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Geriatr Gerontol Int 2015; 15: 296–301
ORIGINAL ARTICLE: EPIDEMIOLOGY, CLINICAL PRACTICE AND HEALTH
Association of urinary incontinence with impaired functional status among older people living in a long-term care setting Aih-Fung Chiu,1 Mei-Huang Huang,1 Mei-Hsiu Hsu,2 Ju-Ling Liu1 and Jui-Fang Chiu3 1 Department of Nursing, 2Department of Recreation, Sport, and Health Promotion, Meiho University, Pingtung, Taiwan; and 3Department of State Hospitals, California Health Care Facility, Stockton, California, USA
Aim: To examine the association between functional status and urinary incontinence. Methods: A total of 27 participants with urinary incontinence and 50 participants without urinary incontinence were analyzed at a long-term care setting in Pingtung County, Taiwan, in 2011. The recruitment criteria were age older than 65 years, ability to communicate with the researcher, agreement to participate in the present study and potential ability to complete at least one measurement of functional status. Urinary incontinence was defined as urine leakage at least once a week during the past 4 weeks, whereas functional status was assessed by the body composition (body mass index and waist circumference), upper body strength (grasp test), lower body strength (30-s and 5-times chair stand test), upper body flexibility (back scratch test), lower body flexibility (chair sit-and-reach test) and agility/dynamic balance (8-ft up-and-go test). Results: In univariate analyses, performances on the tests of 5-time chair stand, 30-s chair stand, 8-ft up-and-go, chair sit-and-reach, and grasp were significantly different between the participants with and without urinary incontinence (all P < 0.05). However, after multiple logistical regression adjusting sex, age and chronic illnesses, just two tests, 8-ft up-and-go and chair sit-and-reach, were independent predictors of urinary incontinence. Conclusion: Poor performance on the tests of 8-ft up-and-go and chair sit-and-reach were the predominated risk factors of urinary incontinence. Further studies regarding how to improve the functional status, especially focusing on the function of the lower body, might be required in order to enhance continence care. Geriatr Gerontol Int 2015; 15: 296–301. Keywords: 8-foot up-and-go, chair sit-and-reach, functional status, urinary incontinence.
Introduction With the global population aging, the issue of urinary incontinence (UI) among older people has gained a great deal of attention during recent decades, especially in institutionalized older adults.1–3 The occurrence of UI in institutionalized older adults ranges from 43% to 77% (median 58%).1 UI is a medical condition with multifactorial etiology. Age and gender were important Accepted for publication 21 January 2014. Correspondence: Miss Mei-Huang Huang MEd, Department of Nursing, Meiho University, 23, Pingguang Rd., Neipu, Pingtung, 91202, Taiwan. Email: [email protected] Addresses of the institution at which the work was carried out: Southern region senior Citizens’ Home, Ministry of Health and Welfare, No.1, Hasiang Yang Lane, Jui Kuang Li, Pingtung City, pingtung Hsien, Taiwan
296 |
doi: 10.1111/ggi.12272
risk factors for UI.2,4 Obesity can weaken the pelvic muscle and induce UI.5 Some chronic conditions, such as hypertension, diabetes, stroke, heart disease and arthritis, are associated with the UI.4,6–8 Low physical activity is considered to be another important risk factor of UI.9 Planning physical activity or exercise can increase the functional status and improve the continence care for older adults. Two studies carried out by Ouslander et al. showed that exercise intervention, in which individualized, functionally-oriented endurance and strengthtraining exercises combined with prompted voiding was provided, had significant effects on the results of measurement in terms of endurance, strength and urinary incontinence on institutionalized older adults in the USA.10,11 Kin et al. reported that multidimensional exercise treatment twice a week for 3 months increased the functional status and the cure rate of urine leakage in © 2014 Japan Geriatrics Society
Urinary continence and functional status
community-dwelling older women in Japan.12 However, the association between functional status and UI was not mentioned. Functional status is defined as an individual’s ability to carry out the normal daily activities required to meet basic needs, fulfil usual roles, and maintain health and well-being. The measurement of functional status applied to older adults was increasingly highlighted in the literature. In a longitudinal survey, Huang et al. reported that more than one standard deviation declined on walking speed (6-m course) and five-time chair-stand test (5-time CST) increased the risk of weekly UI in 6361 American older women, in which the OR was 1.31 (95% CI 1.09–1.56) and 1.40 (95% CI 1.19–1.64), respectively.13 The study by Goode et al. showed that American older women with lower scores (took more time) on the 5-time CST were more likely to develop a new monthly UI over the next 3 years (OR 1.30, 95% CI 1.0–1.6), and as did American older men with impaired physical activities measured by the Physical Performance Score (OR 1.2, CI 1.1–1.3, P < 0.001).14 Silva et al. surveyed 100 older adults aged at least 60 years in outpatient clinics, and showed that older adults who presented decreased walking speed had a higher risk of having UI (OR 4.99, 95% CI 1.90– 13.12).15 However, the study of Krause et al. that targeted 1069 non-institutionalized Brazilian women aged 60 years or older showed that all measurements of body mass index (BMI), 6-min walk, arm curl, chair stand (CST), chair sit-and-reach (CSR) and 8-foot up-and-go (8-ft UG) were not significant predictors for UI, excepting large waist circumference (WC).5 It appears that some physical fitness tests are associated with the development of UI in older adults, but discrepancies exist in the literature.5 In addition, from the viewpoints of continence care, it is important to identify the risk factors of UI, so that effective preventions or treatments can be implemented early on to prevent or manage UI. The present study was carried out to determine which functional fitness tests are independent predictors of UI in institutionalized older adults.
Methods Study design and participants The cross-sectional study was carried out in a long-term care setting in Pingtung County, Taiwan, in 2011. The recruitment criteria for participants were: (i) age more than 65 years; (ii) ability to communicate with the researcher; (iii) agreement to participate in the study; and (iv) potential ability to complete at least one measurement of functional status. Considering the safety and feasibility of tests for older adults, we first excluded participants who: (i) reported that they were incapable of open-eye standing for at least 5 min on both feet © 2014 Japan Geriatrics Society
independently (good static balance); (ii) could not follow simple instructions; or (iii) had a known or potential medical diagnosis, such as end-stage renal disease, acute stroke, severe cognitive decline or other severe medical conditions. The present study was approved by the research ethics committee of the local university, and written informed consent was obtained from each participant before the beginning of the interview and testing. All participants volunteered to participate, and were allowed to withdraw at any time as they wished. A total of 89 participants were selected at first. Just 77 participants completed at least one of the functional tests. The dropout rate was 13.5%.
Interview and UI assessment Trained interviewers carried out all in-person face-toface interviews. The eligible participants were asked to complete the structured questionnaire for sociodemographic information (age, sex, marital status and educational level), self-reported chronic medical conditions (hypertension, diabetes, stroke, heart disease and arthritis) and the assessment of UI. The UI was defined as any degree of urine leakage at least once a week during the past 4 weeks, and determined by the standardized question “In the past 4 weeks, how often do you leak urine”, which was derived from the International Consultation Incontinence Questionnaire (ICIQ). The content validity, reproducibility and responsiveness of the ICIQ have been previously investigated.16 All interviews were completed before tests were carried out.
Measurements of functional status Eight tests in six categories were chosen to assess the participants’ performance on functional status. The measurement protocol was established according to the recommendations of the senior fitness test manual described by Rikli and Jones,17–21 as well as other studies.22,23 All measurements took place in a large room (auditorium) at the participants’ facility. Before all measurements, all participants received the same instruction: to do the best that they could, but never push themselves to a point of overexertion or beyond what they thought was safe for them. After 10 min of general warm-up and stretching exercise, participants were sent to one of eight measurement stations to begin their tests. Two research assistants on each station administered the measurements. Test coordinators on the site oversaw the measurement procedures, and rotated the groups of participants from one station to next station as required. These eight measurements of functional status applied in the present study are briefly described here. BMI and WC were measured as body composition. BMI was calculated as weight divided by height | 297
A-F Chiu et al.
squared,17–19 while WC was measured at the narrowest area below the rib cage and above the umbilicus.22 CST was carried out to examine lower body strength and endurance by measuring the participants’ ability to rise from a standard armless chair (43 cm) to a fully extended standing position, and then sitting back down to the chair.17–19 Two measurements of CST were included. First, 5-time CST was utilized to measure the time that the participant took to complete the five cycles of CST.22 Second, 30-s CST was used to count the number of CST cycles completed within 30 s.17–20 The 8-ft UG was used to examine the power, speed, agility and dynamic balance by documenting the shortest time that a participant took to stand up from a seated position, walk 8-ft to and around a cone, and return to the chair.17–19 CSR was implemented to assess lower body flexibility by measuring the distance between the participant’s fingertips and toes of his or her extended leg in a sitting position and hip flexion.17–19,21 Back scratch was used to determine upper body flexibility by gauging how close the tips of the participant’s two middle fingers could be brought together behind his or her back in a standardized sitting position.17–19 Grip test was also used to detect upper body strength by using a dynamometer to assess the maximum isometric muscle strength of the dominant hand and forearm.23
Statistical analysis All data were expressed as means and standard deviation for continuous variables or as frequency and percentages for categorical variables. In comparison between the UI and non-UI groups, Student’s t-tests were used to compare the mean values for continuous variable, and χ2-tests was used to compare the proportions of categorical variables. Multiple logistic regression adjusting age, sex and chronic medical conditions (hypertension, diabetes, heart disease, stroke and arthritis) were used to explore the associations between UI and fitness tests. UI was treated as a dichotomous variable. For all statistical tests, SPSS for Windows 17.0 (SPSS, Chicago, IL, USA) was used, and P < 0.05 was considered statistically significant.
Results Patient characteristics and objective parameters of the two groups A total of 77 valid older participants (mean age 76.87 ± 7.88 years, range 65–105 years), 23 women and 54 men, were selected from a long-term care setting. A total of 28 (35.9%) participants reported that they had UI at least once a week (32.7% for men and 43.5% for
Table 1 Comparison between urinary incontinence group and non-urinary incontinence group in demographic variables Demographic variables
Non-UI (n = 50)
UI (n = 27)
P-value†
Age, years (mean ± SD) Age range (years) 65–74 75–84 ≥85 Sex Male Female Educational level Less than high school Junior high school Higher than Junior high school Chronic medical conditions Hypertension Diabetes Stroke history Heart disease‡ Arthritis
75.3 ± 6.52
78.7 ± 8.0
0.045*
24 (48.0) 22 (44.0) 4 (8.0)
9 (33.3) 11 (40.7) 7 (25.9)
0.088
37 (74.0) 13 (26.0)
17 (63.0) 10 (37.0)
0.313
44 (88.0) 2 (4.0) 4 (8.3)
24 (88.9) 2 (7.4) 1 (3.7)
0.640
23 (46.0) 10 (20.0) 2 (4.0) 15 (30.0) 18 (36.0)
20 (74.1) 7 (25.9) 6 (22.2) 9 (33.3) 13 (46.4)
0.018* 0.550 0.012* 0.763 0.300
*P < 0.05. †χ2-tests. ‡Coronary artery bypass, angina, myocardial infarction or congestive heart failure were included. SD, standard deviation; UI, urinary incontinence.
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Urinary continence and functional status
Table 2 Comparison of functional measurements in participants with and without urinary incontinence Functional measurements Body component Bodyweight, kg (n = 77) BMI, kg/m2 (n = 77) Waist circumference, cm (n = 77) 5-times chair stands test, s (n = 69) 30-second chair stand test, repetitions (n = 69) 8-ft up-and-go test, s (n = 77) Chair sit-and-reach test, cm Right (n = 67) Left (n = 64) Back scratch test, cm Right (n = 77) Left (n = 77) Grip test, kg (dominant hand, n = 77)
Non-UI group
P-value†
UI group
57.7 ± 9.3 (n = 50) 23.6 ± 3.4 (n = 50) 87.7 ± 11.5 (n = 50) 16.5 ± 5.2 (n = 48) 10.3 ± 3.9 (n = 48) 12.0 ± 4.1 (n = 50)
57.7 ± 11.3 (n = 27) 24.6 ± 4.9 (n = 27) 90.6 ± 12.0 (n = 27) 19.9 ± 5.6 (n = 21) 8.0 ± 2.5 (n = 21) 16.3 ± 5.98 (n = 27)
0.998 0.268 0.298 0.017* 0.017* 0.05), suggesting that they were independent predictors of UI. This result was partially supported by two studies carried out by Huang et al. and Silva et al., in which the significant association between the decline of walking speed and UI was stated.13,15 However, the result regarding WC and 5times CST in the present investigation differed from other previous studies, in which a significant association of UI with large WC5 and slower time of 5-times CST13,14 were reported. The results show that poor performance on the tests of 8-ft UG and CSR might predispose UI. The test of 8-ft UG aims to measure the function of dynamic balance and mobility, whereas the test of CSR serves as a measurement for hamstring and low back flexibility. Both the 8-ft UG and CSR contribute to good lower body strength and power, and also can provide the ability of gait or mobility. The decline of mobility related to the functional decline of 8-ft UG and CSR might be the reason for development of UI as a result of inaccessible toilets, inability to remove clothing in time, uncoordinated pelvic floor muscle or other multifactorial causes. A closed association between the pelvic floor muscles and abdominal muscles has also been described in the literature.24–26 The pelvic floor muscles act as part of the integrated abdominopelvic unit. From this point of view, it is convincing that good strength and coordination of the trunk or abdominal muscle can initiate an efficient contraction of the pelvic floor muscle, which then directly prevents UI episodes. The univariate analyses showed that older adults with UI had poorer performance on the tests of 5-time CST, 30-s CST and grip than those without UI, but these statistical significances disappeared in multivariate analyses with controlled for sex, age and chronic medical conditions. Other significant tests, such as BMI, WC and back scratch, were also not significant determinants of UI. The functional difference between these tests and 8-ft UG and CSR tests could explain the dissimilarity in the present results. Some limitations should be considered within the present study. First, several chronic medical disorders including prostatic hypertrophy and neurogenic bladder that could also be the causes of UI or other lower urinary tract symptoms (LUTS) are not mentioned in the present study. Although the real pathophysiological mechanisms remain unclear, it is thought that the progressive prostate hypertrophy or an unobstructed, but unstable or poorly contracting bladder, are the major causes that lead to UI or LUTS in men.27,28 Neurogenic 300 |
bladder secondary to stroke or other nervous disorders involving the control of micturition might also cause UI or other LUTS.29 However, these medical data, including the severity of stroke, were not available in the present study setting, but they deserve additional investigation in future studies. Second, information derived from studies with cross-sectional and non-experimental design should be interpreted carefully before a causal relationship can be claimed. Third, all participants in the present study were older adults institutionalized in a long-term care setting, and some participants only completed part of the functional measurements because of being either incapable or unwilling to finish these measurements. Therefore, the generalization of the current results might be limited, and advanced investigations are required in the future to consolidate these relationships between functional measurements and UI. In conclusion, the results of the present study show that poor functional performance on the measurements of 8-ft UG and CSR are the predominant determining factors of UI for institutionalized older adults, implying that the function of the lower body has a potential role in the development of UI. Thus, healthcare providers need to be aware of an increased risk of UI among older people with impaired function of the lower body, and provide further assessments and treatment to improve continence care.
Acknowledgments We thank all who collaborated with us. Financial support for this study was obtained in part from Meiho University, Ping County, Taiwan.
Disclosure statement The authors declare no conflict of interest.
References 1 Offermans MPW, Moulin MFMTD, Hamers JPH, Dassen T, Halfens RJG. Prevalence of urinary incontinence and associated risk factors in nursing home residents: a systematic review. Neurourol Urodyn 2009; 28: 288–294. 2 Aggazzotti G, Pesce F, Grassi D et al. Prevalence of urinary incontinence among institutionalized patients: a crosssectional epidemiologic study in a midsized city in northern Italy. Urology 2000; 56: 245–249. 3 Durrant J, Snape J. Urinary incontinence in nursing homes for older people. Age Ageing 2003; 32: 12–18. 4 DuBeau CE, Kuchel GA, Johnson Ii T, Palmer MH, Wagg A. Incontinence in the frail elderly: report from the 4th international consultation on incontinence. Neurourol Urodyn 2010; 29: 165–178. 5 Krause MP, Albert SM, Elsangedy HM, Krinski K, Goss FL, daSilva SG. Urinary incontinence and waist circumference in older women. Age Ageing 2010; 39: 69–73. © 2014 Japan Geriatrics Society
Urinary continence and functional status 6 Chiu AF, Huang MH, Wang CC, Kuo HC. Higher glycosylated hemoglobin levels increase the risk of overactive bladder syndrome in patients with type 2 diabetes mellitus. Int J Urol 2012; 19: 995–1001. 7 Jørgensen L, Engstad T, Jacobsen BK. Self-reported urinary incontinence in noninstitutionalized long-term stroke survivors: a population-based study. Arch Phys Med Rehabil 2005; 86: 416–420. 8 Jackson RA, Vittinghoff E, Kanaya AM et al. Urinary incontinence in elderly women: findings from the Health, Aging, and Body Composition Study. Obstet Gynecol 2004; 104: 301–307. 9 Kikuchi A, Niu K, Ikeda Y et al. Association between physical activity and urinary incontinence in a communitybased elderly population aged 70 years and over. Eur Urol 2007; 52: 868–875. 10 Ouslander JG, Griffiths PC, McConnell E, Riolo L, Kutner M, Schnelle J. Functional Incidental Training: applicability and feasibility in the Veterans Affairs nursing home patient population. J Am Med Dir Assoc 2005; 6: 121–127. 11 Ouslander JG, Griffiths PC, McConnell E, Riolo L, Kutner M, Schnelle J. Functional incidental training: a randomized, controlled, crossover trial in veterans affairs nursing homes. J Am Med Dir Assoc 2005; 53: 1091–1100. 12 Kim H, Yoshida H, Suzuki T. The effects of multidimensional exercise treatment on community-dwelling elderly Japanese women with stress, urge, and mixed urinary incontinence: a randomized controlled trial. Int J Nurs Stud 2011; 48: 1165–1172. 13 Huang AJ, Brown JS, Thom DH, Fink HA, Yaffe K, Group ftSoOFR. Urinary incontinence in older communitydwelling women: the role of cognitive and physical function decline. Obstet Gynecol 2007; 109: 909–916. 14 Goode PS, Burgio KL, Redden DT et al. Population Based Study of Incidence and Predictors of Urinary Incontinence in Black and White Older Adults. J Urol 2008; 179: 1449– 1454. 15 da Silva VA, de Souza KL, D’Elboux MJ. Urinary incontinence and the criteria of frailness among the elderly outpatients. Rev Esc Enferm USP 2011; 45: 670–676. 16 Avery K, Donovan J, Peters TJ, Shaw C, Gotoh M, Abrams P. ICIQ: a brief and robust measure for evaluating the symptoms and impact of urinary incontinence. Eur Urol 2004; 23: 322–330. 17 Rikli RE, Jones CJ. Development and validation of a functional fitness test for community-residing older adults. J Aging Phys Act 1999; 7: 129–161.
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18 Rikli RE, Jones CJ. Functional fitness normative scores for community-residing older adults, ages 60–94. J Aging Phys Act 1999; 7: 162–181. 19 Rikli RE, Jones CJ. Senir Fitness Test Manual. Champaign, IL: Human Kinetics, 2001. 20 Jones CJ, Rikli RE, Beam WC. A 30-s chair-stand test as a measure of lower body strength in community-residing older adults. Res Q Exerc Sport 1999; 70: 113–119. 21 Jones CJ, Rikli RE, Max J, Noffal G. The reliability and validity of a chair sit-and-reach test as a measure of hamstring flexibility in older adults. Res Q Exerc Sport 1998; 69: 338–343. 22 Whitney SL, Wrisley DM, Marchetti GF, Gee MA, Redfern MS, Furman JM. Clinical measurement of sit-to-stand performance in people with balance disorders: validity of data for the five-times-sit-to-stand test. Phys Ther 2005; 85: 1034–1045. 23 Chen HT, Lin CH, Yu LH. Normative physical fitness scores for community-dwelling older adults. J Nurs Res 2009; 17: 30–41. 24 Sapsford RR, Hodges PW, Richardson CA, Cooper DH, Markwell SJ, Jull GA. Co-activation of the abdominal and pelvic floor muscles during voluntary exercises. Neurourol Urodyn 2001; 20: 31–42. 25 Madill SJ, McLean L. Relationship between abdominal and pelvic floor muscle activation and intravaginal pressure during pelvic floor muscle contractions in healthy continent women. Neurourol Urodyn 2006; 25: 722–730. 26 Hung HC, Hsiao SM, Chih SY, Lin HH, Tsauo JY. An alternative intervention for urinary incontinence: retraining diaphragmatic, deep abdominal and pelvic floor muscle coordinated function. Man Ther 2010; 15: 273–279. 27 Oelke M, Baard J, Wijkstra H, de la Rosette JJ, Jonas U, Höfner K. Age and Bladder Outlet Obstruction Are Independently Associated with Detrusor Overactivity in Patients with Benign Prostatic Hyperplasia. Eur Urol 2008; 54: 419–426. 28 Wadie BS, Ebrahim E-HE, Gomha MA. The relationship of detrusor instability and symptoms with objective parameters used for diagnosing bladder outlet obstruction: a prospective study. J Urol 2002; 168: 132–134. 29 Kuei CH, Liao CH, Kuo HC. Urodynamic characteristics of voiding dysfunction in patients with a cerebrovascular accident. Urol Sci 2013; 24: 21–23.
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Geriatr Gerontol Int 2015; 15: 296–301
ORIGINAL ARTICLE: EPIDEMIOLOGY, CLINICAL PRACTICE AND HEALTH
Association of urinary incontinence with impaired functional status among older people living in a long-term care setting Aih-Fung Chiu,1 Mei-Huang Huang,1 Mei-Hsiu Hsu,2 Ju-Ling Liu1 and Jui-Fang Chiu3 1 Department of Nursing, 2Department of Recreation, Sport, and Health Promotion, Meiho University, Pingtung, Taiwan; and 3Department of State Hospitals, California Health Care Facility, Stockton, California, USA
Aim: To examine the association between functional status and urinary incontinence. Methods: A total of 27 participants with urinary incontinence and 50 participants without urinary incontinence were analyzed at a long-term care setting in Pingtung County, Taiwan, in 2011. The recruitment criteria were age older than 65 years, ability to communicate with the researcher, agreement to participate in the present study and potential ability to complete at least one measurement of functional status. Urinary incontinence was defined as urine leakage at least once a week during the past 4 weeks, whereas functional status was assessed by the body composition (body mass index and waist circumference), upper body strength (grasp test), lower body strength (30-s and 5-times chair stand test), upper body flexibility (back scratch test), lower body flexibility (chair sit-and-reach test) and agility/dynamic balance (8-ft up-and-go test). Results: In univariate analyses, performances on the tests of 5-time chair stand, 30-s chair stand, 8-ft up-and-go, chair sit-and-reach, and grasp were significantly different between the participants with and without urinary incontinence (all P < 0.05). However, after multiple logistical regression adjusting sex, age and chronic illnesses, just two tests, 8-ft up-and-go and chair sit-and-reach, were independent predictors of urinary incontinence. Conclusion: Poor performance on the tests of 8-ft up-and-go and chair sit-and-reach were the predominated risk factors of urinary incontinence. Further studies regarding how to improve the functional status, especially focusing on the function of the lower body, might be required in order to enhance continence care. Geriatr Gerontol Int 2015; 15: 296–301. Keywords: 8-foot up-and-go, chair sit-and-reach, functional status, urinary incontinence.
Introduction With the global population aging, the issue of urinary incontinence (UI) among older people has gained a great deal of attention during recent decades, especially in institutionalized older adults.1–3 The occurrence of UI in institutionalized older adults ranges from 43% to 77% (median 58%).1 UI is a medical condition with multifactorial etiology. Age and gender were important Accepted for publication 21 January 2014. Correspondence: Miss Mei-Huang Huang MEd, Department of Nursing, Meiho University, 23, Pingguang Rd., Neipu, Pingtung, 91202, Taiwan. Email: [email protected] Addresses of the institution at which the work was carried out: Southern region senior Citizens’ Home, Ministry of Health and Welfare, No.1, Hasiang Yang Lane, Jui Kuang Li, Pingtung City, pingtung Hsien, Taiwan
296 |
doi: 10.1111/ggi.12272
risk factors for UI.2,4 Obesity can weaken the pelvic muscle and induce UI.5 Some chronic conditions, such as hypertension, diabetes, stroke, heart disease and arthritis, are associated with the UI.4,6–8 Low physical activity is considered to be another important risk factor of UI.9 Planning physical activity or exercise can increase the functional status and improve the continence care for older adults. Two studies carried out by Ouslander et al. showed that exercise intervention, in which individualized, functionally-oriented endurance and strengthtraining exercises combined with prompted voiding was provided, had significant effects on the results of measurement in terms of endurance, strength and urinary incontinence on institutionalized older adults in the USA.10,11 Kin et al. reported that multidimensional exercise treatment twice a week for 3 months increased the functional status and the cure rate of urine leakage in © 2014 Japan Geriatrics Society
Urinary continence and functional status
community-dwelling older women in Japan.12 However, the association between functional status and UI was not mentioned. Functional status is defined as an individual’s ability to carry out the normal daily activities required to meet basic needs, fulfil usual roles, and maintain health and well-being. The measurement of functional status applied to older adults was increasingly highlighted in the literature. In a longitudinal survey, Huang et al. reported that more than one standard deviation declined on walking speed (6-m course) and five-time chair-stand test (5-time CST) increased the risk of weekly UI in 6361 American older women, in which the OR was 1.31 (95% CI 1.09–1.56) and 1.40 (95% CI 1.19–1.64), respectively.13 The study by Goode et al. showed that American older women with lower scores (took more time) on the 5-time CST were more likely to develop a new monthly UI over the next 3 years (OR 1.30, 95% CI 1.0–1.6), and as did American older men with impaired physical activities measured by the Physical Performance Score (OR 1.2, CI 1.1–1.3, P < 0.001).14 Silva et al. surveyed 100 older adults aged at least 60 years in outpatient clinics, and showed that older adults who presented decreased walking speed had a higher risk of having UI (OR 4.99, 95% CI 1.90– 13.12).15 However, the study of Krause et al. that targeted 1069 non-institutionalized Brazilian women aged 60 years or older showed that all measurements of body mass index (BMI), 6-min walk, arm curl, chair stand (CST), chair sit-and-reach (CSR) and 8-foot up-and-go (8-ft UG) were not significant predictors for UI, excepting large waist circumference (WC).5 It appears that some physical fitness tests are associated with the development of UI in older adults, but discrepancies exist in the literature.5 In addition, from the viewpoints of continence care, it is important to identify the risk factors of UI, so that effective preventions or treatments can be implemented early on to prevent or manage UI. The present study was carried out to determine which functional fitness tests are independent predictors of UI in institutionalized older adults.
Methods Study design and participants The cross-sectional study was carried out in a long-term care setting in Pingtung County, Taiwan, in 2011. The recruitment criteria for participants were: (i) age more than 65 years; (ii) ability to communicate with the researcher; (iii) agreement to participate in the study; and (iv) potential ability to complete at least one measurement of functional status. Considering the safety and feasibility of tests for older adults, we first excluded participants who: (i) reported that they were incapable of open-eye standing for at least 5 min on both feet © 2014 Japan Geriatrics Society
independently (good static balance); (ii) could not follow simple instructions; or (iii) had a known or potential medical diagnosis, such as end-stage renal disease, acute stroke, severe cognitive decline or other severe medical conditions. The present study was approved by the research ethics committee of the local university, and written informed consent was obtained from each participant before the beginning of the interview and testing. All participants volunteered to participate, and were allowed to withdraw at any time as they wished. A total of 89 participants were selected at first. Just 77 participants completed at least one of the functional tests. The dropout rate was 13.5%.
Interview and UI assessment Trained interviewers carried out all in-person face-toface interviews. The eligible participants were asked to complete the structured questionnaire for sociodemographic information (age, sex, marital status and educational level), self-reported chronic medical conditions (hypertension, diabetes, stroke, heart disease and arthritis) and the assessment of UI. The UI was defined as any degree of urine leakage at least once a week during the past 4 weeks, and determined by the standardized question “In the past 4 weeks, how often do you leak urine”, which was derived from the International Consultation Incontinence Questionnaire (ICIQ). The content validity, reproducibility and responsiveness of the ICIQ have been previously investigated.16 All interviews were completed before tests were carried out.
Measurements of functional status Eight tests in six categories were chosen to assess the participants’ performance on functional status. The measurement protocol was established according to the recommendations of the senior fitness test manual described by Rikli and Jones,17–21 as well as other studies.22,23 All measurements took place in a large room (auditorium) at the participants’ facility. Before all measurements, all participants received the same instruction: to do the best that they could, but never push themselves to a point of overexertion or beyond what they thought was safe for them. After 10 min of general warm-up and stretching exercise, participants were sent to one of eight measurement stations to begin their tests. Two research assistants on each station administered the measurements. Test coordinators on the site oversaw the measurement procedures, and rotated the groups of participants from one station to next station as required. These eight measurements of functional status applied in the present study are briefly described here. BMI and WC were measured as body composition. BMI was calculated as weight divided by height | 297
A-F Chiu et al.
squared,17–19 while WC was measured at the narrowest area below the rib cage and above the umbilicus.22 CST was carried out to examine lower body strength and endurance by measuring the participants’ ability to rise from a standard armless chair (43 cm) to a fully extended standing position, and then sitting back down to the chair.17–19 Two measurements of CST were included. First, 5-time CST was utilized to measure the time that the participant took to complete the five cycles of CST.22 Second, 30-s CST was used to count the number of CST cycles completed within 30 s.17–20 The 8-ft UG was used to examine the power, speed, agility and dynamic balance by documenting the shortest time that a participant took to stand up from a seated position, walk 8-ft to and around a cone, and return to the chair.17–19 CSR was implemented to assess lower body flexibility by measuring the distance between the participant’s fingertips and toes of his or her extended leg in a sitting position and hip flexion.17–19,21 Back scratch was used to determine upper body flexibility by gauging how close the tips of the participant’s two middle fingers could be brought together behind his or her back in a standardized sitting position.17–19 Grip test was also used to detect upper body strength by using a dynamometer to assess the maximum isometric muscle strength of the dominant hand and forearm.23
Statistical analysis All data were expressed as means and standard deviation for continuous variables or as frequency and percentages for categorical variables. In comparison between the UI and non-UI groups, Student’s t-tests were used to compare the mean values for continuous variable, and χ2-tests was used to compare the proportions of categorical variables. Multiple logistic regression adjusting age, sex and chronic medical conditions (hypertension, diabetes, heart disease, stroke and arthritis) were used to explore the associations between UI and fitness tests. UI was treated as a dichotomous variable. For all statistical tests, SPSS for Windows 17.0 (SPSS, Chicago, IL, USA) was used, and P < 0.05 was considered statistically significant.
Results Patient characteristics and objective parameters of the two groups A total of 77 valid older participants (mean age 76.87 ± 7.88 years, range 65–105 years), 23 women and 54 men, were selected from a long-term care setting. A total of 28 (35.9%) participants reported that they had UI at least once a week (32.7% for men and 43.5% for
Table 1 Comparison between urinary incontinence group and non-urinary incontinence group in demographic variables Demographic variables
Non-UI (n = 50)
UI (n = 27)
P-value†
Age, years (mean ± SD) Age range (years) 65–74 75–84 ≥85 Sex Male Female Educational level Less than high school Junior high school Higher than Junior high school Chronic medical conditions Hypertension Diabetes Stroke history Heart disease‡ Arthritis
75.3 ± 6.52
78.7 ± 8.0
0.045*
24 (48.0) 22 (44.0) 4 (8.0)
9 (33.3) 11 (40.7) 7 (25.9)
0.088
37 (74.0) 13 (26.0)
17 (63.0) 10 (37.0)
0.313
44 (88.0) 2 (4.0) 4 (8.3)
24 (88.9) 2 (7.4) 1 (3.7)
0.640
23 (46.0) 10 (20.0) 2 (4.0) 15 (30.0) 18 (36.0)
20 (74.1) 7 (25.9) 6 (22.2) 9 (33.3) 13 (46.4)
0.018* 0.550 0.012* 0.763 0.300
*P < 0.05. †χ2-tests. ‡Coronary artery bypass, angina, myocardial infarction or congestive heart failure were included. SD, standard deviation; UI, urinary incontinence.
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© 2014 Japan Geriatrics Society
Urinary continence and functional status
Table 2 Comparison of functional measurements in participants with and without urinary incontinence Functional measurements Body component Bodyweight, kg (n = 77) BMI, kg/m2 (n = 77) Waist circumference, cm (n = 77) 5-times chair stands test, s (n = 69) 30-second chair stand test, repetitions (n = 69) 8-ft up-and-go test, s (n = 77) Chair sit-and-reach test, cm Right (n = 67) Left (n = 64) Back scratch test, cm Right (n = 77) Left (n = 77) Grip test, kg (dominant hand, n = 77)
Non-UI group
P-value†
UI group
57.7 ± 9.3 (n = 50) 23.6 ± 3.4 (n = 50) 87.7 ± 11.5 (n = 50) 16.5 ± 5.2 (n = 48) 10.3 ± 3.9 (n = 48) 12.0 ± 4.1 (n = 50)
57.7 ± 11.3 (n = 27) 24.6 ± 4.9 (n = 27) 90.6 ± 12.0 (n = 27) 19.9 ± 5.6 (n = 21) 8.0 ± 2.5 (n = 21) 16.3 ± 5.98 (n = 27)
0.998 0.268 0.298 0.017* 0.017* 0.05), suggesting that they were independent predictors of UI. This result was partially supported by two studies carried out by Huang et al. and Silva et al., in which the significant association between the decline of walking speed and UI was stated.13,15 However, the result regarding WC and 5times CST in the present investigation differed from other previous studies, in which a significant association of UI with large WC5 and slower time of 5-times CST13,14 were reported. The results show that poor performance on the tests of 8-ft UG and CSR might predispose UI. The test of 8-ft UG aims to measure the function of dynamic balance and mobility, whereas the test of CSR serves as a measurement for hamstring and low back flexibility. Both the 8-ft UG and CSR contribute to good lower body strength and power, and also can provide the ability of gait or mobility. The decline of mobility related to the functional decline of 8-ft UG and CSR might be the reason for development of UI as a result of inaccessible toilets, inability to remove clothing in time, uncoordinated pelvic floor muscle or other multifactorial causes. A closed association between the pelvic floor muscles and abdominal muscles has also been described in the literature.24–26 The pelvic floor muscles act as part of the integrated abdominopelvic unit. From this point of view, it is convincing that good strength and coordination of the trunk or abdominal muscle can initiate an efficient contraction of the pelvic floor muscle, which then directly prevents UI episodes. The univariate analyses showed that older adults with UI had poorer performance on the tests of 5-time CST, 30-s CST and grip than those without UI, but these statistical significances disappeared in multivariate analyses with controlled for sex, age and chronic medical conditions. Other significant tests, such as BMI, WC and back scratch, were also not significant determinants of UI. The functional difference between these tests and 8-ft UG and CSR tests could explain the dissimilarity in the present results. Some limitations should be considered within the present study. First, several chronic medical disorders including prostatic hypertrophy and neurogenic bladder that could also be the causes of UI or other lower urinary tract symptoms (LUTS) are not mentioned in the present study. Although the real pathophysiological mechanisms remain unclear, it is thought that the progressive prostate hypertrophy or an unobstructed, but unstable or poorly contracting bladder, are the major causes that lead to UI or LUTS in men.27,28 Neurogenic 300 |
bladder secondary to stroke or other nervous disorders involving the control of micturition might also cause UI or other LUTS.29 However, these medical data, including the severity of stroke, were not available in the present study setting, but they deserve additional investigation in future studies. Second, information derived from studies with cross-sectional and non-experimental design should be interpreted carefully before a causal relationship can be claimed. Third, all participants in the present study were older adults institutionalized in a long-term care setting, and some participants only completed part of the functional measurements because of being either incapable or unwilling to finish these measurements. Therefore, the generalization of the current results might be limited, and advanced investigations are required in the future to consolidate these relationships between functional measurements and UI. In conclusion, the results of the present study show that poor functional performance on the measurements of 8-ft UG and CSR are the predominant determining factors of UI for institutionalized older adults, implying that the function of the lower body has a potential role in the development of UI. Thus, healthcare providers need to be aware of an increased risk of UI among older people with impaired function of the lower body, and provide further assessments and treatment to improve continence care.
Acknowledgments We thank all who collaborated with us. Financial support for this study was obtained in part from Meiho University, Ping County, Taiwan.
Disclosure statement The authors declare no conflict of interest.
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