Annals of Long-Term Care: Clinical Care and Aging. 2013;21(10);16-17.
August 26-30, 2013; Barcelona, Spain
Reducing Nocturnal Urine Volume Might Improve Quality of Life for Nursing Home Residents Wearing Incontinence Products
Nocturnal polyuria (NP) has a high prevalence among older adults and is commonly encountered in nursing homes. The condition can cause nocturia (ie, excessive need to urinate at night) or nocturnal incontinence (ie, involuntary discharge of urine at night), both of which are highly bothersome problems. Although these conditions are prevalent in nursing homes, little research has focused on how they may impact quality of life among nursing home residents. At the ICS meeting, researchers from Ghent University Hospital, Ghent, Belgium, shed some light on this issue when they reported the results of their prospective study, which indicated that reducing nocturnal urine volume might improve quality of life among residents wearing incontinence products.
The study included 55 residents (mean age, 87 years) of a Belgian nursing home; there were 10 men and 45 women. Data for these residents were collected between October and November 2012 and came from completed validated questionnaires that evaluate quality of life (Short Form 36) and urinary symptoms (ICIQ-FLUTS [International Consultation on Incontinence Questionnaire Female Lower Urinary Tract Symptoms Module] and ICIQ-MLUTS [International Consultation on Incontinence Questionnaire Male Lower Urinary Tract Symptoms Module]), as well as a 24-hour frequency volume chart with registration of frequency and volume of each micturition for those with nocturia or the weight of incontinence material for those wearing incontinence products.
The prevalence of NP within the study population was 84% (n=46). Of the individuals with NP, 17 (37%) reported nocturnal incontinence. The prevalence of nocturia could not be determined because 24 (52%) participants used incontinence products; however, the majority of these individuals (72%) reported having nocturnal incontinence. The four patients who wore incontinence products despite no episodes of nocturnal incontinence did so because of physical or mental disabilities and continence policies at the nursing home.
The overall assessment of the data revealed that although NP is a highly prevalent condition among elderly nursing home residents, the use of incontinence products is a major contributor to reduced quality of life. The investigators found that these residents had a significantly higher nocturnal urine volume than those who got up at night to void, with a volume of 1500 ± 1331 mL versus 1286 ± 451 mL, respectively, despite drinking less (1048 ± 326 mL vs 1313 ± 388 mL, respectively). Based on these findings, the investigators surmised that nocturnal hormonal imbalances might contribute to the increased urine volume in these residents, and they suggest that future studies should examine whether a reduction in nocturnal urine volume might improve quality of life within this subgroup of patients.—Christina T. Loguidice
The lead author of the study, An-Sofie Goessaert, PhD student, received an unrestricted grant from Ferring Pharmaceuticals.
Incontinence More Likely to Persist in Black and Hispanic Nursing Home Residents
Racial and ethnic disparities are encountered in a variety of healthcare settings, but there has been a paucity of information about whether these factors have any bearing on time to incontinence cure in nursing home residents. During the ICS meeting, researchers from the University of Minnesota presented the results of their prospective study, which revealed that older black and Hispanic residents were cured later and less often following a nursing home admission than their white counterparts.
The study researchers analyzed the following data sets of a national chain of proprietary nursing homes: (1) the Minimum Data Set (MDS), which includes demographic and health assessment data of individual residents; (2) the Online Survey, Certification, and Reporting (OSCAR) records, which contain measures of nursing home staffing, quality of care, and the care environment; and (3) data from the US Census, which provides sociodemographic and socioeconomic measures of the tract in which each nursing home is located. The researchers examined MDS and OSCAR information from the years 2000 to 2002 and the US Census data from 2000. Using these data sets, all elderly persons (≥65 years) who had incontinence and were admitted to a nursing home were identified (n=39,887). Incontinence was defined as a report of urinary and/or fecal incontinence on the first full (ie, admission) MDS record. Cure of incontinence was defined as a subsequent MDS record reporting the resident to be continent. Predictors of time to incontinence cure from the MDS were analyzed using Cox proportional hazards regression for white residents, and the Peters-Belson method was used to assess for racial or ethnic disparities. This method provided estimates of the expected time to cure of incontinence had each minority group been white, and these estimates were then compared with the reported time to incontinence cure of the minority group using a one sample log-rank test. The Cox regression and Peters-Belson method were rerun with the inclusion of MDS, OSCAR, and US Census predictors.
The average resident age upon nursing home admission was 83 years, 65% were women, 83% were white, 12% were black, 2% were Hispanic, 2.5% were Asian, and 0.5% were American Indians. Overall, 21% of residents were cured of incontinence after their nursing home admission; however, there was a significant disparity in time to cure of incontinence for black (P=.02) and Hispanic (P<.001) residents relative to whites. There were no significant differences in time to incontinence cure for the other minority groups (P>.05). Resident factors that improved the chance for cure included fewer deficits in activities of daily living, better cognitive functioning, fewer comorbidities, not having fecal incontinence or dual incontinence (ie, fecal and urinary), and younger age. Nursing home factors that improved the chance of cure included a higher percentage of admissions who were white, a lower percentage of residents receiving Medicaid, a lower percentage of the community below poverty level, and locations outside of an urban area.
The authors indicate that their findings have several clinical implications, including a need for interventions to treat incontinence early after admission, to improve residents’ function, and to better treat incontinence in cognitively impaired residents. They also indicate the need for policy modifications, including increasing payments to nursing homes with high percentages of minority admissions and admissions who are incontinent, as well as increasing the availability of healthcare for incontinence prevention among elderly in poor communities prior to nursing home admission.—Christina T. Loguidice
The study was funded by the National Institute of Nursing Research, the National Institutes of Health (1R01NR010731-01A2), and the Minnesota Supercomputing Institute of the University of Minnesota.
Study Indicates Lower Urinary Tract Symptoms in Some Women May Result From Bacteria in the Bladder Wall
Overactive bladder (OAB) has a multifactorial etiology, and it has been speculated that the condition might result from a bacterial infection in some patients; however, others have suggested that contaminated urine specimens might falsely lead to such an association. A study presented at the ICS meeting by researchers from London sought to shed light on this issue. The study had a two-fold objective: (1) to determine whether bacteria are present in the bladder wall and associated with a positive urine culture; and (2) to determine if the bacteria in the bladder wall are associated with lower urinary tract symptoms or recurrent urinary tract infections.
The study included 204 women (mean age, 51 years; range, 20-86 years) undergoing cystoscopy. All participants completed a 3-day bladder diary, whether or not lower urinary tract symptoms were present, and those with symptoms (62%) underwent urodynamic studies. Among those receiving these studies, 38% had a history of recurrent urinary tract infections and 42% reported bladder pain. The following conditions were identified: detrusor overactivity in 49%, stress and urgency urinary incontinence in 17%, urodynamic stress urinary incontinence in 14%, and inconclusive findings in 20%.
Before cystoscopy, a catheter sample of urine was collected and sent for microscopy. Thereafter, a rigid cystoscopy was performed under sterile conditions and two bladder biopsies were taken from each patient. One of the bladder specimens was sent for histopathological analysis and the other was transported in normal saline to the laboratory for microbiological assessment. Among the participants, 15 (7.34%) had a positive urine culture, yet only 11 (73%) were found to have positive cultures on bladder biopsy; the organisms detected included Escherichia coli, Enterococcus, Streptococcus, and Proteus mirabilis. A total of 105 patients were found to have a positive culture on bladder biopsy, with 86% of these patients having a negative urine culture, and 171 patients having evidence of nonspecific inflammation on histopathology examination of the bladder biopsy. The bacterial organisms isolated upon culturing the bladder biopsies included Staphylococcus, Streptococcus, Lactobacillus, Enterococcus, E coli, Micrococcus, P mirabilis, and Cornybacterium. Some of the less commonly isolated organisms included Candida, Klebsiella, Gardnerella, and Morganella.
The researchers found no significant relationship between positive bladder cultures and the presence of OAB symptoms, bladder pain, or history of recurrent urinary tract infections (P>.05). In addition, no significant relationship between the positive urine cultures and a history of recurrent urinary tract infections was identified (P>.05); however, when comparing women with no urinary symptoms (n=12) with those who had lower urinary tract symptoms (n=192), there was a significant number with a bladder wall infection in the symptomatic group (Chi-square, 5.667; P=.02). Based on these findings, the researchers conclude that their study supports a link between lower urinary tract symptoms and bacterial infection of the bladder wall and not the urine.—Christina T. Loguidice