Urinary incontinence is a contributing factor in falls among older adults

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A team of University of Alberta researchers focused on aging Albertans has found that urinary incontinence could be a contributing factor in falls among older adults.

incontinence

“Falls are the leading cause of accidental death in seniors, and many people don’t know that having bladder control problems makes you about twice as likely to fall over,” said William Gibson, lead author of the study and assistant professor of geriatric medicine.

“There’s not previously been a lot of evidence that treating people’s incontinence reduces their risk of falling. So this is a jumping-off point, because now we’ve demonstrated that the sensation of urgency is a source of distraction.”

The team studied the gait of nearly 30 older adults diagnosed with overactive bladders with the help of the gait lab in the Syncrude Centre for Motion and Balance at the Glenrose Rehabilitation Hospital.

Using the lab’s 3D capture technology, which takes highly accurate measurements of gait and joint position, the researchers asked subjects to walk the length of the lab and back – first under normal conditions, then while doing a simple cognitive test at the same time, and finally after drinking enough water or tea to make them feel the urge to go to the bathroom.

The team found that the feeling of urgency caused by a full bladder induced similar changes in gait to those caused by the distracting task: The gait of the subjects tended to become slower and narrower, which is associated with increased risk of falling.

“This is pretty good evidence that people with incontinence are being distracted by their bladders, which means that they’re less able to concentrate on walking,” said Gibson.

“Being balanced and walking require some cognitive inputs, and for young, healthy people, they don’t have to think about walking,” he explained. “But when you’re older, with changes to the brain, it requires more cognitive input to maintain balance. If you’ve then got a distracting factor of your bladder, it makes you more likely to fall.”

One of the issues with incontinence is that despite being common in older adults, it isn’t talked about very much, even between a physician and their patient, Gibson said.

“If you don’t ask specifically about incontinence, people won’t tell you,” he said.

“There are many reasons for that: People think it’s a normal part of getting older, people are embarrassed or think there’s nothing you can do about it. But if you’re a family physician looking after someone who is having problems with falls, one of the things that should be asked is,

‘Are you also having problems with your bladder?’

If so, then what can be done about that?”

Gibson said future research could explore whether treating incontinence has any effect on falling risk. One treatment avenue is using medications to treat overactive bladders, but another approach that may show promise is using physiotherapy and special training to reduce incontinence, he said.

Gibson said he hopes the wider health system takes away an increased awareness of the link between incontinence and balance, and a better appreciation of how much of a problem incontinence is.

“This is the first time the link between bladder urgency and falling risk has been demonstrated, and it’s nice to be challenging the preconceived notion that the reason people are falling is because they’re running for the toilet,” he pointed out. “I think we’ve really put that one to bed and shown that it’s much more complicated than that.

“It opens up a big field of potential research, which we’ll be doing more of moving forward.”


The proportion of adults aged ≥65 years is increasing more rapidly than that of people in other age groups because of the global increase in life expectancy. However, this increase in life expectancy also increases the risk of geriatric syndromes, which are defined as the set of multifactorial conditions affecting older adults who are vulnerable to the changing circumstances [1].

Inouye et al. reported a high prevalence of five geriatric syndromes, namely, falls, incontinence, pressure ulcers, delirium, and functional decline, which are associated with high morbidity and poor quality of life [1].

Of these geriatric syndromes, falls represent one of the most important and increasing public health problems affecting older adults because these events often require medical attention. The World Health Organization (WHO) defines falls as “events that result in a person coming to rest inadvertently on the ground or floor or other lower-level.”

These events are often recurrent, and approximately half of the affected individuals experience another fall within 1 year [2]. According to the WHO, 28–35% of people older than 65 years of age fall each year, and this prevalence increases with age [3].

Another study determined that more than 30% of older (>65 years) home-dwelling individuals fall at least once per year [4]. Consequently, a substantial proportion of these individuals develop serious injuries, pain, depression, and other comorbidities.

Even a slight fall can cause a fracture, which increases the risk of institutionalization and the associated economic burden. Falls also instill a source of fear in caregivers and negatively affect the healthcare systems [3]. In summary, falls result in negative health outcomes and limit the quality of life of older individuals, and strategies to prevent this geriatric syndrome should be established.

Assessing the association between falls and other geriatric syndromes [1] is clinically important in preventing falls. This syndrome is highly prevalent in the general population and affects men and women of all ages. Of the other geriatric syndromes, urinary incontinence (UI) is more common in women than in men; however, and the prevalence increases with age.

Current estimates suggest that approximately 20 million women and 6 million men in the United States experience UI during their lives. This condition has been shown to affect 11–34% of men and 13–50% of women older than 60 years and 43–80% of all older nursing home residents [5].

UI is associated with not only a decreased quality of life but also a longer hospital stay and a reduced chance of hospital discharge [5]. However, many patients, particularly older individuals, avoid or do not receive treatment for UI due to the social stigma attached to the condition.

Although several epidemiological studies have evaluated the effects of UI on falls, the results of analyses based on age, sex, and the definition of falls have been inconclusive. Although some studies reported that UI is positively associated with falls [6–8], others indicated no association [9–11].

Hence, a meta-analysis was warranted to clarify our understanding of the role of UI in falls. We, therefore, performed a meta-analysis to provide evidence and determine the effect of UI on the risk of falls based on a comprehensive investigation of the literature. Furthermore, we conducted subgroup analyses based on patients’ mean age, sex, the definition of falls, and type of UI.

Discussion

Although UI is a known risk factor for falls, the strength of the association between these conditions remains unclear because of variability in the study designs and populations used in previous risk estimations. This systematic review and meta-analysis conducted to evaluate the association between falls and UI revealed that UI was associated with overall falls. Our analysis identified a probable excess OR of 65% for at least one fall among people with UI relative to those without UI. An analysis of participants with recurrent falls yielded a similar trend and a higher risk magnitude. The overall OR for recurrent falls was 63% among people with UI relative to those without UI.

In a subgroup analysis, we determined that the OR for falls increased by 59% in older adults (≥65 years) with UI relative to those without UI. These findings exceed those of older systematic reviews that considered a more limited range of fall-related outcomes and consistently reported an increased risk of falls and fractures among participants with UI [47]. UI is of significant concern to older adults and can lead to isolation and reduced self-worth. Previous studies have identified various risk factors for falls, such as old age, female sex, visual disturbances, cognitive disorders, low body mass index, and UI.

We conducted another subgroup analysis according to the type of UI. A previous review highlighted a predominant association of falls with urgency UI, rather than with other types of UI [47]. This association is attributed to the urgent need to use the toilet and the anxiety associated with a failure to reach the toilet. Several studies have shown that behavioral changes induced by UI can affect the likelihood of falls [48, 49]. Our analysis also showed a higher risk of falls in patients with urgency UI than in those with stress UI. Falls related to this condition have been generally reported to occur in the toilet [7, 47]. Despite this relationship, however, the commonly held assumption that urgency leads to falls while rushing to the toilet has not been confirmed yet [6].

Few studies have investigated the relationship between UI and falls [47], and the causality between UI and falls remains unexplained [6]. However, one hypothesis is that a strong desire to void could change gait parameters and thus, increase the risk of falls [50]. The reduced velocity and stride width during strong desire to void conditions (i.e., urgency) in the UI group could explain their high fall rate [50]. The other hypothesis is that women with impaired mobility probably take a longer time to reach the toilet; hence, if there is a high degree of urgency, then impaired mobility can increase the risk of UI [51].

Therefore, the causality between UI and falls could probably be explained by a strong desire to void and physical impairments in mobility and balance [50, 51]. However, although these hypotheses could explain the relationship between the urgency-type UI and falls, they are rather insufficient to explain the association between stress-type UI and falls. Since the symptoms of urgency UI and stress UI are clinically different, the association between stress UI and falls may indicate a general alteration in the striated muscle physiology in the aging population [8]. In addition, restricted mobility in older women may limit their ability to change positions to prevent stress UI [22].

There is a well-recognized association between falls and lower urinary tract symptoms (LUTS) in older adults [7, 8, 47, 52, 53]. Older people with urgency or urgency UI are significantly more likely to fall than age-matched controls, with ORs for falls ranging between 1.5 and 2.3 [6, 47, 54, 55]. However, the reason for this association is not understood and has not been thoroughly studied [6].

In a recent systemic review on the association between falls and LUTS conducted by Noguchi et al., none of the identified studies had investigated the potential causes of these associations. In addition, the categorization of UI and degree of accounting for confounding variables were inconsistent across the studies [56]. Although the data identified were suitable only for qualitative synthesis, UI and storage symptoms among LUTS have been consistently reported to have a weak to moderate association with falls [6, 56].

As our findings suggest that this association is significant, the identification and treatment of UI may be an effective intervention for reducing the risk of falls, especially in older adults. Bladder training, timed or prompt voiding, and environmental modifications (e.g., a bedside commode) may decrease the incidence of falls [7].

Concerning the impact of UI on the risk of falling, many falls are related to a person’s physical condition or medical problems, such as multimorbidities, polypharmacy, neurological diseases, and sarcopenia, as well as urological comorbidities [57]. Especially, multiple medications, such as blood pressure-lowering drugs causing orthostatic hypotension, psychotropics, anticonvulsants, and sedatives, can contribute to falls [57].

In addition, the geriatric syndrome has a multifactorial etiology, with the factors being closely related to each other [1]. Among them, UI and falls are very important for the older population, and both are associated with sarcopenia [8, 58, 59]. Therefore, an appropriate statistical approach to decrease the impact of such confounding variables is necessary for correct analysis of the association between UI and falls.

The strengths of this study include the collection of evidence through a rigorous systematic review and meta-analysis. This study also included a comprehensive search of both published and unpublished studies. Multiple measurements of falls were considered, consistent with multiple types of risk estimates. Although many studies have included UI as a risk factor for falls, only a few studies have identified UI as an individual risk factor [47]. Therefore, this is the first systematic review and meta-analysis to evaluate UI as an individual risk factor for falls.

Despite these strengths, our study was limited largely by the included studies, particularly the significant heterogeneity, quality of the study designs, and reporting scope of the original articles. However, when studies with a critical risk of bias were excluded, significant results were observed.

In addition, no publication bias was observed, and the results were not changed by specific studies in the sensitivity analysis. Furthermore, although we conducted subgroup analyses based on age, sex, and type of UI, we did not perform analyses according to the severity of UI. Finally, the paucity of evidence regarding the severity of UI limits the applicability of our current findings with regard to an accurate correlation between UI and falls.

In conclusion, the continued increase in the proportion of older adults globally will lead to continued increases in the clinical and economic impacts of serious falls. Based on evidence from the published literature and a meta-analysis, we demonstrate here that UI is a predictor of more frequent falls in both general and older adults. Clinicians should, therefore, be aware that UI predicts an increased risk of falls that could lead to fractures and should, therefore, provide appropriate precautions and care. Future studies are needed to address the impact of UI treatment on the incidence of falls.

reference link : https://medicalxpress.com/news/2021-12-links-overactive-bladder-falling-older.html


More information: William Gibson et al, Urinary urgency acts as a source of divided attention leading to changes in gait in older adults with overactive bladder, PLOS ONE (2021). DOI: 10.1371/journal.pone.0257506

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