Supplements New Perspectives on Overactive Bladder: Quality of Life Impact, Medication Persistency, and Treatmen
The Impact of Urinary Incontinence on Quality of Life of the Elderly
About 2.1% (2996) of the subjects did not
answer the UI question. Of the remaining
subjects, 34 292 (24.7%) reported having difficulty
controlling urination. The prevalence
of UI among men and women was 20.9% and
27.5%, respectively. Compared with the non-UI group, the UI group was more likely to be
women, Caucasian, older than 74 years,
unmarried, and had less than a high school
education (Table 1). The distribution of
comorbidities differed significantly between
UI and non-UI groups (P <.001). Patients
with UI tended to have more comorbid medical
conditions than those without UI.
UI and General Health. Generally, patients
with UI had a more negative view on
their health. About 65% of the UI group and
80% of the non-UI group rated their general
health as good or better. Approximately 70%
of the UI group rated their health as good or
better than their peers compared with 85% in
the non-UI group. In addition, 25% of those
with UI perceived their health as declining
compared with 1 year ago, whereas only 13%
of the continent respondents did so.
UI and Depression. Depression was more
prevalent in the UI group. Respondents with
UI were about twice as likely to report being
depressed as the non-UI group. Approximately
28% of the UI population felt
depressed or lost interest for 2 weeks or
more in things that they usually enjoyed
compared with only 15.4% in the non-UI
group. About 18% of persons with UI felt
depressed or sad much of the time in the
past year, whereas less than 10% of continent
respondents felt the same way.
Similarly, 17.7% of persons with UI had
experienced depression for 2 or more years
compared with 9.7% in the non-UI group.
Impact of UI on QOL. As standardized
scores were used, a score of 50 represents
the national average for both the subscale
scores and summary scores. A score of 10
points above or below 50 represents a difference
of 1 standard deviation from the
As shown in Table 2, UI had a significant
impact on QOL. Mean scores for UI were all
lower than 50; this suggests that the UI
group scored lower than the general US population
on all domains of the SF-36. The
largest differences between UI group and
the general US population were observed in
the PF and role-physical domains (Table 2).
The UI group had significantly lower scores
than the non-UI group in all of the 8 subscales
and in the 2 component summaries
(P <.001), indicating that persons with UI
have relatively poorer QOL compared with
those who are continent (Table 2). On average,
the incontinent elderly patient scored 6.6
and 3.9 points lower than the continent group
in PCS and MCS, respectively. The adverse
impact of UI on the SF-36 domain scores
ranged from 4.0 points in MH to 6.7 points in
RP compared with respondents without UI.
After adjusting for age, sex, race, marital
status, education level, and other comorbidities,
UI remained a significant predictor of
all domains of SF-36 and 2 summary scores
(P <.05). Results from multiple regression
indicated that the presence of UI reduced
PCS and MCS by 3.7 and 3.0 points, respectively.
In the 8 domains of SF-36, the UI group
scored 2.9 to 4.2 points less than the non-UI
group. The R2 for the 10 regression models
ranged from .07 for MCS to .32 for PCS.
The standardized regression coefficients
allow us to compare the relative impact of
independent variables; the larger the coefficient,
the greater the impact of a variable on
the outcome. As shown in Table 3, among all
the medical conditions, UI had the largest
standardized coefficient (in absolute value)
on VT, SF, RE, and MH scales. In other
words, UI had a relatively greater impact on
these domains of QOL than other comorbidities.
Moreover, the adverse impact of UI on
PF and GH was the second highest, next only
to emphysema, asthma, COPD and arthritis
of the hip and knee. The adverse impact of UI
on bodily pain was only second to arthritis of
the hand and wrist and hip and knee.
This is the first study investigating the
prevalence of UI among the elderly Medicare
population enrolled in managed care plans.
In this large random sample, about one
fourth of the population reported having
difficulty controlling urination. Moreover,
women were significantly more likely than
men to report suffering with UI, which is
consistent with the results of previous
This study shows that elderly patients
with UI had a worse perception of health and
were more likely to be depressed. However,
these associations could be because respondents
with UI were indeed less healthy as a
result of greater comorbidities. Similar to
previous studies on UI and depression, this
study is based on cross-sectional data and
cannot provide evidence on the temporal or
causal relationships between UI and depression.
Prospective studies are needed in the
future to delineate the causality between the
2 health conditions.
Compared with other medical conditions
included in our models, UI has a more substantial
impact on both physical and mental
dimensions of QOL. UI decreases MCS
scores more than other medical conditions.
This was not surprising, given the plethora
of psychosocial problems associated with
this disease condition. It is notable that the
impact of UI on PCS was only secondary
to that of emphysema/asthma/COPD and
arthritis of the hip/knee. The impact of UI
on the pain domain of QOL further exemplifies
how a medical condition could
affect a person's QOL, even on those
unanticipated domains. A medical condition
that does not directly cause much
pain may, nonetheless, exacerbate other
underlying conditions and intensify the
perception of pain.
As the population in the United States
ages and the proportion of elderly aged 65
years and older grows from 12.7% in 1999 to
18.5% in 2025,43 there is an urgent need for
effective and efficacious management strategies
for chronic degenerative diseases. As
baby boomers (those aged 39-57 years in
2003) grow older, the demand for senior
care will increase rapidly during the 2010 to
2030 period. The goal of healthy aging
should be to not only extend life expectancy,
but improve QOL as well. From a managed
care perspective, the undeniable impact of a
"benign" condition, such as UI on physical
and MH, has policy implications. Future
studies need to focus on whether early diagnosis
and more aggressive interventions for
UI could reduce long-term healthcare costs,
decrease disease burden, and increase QOL
and patient satisfaction of health-plan
There are a few limitations to this study.
The presence or absence of UI and other
health conditions was self-reported. The
extent to which the information was consistent
with medical records is unknown,
although based on the results of a previous
study, the accuracy is generally satisfactory
with a few exceptions.48 In addition, the survey
data used in this study were obtained
from the elderly Medicare beneficiaries
enrolled in managed care plans; therefore,
these survey findings may not be generalized
to a younger population or the elderly covered
by a different type of health plan. As a
result of data limitations, it was not possible
to differentiate the types of incontinence in
respondents, although previous studies indicated
that QOL of the elderly with stress
incontinence was less affected than those
Our results suggest that UI is prevalent
and can have significant impact on both the
physical and mental health of the elderly
population. This is an important epidemiological
and clinical finding that suggests further
study and action, both by clinicians and
policymakers. Some incontinent individuals
do not seek medical help because they
either are not aware that effective treatments
are possible, consider it as a natural
aging process, or are too ashamed to mention
it to their healthcare providers.3,49 As a
result, only one quarter to one half of individuals
actually sought medical help.12
Healthcare providers need to be sensitive to
these deterrents and identify better ways of
evaluating and discussing UI with their
patients. In addition, clinicians can play an
important role in educating patients about
their health condition, treatment options,
and disease management. Several treatment
choices are now available with greater effectiveness
and feasibility, and with increased
awareness, proper differential diagnosis, and
better screening of UI, health providers can
seize opportunities to significantly improve
the QOL of the elderly population along this
The authors wish to thank Pfizer/Pharmacia
Corporation for partial financial support
for this work. We also wish to acknowledge
Zhanna Jumadilova, MD, MBA, of Pfizer's US
Outcomes Research for review of a previous
version of this manuscript.
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