Effects of Urge Urinary Incontinence on Quality of Life in Older People

Do you frequently have to rush to get to the toilet on time? Do you awaken from sleep several times at night to urinate? Do you lose urine on the way to the bathroom? For most of our patients who answer yes, these symptoms are a considerable source of misery and distress. In the practice of geriatrics, we are particularly concerned with relieving our patients' misery and distress and improving their function and quality of life. However, our ability to measure the impact of conditions such as urinary incontinence, and interventions for these conditions, on the quality of life of our older patients remains quite limited. In this issue of the Journal, two brief reports describe the development of tools for measuring the impact of urge urinary incontinence in the geriatric population.1,2 Although tools already exist for the measurement of quality of life among patients with urinary incontinence and related lower urinary tract symptoms,3–10 none have focused specifically on urge type incontinence. The focus on urge incontinence is especially important in the geriatric population for several reasons. First, irritative lower urinary tract symptoms, including urinary frequency (voiding more often than every 2 hours), nocturia (voiding two or more times during normal sleeping hours), urgency, and urge type incontinence are very common in older people. Urge is, in fact, the most common symptomatic type of incontinence among frail older patients, although among women it often coexists with symptoms of stress type incontinence. Further, detrusor hyperactivity, which is generally associated with urge incontinence, is the most common urodynamic abnormality found in the geriatric population. Second, research data suggest that irritative symptoms, including urge incontinence, are more bothersome for older patients than symptoms of stress incontinence and voiding difficulty.11 Third, we now have behavioral and new pharmacologic therapies that are effective in reducing the symptoms of urge incontinence,12,13 and we need validated tools that measure the impact of these interventions on the difficulty these symptoms cause older patients in their everyday lives. Measuring the impact of a condition such as urge incontinence and its treatment on the everyday life of older patients is tricky business. Perhaps this is why many studies in the past have reported the effects of treatment on such parameters as bladder volume at first or must urge to void, bladder capacity, and the presence or absence of involuntary bladder contractions. Although these parameters can also be difficult to measure, they are objective and quantifiable and give us insights into the pathophysiology of the condition and the mechanisms of action of therapies. However, patients do not really care about a 50-mL increase in their bladder capacity, especially when it requires a repeat urodynamic study to document it. They are, however, very concerned about the anxiety caused by not being around a toilet, the fear of embarrassment resulting from a urinary accident in public, and the inability to travel in a car or go grocery shopping or to a social event because of this anxiety and fear. The validation and use of voiding diaries as a key outcome in therapeutic studies is a step in the right direction, but how do we measure impacts on quality of life given the heterogeneity of older patients with urge incontinence in terms of activities, preferences, expectations, and coping mechanisms? The common coexistence of dementia and urge incontinence further challenges our ability to elicit the impacts of therapy on quality of life in this population. Several tools now exist to measure the quality of life impact of incontinence in various populations, but none have been well tested for their sensitivity to change with therapy in older patients. Wyman and colleagues have done particularly important work in developing, validating, and using the Incontinence Impact Questionnaire (IIQ) to measure the effects of behavioral therapy among older women.3,4,7 The lack of a clear relationship between urodynamic and symptomatic responses on one hand and changes in the impact scale on the other highlights the difficulties we face in measurement and points to the need to refine and further validate additional tools. It is in this context that the two Brief Reports in this issue of the Journal provide useful approaches to meeting this need. The study by Brown and colleagues begins with the established IIQ and the Urogenital Distress Inventory (UDI). They have modified these instruments to be more specific to urge or urge dominant incontinence using patient focus groups, previous literature, and expert clinical opinion.1 The instruments were tested in an ethnically diverse sample with a broad age range and relatively severe incontinence. The study by DuBeau and colleagues also reports on the development and testing of a quality of life instrument specific to urge urinary incontinence, but it focuses specifically on older people. These investigators developed a completely new tool using content data derived strictly from focus groups of older men and women with urge incontinence.2,14 These are the first tools designed specifically to assess quality of life and impact of urge incontinence. What sets them apart from other instruments is their specificity for the subtype of incontinence. What distinguishes them from each other is primarily the populations for which they were developed. The urge IIQ and urge UDI reported by Brown and colleagues target women and were tested in a sample of middle-aged and older women with a relatively broad age range of 40 to 85 years (mean age 63.8 years). The Urge Impact Scale (URIS-24) reported by DuBeau and colleagues was designed with the older person in mind. Their sample included both men and women (although most (89%) were women), and all subjects were older, with an age range of 57 to 89 years (mean age 72.1 years). Both instruments focus on a specific subtype of incontinence, but differences in target populations allow for, and may even demand, quite different measures. Though little research has been conducted in this area, the impact of incontinence is thought to vary considerably, depending, for example, on gender and age. This could be true especially to the extent that these two factors reflect a person's tolerance for managing wetness, frailty, their usual physical and social activities (which can be disrupted by incontinence), and the importance of these activities to the individual as well. Another difference between the studies is in the ethnicity and socioeconomic status of the subjects. DuBeau's sample was white and of “generally moderate to high socioeconomic status.” It is similar to previous studies using mostly homogeneous samples of white, educated subjects. Brown et al. targeted blacks, Hispanics, and other ethnic groups, and included a 37% minority participation. They also used criteria assuring inclusion of patients with significant incontinence (at least six accidents per week). This sample had relatively severe symptoms: 83% had daily incontinence. These differences between the studies and the populations from which the data were derived represent their respective strengths as well as limitations to the generalizability of their findings. Both factors need to be considered in selecting a quality of life instrument appropriate to a particular clinical or research population. A close look at the actual items added to the original IIQ reveals that the content of the new urge IIQ is not totally specific to urge incontinence. Addition of items regarding walking, running, jogging, and the use of exercise machines are seen as applicable to stress incontinence as well as urge incontinence. Similarly, the items added to the “Feelings” domain, such as feeling unfeminine, unattractive, helpless, isolated, and lacking in confidence or self-esteem, apply to both stress incontinence and urge incontinence. As the authors state, the differences in items included in the new instrument may reflect differences in participants compared with those used in developing the original version of the instrument. They may or may not indicate differences between the impact of urge versus stress incontinence. It may be that generalizability to women of diverse ages and backgrounds is a larger contribution than is the new instrument's stated specificity to urge incontinence. Similarly, the uniqueness of the DuBeau study may be drawn from its focus on the special impact of urinary incontinence on older adults. We still lack data on how incontinence affects the lives of men. The DuBeau study included a small number of men, but the authors note correctly that the results may not be generalizable to men. Most of the literature on incontinence describes the problem or its treatment in samples of women, with a disproportionately small number of studies addressing the problem in men. Despite the higher prevalence in women, incontinence is not uncommon among older men. Its impact can be equally devastating and requires similar quality of life studies. The next test of both instruments will be their ability to measure change across time, specifically their sensitivity to therapeutic change. The IIQ has been shown to be sensitive to change with treatment in older women, indicating that treatment not only reduces incontinent episodes but also improves quality of life. Quality of life has not always been viewed as a valid endpoint in the treatment of incontinence. However, it has recently received increasing acceptance as a valid concept in measuring the outcomes of intervention, and there has been more interest in development of tools to measure quality of life as it relates to incontinence. These two studies are a step forward in providing methods for measuring the impact of any treatment for incontinence and will likely be used for studies investigating new and existing treatments for urge incontinence in particular. Only further investigation will determine whether these more urge-specific instruments are sensitive to change and how they compare with the more general measures of incontinence-specific quality of life. In addition to the research applications, clinicians might consider using quality of life questions to monitor their patients' response to treatment. What patients say about their progress and satisfaction with treatment does not always provide a complete picture of how their symptoms or their lives have been affected by the interventions they receive. Further developing and validating instruments such as those described in this issue will enable clinicians to capture information that will give them a fuller picture of the effects of incontinence treatment on their patients. Similar to many geriatric conditions, the goal for treating incontinence may not be to cure the problem but to improve the patient's quality of life.