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The Impact of Urinary Incontinence on Quality of Life of the Elderly
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The Impact of Urinary Incontinence on Quality of Life of the Elderly

Yu Ko, MS; Swu-Jane Lin, PhD; J. Warren Salmon, PhD; and Morgan S. Bron, PharmD, MS

Objectives: To investigate the impact of urinary incontinence (UI) on health-related quality of life (QOL), as measured by the Medical Outcomes Study Short Form-36 (SF-36) and to compare UI and non- UI elderly Medicare beneficiaries enrolled in managed care plans on the prevalence of depression and self-rated health.

Methods: After excluding beneficiaries younger than 65 years old, a total of 141 815 completed surveys were used for analysis. The survey included 1 question on difficulty in controlling urination, 3 questions on depression, 3 questions on health, a series of questions regarding comorbid medical conditions, and the SF-36. Self-rated health, prevalence of depression, and scores in each domain of QOL were compared between UI and non-UI groups.

Results: Overall, the prevalence of UI was 24.7% (20.9% in men, 27.5% in women). The UI group was about twice as likely to feel depressed as the non-UI group. The UI group also rated their health more negatively. Compared with continent respondents, those who were incontinent had lower standardized scores on all 8 subscales of SF-36 as well as 2 summary scores. Results from multiple regressions indicated that UI had a significantly negative impact on all aspects of QOL after adjusting for comorbidities and demographic differences.

Conclusion: Findings indicate that elderly patients with UI are more depressed and have worse perceived health. On certain domains of QOL, the negative impact of UI even surpasses that of other severe comorbidities.

(Am J Manag Care. 2005;11:S103-S111)

Urinary incontinence (UI), or the involuntary loss of urine, can occur at any age, but is especially common in elderly women.1,2 UI has been estimated to affect 20% to 33% of adults3,4 or 11% to 55% of the elderly,1,2,5-8 depending on the age of the subjects, the healthcare setting where the study was performed, the definition of UI employed, and, potentially, the format of the questions being asked about UI. The prevalence of UI in older women is approximately 2 times that of older men.1,6 Compared with the elderly living at home, those residing in nursing homes or hospitals also have a higher prevalence of UI,1 which may be one of the contributing factors to institutionalization. Despite the high estimate of prevalence, as many as 50% of all cases of UI may not have been reported, because individuals with UI do not always seek medical help.3,9-11

Current treatments for UI include behavioral (eg, bladder training, fluid manipulation, scheduled toileting, pelvic muscle exercises), pharmacological, and surgical interventions, used either alone or in combination.11-13 Behavioral techniques are now currently recommended as first-line therapy in the treatment of UI.14,15 Behavioral interventions are usually relatively inexpensive and easy to implement, but the effectiveness chiefly depends on the patient's adherence.16 When nonpharmacologic interventions have failed, drug therapy can be an option.11 The effectiveness of older drugs, such as immediate-release (IR) oxybutynin, is not satisfactory, partly because of poor compliance as a result of adverse events (AEs).17 The new generation of pharmacological treatments, such as extendedrelease (ER) tolterodine and transdermal oxybutynin, provide better or comparable efficacy, but with fewer AEs.18-21 Although surgical interventions are used in only the most refractory cases of urge UI, they are more commonly used in the treatment of stress UI.11

Because UI may cause social isolation, loss of sexual function, and other psychosocial problems,3,22,23 it could have significant impact on patients' psychosocial well-being and quality of life (QOL). Studies have shown that patients suffering with UI are more depressed,24,25 psychologically distressed,26 emotionally disturbed,27 and socially isolated.27 Moreover, compared with continent individuals, those patients with UI also have higher levels of anxiety,28 lower QOL,27 and poorer life satisfaction.25 The severity of UI is also correlated with degrees of mental distress, social restrictions, and restricted activities.3,23 As a result, UI has an adverse effect on patients' daily lives and could become a barrier for normal social function.27

Previous studies have indicated that depression was common in adults with UI. A study using the Geriatric Depression Scale on homebound elders with UI found that up to 50% of the elderly patients had significant depressive symptomatology.29 Another study found that those patients with UI were more likely to have major depression than those without UI (odds ratio [OR] = 4.5; 95% confidence interval [CI] = 2.3-8.8), as assessed using the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSMIII).24 Although UI is associated with depression, the causal pathway from UI to depression is not entirely clear.

Several generic and disease-specific instruments have been used to assess the QOL of adults with UI. Although UI-specific instruments, such as the Incontinence Impact Questionnaire30 and the Incontinence Quality of Life Instrument,31 tend to be more sensitive to the unique impact of UI, generic measures permit the comparison among different populations or interventions.32 One study using the Sickness Impact Profile, a generic health status instrument, found that the QOL of community-living women was adversely affected by UI considerably.33 Another study using the Nottingham Health Profile Questionnaire, a generic health status instrument as well, indicated that women with UI were more emotionally disturbed and socially isolated than those from the age-matched control group without UI.27 The literature also suggests that patients with urge UI and mixed UI are more likely to suffer with depression and poorer QOL than those with stress UI.34-36 Among the generic measures of QOL instruments, the Medical Outcome Study Short Form-36 (SF-36) is most widely used and well known in healthcare research. It contains 1 item assessing health transition and 35 items assessing 8 domains of health status—physical functioning (PF), role limitations as a result of physical problems (RP), bodily pain (BP), general health perceptions (GH), vitality (VT), social functioning (SF), role limitations as a result of emotional problems (RE), and mental health (MH).37 These 8 subscales are also used to generate 2 health summary scores, the physical component summary (PCS) and the mental component summary (MCS).38 Two studies showed that SF-36 scores of the patients with UI were lower in all 8 domains compared with the general population or the control group.39,40 However, O'Conor and colleagues found that patients with urge or mixed UI had significantly lower scores in only 5 of 8 dimensions (ie, PF, SF, RE, RP, VT) compared with the general US population,17 and Kutner and colleagues showed that UI significantly affected GH, RP, and RE, but not SF.41 In summary, previous studies are inconsistent regarding the specific domains of QOL affected by UI, but it appears that numerous domains are affected.

Previous studies of QOL and UI usually recruited subjects only from a particular setting, such as nursing homes,7,8 communities,5,23,41 or hospitals,22 and they have a limited sample size, which ranges from several dozen to several hundred persons.8,17,22,23,28,33,39-41 Therefore, the overall prevalence and impact of UI on the US elderly population remains unknown. The primary purpose of this study was to investigate the prevalence of UI among the elderly using a sample of Medicare managed care enrollees. The self-rated health and the presence of depression in the UI and non-UI subjects were also compared.


Data Source. The Medicare Health Outcomes Survey (HOS), formerly titled Health of Seniors, was the first large-scale subject-based outcomes measure funded by the Centers for Medicare and Medicaid Services to assess the quality of care provided to Medicare beneficiaries enrolled in managed care.42 A random sample was selected and surveyed every spring, and the same respondents were surveyed again 2 years later. The first baseline cohort was surveyed in May 1998, which was composed of 279 135 Medicare beneficiaries enrolled in 269 Medicare + Choice Organizations from 287 market areas.42 A combination of mail and phone surveys was used to collect the data. A returned survey was considered "complete" if at least 80% of the response items were completed and 3 specific questions about the respondent's overall health status were answered. The final response rate was about 60%. More detailed descriptions about the data collection process were reported elsewhere.43 In this study, only those respondents aged 65 years and older were included in the analyses.

The HOS is a self-administered survey that includes several questions on demographics, health status, depression, comorbid medical conditions, and the SF-36. The 3 health status questions focus on the subject's general health, health compared with 1 year ago, and health compared with their peers. Each question was measured on a 5-point scale from 1 (excellent/much better now) to 5 (poor/much worse now). Depression was measured by 3 yes/no questions: (1) In the past year, have you had 2 weeks or more during which you felt sad, blue, or depressed, or when you lost interest or pleasure in things that you usually cared about or enjoyed?; (2) In the past year, have you felt depressed or sad much of the time?; and (3) Have you ever had 2 years or more in your life when you felt depressed or sad most days, even if you felt okay sometimes?

The SF-36 is a widely used instrument in health services research for assessing health-related QOL. The validity and reliability of this instrument has been established for measuring QOL in large populations of both healthy and diseased individuals.44-46 Scores of the 8 dimensions of SF-36 range from zero (the worst QOL) to 100 (the best QOL). To compare with the general US population, the zero to 100 scores are also transformed to standardized scores (mean of 50, standard deviation of 10), with a score of 50 representing the national average for a given scale or summary score. In this study, the standardized scores were used.

The question, "Do you have difficulty controlling urination?" in the HOS survey was used to identify respondents suffering from UI. Respondents were classified as the UI or non-UI group depending on whether they answered "yes" or "no" to the same question; persons denying the condition were unable to be distinguished. A checklist of various comorbidities was included in the survey. Eleven common medical conditions that have been reported to have adverse effects on QOL47 were included in this study as covariates; they are hypertension, angina pectoris, congestive heart failure, myocardial infarction, other heart conditions, stroke, emphysema/asthma/chronic obstructive pulmonary disease (COPD), arthritis of the hip/knee, arthritis of the hand/wrist, cancer, and diabetes.

Statistical Methods. The chi square test was used to compare the distributions of demographic characteristics, depression, comorbidities, and perceived health status among the UI group and non-UI group. Two-tailed Student's t-test was used to compare each domain of the SF-36 scores between the 2 groups.

A multiple regression model was conducted for each of the 8 domains and the 2 summary scores of the SF-36. The impact of UI on the QOL scores was estimated, after controlling for age, sex, race, marital status, education level, and the 11 common medical conditions listed above. All analyses were conducted with SPSS for Windows (Version 11.0). Findings were considered statistically significant if P <.05.


Characteristics of Subjects. Of the 141 815 respondents who completed the survey, 60.3% were between the ages of 65 to 74 years old, 90.3% were Caucasian, 58% were women, and 59.1% were married. One third (36.0%) had graduated from high school or held a General Educational Development diploma, and another one third (37.3%) had at least some college education or a 2-year college degree.

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