coverage. Standard medical care is free of charge and accessible to all inhabitants. Within this study we did not specifically offer urological evaluation, but all participants of the VITA study are under close medical surveillance.

All statistical analyses were carried out with SPSS 11.5 (Statistical Package for the Social Sciences; SPSS Inc., Chicago, IL, USA). Group differences in categorical variables were analysed by the chi-squared test, and metric variables were calculated with the t test, all at a level of significance of P= 0.05.

RESULTS

All participants of the VITA study still alive in 2010 (n= 423) were contacted by surface mail to complete the LUTS questionnaire (see Appendix). The response rate was 68%, resulting in a total of 262 questionnaires available for analysis (men n= 96; women n= 166). Characteristics of the study cohort are listed in Table 1. From the total population, one man had a suprapubic catheter and three women had transurethral catheters. The indications for permanent catheterization were UI or recurrent urinary tract infection, two participants had Alzheimer's disease and Parkinson's disease, respectively.

Table 1. Characteristics of the study population
 TotalWomenMen
Number26216696
Age, years: baseline (sd)75.8 (0.45)75.7 (0.45)75.9 (0.44)
Alzheimer's dementia, n (%)2716 (9.6)11 (11.5)
Diabetes mellitus, n (%)2916 (9.6)13 (13.5)
Cerebrovascular insult, n (%)1712 (7.2)5 (5.2)
Parkinson's disease, n (%)126 (3.6)6 (6.3)
Coronary heart disease, n (%)3621 (12.7)15 (15.6)
Polypharmacia 4+, n (%)13796 (57.8)41 (42.7)
Neurovascular disease, n (%)4426 (15.7)18 (18.8)
Sedative use, n (%)3727 (16.2)10 (10.4)

The overall prevalence of UI (definition: any involuntary urine loss during the past 4 weeks) of the entire cohort was 32.4%, higher in women (36.1%) than in men (26%, P= 0.092). The frequency of UI episodes was higher in women (Fig. 1). More frequent UI episodes ranging from two or three times per week to permanent were reported by 27.1% of women and 15% of men ( P= 0.037) (Fig. 1). Stress UI was more frequent in women (39.1%) than in men (13.8%, P < 0.001) (Fig. 1). The difference for urge UI was on the border of significance (women: 35%, men: 25.5%, P= 0.05) (Fig. 1). In general, quality of life impairment caused by UI was moderate: only 6.5% of men and 15% of women (P= 0.083) stated a moderate to severe quality of life impairment as a result of UI.

Figure 1.

Extent of urinary incontinence and impact on quality of life.

Prevalence and severity of urgency and frequency were similar in both sexes (Fig. 2). Any degree of urgency was reported by 56.1% of women and 54.3% of men (P= 0.15). More severe forms of urgency (occasionally, almost always, always) were reported more often by women (25.8%) than men (9.8%) (Fig. 2). Daytime frequency revealed a similar pattern between both sexes. A daytime frequency of every 2 h or more was reported by 23.6% of women and 24.4% of men (P= 0.6). Nocturia was more frequent in men (P= 0.021) (Fig. 2). Only 5.3% of men and 12% of women stated that they did not have to get up during the night. Nocturia of twice or more was reported by 69.2% of men and 49.4% of women. The prevalence of OAB defined according to ICS criteria (see Material and methods section) was 55% for women (23% OABdry and 32% OABwet) and 50% for men (29% OABdry and 21% OABwet).

Figure 2.

Distribution of urgency and nocturia in the study population.

The last question asked whether urinary symptoms in general had a negative impact on quality of life and if so, which symptom was the most bothersome. In the male cohort, 54% reported that their quality of life was not affected at all by LUTS and UI, 29.7% stated that nocturia was the most bothersome symptom followed by daytime frequency (9.5%), strong, uncontrollable urgency (4.1%) and UI (2.7%). The female cohort revealed a similar pattern: 51% reported no negative impact of LUTS and UI on quality of life; similar to the male cohort, nocturia was the most bothersome symptom (28.5%), followed by UI (12.7%), daytime frequency (5.1%) and strong, uncontrollable urgency (2.2%).

Individuals with pure urge UI or mixed UI reported a greater negative impact on quality of life (definition: moderate to severe impairment) than those with pure stress UI (35% versus 20%). As expected, 23.5% of subjects with UI stated a moderate to severe impairment of quality of life compared with only 1.4% without UI.

CORRELATES FOR URINARY INCONTINENCE AND STORAGE SYMPTOMS

Table 2 shows correlates to UI in both sexes. Whereas only a few co-morbidities yielded a significant impact on the presence of UI, several numerical differences were observed (Table 2). Men with Alzheimer's disease, diabetes, Parkinson's disease, cardiovascular disease, multi-medication and sedative use had higher rates of UI (Table 2). In females, Alzheimer's disease, diabetes, Parkinson's disease, neurovascular disease and cardiovascular disease had negative impacts on the continence status (Table 2). Only a few correlates for storage symptoms were identified, in these analyses both sexes were combined: Alzheimer's disease for urgency (P= 0.019), neurovascular disorders for urgency (P= 0.028) and sedative use (P= 0.005) (Table 3).

Table 2. Correlates to urinary incontinence in men and women
 MenWomen
Continent (%)Incontinent (%) P Continent (%)Incontinent (%) P
Alzheimer's disease13200.1610.412.50.073
Diabetes13230.01610.412.50.96
Cerebrovascular insult9.300.567.86.30.35
Parkinson's disease5.6100.82.65.80.56
Neurovascular disease24.1200.515.621.90.27
Cardiovascular disease25.9350.4714.3250.12
Multimedication (>3)58600.0774.762.50.26
Sedative use9.3250.2319.518.80.90
Table 3. Correlate storage symptoms (combined analysis of men and women)
 Alzheimer's diseaseDiabetes mellitusInsultParkinson's diseaseHeart diseaseNeuro-vascular disorderNo medicationSedative use
  1. OAB, overactive bladder. *Significant correlation.

OAB0.040.180.380.170.700.070.420.14
Urgency0.02*0.220.540.190.380.03*0.760.11
Frequency0.110.290.480.270.870.160.290.005*
Nocturia0.440.080.290.560.770.230.530.07

DISCUSSION

This study evaluates the prevalence and severity of and correlates for several aspects of lower urinary tract dysfunction in a geriatric population. A thorough understanding of this issue is of paramount importance given upcoming demographic changes. Lower urinary tract dysfunction is one of the most prevalent disorders in the elderly, yet few studies have specifically investigated this advanced age cohort [6–10]. Just as an example, a large-scale epidemiological trial on overactive bladder did not recruit individuals older than 80 years [8]. The currently most frequently cited study on prevalence of lower urinary tract dysfunction (EPIC) investigated 19 165 individuals [11]. Although 2300 individuals were older than 70 years, separate data on participants aged from 80 to 85+ have not been published [11].

To investigate lower urinary tract dysfunction in a geriatric cohort we analysed participants of the VITA study. Strengths of our approach are the population-based design and – according to our knowledge – uniquely rigid strict age cohort. It is one of the largest population-based cohorts in this geriatric segment. A drawback is the lack of objective data such uroflowmetry, post-void residual volume or invasive urodynamics.

This study underlines the high prevalence of lower urinary tract dysfunction in this advanced age group. In the male cohort, 26% reported on UI, 50% had OAB, 69% had nocturia of twice or more and 54% had urgency. In women, the respective percentages were 36%, 55%, 49% and 54%, respectively. These data underline the importance of this topic. Most octogenarians who participated in this study were relatively fit because they were able to complete a four-page self-administered questionnaire. This is also documented by the fairly high Mini-Mental State examination score of 28. Hence we speculate that this fact induced a positive selection bias and that the prevalence of LUTS and UI might be even higher in unselected 85-year-old individuals (including bed-ridden subjects and those in nursing homes).

Despite these impressive figures the impact of lower urinary tract dysfunction on quality of life in general was moderate. Almost 50% of the study participants neglected any negative impact on quality of life because of their lower urinary tract dysfunction. Both sexes indicated nocturia to be the most bothersome symptom. This was surprising because usually urgency and urge UI have a higher impact on quality of life than nocturia. In a geriatric cohort, however, nocturia was the most bothersome symptom, probably because of the fear of night-time falls that can result in significant morbidity in the oldest old [12].

As indicated above, only a few studies have specifically addressed lower urinary tract dysfunction in a geriatric cohort, the most solid data are available for UI. Smith et al. [13] analysed prevalence of UI in community-dwelling older Latinos. A total of 572 individuals aged 60+ were studied, in the small group of 80+ participants (n= 107) 24% had UI. Correlates to UI in this study were female sex, depressive symptoms, greater medical co-morbidity, worse physical performance, greater activities of daily living impairment and worse cognitive function [13]. Lasserre et al. [14] studied prevalence and correlates for urinary incontinence in French women visiting general practitioners. Out of 2183 women analysed, 206 were 80 years or older, the prevalence of UI in this cohort was 46.6% [14]. The most frequent form of UI in the 80+ cohort was mixed UI (62%) followed by pure stress UI (26%) and pure urge incontinence (9%) [14]. Song and Bae [15] undertook a cross-sectional study of community-dwelling elderly aged 85 years or older living in South Korea, a total of 135 persons completed the interview. In this cohort, 34.8% had UI: mixed UI was reported by 61.7%, pure urge UI by 34% and pure stress UI by 4.3% [15]. In summary, these studies and the VITA data document the high prevalence of UI in geriatric patients with 30–50% being affected. Correlates for UI in geriatrics centre around co-morbidities (diabetes, Alzheimer's disease), polymedication and physical performance.

Data on nocturia, urgency and daytime frequency in a geriatric cohort are scarce. Most studies have analysed patients aged 75+ years with no detailed analysis of geriatric patients. Hence 75+ data might be diluted by ‘younger’ senior adults and are therefore difficult to interpret. In a recent cross-sectional US survey of 5297 men older than 20 years, around 60% in the 75+ cohort had nocturia of two or more [9]. In our male cohort, which was 10 years older, the prevalence increased to 70%, which seems plausible. A more detailed analysis of geriatric patients was not performed by Markland et al. [9] in their series. Burgio et al. [16] analysed prevalence and correlates for nocturia in community-dwelling older adults aged 65–106 years (mean age: 73.8 years), 113 study participants were older than 85 years. The overall prevalence of nocturia of two or more in this cohort was more common for women (63.2%) than men (53.8%) [16]. Again, a separate analysis of the geriatric cohort was not available [16]. Coyne et al. [8] reported on the prevalence of OAB in participants of the EpiLUTS study. Almost 20 000 men and women were recruited. In the highest age group that was analysed (75+) the prevalence of urgency/urge incontinence was in the range of 70%, comparable to our data [8].

In our geriatric cohort with no age bias only few significant correlates to UI and storage symptoms have been identified. The lack of statistical significance despite several numeric differences (see Tables 2 and 3) can be attributed to the rather small sample size. However, one has to be aware that this cohort is unique regarding the narrow age range. Given the profound impact of age on almost all aspects of lower urinary tract dysfunction one can hypothesize that some of the previously reported correlates are impacted by the age bias even if corrected for age.

Our data provide insights into the prevalence of LUTS and UI in individuals in their eighties and shows the high prevalence with significant impact on quality of life. Significant demographic changes in upcoming decades underline the importance of a thorough understanding of lower urinary tract dysfunction in a geriatric population.

CONFLICT OF INTEREST

None declared.

Appendix

LUTS-QUESTIONNAIRE

The following questionnaire was sent out by mail to all participants of the VITA study still alive in 2010.

Do you have a transurethral catheter?

  • □ No
  • □ Yes → if ‘Yes’, since when ? ______ (year)

Reason for catheter

  • □ Urinary retention
  • □ Urinary incontinence
  • □ Urinary tract infection
  • □ Unknown

Do you have suprapubic catheter

  • □ No
  • □ Yes → if ‘Yes’, since when ? ______ (year)

Reason for suprapubic catheter:

  • □ Urinary retention
  • □ Urinary incontinence
  • □ Urinary tract infection
  • □ Unknown

Do you have a condom catheter?

  • □ No
  • □ Yes → if ‘Yes’, since when ? ______ (year)

Reason for condom catheter:

  • □ Urinary retention
  • □ Urinary incontinence
  • □ Urinary tract infection
  • □ Unknown

Have you leaked any urine at all during the past 4 weeks?

  • □ Never
  • □ Once per week
  • □ 2–3 times per week
  • □ Once per day
  • □ Several times per day
  • □ Always

In general, how is your quality of life affected by your involuntary loss of urine?

  • □ Not at all
  • □ A little
  • □ Moderate
  • □ Severe

How often do you lose urine during physical activity, coughing, sneezing, lifting heavy things?

  • □ Never
  • □ Once per week
  • □ 2–3 times per week
  • □ Once per day
  • □ Several times per day
  • □ Always

How often do you lose urine before you reach the toilet?

  • □ Never
  • □ Once per week
  • □ 2–3 times per week
  • □ Once per day
  • □ Several times per day
  • □ Always

How often do you have urgency that is difficult to control or uncontrollable?

  • □ Never
  • □ Rarely
  • □ Occasionally
  • □ Almost always
  • □ Always

How often do you go to the toilet during the day?

  • □ Hourly
  • □ Every two hours
  • □ Every three hours
  • □ Every four hours

How often do you have to go the toilet during the night?

  • □ Never
  • □ Once
  • □ Twice
  • □ Three times
  • □ More than three times

In general how is your quality of life affected by your voiding problems?

  • □ Not at all
  • □ Minimally
  • □ Moderately
  • □ Severely

Which of the following symptoms has the most profound impact on quality of life

  • □ Strong, uncontrollable urge to void
  • □ Nocturia
  • □ Frequent voiding during the day
  • □ Urinary incontinence

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