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Etiology

Weekly urge urinary incontinence was associated with increased risk for falls and nonspinal fractures in older women

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ACP J Club. 2001 Mar-Apr;134:71. doi:10.7326/ACPJC-2001-134-2-071


Source Citation

Brown JS, Vittinghoff E, Wyman JF, et al, for the Study of Osteoporotic Fractures Research Group. Urinary incontinence: does it increase risk for falls and fractures? J Am Geriatr Soc. 2000 Jul;48:721-5. [PubMed ID: 10894308]


Abstract

Question

In community-dwelling older white women, do urge and stress urinary incontinence increase risk for falls and nonspinal fractures?

Design

Cohort study with mean 3-year follow-up (Study of Osteoporotic Fractures [SOF]).

Setting

4 clinical care centers in Maryland, Minnesota, Oregon, and Pennsylvania, United States.

Participants

6049 community-dwelling, ambulatory white women who were ≥ 65 years of age (mean age 79 y), attended 5 SOF clinic or home visits, completed a physical examination and self-administered questionnaire, provided data on urinary incontinence, and returned ≥ 1 postcard reporting falls after visit 5.

Assessment of risk factors

Number of live births; hysterectomy status; smoking status; alcohol use; walking; total weekly excursions outside the home; medical history, including hip or knee replacement, stroke, diabetes, Parkinson or Alzheimer disease or arthritis; self-reported joint pain; falls within the past year; functional status; medication use; and cognitive function. Frequency and type (urge, stress, or mixed) of urinary incontinence were assessed at the fifth clinic visit.

Main outcome measures

Reported falls and nonspinal, nontraumatic fractures (fractures were confirmed by radiography).

Main results

25% of women reported ≥ 1 weekly episode of urge incontinence, and 19% reported ≥ 1 weekly episode of stress incontinence; 12% reported both types of incontinence. Women with no incontinence or less than weekly incontinence formed the control group. 55% of women reported ≥ 1 fall during the mean 3-year follow-up, and 8.5% reported ≥ 1 fracture. After adjusting for age and other potential confounding factors, urge incontinence was associated with falls (P < 0.001) and fractures (P = 0.02), whereas stress incontinence was not (P≥ 0.3) (Table).

Conclusion

In community-dwelling older white women, weekly or more frequent urge but not stress urinary incontinence increased the risk for falls and nonspinal fractures.

Source of funding: In part, National Institute on Aging.

For correspondence: Dr. J.S. Brown, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, 2330 Post Street, Suite 220, San Francisco, CA 94115, USA. FAX 415-353-9509.


Table. Risk for falls and nonspinal fractures in women with ≥ weekly urinary incontinence at mean 3-year follow-up

Outcomes Type of incontinence Adjusted odds ratio (95% CI)
Falls Urge 1.26 (1.14 to 1.40)
Stress 1.06 (0.95 to 1.19)*
Relative hazard (CI)
Fractures Urge 1.34 (1.06 to 1.69)
Stress 0.98 (0.75 to 1.28)*

*Not significant.


Commentary

The study by Brown and colleagues is part of the larger SOF, a U.S. cohort study of community-dwelling elderly women. In this report, data collected at the time of the fifth follow-up visit were examined to determine whether urinary urge and stress incontinence were independent risk factors for falls and fractures. The results show a small but statistically significant increase in risk for falls and fractures from urge but not stress incontinence. From a methodologic standpoint, the study is strong: It included a defined, representative sample of patients; follow-up was sufficiently long; and outcome criteria (fractures) were objective. Multivariate analyses were done, adjusting for several known prognostic factors, including age, use of sedative medication, frailty, relevant medical problems, and gait and balance abnormalities (1). Missing from the multivariate analysis was adjustment for cognitive impairment, and because urge incontinence is often present in patients with subcortical dementia, this omission may be relevant. It is also possible that medication used to treat incontinence (e.g., anticholinergic agents) contributed to the falls. The fact that a dose-response curve existed—with patients who noted more frequent (i.e., daily) urge incontinence having a higher risk for falls (35%) than did patients with weekly incontinence (21%)—supports an etiologic association.

It is premature to speculate about the clinical significance of the findings of this study, other than as another, perhaps unexpected, risk factor for falls. Tinetti and colleagues showed that falls have many causes and that treating some of these contributing factors decreases the risk for falling (1, 2). If incontinence is validated as a risk factor for falls and fractures in an independent group (test set) of patients, then treatment of urge incontinence could be evaluated for the possible added benefit of preventing falls.

Suzanne D. Fields, MD
State University of New York at Stony Brook
Stony Brook, New York, USA


References

1. Tinetti ME, Doucette J, Claus E, Marottoli R. Risk factors for serious injury during falls by older persons in the community. J Am Geriatr Soc. 1995;43:1214-21.

2. Tinetti ME, Baker DI, McAvay G, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med. 1994;331:821-7.