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Urinary Incontinence in the Nursing Home: Resident Characteristics and Prevalence of Drug Treatment
Zhanna Jumadilova, MD, MBA; Teresa Zyczynski, PharmD, MBA, MPH; Barbara Paul, MD; and Siva Narayanan, MS, MHS
PARTICIPATING FACULTY

Urinary Incontinence in the Nursing Home: Resident Characteristics and Prevalence of Drug Treatment

Zhanna Jumadilova, MD, MBA; Teresa Zyczynski, PharmD, MBA, MPH; Barbara Paul, MD; and Siva Narayanan, MS, MHS

Objectives: To provide a descriptive overview of the elderly, nursing home patient population with urinary incontinence (UI).

Methods: This study was a descriptive, cross-sectional database analysis (2002-2003) examining UI prevalence, demographic and clinical characteristics of UI patients, and UI pharmacotherapy prevalence in the nursing home setting.

Results: Of the 29 645 eligible subjects, 8995 experienced some level of UI at the time the minimum data set (MDS) was completed (30%). Compared with continent residents, a greater percentage of incontinent residents were older, white women and had a longer length of stay. Incontinent residents also had more indicators of frailty than those who were continent; they were more impaired on activities of daily living and cognitive performance scale scores, were hospitalized more frequently, and had more urinary tract infections, pressure ulcers, and depression. More incontinent residents were using pads/briefs and had bladder retraining and scheduled toileting. Only 8.7% of those residents rated as having the most severe level of incontinence (MDS level 4) were being treated with pharmacotherapy. Of the 8995 residents with a UI rating of 1 to 4, only 8% (n = 731) had pharmacotherapy.

Conclusion: There is a high prevalence of UI among nursing home residents and having this condition is negatively correlated with measures of resident health status and healthcare utilization. A variety of interventions are used in this setting to treat UI, and use of pharmacologic therapy appears to be quite low. Appropriate use of interventional strategies that may include drug treatment for UI in the nursing home may reduce the substantial personal and cost burdens associated with this condition. However, clinicians may need population-specific scientific evidence in determining which nursing home patients will benefit most from pharmacotherapy.

(Am J Manag Care. 2005;11:S112-S120)


Urinary incontinence (UI) is a significant problem in elderly populations. The prevalence and economic burden of incontinence are difficult to estimate since many sufferers never seek treatment.1,2 It has been reported that 17% to 55% of community-dwelling elderly, and as many as 50% to 70% of elderly nursing home residents may suffer from this condition.3,4 Incontinence has been identified as a risk factor for nursing home placement after hospital discharge.5 The high prevalence of UI in the nursing home population may not indicate the cause of the facility admission per se, but is likely to be related to the many conditions that are associated with UI for which the elderly require care (eg, functional disability, infections, dementia, and neurologic disease). The sequelae of UI, particularly when poorly managed, include skin irritation, pressure ulcers, falls, and fractures. UI also has a devastating impact on self-image and quality of life.4

In a review, Hu et al reported estimates of the annual direct costs of UI in the United States as $19.5 billion, with $5.3 billion associated with care for institutional residents.6 Wilson et al similarly reported annual direct nursing home costs to be $5.5 billion.3 One study included both direct and indirect costs for UI in all persons 65 years of age and older in the United States; it reported total costs at more than $26 billion in 1995, with institutional care (including hospital care) at more than $8.4 billion.7 Others predict that in the year 2025 the estimated 8.5 million nursing home residents will generate $25 billion in direct UI costs.8 Similarly, estimated costs for overactive bladder (OAB), which is related to and includes many UI patients, has been estimated in the United States to be about $3.5 billion annually for institutional residents.6

The care of an incontinent nursing home patient is significantly more expensive than for a continent one. Shih et al found that the incremental labor costs associated with caring for an incontinent patient are an additional $4957 per patient per year more than the costs for caring for a continent patient.9 This estimate included the costs of nursing and aide time for changing diapers and linens, turning and positioning patients, checking for wetness, and assisting patients in getting to the bathroom. However, it should be noted that this study also included the costs of patients with UI who may have also had bowel incontinence.

Treatment of UI typically begins with noninvasive, conservative approaches.4 Nonpharmacologic interventions include behavioral therapy, including patient education, fluid management, bladder retraining, pelvic floor exercises, biofeedback, and timed bladder emptying. However, patients should be cognitively intact. In addition, surgical procedures and catheterization are appropriate for some patients. There are also emerging technologies that involve electrical stimulation of pelvic muscles.10

Pharmacotherapy is effective in many patients and usually is recommended in addition to behavioral modification when that measure alone fails.11 The antimuscarinic medications, tolterodine and oxybutynin, are the most commonly prescribed drugs.12 Pharmacologic therapy is a primary mode of treatment for community-dwelling UI patients, and the trial of such therapies under appropriate circumstances has been suggested as a quality indicator in the nursing home setting.13 However, drug therapy is reported to be underused in the nursing home.4 It is speculated that the reasons for this include a lack of efficacy data in the nursing home population, no studies regarding use of drugs in patients with severe cognitive impairment who have likely failed behavioral therapy, and the risk of contraindications.4

There is a high prevalence of and cost burden for UI in the nursing home setting. Underuse of pharmacologic interventions is reported despite patient preferences and recommendations for treatment.4,13,14 Yet, little is known about UI, its comorbidities and sequelae, and the use of drug treatment in this care setting in the United States.15,16 Although the proliferation of new treatments has resulted in increased interest in UI and OAB overall, there appear to be no descriptive reports in the published literature on prevalence of UI pharmacologic treatment for nursing home patients with these therapies. The objective of this study was to provide a descriptive overview of the elderly, nursing home UI patient population, including demographics and associated conditions, with a specific focus on prevalence of drug therapy for the treatment of UI.

Methods

This study was a descriptive, cross-sectional database analysis examining prevalence of UI, demographic and clinical characteristics of UI patients, and prevalence of drug use for UI by residents in the nursing home setting.

Data Source. Multicenter data from 378 skilled nursing facilities (SNFs) from across the United States were used for this analysis. The data include comprehensive information on more than 200 000 residents nationwide with varying demographics. It has data from a variety of sources including minimum data set (MDS) assessments, nursing progress notes, related care plans, medication and treatment records, physicians' orders, accounts payable/receivable, and cost accounting.

Study Population. All nursing home patients were eligible if they were admitted and received care in 1 of the 378 participating nursing homes in the United States between January 1, 2002, and December 31, 2003. Residents were not eligible for inclusion if they were receiving hospice care, were comatose, or had any level of bowel incontinence during the period as indicated on the MDS (Section H, question 1.a). Also, any patient with a short stay of 14 days or less was excluded.

Study Measures. The MDS question on bladder incontinence (Section H, 1.b) was used to classify patients on level of UI, with 0 (no incontinence) to 4 (incontinent most of the time). The maximum level found on any available MDS completed during the study period was used. That highest-level MDS was the source for the data used in the study. Each resident was assured of having a minimum of 1 MDS completed as all were admitted during the study period and an MDS must be completed on admission by regulation. Additional MDS assessments may have been completed after admission, as at least 1 is required annually (more often in some states) and 1 is required on a significant change in health status.

Residents were considered to have had pharmacologic treatment for UI if they were prescribed any of the following medications during the follow-up period: tolterodine immediate or extended release; oxybutynin immediate, transdermal, or extended release; desmopressin; or flavoxate. Patients who did not receive any of these medications were considered not pharmacologically treated.

Because this was a cross-sectional analysis, it was not possible to discern the time sequence of comorbid events and outcomes to distinguish existing conditions, risk factors, or the sequelae of UI. Thus, these conditions are referred to here as associated conditions. Study data were grouped into 3 categories: (1) Patient demographics: age, sex, ethnicity, and length of stay (LOS); (2) Associated conditions and other indicators of patient health status: activities of daily living (ADLs), average time involved in care, cognitive performance score (CPS), all-cause hospitalization, urinary tract infection, insomnia, pressure ulcer, depression, use of wheelchair for locomotion, and bedfast; and (3) Use of incontinence-related program or device: bladder retraining, pads/briefs, and scheduled toileting. For example, the following measures were derived from the MDS assessments in the following ways:

  • ADL: Score was calculated as the sum of MDS items G-1.a to G-1.j, and ranged from 0 = totally independent to 40 = totally dependent
  • Average time involved in activities: score reported as MDS question N-2 and ranged from 0 = more than two thirds of the time to 3 = none of the time
  • CPS: As measured using questions B-1, B-2.a, B-4, C-4, G-1.h.A and ranged from 0 = intact to 6 = very severe impairment17
  • Presence of pressure ulcer: score was from item M-2 and coded as 0 = no ulcer or 1 = an ulcer at any stage
  • All-cause hospitalizations: score was from MDS item P-5 and ranged from 0 = no hospitalization to 1 = at least 1 hospitalization

Statistical Analyses. This was an exploratory study that was not intended to test any specific hypotheses, but was intended to gather hypothesis-generating information on this population. As such, there was no adjustment made for examining multiple end points. Bivariate analyses, stratified by UI levels and treatment group, were conducted to evaluate resident demographics, associated conditions, and clinical characteristics. Primary analyses were unadjusted, and descriptive statistics (proportions, means, and 95% confidence intervals of the means, as appropriate) were prepared to compare different patient groups. Associated conditions were evaluated, stratified by the maximum bladder-continence level achieved by the patient during his/her stay in the SNF and by treatment with drug (or no drug treatment).

Analyses of covariance (ANCOVA) methods were employed to adjust for covariates that were found statistically significantly different in bivariate analyses. The ANCOVA analyses were conducted with ADL score, average time involved in activities, CPS, presence of pressure ulcers, and all-cause hospitalizations as the dependent variable. Other study end points (significant in the bivariate analyses) were used as control variables (eg, demographics, associated conditions, and other indicators of patient health status). Two regression models were examined, one controlling for pharmacological treatment (treated vs untreated) and the second for UI level.

Results

A total of 87 000 residents had at least 1 MDS assessment available during the study period, 2002 and 2003. Of those residents, 29 645 met the inclusion criteria. It should be noted that 27 951 patients were excluded because of having had some level of bowel incontinence, alone or in conjunction with UI, which was indicated on their MDS during the study period. Before excluding those patients with bowel incontinence, the prevalence of UI was 58% (33 415 of 57 596).

However, among the 29 645 eligible for this study, 8995 were experiencing some level of UI at the time their MDS was completed, a prevalence of 30%.

 
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