The prevalence of faecal incontinence in older people living at home

Transcription

1 Age and Ageing 2001; 30: 503±507 # 2001, British Geriatrics Society The prevalence of faecal incontinence in older people living at home NIA I. EDWARDS, DEE JONES 1 Department of Medicine for the Elderly, The James Cook University Hospital, Marton Road, Middlesbrough, Cleveland TS4 3BW, UK 1 Research Team for the Care of Elderly People, University of Wales College of Medicine, Llandough Hospital, Cardiff, UK Address correspondence to: N. I. Edwards. Fax: q44) Abstract Background: faecal incontinence affects quality of life and causes caregiver strain. Patients are often reluctant to seek help because of embarrassment and perceived lack of effective treatment. Persisting faecal soiling may lead to unwanted and premature institutionalization. Objective: to ascertain the prevalence of faecal incontinence and to identify health and socio-demographic characteristics of patients with this problem. Design: a sample of 3000 older people, living at home in the UK, randomly selected from three Family Health Service Authorities. Participants: we interviewed 2818 men and women aged 065 years in their own homes: a response rate of 94%. Results: 78 respondents 3%) reported faecal incontinence. There was a small but non-signi cant association with increasing age: 38 2%) of those reporting incontinence were aged 65±74 years; 40 3%) were aged 075 years. Faecal incontinence was signi cantly associated with sex, with reports from 15 men 1%) versus 63 women 4%; P ). It was also signi cantly associated with anxiety and with depression P ) and very signi cantly associated with increasing disability P ). Forty-six 59%) of those who had faecal incontinence had severe disability, compared with %) of those who did not P ). The association with urinary incontinence was also strong: 54 69%) of those with faecal incontinence 2% of the total sample) had coexistent urinary incontinence. Over 50% had not discussed their problems with a healthcare professional. Conclusions: a reluctance to report symptoms and a signi cant association between faecal incontinence and symptoms of anxiety, depression and disability suggest that older people should be asked about faecal incontinence. Increasing the awareness of the scale of the problem among health- and social-care professionals, older people and their carers may lead to more appropriate management and effective provision of care. Keywords: depression, disability, elderly, faecal incontinence, urinary incontinence Introduction The symptom of incontinence, one of the `geriatric giants' [1], has considerable impact upon the quality of life of an individual. Faecal incontinence is a distressing disorder that affects both sufferers and their carers [2±4]. One adult in eight 13%) provides informal care to an older person [5]; dif culties with continence may lead to a breakdown in carers' coping strategies and premature institutionalization which may be avoidable, undesired by the sufferer and carer, and have important cost implications for the individual and the state [2, 6±8]. Indeed, in the United States, faecal incontinence is the second commonest reason for requesting nursing-home placement [9, 10]. The steep rise in the proportion of people aged 080 years an age group characterized by multiple morbidity and disability [5]), and an increasing emphasis upon care of older people in their own homes, mean that debilitating conditions such as faecal incontinence are becoming even more important [11]. However, there are few epidemiological studies of faecal incontinence. Faecal incontinence has been de ned as ``an involuntary leakage of rectal contents through the anal canal'' [3] and urinary incontinence as ``the involuntary loss of urine at least twice per week, irrespective of the 503

2 N. I. Edwards, D. Jones amount lost'' [12]. Among older people in the United Kingdom who live at home, prevalence estimates of faecal incontinence vary between 2 and 6% [13, 14], while estimates of prevalence among people who live in residential and nursing homes vary between 2.9 and 10.3% for residential homes and between 4 and 30% for nursing homes [2, 3, 15]. Sufferers are often reluctant to seek help because of embarrassment and perceived lack of effective treatment: consequent underestimation of the prevalence of faecal incontinence is well recognized [3, 6, 12, 13, 16]. Even patients with bowel disturbances who consult gastro-enterologists do not report faecal incontinence [14, 16]. Co-morbidities, such as stroke, dementia and limited physical ability, can contribute to an increased risk of faecal incontinence [17±19]. Other aetiological factors include anorectal pathology, sphincter or pelvic oor damage, in ammatory bowel disease, irritable bowel syndrome, neurological disease, faecal impaction with over ow, poor toilet facilities or inadequate care [20]. Therapeutic intervention needs to be tailored to underlying aetiology and can considerably improve symptoms and quality of life [20]. Most studies of the prevalence of incontinence have investigated urinary incontinence. Studies of faecal incontinence in the UKhave tended to be small, non-representative and conducted in either nursing or residential homes [2]. Those community studies where respondents were interviewed personally in the USA or Japan employed mixed methodology, telephone or household interviews and have been small, non-random and con ned to one geographical location. The aims of our study were to establish the prevalence of faecal incontinence in older people at home and to identify the health and socio-demographic characteristics of people with this disorder. Methods We conducted this study of prevalence of faecal incontinence and double incontinence in older people as part of a larger study examining health, well being and use of services in representative samples of communitybased older people. We selected a random sample of 1000 people aged 065 years from each of three Family Health Service Authority registers which together re ected the general population of England and Wales [21]. We used trained, independent eld-workers to interview participants in their own homes. The interview schedule contained standardized questionnaires appropriate to community-based older people and included socio-demographic factors such as age, sex and living arrangements. Functional and physical disability were assessed, as were anxiety and depression [22, 23]. Speci c questions on incontinence used in our study were ``Do you have any dif culty in controlling your bowels?'' and ``Do you ever wet yourself if you are unable to get to the lavatory as soon as you need to, or when you are asleep at night, or when you cough or sneeze?'' [24]. Statistical analysis was performed by means of x 2 test with a P value of de ned as signi cant). The Mantel±Haenszel test for trend was used when appropriate. Results Of 3000 people approached, 2818 were interviewed, giving a response rate of 94%: %) were women; %) were aged 65±74 years and %) were aged 075 years. Seventy-eight respondents 3%) reported dif culty in controlling their bowels. Sixteen 0.6%) had a colostomy: of these, 13 were aged 65±74 years, nine were women and eight were severely disabled; none was signi cantly anxious or depressed. We excluded all of these respondents from further analysis. Details of the other participants are shown in Table 1. Age and sex There was no signi cant association between dif culty in controlling bowels and ageð2% of those aged 65±74 years and 3% of those aged 075 years had faecal incontinence P =0.11). This remained the case when age and sex were controlled for. There was, however, a signi cant association with sex: 15 1%) of the men but 63 4%) of the women had faecal incontinence P ). Physical disability There was also a signi cant relationship between dif culty in controlling bowels and increasing disabilityð3% of those with faecal incontinence had no disability while 59% were severely disabled P ); in contrast, 29% of those who were not incontinent had no disability while 16% were severely disabled P ). This association was consistent across age groups, with more older than younger sufferers being severely disabledð31 78%) versus 14 40%; P ). Similarly, a signi cant association between faecal incontinence and disability was demonstrated in both men and womenðeight 53%) of men and 38 60%) of women who were severely disabled had faecal incontinence P ). Social and psychological factors There was no overall association between faecal incontinence and living arrangementsð41% of those reporting faecal incontinence lived alone. Among 504

3 Prevalence of faecal incontinence Table 1. Prevalence of faecal incontinence and its relation to socio-demographic and health factors No. and %) of subjects, by faecal incontinence With Without Age, years n=2794, P=0.11) 65± ) ) ) ) Sex n=2794, P ) Male 15 1) ) Female 63 4) ) Physical disability n=2793, P ) None 2 3) ) Some 21 27) ) Appreciable 9 12) ) Severe 46 59) ) Living arrangements n=2794, P=0.1) Alone 32 41) ) Spouse only 27 35) ) Spouseqothers 4 5) 216 8) Others 15 19) ) Anxiety n=2736, P ) Yes 13 20) 132 5) No 53 80) ) Depression n=2734, P ) Yes 10 15) 70 3) No 56 85) ) Urinary incontinence n=2794, P ) Yes 54 69) ) No 24 31) ) younger respondents, signi cantly more of those with faecal incontinence lived aloneð18 47%) versus %; P-0.05), while signi cantly more older respondents with faecal incontinence lived with othersð13 33%) versus %; P-0.05). Anxiety was signi cantly associated with faecal incontinence: 20% of those who reported faecal incontinence were anxious, compared with 5% of those who did not P ). There was no variation between age groups but the association was consistent for both sexes, with anxiety seen in two 17%) versus 23 3%) of the men P-0.01) and 11 20%) versus 99 6%) of the women P ). Depression was also signi cantly associated with faecal incontinence. Fifteen percent of those reporting faecal incontinence were signi cantly depressed compared with 3% of those without faecal incontinence P ). Again, this association remained when examined by sex, with depression seen in two 17%) versus 18 2%) of the men P ) and eight 15%) versus 52 3%) of the women P ). Combined urinary and faecal incontinence Five hundred and ve respondents 18%) were incontinent of urine. In the total population, 11 1%) of 1099 men and %) of 1695 women were doubly incontinent. A highly signi cant association was demonstrated between faecal and urinary incontinence: urinary incontinence was reported by 69% of those who reported faecal incontinence but only 17% of those who did not P ). This association was consistent for both men and women, with urinary incontinence in 11 73%) versus 84 8%) of the men P ) and 43 68%) versus %) of the women P ). There was also a signi cant association between faecal and urinary incontinence in respondents in both age groups: in the younger group urinary incontinence was reported in 12 75%) of those with faecal incontinence and in %) of those without P ), while among those aged 075 the gures were 42 68%) and %; P ). Discussion with a healthcare professional Respondents reporting faecal incontinence were asked if they had discussed their symptoms with a healthcare professional within the last 2 years: 41 54%) had not discussed the problem with a professional, and this proportion did not vary with either age nor sex. Of these, 11 would like to do so, most being women eight) and aged 075 nine). Discussion The size and nature of the samples and the high response rate suggest that these ndings are representative and applicable to the general population of older people. Our prevalence rate of 3% falls within the range of previously published studies. An American survey found 2±18.4% of those aged 018 years had faecal incontinence [13, 16]. Talley et al. reported a prevalence rate of 3.7% in their Minnesota postal survey of people over 65 living at home [25] and Nelson et al. reported 3.9% in their US community telephone survey [17]. As they asked one member about the health status of each member of the household, this probably represents an underestimate. Thomas et al. reported a prevalence of 4.2% [6] whilst and Perry et al. reported a prevalence of 6% [14] in postal questionnaire studies of UKresidents living at home aged 015 years and 040 respectively. Roberts and co-workers' US postal study reported that 11.1% of men and 15.2% of women had faecal incontinence [26]. This high prevalence is probably due to the de nition being ``leakage and lack of control within the previous year''ðwhich includes temporary, self-limiting symptoms. Kok and co-workers' Dutch postal study of women aged 060 found prevalence rates of 4.2% in those aged 60±84 years and 16.9% in older women [12]. Inconsistencies in prevalence rates may be explained by variations in de nitions, standardized measures and methodology, the use of 505

4 N. I. Edwards, D. Jones small and non-representative samples and low response rates. Contrary to previous studies, we did not demonstrate a signi cantly increased prevalence rate amongst older people, but this could be explained by small numbers. Kok et al. reported faecal incontinence in 17% of women aged 085 years compared with 4.2% of women aged 60±85 years [12]. Similarly, the Royal College of Physicians of London reported a prevalence of 15% among those aged 085 years compared with 3±5% among those aged 65±84 years [3]. This could be explained by the differing age groups studied, the comparatively small number of very elderly people in their study or the possibility that their results were related to sex rather than age. We did, however, nd a signi cant association with sex 1% among men versus 4% among women) which is consistent with previous ndings of 11% among men versus 15.2% among women [27]. However, Thomas et al. found no sex difference in prevalence rates amongst those aged 065 years 4.7% among men versus 4.1% among women) [6] and Johanson and Lafferty report that faecal incontinence is 1.3 times more common in men [16]. Consistent with previous ndings, both men and women who had faecal incontinence were also more physically disabled. This was particularly true among older women, which would indicate the presence of co-morbidity and may suggest an association between physical disability and faecal incontinence, independent of age or sex. Our results show that, in the younger age group, people with faecal incontinence do live alone but, as they become older, they tend to live with othersðpresumably being more dependent and disabled and requiring more support from informal carers [4]. As with previous ndings, anxiety and depression were higher, particularly amongst women [27]. Although a causal relationship is possible between associated factors, this cannot be assumed as this is a cross-sectional study. In our study, 2% of the total population had double incontinence, with over two-thirds of those with faecal incontinence also having urinary incontinence 68% for women and 73% for men). Other studies have reported similar ndings, with over half of those who report faecal incontinence also having urinary incontinence [6, 26]. The prevalence of faecal incontinence in people living at home suggests that there is much unmet need. Despite evidence of effectiveness of treatment, more than half of sufferers had not discussed faecal incontinence with a healthcare professional, although one-quarter of these would like to do so. Johanson et al. also reported that less than one-quarter of those with faecal incontinence had discussed their problem with a primary-care doctor and less than half had reported it when consulting a gastro-enterologist [16]. A reluctance to report symptomatology coupled with increased anxiety, depression, disability and perceived lack of treatment suggests that older people should be questioned proactively about incontinence. This could be done as part of their regular assessments in primary care. Increasing the awareness of the scale of the problem among health- and social-care professionals, older people and their carers may lead to more appropriate management and effective provision of care, thereby improving the quality of life of older people, reducing the strain on carers and postponing or even preventing institutionalization. Key points. Faecal incontinence occurred in 4% of women and 1% of men aged 065 living at home.. Over 50% of subjects had not discussed this symptom with a health professional.. Faecal incontinence is associated with symptoms of anxiety, depression and disability.. Older people should be asked about faecal incontinence. Acknowledgements We should like to thank Mark Chamberlain computing), our interviewers and the many respondents who so generously gave of their time. References 1. Isaacs B. Incontinence. The challenge of geriatric medicine. Oxford: Oxford University Press, 1992; 101± Tobin G, Brocklehurst JC. Faecal incontinence in residential homes for the elderly: prevalence, aetiology and management. Age Ageing 1986; 15: 41±6. 3. Anon. Incontinence. Causes, management and provision of services. Summary of a Report of a Working Party of the Royal College of Physicians. J R Coll Physicians Lond 1995; 29: 272±4. 4. Jones D. A Survey of Carers of Elderly Dependants Living in the Community. Final report to Department of Health. Cardiff: University of Wales College of Medicine, Of ce for National Statistics. Social Survey Division. Informal Carers General Household Survey suppl. A). London: HMSO, Thomas TM, Egan M, Walgrove A, Meade TW. The prevalence of faecal and double incontinence. Commun Med 1984; 6: 216± Sanford JR. Tolerance of debility in elderly dependants by supporters at home: its signi cance for hospital practice. Br Med J 1975; 3: 471±3. 8. Diokno AC. Epidemiology and psychosocial aspects of incontinence. Urol Clin North Am 1995; 22: 481±5. 506

5 Prevalence of faecal incontinence 9. Lahr CJ. Evaluation and treatment of incontinence. Practical Gastroenterol 1998; 12: 27± Anon. Pro le of Wisconsin Nursing Home Residents Maddison, WI, USA: Center for Health Statistics, Division of Health, Department of Health and Social Services, Department of Health. Caring for People: community care in the next decade and beyond. London: HMSO, Kok ALM, Voorhorst FJ, Burger CW et al. Urinary and faecal incontinence in community-residing elderly women. Age Ageing 1992; 21: 211± Leigh RJ, Turnberg LA. Faecal incontinence: the unvoiced symptom. Lancet 1982; i: 1349± Perry SI, Shaw C, Mensah FK et al. The prevalence of faecal incontinence in a community based population [Abstract]. Age Ageing 1998; 27 suppl. 2): Peet SM, Castleden CM, McGrother CW. Prevalence of urinary and faecal incontinence in hospitals and residential and nursing homes for older people. Br Med J 1995; 311: 1063± Johanson JF, Lafferty J. Epidemiology of fecal incontinence: the silent af iction. Am J Gastroenterol 1996; 91: 33± Nelson R, Norton N, Cautley E, Furner S. Community based prevalence of anal incontinence. J Am Med Assoc 1995; 274: 559± Nakanishi N, Tatara K, Naramura H et al. Urinary and fecal incontinence in a community-residing older population in Japan. J Am Geriatr Soc 1997; 45: 215± Brittain KR, Peet SM, Perry SI et al. The prevalence of faecal incontinence in community dwelling stroke survivors [Abstract]. Age Ageing 1998; 27 suppl. 2): Norton C. Faecal incontinence in adults: prevalence and causes. Br J Nursing 1996; 22: 1366± Webber R, Craig J. Socio-economic Classi cation of Local Authority Studies on Medical and Population Subjects. No. 35. London: OPCS, Townsend P. Poverty in the United Kingdom. Harmondsworth, UK: Penguin Books, McNab A, Phillip AS. Screening an elderly population for psychological well-being. Health Bull 1980; 38: 160± Bond J, Carstairs B. A Survey of Older People. No. 42. Edinburgh: The Scottish Home and Health Department, Talley NJ, O'Keefe EA, Zinsmeister AR, Melton LJ. Prevalence of gastrointestinal symptoms in the elderly: a population-based study. Gastroenterology 1992; 102: 895± Roberts RO, Jacobsen SJ, Reilly WT et al. Prevalence of combined faecal and urinary incontinence: a community-based study. J Am Geriatr Soc 1999; 47: 837± Hunskaar S, Sandvik H. One hundred and fty men with urinary incontinence. III. Psychosocial consequences. Scand J Prim Health Care 1993; 11: 193±6. Received 2 April 2001; accepted 12 July