bs_bs_banner
International Journal of Urology (2014) 21, 683–687
doi: 10.1111/iju.12420
Original Article: Clinical Investigation
Urinary incontinence in patients with Alzheimer’s disease: Relationship between symptom status and urodynamic diagnoses Seong Ho Lee,1 Sung Tae Cho,1 Hae Ri Na,2 Seok Bum Ko2 and Moon Ho Park3 1
Department of Urology, College of Medicine, Hallym University, Seoul, 2Department of Neurology, Bobath Memorial Hospital, Seongnam-si, and 3Department of Neurology, College of Medicine, Korea University, Seoul, Korea
Abbreviations & Acronyms AChEI = acetylcholinesterase inhibitors B-ADL = Barthel’s Activities of Daily Living CDR = Clinical Dementia Rating CI = confidence interval DO = detrusor overactivity DSD = detrusor–sphincter dyssynergia; FVC = frequency–volume chart GDS = Global Deterioration Scale ICIQ-UI = International Consultation on Incontinence Questionnaire on Urinary Incontinence Short Form MCC = maximal cystometric capacity MMSE = Mini-Mental State Examination MUCP = maximal urethral closing pressure OR = odds ratio PdetQmax = detrusor pressure at maximal flow PVR = post-void residual volume Qmax = maximal flow rates UDS = urodynamic study UI = urinary incontinence Correspondence: Sung Tae Cho M.D., Ph.D., Department of Urology, Hallym University Kangnam Sacred Heart Hospital, College of Medicine, Hallym University, 948-1 Daerim 1-dong, Youngdeungpo-gu, Seoul 150-950, Korea. Email: [email protected] Received 19 November 2013; accepted 23 January 2014. Online publication 4 March 2014 © 2014 The Japanese Urological Association
Objective: To assess factors associated with detrusor overactivity in urinary incontinence patients with Alzheimer’s disease, and to determine the correlation between the degree of Alzheimer’s disease and the presence of detrusor overactivity. Methods: A total of 144 Alzheimer’s disease patients (48 men, 96 women; aged 56–97 years) with urinary incontinence were enrolled in this protocol. Cognitive testing was carried out using the Mini-Mental State Examination, the Clinical Dementia Rating scale, the Global Deterioration Scale and Barthel’s Activities of Daily Living. Urinary incontinence was assessed using a frequency–volume chart and the Incontinence Questionnaire on Urinary Incontinence Short Form. All study participants had a urodynamic study carried out. Results: Based on the Incontinence Questionnaire on Urinary Incontinence Short Form, the most common type of urinary incontinence was urge urinary incontinence followed by enuresis in men, whereas women most commonly complained of urge urinary incontinence followed by stress urinary incontinence. Detrusor overactivity was found in 57.6% of patients (25 men, 58 women) on urodynamic study. No statistical differences were found between those with and without detrusor overactivity in terms of age, sex or duration of education. No significant correlation was found between changes in Incontinence Questionnaire on Urinary Incontinence Short Form scores and those in the Mini-Mental State Examination, Clinical Dementia Rating and Barthel’s Activities of Daily Living status. Multiple logistic regression analysis showed the presence of detrusor overactivity could be predicted using Clinical Dementia Rating and Barthel’s Activities of Daily Living scores (P < 0.05). Conclusions: The most common type of urinary incontinence in patients with Alzheimer’s disease is urge urinary incontinence. Clinical Dementia Rating and Barthel’s Activities of Daily Living predict the severity of detrusor overactivity in this patient population.
Key words: Alzheimer’s disease, dementia, detrusor overactivity, urinary incontinence, urodynamics.
Introduction Dementia is a serious loss of cognitive ability and has become increasingly common among the aged. It can have a profound psychological effect on patients as well as caregivers. UI, as defined by the International Continence Society, is the complaint of any involuntary leakage of urine.1 Dementia and UI are common, often coexisting, problems in older people; the diagnosis of which has grown rapidly in recent decades. UI is more prevalent in demented than in non-demented older individuals. However, UI in persons with dementia has not been studied in detail.2 It is difficult to precisely assess UI in patients who have severe cognitive and physical deterioration. Although there are validated urinary symptom questionnaires, application of these questionnaires for the assessment of UI in patients with AD is limited. AD is the most common cause of dementia in the elderly, and accounts for more than 50% of dementia patients.2 The precise nature of the pathophysiological association between UI and AD has not been established. Several studies have shown that cerebral dysfunction can lead to a loss of the brain’s inhibitory influence of the micturition reflex, resulting in involuntary detrusor contraction.3 DO is the urodynamic observation of involuntary detrusor contraction during the filling phase.1 Traditionally, it has been assumed that DO is the principal cause of UI in dementia.3 DO in patients with AD might be as a result of pathological changes in the substantia nigra and the frontal cortex.4 However, more recent findings suggest that DO alone might not account for UI in patients with dementia. However, It is thought that dementia could increase vulnerability to 683
SH LEE ET AL.
developing UI if other factors are present.3,5 DO can only be diagnosed by a UDS, which has been widely used, and remains the most specific and sensitive test for diagnosing voiding and storage abnormalities of the lower urinary tract.6,7 The present study sought to evaluate the UI symptom status of patients with AD using the CIQ-UI, and assess the factors associated with DO in patients diagnosed with both UI and AD. In addition, we looked for a correlation between the degree of AD and the presence of DO, using the objective measures of UDS.
Methods Inclusion criteria included AD patients with UI. Patients who were bedridden, had an indwelling catheter with urinary retention, or suffered from severe dementia with behavioral disturbances and inability to communicate were excluded. Patients who had been previously treated with anticholinergic medications were also excluded. The institutional review board approved the study protocol, and informed consent was obtained from participants. In patients who consented, but were unable to write or had cognitive impairments that could preclude them from understanding the UDS, informed consent was also obtained from the nearest relative or caregiver. All participants underwent an extensive evaluation that included a detailed history of UI, physical and neurological examinations, laboratory tests, and brain imaging studies. They also carried out neuropsychological tests, with all patients fulfilling the National Institute of Neurological Disorders and Stroke–Alzheimer Disease and Related Disorders criteria for probable AD.8 Cognitive testing was carried out using the Korean versions of the MMSE, the CDR scale, the GDS and B-ADL. The results were assessed and evaluated by an experienced neurologist. Lower urinary tract symptoms were assessed using a 3-day FVC after elimination of possible causes of transient UI. Enrolled patients or their caregivers reported the sensation associated with each micturition or urge UI episode on the FVC using the five-point Urinary Sensation Scale (1 = no urgency, 2 = mild urgency, 3 = moderate urgency, 4 = severe urgency, 5 = urge UI).9 They also were evaluated using the Korean version of the ICIQ-UI. To determine the presence and type of UI, patients were asked, “When do you leak urine?” They then selected their answer from a list of responses on the ICIQ-UI. UDS (Dantec Menuet Urodynamic Investigation System; Dantec, Copenhagen, Denmark) was used to establish the type of UI and bladder filling sensation.10 UDS was comprised of free Qmax, PVR (BioCon-500; Mcube Technology, Seoul, Korea), filling cystometry, PdetQmax and MUCP. UDS was carried out in the sitting position using a 6-Fr dual lumen catheter and a 9-Fr rectal balloon catheter with medium filling rate. Medication prescribed to influence bladder function was discontinued a week before UDS. Free Qmax was carried out when voided volumes were more than 150 mL. DO was defined as the urodynamic observation of involuntary detrusor contraction during the filling phase.1 An experienced urologist, who was otherwise blinded to the other aspects of the study, interpreted the data. UDS methods and terminology conformed to the standards recommended by the International Continence Society guidelines.1 684
Table 1
Type and severity of urinary incontinence on ICIQ-UI
Age (years) Type of UI (%) Stress Urge Mixed Enuresis Unexplained How often do you leak? (%) Once a week or less Two or three times per week About once per day Several times per day All the time How much urine leaks? (%) Small amount Moderate amount Large amount
Men (n = 48)
Women (n = 96)
P-value
76.3 ± 8.8
79.8 ± 7.7
>0.05
4 (8.3) 26 (54.2) 2 (4.2) 11 (22.9) 5 (10.4)
24 (25) 42 (43.8) 14 (14.6) 11 (11.4) 5 (5.2)
16 (33.3) 15 (31.3) 12 (25.0) 5 (10.4) 0 (0)
33 (34.4) 37 (38.5) 18 (18.8) 7 (7.3) 1 (1.0)
19 (39.6) 22 (45.8) 7 (14.6)
33 (34.4) 51 (53.1) 12 (12.5)
>0.05
>0.05
Values are presented as mean ± standard deviation.
Data in the text and table are expressed as means and standard deviations. A P-value was calculated by using the independent t-test for continuous variables and the Pearson χ2-test for categorical variables. Multiple logistic regression analysis was used to determine the independent risk factors for DO. All tests with P-values 0.05 >0.05
230.19 ± 72.51 38.60 ± 11.48 52.65 ± 16.03 25 (52.1) 0
214.19 ± 67.41 32.35 ± 11.45 47.65 ± 15.25 58 (60.4) 0
>0.05 0.002 >0.05 >0.05
Values are presented as mean ± standard deviation.
without DO. There were no significant differences in MMSE and GDS between UI patients with and without DO (Table 3). The associations between the reported symptoms and DO are presented in Table 4. Urgency episodes were significantly associated with the presence of DO. However, there were no significant differences in ICIQ-UI, the number of episodes of UI, micturition, nocturia or maximum urgency intensity between UI patients with and without DO (Table 4). Multiple logistic regression analysis was carried out to investigate possible independent risk factors for DO. CDR (OR 0.64, 95% CI 0.44–0.93; P = 0.018) and B-ADL (OR 1.09, 95% CI 1.03–1.15; P = 0.004) were identified as significant risk factors associated with DO. MMSE and GDS scores were not associated independently with risk of DO. After adjustment for age and sex, slight decreases in the OR were observed in CDR (OR 0.50, 95% CI 0.30–0.84; P = 0.009). GDS scores tended to increase in UI patients with DO after adjustment for age and sex, although the difference was not significant (P = 0.099; Table 5).
Discussion The purpose of the present study was to determine the factors associated with DO in UI patients with AD. We used the ICIQ-UI to determine the presence, type and degree of UI. Among the available instruments for assessing UI, the ICIQ-UI is a brief scale that is used in various populations and is easy to administer.6 The scoring system used in this questionnaire is very simple. The ICIQ-UI can measure not only the impact of UI on daily life, but also the frequency and amount of UI.11 Thus, many clinicians prefer to use the ICIQ-UI in daily practice. Using the ICIQ-UI, we showed that urge UI was the most common type of UI among patients with AD (men 54.2%, women 43.8%). We have previously carried out a multicenter evaluation of UI in 464 patients with probable AD, and reported that the most common types of UI were urge UI (44.3%) and functional UI (25.3%).12 The results of the present study correspond with the our previous study. Many studies have shown that functional UI is common among patients with AD as a result of cognitive disability and decreased motivation.2 Furthermore, functional UI in AD is often associated with a severe cognitive decline.13 We excluded severely demented patients in the present study. It has been suggested that the severity of immobility and dementia are positively correlated with functional UI.14 © 2014 The Japanese Urological Association
Recently, there have been several studies showing that brain white matter lesions are a more significant contributor to overactive bladder and UI than AD.15,16 In the present study, the brain images were used for the purpose of ruling out other causes that would result in dementia. We could not take a brain MRI for all patients, but for those patients who did not receive an MRI, we carried out a brain computed tomography scan. This might be a weak point of our study. In follow-up studies, it will be necessary to analyze white matter changes and numbers of lacunes with brain MRI, which would strongly influence the symptoms of loss of initiative and gait difficulty. Analysis of UDS showed PdetQmax was significantly higher in men, which can be explained by the sex difference in the lower urinary tract. Although, the presence of prostatic hypertrophy could explain this finding, there were no significant differences in other UDS findings including Qmax and PVR. In the present study, DO was found in 57.6% patients (25 men, 58 women) and positively associated with the severity of AD. Traditionally, it has been assumed that DO is a principle cause of UI in individuals with dementia.2,3 Tobin et al. examined 174 nursing home patients, of whom 78% were diagnosed as having dementia. Of those, 93% of women and 97% of men had DO.17 Castleden et al. also reported that 71% of UI patients with moderate to severe cognitive impairment had DO compared with 65% of those with mild or no impairment.18 However, although associations between dementia severity and DO have been reported, some studies have found that DO is primarily related to aging, being reported in up to 50% of continent, cognitively intact older people.2,3,14,19 These findings, therefore, suggest that DO might not be the specific cause of UI in patients with dementia.3 Although many studies have not specified the types of dementia, Mori et al. carried out UDS in 46 dementia patients, and found DO in 58% of patients with AD and in 91% of multi-infarct dementia patients.20 In a sample of 20 patents with AD, Sugiyama et al. found DO in 40%. In particular, DO was noted in eight of 13 incontinent patients (62%) and in none of the seven continent patients (0%).21 In our present study, we examined DO in AD patients, with our results corresponding well to the results of previous studies. In the analysis of cognitive testing, CDR was significantly higher and B-ADL was significantly lower in UI patients with DO in comparison with those without DO. Furthermore, multiple regression analysis showed that of the associated factors (cognitive, behavioral and clinical), the severity of cognitive impairment as measured by CDR and functional limitation as measured by B-ADL were identified as significant risk factors associated with DO. Although not statistically significant, trends were noted in the MMSE and GDS scores between groups. However, the present study does show a correlation between the presence of DO with that of cognitive (CDR) and functional (B-ADL) impairment. Recent studies have shown the possible role of DO in AD patients with UI.2,22–24 The pathology of AD involves the medial frontal lobe, which receives various inputs from another brain areas. Of particular importance is the cholinergic pathway that originates from the nucleus basalis Meynert (Ch4 cell group).2,24 In experimental studies, lesions in this small nucleus 685
SH LEE ET AL.
Table 3
Comparison between UI patients with and without DO
Age, years (range) Sex (male/female) Duration of education (years) Duration of dementia (months) History of taking AChEI (%) MMSE CDR GDS B-ADL
DO group (n = 83)
Non-DO group (n = 61)
P-value
79.32 ± 9.24 (61–97) 25/58 6.57 ± 4.36 33.73 ± 16.39 36 (43.4%) 13.95 ± 7.60 2.44 ± 0.98 5.46 ± 1.03 11.35 ± 5.47
77.67 ± 6.58 (56–91) 23/38 7.14 ± 5.02 28.84 ± 19.99 25 (41.0%) 15.02 ± 7.73 2.06 ± 0.86 5.43 ± 0.92 14.62 ± 7.45
>0.05
DO group (n = 83)
Non-DO group (n = 61)
P-value
9.80 ± 2.86 2.11 ± 0.88 3.61 ± 1.31 4.07 ± 2.67
9.75 ± 3.23 1.98 ± 1.09 3.44 ± 1.37 4.33 ± 2.73
>0.05 >0.05 >0.05 >0.05
1.40 ± 0.98 9.20 ± 3.91 1.37 ± 0.87 1.35 ± 0.83 1.75 ± 0.93
1.09 ± 1.00 8.94 ± 3.08 1.13 ± 0.87 0.91 ± 0.86 1.59 ± 1.07
>0.05 >0.05 >0.05 0.03 >0.05
>0.05 >0.05 >0.05 >0.05 >0.05 0.014 >0.05 0.003
Values are presented as mean ± standard deviation.
Table 4
Association of ICIQ-UI score, symptom severity and presence or absence of DO
ICIQ-UI Frequency of UI (0–5) Amount of UI (0–6) Bothersome UI (0–10) Frequency-volume chart (/24h) No. UI episodes No. micturition No. nocturia No. of urgency episodes Maximum urgency intensity Values are presented as mean ± standard deviation.
Table 5
MMSE CDR GDS B-ADL
Univariate and multivariate analysis for DO and cognitive status OR (95% CI)
P-value
Adjusted OR† (95% CI)
P-value
1.02 (0.98–1.06) 0.64 (0.44–0.93) 0.97 (0.69–1.36) 1.09 (1.03–1.15)
0.408 0.018 0.848 0.004
1.02 (0.97–1.06) 0.50 (0.30–0.84) 1.52 (0.92–2.51) 1.08 (1.02–1.14)
0.606 0.009 0.099 0.010
†Adjusted for age and sex.
give rise to DO, suggesting cortical cholinergic neurons have an inhibitory role in the micturition reflex.22–24 We also looked for an association between UI symptoms and DO using the ICIQ-UI, but found no relationship between the ICIQ-UI subscores and the presence of DO. The FVC helped us analyze the distribution of micturition objectively. It was also used to record the numbers of UI and urgency episodes, and maximum urgency intensity. However, there were no significant differences in these parameters, except the number of urgency episodes, between the patients with and without DO. In UI patients with AD, FVC could not be precisely assessed because of patient cooperation and compliance. This could be one reason why we did not find significant differences in the numbers of episodes of UI, micturition or nocturia between the groups. Subjective assessments of UI by patient interview might differ from the objective findings of FVC. Although the 686
ICIQ-UI could help determine the type of UI, it is ineffective at measuring the severity of UI. Overactive bladder is a clinical symptom complex characterized by urgency, usually with frequency and nocturia, and it occurs with or without urge UI.1 DO is a urodynamic diagnosis of detrusor contractions during filling cystometry, and these are associated with the feeling of urgency.1 Although the term overactive bladder is usually used interchangeably with urge UI and refers to the idiopathic type of DO, each term has a clearly different meaning. Some authors have suggested that patients with this symptom complex can be treated on the basis of their history, without a requirement for urodynamic DO.25 However, several studies have shown that urinary symptoms do not accurately diagnose the underlying pathology compared with UDS.25 UDS plays a particularly critical role in the evaluation and diagnosis of neurological disorders associated with UI, and their results are generally correct.26 Our study showed the most common type of UI in patients with AD is urge UI. Additionally, CDR and B-ADL might have the greatest power to predict DO in this population. The strong relationship between DO and level of cognition in UI patients warrants more study.
Acknowledgment The present study was supported by grants of the Korea Healthcare Technology R&D Project, Ministry of Health and Welfare, Korea (A102065). © 2014 The Japanese Urological Association
bs_bs_banner
Urodynamic diagnoses and Alzheimer’s disease
Conflict of interest None declared.
References 1 Abrams P, Cardozo L, Fall M et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol. Urodyn. 2002; 21: 167–78. 2 Sakakibara R, Uchiyama T, Yamanishi T, Kishi M. Dementia and lower urinary dysfunction: with a reference to anticholinergic use in elderly population. Int. J. Urol. 2008; 15: 778–88. 3 Skelly J, Flint AJ. Urinary incontinence associated with dementia. J. Am. Geriatr. Soc. 1995; 43: 286–94. 4 Ransmayr GN, Holliger S, Schletterer K et al. Lower urinary tract symptoms in dementia with Lewy bodies, Parkinson disease, and Alzheimer disease. Neurology 2008; 70: 299–303. 5 Yap P, Tan D. Urinary incontinence in dementia – a practical approach. Aust. Fam. Physician 2006; 35: 237–41. 6 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. Neurourol. Urodyn. 2004; 23: 322–30. 7 Al-Ghazo MA, Ghalayini IF, Al-Azab R, Hani OB, Matani YS, Haddad Y. Urodynamic detrusor overactivity in patients with overactive bladder symptoms. Int. Neurourol. J. 2011; 15: 48–54. 8 McKhann G, Drachman D, Folstein M, Katzman R, Price D, Stadlan EM. Clinical diagnosis of Alzheimer’s disease: report of the NINCDS-ADRDA Work Group under the auspices of Department of Health and Human Services Task Force on Alzheimer’s Disease. Neurology 1984; 34: 939–44. 9 Coyne KS, Tubaro A, Brubaker L, Bavendam T. Development and validation of patient-reported outcomes measures for overactive bladder: a review of concepts. Urology 2006; 68: 9–16. 10 Griffiths D. Clinical studies of cerebral and urinary tract function in elderly people with urinary incontinence. Behav. Brain Res. 1998; 92: 151–5. 11 Tannenbaum C, Corcos J. Outcomes in urinary incontinence: reconciling clinical relevance with scientific rigour. Eur. Urol. 2008; 53: 1151–61. 12 Na HR, Park MH, Cho ST et al. Urinary incontinence in Alzheimer’s disease is associated with Clinical Dementia Rating-Sum of Boxes and Barthel Activities of Daily Living. Asia Pac. Psychiatry 2012. doi: 10.1111/appy.12007.
13 Del-Ser T, Munoz DG, Hachinski V. Temporal pattern of cognitive decline and incontinence is different in Alzheimer’s disease and diffuse Lewy body disease. Neurology 1996; 46: 682–6. 14 Yu LC, Rohner TJ, Kaltreider DL, Hu TW, Igou JF, Dennis PJ. Profile of urinary incontinent elderly in long-term care institutions. J. Am. Geriatr. Soc. 1990; 38: 433–9. 15 Takahashi O, Sakakibara R, Panicker J et al. White matter lesions or Alzheimer’s disease: which contributes more to overactive bladder and incontinence in elderly adults with dementia? J. Am. Geriatr. Soc. 2012; 60: 2370–1. 16 Sakakibara R, Panicker J, Fowler CJ et al. Vascular incontinence: incontinence in the elderly due to ischemic white matter changes. Neurol. Int. 2012; 4: e13. 17 Tobin GW, Brocklehurst JC. The management of urinary incontinence in local authority residential homes for the elderly. Age Ageing 1986; 15: 292–8. 18 Castleden CM, Duffin HM, Asher MJ. Clinical and urodynamic studies in 100 elderly incontinent patients. Br. Med. J. (Clin. Res. Ed.) 1981; 282: 1103–5. 19 Jin LH, Lee HJ, Shin HY et al. Development and changes with age of detrusor overactivity in spontaneous hypertensive rats as observed by simultaneous registrations of intravesical and intraabdominal pressures. Int. Neurourol. J. 2011; 15: 192–8. 20 Mori S, Kojima M, Sakai Y, Nakajima K. Bladder dysfunction in dementia patients showing urinary incontinence: evaluation with cystometry and treatment with propiverine hydrochloride. Nihon Ronen Igakkai Zasshi 1999; 36: 489–94. 21 Sugiyama T, Hashimoto K, Kiwamoto H et al. Urinary incontinence in senile dementia of the Alzheimer type (SDAT). Int. J. Urol. 1994; 1: 337–40. 22 Nakada Y, Yokoyama O, Komatsu K et al. Effects of aniracetam on bladder overactivity in rats with cerebral infarction. J. Pharmacol. Exp. Ther. 2000; 293: 921–8. 23 Ishiura Y, Yoshiyama M, Yokoyama O, Namiki M, de Groat WC. Central muscarinic mechanisms regulating voiding in rats. J. Pharmacol. Exp. Ther. 2001; 297: 933–9. 24 Nakai M, Akino H, Kaneda T et al. Acetylcholinesterase inhibitor acting on the brain improves detrusor overactivity caused by cerebral infarction in rats. Neuroscience 2006; 142: 475–80. 25 Digesu GA, Khullar V, Cardozo L, Salvatore S. Overactive bladder symptoms: do we need urodynamics? Neurourol. Urodyn. 2003; 22: 105–8. 26 Li WJ, Oh SJ. Management of lower urinary tract dysfunction in patients with neurological disorders. Korean J. Urol. 2012; 53: 583–92.
Editorial Comment Editorial Comment to Urinary incontinence in patients with Alzheimer’s disease: Relationship between symptom status and urodynamic diagnoses It is well recognized that in the geriatric population, urinary incontinence (UI) is most often associated with dementia. This is not only because UI occurs secondarily from dementia (functional UI in advanced cases; urinating in the corner of the corridor etc.), but also because UI and dementia originate from the same brain pathology (neurogenic UI in relatively early cases, cannot defer urinating because of overactive bladder [OAB]/urinary urgency).1 Among the underlying diseases of OAB/urge UI in elderly dementia, the most important are white matter disease (WMD; also called vascular dementia) and dementia with Lewy bodies (DLB) because of the high frequency of OAB/urge UI, being estimated to be 80–90%.2 The second important factor is Alzheimer’s disease (AD), with the frequency of OAB/urge UI being estimated to be 40%.2 © 2014 The Japanese Urological Association
However, it remained not well known about the relationship between UI with cognitive function and activities of daily living (ADL) in this population. In this study, Lee et al.3 studied the relationship between bladder function (the Incontinence Questionnaire on Urinary Incontinence Short Form [ICIQ-UI] questionnaire and standard urodynamics) with cognitive (the Mini-Mental State Examination [MMSE] and the Clinical Dementia Rating [CDR]) and ADL measures (Barthel Index [B-ADL]) in 144 AD patients (48 male, 96 female; aged 56–97 years, including some youngonset cases; moderate cognitive decline [MMSE score 13.9–15/ 30, normal >24]). As a result, they found the most common UI type was urge UI in both men and women. Detrusor overactivity was found in 57.6% of patients. They found no relationship 687
International Journal of Urology (2014) 21, 683–687
doi: 10.1111/iju.12420
Original Article: Clinical Investigation
Urinary incontinence in patients with Alzheimer’s disease: Relationship between symptom status and urodynamic diagnoses Seong Ho Lee,1 Sung Tae Cho,1 Hae Ri Na,2 Seok Bum Ko2 and Moon Ho Park3 1
Department of Urology, College of Medicine, Hallym University, Seoul, 2Department of Neurology, Bobath Memorial Hospital, Seongnam-si, and 3Department of Neurology, College of Medicine, Korea University, Seoul, Korea
Abbreviations & Acronyms AChEI = acetylcholinesterase inhibitors B-ADL = Barthel’s Activities of Daily Living CDR = Clinical Dementia Rating CI = confidence interval DO = detrusor overactivity DSD = detrusor–sphincter dyssynergia; FVC = frequency–volume chart GDS = Global Deterioration Scale ICIQ-UI = International Consultation on Incontinence Questionnaire on Urinary Incontinence Short Form MCC = maximal cystometric capacity MMSE = Mini-Mental State Examination MUCP = maximal urethral closing pressure OR = odds ratio PdetQmax = detrusor pressure at maximal flow PVR = post-void residual volume Qmax = maximal flow rates UDS = urodynamic study UI = urinary incontinence Correspondence: Sung Tae Cho M.D., Ph.D., Department of Urology, Hallym University Kangnam Sacred Heart Hospital, College of Medicine, Hallym University, 948-1 Daerim 1-dong, Youngdeungpo-gu, Seoul 150-950, Korea. Email: [email protected] Received 19 November 2013; accepted 23 January 2014. Online publication 4 March 2014 © 2014 The Japanese Urological Association
Objective: To assess factors associated with detrusor overactivity in urinary incontinence patients with Alzheimer’s disease, and to determine the correlation between the degree of Alzheimer’s disease and the presence of detrusor overactivity. Methods: A total of 144 Alzheimer’s disease patients (48 men, 96 women; aged 56–97 years) with urinary incontinence were enrolled in this protocol. Cognitive testing was carried out using the Mini-Mental State Examination, the Clinical Dementia Rating scale, the Global Deterioration Scale and Barthel’s Activities of Daily Living. Urinary incontinence was assessed using a frequency–volume chart and the Incontinence Questionnaire on Urinary Incontinence Short Form. All study participants had a urodynamic study carried out. Results: Based on the Incontinence Questionnaire on Urinary Incontinence Short Form, the most common type of urinary incontinence was urge urinary incontinence followed by enuresis in men, whereas women most commonly complained of urge urinary incontinence followed by stress urinary incontinence. Detrusor overactivity was found in 57.6% of patients (25 men, 58 women) on urodynamic study. No statistical differences were found between those with and without detrusor overactivity in terms of age, sex or duration of education. No significant correlation was found between changes in Incontinence Questionnaire on Urinary Incontinence Short Form scores and those in the Mini-Mental State Examination, Clinical Dementia Rating and Barthel’s Activities of Daily Living status. Multiple logistic regression analysis showed the presence of detrusor overactivity could be predicted using Clinical Dementia Rating and Barthel’s Activities of Daily Living scores (P < 0.05). Conclusions: The most common type of urinary incontinence in patients with Alzheimer’s disease is urge urinary incontinence. Clinical Dementia Rating and Barthel’s Activities of Daily Living predict the severity of detrusor overactivity in this patient population.
Key words: Alzheimer’s disease, dementia, detrusor overactivity, urinary incontinence, urodynamics.
Introduction Dementia is a serious loss of cognitive ability and has become increasingly common among the aged. It can have a profound psychological effect on patients as well as caregivers. UI, as defined by the International Continence Society, is the complaint of any involuntary leakage of urine.1 Dementia and UI are common, often coexisting, problems in older people; the diagnosis of which has grown rapidly in recent decades. UI is more prevalent in demented than in non-demented older individuals. However, UI in persons with dementia has not been studied in detail.2 It is difficult to precisely assess UI in patients who have severe cognitive and physical deterioration. Although there are validated urinary symptom questionnaires, application of these questionnaires for the assessment of UI in patients with AD is limited. AD is the most common cause of dementia in the elderly, and accounts for more than 50% of dementia patients.2 The precise nature of the pathophysiological association between UI and AD has not been established. Several studies have shown that cerebral dysfunction can lead to a loss of the brain’s inhibitory influence of the micturition reflex, resulting in involuntary detrusor contraction.3 DO is the urodynamic observation of involuntary detrusor contraction during the filling phase.1 Traditionally, it has been assumed that DO is the principal cause of UI in dementia.3 DO in patients with AD might be as a result of pathological changes in the substantia nigra and the frontal cortex.4 However, more recent findings suggest that DO alone might not account for UI in patients with dementia. However, It is thought that dementia could increase vulnerability to 683
SH LEE ET AL.
developing UI if other factors are present.3,5 DO can only be diagnosed by a UDS, which has been widely used, and remains the most specific and sensitive test for diagnosing voiding and storage abnormalities of the lower urinary tract.6,7 The present study sought to evaluate the UI symptom status of patients with AD using the CIQ-UI, and assess the factors associated with DO in patients diagnosed with both UI and AD. In addition, we looked for a correlation between the degree of AD and the presence of DO, using the objective measures of UDS.
Methods Inclusion criteria included AD patients with UI. Patients who were bedridden, had an indwelling catheter with urinary retention, or suffered from severe dementia with behavioral disturbances and inability to communicate were excluded. Patients who had been previously treated with anticholinergic medications were also excluded. The institutional review board approved the study protocol, and informed consent was obtained from participants. In patients who consented, but were unable to write or had cognitive impairments that could preclude them from understanding the UDS, informed consent was also obtained from the nearest relative or caregiver. All participants underwent an extensive evaluation that included a detailed history of UI, physical and neurological examinations, laboratory tests, and brain imaging studies. They also carried out neuropsychological tests, with all patients fulfilling the National Institute of Neurological Disorders and Stroke–Alzheimer Disease and Related Disorders criteria for probable AD.8 Cognitive testing was carried out using the Korean versions of the MMSE, the CDR scale, the GDS and B-ADL. The results were assessed and evaluated by an experienced neurologist. Lower urinary tract symptoms were assessed using a 3-day FVC after elimination of possible causes of transient UI. Enrolled patients or their caregivers reported the sensation associated with each micturition or urge UI episode on the FVC using the five-point Urinary Sensation Scale (1 = no urgency, 2 = mild urgency, 3 = moderate urgency, 4 = severe urgency, 5 = urge UI).9 They also were evaluated using the Korean version of the ICIQ-UI. To determine the presence and type of UI, patients were asked, “When do you leak urine?” They then selected their answer from a list of responses on the ICIQ-UI. UDS (Dantec Menuet Urodynamic Investigation System; Dantec, Copenhagen, Denmark) was used to establish the type of UI and bladder filling sensation.10 UDS was comprised of free Qmax, PVR (BioCon-500; Mcube Technology, Seoul, Korea), filling cystometry, PdetQmax and MUCP. UDS was carried out in the sitting position using a 6-Fr dual lumen catheter and a 9-Fr rectal balloon catheter with medium filling rate. Medication prescribed to influence bladder function was discontinued a week before UDS. Free Qmax was carried out when voided volumes were more than 150 mL. DO was defined as the urodynamic observation of involuntary detrusor contraction during the filling phase.1 An experienced urologist, who was otherwise blinded to the other aspects of the study, interpreted the data. UDS methods and terminology conformed to the standards recommended by the International Continence Society guidelines.1 684
Table 1
Type and severity of urinary incontinence on ICIQ-UI
Age (years) Type of UI (%) Stress Urge Mixed Enuresis Unexplained How often do you leak? (%) Once a week or less Two or three times per week About once per day Several times per day All the time How much urine leaks? (%) Small amount Moderate amount Large amount
Men (n = 48)
Women (n = 96)
P-value
76.3 ± 8.8
79.8 ± 7.7
>0.05
4 (8.3) 26 (54.2) 2 (4.2) 11 (22.9) 5 (10.4)
24 (25) 42 (43.8) 14 (14.6) 11 (11.4) 5 (5.2)
16 (33.3) 15 (31.3) 12 (25.0) 5 (10.4) 0 (0)
33 (34.4) 37 (38.5) 18 (18.8) 7 (7.3) 1 (1.0)
19 (39.6) 22 (45.8) 7 (14.6)
33 (34.4) 51 (53.1) 12 (12.5)
>0.05
>0.05
Values are presented as mean ± standard deviation.
Data in the text and table are expressed as means and standard deviations. A P-value was calculated by using the independent t-test for continuous variables and the Pearson χ2-test for categorical variables. Multiple logistic regression analysis was used to determine the independent risk factors for DO. All tests with P-values 0.05 >0.05
230.19 ± 72.51 38.60 ± 11.48 52.65 ± 16.03 25 (52.1) 0
214.19 ± 67.41 32.35 ± 11.45 47.65 ± 15.25 58 (60.4) 0
>0.05 0.002 >0.05 >0.05
Values are presented as mean ± standard deviation.
without DO. There were no significant differences in MMSE and GDS between UI patients with and without DO (Table 3). The associations between the reported symptoms and DO are presented in Table 4. Urgency episodes were significantly associated with the presence of DO. However, there were no significant differences in ICIQ-UI, the number of episodes of UI, micturition, nocturia or maximum urgency intensity between UI patients with and without DO (Table 4). Multiple logistic regression analysis was carried out to investigate possible independent risk factors for DO. CDR (OR 0.64, 95% CI 0.44–0.93; P = 0.018) and B-ADL (OR 1.09, 95% CI 1.03–1.15; P = 0.004) were identified as significant risk factors associated with DO. MMSE and GDS scores were not associated independently with risk of DO. After adjustment for age and sex, slight decreases in the OR were observed in CDR (OR 0.50, 95% CI 0.30–0.84; P = 0.009). GDS scores tended to increase in UI patients with DO after adjustment for age and sex, although the difference was not significant (P = 0.099; Table 5).
Discussion The purpose of the present study was to determine the factors associated with DO in UI patients with AD. We used the ICIQ-UI to determine the presence, type and degree of UI. Among the available instruments for assessing UI, the ICIQ-UI is a brief scale that is used in various populations and is easy to administer.6 The scoring system used in this questionnaire is very simple. The ICIQ-UI can measure not only the impact of UI on daily life, but also the frequency and amount of UI.11 Thus, many clinicians prefer to use the ICIQ-UI in daily practice. Using the ICIQ-UI, we showed that urge UI was the most common type of UI among patients with AD (men 54.2%, women 43.8%). We have previously carried out a multicenter evaluation of UI in 464 patients with probable AD, and reported that the most common types of UI were urge UI (44.3%) and functional UI (25.3%).12 The results of the present study correspond with the our previous study. Many studies have shown that functional UI is common among patients with AD as a result of cognitive disability and decreased motivation.2 Furthermore, functional UI in AD is often associated with a severe cognitive decline.13 We excluded severely demented patients in the present study. It has been suggested that the severity of immobility and dementia are positively correlated with functional UI.14 © 2014 The Japanese Urological Association
Recently, there have been several studies showing that brain white matter lesions are a more significant contributor to overactive bladder and UI than AD.15,16 In the present study, the brain images were used for the purpose of ruling out other causes that would result in dementia. We could not take a brain MRI for all patients, but for those patients who did not receive an MRI, we carried out a brain computed tomography scan. This might be a weak point of our study. In follow-up studies, it will be necessary to analyze white matter changes and numbers of lacunes with brain MRI, which would strongly influence the symptoms of loss of initiative and gait difficulty. Analysis of UDS showed PdetQmax was significantly higher in men, which can be explained by the sex difference in the lower urinary tract. Although, the presence of prostatic hypertrophy could explain this finding, there were no significant differences in other UDS findings including Qmax and PVR. In the present study, DO was found in 57.6% patients (25 men, 58 women) and positively associated with the severity of AD. Traditionally, it has been assumed that DO is a principle cause of UI in individuals with dementia.2,3 Tobin et al. examined 174 nursing home patients, of whom 78% were diagnosed as having dementia. Of those, 93% of women and 97% of men had DO.17 Castleden et al. also reported that 71% of UI patients with moderate to severe cognitive impairment had DO compared with 65% of those with mild or no impairment.18 However, although associations between dementia severity and DO have been reported, some studies have found that DO is primarily related to aging, being reported in up to 50% of continent, cognitively intact older people.2,3,14,19 These findings, therefore, suggest that DO might not be the specific cause of UI in patients with dementia.3 Although many studies have not specified the types of dementia, Mori et al. carried out UDS in 46 dementia patients, and found DO in 58% of patients with AD and in 91% of multi-infarct dementia patients.20 In a sample of 20 patents with AD, Sugiyama et al. found DO in 40%. In particular, DO was noted in eight of 13 incontinent patients (62%) and in none of the seven continent patients (0%).21 In our present study, we examined DO in AD patients, with our results corresponding well to the results of previous studies. In the analysis of cognitive testing, CDR was significantly higher and B-ADL was significantly lower in UI patients with DO in comparison with those without DO. Furthermore, multiple regression analysis showed that of the associated factors (cognitive, behavioral and clinical), the severity of cognitive impairment as measured by CDR and functional limitation as measured by B-ADL were identified as significant risk factors associated with DO. Although not statistically significant, trends were noted in the MMSE and GDS scores between groups. However, the present study does show a correlation between the presence of DO with that of cognitive (CDR) and functional (B-ADL) impairment. Recent studies have shown the possible role of DO in AD patients with UI.2,22–24 The pathology of AD involves the medial frontal lobe, which receives various inputs from another brain areas. Of particular importance is the cholinergic pathway that originates from the nucleus basalis Meynert (Ch4 cell group).2,24 In experimental studies, lesions in this small nucleus 685
SH LEE ET AL.
Table 3
Comparison between UI patients with and without DO
Age, years (range) Sex (male/female) Duration of education (years) Duration of dementia (months) History of taking AChEI (%) MMSE CDR GDS B-ADL
DO group (n = 83)
Non-DO group (n = 61)
P-value
79.32 ± 9.24 (61–97) 25/58 6.57 ± 4.36 33.73 ± 16.39 36 (43.4%) 13.95 ± 7.60 2.44 ± 0.98 5.46 ± 1.03 11.35 ± 5.47
77.67 ± 6.58 (56–91) 23/38 7.14 ± 5.02 28.84 ± 19.99 25 (41.0%) 15.02 ± 7.73 2.06 ± 0.86 5.43 ± 0.92 14.62 ± 7.45
>0.05
DO group (n = 83)
Non-DO group (n = 61)
P-value
9.80 ± 2.86 2.11 ± 0.88 3.61 ± 1.31 4.07 ± 2.67
9.75 ± 3.23 1.98 ± 1.09 3.44 ± 1.37 4.33 ± 2.73
>0.05 >0.05 >0.05 >0.05
1.40 ± 0.98 9.20 ± 3.91 1.37 ± 0.87 1.35 ± 0.83 1.75 ± 0.93
1.09 ± 1.00 8.94 ± 3.08 1.13 ± 0.87 0.91 ± 0.86 1.59 ± 1.07
>0.05 >0.05 >0.05 0.03 >0.05
>0.05 >0.05 >0.05 >0.05 >0.05 0.014 >0.05 0.003
Values are presented as mean ± standard deviation.
Table 4
Association of ICIQ-UI score, symptom severity and presence or absence of DO
ICIQ-UI Frequency of UI (0–5) Amount of UI (0–6) Bothersome UI (0–10) Frequency-volume chart (/24h) No. UI episodes No. micturition No. nocturia No. of urgency episodes Maximum urgency intensity Values are presented as mean ± standard deviation.
Table 5
MMSE CDR GDS B-ADL
Univariate and multivariate analysis for DO and cognitive status OR (95% CI)
P-value
Adjusted OR† (95% CI)
P-value
1.02 (0.98–1.06) 0.64 (0.44–0.93) 0.97 (0.69–1.36) 1.09 (1.03–1.15)
0.408 0.018 0.848 0.004
1.02 (0.97–1.06) 0.50 (0.30–0.84) 1.52 (0.92–2.51) 1.08 (1.02–1.14)
0.606 0.009 0.099 0.010
†Adjusted for age and sex.
give rise to DO, suggesting cortical cholinergic neurons have an inhibitory role in the micturition reflex.22–24 We also looked for an association between UI symptoms and DO using the ICIQ-UI, but found no relationship between the ICIQ-UI subscores and the presence of DO. The FVC helped us analyze the distribution of micturition objectively. It was also used to record the numbers of UI and urgency episodes, and maximum urgency intensity. However, there were no significant differences in these parameters, except the number of urgency episodes, between the patients with and without DO. In UI patients with AD, FVC could not be precisely assessed because of patient cooperation and compliance. This could be one reason why we did not find significant differences in the numbers of episodes of UI, micturition or nocturia between the groups. Subjective assessments of UI by patient interview might differ from the objective findings of FVC. Although the 686
ICIQ-UI could help determine the type of UI, it is ineffective at measuring the severity of UI. Overactive bladder is a clinical symptom complex characterized by urgency, usually with frequency and nocturia, and it occurs with or without urge UI.1 DO is a urodynamic diagnosis of detrusor contractions during filling cystometry, and these are associated with the feeling of urgency.1 Although the term overactive bladder is usually used interchangeably with urge UI and refers to the idiopathic type of DO, each term has a clearly different meaning. Some authors have suggested that patients with this symptom complex can be treated on the basis of their history, without a requirement for urodynamic DO.25 However, several studies have shown that urinary symptoms do not accurately diagnose the underlying pathology compared with UDS.25 UDS plays a particularly critical role in the evaluation and diagnosis of neurological disorders associated with UI, and their results are generally correct.26 Our study showed the most common type of UI in patients with AD is urge UI. Additionally, CDR and B-ADL might have the greatest power to predict DO in this population. The strong relationship between DO and level of cognition in UI patients warrants more study.
Acknowledgment The present study was supported by grants of the Korea Healthcare Technology R&D Project, Ministry of Health and Welfare, Korea (A102065). © 2014 The Japanese Urological Association
bs_bs_banner
Urodynamic diagnoses and Alzheimer’s disease
Conflict of interest None declared.
References 1 Abrams P, Cardozo L, Fall M et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol. Urodyn. 2002; 21: 167–78. 2 Sakakibara R, Uchiyama T, Yamanishi T, Kishi M. Dementia and lower urinary dysfunction: with a reference to anticholinergic use in elderly population. Int. J. Urol. 2008; 15: 778–88. 3 Skelly J, Flint AJ. Urinary incontinence associated with dementia. J. Am. Geriatr. Soc. 1995; 43: 286–94. 4 Ransmayr GN, Holliger S, Schletterer K et al. Lower urinary tract symptoms in dementia with Lewy bodies, Parkinson disease, and Alzheimer disease. Neurology 2008; 70: 299–303. 5 Yap P, Tan D. Urinary incontinence in dementia – a practical approach. Aust. Fam. Physician 2006; 35: 237–41. 6 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. Neurourol. Urodyn. 2004; 23: 322–30. 7 Al-Ghazo MA, Ghalayini IF, Al-Azab R, Hani OB, Matani YS, Haddad Y. Urodynamic detrusor overactivity in patients with overactive bladder symptoms. Int. Neurourol. J. 2011; 15: 48–54. 8 McKhann G, Drachman D, Folstein M, Katzman R, Price D, Stadlan EM. Clinical diagnosis of Alzheimer’s disease: report of the NINCDS-ADRDA Work Group under the auspices of Department of Health and Human Services Task Force on Alzheimer’s Disease. Neurology 1984; 34: 939–44. 9 Coyne KS, Tubaro A, Brubaker L, Bavendam T. Development and validation of patient-reported outcomes measures for overactive bladder: a review of concepts. Urology 2006; 68: 9–16. 10 Griffiths D. Clinical studies of cerebral and urinary tract function in elderly people with urinary incontinence. Behav. Brain Res. 1998; 92: 151–5. 11 Tannenbaum C, Corcos J. Outcomes in urinary incontinence: reconciling clinical relevance with scientific rigour. Eur. Urol. 2008; 53: 1151–61. 12 Na HR, Park MH, Cho ST et al. Urinary incontinence in Alzheimer’s disease is associated with Clinical Dementia Rating-Sum of Boxes and Barthel Activities of Daily Living. Asia Pac. Psychiatry 2012. doi: 10.1111/appy.12007.
13 Del-Ser T, Munoz DG, Hachinski V. Temporal pattern of cognitive decline and incontinence is different in Alzheimer’s disease and diffuse Lewy body disease. Neurology 1996; 46: 682–6. 14 Yu LC, Rohner TJ, Kaltreider DL, Hu TW, Igou JF, Dennis PJ. Profile of urinary incontinent elderly in long-term care institutions. J. Am. Geriatr. Soc. 1990; 38: 433–9. 15 Takahashi O, Sakakibara R, Panicker J et al. White matter lesions or Alzheimer’s disease: which contributes more to overactive bladder and incontinence in elderly adults with dementia? J. Am. Geriatr. Soc. 2012; 60: 2370–1. 16 Sakakibara R, Panicker J, Fowler CJ et al. Vascular incontinence: incontinence in the elderly due to ischemic white matter changes. Neurol. Int. 2012; 4: e13. 17 Tobin GW, Brocklehurst JC. The management of urinary incontinence in local authority residential homes for the elderly. Age Ageing 1986; 15: 292–8. 18 Castleden CM, Duffin HM, Asher MJ. Clinical and urodynamic studies in 100 elderly incontinent patients. Br. Med. J. (Clin. Res. Ed.) 1981; 282: 1103–5. 19 Jin LH, Lee HJ, Shin HY et al. Development and changes with age of detrusor overactivity in spontaneous hypertensive rats as observed by simultaneous registrations of intravesical and intraabdominal pressures. Int. Neurourol. J. 2011; 15: 192–8. 20 Mori S, Kojima M, Sakai Y, Nakajima K. Bladder dysfunction in dementia patients showing urinary incontinence: evaluation with cystometry and treatment with propiverine hydrochloride. Nihon Ronen Igakkai Zasshi 1999; 36: 489–94. 21 Sugiyama T, Hashimoto K, Kiwamoto H et al. Urinary incontinence in senile dementia of the Alzheimer type (SDAT). Int. J. Urol. 1994; 1: 337–40. 22 Nakada Y, Yokoyama O, Komatsu K et al. Effects of aniracetam on bladder overactivity in rats with cerebral infarction. J. Pharmacol. Exp. Ther. 2000; 293: 921–8. 23 Ishiura Y, Yoshiyama M, Yokoyama O, Namiki M, de Groat WC. Central muscarinic mechanisms regulating voiding in rats. J. Pharmacol. Exp. Ther. 2001; 297: 933–9. 24 Nakai M, Akino H, Kaneda T et al. Acetylcholinesterase inhibitor acting on the brain improves detrusor overactivity caused by cerebral infarction in rats. Neuroscience 2006; 142: 475–80. 25 Digesu GA, Khullar V, Cardozo L, Salvatore S. Overactive bladder symptoms: do we need urodynamics? Neurourol. Urodyn. 2003; 22: 105–8. 26 Li WJ, Oh SJ. Management of lower urinary tract dysfunction in patients with neurological disorders. Korean J. Urol. 2012; 53: 583–92.
Editorial Comment Editorial Comment to Urinary incontinence in patients with Alzheimer’s disease: Relationship between symptom status and urodynamic diagnoses It is well recognized that in the geriatric population, urinary incontinence (UI) is most often associated with dementia. This is not only because UI occurs secondarily from dementia (functional UI in advanced cases; urinating in the corner of the corridor etc.), but also because UI and dementia originate from the same brain pathology (neurogenic UI in relatively early cases, cannot defer urinating because of overactive bladder [OAB]/urinary urgency).1 Among the underlying diseases of OAB/urge UI in elderly dementia, the most important are white matter disease (WMD; also called vascular dementia) and dementia with Lewy bodies (DLB) because of the high frequency of OAB/urge UI, being estimated to be 80–90%.2 The second important factor is Alzheimer’s disease (AD), with the frequency of OAB/urge UI being estimated to be 40%.2 © 2014 The Japanese Urological Association
However, it remained not well known about the relationship between UI with cognitive function and activities of daily living (ADL) in this population. In this study, Lee et al.3 studied the relationship between bladder function (the Incontinence Questionnaire on Urinary Incontinence Short Form [ICIQ-UI] questionnaire and standard urodynamics) with cognitive (the Mini-Mental State Examination [MMSE] and the Clinical Dementia Rating [CDR]) and ADL measures (Barthel Index [B-ADL]) in 144 AD patients (48 male, 96 female; aged 56–97 years, including some youngonset cases; moderate cognitive decline [MMSE score 13.9–15/ 30, normal >24]). As a result, they found the most common UI type was urge UI in both men and women. Detrusor overactivity was found in 57.6% of patients. They found no relationship 687
