Maturitas 80 (2015) 308–311
Contents lists available at ScienceDirect
Maturitas journal homepage: www.elsevier.com/locate/maturitas
Lower urinary tract symptoms and falls in older women: A case control study Rhodri Edwards a,∗ , Kathleen Hunter b , Adrian Wagg b a b
Department of Healthcare for Older People, Whittington Health, London, United Kingdom Division of Geriatric Medicine, Department of Medicine, University of Alberta, Edmonton, AB, Canada
a r t i c l e
i n f o
Article history: Received 26 October 2014 Received in revised form 14 December 2014 Accepted 16 December 2014 Keywords: Falls Lower urinary tract symptoms Urinary incontinence Older people
a b s t r a c t Objectives: To examine the distribution of lower urinary tract symptoms (LUTS) in women >65 y old presenting to the emergency department following a fall or fall related injury. Study design: A prospective, case controlled postal questionnaire study. Setting: University Teaching Hospital, London, UK. Main outcome measures: The distribution of LUTS were assessed using the International Consultation on Incontinence Modular Questionnaire for female lower urinary tract symptoms. Data were analysed using descriptive statistics to determine whether there was a difference in the distribution of LUTS between women presenting with a fall or non-fall related health problem. The proportion of women who attributed their fall to lower urinary tract symptoms was also assessed. Results: No difference in the distribution of LUTS was found between older women presenting with a fall and those without. Only 6.5% of women presenting with falls attributed their fall to antecedent LUTS. Conclusion: No relationship between falls and urgency or urgency incontinence was found in a cohort of older women presenting to the emergency department having fallen. A temporal association between falls and LUTS was observed in only a minority of falls. © 2015 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Falls and urinary incontinence are common problems for older people both are associated with significant morbidity, and consumption of health care resources [1–3]. Multiple risk factors for falls have been identified and a strong evidence base has developed to advocate multi-factorial interventions including comprehensive geriatric assessment and strength and balance training to effectively reduce the risk of falling [4,5]. The management of urinary incontinence as a risk factor for falls has received less attention [6,7]. However, urinary incontinence, urgency and nocturia, but not stress urinary incontinence, have been identified as risk factors for falls in epidemiological studies [8–10]. A meta-analysis of nine studies investigating falls and urinary incontinence in community dwelling older people showed the odds of falling were OR 1.54 (95% CI 1.41 to 1.69) in the presence of urgency incontinence and 1.92 (95% CI 1.69 to 2.19) in the presence of mixed incontinence [11].
∗ Corresponding author. Tel.: +44 20 7288 5324; fax: +44 20 7288 3008. E-mail address: [email protected] (R. Edwards). http://dx.doi.org/10.1016/j.maturitas.2014.12.008 0378-5122/© 2015 Elsevier Ireland Ltd. All rights reserved.
A continence assessment is often advocated in falls guidelines. The 2013 updated National Institute for Clinical & Healthcare Excellence (NICE) guidelines on falls assessment and prevention advocate a continence assessment as part of multi-factorial, multi-disciplinary investigation and management of falls [12]. Unfortunately, national audit data have shown such assessments are frequently neglected or omitted [13]. There has been no prospective systematic examination of the distribution of LUTS in older women who fall or research to temporally link LUTS to the occurrence of a fall. Many lower urinary tract symptoms other than incontinence are amenable to successful management and these may also prove to be modifiable risk factor for falls [7].
1.1. Aim The aim of this study was to assess the distribution of lower urinary tract symptoms in older women presenting to the emergency department having fallen, to compare them with an age matched control group of older women without a fall in the previous year and to estimate the proportion of women who temporally related their fall to lower urinary tract symptoms.
R. Edwards et al. / Maturitas 80 (2015) 308–311
2. Method A prospective case controlled questionnaire study of women aged 65 years and above presenting to the emergency department at University College Hospital between December 2010 and July 2011 was conducted. Eligible participants were identified by daily screening of the emergency department register. Women aged 65 and over presenting with a fall or fall related injury during the study period were eligible for recruitment to the falls group. The control sample was identified by inviting the next >65 y old woman presenting to the A&E department without a fall to participate. Patients could be either discharged or admitted to the hospital. A fall was defined as an unexpectant event in which the participant came to rest on the ground, floor or lower level [14]. Patients with documented significant cognitive impairment or dementia at the time of presentation were excluded. In the falls group, patients with syncope, myocardial infarction, stroke or epilepsy were excluded. In the control group any subject who was identified as having fallen in the previous year was excluded. Potential participants were approached by post with a letter inviting them to participate in the study along with the study information sheet, consent form and questionnaires which they were requested to complete. A return stamped addressed envelope was provided. Consent was assumed by the receipt of a signed consent form and the completed questionnaires. Initially no reminder letter was sent to comply with the ethics committee recommendations, however, after an initial disappointing response the ethics committee approved a single reminder letter sent at six weeks following the emergency department attendance. A register of age and sex of non-responders was kept. The questionnaires collected data in six areas:
• Socio-demographics (age, sex, ethnicity, socio-economic group, level of education). • Co morbidity and drug history. • Falls history (frequency and injury sustained). • Lower urinary tract symptoms assessed using the International Consultation on Incontinence Modular Questionnaire (ICIQ) for female lower urinary tract symptoms (long version) [15]. • Functional ability (postal version of Barthel index) [16]. • Cognitive function; self administered “Test Your Memory” score [17].
The ICIQ modules have been fully validated and are used internationally in both clinical practice and research. These questionnaires facilitate the assessment lower urinary tract symptoms in terms of frequency, nocturia, quality of flow and stream as well as symptoms of stress incontinence, urgency incontinence and overactive bladder. They also demand a qualitative assessment of the troublesomeness of symptoms on the patient’s quality of life using a scale of 1–10 [15]. The Bartel index is a well recognised index scoring the ability of a person to care for themselves whilst undertaking basic activities of daily living. It is frequently used as a measure of functional disability. Scored out of 20 a higher score reflects a greater level of independence. A postal version of the index has been validated [16]. The “Test Your Memory” (TYM) assessment is a cognitive test validated for screening in the detection of Alzheimer’s dementia. It was designed to minimise operator time and to be suitable for non specialist use, A score of < or =42/50 is suggestive of Alzheimers [17].
309
Table 1 Demographics.
Age (mean, range) Ethnicity (white British) Owner occupier Pet ownership (yes %) Test your memory (mean,/50)* Barthel index (mean,/20)** * **
Cases (n = 87)
Controls (n = 58)
p
76.8 (65–95) 74/87 (85.1%) 58/86 (67.4%) 16/86 (18.6%) 46.2 (SD 5.18) 18.3 (SD 2.55)
75.6 (65–89) 42/58 (72.4%) 27/56 (48.2%) 11/57 (19.2%) 45.6 (SD 5.41) 17.6 (SD 2.96)
NS
n = 76 Cases, 54 controls. n = 80 Cases, 55 controls, SD.
3. Sample size Assuming the prevalence of LUTS in patients attending without a fall is 25% for women (mid-point of 20–30% estimate); to detect a doubling of this distribution in patients who attend after a fall then with 5% two sided significance and 90% power 85 cases and 85 controls for women were required. 4. Analysis Baseline characteristics of the fallers and non-fallers were compared. The distribution of lower urinary tract symptoms in the two groups were illustrated using descriptive statistics. Differences in proportions were analysed using Chi-squared test, for means using unpaired t-tests, for categorical data, Wilcoxon ranked sum test. 5. Results Seven hundred and forty six potential participants were identified (349 with falls and 297 controls). 87 (24.9%) patients with falls and 58 (14.6%) patients in the control sample returned completed questionnaires. Response rates and characteristics are summarised in Fig. 1. No significant difference was detected in terms of age between the responder and non responders groups. The demographics characteristics of the falls and control groups were similar and are summarised in Table 1. There was no difference in the mean number of comorbid diseases between the two groups (11.2 co-morbidities in fall group vs 9.8 co-morbidities in control group, p = 0.79)). Participants presenting with falls took significantly fewer medications with a mean of 3.6 (95% CI 2.9–4.2) prescriptions compared with the control group who reported a mean of 5.3 (95% CI 4.3–6.2) prescription (p = 0.03). The number of prescription ranged from 0 to 12 in both groups. In the falls group, 42 (65.6%) of those who responded reported their fall occurred away from the home and 39 (44.8%) of falls resulted in a fracture (14 (35.8%) non hip fragility fractures, 5, (12.8%) hip fractures). The distribution of LUTS is shown in Fig. 2. Twenty eight (32.1%) patients with falls and 20 (34.4%) controls had incontinence >two to three times per week. There was no significant difference in terms of frequency, nocturia, stress urinary incontinence, hesitancy, straining, interrupted stream, nocturnal enuresis or incomplete emptying experienced by patients in the two groups. However, the control group reported urgency, more than occasionally, more frequently than the group with a fall (p = 0.01). Of women who had fallen, 27.5% (n = 24) vs 22.4% (n = 13) had urgency incontinence more than “sometimes”, (p = NS). Only 4 (6.2%) of the 65 patient presenting with falls recalled a temporal relationship between their LUTS and the fall. 6. Discussion In this prospective case-control study we found a similar distribution of lower urinary tract symptoms amongst older women presenting to the emergency department regardless of whether
310
R. Edwards et al. / Maturitas 80 (2015) 308–311
Fig. 1. Response rates.
their presentation was with a fall or not. Only 6.5% of participants related the fall to their lower urinary tract symptoms. Contrary to other epidemiological studies we did not find that urgency, urgency incontinence or nocturia were more common in women who fall. This potentially casts doubt upon a causal association postulated between urinary urgency and falls [8–11,18]. The prevalence of urinary incontinence in the adult population is estimated between 20 and 30% in women. This increases with age and functional dependence with up to 60% of people in institutional care suffering with urinary incontinence [19]. In this study approximately a third of participants reported urinary incontinence at least 2–3 times per week. This reflects the population prevalence for incontinence and is similar to prevalence reported in other studies where an association with falls was demonstrated [8,9,20]. Clinically it makes sense to suggest a common nature of the relationship between LUTS and falls. Potentially rushing to the toilet or commode sets the scene for accidental falls. The stress and anxiety associated with the threat of impending incontinence conceivably augments this and toileting at night may pose its own inherent challenges and hazards. Alternatively, however, a relationship between urinary incontinence and falls may reflect shared predisposing factors such as cognitive impairment and frailty. Cerebral white matter ischaemic changes have been associated with urinary incontinence, impaired physical function and cognitive impairment [21].
Urgency incontinence has been associated with reduced physical activity [22], impaired balance and gait impairment [23]. Whether, however, urgency itself directly predisposes to these problems is unclear. It is plausible that urgency leads to the avoidance in physical activity and consequent deconditioning which subsequently may predispose to falls. Interestingly, the only study on gait and urgency suggests that people slow down their gait in the face of urgency, rather than “rush to the toilet” [24]. This again may suggest either frailty or prior deconditioning as common risk factors for falls rather than a direct association between urinary urgency and falls. Overall the participants in this study were fairly independent and cognitively intact as assessed by their Barthel and test your memory score. Almost all respondents lived in their own home and none lived in residential or nursing care. Given that cognitive impairment, dementia and functional dependence are all risk factors for urinary incontinence this study did not capture the frailer population where lower urinary tract dysfunction may have a stronger association with fall risk. Other studies have reported higher odds ratios for falling and urinary incontinence amongst people living in institutional care [20,25]. The relatively light burden of co-morbidity and polypharmacy in the both groups, in particular in the falls group, may point to a selection bias imposed by completing our detailed questionnaire. Although we did not find a significant difference in the ages of
Fig. 2. Distribution of LUTS.
R. Edwards et al. / Maturitas 80 (2015) 308–311
responders and non responders, potentially frailer non-responders in both the falls and control group may have found the burden of completing our questionnaire excessive. This study is limited by a number of other factors; the poor response rate, the small number of controls and most likely the study setting. Despite contacting 746 potential participants only a quarter of patients with falls and fewer control subjects responded. Our expectation that LUTS might occur at double the rate in those women with a fall may have, additionally, been overoptimistic. The study only included falls of sufficient severity to require attendance at hospital and almost half of the patients in the falls group sustained a fracture. Whilst such patients may represent a high risk group for falls, they probably do not reflect the distribution of LUTS amongst people who fall in the community. In addition the definition of falls used in this study may differ from other studies. An analysis of national audit data relating to continence assessment in patients with non hip fragility fractures in England and Wales showed that only a minority of patients were assessed. However, where theses assessments were done 26.6% showed urinary dysfunction similar to that found in this study. 7. Conclusion This study found no relationship between falls and urgency or urgency incontinence in a cohort of older women presenting to the emergency department with falls. In addition only a minority of women reported a temporal association between falls and LUTS. It may be that the association described previously between LUTS and falls reflects frailty rather than a direct association. Given the limitations of this study, a larger, community based study to elucidate the nature of the relationship between LUTS and falls of a more common nature is desirable. Contributors Adrian Wagg and Rhodri Edwards designed and managed the study. Rhodri Edwards collected the data. Adrian Wagg, Kathleen Hunter and Rhodri Edwards analysed the results. Rhodri Edwards prepared the manuscript. Competing interest Rhodri Edwards salary was funded with a grant from Pfizer to conduct this study. Adrian Wagg has received research funding from Astellas Pharma and Pfizer Corp, speaker honoraria from Astellas Pharma, Pfizer Corp, Merus Labs and SCA AB, fees for consultancy from Pfizer Corp, Astellas Pharma and SCA AB. Funding Adrian Wagg secured funding from Pfizer to conduct this study. Pfizer had no role in design, collection, analysis or interpretation of the data. Ethical approval Ethical committee approval was gained from the Outer South East London Ethics Committee and section 251 approval to use the
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patients name, address and date of birth to invite them to participate in the study was obtained from the Ethics and Confidentiality Committee of the National Information Governance Board. References [1] Tinnetti ME, Speechley M, Ginter SF. Risk factors for falls amongst elderly persons living in the community. N Engl J Med 1988;319:1701–7. [2] Thomas TM, Playmat KR, Blannin J, Meade TW. Prevalence of urinary incontinence. Br Med J 1980;281:1243–5. [3] Scuffham P, Chaplin S, Legood R. Incidence and cost of unintentional falls in older people in the United Kingdom. J Epidemiol Community Health 2003;57:740–4. [4] Close J, Ellis M, Hooper R, Glucksman E, Jackson S, Swift C. Prevention of falls in the elderly trial (PROFET): a randomised controlled trial. Lancet 1999;353:93–7. [5] Tinetti ME, Baker DI, McAvay G, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med 1994;13(331):821–7. [6] Morris V, Wagg A. Lower urinary tract symptoms, incontinence and falls in elderly people: time for an interventional study. Int J Clin Pract 2007;61: 320–3. [7] Morris V, Hunter KF, Wagg A. Urinary incontinence and falls: a link ripe for interventions. Geriatr Med 2011;41(6):333–6. [8] Tromp AM, Pluijm SM, Smit JH, Deeg DJ, Bouter LM, Lips P. Fall risk screening test: a prospective study on predictors for falls in community dwelling elderly. J Clin Epidemiol 2001;54:837–44. [9] Brown JS, Vittinghoff E, Wyman JF, et al. Urinary Incontinence: does it increase risk for falls and fractures? Study of osteoporotic fractures research group. J Am Geriatr Soc 2000;48:721–5. [10] Stewart RB, Moore MT, May FE, Marke RG, Hale WE. Nocturia: a risk factor for falls in the elderly. J Am Geriatr Soc 1992;40:1217–20. [11] Chiarelli PE, Mackenzie LA, Osmotherly PG. Urinary Incontinence is associated with an increase in falls: a systematic review. Aust J Physiother 2009;55: 89–95. [12] NICE. The assessment and prevention of falls in older people. In: NICE Guidelines. London, UK: NICE; 2013. [13] Edwards R, Martin FC, Grant R, et al. Is urinary continence considered in the assessment of older people after a fall in England and Wales?: cross-sectional clinical audit results. Maturitas 2011;69:179–83. [14] Hauer Klaus, Lamb Sarah E, Jorstad Ellen C, Todd Chris, Becker Clemens. On Behalf of the Profane-Group, Systematic review of definitions and methods of measuring falls in randomised controlled fall prevention trials. Age Ageing 2006;35(1):5–10. [15] Jackson S, Donovan J, Brookes S, Eckford S, Swithinbank L, Abrams P. The Bristol Female Lower Urinary Tract Symptoms questionnaire: development and psychometric testing. BJU 1996;77:805–12. [16] Gompertz P, Pound P, Ebrahim S. A postal version of the Bartel index. Clin Rehabil 1994;8:233–9. [17] Brown J, Pengas G, Dawson K, Brown L, Clatworthy P. Self administered cognitive screening test (TYM) for detection of Alzheimer’s disease: cross sectional study. BMJ 2009;388:b2030. [18] Foley AL, Loharuka S, Barrett JA, et al. Association between geriatric giants of urinary incontinence and falls in older people using data from the Leicestershire MRC Incontinence Study. Age Ageing 2012;41:35–40. [19] Milsom I. Lower urinary tract symptoms in women. Curr Opin Urol 2009;19(4):337–41. [20] Graafmans WC, Ooms ME, Hofstee MA, Bezemer PD, Bouter LM, Lips P. Falls in the elderly: a prospective study of risk factors and risk profiles. Am J Epidemiol 1996;143:1129–36. [21] Kuchel GA, Moscufo N, Guttmann CR, et al. Localisation of brain white matter hyperintensities and urinary incontinence in community dwelling older adults. J Gerontol A Biol Sci Med Sci 2009;64(8):902–9. [22] Coyne KS, Sexton CC, Clemens JQ, et al. The impact of OAB on physical activity in the United States: results from OAB-POLL. Urology 2013;82(4): 799–806. [23] Fritel X, Lachal L, Cassou B, Fauconnier A, Dargent-Molina P. Mobility impairment is associated with urge but not stress urinary incontinence in community dwelling older women—results from Ossebo study. BJOG 2013;120(12):1566–72. [24] Booth J, Paul L, Rafferty D, Macinnes C. The relationship between urinary bladder control and gait in women. Neurourol Urodyn 2013;32(1): 43–7. [25] Chen JS, March LM, Schwarz J, et al. A multivariate regression model predicted falls in residents living in intermediate hostel care. J Clin Epidemiol 2005;58:503–8.
Contents lists available at ScienceDirect
Maturitas journal homepage: www.elsevier.com/locate/maturitas
Lower urinary tract symptoms and falls in older women: A case control study Rhodri Edwards a,∗ , Kathleen Hunter b , Adrian Wagg b a b
Department of Healthcare for Older People, Whittington Health, London, United Kingdom Division of Geriatric Medicine, Department of Medicine, University of Alberta, Edmonton, AB, Canada
a r t i c l e
i n f o
Article history: Received 26 October 2014 Received in revised form 14 December 2014 Accepted 16 December 2014 Keywords: Falls Lower urinary tract symptoms Urinary incontinence Older people
a b s t r a c t Objectives: To examine the distribution of lower urinary tract symptoms (LUTS) in women >65 y old presenting to the emergency department following a fall or fall related injury. Study design: A prospective, case controlled postal questionnaire study. Setting: University Teaching Hospital, London, UK. Main outcome measures: The distribution of LUTS were assessed using the International Consultation on Incontinence Modular Questionnaire for female lower urinary tract symptoms. Data were analysed using descriptive statistics to determine whether there was a difference in the distribution of LUTS between women presenting with a fall or non-fall related health problem. The proportion of women who attributed their fall to lower urinary tract symptoms was also assessed. Results: No difference in the distribution of LUTS was found between older women presenting with a fall and those without. Only 6.5% of women presenting with falls attributed their fall to antecedent LUTS. Conclusion: No relationship between falls and urgency or urgency incontinence was found in a cohort of older women presenting to the emergency department having fallen. A temporal association between falls and LUTS was observed in only a minority of falls. © 2015 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Falls and urinary incontinence are common problems for older people both are associated with significant morbidity, and consumption of health care resources [1–3]. Multiple risk factors for falls have been identified and a strong evidence base has developed to advocate multi-factorial interventions including comprehensive geriatric assessment and strength and balance training to effectively reduce the risk of falling [4,5]. The management of urinary incontinence as a risk factor for falls has received less attention [6,7]. However, urinary incontinence, urgency and nocturia, but not stress urinary incontinence, have been identified as risk factors for falls in epidemiological studies [8–10]. A meta-analysis of nine studies investigating falls and urinary incontinence in community dwelling older people showed the odds of falling were OR 1.54 (95% CI 1.41 to 1.69) in the presence of urgency incontinence and 1.92 (95% CI 1.69 to 2.19) in the presence of mixed incontinence [11].
∗ Corresponding author. Tel.: +44 20 7288 5324; fax: +44 20 7288 3008. E-mail address: [email protected] (R. Edwards). http://dx.doi.org/10.1016/j.maturitas.2014.12.008 0378-5122/© 2015 Elsevier Ireland Ltd. All rights reserved.
A continence assessment is often advocated in falls guidelines. The 2013 updated National Institute for Clinical & Healthcare Excellence (NICE) guidelines on falls assessment and prevention advocate a continence assessment as part of multi-factorial, multi-disciplinary investigation and management of falls [12]. Unfortunately, national audit data have shown such assessments are frequently neglected or omitted [13]. There has been no prospective systematic examination of the distribution of LUTS in older women who fall or research to temporally link LUTS to the occurrence of a fall. Many lower urinary tract symptoms other than incontinence are amenable to successful management and these may also prove to be modifiable risk factor for falls [7].
1.1. Aim The aim of this study was to assess the distribution of lower urinary tract symptoms in older women presenting to the emergency department having fallen, to compare them with an age matched control group of older women without a fall in the previous year and to estimate the proportion of women who temporally related their fall to lower urinary tract symptoms.
R. Edwards et al. / Maturitas 80 (2015) 308–311
2. Method A prospective case controlled questionnaire study of women aged 65 years and above presenting to the emergency department at University College Hospital between December 2010 and July 2011 was conducted. Eligible participants were identified by daily screening of the emergency department register. Women aged 65 and over presenting with a fall or fall related injury during the study period were eligible for recruitment to the falls group. The control sample was identified by inviting the next >65 y old woman presenting to the A&E department without a fall to participate. Patients could be either discharged or admitted to the hospital. A fall was defined as an unexpectant event in which the participant came to rest on the ground, floor or lower level [14]. Patients with documented significant cognitive impairment or dementia at the time of presentation were excluded. In the falls group, patients with syncope, myocardial infarction, stroke or epilepsy were excluded. In the control group any subject who was identified as having fallen in the previous year was excluded. Potential participants were approached by post with a letter inviting them to participate in the study along with the study information sheet, consent form and questionnaires which they were requested to complete. A return stamped addressed envelope was provided. Consent was assumed by the receipt of a signed consent form and the completed questionnaires. Initially no reminder letter was sent to comply with the ethics committee recommendations, however, after an initial disappointing response the ethics committee approved a single reminder letter sent at six weeks following the emergency department attendance. A register of age and sex of non-responders was kept. The questionnaires collected data in six areas:
• Socio-demographics (age, sex, ethnicity, socio-economic group, level of education). • Co morbidity and drug history. • Falls history (frequency and injury sustained). • Lower urinary tract symptoms assessed using the International Consultation on Incontinence Modular Questionnaire (ICIQ) for female lower urinary tract symptoms (long version) [15]. • Functional ability (postal version of Barthel index) [16]. • Cognitive function; self administered “Test Your Memory” score [17].
The ICIQ modules have been fully validated and are used internationally in both clinical practice and research. These questionnaires facilitate the assessment lower urinary tract symptoms in terms of frequency, nocturia, quality of flow and stream as well as symptoms of stress incontinence, urgency incontinence and overactive bladder. They also demand a qualitative assessment of the troublesomeness of symptoms on the patient’s quality of life using a scale of 1–10 [15]. The Bartel index is a well recognised index scoring the ability of a person to care for themselves whilst undertaking basic activities of daily living. It is frequently used as a measure of functional disability. Scored out of 20 a higher score reflects a greater level of independence. A postal version of the index has been validated [16]. The “Test Your Memory” (TYM) assessment is a cognitive test validated for screening in the detection of Alzheimer’s dementia. It was designed to minimise operator time and to be suitable for non specialist use, A score of < or =42/50 is suggestive of Alzheimers [17].
309
Table 1 Demographics.
Age (mean, range) Ethnicity (white British) Owner occupier Pet ownership (yes %) Test your memory (mean,/50)* Barthel index (mean,/20)** * **
Cases (n = 87)
Controls (n = 58)
p
76.8 (65–95) 74/87 (85.1%) 58/86 (67.4%) 16/86 (18.6%) 46.2 (SD 5.18) 18.3 (SD 2.55)
75.6 (65–89) 42/58 (72.4%) 27/56 (48.2%) 11/57 (19.2%) 45.6 (SD 5.41) 17.6 (SD 2.96)
NS
n = 76 Cases, 54 controls. n = 80 Cases, 55 controls, SD.
3. Sample size Assuming the prevalence of LUTS in patients attending without a fall is 25% for women (mid-point of 20–30% estimate); to detect a doubling of this distribution in patients who attend after a fall then with 5% two sided significance and 90% power 85 cases and 85 controls for women were required. 4. Analysis Baseline characteristics of the fallers and non-fallers were compared. The distribution of lower urinary tract symptoms in the two groups were illustrated using descriptive statistics. Differences in proportions were analysed using Chi-squared test, for means using unpaired t-tests, for categorical data, Wilcoxon ranked sum test. 5. Results Seven hundred and forty six potential participants were identified (349 with falls and 297 controls). 87 (24.9%) patients with falls and 58 (14.6%) patients in the control sample returned completed questionnaires. Response rates and characteristics are summarised in Fig. 1. No significant difference was detected in terms of age between the responder and non responders groups. The demographics characteristics of the falls and control groups were similar and are summarised in Table 1. There was no difference in the mean number of comorbid diseases between the two groups (11.2 co-morbidities in fall group vs 9.8 co-morbidities in control group, p = 0.79)). Participants presenting with falls took significantly fewer medications with a mean of 3.6 (95% CI 2.9–4.2) prescriptions compared with the control group who reported a mean of 5.3 (95% CI 4.3–6.2) prescription (p = 0.03). The number of prescription ranged from 0 to 12 in both groups. In the falls group, 42 (65.6%) of those who responded reported their fall occurred away from the home and 39 (44.8%) of falls resulted in a fracture (14 (35.8%) non hip fragility fractures, 5, (12.8%) hip fractures). The distribution of LUTS is shown in Fig. 2. Twenty eight (32.1%) patients with falls and 20 (34.4%) controls had incontinence >two to three times per week. There was no significant difference in terms of frequency, nocturia, stress urinary incontinence, hesitancy, straining, interrupted stream, nocturnal enuresis or incomplete emptying experienced by patients in the two groups. However, the control group reported urgency, more than occasionally, more frequently than the group with a fall (p = 0.01). Of women who had fallen, 27.5% (n = 24) vs 22.4% (n = 13) had urgency incontinence more than “sometimes”, (p = NS). Only 4 (6.2%) of the 65 patient presenting with falls recalled a temporal relationship between their LUTS and the fall. 6. Discussion In this prospective case-control study we found a similar distribution of lower urinary tract symptoms amongst older women presenting to the emergency department regardless of whether
310
R. Edwards et al. / Maturitas 80 (2015) 308–311
Fig. 1. Response rates.
their presentation was with a fall or not. Only 6.5% of participants related the fall to their lower urinary tract symptoms. Contrary to other epidemiological studies we did not find that urgency, urgency incontinence or nocturia were more common in women who fall. This potentially casts doubt upon a causal association postulated between urinary urgency and falls [8–11,18]. The prevalence of urinary incontinence in the adult population is estimated between 20 and 30% in women. This increases with age and functional dependence with up to 60% of people in institutional care suffering with urinary incontinence [19]. In this study approximately a third of participants reported urinary incontinence at least 2–3 times per week. This reflects the population prevalence for incontinence and is similar to prevalence reported in other studies where an association with falls was demonstrated [8,9,20]. Clinically it makes sense to suggest a common nature of the relationship between LUTS and falls. Potentially rushing to the toilet or commode sets the scene for accidental falls. The stress and anxiety associated with the threat of impending incontinence conceivably augments this and toileting at night may pose its own inherent challenges and hazards. Alternatively, however, a relationship between urinary incontinence and falls may reflect shared predisposing factors such as cognitive impairment and frailty. Cerebral white matter ischaemic changes have been associated with urinary incontinence, impaired physical function and cognitive impairment [21].
Urgency incontinence has been associated with reduced physical activity [22], impaired balance and gait impairment [23]. Whether, however, urgency itself directly predisposes to these problems is unclear. It is plausible that urgency leads to the avoidance in physical activity and consequent deconditioning which subsequently may predispose to falls. Interestingly, the only study on gait and urgency suggests that people slow down their gait in the face of urgency, rather than “rush to the toilet” [24]. This again may suggest either frailty or prior deconditioning as common risk factors for falls rather than a direct association between urinary urgency and falls. Overall the participants in this study were fairly independent and cognitively intact as assessed by their Barthel and test your memory score. Almost all respondents lived in their own home and none lived in residential or nursing care. Given that cognitive impairment, dementia and functional dependence are all risk factors for urinary incontinence this study did not capture the frailer population where lower urinary tract dysfunction may have a stronger association with fall risk. Other studies have reported higher odds ratios for falling and urinary incontinence amongst people living in institutional care [20,25]. The relatively light burden of co-morbidity and polypharmacy in the both groups, in particular in the falls group, may point to a selection bias imposed by completing our detailed questionnaire. Although we did not find a significant difference in the ages of
Fig. 2. Distribution of LUTS.
R. Edwards et al. / Maturitas 80 (2015) 308–311
responders and non responders, potentially frailer non-responders in both the falls and control group may have found the burden of completing our questionnaire excessive. This study is limited by a number of other factors; the poor response rate, the small number of controls and most likely the study setting. Despite contacting 746 potential participants only a quarter of patients with falls and fewer control subjects responded. Our expectation that LUTS might occur at double the rate in those women with a fall may have, additionally, been overoptimistic. The study only included falls of sufficient severity to require attendance at hospital and almost half of the patients in the falls group sustained a fracture. Whilst such patients may represent a high risk group for falls, they probably do not reflect the distribution of LUTS amongst people who fall in the community. In addition the definition of falls used in this study may differ from other studies. An analysis of national audit data relating to continence assessment in patients with non hip fragility fractures in England and Wales showed that only a minority of patients were assessed. However, where theses assessments were done 26.6% showed urinary dysfunction similar to that found in this study. 7. Conclusion This study found no relationship between falls and urgency or urgency incontinence in a cohort of older women presenting to the emergency department with falls. In addition only a minority of women reported a temporal association between falls and LUTS. It may be that the association described previously between LUTS and falls reflects frailty rather than a direct association. Given the limitations of this study, a larger, community based study to elucidate the nature of the relationship between LUTS and falls of a more common nature is desirable. Contributors Adrian Wagg and Rhodri Edwards designed and managed the study. Rhodri Edwards collected the data. Adrian Wagg, Kathleen Hunter and Rhodri Edwards analysed the results. Rhodri Edwards prepared the manuscript. Competing interest Rhodri Edwards salary was funded with a grant from Pfizer to conduct this study. Adrian Wagg has received research funding from Astellas Pharma and Pfizer Corp, speaker honoraria from Astellas Pharma, Pfizer Corp, Merus Labs and SCA AB, fees for consultancy from Pfizer Corp, Astellas Pharma and SCA AB. Funding Adrian Wagg secured funding from Pfizer to conduct this study. Pfizer had no role in design, collection, analysis or interpretation of the data. Ethical approval Ethical committee approval was gained from the Outer South East London Ethics Committee and section 251 approval to use the
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