PREVALENCE OF URINARY INCONTINENCE AND INTENTION TO SEEK TREATMENT IN THE ELDERLY

Prevalence of Urinary Incontinence in the Elderly PREVALENCE OF URINARY INCONTINENCE AND INTENTION TO SEEK TREATMENT IN THE ELDERLY I-Jen Tseng, Yen-Ta Chen, Ming-Tan Chen, Hsin-Yi Kou, 1 and Shu-Fen Tseng 2 Background and purpose: Urinary incontinence (UI) is a common, distressing, and often disabling condition in the elderly. The objectives of this study were to estimate the prevalence and clinical characteristics of UI among elderly indivduals living at home and to explore their perceptions of UI and intention to seek medical care. Methods: A total of 504 elderly subjects aged 65 and older residing in Tungkang town (located in the southwestern part of Taiwan) were randomly sampled and surveyed face to face by registered nurses. The prevalence, clinical types, and perceptions of UI, and intention to seek treatment, were compared with chi-square statistics across various sociodemographic characteristics. Logistic regression analyses were conducted to identify factors associated with UI experience and intention to seek treatment. Results: About 22% of respondents reported that they had experienced involuntary loss of urine in daily life. Women, people who were overweight, and those who were aged 70 years or older were at higher risk of UI. While women were more likely to suffer from stress incontinence, men were at higher risk of urge incontinence. Women, illiterate individuals, and those who perceived UI as a normal part of the aging process showed low intention to seek treatment for UI. Conclusions: The results of this study suggest that public awareness programs about UI and promotion of available treatment options are necessary to increase the intention to seek treatment among the elderly. Culturally sensitive programs should be designed, particularly for female and illiterate elderly, to provide incentives to seek medical care. The increasing availability of various treatment modalities coupled with education to correct commonly held misconceptions about UI might enable more elderly individuals to receive treatment for this common condition. (J Formos Med Assoc 2000;99:753 8) Key words: urinary incontinence prevalence elderly treatment-seeking intention A variety of studies have shown that urinary incontinence (UI) is a common, distressing, and often disabling condition in the elderly [1 4]. Of those older than 65 years, 10% to 20% in the community suffer some degree of UI [5 7]. A sample survey of American households conducted in the early 1980s by the National Health and Nutrition Examination Survey (NHANES) Follow-Up found a high UI prevalence (33%) [8]. This problem is intensified in nursing homes, where 38% to 83% of residents suffer from UI [9]. Some studies indicate that symptoms of stress incontinence are much more prevalent among older women than older men [1, 4, 8]. In a study of 541 women, Milsom et al found that stress incontinence was the most common type, followed by mixed symptoms of stress and urge incontinence, and urge incontinence alone [10]. Some studies suggest that combined incontinence is more prevalent among older women [1, 4]. UI is a symptom with widespread human and social implications, causing discomfort, shame, and loss of Departments of Urology and 1 Nursing, Affiliated Hospital of Foo-Yin Institute of Technology, Pingtung; and 2 Graduate School of Information Sociology, Yuan Ze University, Taoyuan. Received: 13 October 1999. Revised: 4 November 1999. Accepted: 16 May 2000. Reprint requests and correspondence to: Dr. I-Jen Tseng, Department of Urology, Affiliated Hospital of Foo-Yin Institute of Technology, 5 Chung-Shan Road, Tungkang, Pingtung, Taiwan. J Formos Med Assoc 2000 Vol 99 No 10 753

I.J. Tseng, Y.T. Chen, M.T. Chen, et al self-confidence, and it may negatively affect quality of life among the elderly [10]. The estimates of UI prevalence provide an indication of how widespread the problem is and have important implications for determining the level of medical and self-care that is needed. In addition, exploring perceptions and intention to seek treatment among elderly incontinent persons is crucial to developing strategies to improve the management of these conditions. Although inappropriate leakage of urine is recognized by many aged persons, it is not always reported to the physician. Since UI is often viewed by elderly patients, their families, and health professionals as an inevitable consequence of old age, it is frequently left unevaluated and improperly managed [5]. Although previous studies have examined the prevalence of incontinence, few have characterized the perception of UI among the elderly and their intention to seek medical care. Most studies of UI in Taiwan have focused on the clinical symptoms and therapies available to manage incontinence. Yu et al interviewed 500 communitybased respondents aged 40 to 79 years and found a prevalence of 26.1% [11]. Ho et al reviewed the existing literature and found that the reported prevalence of UI among elderly women ranged from 15% to 30%. The prevalence of UI in elderly women was twice as high as that in elderly men [12]. In contrast, few studies have examined the effects of various demographic characteristics on the prevalence, clinical types, or perceptions of UI, or help-seeking intention among the elderly. This study estimated the prevalence and clinical characteristics of UI in a community-dwelling elderly population in relation to several predisposing factors including sex, age, body weight, and childbearing history. The perceptions of UI and intention to seek medical care were also examined. 754 Subjects and Methods Sample The total population aged 65 years and over residing in Tungkang town (located in the southwestern part of Taiwan) at the time of this study was about 3,246. A total of 504 elderly residents were randomly sampled and interviewed face to face by registered nurses during March and April of 1997. The response rate was 80%. To facilitate analysis, we stratified Tungkang town into administrative townships (the Chinese word for township is li), in order to fix the proportion of different strata within the sample. Within each li we stratified according to sex, to guarantee equal representation of genders in the sample. A systematic sampling method was employed to select a random sample for each female and male population within each li. Each of the selected respondents was interviewed using a threepage structured questionnaire that covered personal background, general medical history, urinary status and symptoms, perception of UI, and intention to seek treatment for UI. Variables Sociodemographic characteristics included in this study were sex, age, education, weight, and number of births. was categorized using a formula of ideals for men and women [13]. Subjects who were at least 10% above the ideal weight were categorized as overweight, and those who were at least 10% below the ideal weight were categorized as underweight. UI experience was assessed by asking subjects whether they had ever experienced inappropriate leakage of urine. The clinical types of incontinence were determined from the history given by the subject. Stress incontinence was recorded if subjects reported urine loss associated with physical exertion (coughing, sneezing, lifting, or other physical activity). Urge incontinence was defined as urine loss because of inability to delay voiding following a micturition urge. When features of stress and urge incontinence were present, mixed incontinence was recorded. The perception of UI was classified into three categories as follows: a normal consequence of old age; an inevitable illness; and an illness that can be treated. The intention to seek treatment was defined as whether subjects would consult doctors or take medicine if they experienced UI, or would do nothing about it. Analyses Descriptive statistics were used to examine the distribution of all variables. The prevalence, clinical types, and perceptions of UI, and intention to seek treatment, were compared with chi-square statistics across various sociodemographic characteristics. Logistic regression was employed for multivariate modeling of the effects of sociodemographic variables and UI perception on the intention to seek treatment. Results Characteristics of respondents A total of 504 subjects entered the study (Table 1). Among these, 256 (50.8%) were women. Subjects were categorized into four age ranges: 65 to 70 years (41.3%), 71 to 75 years (28.1%), 76 to 80 years (18.4%), J Formos Med Assoc 2000 Vol 99 No 10

Prevalence of Urinary Incontinence in the Elderly Table 1. Sociodemographic characteristics of subjects, urinary incontinence (UI) prevalence and clinical type, and patients perceptions and intention to seek treatment Characteristic No. (%) Sex (n = 504) Male 248 (49.2) Female 256 (50.8) (n = 499 * ) < 70 206 (41.3) 70 293 (58.7) Education (493 * ) None 300 (60.9) Elementary 87 (17.6) Junior high 37 (7.5) Senior high 69 (14.0) Fitness (n = 319 * ) Non-overweight 194 (60.8) Overweight 125 (39.2) Number of deliveries (n = 255 * ) 0 3 51 (20.0) 4 6 150 (54.9) 7 63 (25.2) UI experience (n = 500 * ) No 392 (78.4) Yes 108 (21.6) UI type (n = 101) Stress 31 (30.7) Urge 31 (30.7) Mixed 23 (22.8) Undetermined 16 (15.8) UI perception (n = 445 * ) Normal process 310 (69.7) Inevitable illness 30 (6.7) Treatable illness 105 (23.6) Treatment intention (n = 484 * ) No 107 (22.1) Yes 377 (77.9) * Excluding non-response and invalid responses; female respondents only. and older than 80 years (12.1%). Most subjects (60.9%) were illiterate and 17.6% of subjects had an elementary school education. About 39.2% of subjects were overweight, 14.4% were underweight, and 46.4% were in the normal range. All women subjects were postmenopausal upon entry into the study; most (54.9%) had given birth four to six times, and 25.2% had given birth more than seven times. A history of diabetes mellitus was found in 16.5% of subjects, prior urinary surgery in 2.6%, and previous cerebral vascular accident in 5.2%. Prevalence of UI A total of 21.6% of subjects reported having experienced involuntary loss of urine at some time (95% confidence interval [CI] = 18% 25.2%) (Table 1). The overall prevalence was significantly greater in women (27.7%) than in men (15.0%) (Table 2). Among women, the prevalence of UI was significantly higher among those who were overweight (26.1%) than those who were in the normal or underweight range (11.7%). Similarly, among men the prevalence of UI was significantly higher among those who were overweight (24.1%) than those who were in the normal or underweight range (10.3%). Logistic regression analyses were conducted to identify factors associated with UI among men and women. In both groups, subject weight was significantly related to UI. The odds ratio of experiencing UI for women who were overweight was 4.5 times higher than that for nonoverweight women (odds ratio = 4.5; 95% CI = 1.8 11.1). Men who were overweight had a chance of experiencing UI that was 2.9 times higher than that for non-overweight men (odds ratio = 2.9; 95% CI = 1.2 6.7). Clinical types of UI Among those who had experienced UI, 30.7% were categorized as having stress incontinence, 30.7% had urge incontinence, and 22.8% had mixed types of stress and urge incontinence. In the remaining 15.8%, incontinence status remained undetermined because of insufficient data (Table 1). Women were more likely to suffer from stress incontinence (45.9%), while men were at a higher risk of urge incontinence (58.3) (Table 3). Among women, stress incontinence was Table 2. Gender and sociodemographic distribution of urinary incontinence (UI) among the elderly UI No UI All women 71 185* < 70 18 57 70 52 122 Non-overweight 9 68* Overweight 18 51 Number of births 0 3 9 42 4 6 40 110 7 59 4 All men 37 211 < 70 9 56 70 28 153 Non-overweight 12 104* Overweight 13 40 * p < 0.05. J Formos Med Assoc 2000 Vol 99 No 10 755

I.J. Tseng, Y.T. Chen, M.T. Chen, et al Table 3. Clinical types of urinary incontinence (UI) reported by subjects Stress Urge Mixed Total Sex Male 3 14 7* 24 Female 28 17 16 61 Non-overweight 3 8 2 13 Overweight 7 11 7 25 Female < 70 13 1 4 18 70 19 10 14 43 Male < 70 1 1 1 3 70 2 12 6 20 *p < 0.05, chi-square test. Incomplete data meant that weight could not be compared by UI type between genders. more common among those below 70 years of age (72.2%) than those 70 or older (44.2%). Perceptions of UI Most subjects perceived UI as a normal part of old age (69.7%), 6.7% viewed UI as an inevitable illness, and 23.6% perceived UI as an illness that could be treated (Table 1). Illiterate respondents were most likely to perceive UI as a normal consequence of old age (77.3%) and least likely to view UI as a treatable illness (16.5%) (Table 4). Elderly subjects tended to view UI as a normal or an inevitable illness and were least likely to perceive it as a treatable illness. More men than women viewed UI as a treatable illness. However, differences in UI perception related to age and gender did not reach a statistically significant level. Intention to seek treatment A total of 22.1% of subjects reported that they would do nothing about UI even if they experienced it (Table 1). Table 4 gives the proportion of subjects with helpseeking intention according to demographic variables. Women (73.6%) were less likely than men (82.4%) to say they would seek medical care if they experienced UI. Subjects who were illiterate showed the lowest intention to seek medical care. Those who perceived UI as a normal consequence of old age were less likely to say that they would seek treatment (68.8%) than those who viewed UI as an inevitable illness (90%) or those who viewed it as a treatable illness (97.1%). A further logistic regression analysis was conducted to identify the predictors of intention to say that they would seek treatment for UI. Subjects who perceived UI as an illness and who had an elementary level of education or above were more likely to seek treatment, controlling for other factors (Table 5). Specifically, the estimated odds for those who perceived UI as an illness to seek treatment were 20% higher than for those who Table 4. Perception of and intention to seek treatment for urinary incontinence (UI) among elderly subjects Perception Treatment intention Normal part of aging process Inevitable illness Treatable illness Yes No Sex Male 151 12 57 206 42* Female 159 18 48 191 65 < 70 57 5 17 81 15 70 253 25 86 316 92 Education None 201 16 43* 215 85* Elementary 45 6 26 78 9 Junior high 25 4 6 32 5 Senior high 33 3 27 62 7 UI experience No 249 18 79 305 88 Yes 59 10 24 88 19 UI perception Normal part of aging 217 93* Inevitable illness 27 3 Treatable illness 100 3 * p < 0.05, chi-square test. 756 J Formos Med Assoc 2000 Vol 99 No 10

Prevalence of Urinary Incontinence in the Elderly Table 5. Logistic regression analysis of sociodemographic factors, and perception of and intention to seek treatment for urinary incontinence (UI) Odds ratio 95% confidence interval Sex Male 1.0 Female 1.0 0.5 1.9 < 70 1.0 70 0.7 0.3 1.5 Education None 1.0* Elementary 4.8 2.4 9.6 Non-overweight 1.0 Overweight 1.4 0.8 2.5 UI experience No 1.0 Yes 1.4 0.6 3.2 UI perception Normal process 1.0* Illness 1.2 1.0 1.4 Constant 0.45 N 322 * p < 0.05. perceived UI as a normal consequence of old age (odds ratio = 1.2; 95% CI = 1.0 1.4). Those who had an elementary school-level education or above had a 4.8- times higher likelihood of reporting intention to seek treatment than those who were illiterate (odds ratio = 4.8; 95% CI = 2.4 9.6). Discussion The study of UI prevalence in the elderly is necessary to understand their medical care needs. Our findings of the prevalence of UI among the elderly living in the community (21.6%) are similar to those reported previously by researchers in Taiwan [11, 12]. The high prevalence of UI among women has become increasingly recognized in recent years and was confirmed by our study. Subjects who were overweight were at a higher risk of UI. Stress incontinence was more prevalent among women, while men were at a higher risk of urge incontinence. In the present study, almost 70% of subjects perceived UI as a normal consequence of old age. This finding is consistent with the study of Holst and Wilson, where UI was not considered abnormal among the elderly [14]. Particularly, illiterate subjects were most likely to perceive UI as a normal consequence of old age. About 22.1% of subjects showed no intention to seek medical care even if they experienced UI. Previous studies suggest that women avoid seeking help largely because they are embarrassed or ashamed, or because they do not understand that the condition is treatable [8, 9, 15]. Because embarrassment and misconceptions about incontinence being normal or untreatable are common, there is a need for public education and dissemination of information that will dispel misconceptions about UI. In addition, culturally sensitive programs should be designed, in Taiwan and in other countries with high rates of illiterate elderly, to encourage these individuals to seek medical care. Our results confirm previous reports that the failure to perceive UI as a disease that can be overcome or cured is a barrier to seeking help [16]. Studies have suggested that a great proportion of patients are not aware that their physicians can help them with incontinence [15]. Apparently, public awareness programs about UI and promotion of available treatment are necessary to increase the intention to seek treatment among the elderly. Prior research also suggests that much unrecognized incontinence is perceived as a minor symptom by patients as well as physicians. An obvious but underused method of information dissemination is for primary health care providers to ask older patients about incontinence symptoms as part of routine physical examination and health care [9]. The increasing availability of various treatment modalities, such as medication (oxybutynin, probanthine, estrogen, etc), pelvic floor exercise, and urinary surgery (neck suspension, sling procedure) [12, 17], coupled with education to correct commonly held misconceptions about UI, might enable more elderly patients to receive treatment for this common condition. ACKNOWLEDGMENT: The authors would like to thank the Affiliated Hospital of Foo-Yin Institute of Technology for providing manpower and supporting this study. References 1. Diokno AC, Brock BM, Brown MB, et al: Prevalence of urinary incontinence and other urological symptoms in the noninstitutionalized elderly. J Urol 1986;136:1022 5. 2. Vetter NJ, Jones DA, Victor CR: Urinary incontinence in the elderly at home. Lancet 1981;ii:1275. 3. Yarnell JWG, Voyle GJ, Richards CJ, et al: The prevalence and severity of urinary incontinence in women. J Epidemiol Com Health 1981;35:71 4. J Formos Med Assoc 2000 Vol 99 No 10 757

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