DOI: 10.1111/ajag.12049
Invited Commentary Evidence of limited evidence: A systematic review of continence management interventions to reduce falls in older adults Joan Ostaszkiewicz School of Nursing and Midwifery, Deakin University, Melbourne, Victoria, Australia
Falls are common in older adults. Approximately one in three people over the age of 65 experiences at least one fall each year [1] and multiple factors are implicated, including environmental, social and physiological factors. Incontinence is also more common in older people than in the younger age group. Forty-three per cent of Australian women and 7% of Australian men over the age of 60 report symptoms of stress incontinence compared with 18% of women and 1% of men aged 15–39 years [2]. The prevalence rate of incontinence is much higher in residential aged care facilities, where 70.9% of residents have urinary or faecal incontinence or symptoms of both [3]. The authors of the systematic review titled, ‘Do continence management strategies reduce falls? A systematic review’, rightly point out that there are a number of studies that show urinary incontinence is a risk factor for falls, and a previous systematic review showed that the odds of falling in the presence of urge or mixed incontinence were substantially higher, and symptoms of overactive bladder but not stress urinary incontinence were associated with falls [4]. Therefore, it stands to reason that interventions to reduce an older person’s symptoms of an overactive bladder should also reduce their risk of falling. The authors conducted a systematic review of the literature to identify continence management interventions in older adults (from community and residential care settings) that are effective in decreasing falls. Systematic reviews provide health providers, researchers and policy-makers with an efficient method to summarise existing information in order to make evidence-based decisions. Because systematic reviews require a systematic and explicit methodology, they minimise the uncertainty associated with findings from traditional narrative reviews. The authors adhered to established systematic review methodology, in so far as they developed and documented clear objectives, a comprehensive search strategy, an explicit appraisal of the findings, and provided information about how evidence from each study was combined. One of the noteworthy features of the review was that the eligibility criteria were designed to be broad enough to Correspondence to: Ms Joan Ostaszkiewicz, School of Nursing and Midwifery, Deakin University. Email: [email protected] 200
identify any/all continence management interventions that included falls as an outcome of interest among older adults with any type of urinary incontinence and who lived in either a community or residential aged care setting. Given the risk of falling varies with different types of incontinence, the lack of reporting and analyses by incontinence symptoms is a limitation of the review. Specific interventions aimed at ameliorating symptoms of overactive bladder are quite different from those that might impact on stress urinary incontinence. Another feature of the inclusion criteria was that the studies were not limited to randomised controlled design methodologies. Despite using broad criteria, only four studies were found eligible. These studies addressed diverse continence management interventions: two studies described the effect of pharmacological agents; one described the effect of a twohourly daytime toileting assistance program combined with a low-intensity exercise program, and the fourth study evaluated an individualised treatment plan from a range of interventions including a toileting assistance program, dietary changes, medication, and pelvic floor muscle training with or without biofeedback administered by registered nurses and supervised by a continence specialist nurse. Studies also differed in terms of the population and setting. Three of the trials were conducted in long-term care facilities in the USA, and the fourth trial involved a populationbased sample of patients 66 years of age or older in Ontario, Canada, who were hospitalised for a fall within 90 days of receiving anticholinergic medication for their incontinence. Therefore, the main methodological limitations of the review are the heterogeneity of studies and the small number of studies, which limits the consistency of the findings and their generalisability. Nevertheless, the review offers evidence of a major gap in research, and shows the need for well-designed intervention studies that specifically target continence as one of the components and include falls as a primary outcome. As the multifactorial nature of the interventions and the lack of reporting made it difficult to isolate the effect of the continence management strategy on falls, the authors also recommended that researchers clearly document what interventions are undertaken to determine the effectiveness of specific interventions. The difficulty is that older people who fall or are incontinent often have impairments in multiple domains that decrease their compensatory ability. Indeed, older people’s risks of falling and of developing incontinence are a result of a complex interplay of multiple factors [5]. Australasian Journal on Ageing, Vol 32 No 4 December 2013, 200–201 © 2013 ACOTA
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E v i d e n c e
Therefore, interventions designed to target falls and incontinence in older people are, by necessity, characterised by a level of complexity that is difficult to quantify. Unravelling the complex relationship between falls and incontinence is compounded by the fact that not only is incontinence an identified risk factor for a fall, but a fall that results in a loss of mobility and subsequent functional decline is a risk factor for incontinence.
References 1
2 3
4 5
o f
l i m i t e d
e v i d e n c e
Avery A, Taylor A, Gill T. Incontinence in South Australia: Prevalence, Risks and Priorities. Adelaide: Population Research and Outcomes Studies Unit, South Australian Department of Health, 2004. Access Economics. The economic impact of incontinence in Australia. 2011 [Cited 6 February 2013.] Available from URL: http://www .continence.org.au/news.php/72/the-economic-impact-of-incontinence -in-australia Chiarelli PE, Mackenzie LA, Osmotherly PG. Urinary incontinence is associated with an increase in falls: A systematic review. Australian Journal of Physiotherapy 2009; 55: 89–95. Tinetti M, Inouye S, Gill T, Doucette J. Shared risk factors for falls, incontinence, and functional dependence. Unifying the approach to geriatric syndromes. Journal of the American Medical Association 1995; 273: 1348–1353.
Watson W, Clapperton A, Mitchell R. 2010. The incidence and cost of falls injury among older people in New South Wales 2006/2007. NSW Department of Health.
Australasian Journal on Ageing, Vol 32 No 4 December 2013, 200–201 © 2013 ACOTA
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Invited Commentary Evidence of limited evidence: A systematic review of continence management interventions to reduce falls in older adults Joan Ostaszkiewicz School of Nursing and Midwifery, Deakin University, Melbourne, Victoria, Australia
Falls are common in older adults. Approximately one in three people over the age of 65 experiences at least one fall each year [1] and multiple factors are implicated, including environmental, social and physiological factors. Incontinence is also more common in older people than in the younger age group. Forty-three per cent of Australian women and 7% of Australian men over the age of 60 report symptoms of stress incontinence compared with 18% of women and 1% of men aged 15–39 years [2]. The prevalence rate of incontinence is much higher in residential aged care facilities, where 70.9% of residents have urinary or faecal incontinence or symptoms of both [3]. The authors of the systematic review titled, ‘Do continence management strategies reduce falls? A systematic review’, rightly point out that there are a number of studies that show urinary incontinence is a risk factor for falls, and a previous systematic review showed that the odds of falling in the presence of urge or mixed incontinence were substantially higher, and symptoms of overactive bladder but not stress urinary incontinence were associated with falls [4]. Therefore, it stands to reason that interventions to reduce an older person’s symptoms of an overactive bladder should also reduce their risk of falling. The authors conducted a systematic review of the literature to identify continence management interventions in older adults (from community and residential care settings) that are effective in decreasing falls. Systematic reviews provide health providers, researchers and policy-makers with an efficient method to summarise existing information in order to make evidence-based decisions. Because systematic reviews require a systematic and explicit methodology, they minimise the uncertainty associated with findings from traditional narrative reviews. The authors adhered to established systematic review methodology, in so far as they developed and documented clear objectives, a comprehensive search strategy, an explicit appraisal of the findings, and provided information about how evidence from each study was combined. One of the noteworthy features of the review was that the eligibility criteria were designed to be broad enough to Correspondence to: Ms Joan Ostaszkiewicz, School of Nursing and Midwifery, Deakin University. Email: [email protected] 200
identify any/all continence management interventions that included falls as an outcome of interest among older adults with any type of urinary incontinence and who lived in either a community or residential aged care setting. Given the risk of falling varies with different types of incontinence, the lack of reporting and analyses by incontinence symptoms is a limitation of the review. Specific interventions aimed at ameliorating symptoms of overactive bladder are quite different from those that might impact on stress urinary incontinence. Another feature of the inclusion criteria was that the studies were not limited to randomised controlled design methodologies. Despite using broad criteria, only four studies were found eligible. These studies addressed diverse continence management interventions: two studies described the effect of pharmacological agents; one described the effect of a twohourly daytime toileting assistance program combined with a low-intensity exercise program, and the fourth study evaluated an individualised treatment plan from a range of interventions including a toileting assistance program, dietary changes, medication, and pelvic floor muscle training with or without biofeedback administered by registered nurses and supervised by a continence specialist nurse. Studies also differed in terms of the population and setting. Three of the trials were conducted in long-term care facilities in the USA, and the fourth trial involved a populationbased sample of patients 66 years of age or older in Ontario, Canada, who were hospitalised for a fall within 90 days of receiving anticholinergic medication for their incontinence. Therefore, the main methodological limitations of the review are the heterogeneity of studies and the small number of studies, which limits the consistency of the findings and their generalisability. Nevertheless, the review offers evidence of a major gap in research, and shows the need for well-designed intervention studies that specifically target continence as one of the components and include falls as a primary outcome. As the multifactorial nature of the interventions and the lack of reporting made it difficult to isolate the effect of the continence management strategy on falls, the authors also recommended that researchers clearly document what interventions are undertaken to determine the effectiveness of specific interventions. The difficulty is that older people who fall or are incontinent often have impairments in multiple domains that decrease their compensatory ability. Indeed, older people’s risks of falling and of developing incontinence are a result of a complex interplay of multiple factors [5]. Australasian Journal on Ageing, Vol 32 No 4 December 2013, 200–201 © 2013 ACOTA
bs_bs_banner
E v i d e n c e
Therefore, interventions designed to target falls and incontinence in older people are, by necessity, characterised by a level of complexity that is difficult to quantify. Unravelling the complex relationship between falls and incontinence is compounded by the fact that not only is incontinence an identified risk factor for a fall, but a fall that results in a loss of mobility and subsequent functional decline is a risk factor for incontinence.
References 1
2 3
4 5
o f
l i m i t e d
e v i d e n c e
Avery A, Taylor A, Gill T. Incontinence in South Australia: Prevalence, Risks and Priorities. Adelaide: Population Research and Outcomes Studies Unit, South Australian Department of Health, 2004. Access Economics. The economic impact of incontinence in Australia. 2011 [Cited 6 February 2013.] Available from URL: http://www .continence.org.au/news.php/72/the-economic-impact-of-incontinence -in-australia Chiarelli PE, Mackenzie LA, Osmotherly PG. Urinary incontinence is associated with an increase in falls: A systematic review. Australian Journal of Physiotherapy 2009; 55: 89–95. Tinetti M, Inouye S, Gill T, Doucette J. Shared risk factors for falls, incontinence, and functional dependence. Unifying the approach to geriatric syndromes. Journal of the American Medical Association 1995; 273: 1348–1353.
Watson W, Clapperton A, Mitchell R. 2010. The incidence and cost of falls injury among older people in New South Wales 2006/2007. NSW Department of Health.
Australasian Journal on Ageing, Vol 32 No 4 December 2013, 200–201 © 2013 ACOTA
201
