URINARY incontinence is an important and common

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1 Urinry incontinence in older people in the community: neglected problem? Helen Stoddrt, Jenny Donovn, Elise Whitley, Deborh Shrp nd In Hrvey SUMMARY Bckground: The prevlence nd impct of urinry incontinence hs been investigted much less in older men thn in older women. It is suggested tht those who perceive tht their dily lives re ffected should hve priority for services. However, mny people do not seek medicl help, even though they my be severely ffected. Aim: To investigte unmet need in reltion to the prevlence nd impct on everydy life of urinry incontinence in men nd women over the ge of 65 yers. Design of study: Cross-sectionl survey to mesure prevlence of urinry incontinence, the impct on people s lives, use of protection, nd helth services. Setting: Strtified rndom smple of 2000 community-living elderly (equl numbers of men nd women, ged 65 to 74 yers nd over 75 yers) in 11 generl prctices in British city. Results: The response rte ws 79%. The overll prevlence of incontinence in the previous month ws 31% for women nd 23% for men. Women generlly hd more severe frequency of incontinence nd greter degree of wetness thn men. Protection use ws greter in women thn in men. Only 40% of men nd 45% of women with incontinence hd ccessed helth services. Significnt predictors of the use of helth services were: incontinence reported s problem, incresed frequency of incontinence, nd greter degree of wetness. About one-third of people who leked with severe frequency or who reported tht it ws problem hd not ccessed NHS services for incontinence. Conclusions: Urinry incontinence is common problem for older men nd women living in the community nd cn hve deleterious effect on their lives. There is the opportunity to improve the lives of mny older people with urinry incontinence, probbly by combintion of incresed public, ptient, nd professionl wreness tht should led to erlier presenttion nd initition of effective cre. Keywords: urinry incontinence; older people; prevlence; primry cre. H Stoddrt, MFPHM, MRCGP, clinicl lecturer in primry helth cre, Division of Primry Helth Cre; J Donovn, BA, PHD, reder in socil medicine; E Whitley, BSC, MSC, PHD, lecturer in medicl sttistics, Deprtment of Socil Medicine; nd D Shrp, PHD, FRCGP, professor of primry helth cre, Division of Primry Helth Cre, Deprtment of Clinicl Medicine, University of Bristol. I Hrvey, BA, MB BCH, PHD, professor of epidemiology nd public helth, School of Helth Policy nd Prctice, University of Est Angli, Norwich. Address for correspondence Dr Helen Stoddrt, Division of Primry Helth Cre, Deprtment of Clinicl Medicine, University of Bristol, Cnynge Hll, Whiteldies Rod, Bristol BS8 2PR. E-mil: Helen.Stoddrt@bristol.c.uk Submitted: 27 June 2000; Editor s response: 4 October 2000; finl cceptnce: 30 November British Journl of Generl Prctice, 2001, 51, Introduction URINARY incontinence is n importnt nd common problem in older people. 1,2 Accurte estimtes of its prevlence depend on the prticulr ge group s well s on sex. 3 In older women, estimtes rnge between 17% nd 42%. 1,4 The prevlence for older men in the community hs been investigted less but is reported t bout 20%. 3,5 Incontinence is predictor of institutionlistion nd cn cuse severe socil nd psychologicl problems. 6,7 The socil consequences my rise from the restrictive strtegies used to mnge it; for exmple, voiding socil ctivities nd public events becuse of embrrssment, with the impct generlly independent of the severity of the incontinence. 7,8 In terms of selecting people for tretment, it is suggested tht those who perceive tht their dily lives re ffected by urinry incontinence should hve priority for services. 9,10 However, mny people do not seek medicl help for urinry incontinence, even though they my be severely ffected 4 nd the incontinence cn be cured or significntly improved in over 60% of cses with conservtive mngement lone. 14,15 This my be becuse incontinence cn mistkenly be seen s n inevitble, irreversible, nd norml prt of geing. 4,16,17 Very little reserch hs focused on the impct of incontinence on men, lthough lower urinry trct symptoms hve been reported to hve n impct on men s everydy lives, prticulrly irrittive (storge) symptoms such s frequency, urgency, nocturi, nd incontinence. 18 To our knowledge, no previous work hs exmined the reltionship between use of helth services in the United Kingdom (UK) for older people with urinry incontinence nd its impct on their lives. The im of this study ws therefore to investigte unmet need relting to urinry incontinence in men nd women over the ge of 65 yers living in the community in British city. Of prticulr interest ws the prevlence nd impct of the incontinence on their lives, their strtegies for deling with it, nd their use of helth services, prticulrly in primry cre. Method A postl questionnire bout incontinence (prt of lrger study of determinnts of socil networks, socil support, nd use of home cre services) ws sent to rndom smple of 2000 elderly people, strtified by ge nd sex (to yield equl numbers of men nd women, between the ges of 65 nd 74 yers, nd 75 yers nd over) registered with 11 generl prctices in British city. Prctices hd rnge of incontinence services vilble in both primry nd secondry cre, including specilist community continence nurse. Severl questions were sked bout urinry incontinence (Box 1) nd detils of responses re shown in Tble British Journl of Generl Prctice, July 2001

2 Originl ppers HOW THIS FITS IN Wht do we know? Urinry incontinence is common problem in older people, but mny do not use NHS services. Little is known bout the reltionship between the use of helth services nd the impct of urinry incontinence on older people s lives, prticulrly for men. Wht does this pper dd? Urinry incontinence is common problem for both men nd women, tht cn ffect their dily lives. It is likely tht there is unmet need s third of those who leked with severe frequency, or felt tht urinry incontinence ws problem, hd not ccessed NHS services. There is the opportunity to improve the lives of mny older people with urinry incontinence. Hve you leked urine in the pst month? How often do you lek urine? How much of problem is this for you? How much lekge occurs? When does the lekge hppen? Do you usully protect yourself ginst leking? Overll, how much does leking urine interfere with your life? Wht hve you done bout the lekge? Box 1. Questions sked bout urinry incontinence in the postl questionnire. Tble 1. Urinry incontinence in the pst month in the whole smple (n = 1540). Urinry Number (%) in ech ge group incontinence by ge (yers) Mle Femle (167 mle, 150 femle) 20 (12) 44 (29) (194 mle, 206 femle) 41 (21) 46 (22) (198 mle, 200 femle) 44 (22) 61 (31) 80 (222 mle, 184 femle) 76 (34) 78 (42) All ges (781 mle, 740 femle) 183 (23) 233 (31) Numbers my differ slightly for ech item owing to missing vlues. There re considerble problems with the definition of incontinence nd its mesurement. The Interntionl Continence Society s definition suggests tht it is the involuntry loss of urine which is socil or hygienic problem. 19 In this study, subject ws defined s hving urinry incontinence if they reported tht, in the lst month, they leked urine or indicted how much lekge occurred, tht they protected themselves ginst lekge, or tht lekge hppened t defined time; for exmple, when they coughed. In terms of frequency, urinry incontinence once per week or less ws defined s mild ; between twice week nd once per dy moderte ; nd severl times dy or more s severe. Dt were nlysed using STATA 6.0. Frequencies nd proportions re presented. The severity nd impct of incontinence on subjects lives were explored using χ 2 tests nd likelihood rtio tests for heterogeneity or trend s pproprite. Results One thousnd five hundred nd forty people (79%) completed nd returned the questionnire. Of the originl 2000 identified, 22 hd died nd 25 hd moved out of the re nd were removed from the denomintor. There ws no significnt difference in response rtes cross prctices. Dt were vilble on the ge nd sex of non-responders, who were more likely to be over 75 yers nd, within this older ge group, more likely to be femle. The overll prevlence of urinry incontinence, s defined bove, ws 27%: 23% for men nd 31% for women (Tble 1). The prevlence ws greter in women thn men t ll ges nd incresed to 42% in women nd 34% in men ged 80 yers or over. In those who reported urinry incontinence, 61% of women nd 54% of men reported the frequency s moderte or severe (Tble 2). Forty-six per cent of women nd 49% of men with incontinence reported tht it ws problem for them. The consequences of incontinence re lso shown. In generl, women reported greter degree of wetness thn men, with over one-qurter reporting they hd wet underwer, wet outer clothing or hd urine running onto the floor, compred with 16% of men. The perceived cuses or circumstnces under which lekge occurred re presented (Tble 2). Urge incontinence ( before I cn get to the toilet ) ws common in both men nd women (43% men, 53% women), but more so in women, P = Post-micturition dribbling ( when finished nd dressed ) ws reported by 28% of men but only 6% of women, P< Stress incontinence ws much more common in women thn men, following coughing nd sneezing, (48% women, 8% men, P<0.001) nd fter physicl exercise, lthough the sex difference with physicl exercise ws not sttisticlly significnt. Unpredictble leking (without obvious reson) ws reported by 20% of men nd 16% of women. The rnge of protection used is presented in Tble 2. Protection use ws greter in women thn men, t ll level of severity nd frequency of incontinence. Incontinence ws more likely to interfere with life s the frequency incresed (P<0.001 for both men nd women, Tble 3). Similrly, s the frequency of incontinence incresed it ws more likely to be problem (P<0.001 for both men nd women, Tble 3). Methods of deling with lekge of urine re presented in Tble 2. About hlf of those with incontinence did not do nything bout their lekge, with only 40% of men nd 45% of women using helth services. Further nlysis (not shown) found tht 34% of those who leked with severe frequency did not ccess helth services nd 37% who reported it ws problem lso did not ccess helth services. Eighteen per cent of men nd 20% of women used non-nhs sources of help (sent wy for informtion, discussed with friends or did something else). Significnt predictors of the use of helth services were: incontinence reported to be problem, incresing frequency of incontinence, nd more severe wetness (Tble 4). Sex, ge group, nd socil clss did not ffect the use of helth services. The significnt univrible ssocition between use of NHS services nd interference with life ws ttenuted with djustment for urine frequency, wetness, nd incontinence being problem. British Journl of Generl Prctice, July

3 Tble 2. The impct of urinry incontinence on people s lives (denomintor re the 416 people with urinry incontinence only). Discussion Number (%) in ech ctegory Mle Femle Frequency of incontinence Mild b 81 (46) 82 (39) Moderte c 66 (38) 72 (35) Severe d 29 (16) 54 (26) Whether lekge ws problem e Yes 89 (51) 118 (54) No 87 (49) 99 (46) Whether lekge interfered with their lives f Yes 93 (53) 126 (58) No 81 (47) 90 (42) Degree of wetness Underwer dmp 136 (84) 150 (74) Underwer wet 17 (11) 33 (16) Wet outer clothes/on floor 8 (5) 21 (11) Occsions when lekge occurs g Before getting to the toilet (urge) 79 (43) 125 (53) Cough/sneeze (stress) 12 (8) 111 (48) When sleep (nocturnl) 12 (7) 18 (8) Physicl exercise (stress) 14 (8) 30 (13) When finished/dressed (post-micturition dribble) 51 (28) 14 (6) Without obvious reson (unpredictble) 36 (20) 37 (16) Other 10 (5) 5 (2) Type of protection g None 58 (32) 27 (12) Chnge clothes 93 (51) 84 (36) Use pper 23 (13) 28 (12) Mini-pds 1 (1) 51 (22) Snitry pds 2 (1) 23 (10) Incontinence pds 10 (5) 33 (14) Other methods 3 (2) 5 (2) Action g Did nothing 90 (49) 110 (47) Sent wy for informtion 10 (5) 11 (5) Discussed with GP 55 (30) 60 (26) Discussed with nurse 16 (9) 30 (13) Mediction 20 (11) 11 (5) Exercises 14 (8) 49 (21) Hospitl outptient 16 (9) 18 (8) Hospitl inptient 8 (4) 9 (4) Did something else 5 (3) 1 (0) Numbers my differ slightly for ech item owing to missing vlues. b Once per week or less. c Between twice week nd once per dy. d Severl times dy or more. e Problem ws defined s those reporting little, quite lot or serious problem with the lekge. f Interference ws defined s those reporting tht the lekge interfered with life little, somewht or lot. g Columns do not dd up to 100% s people could give more thn one response. This study suggests tht incontinence is common ffliction mong older people nd cn hve deleterious impct on their everydy lives, with evidence lso of considerble unmet need. The ssocitions of urinry incontinence with sex nd ge, nd the type of incontinence with sex, were generlly s nticipted. 3,5,20 In terms of prevlence, the figures for those ged 65 to 69 yers re similr to Bogren s smple of people ged 65 yers in Sweden 20 nd the overll prevlence in women, t 31%, ws similr to tht found elsewhere. 5,21 Little comprble dt hve been published bout men, lthough the prevlence found here (23% overll nd 34% in the over-80-yer-olds) suggests tht it is serious public helth problem for older men, with 54% of men with incontinence reporting lekge t lest twice per week. Surprisingly, 20% of men nd 16% of women reported unpredictble incontinence which my be prticulrly difficult to del with. Women protected themselves ginst lekge more often thn men t ll levels of severity of incontinence, probbly becuse of their greter knowledge of, nd ccess to, devices. Mini-pds were the commonest device used by women. The smple for this study ws drwn from slightly more ffluent nd predomintely white popultion thn the verge for the UK, with its own rnge of services, which my hinder generlisbility. The study ws, however, bsed cross 11 different prctices nd hd reltively high response rte. With older women hving both the highest levels of incontinence nd being more likely to be nonresponders, it my be tht the true prevlence mong older people my be even greter thn presented. The definition of incontinence hs been problemtic for reserch in this re with vrious definitions nd timescles employed. In this study, the question Hve you leked urine in the lst month? ws sometimes left blnk, with other questions bout the frequency nd severity of incontinence completed, suggesting tht simple dichotomous questions bout urinry incontinence re problemtic. We did not vlidte the reporting of incontinence in reltion to pd tests becuse this would hve reduced response nd lso becuse definitions, such s tht employed by the Interntionl Continence Society, rely on whether it is socil or hygiene problem which cn only be obtined by self-report. The fct tht similr prevlence of incontinence mong women in this study hs been found elsewhere 21 suggests tht the questionnire hs vlidity nd relibility. A prticulr strength of this study is tht it comprises lrge smple of older people living in the community, including men nd the older elderly who hve been under-reserched in the pst. 22 Among these community-dwelling older people, fewer thn one-hlf of those reporting incontinence hd ccessed helth services for it, consistent with other work. 13,14 There my therefore be considerble unmet need mong older people in reltion to incontinence, prticulrly s it is well recognised tht simple interventions cn improve incontinence nd thus the qulity of life of elderly people. 23 Urinry incontinence is therefore similr to other conditions for which clinicl iceberg exists, with mny people with symptoms not pproching professionl cre. 24 The processes tht led people to seek medicl help re complex nd depend on fctors, such s their perceptions of ill helth, ttitudes towrds illness, nd vilbility of services. In this study, ccess to helth services did not vry by ge, sex or socil clss but service use ws more likely if the incontinence ws perceived to be problem, ws more frequent or led to more wetness, supporting the contention tht it is the perception of problem tht is key fctor determining ccess to services. 18 This supports the clim by 550 British Journl of Generl Prctice, July 2001

4 Originl ppers Tble 3: To show whether urinry incontinence interfered with peoples lives or ws problem becuse of its frequency. Mild incontinence Moderte Severe P-vlue n (%) incontinence n (%) incontinence n (%) for trend Lekge interfered with peoples lives Men Yes 53 (70) 29 (45) 7 (24) No 23 (30) 36 (55) 22 (76) <0.001 Women Yes 55 (73) 36 (50) 20 (39) No 20 (27) 36 (50) 31 (61) <0.001 Lekge ws regrded s problem Men Yes 59 (73) 23 (36) 4 (14) No 22 (27) 41 (64) 24 (86) <0.001 Women Yes 58 (73) 32 (45) 16 (31) No 21 (27) 39 (55) 36 (69) <0.001 Tble 4. Odds rtio (95% confidence intervl) for use of NHS services for urinry incontinence by those with urinry incontinence. Vrible n Univrible Multivrible c Frequency of lekge Mild 52/ Moderte 65/ ( ) 1.1 ( ) Severe 55/ ( ) 2.1 ( ) P-vlue b < Degree of wetness Underwer dmp 118/ Underwer wet 34/ ( ) 2.5 ( ) Wet outer clothes/onto floor 23/6 5.5 ( ) 3.9 ( ) P-vlue < Lekge is problem No 54/ Yes 117/ ( ) 2.6 ( ) P-vlue < Lekge interferes with life No 70/ Yes 108/ ( ) 1.0 ( ) P-vlue < Use/do not use NHS services. b P-vlue for liner trend. c Adjusted for the other three fctors. some uthors tht services should be trgeted towrds those who perceive themselves to be in gretest need. 9,10 However, bout one-third of people in this study reporting troublesome incontinence (i.e. those who leked with severe frequency or who reported tht it ws problem for them) hd not ccessed NHS services. It could be rgued tht these individuls could benefit from simple interventions, such s pelvic floor exercises or bldder trining provided by primry helth cre professionls, prticulrly nurses, 14,23 but currently they do not present for help. As the mjority of older people re in regulr contct with members of the primry helth cre tem, simple questionnire, such s the one used in this study, could be dministered t the over-75- yer-old helth check to llow the identifiction nd mngement of people who re seriously troubled by incontinence. It my lso be necessry to chnge the ttitudes of some helth cre professionls. There is conflicting evidence, for exmple, bout how well incontinence is mnged in primry cre. Some report tht people re well cred for in generl prctice. 10,14,15,25 However, it hs lso been suggested tht, in older people, incontinence my be dismissed s not worthy of investigtion or tretment 22,23 nd tht physicins re less likely to sk older people bout it. 26 Finlly, there is further issue concerning the public wreness of incontinence nd its tretments. Incontinence remins something of tboo subject nd public wreness cmpigns should be encourged, so tht those with incontinence cn lern bout the tretments tht re vilble nd feel ble to present to primry cre. There is considerble opportunity to improve the lives of mny older people with urinry incontinence; however, this will require combintion of pproches. Prticulrly importnt will be n increse in public, ptient, nd professionl wreness of incontinence which should, in turn, led to erlier presenttion nd initition of effective cre. References 1. Yrnell JWG, St Leger AS. The prevlence, severity nd fctors ssocited with urinry incontinence in rndom smple of the elderly. Age Ageing 1979; 8: Feneley RC, Shepherd AM, Powell PH, Blnnin J. Urinry incontinence: prevlence nd needs. Br J Urol 1979; 51: Thom D. Vrition in estimtes of urinry incontinence prevlence British Journl of Generl Prctice, July

5 in the community: effects of differences in definition, popultion chrcteristics, nd study type. J Am Geritr Soc 1998; 46: Thoms TM, Plymt KR, Blnnin J, Mede TW. Prevlence of urinry incontinence. BMJ 1980; 281: Hunskr S, Arnold EP, Burgio AC. Epidemiology nd nturl history of urinry incontinence. In: Abrms P, Khoury S, Wein A (eds). Incontinence: Proceedings of the First Interntionl Consulttion on Incontinence. Plymouth: Helth Publiction Ltd, 1999; Brown JS, Subk LL, Grs J, et l. Urge incontinence: the ptient s perspective. J Women s Helth 1998; 7: Norton C. The effects of urinry incontinence in women. Int Rehb Med 1982; 4: Donovn JL, Nughton M, Gotoh M, et l. Symptom nd qulity of life ssessment. In: Abrms P, Khoury S, Wein A (eds). Incontinence: Proceedings of the First Interntionl Consulttion on Incontinence. Plymouth: Helth Publictions Ltd, 1999; Perry S, Shw C, Assss P, et l. An epidemiologicl study to estblish the prevlence of urinry symptoms nd felt need in the community: the Leicestershire MRC Incontinence Study. J Public Helth Med 2000; 22: Hunskr S. Fluctutions in lower urinry trct symptoms in women. BMJ 2000; 320: Roberts RO, Jcobsen SJ, Rhodes T, et l. Urinry incontinence in community-bsed cohort: prevlence nd helthcre-seeking. J Am Geritr Soc 1998; 46: Simeonov Z, Milsom I, Kullendorff A-M, et l. The prevlence of urinry incontinence nd its influence on the qulity of life in women from n urbn Swedish popultion. Act Obstet Gynecol Scnd 1999; 78: Brocklehurst JC. Urinry incontinence in the community-nlysis of MORI poll. BMJ 1993; 306: O Brien J, Austin M, Sethi P, O Boyle P. Urinry incontinence: prevlence, need for tretment, nd effectiveness of intervention by nurse. BMJ 1991; 303: Fntl JA, Newmn DK, Colling J, et l. Urinry incontinence in dults: cute nd chronic mngement. Clinicl prctice guideline, No. 2. Updte. US Deprtment of Helth nd Humn Services. Public Helth Service, Agency for Helth cre Policy nd Reserch. [AHCPR Publiction No ] Mrch Brnch LG, Wlker LA, Wetle TT, et l. Urinry incontinence knowledge mong community-dwelling people 65 yers of ge nd older. J Am Geritr Soc 1994; 42: Mitteness LS. Knowledge nd beliefs bout urinry incontinence in dulthood nd old ge. J Am Geritr Soc 1990; 38: Peters T, Donovn J, Abrms P, et l. The ICS- BPH Study: The bothersomeness of urinry symptoms. Br J Urol 1997; 157: Abrms P, Blivis JG, Sturt L, Andersen T. The stndrdistion of terminology of lower urinry trct infection. Scnd J Urol Nephrol 1988; Bogren MA, Hvrfwen E, Fridlund B. Urinry incontinence mong 65-yer-old Swedish popultion: medicl history nd psychosocil consequences. Vrd i Norden 1997; 17: Sndvik H, Hunskr S, Seim A, et l. Vlidtion of severity index in femle urinry incontinence nd its implementtion in n epidemiologicl survey. J Epidemiol Community Helth 1993; 47: Fond D, Benvenuti F, Cstleden M. Mngement of incontinence in older people. In: Abrms P, Khoury S, Wein A (eds). Incontinence: Proceedings of the First Interntionl Consulttion on Incontinence. Plymouth: Helth Publiction Ltd, 1999; Abrms P, Wein A, Schussler B. Recommendtions of the interntionl scientific committee: the evlution nd tretment of urinry incontinence. In: Abrms P, Khoury S, Wein A (eds). Incontinence: Proceedings of the First Interntionl Consulttion on Incontinence. Plymouth: Helth Publictions Ltd, 1999; 24. Hnny DR. The symptom iceberg. London: Routledge & Kegn Pul, Seim A, Sivertsen B, Hunskr S. Tretment of urinry incontinence in women in generl prctice: observtionl study. BMJ 1996; 312: Cohen SJ, Robinson D, Dugn E, et l. Communiction between older dults nd their physicins bout urinry incontinence. Journls of Gerontology Series A-Biologicl Sciences & Medicl Sciences 1999; 54: M34-M British Journl of Generl Prctice, July 2001