VOL: 101, ISSUE: 47, PAGE NO: 52
Shankar Loharuka, MBBS, MRCP, is specialist registrar, Department of Geriatric Medicine, University Hospital, Aintree
James Barrett, MD, FRCP, is consultant physician, Department of Elderly Medicine, Wirral Hospital NHS Trust, Clatterbridge Hospital, Bebington, Wirral;Brenda Roe, PhD, RN, RHV, FRSH, is professor of health sciences, Faculty of Health and Social Sciences, Liverpool John Moores University, Liverpool
Incontinence, falling and cognitive impairment have been recognised as ‘geriatric syndromes’ for many years (Reuben, 1991). They often result from the accumulated effect of impairments in multiple domains (organ systems) (Tinetti et al, 1988). The relationship between cognitive impairment and incontinence has been extensively written about (McGrother et al, 1990), but the relationship between falls and urinary incontinence (UI) has hardly been studied.
In the past decade, falls research has produced evidence to suggest that a falls service should be developed in every health district (DoH 2001; Chang et al, 2004). Falls are common in older patients and often lead to low-trauma fractures (those that occur from a fall from standing height or less), fear of falling, anxiety, depression and loss of confidence (Tinetti et al, 1995a; Nevitt et al, 1991; Sattin et al, 1990), all of which can lead to disability for the first time or increase pre-existing disability. They account for many hospital admissions (Alexander et al, 1992). Some studies show that the prevalence of falls is similar to that of urinary incontinence.
In women living in the community aged 65 or older, the prevalence of urinary incontinence is estimated to be 30 to 50 per cent (Hunskaar et al, 1999), and the prevalence of falls 19 to 42 per cent (Tinetti et al, 1988). For both men and women, the prevalence of urinary and faecal incontinence increases with age, institutionalisation, cognitive impairment and loss of mobility. The commonly used falls risk scores tend to include a bladder component, as patients who need frequent toileting are at risk of falls (Oliver et al, 1997).
Incontinence and falls
Three studies have reported on the association between falls and incontinence. Tinetti et al (1995b) completed 1,103 base-line face-to-face interviews in a study of patients in the community aged 72 and over in the USA. Of these participants, 927 (mean age 79.7 years) completed a second face-to-face interview one year later to identify the presence of the ‘geriatric syndromes’: incontinence (at least one episode a week); falls (at least two falls in the year); and functional dependence. They were asked: ‘How often in a typical week would you lose control of urine and wet yourself?’ to determine their urinary continence. The occurrence and frequency of falls were ascertained throughout the study year by a falls calendar. At the one-year follow-up visit, 16 per cent of the subjects were incontinent of urine and 10 per cent had experienced two or more falls.
The risk factors that were identified to be associated with falls and incontinence were also associated with functional dependence. The main associations were with vision and hearing impairment, anxiety or depression, lower limb impairment and upper limb impairment. No association was found with cognitive impairment. The risk of falling and/or incontinence increased with the number of impaired functional domains.
Brown et al (2000) performed a study in 6,049 women living in the community in California (mean age 78.5 years), looking at osteoporotic fractures. All the subjects completed a baseline questionnaire and were asked every four months to return a postcard to report any falls and/or fractures. The postcards were completed by the women and included other health questions besides continence. During an average follow-up of three years, 55 per cent of the women reported at least one fall and 8.5 per cent reported at least one non-spine, non-traumatic fracture; 47 per cent of the women reported at least one episode of urinary incontinence. Weekly or more frequent urge urinary incontinence was found to be independently associated with falling and non-spine traumatic fracture.
There appeared to be a dose response relationship, as the risk of falling was even greater with daily urge urinary incontinence. The same did not apply to falls in people with weekly or more frequent stress incontinence or fractures. Brown et al (2000) suggested that early diagnosis and appropriate treatment of urinary incontinence in older women, particularly those with urge incontinence, has the potential to reduce the number of falls and fractures, but this suggestion has not been tested.
In a study by Tromp et al (2001) the occurrence of falls among 1,285 people living in the community aged 65 years and over was followed during one year by means of a fall calendar. Previous falls, visual impairment, urinary incontinence and use of benzodiazepines were the strongest predictors identified in the risk profile model for any falls.
These risk factors studies have all been community-based and have excluded nursing home residents. In contrast, the only moderate size intervention trial was conducted by Schnelle et al (2003) in a nursing home. A total of 190 incontinent residents were provided with low intensity, functionally oriented exercise and incontinence care every two hours from 8.00am to 4.00pm for five days a week for eight months. The incontinence care significantly reduced the number of times the residents were found incontinent of urine and stool, but these improvements occurred during the 8am to 4pm period and during the five days of the week that research staff implemented the intervention. Despite this, there was no significant difference in the number of people falling in the intervention group.
Implications for policy, research and clinical practice
Guidelines on falls from the National Institute for Clinical Excellence (NICE, 2004) were unable to recommend continence promotion as an intervention to reduce falling, mainly owing to a lack of evidence, although the association between continence problems and falls is accepted.
In clinical practice, older people who have a fall should have a multifactorial falls risk assessment performed by a health care professional with appropriate skills and experience, and this should include a continence assessment. Further research is required on whether continence promotion in the community and/ or other settings based on an assessment might simultaneously reduce falls and restore continence.
- There is a lack of evidence to support continence promotion as an intervention to reduce falling, although the association between continence problems and falls is accepted;
- Older people who have a fall should have a multifactorial risk assessment that includes a continence assessment.