National Institutes of Health State-of-the-Science Conference Statement: Prevention of Fecal and Urinary Incontinence in Adults

NIH Conferences18 March 2008National Institutes of Health State-of-the-Science Conference Statement: Prevention of Fecal and Urinary Incontinence in AdultsFREEC. Seth Landefeld, MD, Barbara J. Bowers, PhD, RN, Andrew D. Feld, MD, JD, Katherine E. Hartmann, MD, PhD, Eileen Hoffman, MD, Melvin J. Ingber, PhD, Joseph T. King Jr., MD, MSCE, W. Scott McDougal, MD, Heidi Nelson, MD, Endel John Orav, PhD, Michael Pignone, MD, MPH, Lisa H. Richardson, Robert M. Rohrbaugh, MD, Hilary C. Siebens, MD, and Bruce J. Trock, PhD*C. Seth Landefeld, MDFrom the University of California, San Francisco, and San Francisco Veterans Affairs Medical Center, San Francisco, California; University of Wisconsin–Madison, Madison, Wisconsin; University of Washington, Seattle, Washington; Vanderbilt Institute for Medicine and Public Health, Nashville, Tennessee; New York University School of Medicine, New York, New York; RTI International, Washington, D.C.;Veterans Affairs Connecticut Healthcare System and Yale University School of Medicine, New Haven, Connecticut; Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts; Mayo Medical School, Rochester, Minnesota; University of North Carolina Hospital, Chapel Hill, North Carolina; Crohn's and Colitis Foundation of America, Houston, Texas; University of Virginia, Charlottesville, Virginia; and The Johns Hopkins University School of Medicine, Baltimore, Maryland., Barbara J. Bowers, PhD, RNFrom the University of California, San Francisco, and San Francisco Veterans Affairs Medical Center, San Francisco, California; University of Wisconsin–Madison, Madison, Wisconsin; University of Washington, Seattle, Washington; Vanderbilt Institute for Medicine and Public Health, Nashville, Tennessee; New York University School of Medicine, New York, New York; RTI International, Washington, D.C.;Veterans Affairs Connecticut Healthcare System and Yale University School of Medicine, New Haven, Connecticut; Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts; Mayo Medical School, Rochester, Minnesota; University of North Carolina Hospital, Chapel Hill, North Carolina; Crohn's and Colitis Foundation of America, Houston, Texas; University of Virginia, Charlottesville, Virginia; and The Johns Hopkins University School of Medicine, Baltimore, Maryland., Andrew D. Feld, MD, JDFrom the University of California, San Francisco, and San Francisco Veterans Affairs Medical Center, San Francisco, California; University of Wisconsin–Madison, Madison, Wisconsin; University of Washington, Seattle, Washington; Vanderbilt Institute for Medicine and Public Health, Nashville, Tennessee; New York University School of Medicine, New York, New York; RTI International, Washington, D.C.;Veterans Affairs Connecticut Healthcare System and Yale University School of Medicine, New Haven, Connecticut; Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts; Mayo Medical School, Rochester, Minnesota; University of North Carolina Hospital, Chapel Hill, North Carolina; Crohn's and Colitis Foundation of America, Houston, Texas; University of Virginia, Charlottesville, Virginia; and The Johns Hopkins University School of Medicine, Baltimore, Maryland., Katherine E. Hartmann, MD, PhDFrom the University of California, San Francisco, and San Francisco Veterans Affairs Medical Center, San Francisco, California; University of Wisconsin–Madison, Madison, Wisconsin; University of Washington, Seattle, Washington; Vanderbilt Institute for Medicine and Public Health, Nashville, Tennessee; New York University School of Medicine, New York, New York; RTI International, Washington, D.C.;Veterans Affairs Connecticut Healthcare System and Yale University School of Medicine, New Haven, Connecticut; Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts; Mayo Medical School, Rochester, Minnesota; University of North Carolina Hospital, Chapel Hill, North Carolina; Crohn's and Colitis Foundation of America, Houston, Texas; University of Virginia, Charlottesville, Virginia; and The Johns Hopkins University School of Medicine, Baltimore, Maryland., Eileen Hoffman, MDFrom the University of California, San Francisco, and San Francisco Veterans Affairs Medical Center, San Francisco, California; University of Wisconsin–Madison, Madison, Wisconsin; University of Washington, Seattle, Washington; Vanderbilt Institute for Medicine and Public Health, Nashville, Tennessee; New York University School of Medicine, New York, New York; RTI International, Washington, D.C.;Veterans Affairs Connecticut Healthcare System and Yale University School of Medicine, New Haven, Connecticut; Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts; Mayo Medical School, Rochester, Minnesota; University of North Carolina Hospital, Chapel Hill, North Carolina; Crohn's and Colitis Foundation of America, Houston, Texas; University of Virginia, Charlottesville, Virginia; and The Johns Hopkins University School of Medicine, Baltimore, Maryland., Melvin J. Ingber, PhDFrom the University of California, San Francisco, and San Francisco Veterans Affairs Medical Center, San Francisco, California; University of Wisconsin–Madison, Madison, Wisconsin; University of Washington, Seattle, Washington; Vanderbilt Institute for Medicine and Public Health, Nashville, Tennessee; New York University School of Medicine, New York, New York; RTI International, Washington, D.C.;Veterans Affairs Connecticut Healthcare System and Yale University School of Medicine, New Haven, Connecticut; Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts; Mayo Medical School, Rochester, Minnesota; University of North Carolina Hospital, Chapel Hill, North Carolina; Crohn's and Colitis Foundation of America, Houston, Texas; University of Virginia, Charlottesville, Virginia; and The Johns Hopkins University School of Medicine, Baltimore, Maryland., Joseph T. King Jr., MD, MSCEFrom the University of California, San Francisco, and San Francisco Veterans Affairs Medical Center, San Francisco, California; University of Wisconsin–Madison, Madison, Wisconsin; University of Washington, Seattle, Washington; Vanderbilt Institute for Medicine and Public Health, Nashville, Tennessee; New York University School of Medicine, New York, New York; RTI International, Washington, D.C.;Veterans Affairs Connecticut Healthcare System and Yale University School of Medicine, New Haven, Connecticut; Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts; Mayo Medical School, Rochester, Minnesota; University of North Carolina Hospital, Chapel Hill, North Carolina; Crohn's and Colitis Foundation of America, Houston, Texas; University of Virginia, Charlottesville, Virginia; and The Johns Hopkins University School of Medicine, Baltimore, Maryland., W. Scott McDougal, MDFrom the University of California, San Francisco, and San Francisco Veterans Affairs Medical Center, San Francisco, California; University of Wisconsin–Madison, Madison, Wisconsin; University of Washington, Seattle, Washington; Vanderbilt Institute for Medicine and Public Health, Nashville, Tennessee; New York University School of Medicine, New York, New York; RTI International, Washington, D.C.;Veterans Affairs Connecticut Healthcare System and Yale University School of Medicine, New Haven, Connecticut; Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts; Mayo Medical School, Rochester, Minnesota; University of North Carolina Hospital, Chapel Hill, North Carolina; Crohn's and Colitis Foundation of America, Houston, Texas; University of Virginia, Charlottesville, Virginia; and The Johns Hopkins University School of Medicine, Baltimore, Maryland., Heidi Nelson, MDFrom the University of California, San Francisco, and San Francisco Veterans Affairs Medical Center, San Francisco, California; University of Wisconsin–Madison, Madison, Wisconsin; University of Washington, Seattle, Washington; Vanderbilt Institute for Medicine and Public Health, Nashville, Tennessee; New York University School of Medicine, New York, New York; RTI International, Washington, D.C.;Veterans Affairs Connecticut Healthcare System and Yale University School of Medicine, New Haven, Connecticut; Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts; Mayo Medical School, Rochester, Minnesota; University of North Carolina Hospital, Chapel Hill, North Carolina; Crohn's and Colitis Foundation of America, Houston, Texas; University of Virginia, Charlottesville, Virginia; and The Johns Hopkins University School of Medicine, Baltimore, Maryland., Endel John Orav, PhDFrom the University of California, San Francisco, and San Francisco Veterans Affairs Medical Center, San Francisco, California; University of Wisconsin–Madison, Madison, Wisconsin; University of Washington, Seattle, Washington; Vanderbilt Institute for Medicine and Public Health, Nashville, Tennessee; New York University School of Medicine, New York, New York; RTI International, Washington, D.C.;Veterans Affairs Connecticut Healthcare System and Yale University School of Medicine, New Haven, Connecticut; Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts; Mayo Medical School, Rochester, Minnesota; University of North Carolina Hospital, Chapel Hill, North Carolina; Crohn's and Colitis Foundation of America, Houston, Texas; University of Virginia, Charlottesville, Virginia; and The Johns Hopkins University School of Medicine, Baltimore, Maryland., Michael Pignone, MD, MPHFrom the University of California, San Francisco, and San Francisco Veterans Affairs Medical Center, San Francisco, California; University of Wisconsin–Madison, Madison, Wisconsin; University of Washington, Seattle, Washington; Vanderbilt Institute for Medicine and Public Health, Nashville, Tennessee; New York University School of Medicine, New York, New York; RTI International, Washington, D.C.;Veterans Affairs Connecticut Healthcare System and Yale University School of Medicine, New Haven, Connecticut; Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts; Mayo Medical School, Rochester, Minnesota; University of North Carolina Hospital, Chapel Hill, North Carolina; Crohn's and Colitis Foundation of America, Houston, Texas; University of Virginia, Charlottesville, Virginia; and The Johns Hopkins University School of Medicine, Baltimore, Maryland., Lisa H. RichardsonFrom the University of California, San Francisco, and San Francisco Veterans Affairs Medical Center, San Francisco, California; University of Wisconsin–Madison, Madison, Wisconsin; University of Washington, Seattle, Washington; Vanderbilt Institute for Medicine and Public Health, Nashville, Tennessee; New York University School of Medicine, New York, New York; RTI International, Washington, D.C.;Veterans Affairs Connecticut Healthcare System and Yale University School of Medicine, New Haven, Connecticut; Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts; Mayo Medical School, Rochester, Minnesota; University of North Carolina Hospital, Chapel Hill, North Carolina; Crohn's and Colitis Foundation of America, Houston, Texas; University of Virginia, Charlottesville, Virginia; and The Johns Hopkins University School of Medicine, Baltimore, Maryland., Robert M. Rohrbaugh, MDFrom the University of California, San Francisco, and San Francisco Veterans Affairs Medical Center, San Francisco, California; University of Wisconsin–Madison, Madison, Wisconsin; University of Washington, Seattle, Washington; Vanderbilt Institute for Medicine and Public Health, Nashville, Tennessee; New York University School of Medicine, New York, New York; RTI International, Washington, D.C.;Veterans Affairs Connecticut Healthcare System and Yale University School of Medicine, New Haven, Connecticut; Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts; Mayo Medical School, Rochester, Minnesota; University of North Carolina Hospital, Chapel Hill, North Carolina; Crohn's and Colitis Foundation of America, Houston, Texas; University of Virginia, Charlottesville, Virginia; and The Johns Hopkins University School of Medicine, Baltimore, Maryland., Hilary C. Siebens, MDFrom the University of California, San Francisco, and San Francisco Veterans Affairs Medical Center, San Francisco, California; University of Wisconsin–Madison, Madison, Wisconsin; University of Washington, Seattle, Washington; Vanderbilt Institute for Medicine and Public Health, Nashville, Tennessee; New York University School of Medicine, New York, New York; RTI International, Washington, D.C.;Veterans Affairs Connecticut Healthcare System and Yale University School of Medicine, New Haven, Connecticut; Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts; Mayo Medical School, Rochester, Minnesota; University of North Carolina Hospital, Chapel Hill, North Carolina; Crohn's and Colitis Foundation of America, Houston, Texas; University of Virginia, Charlottesville, Virginia; and The Johns Hopkins University School of Medicine, Baltimore, Maryland., and Bruce J. Trock, PhD*From the University of California, San Francisco, and San Francisco Veterans Affairs Medical Center, San Francisco, California; University of Wisconsin–Madison, Madison, Wisconsin; University of Washington, Seattle, Washington; Vanderbilt Institute for Medicine and Public Health, Nashville, Tennessee; New York University School of Medicine, New York, New York; RTI International, Washington, D.C.;Veterans Affairs Connecticut Healthcare System and Yale University School of Medicine, New Haven, Connecticut; Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts; Mayo Medical School, Rochester, Minnesota; University of North Carolina Hospital, Chapel Hill, North Carolina; Crohn's and Colitis Foundation of America, Houston, Texas; University of Virginia, Charlottesville, Virginia; and The Johns Hopkins University School of Medicine, Baltimore, Maryland.Author, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-148-6-200803180-00210 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail National Institutes of Health consensus and state-of-the-science statements are prepared by independent panels of health professionals and public representatives on the basis of 1) the results of a systematic literature review prepared under contract with the Agency for Healthcare Research and Quality (AHRQ), 2) presentations by investigators working in areas relevant to the conference questions during a 2-day public session, 3) questions and statements from conference attendees during open discussion periods that are part of the public session, and 4) closed deliberations by the panel during the remainder of the second day and morning of the third. This statement is an independent report of the panel and is not a policy statement of the National Institutes of Health or the U.S. government.Fecal incontinence and urinary incontinence are conditions with ramifications that extend well beyond their physical manifestations. Many individuals find themselves withdrawing from their social lives and attempting to hide the problem from their families, friends, and even their doctors. The shame, embarrassment, and stigma associated with these conditions pose significant barriers to seeking professional treatment, resulting in many persons who suffer from these conditions without help. As baby boomers approach their sixties, the incidence and public health burden of incontinence are likely to increase.Fecal incontinence is a syndrome that involves the unintentional loss of solid or liquid stool. It is serious and embarrassing. Fecal incontinence may affect individuals living at home, as well as many living in nursing homes. Although fecal incontinence affects individuals of all ages, it is more common in women and older persons. Bowel function is controlled by 4 factors: rectal sensation, rectal storage capacity, anal sphincter pressure, and established bowel habits. If any of these is compromised, fecal incontinence can occur. Despite its serious effects on patients, families, and society, fecal incontinence is often ignored and has been studied less than have many other conditions.Urinary incontinence can affect persons of all ages and is most common in child-bearing women and older men and women. Urinary incontinence is generally classified as urge incontinence (when a person has the sudden urge to urinate and cannot get to the bathroom in time); stress incontinence (when a person leaks urine after strains, such as laughing, coughing, sneezing, or lifting); mixed incontinence (when a person has both urge and stress incontinence); and other incontinence (for example, when urine continues to leak after urination or leaks constantly). Urinary incontinence has been studied more extensively than fecal incontinence, but the magnitude of the problem of urinary incontinence is disproportionate to the amount of research on its prevention and treatment.It has been difficult to identify persons at risk for or affected by incontinence because the condition is often not reported or diagnosed. Prevention of fecal and urinary incontinence has been hindered by limited research and incomplete knowledge about the biological causes and interacting social and environmental factors.To promote work that will reduce suffering from fecal and urinary incontinence, as well as their costs by preventing their occurrence, the National Institute of Diabetes and Digestive and Kidney Diseases and the Office of Medical Applications of Research of the National Institutes of Health convened a State-of-the-Science Conference from 10 to 12 December 2007 to assess the available scientific evidence relevant to the following questions: 1) What are the prevalence, incidence, and natural history of fecal and urinary incontinence in the community and long-term care settings? 2) What are the burden of illness and impact of fecal and urinary incontinence on the individual and society? 3) What are the risk factors for fecal and urinary incontinence? 4) What can be done to prevent fecal and urinary incontinence? 5) What are the strategies to improve the identification of persons at risk and patients who have fecal and urinary incontinence? 6) What are the research priorities in reducing the burden of illness in these conditions?At the conference, invited speakers presented information pertinent to these questions, and a systematic literature review prepared under contract with the AHRQ (www.ahrq.gov/clinic/tp/fuiadtp.htm) was summarized. Conference attendees provided both oral and written statements in response to the key questions. The panel members weighed all of this evidence as they addressed the conference questions.This conference focused on preventing fecal and urinary incontinence and detecting persons at risk for and persons with untreated incontinence. The treatment of incontinence with surgery or drugs was beyond the scope of the conference.1. What Are the Prevalence, Incidence, and Natural History of Fecal and Urinary Incontinence in the Community and Long-Term Care Settings?The occurrence of fecal and urinary incontinence can be described in terms of prevalence (the number of individuals who have incontinence at a point in time), incidence (the number of individuals who newly develop incontinence in a period of time), and the natural history (whether incontinence improves, stays the same, or worsens over time). Each of these measures varies with factors, such as whether the individual is living in the community or in a nursing home and the individual's sex, age, and racial or ethnic group.Severity of incontinence varies in frequency and amount. In addition, incontinence has many different causes. Little information describes rates of incontinence due to each specific cause or by severity. Therefore, this section describes prevalence, incidence, and natural history for all causes of incontinence combined. To provide a sense of the impact of fecal and urinary incontinence, we provide estimates of incontinence rates derived from several studies. Because rates vary considerably across studies, we provide rates that are consistent with the largest body of data for each category of incontinence. Important limitations in this information include underreporting of symptoms, the lack of consistency in the definition of incontinence, and limited numbers of studies on specific topics.Fecal IncontinenceMany definitions of fecal incontinence exist, some of which include flatus (passing gas), while others are confined to stool. The following data refer to incontinence of stool. Prevalence of fecal incontinence in women living in the community increases with age, from 6% in those younger than 40 years of age to 15% in older women. Among men living in the community, fecal incontinence is experienced by 6% to 10%, with the rate increasing slightly as they age. Among both men and women who have fecal incontinence, approximately 50% will also have urinary incontinence. Severity of fecal incontinence increases with age. The few studies comparing racial or ethnic groups did not find differences.In nursing homes, prevalence of fecal incontinence varies widely according to the physical and mental status of the residents. The overall prevalence is about 45%, with a rate as low as 10% to 15% in more independent residents and up to 70% in the most dependent. Combined fecal and urinary incontinence occurs in a large proportion of nursing home residents.Data on incidence of fecal incontinence in the community are too sparse to permit estimates that can be generalized to the population. Similarly, the natural history of fecal incontinence is not well studied. Therefore, meaningful conclusions cannot be made regarding the rate of development of fecal incontinence and rates of improvement or worsening.Urinary IncontinencePrevalence of urinary incontinence in women living in the community increases with age, from 19% at age younger than 45 years to 29% in age 80 years or older; the rate levels off from age 50 to 70 years, after which prevalence again increases. Current national estimates are that more than 20 million women have urinary incontinence or have experienced it at some point in their lives. For women, stress incontinence decreases with age, whereas urge incontinence increases with age. Information comparing prevalence in racial or ethnic groups suggests that urinary incontinence is prevalent in all ethnic groups, with some suggestion of higher rates among white women.The epidemiology of urinary incontinence in men has not been studied to the same extent as that in women. In men living in the community, the prevalence of urinary incontinence is 5% to 15% and exhibits a more steady increase with age than among women: 5% at younger than 45 years of age to 21% in men age 65 years or older. This increase primarily reflects urge incontinence and mixed urinary incontinence, with stress incontinence decreasing after age 65 years. Nationally, the prevalence of urinary incontinence in men during their lifetime is approximately 6 million. Few studies have examined racial or ethnic differences in prevalence of urinary incontinence among men, so reliable comparisons cannot be made.Prevalence of urinary incontinence in nursing homes is much higher than that in the community. Rates are 60% to 78% in women and 45% to 72% in men and increase with age. This may be due, in part, to impaired mobility and difficulty getting to the toilet. Urinary incontinence can also be a reason for admission to a nursing home or a complication of other conditions that prompt admission. The few studies that have evaluated racial or ethnic differences suggest that such differences are minimal.Data for incidence of urinary incontinence are considerably more sparse than prevalence data. In the community, annual incidence in women increases with age, from less than 2% for age younger than age 45 years to 8% for age 80 years or older, with an overall annual rate of 6%. Only 4 studies have evaluated incidence in men; the overall annual rate of 4% and increases with age. Comparisons of incidence data by race or ethnicity, or by type of urinary incontinence, are very limited.Little is known about how sex and age affect the natural history of urinary incontinence. Urinary incontinence resolves in some but not all individuals; whether resolution resulted from any treatments is unclear. It is not known whether resolution is temporary or permanent and whether it differs by type of incontinence.Other Populations to ConsiderCase reports or smaller series may identify previously unrecognized behaviors and communities at risk for fecal or urinary incontinence. For example, injuries incurred during sports, work, and sexual activity may identify unique causes of incontinence. These causes could generate new hypotheses about how fecal or urinary incontinence occurs.Strength of EvidenceWith the exception of prevalence of urinary incontinence, most estimates of the incidence and prevalence of incontinence in adults are based on relatively few studies. Because these studies used varying definitions of incontinence and different methods of population sampling, the preceding statistics should be considered to be fairly crude estimates. Areas in particular need of further studies are incidence of both fecal and urinary incontinence, studies of type and severity of incontinence, comparisons of racial and ethnic groups with larger sample sizes and ability to evaluate cultural differences and risk factors, and studies of natural history.2. What Are the Burden of Illness and Impact of Fecal and Urinary Incontinence on the Individual and Society?The burdens of fecal and urinary incontinence fall into economic and noneconomic categories, and each is complex. We will use the term costs when referring to the economic dimension and burden when referring to the noneconomic dimension. The quality of evidence for both cost and burden is limited. Economic cost can be obscured by the often more life-threatening comorbid conditions, and current estimates are based on older data modified by estimates of inflation. Studies on burden are limited by the paucity of validated instruments measuring quality of life and the variability in personal response to the condition. Also, individuals who are incontinent live in a variety of situations—from independent community living to community living with home care to living in a nursing home—with different implications for both costs and personal stresses. Interventions that reduce the burden of incontinence should address both costs and stresses.For some individuals, costs can be reduced absolutely, even with the current state of knowledge; for many others, however, there is a tradeoff between reductions in burden and increased costs. Although the total costs to society are great, costs and burden range widely on an individual level, as does the spectrum of incontinence itself.Burden to Individuals Who Are IncontinentIndividuals who are incontinent may have an emotional burden of shame and embarrassment as well as the physical discomfort and disruption of their lives that occur with episodes of incontinence. The impact of incontinence on individuals varies by age, sex, type of incontinence, individual differences in coping skills, and the quality of social support. The emotional and social burdens are not easily measured. For example, some persons may experience stresses in relationships, low productivity at work, job difficulties, arranging daily activities by bathroom location, and avoiding activities that provoke incontinence.Individuals who are incontinent may experience anxiety about "accidents," depression, social isolation, and social exclusion. The management of incontinence itself is burdensome. Quality of life is a subjective measure and is difficult to associate with physiologic measures of urinary incontinence. This bears further investigation for both urinary and fecal incontinence. Few objective data exist on the effect of incontinence on quality of relationships: sexual, parent–child, sibling, employer–employee. Stress may result when these relationships involve caregiving.Caregiver BurdenIncontinence requires greater amounts of informal and formal caregiving. Informal caregivers are usually family members or friends who give unpaid assistance. Formal caregivers are those paid to provide that assistance. Caregiver responsibilities range from helping to stock the refrigerator and preparing food to supervising the taking of medicine or helping with toileting. A major source of stress for caregivers is the physical and mental effort needed for some of their tasks and the unpleasantness of dealing with incontinence. Despite the large numbers of informal caregivers, research examining the impact of incontinence on caregiver burden is limited. The dramatic increase in baby boomers faced with caring for their elderly parents now will affect how they choose to get care for themselves when they are the elders. Efforts to avoid nursing home placement are generating many creative ways to "age in place." The need for caregivers, informal or formal, will have to be factored into these efforts.After adjustment for comorbid illness, socioeconomic status, and living situation, older individuals who have urinary incontinence require more informal care than those who are contine