Currently Viewing:
Supplements New Perspectives on Overactive Bladder: Quality of Life Impact, Medication Persistency, and Treatmen
New Perspectives on Overactive Bladder: Quality of Life Impact, Medication Persistency, and Treatment Costs
C. Daniel Mullins, PhD; and Leslee L. Subak, MD
Persistence With Overactive Bladder Pharmacotherapy in a Medicaid Population
Fadia T. Shaya, PhD, MPH; Steven Blume, MS; Anna Gu, MA; Teresa Zyczynski, PharmD, MBA, MPH; and Zhanna Jumadilova, MD, MBA
Currently Reading
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
Medical Costs After Initiation of Drug Treatment for Overactive Bladder: Effects of Selection Bias on Cost Estimates
Nicole M. Nitz, PhD; Zhanna Jumadilova, MD, MBA; Theodore Darkow,   PharmD; Jennifer R. Frytak, PhD; and Tamara Bavendam, MD
Economic Impact of Extended-release Tolterodine versus Immediate-and Extended-release Oxybutynin Among Commercially Insured Persons With Overactive Bladder
Sujata Varadharajan, MS; Zhanna Jumadilova, MD, MBA; Prafulla Girase, MS; and Daniel A. Ollendorf, MPH
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
Treatment of Overactive Bladder: A Model Comparing Extended-release Formulations of Tolterodine and Oxybutynin
Eleanor M. Perfetto, PhD; Prasun Subedi, MS; and Zhanna Jumadilova, MD, MBA

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

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 national average.

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 studies.1,6

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 enrollees.

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 with UI.27,33,39


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 dimension.


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.

1. Hellstrom L, Ekelund P, Milsom I, Mellstrom D. The prevalence of urinary incontinence and use of incontinence aids in 85-year-old men and women. Age Ageing. 1990;19:383-389.

2. Brown JS, Seeley DG, Fong J, Black DM, Ensrud KE, Grady D. Urinary incontinence in older women: who is at risk? Study of Osteopathic Fractures Research Group. Obstet Gynecol. 1996;87:715-721.

3. Shaw C. A review of the psychosocial predictors of help-seeking behaviour and impact on quality of life in people with urinary incontinence. J Clin Nurs. 2001;10:15-24.

4. Lagace EA, Hansen W, Hickner JM. Prevalence and severity of urinary incontinence in ambulatory adults: an UPRNet study. J Fam Pract. 1993;36:610-614.

5. Diokno AC, Brock BM, Brown MB, Herzog AR. Prevalence of urinary incontinence and other urological symptoms in the noninstitutionalized elderly. J Urol. 1986;136:1022-1025.

6. Thom D. Variation in estimates of urinary incontinence prevalence in the community: effects of differences in definition, population characteristics, and study type. J Am Geriatr Soc. 1998;46:473-480.

7. Ouslander JG, Kane RL, Abrass IB. Urinary incontinence in elderly nursing home patients. JAMA. 1982;248:1194-1198.

8. Ouslander JG, Palmer MH, Rovner BW, German PS. Urinary incontinence in nursing homes: incidence, remission and associated factors. J Am Geriatr Soc. 1993;41:1083-1089.

9. Burgio KL, Matthews KA, Engel BT. Prevalence, incidence and correlates of urinary incontinence in healthy, middle-aged women. J Urol. 1991;146:1255-1259.

10. Hampel C, Wienhold D, Benken N, Eggersmann C, Thuroff JW. Definition of overactive bladder and epidemiology of urinary incontinence. Urology. 1997;50:4-14.

11. Couture JA, Valiquette L. Urinary incontinence. Ann Pharmacother. 2000;34:646-655.

12. Wilson L, Brown JS, Shin GP, Luc KO, Subak LL. Annual direct cost of urinary incontinence. Obstet Gynecol. 2001;98:398-406.

13. Gormley EA. Biofeedback and behavioral therapy for the management of female urinary incontinence. Urol Clin North Am. 2002;29:551-557.

14. Sampselle CM. Behavioral intervention: the first-line treatment for women with urinary incontinence. Curr Urol Rep. 2003;4:356-361.

15. Marcell D, Ransel S, Schiau M, Duffy EG. Treatment options alleviate female urge incontinence. Nurse Pract. 2003;28:48-54.

16. Vapnek JM. Urinary incontinence. Screening and treatment of urinary dysfunction. Geriatrics. 2001;56:25-29.

17. O'Conor RM, Johannesson M, Hass SL, Kobelt- Nguyen G. Urge incontinence. Quality of life and patients' valuation of symptom reduction. Pharmacoeconomics. 1998;14:531-539.

18. Van Kerrebroeck P, Kreder K, Jonas U, Zinner N, Wein A. Tolterodine once-daily: superior efficacy and tolerability in the treatment of the overactive bladder. Urology. 2001;57:414-421.

19. Harvey MA, Baker K, Wells GA. Tolterodine versus oxybutynin in the treatment of urge urinary incontinence: a meta-analysis. Am J Obstet Gynecol. 2001;185:56-61.

20. Dmochowski RR, Sand PK, Zinner NR, Gittelman MC, Davila GW, Sanders SW. Comparative efficacy and safety of transdermal oxybutynin and oral tolterodine versus placebo in previously treated patients with urge and mixed urinary incontinence. Urology. 2003;62:237-242.

21. Homma Y, Paick JS, Lee JG, Kawabe K. Clinical efficacy and tolerability of extended-release tolterodine and immediate-release oxybutynin in Japanese and Korean patients with an overactive bladder: a randomized, placebo-controlled trial. BJU Int. 2003;92:741-747.

22. Stach-Lempinen B, Kujansuu E, Laippala P, Metsanoja R. Visual analogue scale, urinary incontinence severity score and 15 D—psychometric testing of three different health-related quality-of-life instruments for urinary incontinent women. Scand J Urol Nephrol. 2001;35:476-483.

23. Hunskaar S, Sandvik H. One hundred and fifty men with urinary incontinence. III. Psychosocial consequences. Scand J Prim Health Care. 1993;11:193-196.

24. Valvanne J, Juva K, Erkinjuntti T, Tilvis R. Major depression in the elderly: a population study in Helsinki. Int Psychogeriatr. 1996;8:437-443.

25. Herzog AR, Fultz NH, Brock BM, Brown MB, Diokno AC. Urinary incontinence and psychological distress among older adults. Psychol Aging. 1988;3:115-121.

26. Bogner HR, Gallo JJ, Sammel MD, Ford DE, Armenian HK, Eaton WW. Urinary incontinence and psychological distress in community-dwelling older adults. J Am Geriatr Soc. 2002;50:489-495.

27. Grimby A, Milsom I, Molander U, Wiklund I, Ekelund P. The influence of urinary incontinence on the quality of life of elderly women. Age Ageing. 1993;22:82-89.

28. Berglund AL, Eisemann M, Lalos O. Personality characteristics of stress incontinent women: a pilot study. J Psychosom Obstet Gynaecol. 1994;15:165-170.

29. Engberg S, Sereika S, Weber E, Engberg R, McDowell BJ, Reynolds CF. Prevalence and recognition of depressive symptoms among homebound older adults with urinary incontinence. J Geriatr Psychiatry Neurol. 2001;14:130-139.

30. Uebersax JS, Wyman JF, Shumaker SA, McClish DK, Fantl JA. Short forms to assess life quality and symptom distress for urinary incontinence in women: the Incontinence Impact Questionnaire and the Urogenital Distress Inventory. Continence Program for Women Research Group. Neurourol Urodyn. 1995;14:131-139.

31. Patrick DL, Martin ML, Bushnell DM, Yalcin I, Wagner TH, Buesching DP. Quality of life of women with urinary incontinence: further development of the incontinence quality of life instrument (I-QOL). Urology. 1999;53:71-76.

32. Patrick DL, Deyo RA. Generic and disease-specific measures in assessing health status and quality of life. Med Care. 1989;27(3 suppl):S217-S232.

33. Hunskaar S, Vinsnes A. The quality of life in women with urinary incontinence as measured by the sickness impact profile. J Am Geriatr Soc. 1991;39:378-382.

34. Zorn BH, Montgomery H, Pieper K, Gray M, Steers WD. Urinary incontinence and depression. J Urol. 1999;162:82-84.

35. Melville JL, Walker E, Katon W, Lentz G, Miller J, Fenner D. Prevalence of comorbid psychiatric illness and its impact on symptom perception, quality of life, and functional status in women with urinary incontinence. Am J Obstet Gynecol. 2002;187:80-87.

36. Lenderking WR, Nackley JF, Anderson RB, Testa MA. A review of the quality-of-life aspects of urinary urge incontinence. Pharmacoeconomics. 1996;9:11-23.

37. Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992;30:473-483.

38. Ware JE Jr. SF-36 Health Survey. Manual & Interpretation Guide. Boston: The Health Institute, New England Medical Center; 1993.

39. Hagglund D, Walker-Engstrom ML, Larsson G, Leppert J. Quality of life and seeking help in women with urinary incontinence. Acta Obstet Gynecol Scand. 2001;80:1051-1055.

40. Kobelt G. Economic considerations and outcome measurement in urge incontinence. Urology. 1997;50:S100-S107.

41. Kutner NG, Schechtman KB, Ory MG, Baker DI. Older adults' perceptions of their health and functioning in relation to sleep disturbance, falling, and urinary incontinence. FICSIT Group. J Am Geriatr Soc. 1994;42:757-762.

42. Stevic MO, Haffer SC, Cooper JK, Adams RW, Michael JA. How healthy are our seniors? Baseline results from the Medicare Health Outcomes Survey. J Clin Outcomes Manage. 2000;7:39-42.

43. Arday DR, Milton MH, Husten CG, et al. Smoking and functional status among Medicare managed care enrollees. Am J Prev Med. 2003;24:234-241.

44. Tarlov AR, Ware JE Jr, Greenfield S, et al. The Medical Outcomes Study. An application of methods for monitoring the results of medical care. JAMA. 1989;262:925-930.

45. McHorney CA, Ware JE Jr, Lu JF, Sherbourne CD. The MOS 36-item Short-Form Health Survey (SF-36): III. Tests of data quality, scaling assumptions, and reliability across diverse patient groups. Med Care. 1994;32:40-66.

46. McHorney CA, Ware JE Jr, Raczek AE. The MOS 36-Item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Med Care. 1993;31:247-263.

47. Gage H, Hendricks A, Zhang S, Kazis L. The relative health related quality of life of veterans with Parkinson's disease. J Neurol Neurosurg Psychiatry. 2003;74:163-169.

48. Kriegsman DM, Penninx BW, van Eijk JT, Boeke AJ, Deeg DJ. Self-reports and general practitioner information on the presence of chronic diseases in community dwelling elderly. A study on the accuracy of patients' self-reports and on determinants of inaccuracy. J Clin Epidemiol. 1996;49:1407-1417.

49. Mitteness LS, Barker JC. Stigmatizing a "normal" condition: urinary incontinence in late life. Med Anthropol Q. 1995;9:188-210.

Copyright AJMC 2006-2020 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
Welcome the the new and improved, the premier managed market network. Tell us about yourself so that we can serve you better.
Sign Up