Incontinence Elderly Women

Urinary Incontinence 

Urinary Incontinence 

Urinary Incontinence is common in older women and doubles the risk of falls in this population. The association between urinary incontinence, especially urgency urinary incontinence, and falls is multifactorial and likely the result of a complex interaction between physical, mental, social, and environmental factors. As a result of this multifactorial etiology and based on existing evidence, the integration of different fall prevention strategies, including strength and resistance exercises, bladder training, and home hazard reduction have the potential to decrease the risk of falls in older women with urinary incontinence. Given the prevalence of urinary incontinence and the significant morbidity associated with falls, effective interventions to reduce fall risk in older women with urinary incontinence is of high public health significance.

Keywords: urinary incontinence, falls, exercise, bladder training

INTRODUCTION

Falls in older women have a profound impact on quality of life, and a fall may have devastating consequences. Falls and urinary incontinence are commonly co-occurring geriatric syndromes that are associated with increased morbidity. 

Interventions to reduce fall risk in older women with urinary incontinence would address these highly prevalent conditions and would be of high public health significance.

CO-OCCURRENCE OF URINARY INCONTINENCE AND FALLS IN OLDER WOMEN.  Nearly a third of adult women over the age of 65 in the United States have experienced a fall within the preceding 12 months and the rate of falls is higher in older women than men Women are also at higher risk of osteoporosis and reduced muscle strength, which makes their bones more likely to break during a fall.  Consequently, older women are more likely to sustain a fall-related injury. According to National Health and Nutrition Examination Survey (NHANES) data from 2015–2018, over 60% of community-dwelling adult women have urinary incontinence.

ASSESSMENT AND QUANTIFICATION OF FALL RISK AND URINARY INCONTINENCE IN OLDER WOMEN.  Guidelines from the American Geriatrics Society and British Geriatrics Society recommend a multifactorial falls risk assessment in older adults who have a fall and/or report gait or balance difficulties Falls risk can also be assessed using the Activities Balance Specific (ABC) Scale, which is a validated and reliable 16-item questionnaire that asks participants to rate their confidence levels when asked to complete various physical activities in situation-specific scenarios. A diagnosis of urinary incontinence can be made by asking a patient if they have had any involuntary leakage of urine in the past 12 months. The type of incontinence (stress or urge) can be determined by asking if the leakage is associated with a strong urge to urinate (consistent with urge urinary incontinence) or with an activity such as coughing, laughing or exercise (consistent with stress urinary incontinence). Women who have both stress and urge incontinence can be classified as having mixed urinary incontinence

Urinary symptoms can also be assessed using the Lower Urinary Dysfunction Network (LURN) Symptom Index-29 (LURN SI-29) tool, which assesses the nature, severity, and bother from a broad range of lower urinary tract symptoms. The instrument was created by the NIH-NIDDK-sponsored Lower Urinary Tract Dysfunction Research Network and allows for an assessment of symptoms beyond urinary incontinence. and has been shown to have internal consistency and correlates with other measures of lower urinary tract symptoms 

ASSOCIATION BETWEEN URINARY INCONTINENCE AND FALLS IN OLDER WOMEN

There is an association between urinary incontinence, especially urge urinary incontinence, and falls, and the reasons for this association are likely multifactorial. A simple model in which an older woman with incontinence slips in urine and falls is not supported by evidence. A more likely situation is one in which an older woman wakes at night with a strong urge to urinate, is anxious about leakage en route to the toilet, and may have environmental hazards in her home such as loose rugs, stairs, or absence of hand rails—all factors that increase her risk for falling. The Health Integration Theory posits that although the foci of illness and injury are within the body and mind, the physical and social environments contain elements that can cause or exacerbate disease and lead to injuries and disabilities. Considering this framework, we have developed a bio-psycho-ecological model with recurrent.  Falls in older women with UUI. Urinary symptoms also closely interact with mental factors to cause falls. Women with UUI have significantly higher rates of anxiety and depression compared to continent women, and a strong association exists between urinary incontinence and cognitive decline. Older adults with cognitive impairment are also at risk for falls due to challenges with dual-tasking while walking. There is emerging evidence that urinary urgency affects gait in older adults by diverting attention from the task of walking. A small study of older adults with overactive bladder found that the condition increased the risk for falls.  Additionally, anxiety and depression are also worse in women with UUI who have already suffered a fall. In a cross-sectional study of over 5000 adults age 70 or older, participants with both incontinence and falls were significantly more likely to report symptoms of feeling upset or distressed and perception of worse quality of life than those with incontinence alone. It is, therefore, critical that an effective fall intervention program address urgency-related anxiety.  The decline in physical performance has been associated with urinary incontinence in older women. Existing literature supports a bidirectional relationship between physical function and urge urinary incontinence: Worsening urinary incontinence is associated with worsening physical function, including increased fall risk, and conversely, deterioration of physical function is associated with the development of urinary incontinence. This decline in physical performance may also impact the quality of life. In a small study of women over age 70 with symptomatic urinary incontinence, functional status was evaluated using the Modified Physical Performance Test (MPPT) and Short Physical Performance Battery (SPPB), as well as physical performance measures such as Timed Up and Go (TUG). There was an association between lower MPPT score and worse TUG performance with greater UI impact on quality of life.

FALL PREVENTION IN OLDER WOMEN WITH URINARY INCONTINENCE According to the Center for Disease Control (CDC), unintentional falls are the top cause of injury-related morbidity and mortality in the United States, and therefore, fall prevention in older adults is of great public health interest. Based on existing evidence, the United States Preventative Services Task Force (USPSTF) has supported the implementation of exercise and multifactorial interventions for fall prevention in older adults, however, data is lacking on the impact of these established fall prevention strategies as well as novel approaches specifically focused on women with urinary incontinence.  Strength and Balance Exercise and fall prevention exercise programs, especially those that incorporate balance and functional exercises with resistance training, reduce the risks of falls in community-dwelling adults. Several studies have examined the efficacy of exercise interventions on fall prevention. A large systematic review of randomized controlled trials of exercise programs (mostly multicomponent exercise incorporating aerobic, strength and balance training) in adults over age 60 found that exercise significantly decreased fall risk and injuries associated with falls, Additionally, a recent systematic review examining exercise interventions for fall prevention among older community-dwelling adults found that when compared to the control, exercise reduced the rate of falls by 23%. There is also evidence that interventions that include any type of exercise alone, as well as programs that combine exercise with various other strategies, can both be effective strategies to decrease injurious falls in older adults. This growing body of evidence supports the benefits of exercise on reducing fall risk in older women; however, whether these strategies can be applied to women with urinary incontinence still needs to be established. Barriers to exercise must also be considered; for some women with urinary incontinence, urinary leakage may pose a barrier. In fact, a focus group of older women identified urinary leakage and shame associated with leakage as a barrier to participating in exercise. Women may make adaptive behavioral changes to avoid or decrease leakage during exercise, such as voiding before activity, taking breaks to void, restricting fluid intake, or avoiding specific exercises altogether

Treatment of Incontinence There is a paucity of literature regarding the effect of treatment of urinary symptoms on the risk of falls in older women with urinary incontinence. Pelvic floor muscle training (PFMT) is a recommended first-line conservative management of urinary incontinence in women but there is not strong evidence that PFMT alone reduces fall risk. However, when PFMT is combined with other functional exercises, there may be a benefit in decreasing fall risk. A study of 88 older women who underwent PFMT combined with cognitive and balance strategies showed improvement on the performance-oriented mobility assessment (POMA) and a 21% reduction in fall risk Additionally, an increase in physical activity has been associated with a reduced risk of urinary incontinence  and there is emerging evidence that combining physical activity (such as walking and strength training) with behavioral treatment can benefit frail women with urinary incontinence Medical treatment of UUI can include use of medications also used for overactive bladder (OAB), such as anticholinergics or beta agonists Home Hazard Reduction, Environmental hazards are implicated in as many as one-third of all falls among older adults 

CONCLUSIONS, Falls and urinary incontinence are commonly co-occurring geriatric syndromes that increase morbidity for older women. Strength and balance exercise interventions have been studied as an effective means to reduce fall risk and, when combined with bladder training interventions that improve urinary incontinence and home hazard assessments that improve the safety of the home, may further decrease the risk of falls in older women with urinary incontinence. Home-based interventions are a promising way to implement exercise programs in this highly vulnerable population. A home-based integrated exercise and bladder training program has immense potential to simultaneously address two prevalent geriatric syndromes and could greatly decrease morbidity for older women. Further investigation is needed to evaluate the efficacy of integrated programs as well as identify barriers and facilitators of implementation.