            gerona      J Gerontol A Biol Sci Med Scigerona      The Journals of Gerontology Series A: Biological Sciences and Medical Sciences      J Gerontol A Biol Sci Med Sci      1079-5006      1758-535X              Oxford University Press                    0012710.1093/gerona/56.1.M14                        Journal of Gerontology: Medical Sciences                            Prevalence Rate of Urinary Incontinence in Community-Dwelling Elderly Individuals        The Veneto Study                                          Maggi            Stefania                                a                                                Minicuci            Nadia                                a                                                Langlois            Jean                                b                                                Pavan            Mara                                a                                                Enzi            Giuliano                                a                                                Crepaldi            Gaetano                                a                          aCenter on Aging, National Research Council, Padova, Italy        bNational Center for Injury Prevention and Control, Centers for Disease Control, Atlanta, Georgia                    1        1        2001            56      1      M14      M18                        26          6          2000                          20          6          2000                            The Gerontological Society of America        2001                    Background. Urinary incontinence (UI) is a common problem in elderly people, due mainly to functional impairments and concurrent medical diseases. Few studies, however, have assessed the prevalence of UI in noninstitutionalized individuals. The objectives of the present work were to estimate the prevalence of UI in a community-based population of elderly Italians and to determine the associated physical, social, and psychological factors.        Methods. A random sample of noninstitutionalized men (n = 867) and women (n = 1531), aged 65 years and older, from the Veneto region of northeastern Italy, were interviewed at home, using an extensive multidisciplinary questionnaire, to assess their quality of life and social, biological, and psychological correlates.        Results. The prevalence rate of UI was of 11.2% among men and of 21.6% among women. Among those reporting the condition, approximately 53% of women and 59% of men reported experiencing incontinence daily or weekly. Association of UI was found for participants older than 70 years in both men (odds ratio [OR] 2.49, 95% confidence interval [CI] 1.45–4.28) and women (OR 1.49, 95% CI 1.11–2.02). Three of the medical conditions investigated were associated with increases in the odds in women, namely chronic obstructive pulmonary disease (OR 1.53, 95% CI 1.11–2.12), Parkinsonism (OR 2.27, 95% CI 1.14–4.54), and hip fracture (OR 1.38, 95% CI 1.02–1.88), whereas chronic diarrhea was the only condition associated with UI in men (OR 6.92, 95% CI 2.22–21.5). Participants with a physical disability were two times more likely to report incontinence, and the odds were increased by 50% in women who had sleep disturbances.        Conclusions. Incontinence is highly prevalent in the Italian elderly population, and several common chronic conditions are significantly associated with it. Moreover, very few people with incontinence seek health care or are aware of potential treatments.                              hwp-legacy-fpage          M14                          hwp-legacy-dochead          RESEARCH ARTICLE                            Decision Editor: John E. Morley, MB, BCh            URINARY incontinence (UI) is a common problem in elderly people, due mainly to functional impairments and concurrent medical diseases (1)(2). Several studies have determined the prevalence of UI in nursing homes (3)(4) and in the community (5)(6). The reported prevalence rates approximate 50% for people in nursing homes and range between 2% and 55% for adults living in the community, depending on the definition of incontinence, the population characteristics, and the methodological approach (7).    The burden of UI on elderly people is evidenced not only by the economic costs but also by other adverse effects on health and quality of life. UI has been estimated to account for 2% of health care costs in the United States and Sweden (8) and is one of the main reasons for the permanent institutionalization of elderly people (9). In Italy, cost estimates are available for patients with dementia and UI: An average of 1000 US$ is spent each year for pads alone, the most commonly used remedy for incontinence in elderly persons (10). The physical complications may be serious and include an increased risk of urinary tract infections, pressure sores and other skin problems, and sleep disturbance. People with UI also report significant and often long-lasting social and psychological effects such as decreased social interaction and greater feelings of depression and isolation (11)(12)(13)(14)(15)(16)(17).    The purpose of this cross-sectional study was to estimate the prevalence of UI in a community-dwelling population of elderly Italians and to determine the associated physical, social, and psychological factors.          Methods              Study Population        The details of the methods have been described elsewhere (18). Briefly, the population for the Veneto Study consisted of a random sample of 2700 noninstitutionalized individuals aged 65 years and older, residing in the community on May 1, 1989 in five rural and four urban defined geographic areas of the Veneto region of northeastern Italy. Names and addresses of eligible individuals were obtained from the resident lists maintained by the municipalities, in which all births and deaths are registered within one week of their occurrence. A random sample from each of five age strata (65–69, 70–74, 75–79, 80–84, and 85+ years) was taken, with an over-sampling of those aged 85 years and older to obtain 20% of the total sample in this age category. Approximately 8.4% of the total elderly population of the Veneto Region was aged 85 years and older in 1989 (19).        Eighty-nine percent (n = 2402) of people identified as eligible participated in the study. The 298 nonrespondents included those who refused to participate, those who were not found at home after three attempts on different days, or those for whom a proxy refused their participation due to severe dementia or terminal illness (approximately 2%). Only basic demographic data for nonrespondents were collected from a proxy; all data presented herein were provided by the respondents themselves. After exclusion of four people with missing or incorrect demographic data, the final number available for analysis was 2398.                    Assessment of Participants        All participants were administered a comprehensive interview and a brief physical examination in the home. The interview obtained information on sociodemographic characteristics, living arrangements, family composition, social support, income (including family contributions), participation in social activities, self-reported history of medical conditions, health status, physical functioning (including activities of daily living [ADLs] (20) and instrumental activities of daily living) (21), health behaviors, self-rated health, and use of health and social services. Low mental status score was defined as a score of <0.8 for the ratio of the number of questions answered correctly to the number of possible answers (i.e., less than 24 correct answers out of 30, if all questions were applicable), or an adjusted score (number of questions answered correctly divided by the number answered, if some of the questions were not applicable) on the Mini-Mental State Examination (22). Participants whose scores on the Center for Epidemiologic Studies–Depression scale (CES-D) (23) were in the upper quintile (CES-D score >8.8 for men and >24.5 for women) were categorized as having depressive symptomatology.        The interviewers were physicians enrolled in a postgraduate geriatric medicine program, trained to administer performance measures in a standardized manner and certified by a scientific training committee. The examination included assessments of height, weight, vision, hearing, and a qualitative assessment of physical performance.                    Assessment of Urinary Incontinence        Participants were asked if they had UI problems and how often they occurred: rarely, 1 to 2 times per month, at least once per week, or every day. Participants were asked whether the incontinence occurred only under strain (i.e., during coughing or sneezing), if they used any remedies, and if they were aware that there are remedies.                    Health Status Indicators and Medical Conditions        Participants were classified as having a disability in the basic ADLs if they reported that they needed help from another person or that they were unable to perform one or more of the following activities: bathing, dressing, getting out of bed, or eating. Mobility disability was classified as “difficult” or “impossible” to climb stairs, to walk 800 m without resting, or as the need for help from another person or the inability to walk across a room.        Participants were asked how often they (i) have trouble falling asleep, (ii) have trouble with waking up during the night, (iii) have trouble with waking up too early and not being able to fall asleep again, and (iv) feel really rested when they wake up in the morning. Night awakeners were defined as those who reported often or always waking up during the night.        History of arthritis, diabetes, hypertension, chronic respiratory disease, stroke, heart disease, Parkinsonism, and chronic diarrhea was ascertained by asking participants if a doctor had ever told them that they had the condition.                    Data Analysis        To account for the over-sampling of persons aged 85 years and older, the prevalence of urine incontinence was calculated using weights determined by the ratio between the population fraction relative to the 1991 census population and the sampling fraction relative to the age stratum. All statistical analyses were conducted using the SAS statistical analysis package (SAS, Inc, Cary, NC) (24). The association of UI with the sociodemographic, behavioral, health, and other factors was assessed in logistic regression models with incontinence as the dependent variable.                    Results      Table 1  shows the distribution of our sample by the main demographic and health-related characteristics. The final sample consisted of 867 men (mean age 75.2 ± 7.1 years) and 1531 women (mean age 76.9 ± 7.6 years). Women had a significantly lower education level and higher prevalence rates of mental and physical health disorders and obesity than males. A greater percentage of women reported fair or poor self-rated health and used sleep medications more often than men. Conversely, more men than women reported drinking alcohol and cigarette smoking.      Data regarding the prevalence rates and the frequency of UI are presented in Table 2  and Table 3 . The prevalence rate was 11.5% among men and ranged from 4.6% for those aged 65 to 69 years to 23.6% for participants aged 85 years and older. In women, the prevalence rate was of 21.6%, ranging from 16.4% to 34.7% for the same age groups. Among the 415 participants with this condition, 36.8% reported that they experienced incontinence every day, and 17.7% reported that they experienced incontinence every week. Approximately 59% of men and 53% of women reported that they experienced UI frequently (every week or day). Although the percentages showed a trend with age, the association was not statistically significant (p = .06). Nevertheless, more than 50% of the affected people aged 65 to 69 years faced this problem frequently versus 67% of subjects aged 85 years and older. Approximately 58% of women and 28.5% of men (data not shown) stated that they experienced incontinence only under stress.      Table 4  shows the ORs for the association of all sociodemographic and health-related factors with incontinence by sex. After adjustment for other factors, age 70 years and older, ADL disability, and mobility disability were significantly associated with incontinence in both elderly men and women. Diarrhea showed the strongest association in men but was not significant in women. Chronic obstructive pulmonary disease (COPD), Parkinsonism, hip fracture, and night awakening were significant in women but not in men. Self-rated health was borderline significant in men only.              Discussion      UI is a highly prevalent condition in elderly persons and deeply affects quality of life because of its negative effects mainly on social interactions, but also on physical health. The prevalence rates of UI in our study are high, similar to those reported in previous studies (25)(26)(27), but seem to be higher compared with those reported in a recent study conducted in Italy (28). However, the different methodologies could easily explain the discrepancies. The study by Bortolotti and colleagues (28) was carried out using a telephone interview, and we believe that it might exclude sicker people and therefore those at higher risk for incontinence and other chronic conditions. Moreover, our survey was carried out by physicians, who left the most sensitive questions, such as those related to incontinence, toward the end of the personal interview, when a more relaxed interaction with the participants was established, which would enhance the reliability of their answers.      We confirmed a higher prevalence of UI among women than men and noted that it represents a severe problem for most of them, given that about half of those reporting incontinence experience it every day or more than once a week. The increasing prevalence with age has been also found in other studies (7), and this could be associated with age-related conditions, such as prostatic hyperplasia among men (29). Data on the presence of diseases were self-reported by the participants, and therefore we did not ask information about the prevalence of prostatic hyperplasia because of the high probability of underreporting for that condition. Age, parity, and menopausal status with the consequent incompetence of the internal urethral sphincter could be determinants of stress incontinence among elderly women (30), and, indeed, its frequency was twice as much as in men. Physical disability was a positive risk factor for functional incontinence in this population, and problems in mobility could easily explain this association. We also found a strong association with Parkinsonism and hip fracture, easily explained both in terms of the neurological impairments and mobility problems of these patients (31). The higher risk of incontinence in women with COPD could be due to the effect of increased abdominal pressure when coughing and the consequent stress incontinence, as already described in previous reports (32).      Night awakening was associated with incontinence in women and not in men. This was surprising, given that prostatic problems and need to void urine usually lead to frequent night awakening and to nocturia among elderly men. It is possible that the higher prevalence of physical disability among women was responsible for their functional incontinence.      A recent study (5) has underlined that few community-dwelling elderly persons seek health care for UI in spite of its high prevalence in this group. Given that symptomatic improvement or a cure would be possible in many cases, a better evaluation of this condition is needed. This would require increasing the sensitivity and knowledge of the population about these problems and about potential medical and behavioral interventions. It is certain that most people, particularly women, tend to use pads as the only solution to the problem, ignoring completely that other more appropriate and definite approaches could be very effective. Of course, treatment of incontinence requires attention to the general health status of an individual (1)(33). Treatment of urinary infections or estrogen deficiency or prostatic problems should be the first step when these conditions are present. Pelvic floor exercise could be very effective for patients with stress incontinence, while behavioral interventions, such as decreasing fluid intake, particularly caffeine-rich drinks, could be general measures applied to all patients (34)(35).      This study has some limitations. First, the use of cross-sectional data does not allow for the assessment of the cause-and-effect relationship between incontinence and health conditions. Second, information on medical conditions and physical function was self-reported. However, several studies support the reliability of information on health status reported by the elderly population (36)(37). Moreover, the prevalence of diseases investigated was comparable to that reported in other studies (38), and the association with incontinence was consistent with previously reported findings in different populations (1)(2)(3)(4)(5)(6). This study has some peculiar strengths, such as the high response rate and the representativeness of the sample, that allow the generalizability of our results to the elderly population of Italy.      In conclusion, incontinence is probably more frequent than generally known among community-dwelling individuals and has a negative impact on their quality of life and general health status. Given that symptomatic improvement or treatment is possible in many cases, physicians should always ask their elderly patients about incontinence and then provide appropriate evaluation and management of it.                                                  Table 1.                                 Sociodemographic and Health-Related Characteristics by Sex (Veneto Study, 1989)                                                                                                              p Value                                                                                            Men (n = 867)                Women (n = 1531)                Difference Between Men and Women                Age Trend for Men                Age Trend for Women                                            Demographics                                                                                                                            Mean Age, y (SD)                75.2 (7.1)                76.9 (7.6)                <.001                                                                            Marital Status (%)                                                <.001                <.001                <.001                                            Married                78.1                32.0                                                                                            Not married                5.9                12.5                                                                                            Widowed                15.1                54.1                                                                                            Divorced                0.9                1.4                                                                                            Education (%)                                                <.001                .156                <.001                                            ≤5 y                70.6                82.5                                                                                            6–8 y                14.8                10.7                                                                                            9–13 y                9.7                5.7                                                                                            University                4.9                1.1                                                                                            Mental Health (%)                                                <.001                <.001                <.001                                            Low mental status\|[dagger]\|                18.8                27.1                                                                                            Depressive symptomatology (%)                                                <.001                .522                .028                                            Low CES-D score\|[Dagger]\|                8.8                24.5                                                                                            Physical Health (%)                                                                                                                            Disability status                                                                                                                            Mobility disability\|[sect  ]\|                28.5                41.5                <.001                <.001                <.001                                            ADL disability\|[Verbar]\|                12.4                17.6                <.001                <.001                <.001                                            Body mass index\|[para  ]\|                                                <.001                <.001                <.001                                            ≤20                4.1                4.8                                                                                            >20 and <26                46.1                38.9                                                                                            ≥26 and <31                37.8                37.4                                                                                            ≥31 and <35                10.5                15.0                                                                                            ≥35                1.5                3.9                                                                                            Self-rated health                                                <.001                .017                0.837                                            Excellent/good                62.6                50.3                                                                                            Fair/poor                37.4                49.7                                                                                            Behavioral Factors (%)                                                                                                                            Use of sleep medications                                                <.001                .219                .702                                            Sometimes                6.6                11.3                                                                                            Often/always                13.9                24.2                                                                                            Alcohol use                                                <.001                .157                .412                                            Abstainers                3.6                16.2                                                                                            Past users                10.5                15.2                                                                                            Current users                86.0                68.5                                                                                            Cigarette smoking                                                <.001                <.001                <.001                                            Never smokers                17.6                81.1                                                                                            Former smokers                57.9                10.9                                                                                            Current smokers                24.4                8.0                                                                                                                        Note: CES-D = Center for Epidemiologic Studies–Depression Scale; ADL = activities of daily living.                                      \|[dagger]\|              Mini Mental State Examination score ratio ≤0.8.                                      \|[Dagger]\|              CES-D score >80th percentile.                                      \|[sect  ]\|              Reported climbing stairs or walking 800 m without resting as difficult or impossible.                                      \|[Verbar]\|              Reported needing help from another person or unable to perform one or more of the following activities: bathing, dressing, getting out of bed, eating, or walking across a room.                                      \|[para  ]\|              Weight (kg)/height (m)2.                                                            Table 2.                                 Prevalence of Urinary Incontinence by Age and Sex                                                                              65–69 y                70–74 y                75–79 y                80–84 y                ≥85 y                Total                                            Men                4.6                12.6                12.3                22.2                23.6                11.5                                            Women                16.4                17.8                24.8                23.9                34.7                21.6                                                                        Note: Data are given as percentages.                                                            Table 3.                                 Frequency of Urinary Incontinence by Age and Sex                                                                              65–69 y                70–74 y                75–79 y                80–84 y                ≥85 y                Total                Men                Women                                            Rarely                34.6                44.6                24.7                33.3                20.0                31.6                26.5                33.3                                            1 to 2 times a mo                13.0                10.8                18.0                14.1                12.6                13.9                14.5                13.7                                            Every week                20.2                13.4                22.9                15.4                14.1                17.7                13.6                19.0                                            Every day                32.2                31.2                34.4                37.2                53.3                36.8                45.4                34.0                                                                        Note: Data are given as percentages.                                                            Table 4.                                 Odds Ratios for the Association of Sociodemographic and Health-Related Factors With Incontinence, by Sex                                                              Factor                Odds Ratio                95% CI                p Value                                            Men                                                                                            Age ≥70 y                2.49                1.45–4.28                .0009                                            Diarrhea                6.92                2.22–21.50                .0008                                            Comorbidity                1.52                0.89–2.61                .12                                            ADL disability                2.31                1.23–4.32                .009                                            Mobility disability                2.11                1.16–3.85                .01                                            Self-rated health                1.69                0.997–2.88                .05                                            Women                                                                                            Age ≥70 y                1.49                1.11–2.02                .008                                            COPD                1.53                1.11–2.12                .01                                            Parkinsonism                2.27                1.14–4.54                .02                                            Hip fracture                1.38                1.02–1.88                .04                                            ADL disability                1.75                1.22–2.52                .002                                            Mobility disability                1.81                1.32–2.49                .0003                                            Night awakening                1.48                1.11–1.97                .007                                                                        Note: CI = confidence interval; ADL = activities of daily living; COPD = chronic obstructive pulmonary disease.                                                      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