Caffeine worsens symptoms in overactive bladder and urge urinary incontinence by five fold. What modifiable factors would affect bladder symptoms?

1. Urinary incontinence
type, cause and effect: result of a pilot study
Michelle Lai1, Chok Lui2, Charles Inderjeeth2, Jan Little1, Mary King3
1
Dept of Community and Geriatric Medicine, Fremantle Hospital, Fremantle, Western Australia.
2
Dept of Rehabilitation and Aged Care, Sir Charles Gairdner Hospital, Perth, Western Australia.
3
Corporate nursing, Sir Charles Gairdner Hospital, Perth, Western Australia.
Background:
•
•
Key management in urinary incontinence (UI) in older patients is to identify
potentially reversible causes, so appropriate steps can be instituted to reduce
their impact.
Little data exist pertaining to modifiable causes of UI among older ambulatory
patients. Most studies examining risk factors were conducted in middle aged(1)
(2)
, homebound, frail(3)(4) or institutionalised older patients(5). Known risk factors
in older community dwelling individuals were ill-defined. These include comorbidities such as stroke, diabetes, arthritis, obesity, depression, mobility
and functional impairment(6)(7).
Aim:
•
To describe the correlates of modifiable causes of UI in this population.
Method:
•
In this cross-sectional study, 91 patients were recruited from a general
geriatric and 2 continence clinics, including 27 patients without incontinence
as control. Continence advisors or clinicians completed questionnaires after
initial assessment with history, clinical examination, bladder chart and bladder
scan. Univariate and multivariate analysis were performed.
Result:
•
•
•
•
•
Patients were predominantly Caucasian (92.2%) and female (76.6%) [mean
age=79.24, SD=8.47] .
Logistic regression analysis (table 3) revealed that patients presented with
urge incontinence were more likely to consume regular tea/coffee (adjusted
OR 5.62, 95% CI 1.73-18.32) and have functional disability (adjusted OR 3.55,
95% CI 1.18-10.66).
Patients with mixed (urge and stress) incontinence were more likely to have
depression (adjusted OR 4.33, 95% CI 1.03-18.13), use diuretics (adjusted OR 3.75,
95% CI 0.96-14.60) and hypnotics (adjusted OR 8.12, 95% CI 1.54-42.77).
For both types of incontinence, only patients with diuretics reported worse
perceived bladder symptoms (OR 5.18, 95% CI 1.03-26.13 respectively)
compared to those without these 2 features. However, there was no difference
in bladder charts between the 2 groups.
Table 2.
Univariate analysis of reversible factors and age with urinary urge and
mixed (urge and stress) incontinence
Attributes Case (N) Urge incontinence
OR (95% CI)
Age, years
55-75 26 1.0 (referent)
>75 65 0.46 (0.18-1.16)
Lifestyle factors
Tea/coffee consumption 18 4.43 (1.42-13.79)
Medications
Diuretics 21 0.73 (0.27-1.98)
NSAID 9 1.68 (0.42-6.71)
Anti-psychotics 3 0.63 (0.06-7.19)
Anti-depressants 18 0.63 (0.27-2.21)
Hypnotics 8 0.40 (0.08-2.07)
Medical conditions
Congestive cardiac failure 10 2.07 (0.54-7.92)
Diabetes Mellitus 20 2.30 (0.84-6.35)
Depression 13 0.52 (0.15-1.83)
Urinary tract infection 9 1.68 (0.42-6.71)
Constipation 13 0.79 (0.24-2.64)
Poor ADL 19 2.69 (0.95-7.67)
Likelihood ratio chi-square test was performed.
Level of significance at *p<0.01, #p<0.05 and ^p≤0.10
OR = odds ratio
NAa not applicable - no case in one cell
(n=40)
p-value OR
Mixed incontinence (n=15)
(95% CI) p-value
0.11
1.0 (referent)
3.00 (0.65-14.35) 0.22
<0.01*
1.02 (0.25-4.06)
0.98
0.54
0.46
0.70
0.63
0.25
2.71 (0.84-8.80)
0.61 (0.70-5.25)
NAa
1.61 (0.45-5.81)
6.55 (1.43-30.05)
0.11
0.63
0.29
0.49
0.02*
0.28
0.10^
0.29
0.46
0.70
0.06^
0.53 (0.06-4.54)
0.87 (0.22-3.43)
4.25(1.16-15.59)
0.61 (0.07-5.25)
0.90 (0.18-4.53)
0.94 (0.24-3.73)
0.57
0.84
0.04#
0.54
0.89
0.93
Table 3.
Multivariate analysis of reversible risk factors for urge and mixed
(urge and stress) incontinence
Attributes
Unadjusted
OR (95% CI)
For urge incontinence (n=40/91):
Tea/coffee consumption
5.48(1.70-17.70)
Poor ADL 3.52(1.18-10.51)
Constant
For mixed incontinence (n=15/91):
Depression 4.32(1.05-17.72)
Diuretics 3.76(1.02-13.85)
Hypnotics 8.12(1.54 -42.77)
Constant
where OR=odds ratio
p-value
Age-adjusted
OR (95% CI)
<0.01
0.02
-1.27
5.62(1.73-18.32) <0.01
3.55(1.18-10.66) 0.02
0.59
0.04
0.05
0.01
-2.61
4.33(1.03-18.13)
3.75(0.96-14.60)
8.12(1.54-42.77)
p-value
0.05
0.06
0.01
-2.63
Power analysis:
• We have 80% power to detect an odds ratio of 2.6, based on the assumption
that 10% of patients having the attribute.
Sample size consideration:
• We intend to recruit 283 patients to have 80% power to detect an odds ratio
of 2 with significance level of _=0.05.
Graph1. Sample size analysis against power from the pilot study
The number of patients with stress incontinence was too small to perform
risk factor analysis.
Table 1
Demographic characteristics of patients with all cause incontinence
Characteristics
Age
Residence (n,%)
Community
Hostel
Ethnicity
White
Asian
Others
Cognition
Normal
MCI
Dementia
Not documented
MMSE
ADL
High functioning
Moderately impaired
Severely impaired
Patients with (n=64) Male (n=15)
all cause incontinence
79.56± 8.53 74.40 ±6.22
Female (n= 49)
63 (98.4)
1 (1.6)
15 (100)
0 (0)
48 (98.0)
1 (2.0)
59 (92.2)
2 (3.1)
3 (1.7)
13 (86.7)
1 (6.7)
1 (6.7)
46 (93.9)
1 (2.0)
2 (4.1)
50 (78.1)
1 (1.6)
8 (12.5)
5 (7.8)
25.70±4.21
12 (80.0)
1 (6.7)
1 (6.7)
1 (6.7)
28.00±2.35
38 (77.6)
1 (2.0)
7 (14.3)
3 (6.1)
24.93±4.46
20 (31.2)
34 (53.1)
5 (7.8)
Not documented 5 (7.8)
aP =0.05, compared with male group
81.14 ±8.57a
1 (6.7)
13 (86.7)
1 (6.7)
19 (38.8)
21 (42.9)
4 (8.2)
0
Discussion:
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Some predictors of UI proven in nursing home setting are not applicable to
community patients such as delirium and different levels of restraint. A separate
model of risk factors is warranted.
•
UI was not shown to increase with age in our study. It may be explained by
healthy survival bias with the cross-sectional design. Those older than 75 who
survived may be healthier and more likely to be continent. The association of
UI with hypnotics deserves further investigation.
5 (10.1)
Conclusion:
Reference:
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Palmer MH, German PS, Ouslander JG. Risk factors for urinary incontinence one year after nursing home admission.
Res Nurs Health 1991;14:405-12.
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Composition Study. Obstet Gynecol. 2004 Aug;104(2):301-7.
•
The modifiable independent risk factors of UI with urgency symptoms in older
patients were excessive tea/coffee, diuretic, hypnotic use, depression and
functional disability.
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Poorer perceived symptoms were reported with diuretic use.
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Established UI in the elderly is often multifactorial. Identifying important factors
will alert healthcare workers in identifying patients at risk of developing the
condition and implementing early preventive measures.
•
Our results support an extended study to provide evidence to our practice and
to explore the effect size of these risk factors.
1.
AVPU REF NO: 2317-08