- Email: [email protected]
Geriatrics
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GERIATRICS
for significant comorbidities. In this series hypertension (36%) and obesity (36%) were the most common. In an era when those on a Western diet are gaining weight at an alarming rate recognition of certain patient profiles, ie those with multiple components of the metabolic syndrome, will help us to drill down more accurately to patients at risk for male pelvic dysfunction. These observations are also applicable to women. In an era of increasing obesity, diabetes and dyslipidemia urologists must be keenly aware of these associations. Steven A. Kaplan, M.D.
Geriatrics Complications of Sling Surgery Among Female Medicare Beneficiaries J. T. Anger, M. S. Litwin, Q. Wang, C. L. Pashos and L. V. Rodriguez Department of Urology, David Geffen School of Medicine and School of Public Health, University of California, Los Angeles, California Obstet Gynecol 2007; 109: 707–714.
Objective: To analyze Medicare claims data to determine short-term complications after sling surgery among female beneficiaries aged 65 years and over. Methods: We analyzed the 1999 –2001 Medicare Public Use Files provided by the Centers for Medicare and Medicaid Services on a 5% national random sample of beneficiaries. Women undergoing sling procedures between January 1, 1999, and July 31, 2000, (the index period) were identified by Physicians Current Procedural Terminology Coding System (4th edition) and tracked for 12 months. Main outcome measures were complications as identified by International Classification of Diseases (9th revision) (ICD-9) diagnosis codes and Current Procedural Terminology procedure codes in the first postoperative year. Results: A total of 1,356 sling procedures were performed during the index period. In the 3 months after the procedure, 12.5% of women developed surgical or urologic complications, and 33.6% were diagnosed with urinary tract infections. Within 1 year of the procedure, 6.9% of subjects had a new diagnosis of outlet obstruction, and 8.0% underwent treatments to manage outlet obstruction. There was a high incidence of new diagnoses of urge incontinence (15.2%) and treatment of pelvic prolapse (23.2%). Both cystoscopy and urodynamic testing, which may serve as indicators of possible complications, were performed frequently during the first year after surgery (32.4% and 30.5%, respectively). Patient race, age, and comorbidity each had a significant influence on outcomes. Conclusion: Complication rates within 1 year after sling surgery among Medicare beneficiaries were found to be higher than those reported in the clinical literature. The high rates of postoperative urinary tract infections, prolapse, and outlet obstruction suggest the need for quality improvement measures in the management of women with incontinence and pelvic prolapse. Level of Evidence: III. Editorial Comment: Surgical therapy is widely used in the management of stress urinary incontinence in women. However, some surgeons are more hesitant to operate in elderly women due to concerns about increased risks of complications or poor outcomes. This population based study examined the complications of sling procedures in elderly women using a nationally representative sample of Medicare beneficiaries. The overall complication rate in this sample was 12.5%, and urinary tract infection was one of the most common complications. The findings support prior literature demonstrating an approximately 15% incidence of de novo urinary urgency and urge incontinence. Postoperative outlet obstruction was diagnosed in 6.9% of subjects, and 8.0% underwent treatment for this condition. Subsequent treatment for pelvic prolapse was required in 23.2% of women within 1 year after slingplasty. Although these findings revealed higher rates of complications than previous studies, the inherent limitations of using claims based analysis must
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be recognized. Additional research on clinical outcomes and complications will help to define the role of surgical therapy for stress incontinence in elderly women. Tomas L. Griebling, M.D., M.P.H.
Urinary Incontinence and Self-Reported Health Among the U.S. Medicare Managed Care Beneficiaries C. H. Chang, C. M. Gonzalez, D. T. Lau and H. C. Sier Buehler Center on Aging, Health and Society, Northwestern University Feinberg School of Medicine, Chicago, Illinois J Aging Health 2008; 20: 405– 419.
Objective: To examine the prevalence and management of urinary incontinence (UI) and their impact on self-reported health in the U.S. Medicare managed care beneficiaries. Methods: Data were from the 2003 Medicare Health Outcomes Survey Cohort VI Baseline. Only beneficiaries aged 65 years or older and who self-completed the telephone interview were included. Results: About 37% of the study sample (N ⫽ 82,196) reported having accidental urine leakage (the UI group). A total of 75% of the UI group indicated UI’s being a problem and 41% of them had spoken with a doctor about it. Of these, 50% had received treatment. The findings indicate the UI group generally had significantly worse SF-36 Survey Scale scores than the non-UI group with and without adjusting other covariates. Discussion: UI is prevalent but undertreated as it adversely affects many health domains in this population. This study highlights the need for early detection, proper education, and access to effective treatment options for UI in the elderly. Editorial Comment: Epidemiological research has demonstrated that urinary incontinence is quite common in older adults, although most studies suggest that age by itself is not a significant risk factor. Incontinence can have a negative impact on health related quality of life in older adults. This study sought to identify the prevalence of urinary incontinence and its relationship to self-reported health in a community based cohort of 82,196 Medicare beneficiaries 65 years or older. To minimize response bias, information from proxy respondents was excluded from the analysis. The overall prevalence of incontinence was 37%, and of this group 75% considered their incontinence to be a problem. However, only 41% of subjects had spoken to a health care provider about their incontinence, and only 50% of these patients had actually received treatment. Incontinence was associated with worse health related quality of life based on self-reports using validated instruments. These results underscore the fact that although urinary incontinence is a highly prevalent condition in community dwelling older adults, the condition is undertreated and can negatively impact quality of life. Tomas L. Griebling, M.D., M.P.H.
Biochemical and Body Composition Analysis of Nocturia in the Elderly K. Sugaya, S. Nishijima, M. Oda, T. Owan, M. Miyazato and Y. Ogawa Division of Urology, Faculty of Medicine, Department of Organ-Oriented Medicine, University of Ryukyus, Okinawa, Japan Neurourol Urodyn 2008; 27: 205–211.
Aims: Nocturia is a common symptom in the elderly, and various contributing factors have been suggested. Therefore, in order to investigate which factors are strongly related to occurrence of nocturia, we performed a suite of examinations. Methods: One hundred eighty volunteers were divided into three groups: a young adult control group (60 healthy persons without nocturia), an elderly control group (60 healthy persons with a low mean frequency of nocturnal urination, i.e., ⬍once per night), and an elderly nocturia group (60 healthy persons with a high mean frequency of nocturnal urination, i.e., more than twice per night). Biochemistry tests, measurement of the osmotic pressure of plasma and urine, and body
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composition analysis were performed in three groups during the daytime and nighttime. In the elderly control group and the elderly nocturia group, measurement of blood pressure and recording of urinary frequency-volume charts were performed. Results: The features specific to the elderly nocturia group are as follows: (1) a decrease of the nighttime plasma melatonin level, (2) an increase of nighttime plasma catecholamine levels, (3) an increase of daytime and nighttime plasma natriuretic peptide levels, (4) an increase of blood pressure, (5) a decrease of daytime and nighttime urinary osmotic pressure, (6) an increase of total urine volume, and (7) an increase of the edema ratio before sleeping. Conclusions: These results suggest that sleep disturbance, hypertension, and excessive fluid intake are major factors contributing to an increased frequency of nocturnal urination (⬎twice per night) in the elderly. Editorial Comment: Nocturia is one of the most common and most distressing lower urinary tract symptoms in older adults. The cause is multifactorial, and a wide variety of clinical characteristics have been associated with this condition. This study sought to examine these factors in 60 healthy elderly people (mean age 72 ⴞ 5 years) with nocturia compared to a control group of 60 healthy elderly people (70 ⴞ 4 years) without nocturia and a control group of 60 healthy young people (32 ⴞ 8 years) without nocturia. A variety of biochemical and morphometric tests were performed. As outlined in the abstract, a number of parameters were significantly different in the older patients with nocturia compared to the 2 control groups. This finding suggests that alterations in sleep quality, hypertension and excessive fluid intake may contribute to nocturia in older adults. These factors could be important targets for therapeutic intervention to help manage this bothersome condition. Tomas L. Griebling, M.D., M.P.H.
Rating Improvements in Urinary Incontinence: Do Patients and Their Physicians Agree? C. Tannenbaum, J. Brouillette and J. Corcos Department of Geriatric Medicine, Institut Universitaire de Geriatrie de Montreal, Montreal, Quebec, Canada Age Ageing 2008; 37: 379 –383.
Objective: To determine whether patients’ perceptions of improvement following behavioural interventions for urinary incontinence (UI) correspond with physicians’ global ratings of change, and to compare both these ratings with more objective UI outcome measures. Methods: consecutive new female patients aged 65 years and older recruited from outpatient UI clinics in Quebec received a behavioural management protocol for UI. At 3-month follow-up, patients and physicians were independently asked for their global impression of change in UI status. Patients completed 3-day voiding diaries and a UI-specific quality-of-life index before and after treatment. Results: 108 patients (mean age 73 ⫹/⫺ 5 years, range 65– 86 years) with stress, urge and mixed UI participated. There was concordance between patients’ and physicians’ ratings of change in 57% of cases. Among the remaining cases, patients were 1.6 times as likely to report significant improvements compared to physicians. Patients’ ratings correlated more strongly with improvements in UI episodes in the voiding diary (r ⫽ 0.4, P ⫽ 0.002 versus r ⫽ 0.3, P ⫽ 0.004 for physicians) and on the quality-of-life index (r ⫽ ⫺0.5, P ⬍ 0.0001 versus r ⫽ ⫺0.4, P ⬍ 0.0001 for physicians). Conclusion: physicians underestimate clinically meaningful changes in UI in older women following behavioural interventions. Editorial Comment: The decision to seek treatment for urinary incontinence is usually symptom based. Although urodynamic and physiological parameters are important, clinical perception of the problem is typically what drives evaluation and management. This study compared physician and patient perceptions of improvements in urinary incontinence following behavioral therapy in a cohort of 108 women older than 65 years (mean age 73 ⴞ 5). Concordance of ratings for improvement between physicians and patients was found in only 57% of cases. In instances of nonconcordance physicians were more likely to underestimate the degree of improvement experienced by patients. Objective measurements (pad use and
GERIATRICS
723
voiding diaries) and subjective measurements (validated quality of life scales) were used to assess outcomes. These results emphasize the need to determine patient perceptions of improvement in urinary continence status for behavioral interventions before pursuing other treatments. This is particularly important in elderly women, who could have greater potential risks of complications or adverse events with more invasive therapies. Tomas L. Griebling, M.D., M.P.H.
GERIATRICS
for significant comorbidities. In this series hypertension (36%) and obesity (36%) were the most common. In an era when those on a Western diet are gaining weight at an alarming rate recognition of certain patient profiles, ie those with multiple components of the metabolic syndrome, will help us to drill down more accurately to patients at risk for male pelvic dysfunction. These observations are also applicable to women. In an era of increasing obesity, diabetes and dyslipidemia urologists must be keenly aware of these associations. Steven A. Kaplan, M.D.
Geriatrics Complications of Sling Surgery Among Female Medicare Beneficiaries J. T. Anger, M. S. Litwin, Q. Wang, C. L. Pashos and L. V. Rodriguez Department of Urology, David Geffen School of Medicine and School of Public Health, University of California, Los Angeles, California Obstet Gynecol 2007; 109: 707–714.
Objective: To analyze Medicare claims data to determine short-term complications after sling surgery among female beneficiaries aged 65 years and over. Methods: We analyzed the 1999 –2001 Medicare Public Use Files provided by the Centers for Medicare and Medicaid Services on a 5% national random sample of beneficiaries. Women undergoing sling procedures between January 1, 1999, and July 31, 2000, (the index period) were identified by Physicians Current Procedural Terminology Coding System (4th edition) and tracked for 12 months. Main outcome measures were complications as identified by International Classification of Diseases (9th revision) (ICD-9) diagnosis codes and Current Procedural Terminology procedure codes in the first postoperative year. Results: A total of 1,356 sling procedures were performed during the index period. In the 3 months after the procedure, 12.5% of women developed surgical or urologic complications, and 33.6% were diagnosed with urinary tract infections. Within 1 year of the procedure, 6.9% of subjects had a new diagnosis of outlet obstruction, and 8.0% underwent treatments to manage outlet obstruction. There was a high incidence of new diagnoses of urge incontinence (15.2%) and treatment of pelvic prolapse (23.2%). Both cystoscopy and urodynamic testing, which may serve as indicators of possible complications, were performed frequently during the first year after surgery (32.4% and 30.5%, respectively). Patient race, age, and comorbidity each had a significant influence on outcomes. Conclusion: Complication rates within 1 year after sling surgery among Medicare beneficiaries were found to be higher than those reported in the clinical literature. The high rates of postoperative urinary tract infections, prolapse, and outlet obstruction suggest the need for quality improvement measures in the management of women with incontinence and pelvic prolapse. Level of Evidence: III. Editorial Comment: Surgical therapy is widely used in the management of stress urinary incontinence in women. However, some surgeons are more hesitant to operate in elderly women due to concerns about increased risks of complications or poor outcomes. This population based study examined the complications of sling procedures in elderly women using a nationally representative sample of Medicare beneficiaries. The overall complication rate in this sample was 12.5%, and urinary tract infection was one of the most common complications. The findings support prior literature demonstrating an approximately 15% incidence of de novo urinary urgency and urge incontinence. Postoperative outlet obstruction was diagnosed in 6.9% of subjects, and 8.0% underwent treatment for this condition. Subsequent treatment for pelvic prolapse was required in 23.2% of women within 1 year after slingplasty. Although these findings revealed higher rates of complications than previous studies, the inherent limitations of using claims based analysis must
GERIATRICS
721
be recognized. Additional research on clinical outcomes and complications will help to define the role of surgical therapy for stress incontinence in elderly women. Tomas L. Griebling, M.D., M.P.H.
Urinary Incontinence and Self-Reported Health Among the U.S. Medicare Managed Care Beneficiaries C. H. Chang, C. M. Gonzalez, D. T. Lau and H. C. Sier Buehler Center on Aging, Health and Society, Northwestern University Feinberg School of Medicine, Chicago, Illinois J Aging Health 2008; 20: 405– 419.
Objective: To examine the prevalence and management of urinary incontinence (UI) and their impact on self-reported health in the U.S. Medicare managed care beneficiaries. Methods: Data were from the 2003 Medicare Health Outcomes Survey Cohort VI Baseline. Only beneficiaries aged 65 years or older and who self-completed the telephone interview were included. Results: About 37% of the study sample (N ⫽ 82,196) reported having accidental urine leakage (the UI group). A total of 75% of the UI group indicated UI’s being a problem and 41% of them had spoken with a doctor about it. Of these, 50% had received treatment. The findings indicate the UI group generally had significantly worse SF-36 Survey Scale scores than the non-UI group with and without adjusting other covariates. Discussion: UI is prevalent but undertreated as it adversely affects many health domains in this population. This study highlights the need for early detection, proper education, and access to effective treatment options for UI in the elderly. Editorial Comment: Epidemiological research has demonstrated that urinary incontinence is quite common in older adults, although most studies suggest that age by itself is not a significant risk factor. Incontinence can have a negative impact on health related quality of life in older adults. This study sought to identify the prevalence of urinary incontinence and its relationship to self-reported health in a community based cohort of 82,196 Medicare beneficiaries 65 years or older. To minimize response bias, information from proxy respondents was excluded from the analysis. The overall prevalence of incontinence was 37%, and of this group 75% considered their incontinence to be a problem. However, only 41% of subjects had spoken to a health care provider about their incontinence, and only 50% of these patients had actually received treatment. Incontinence was associated with worse health related quality of life based on self-reports using validated instruments. These results underscore the fact that although urinary incontinence is a highly prevalent condition in community dwelling older adults, the condition is undertreated and can negatively impact quality of life. Tomas L. Griebling, M.D., M.P.H.
Biochemical and Body Composition Analysis of Nocturia in the Elderly K. Sugaya, S. Nishijima, M. Oda, T. Owan, M. Miyazato and Y. Ogawa Division of Urology, Faculty of Medicine, Department of Organ-Oriented Medicine, University of Ryukyus, Okinawa, Japan Neurourol Urodyn 2008; 27: 205–211.
Aims: Nocturia is a common symptom in the elderly, and various contributing factors have been suggested. Therefore, in order to investigate which factors are strongly related to occurrence of nocturia, we performed a suite of examinations. Methods: One hundred eighty volunteers were divided into three groups: a young adult control group (60 healthy persons without nocturia), an elderly control group (60 healthy persons with a low mean frequency of nocturnal urination, i.e., ⬍once per night), and an elderly nocturia group (60 healthy persons with a high mean frequency of nocturnal urination, i.e., more than twice per night). Biochemistry tests, measurement of the osmotic pressure of plasma and urine, and body
722
GERIATRICS
composition analysis were performed in three groups during the daytime and nighttime. In the elderly control group and the elderly nocturia group, measurement of blood pressure and recording of urinary frequency-volume charts were performed. Results: The features specific to the elderly nocturia group are as follows: (1) a decrease of the nighttime plasma melatonin level, (2) an increase of nighttime plasma catecholamine levels, (3) an increase of daytime and nighttime plasma natriuretic peptide levels, (4) an increase of blood pressure, (5) a decrease of daytime and nighttime urinary osmotic pressure, (6) an increase of total urine volume, and (7) an increase of the edema ratio before sleeping. Conclusions: These results suggest that sleep disturbance, hypertension, and excessive fluid intake are major factors contributing to an increased frequency of nocturnal urination (⬎twice per night) in the elderly. Editorial Comment: Nocturia is one of the most common and most distressing lower urinary tract symptoms in older adults. The cause is multifactorial, and a wide variety of clinical characteristics have been associated with this condition. This study sought to examine these factors in 60 healthy elderly people (mean age 72 ⴞ 5 years) with nocturia compared to a control group of 60 healthy elderly people (70 ⴞ 4 years) without nocturia and a control group of 60 healthy young people (32 ⴞ 8 years) without nocturia. A variety of biochemical and morphometric tests were performed. As outlined in the abstract, a number of parameters were significantly different in the older patients with nocturia compared to the 2 control groups. This finding suggests that alterations in sleep quality, hypertension and excessive fluid intake may contribute to nocturia in older adults. These factors could be important targets for therapeutic intervention to help manage this bothersome condition. Tomas L. Griebling, M.D., M.P.H.
Rating Improvements in Urinary Incontinence: Do Patients and Their Physicians Agree? C. Tannenbaum, J. Brouillette and J. Corcos Department of Geriatric Medicine, Institut Universitaire de Geriatrie de Montreal, Montreal, Quebec, Canada Age Ageing 2008; 37: 379 –383.
Objective: To determine whether patients’ perceptions of improvement following behavioural interventions for urinary incontinence (UI) correspond with physicians’ global ratings of change, and to compare both these ratings with more objective UI outcome measures. Methods: consecutive new female patients aged 65 years and older recruited from outpatient UI clinics in Quebec received a behavioural management protocol for UI. At 3-month follow-up, patients and physicians were independently asked for their global impression of change in UI status. Patients completed 3-day voiding diaries and a UI-specific quality-of-life index before and after treatment. Results: 108 patients (mean age 73 ⫹/⫺ 5 years, range 65– 86 years) with stress, urge and mixed UI participated. There was concordance between patients’ and physicians’ ratings of change in 57% of cases. Among the remaining cases, patients were 1.6 times as likely to report significant improvements compared to physicians. Patients’ ratings correlated more strongly with improvements in UI episodes in the voiding diary (r ⫽ 0.4, P ⫽ 0.002 versus r ⫽ 0.3, P ⫽ 0.004 for physicians) and on the quality-of-life index (r ⫽ ⫺0.5, P ⬍ 0.0001 versus r ⫽ ⫺0.4, P ⬍ 0.0001 for physicians). Conclusion: physicians underestimate clinically meaningful changes in UI in older women following behavioural interventions. Editorial Comment: The decision to seek treatment for urinary incontinence is usually symptom based. Although urodynamic and physiological parameters are important, clinical perception of the problem is typically what drives evaluation and management. This study compared physician and patient perceptions of improvements in urinary incontinence following behavioral therapy in a cohort of 108 women older than 65 years (mean age 73 ⴞ 5). Concordance of ratings for improvement between physicians and patients was found in only 57% of cases. In instances of nonconcordance physicians were more likely to underestimate the degree of improvement experienced by patients. Objective measurements (pad use and
GERIATRICS
723
voiding diaries) and subjective measurements (validated quality of life scales) were used to assess outcomes. These results emphasize the need to determine patient perceptions of improvement in urinary continence status for behavioral interventions before pursuing other treatments. This is particularly important in elderly women, who could have greater potential risks of complications or adverse events with more invasive therapies. Tomas L. Griebling, M.D., M.P.H.